2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 531 - Health and Human Services Commission › Subchapter B. Powers and Duties › Section 531.02194. Reimbursement Methodology for Rural Hospitals

Text of section effective until April 01, 2025
Sec. 531.02194.  REIMBURSEMENT METHODOLOGY FOR RURAL HOSPITALS.  (a)  In this section, "rural hospital" has the meaning assigned by commission rules for purposes of the reimbursement of hospitals for providing inpatient or outpatient services under Medicaid.
(b)  To the extent allowed by federal law and subject to limitations on appropriations, the executive commissioner by rule shall adopt a prospective reimbursement methodology for the payment of rural hospitals participating in Medicaid that ensures the rural hospitals are reimbursed on an individual basis for providing inpatient and general outpatient services to Medicaid recipients by using the hospitals' most recent cost information concerning the costs incurred for providing the services.  The commission shall calculate the prospective cost-based reimbursement rates once every two years.
(c)  In adopting rules under Subsection (b), the executive commissioner may:
(1)  adopt a methodology that requires:
(A)  a managed care organization to reimburse rural hospitals for services delivered through the Medicaid managed care program using a minimum fee schedule or other method for which federal matching money is available; or
(B)  both the commission and a managed care organization to share in the total amount of reimbursement paid to rural hospitals; and
(2)  require that the amount of reimbursement paid to a rural hospital is subject to any applicable adjustments made by the commission for payments to or penalties imposed on the rural hospital that are based on a quality-based or performance-based requirement under the Medicaid managed care program.
(d)  Not later than September 1 of each even-numbered year, the commission shall, for purposes of Subsection (b), determine the allowable costs incurred by a rural hospital participating in the Medicaid managed care program based on the rural hospital's cost reports submitted to the federal Centers for Medicare and Medicaid Services and other available information that the commission considers relevant in determining the hospital's allowable costs.
(e)  Notwithstanding Subsection (b) and subject to Subsection (f), the executive commissioner shall adopt and the commission shall implement, beginning with the state fiscal year ending August 31, 2022, a true cost-based reimbursement methodology for inpatient and general outpatient services provided to Medicaid recipients at rural hospitals that provides:
(1)  prospective payments during a state fiscal year to the hospitals using the reimbursement methodology adopted under Subsection (b); and
(2)  to the extent allowed by federal law, in the subsequent state fiscal year a cost settlement to provide additional reimbursement as necessary to reimburse the hospitals for the true costs incurred in providing inpatient and general outpatient services to Medicaid recipients during the previous state fiscal year.
(f)  Notwithstanding Subsection (e), if federal law does not permit the use of a true cost-based reimbursement methodology described by that subsection, the commission shall continue to use the prospective cost-based reimbursement methodology adopted under Subsection (b) for the payment of rural hospitals for providing inpatient and general outpatient services to Medicaid recipients.
Added by Acts 2019, 86th Leg., R.S., Ch. 416 (S.B. 170), Sec. 1, eff. September 1, 2019.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01, eff. April 1, 2025.