Benefit: Hospital Outpatient Surgery

Definition: An outpatient is a patient who is not hospitalized overnight but who visits a hospital, clinic, or facility for diagnosis or treatment. Treatment provided in this fashion is called ambulatory care.

Limits:  Medicaid coverage for outpatient hospital services is limited to $1,500 per recipient, per state fiscal year (July 1 through June 30) for recipients who are age 21 and older. There is no reimbursement limitation for children 20 years of age or younger.

Exceptions: Exceptions to the outpatient fiscal year limitation are made for surgical procedures performed in an outpatient setting, infant delivery, chemotherapy services, and dialysis services. Examples of outpatient surgery are: cataract surgery, myringotomy with insertion of tube, single mastoidectomy, ligation and stripping of varicose lower limb veins, inguinal hernia repair, tubal ligation, ligation of vas deferens, and dilation and curettage.

Medicaid will reimburse outpatient hospital services furnished by a non-Medicaid participating hospital in an emergency, for the duration of the emergency.

Co-pays:$3 for each hospital outpatient or clinic visit unless exempt. Also there is a five percent coinsurance on the first $300 of a Medicaid payment for an emergency room visit to receive non-emergency services not to exceed $15.00, unless the recipient is exempt.

Reform items that can vary: None