Texas Hospital & Medicaid Lien Resolution
Lien-reduction rules for Texas med-mal settlements: hospital, Medicaid, Medicare, ERISA.
Texas — Hospital Lien
Capped at 50%
Tex. Prop. Code §55.002; §55.004 (as amended by HB 2929, 2019)
The rule at a glance
- Hospital lien (Texas)
- Hospital lien amount = LESSER OF (first 100 days of charges) OR (50% of recovery). Hospital must admit within 72 hours of discharge and provide itemized bill.
- Medicaid recovery
- HHSC — Ahlborn applies. Only past-medical allocation is recoverable per Ahlborn (2006) + Wos v. E.M.A. (2013).
- Medicare (MSP)
- Federal procurement-ratio reduction under 42 CFR §411.37. Conditional Payment Letter + Final Demand required.
- ERISA self-funded plans
- Montanile strict tracing applies. Apply procurement reduction if plan consents.
- ERISA fully-insured plans
- Subject to state anti-subrogation doctrine. Most plans negotiate 40-60% off claimed amount.
- Statutory reference
- Tex. Prop. Code §55.002; §55.004 (as amended by HB 2929, 2019)
Common pitfalls in Texas
- Treating the hospital's claimed lien as final. Texas's procurement-ratio rule (or equivalent equitable doctrine) entitles you to a proportional reduction for fees + costs.
- Failing to perfect timing. Texas hospital liens typically require written notice within a short window — missing that window can invalidate the lien entirely.
- Paying Medicaid's full claim without Ahlborn allocation. Settlement should allocate past-medical vs. non-past-medical; only past-medical is subject to Medicaid recovery.
- Ignoring ERISA plan-type distinctions. Self-funded (Montanile) and fully-insured plans have dramatically different negotiation leverage.
Frequently asked questions
Can a hospital lien be reduced in Texas?
Yes — Texas's hospital lien is statutorily capped at 50%. Hospital lien amount = LESSER OF (first 100 days of charges) OR (50% of recovery). Hospital must admit within 72 hours of discharge and provide itemized bill.
What's the Ahlborn rule for Medicaid recovery?
Arkansas Dept. of Human Services v. Ahlborn (2006) + Wos v. E.M.A. (2013) limit Medicaid recovery to the past-medical-expense portion of a tort settlement. Texas Medicaid (HHSC — Ahlborn applies.) must allocate and cannot touch non-medical allocations.
How does the procurement ratio reduce Texas liens?
Procurement ratio = (attorney fee + costs) ÷ gross settlement. Medicare applies this automatically under 42 CFR §411.37. Most state lien statutes (and negotiated private liens) follow the same approach: the lienholder reduces its claim by the procurement ratio.
Does ERISA preempt Texas's lien reduction rules?
For ERISA self-funded plans, Montanile v. Board of Trustees (2016) requires strict tracing — the plan's lien applies if settlement funds are still identifiable. Fully-insured ERISA plans are subject to state anti-subrogation doctrine and are generally negotiable (often 40-60% off claimed).
Calculate Texas net-to-client
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