Inpatient Services

Overview

Inpatient hospital services include medically necessary items and services ordinarily furnished by a Medicaid hospital provided under the direction of physician for the care and treatment of inpatient clients.

Inpatient Reimbursement

According to the Texas Administrative Code, §355.8052  related to Inpatient Hospital Reimbursement, hospitals may receive an annual SDA adjustment based upon their trauma designation.

Methodology / Rules

The Hospital Services program rules are located at Title 1 of the Texas Administrative Code, Part 15, Chapter 354, SubChapter A, Division 6, Rules 1071-1073, 1075, and 1077.

Reimbursement rules applicable to Hospitals are located at Title 1 of the Texas Administrative Code, Part 15, Chapter 355, SubChapter J, Division 4, Rules 8052, 8056, 8058, 8060, 8061, 8065, and 8066.

Prospective Payment Methodology

Inpatient hospital stays except in state-owned teaching hospitals and psychiatric facilities (CCP) are reimbursed according to a prospective payment methodology based on diagnosis-related groups (DRGs). The reimbursement method itself does not affect inpatient benefits and limitations. Inpatient admissions must be medically necessary and are subject to Texas Medicaid's UR requirements.

TEFRA Payment Methodology

Medicaid providers that are cost-reimbursed according to the TEFRA reimbursement principles on a reasonable cost basis are subject to cost reporting, cost reconciliation, and cost settlement processes. This includes state-owned teaching hospitals.

Additional information is available on the Texas Medicaid & Health Partnership (TMHP) website.

Payment Information

Hospital Inpatient Payments

FY 2022 Urban Hospital Prospective Standard Dollar Amount (SDA) with Add-on (.pdf)

FY 2022 Rural Hospital Prospective Standard Dollar Amount (SDA) (.pdf)

FY 2022 Children's Hospital Prospective Standard Dollar Amount and Rate for Labor and Delivery Services provided to Adults (SDA) (.pdf)

View the Delivery Related DRGs (.pdf)

HHSC is processing claims for Inpatient reimbursement with Grouper 38, Effective 10/01/2021. View TMHP Announcement here.

Texas APR-DRG Grouper current version (V38) (.pdf)

View Grouper 38 Implementation FAQ (.pdf)

View Grouper 38 MCO Notice (.pdf)

Current and previous versions of all SDA rates and APR DRG Grouper information are available on the TMHP website.

HHSC Reverts Inpatient Reimbursements to APR-DRG Grouper 36 Effective 11/1/2019 to 9/30/2021

Inpatient Ratio of Cost to Charges (RCC Rates) - effective 01/01/2022

Previous Inpatient Ratio of Cost to Charges (RCC Rates)

FY 2022 Psychiatric Hospital (Per Diem Rates) (.pdf)

Cost Report Requirements

Provider Cost and Reporting

The method of determining reasonable cost is similar to that used by Title XVIII (Medicare). Hospitals must include inpatient and outpatient costs in the cost reports submitted annually. The provider must prepare one copy of the applicable CMS Cost Report Form. Additional information is available on the Texas Medicaid & Health Partnership (TMHP) website.