Although most Medicaid enrollees obtain medical services within their state of residence, some enrollees seek care out-of-state under certain circumstances. Current Medicaid regulations describe four situations in which states must provide out-of-state coverage:
- a medical emergency;
- the beneficiary’s health would be endangered if required to travel to the state of residence;
- services or resources are more readily available in another state; or,
- it is general practice for recipients in a particular locality to use medical resources in another state.
States have broad flexibility to determine payment rates for services provided out of state and the processes that providers must follow to enroll as an out-of-state Medicaid provider. Hospital services comprise the largest category of Medicaid spending and the only one for which we have reliable data about out-of-state service use. This brief reviews use of out-of-state hospital services and the various ways that states pay out-of-state hospitals.
