This section requires Texas Medicaid rural hospital reimbursement rules to use cost-based methods and periodic rate calculations.
Sec. 532.0155. RURAL HOSPITAL REIMBURSEMENT. (a) In this section, "rural hospital" has the meaning assigned by commission rules for purposes of reimbursing hospitals for providing Medicaid inpatient or outpatient services. (b) To the extent allowed by federal law, 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 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 Medicaid 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 Medicaid managed care organization to share in the total amount of reimbursement paid to rural hospitals; and (2) require that the reimbursement amount paid to a rural hospital is subject to any applicable adjustments the commission makes 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 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 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 recipients during the previous state fiscal year. (f) If federal law does not permit the use of a true cost-based reimbursement methodology described by Subsection (e), the commission shall continue to use the prospective cost-based reimbursement methodology the executive commissioner adopts under Subsection (b) for the payment of rural hospitals for providing inpatient and general outpatient services to recipients. (g) To the extent allowed by federal law, the executive commissioner, in addition to the cost-based reimbursement rate calculated by the executive commissioner under Subsection (b), shall develop and calculate an add-on reimbursement rate for rural hospitals that have a department of obstetrics and gynecology. The executive commissioner shall calculate the rate required by this subsection annually. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025. Amended by: Acts 2025, 89th Leg., R.S., Ch. 707 (H.B. 18), Sec. 5, eff. June 20, 2025.