MedicaidReimbursementMedium impact
Inpatient hospital DRG outlier threshold increase; effective January 1, 2026
Washington Apple Health·WA·Reimbursement
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
Washington State Medicaid (Apple Health) increased the DRG outlier threshold for inpatient hospital payments from $40,000 to $45,000, effective January 1, 2026. This change reduces enhanced outlier payments to stay within budget neutral amounts from the 2021 hospital rebasing period.
Action Required
Immediately: Hospital billing teams must update DRG outlier calculations in billing systems to use the new $45,000 threshold instead of $40,000 for Washington State Medicaid claims with dates of service on or after January 1, 2026. Review the updated Inpatient Hospital Services Billing Guide published January 15, 2026 for complete details.