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Rate Tables

Overview

The Texas Health and Human Services Commission (HHSC) Provider Finance Department (PFD) is responsible for setting Medicaid and non-Medicaid reimbursement rates. The provider reimbursement rate tables serve as a transparent resource about reimbursement levels for various Medicaid and non-Medicaid services reimbursed by the state. The rate tables contain overall percent rate changes required to recognize increases or decreases in provider costs based on various established rate methodologies. The estimated fiscal impact of a one percent rate change can be used to estimate the fiscal impact on the state for provider reimbursement.

HHSC PFD follows a biennial fee review schedule to systemically review Medicaid and non-Medicaid reimbursement rates. Stakeholder sessions are held to receive feedback on reimbursement rates during the review process. If applicable, proposed reimbursement rate updates are published for public comment, which can be provided either during a rate hearing or in writing. Proposed rate packets are published on the PFD website, Rate Packets webpage.

Relationship between FFS Rates and Managed Care Capitation Rates

Fee-for-Service (FFS) rates are paid to providers contracted directly with HHSC for each Medicaid and non-Medicaid service from claims submitted to the state. For several reasons, FFS rates are also important in the managed care delivery system. FFS rate changes are often incorporated into calculating managed care capitation rates. Managed care capitation rates are paid to a managed care organization (MCO) per member per month with the expectation that the MCO will manage payments for services to providers on behalf of their enrolled clients through contractual arrangements with providers. HHSC establishes managed care capitation rates using a mathematical analysis that evaluates experience, risk, and FFS rate modifications.

In addition, FFS rates are used as a reference tool in certain ways. Many contracts between MCOs and providers incorporate payment rates based on a percentage of the same service’s FFS rate. In accordance with 42 CFR §447.204, HHSC requires MCOs to pay rates to Medicaid providers that follow the reimbursement principles “consistent with efficiency, economy, and quality of care” and are “sufficient to enlist enough providers so that services…are available to beneficiaries at least to the extent that those services are available to the general population.” HHSC does not require MCOs to utilize the FFS rates, and some MCOs use proprietary reimbursement structures and alternate reimbursement models. These arrangements are negotiated contracts between the MCO and the Medicaid provider to which HHSC is not a party.

In addition, the minimum reimbursement rate paid to a nursing facility in the managed care program is currently equivalent to the FFS nursing facility reimbursement rate. HHSC also produces FFS equivalent rates for former FFS services wholly carved into managed care to facilitate MCO capitation development.

Although these rate tables include both FFS and Managed Care, an FFS methodology was used to calculate the impacts, and the total costs associated with paying these services through the state capitation rate do not necessarily reflect the state's total costs. These costs do include a gross-up factor for managed care premium tax costs, risk margin costs, and administrative costs.

STAR+PLUS state plan services, STAR+PLUS Home and Community-Based Services, STAR Health, STAR Kids, and STAR Kids Medically Dependent Children's Program are paid through a managed care model using a state capitation rate. The STAR+PLUS costs do not include costs associated with dual demonstration.

Additional Information for Acute Care and Hospital Rate Tables

HHSC PFD’s acute care and hospital teams develop payment rates/fees in accordance with published rules and policy guidelines. Methodologies for reimbursement rates are defined in Chapter 355 of the Texas Administrative Code. The rate tables utilize state fiscal year 2023 (September 1, 2022 – August 31, 2023) base data, so it will not incorporate additional expenditures associated with funds appropriated through rate actions effective September 1, 2023, in accordance with the 2024-25 General Appropriations Act, House Bill (H.B.) 1, 88th Legislature, Regular Session, 2023 (Article II, HHSC).

Hospital inpatient rebasing: Additional work is being completed related to hospital rebasing and will be provided as a separate item from these rate tables.

More information on acute care rate-setting methodologies and programs is available on the Acute Care PFD webpage.

More information on hospital rate setting methodologies and programs is available on the Hospital and Clinic Services PFD webpage.

Additional Information for LTSS Rate Table

The PFD Long-term Services and Supports (LTSS) rate table includes estimates for services for which HHSC sets a payment rate and has current utilization. Items reimbursed at cost, such as adaptive aids, minor home modifications, or dental services provided in the 1915(c) waivers or institutional settings, were not included in the fiscal estimates. Additionally, the fiscal estimates do not reflect costs or potential offsets for voluntary programs, such as the Attendant Compensation Rate Enhancement program, Nursing Facility Direct Care Staff Enhancement program, and the Quality Incentive Payment Program (QIPP) that provide enhanced payments for meeting certain metrics or spending requirements.

LTSS Base Data

The PFD LTSS rate table utilizes state fiscal year 2023 adjudicated claims and financially examined 2021 and 2022 cost report data applicable to the methodology cited on the rate table.

The base data would not have included cost impacts associated with rate actions effective September 1, 2023, based on appropriations provided in accordance with the 2024-25 General Appropriations Act, H.B. 1, 88th Legislature, Regular Session, 2023 (Article II, HHSC). Therefore, HHSC adjusted the estimated 2024-25 Biennial cost and the 2026-27 methodological rates to account for September 1, 2023, rate increases in accordance with 2024-25 General Appropriations Act.

Furthermore, the base data was trended to state fiscal year 2026-27 from the applicable base period. A Personal Consumption Expenditures (PCE) price index (approximately 12 percent for 2022 to 2026-27) was utilized from the base period for costs assumed in the fully funded rates. These costs may change as new inflation factors become available.

Individualized Skills and Socialization Services

HHSC replaced day habilitation with a new, more integrated service called individualized skills and socialization services by March 2023. HHSC made this change to comply with 42 Code of Federal Regulations Section 441.301(c)(4), regarding requirements for settings where Medicaid Home and Community-Based Services (HCBS) are provided. The new service is available in the Deaf Blind Multiple Disabilities (DBMD), Home and Community-based Services (HCS), and the Texas Home Living (TxHmL) waiver programs. HHSC implemented the individualized skills and socialization services methodological rates effective January 1, 2023. Given that individualized skills and socialization utilization was only administered for part of state fiscal year 2023, it was annualized for a full year and trended accordingly for estimating 2024-25 biennial cost and 2026-27 methodological rate fiscal impacts.

Nursing Facility

HHSC is implementing a new reimbursement methodology for nursing facilities, called the Patient Driven Payment Model for Long-term Care (PDPM LTC), effective September 1, 2025. HHSC adopted new Texas Administrative Code rule §355.318 concerning Reimbursement Setting Methodology for Nursing Facilities on or after September 1, 2025.  HHSC held a rate hearing to propose rates for nursing facilities in support of the PDPM LTC rate methodology on October 1, 2024. The proposed rates were modeled to be revenue neutral to current program appropriations, plus appropriations provided in accordance with the 2024-25 General Appropriations Act, H.B. 1, 88th Legislature, Regular Session, 2023 (Article II, HHSC, Rider 25). The fiscal impacts and percent to fully fund compare the proposed nursing facility rates under PDPM LTC to the methodological rates using the PDPM LTC methodology for 2026-27.

The information provided in the rate tables for nursing facilities reflects the percentage change based on only the Medicaid daily rate reimbursement, and not on other revenue sources nursing facilities may receive. Evaluation of the Upper Payment Limit Demonstration should be considered if any rate increase is considered. This evaluation includes the consideration of the Medicaid daily rate and other revenue sources, which include, but are not limited to, the following:

  • Quality Incentive Payment Program is a voluntary performance-based payment program designed to incentivize nursing facilities to improve the quality and innovation of their services. The program is estimated at $1.75 billion annually.
  • NFs Direct Care Staff Enhancement (rate enhancement) is a voluntary program where participating providers agree to use the additional funding to compensate direct care staff. Participating providers who fail to meet the spending requirements are subject to recoupment.
  • NFs Liability Insurance Add-On, H.B. 154, 77th Texas Legislative, Regular Session, requires HHSC to ensure that the rate determination rules for NFs “provide for the rate component derived from reported liability insurance costs to be paid only to those homes that purchase liability insurance acceptable to the commission.” In compliance with H.B. 154, HHSC distributes the liability insurance add-on to NFs that verify acceptable liability insurance coverage. The rate add-ons are Professional Liability and General Liability (PL/GL) at $1.67 per day of service.

More information on LTSS rate setting methodologies and programs is available on the PFD LTSS webpage.

Attendant Base Wage Calculator

In addition to the rate tables, HHSC PFD is publishing the Personal Attendant Base Wage Fiscal Estimate Calculator. The current base wage for personal attendants is $10.60/hour. The calculator allows the user to enter a proposed hourly wage and see the estimated fiscal impact in total and by program/service. The calculator also allows the user to select an assumed factor for payroll taxes, worker’s compensation, and benefits.

LTSS Waiver Nursing Wage and PDN Calculator

HHSC PFD is publishing the Nursing Wage Fiscal Estimate Calculator for LTSS waiver services and Medicaid Private Duty Nursing (PDN) Services (both fee-for-service and managed care).

For the LTSS waiver services, the calculator allows the user to enter a proposed hourly wage for registered nurses (RN) and licensed vocational nurses (LVN) providing LTSS waiver services and view the estimated fiscal impact in total and by program and service. The calculator also allows the user to select an assumed factor for payroll taxes, workers’ compensation, and benefits.

For PDN, the calculator allows the user to enter an hourly proposed wage (the same as the proposed hourly wage for RN and LVN services for the LTSS waiver services) and display the estimated total fiscal impact of the changes. Please note that PDN reimbursement rates vary based on client severity, so the wage calculator would not reduce any current rates. For example, Medicaid reimbursement rates are higher for clients with tracheostomy or ventilators. The wage calculator only shows the impacts of increases. The fiscal impact assumes both fee-for-service and managed care Medicaid rate increases for PDN.

A summary row available at the top of the calculator reflects the total estimated fiscal impact for the selected LTSS waiver services and PDN increases. These impacts will update automatically based on the rates for RN or LVN services inputted by the user.

Questions and Inquiries

For questions and inquiries, please email HHSC PFD at:

Rate Tables

View the 2026-2027 PFD LTSS Rate Tables (.pdf) Excel version (.xlsx) (11/26/2024)

View the LTSS Personal Attendant Base Wage Calculator (.xlsx) (11/26/2024)

View the LTSS Waiver Nursing Wage Calculator (.xlsx) (11/26/2024)

View the 2026-2027 PFD Hospitals Rate Tables (.pdf) Excel version (.xlsx) (11/26/2024)

View the 2026-2027 PFD Acute Care Rate Tables (.pdf) Excel version (.xlsx) (11/26/2024)