Provider Rate Increases in Managed Care

As of Sept. 1, 2019, the fiscal year 2020 managed care capitation rates set by HHSC now include additional funding to increase the reimbursement rates for the following providers and services:

  • Rural Hospitals
  • Children’s Hospitals
  • Private Duty Nursing
  • Attendant Wages
  • Therapy Services

Managed care organizations (MCOs) must make every effort to ensure the additional funding is fully reflected in the reimbursement rates for these providers and services.

Monitoring MCO Implementation

Federal rules limit HHSC’s authority to require MCOs to increase rates. The agency issued guidance to the MCOs and is actively monitoring implementation of the new reimbursement rates.

Monitoring activities include:

  • A Sept. 2019 survey was issued to the MCOs to request the status of rate increase implementation. The results showed varying levels of compliance.
    • HHSC interprets a “yes” response to mean an MCO is increasing the rates for the provider type. Individual provider rates may vary.
  • HHSC provided the full survey results to all MCOs and asked them to note any reasons for not being fully compliant. View the MCO Reported Rate Implementation (PDF).
  • HHSC will also monitor the amount MCOs pay in claims for these services. Full data for claims paid in fiscal year 2020 will be available in March 2021.

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