Texas Medicaid Fee Schedule
Texas Medicaid pays $33.95 to $39.90 for an established-patient office visit (99213), depending on the rate type. Its median across rate types, $36.92, is the 2nd-lowest of 45 Medicaid programs.
- Schedule as of
- September 2026
- Codes priced
- 8,435
- 99213 vs. median
- 52% of median
Current Texas Medicaid rates for common codes
Each amount is the unmodified non-facility rate in the September 2026 schedule. Where a code appears under more than one rate type, it is the state's ordinary statewide rate when its rules name one, and otherwise the median across rate types. Modifier-specific and facility-only rows are listed separately under the service.
| Code | Service | Non-facility rate |
|---|---|---|
| 99213 | Office visit, established patient (low complexity)$33.95 to $39.90 across 4 rate types
2 rate types
| $36.92Median across rate typesIn effect since Sep 1, 20232nd-lowest of 45 · 52% of median |
| 99214 | Office visit, established patient (moderate complexity)$47.68 to $56.03 across 4 rate types
4 rate types
| $51.86Median across rate typesIn effect since Sep 1, 2023Lowest of 45 · 51% of median |
| 99203 | Office visit, new patient (low complexity)$55.52 to $65.25 across 4 rate types
2 rate types
| $60.39Median across rate typesIn effect since Sep 1, 20234th-lowest of 45 · 68% of median |
| 99204 | Office visit, new patient (moderate complexity)$81.24 to $95.47 across 4 rate types
4 rate types
| $88.35Median across rate typesIn effect since Sep 1, 20232nd-lowest of 45 · 66% of median |
| 99285 | Emergency department visit, high severity with threat to function2 rate types
| See rate choices |
Dot: Texas. Tick: median across state programs. Line: lowest to highest state. Base fee-for-service rates; supplemental payments some states add are not included.
Texas's median is 2nd-lowest of 45 for 99213. See where all 8,435 Texas Medicaid codes rank.
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Compare any other code across state programs. The free view shows a few states per code; Texas's full schedule is in the complete dataset.
What to know about the Texas Medicaid fee schedule
- Physician fees are Medicare RVUs times a Texas conversion factor, set by class of service with no geographic or specialty differential. 1 TAC 355.8085 TMPPM Section 2: Fee-for-Service Reimbursement
- Nurse practitioners, clinical nurse specialists and physician assistants get 92% of the physician rate, and CRNAs 92% of the anesthesiologist rate. TMPPM Section 2: Fee-for-Service Reimbursement
- Office-type services in a hospital clinic or emergency room are cut to 60% of the Medicaid rate unless the visit is high-severity or urgent. TMPPM Section 2: Fee-for-Service Reimbursement
- About 93% of enrollees are in managed care, and plans are not required to follow the Texas Medicaid fee schedules. CMS Medicaid managed care enrollment, 2024 TMPPM Section 2: Fee-for-Service Reimbursement
Texas Medicaid fee schedule FAQ
Does a listed code mean the service is covered by Texas Medicaid?
No. A listed Texas Medicaid fee is not a coverage, authorization, or payment guarantee. Benefits, limitations and prior authorization rules are set out in the Texas Medicaid Provider Procedures Manual (TMPPM), which TMHP updates monthly.
Does this Texas rate apply to Medicaid managed-care plans?
Most Texas Medicaid clients are enrolled in managed care programs such as STAR, STAR+PLUS, STAR Kids and STAR Health: CMS reports 93.3% of Texas Medicaid enrollees were in some form of managed care in 2024. TMHP states that 'MCOs and dental plans are not required to follow the Texas Medicaid fee schedules', so plan rates can differ from this schedule. The fee-for-service rates apply when Texas Medicaid pays a claim directly.
Why might my actual payment differ from the displayed rate?
These are the September 2026 Texas Medicaid rates. A claim can pay a different amount because of the date of service, modifier, place of service, units billed, provider enrollment or taxonomy, bundling with another service, coverage policy, prior authorization, and claim edits.
Why is there no published rate for this code?
Texas uses manual pricing: when a service has no established amount, the claim is reviewed individually to set the payment. A code may also be bundled into another service or priced on a different Texas Medicaid schedule. A missing rate does not mean the service is noncovered or pays $0.
Where can I find other Texas Medicaid fee schedules?
Texas Medicaid publishes separate fee schedules by provider type alongside the Texas Medicaid physician fee schedule (TMHP), and its provider manual sets the coverage and billing rules.
How does Texas set Medicaid physician fees?
Under 1 TAC 355.8085, HHSC multiplies the Medicare RVUs for a service by a Texas conversion factor, and may use different conversion factors for classes of service such as obstetrics, pediatrics, general surgery and primary care. HHSC may also set access-based fees where access is inadequate. Fees are uniform statewide and by provider type, reviewed at least every two years, and paid at the lower of billed charges or the Medicaid rate.
How do Texas Medicaid fees compare to Medicare?
KFF's 2024 Medicaid-to-Medicare fee index puts Texas at 0.63 of Medicare for all services, one of the lower ratios nationally, with primary care at 0.52 and obstetric care at 0.75. Other services sit higher, at 0.86. The index covers fee-for-service fees only.
How are nurse practitioners, physician assistants and CRNAs paid relative to the physician fee in Texas?
Under HHSC's reimbursement rules, nurse practitioners, clinical nurse specialists and physician assistants are paid 92 percent of the physician rate for the same service, and 100 percent for laboratory services, X-ray services and injections. CRNAs are paid 92 percent of the physician anesthesiologist rate for the same service.
Why was a Texas office-type visit paid less in the hospital or emergency room?
Under the TEFRA rules, Texas limits office-type physician services to 60 percent of the Medicaid rate when furnished in an outpatient hospital setting such as a clinic or emergency room. The cut does not apply to high-severity, urgent or critical problems, and RHC services, covered ASC/HASC surgery, anesthesia, radiology and prenatal visits billed with modifier TH are excluded.
How does Texas Medicaid pay Medicare crossover claims?
For Part B crossover claims, Texas Medicaid pays the lesser of the coinsurance and deductible, or the Medicaid allowed amount minus what Medicare paid. If Medicare's payment equals or exceeds the Medicaid allowed amount, Medicaid pays no coinsurance, and the client owes nothing further for Medicaid-covered services. For contracted Medicare Advantage plans, cost-sharing is billed to the plan, not TMHP.
Does a Texas Medicaid managed care plan have to pay the fee schedule rate?
No. TMHP tells providers to contact the client's MCO for reimbursement information because 'MCOs and dental plans are not required to follow the Texas Medicaid fee schedules.' The published fees are the fee-for-service rates only, already net of the state's mandated rate reductions, and TMHP announces changes on its rate changes page.
Neighboring and high-enrollment Medicaid fee schedules
States bordering Texas first, then the largest programs.