Benefit: Outpatient Hospital Services (non-emergency)

Definition: Outpatient hospital services are provided by a doctor or dentist at a licensed Medicaid hospital or clinic for preventive, diagnostic, therapeutic or palliative (treatment that may reduce the severity of disease symptoms) care and service items that are scheduled and don’t require an overnight stay.

Medicaid covers supplies, nursing care, therapy and medications. Primary care services such as regular checkups or visits to a PCP provided in an outpatient hospital setting, hospital-owned clinic or satellite facility are not considered outpatient hospital services.

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 $1,500 limit are made for the surgical procedures that are performed in an outpatient setting for child delivery, chemotherapy services, and dialysis services.

Co-pays: $3 per visit unless the recipient is exempt.
Co-insurance: There is a 5 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