Out-of-State Hospital Services Reimbursement Plan

PURPOSE: This rule establishes the method of reimbursing outof-state hospitals for inpatient or outpatient care provided to any recipients of Missouri Medicaid, whether they are under age twenty-one (21) or age twenty-one (21) and over. (1) Covered inpatient hospital services include those items and services allowed by the Medicaid State Plan including medically necessary care in a semi-private room. If prior authorized, Missouri Medicaid may reimburse for a private room if it is certified medically necessary by a physician to avoid jeopardizing the health of the patient or to protect the health and safety of other patients. No payment will be made for any portion of the room charge when the participant requests and is provided a private room when the private room is not medically necessary. (2) Payment for authorized inpatient hospital services shall be made according to subsections (2)(A) or (2)(B) for services provided outside Missouri if the services are covered by the Missouri Medicaid Program. To be reimbursed for furnishing services to Missouri Medicaid participants, out-of-state hospitals must complete a Missouri Medicaid Program Provider Participation Application and have the application approved by the Missouri Department of Social Services, Missouri Medicaid Audit and Compliance (MMAC). (A) The payment for authorized inpatient hospital services provided by an out-of-state free-standing psychiatric hospital shall be the lowest of— 1. The hospital’s per diem rate, which will be the weighted statewide average per diem rate for Missouri free-standing psychiatric hospitals as calculated by the MO HealthNet Division for the State Fiscal Year (SFY) in which the service was provided; or 2. The amount of total charges billed by the hospital. The hospital’s billed charges must be their usual and customary charges for services; or 3. The Medicare deductible or coinsurance, if applicable, up to the amount allowed by the Missouri Medicaid program. (B) The payment for authorized inpatient hospital services provided by an out-of-state hospital, except for free-standing psychiatric hospitals, shall be calculated using an All Patient Refined Diagnosis Related Groups (APR DRG) reimbursement methodology as described in 13 CSR 70-15.010(6). (3) The payment for authorized outpatient hospital services provided by an out-of-state hospital shall be the lower of— (A) The outpatient reimbursement as described in 13 CSR 70-15.160; or (B) The amount of total charges billed by the hospital. (4) Disproportionate Share Hospital (DSH) Payments. Out-ofstate hospitals do not qualify for DSH payments. (5) Definitions. (A) The definitions from regulation 13 CSR 70-15.010 are incorporated as 13 CSR 70-15.190. (B) Out-of-state is defined as not within the physical boundaries of Missouri. (C) Usual and customary charge is the amount which the individual provider charges the general public in the majority of cases for a specific procedure or service. AUTHORITY: sections 208.201 and 660.017, RSMo 2016.* Original rule filed April 15, 2004, effective Oct. 30, 2004. Emergency amendment filed June 16, 2022, effective July 1, 2022, expired Feb. 23, 2023. Amended: Filed June 16, 2022, effective Jan. 30, 2023. Emergency amendment filed June 20, 2025, effective July 7, 2025, expired Feb. 26, 2026. Amended: Filed June 23, 2025, effective Jan. 30, 2026. *Original authority: 208.201, RSMo 1987, amended 2007, and 660.017, RSMo 1993, amended 1995.