Medicaid Benefits: Diagnostic, Screening and Preventive Services
This data is presented as an interactive tool that allows users to: filter by timeframe/year, select specific data columns (distributions), filter by state or geography, and view the data as a table, map, or trend chart.
2018
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limits on Services | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 42 No - 3 NR - 6 | 2018 data limited to CN | Yes - 10 | Yes - 15 | Included in "Limits on Services" for 2018 | Not included in 2018 survey |
| Alabama | No | - | - | |||
| Alaska | Yes | CN | $3 | No | - | - |
| Arizona | Yes | CN | No | Genetic testing not included | - | - |
| Arkansas | Yes | CN | NR | NR | - | - |
| California | Yes | CN | No | No | - | - |
| Colorado | Yes | CN | No | No | - | - |
| Connecticut | Yes | CN | No | No | - | - |
| Delaware | Yes | CN | No | Diagnostic -apnea monitor for breathing of infant with diagnosis of apneic episodes, no limits for preventative and no coverage for screening >21 | - | - |
| District of Columbia | Yes | CN | No | No | - | - |
| Florida | Yes | CN | Per specific coverage policy | Per specific coverage policy | - | - |
| Georgia | Yes | CN | Yes - Not Specified | Medically Necessary | - | - |
| Hawaii | Yes | CN | No | No | - | - |
| Idaho | Yes | CN | No | No | - | - |
| Illinois | NR | NR | NR | NR | - | - |
| Indiana | Yes | CN | No | Medicaid Rehab Option package of services required | - | - |
| Iowa | NR | NR | NR | NR | - | - |
| Kansas | Yes | CN | No | No | - | - |
| Kentucky | Yes | CN | No | Fetal diagnostic ultrasound - 2 per 9 months | - | - |
| Louisiana | Yes | CN | No | One well visit per year (current evaluation in process to increase to two) | - | - |
| Maine | Yes | CN | No | No | - | - |
| Maryland | Yes | CN | No | No | - | - |
| Massachusetts | Yes | CN | No | No | - | - |
| Michigan | Yes | CN | No | Most preventive services limited to USPSTF A&B services and ACIP vaccines. | - | - |
| Minnesota | Yes | CN | No | No | - | - |
| Mississippi | Yes | CN | No | NR | - | - |
| Missouri | Yes | CN | Depends on what type of provider the participant sees. | There are daily quantity limits on services. | - | - |
| Montana | Yes | CN | Income at or below 100% FPL - $4 per visit; above FPL - 10% of payment amount; copay not required for preventive services | Limits dependent upon service | - | - |
| Nebraska | No | - | - | |||
| Nevada | NR | NR | NR | NR | - | - |
| New Hampshire | NR | NR | NR | NR | - | - |
| New Jersey | Yes | CN | No | No | - | - |
| New Mexico | Yes | CN | No | Coverage is limited to some age appropriate diagnostic tests | - | - |
| New York | NR | NR | NR | NR | - | - |
| North Carolina | Yes | CN | No | NR | - | - |
| North Dakota | Yes | CN | $2 per office visit | No | - | - |
| Ohio | Yes | CN | No | No | - | - |
| Oklahoma | Yes | CN | Yes - Not Specified | NR | - | - |
| Oregon | Yes | CN | No | No | - | - |
| Pennsylvania | Yes | CN | No | No | - | - |
| Rhode Island | Yes | CN | No | No | - | - |
| South Carolina | NR | NR | NR | NR | - | - |
| South Dakota | Yes | CN | No | NR | - | - |
| Tennessee | Yes | CN | No | No | - | - |
| Texas | Yes | CN | No | No | - | - |
| Utah | No | - | - | |||
| Vermont | Yes | CN | No | Diagnostic testing limited to tests ordered by a physician for determining the nature and severity of an illness or medical condition. Administratively necessary or court ordered tests not covered unless medically necessary | - | - |
| Virginia | Yes | CN | $1 per visit | NR | - | - |
| Washington | Yes | CN | No | No | - | - |
| West Virginia | Yes | CN | No | Radiology and Lab services are subject to the above requirements. | - | - |
| Wisconsin | Yes | CN | See Laboratory and x-ray services, outside hospital or clinic; no copayment for preventive services with an A or B rating from the USPSTF | A small number of services require prior approval. | - | - |
| Wyoming | Yes | CN | $2.45 for non - emergent physician office/ clinic visits | Prior authorization is required after the first 12 visits to confirm ongoing medical necessity | - | - |
2012
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 48 No - 8 | Yes - 9 No - 39 | ||||
| Alabama | No | |||||
| Alaska | Yes | CN | Limited to diagnostic and screening services only, specified coverage criteria for mammography | Fee for service | ||
| American Samoa | Yes | See territory-specific FN | Diagnostic services must be medically necessary; screening services are covered; preventive services include pelvic exams, screening mammographies and pap smears for women with frequency limits established by age; tobacco cessation services are not limited by age and include counseling and medication coverage for at least two cessation attempts/year with face-to-face counseling for each attempt of at least four 30-minute sessions | |||
| Arizona | Yes | CN & MN | Specified age and gender criteria for clinical screening, health education and immunizations | Fee for service | ||
| Arkansas | No | |||||
| California | Yes | CN & MN | Fee for service | |||
| Colorado | Yes | CN | $2/visit or $1/date of service for lab or x-ray | 1 physical exam/year | Dependent upon service and billing provider | |
| Connecticut | Yes | CN & MN | Fee for service | |||
| Delaware | Yes | CN | Fee for service | |||
| District of Columbia | Yes | CN & MN | Limited to diagnostic and preventive services only | Yes | Dependent upon service and billing provider | |
| Florida | Yes | CN & MN | $1-$3 depending on service | Limitations vary depending on service and provider | Specified services | Fee for service |
| Georgia | Yes | CN & MN | Fee for service at 84.645% of CMS RBRVS rates for 2000 | |||
| Guam | Yes | CN | Specified coverage criteria for screening services | Fee for service using Medicare fee schedule | ||
| Hawaii | Yes | CN & MN | Specified services | Fee for service | ||
| Idaho | Yes | CN | 1 preventive physical exam/year | Fee for service | ||
| Illinois | Yes | CN & MN | Limited to diagnostic and screening services only, specified coverage criteria for mammography | Dependent upon service and billing provider | ||
| Indiana | Yes | CN | Fee for service | |||
| Iowa | Yes | CN & MN | $1-$3 depending on service | Limitations vary depending on service and provider | Specified services | Fee for service or cost based payment |
| Kansas | No | |||||
| Kentucky | Yes | A, B & C - See state-specific FN | Limited to diagnostic services only | Reasonable charge | ||
| Louisiana | Yes | CN & MN | Limited to specified screening services, including mammography | Fee for service | ||
| Maine | Yes | CN & MN | Screening services limited to diagnostic and preventive services, clinics specializing in screening services for sexually transmitted diseases not covered | Fee for service | ||
| Maryland | Yes | CN & MN | Fee for service | |||
| Massachusetts | Yes | CN & MN | Dependent upon service and billing provider | |||
| Michigan | Yes | CN & MN | Specified procedures | Fee for service | ||
| Minnesota | Yes | A & B - See state-specific FN | Fee for service | |||
| Mississippi | Yes | CN | Fee for service | |||
| Missouri | Yes | CN | Copayment amount varies with provider type rendering service | Fee for service | ||
| Montana | Yes | A & B - See state-specific FN | Dependent upon service and billing provider | Dependent upon service and billing provider | ||
| Nebraska | Yes | CN & MN | Limited to screening services only, specified coverage criteria for mammography | Fee for service | ||
| Nevada | Yes | CN | Limited to screening and preventive services only, and aligned with USPSTF guidelines, specified coverage criteria for mammography and annual gynecological exams | Fee for service | ||
| New Hampshire | Yes | CN & MN | Fee for service or negotiated rate | |||
| New Jersey | Yes | CN & MN | Specified services only | Fee for service | ||
| New Mexico | No | |||||
| New York | Yes | CN & MN | Fee for service | |||
| North Carolina | Yes | CN & MN | Services limited to programs for mental illness, developmental disability and substance abuse | Specified services | Capitated rate | |
| North Dakota | Yes | CN & MN | Fee for service | |||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | Limited to preventive services | Fee for service | ||
| Oklahoma | Yes | CN | Medically necessary outpatient and diagnostic x-rays and laboratory services, specified coverage criteria for mammography, limited coverage of hepatitis screening for at risk beneficiaries | Fee for service | ||
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Fee for service, using Medicare Relative Value Units and a state conversion factor | ||
| Pennsylvania | Yes | CN & MN | $1/x-ray | Diagnostic services only | Fee for service | |
| Puerto Rico | Yes | CN & MN | Influenza and pneumonia vaccines covered for elderly and for non-elderly at high risk | Service is included in the capitated rate paid to managed care plans | ||
| Rhode Island | Yes | See state-specific FN | Yes | Fee for service | ||
| South Carolina | Yes | CN | $3.30/visit | Limited to preventive services only | Fee for service | |
| South Dakota | Yes | CN | Fee for service or percentage of charge | |||
| Tennessee | Yes | A, B & C - See state-specific FN | B1 - $5/visit except preventive care and $5/specialty care visit B2 - $15/visit except preventive care and $20/specialty care visit | See state-specific FN | ||
| Texas | Yes | CN & MN | Limited to specified preventive services only | Fee for service | ||
| Utah | Yes | A, B & C - See state-specific FN | Limited to preventive services only | Dependent upon service and billing provider | ||
| Vermont | Yes | A & B - See state-specific FN | Dependent upon service and billing provider | |||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | Diagnostic services only covered as part of another service, specified coverage criteria for screening and preventive services | Fee for service | ||
| Washington | Yes | CN & MN | Limited to preventive services only | Fee for service, contracted rate for disease management services | ||
| West Virginia | Yes | A, B & C | Fee for service | |||
| Wisconsin | No | |||||
| Wyoming | No |
2010
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 46 No - 10 | Yes - 8 No - 38 | ||||
| Alabama | No | |||||
| Alaska | Yes | CN | Limited to diagnostic and screening services only, specified coverage criteria for mammography | Fee for service | ||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | Specified age and gender criteria for clinical screening, health education and immunizations | Fee for service | ||
| Arkansas | No | |||||
| California | No | |||||
| Colorado | Yes | CN | $2/visit or $1/date of service for lab or x-ray | 1 physical exam/year | Dependent upon service and billing provider | |
| Connecticut | Yes | CN & MN | Fee for service | |||
| Delaware | Yes | CN | Fee for service | |||
| District of Columbia | Yes | CN & MN | Limited to diagnostic and preventive services only | Yes | Dependent upon service and billing provider | |
| Florida | Yes | CN & MN | $1-$3 depending on service | Limitations vary depending on service and provider | Specified services | Fee for service |
| Georgia | Yes | CN & MN | Fee for service at 84.645% of CMS RBRVS rates for 2000 | |||
| Guam | Yes | CN | Specified coverage criteria for screening services | Fee for service | ||
| Hawaii | Yes | CN & MN | Specified services | Fee for service | ||
| Idaho | Yes | CN | 1 preventive physical exam/year | Fee for service | ||
| Illinois | Yes | CN & MN | Limited to diagnostic and screening services only, specified coverage criteria for mammography | Dependent upon service and billing provider | ||
| Indiana | Yes | CN | Dependent upon service and billing provider | |||
| Iowa | Yes | CN & MN | $1-$3 depending on service | Limitations vary depending on service and provider | Specified services | Fee for service or cost based payment |
| Kansas | No | |||||
| Kentucky | Yes | A, B & C - See state-specific FN | Limited to diagnostic services only | Reasonable charge | ||
| Louisiana | Yes | CN & MN | Limited to specified screening services, including mammography | Fee for service | ||
| Maine | Yes | CN & MN | Screening services limited to sexually transmitted diseases, diagnostic and preventive services | Fee for service | ||
| Maryland | Yes | CN & MN | Fee for service | |||
| Massachusetts | Yes | CN & MN | Dependent upon service and billing provider | |||
| Michigan | No | |||||
| Minnesota | Yes | A & B - See state-specific FN | Fee for service | |||
| Mississippi | Yes | CN | Fee for service | |||
| Missouri | Yes | CN | Copayment amount varies with provider type rendering service | Fee for service | ||
| Montana | Yes | A & B - See state-specific FN | Dependent upon service and billing provider | Dependent upon service and billing provider | ||
| Nebraska | Yes | CN & MN | Limited to screening services only, specified coverage criteria for mammography | Fee for service | ||
| Nevada | Yes | CN | Limited to screening and preventive services only, specified coverage criteria for mammography and annual gynecological exams | Fee for service | ||
| New Hampshire | Yes | CN & MN | Preventive services to newborns and their mothers are counted in the 18-visit physician limit | Fee for service or negotiated rate | ||
| New Jersey | Yes | CN & MN | Specified services only | Dependent upon service and billing provider | ||
| New Mexico | No | |||||
| New York | Yes | CN & MN | Fee for service | |||
| North Carolina | Yes | CN & MN | Services limited to programs for mental illness, developmental disability and substance abuse | Specified services | Fee for service | |
| North Dakota | Yes | CN & MN | Fee for service | |||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | Limited to preventive services | Fee for service | ||
| Oklahoma | Yes | CN | Medically necessary outpatient and diagnostic x-rays and laboratory services, specified coverage criteria for mammography, limited coverage of hepatitis screening for at risk beneficiaries | Fee for service | ||
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Fee for service, using Medicare Relative Value Units and a state conversion factor | ||
| Pennsylvania | Yes | CN & MN | $1/x-ray | Diagnostic services only | Fee for service | |
| Puerto Rico | Yes | CN & MN | Service is included in the capitated rate paid to managed care plans | |||
| Rhode Island | Yes | See state-specific FN | Yes | Fee for service | ||
| South Carolina | Yes | CN | Limited to preventive services only | Fee for service | ||
| South Dakota | Yes | CN | Fee for service or percentage of charge | |||
| Tennessee | Yes | A & B - See state-specific FN | B1 - $5/visit except preventive care and $15/specialty care visit B2 - $10/visit except preventive care and $20/specialty care visit | See state-specific FN | ||
| Texas | Yes | CN & MN | Limited to specified screenings only | Fee for service | ||
| Utah | Yes | A, B & C - See state-specific FN | Limited to preventive services only | Dependent upon service and billing provider | ||
| Vermont | Yes | A & B - See state-specific FN | Dependent upon service and billing provider | |||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | Diagnostic services only covered as part of another service, specified coverage criteria for screening and preventive services | Fee for service | ||
| Washington | Yes | CN & MN | Limited to preventive services only | Fee for service, contracted rate for disease management services | ||
| West Virginia | Yes | A, B & C | Fee for service | |||
| Wisconsin | No | |||||
| Wyoming | No |
2008
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 45 No - 11 | Yes - 5 No - 40 | ||||
| Alabama | No | |||||
| Alaska | Yes | CN | Limited to diagnostic and screening services only, specified coverage criteria for mammography | Fee for service | ||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | Specified age and gender criteria for clinical screening, health education and immunizations | Fee for service | ||
| Arkansas | No | |||||
| California | No | |||||
| Colorado | Yes | CN | Dependent upon service and billing provider | |||
| Connecticut | Yes | CN & MN | Fee for service | |||
| Delaware | No | |||||
| District of Columbia | Yes | CN & MN | Limited to diagnostic and preventive services only | Yes | Dependent upon service and billing provider | |
| Florida | Yes | CN & MN | $1-$3 depending on service | Limitations vary depending on service and provider | Specified services | Fee for service |
| Georgia | Yes | CN & MN | Fee for service at 84.645% of CMS RBRVS rates for 2000 | |||
| Guam | Yes | CN | Specified coverage criteria for screening services | Fee for service | ||
| Hawaii | Yes | CN & MN | Specified services | Fee for service | ||
| Idaho | Yes | CN | 1 preventive physical exam/year | Fee for service | ||
| Illinois | Yes | CN & MN | Limited to diagnostic and screening services only, specified coverage criteria for mammography | Dependent upon service and billing provider | ||
| Indiana | Yes | CN | Dependent upon service and billing provider | |||
| Iowa | Yes | CN & MN | $1-$3 depending on service | Limitations vary depending on service and provider | Specified services | Fee for service or cost based payment |
| Kansas | No | |||||
| Kentucky | Yes | A, B & C - See state-specific FN | Limited to diagnostic services only | Reasonable charge | ||
| Louisiana | Yes | CN & MN | Limited to specified screening services, including mammography | Fee for service | ||
| Maine | Yes | CN & MN | Screening services limited to sexually transmitted diseases, diagnostic and preventive services | Fee for service | ||
| Maryland | Yes | CN & MN | Fee for service | |||
| Massachusetts | Yes | CN & MN | Dependent upon service and billing provider | |||
| Michigan | No | |||||
| Minnesota | Yes | A & B - See state-specific FN | Fee for service | |||
| Mississippi | Yes | CN | Limited to annual preventive physical exams | Fee for service | ||
| Missouri | Yes | CN | Fee for service | |||
| Montana | Yes | A & B - See state-specific FN | Dependent upon service and billing provider | Dependent upon service and billing provider | ||
| Nebraska | Yes | CN & MN | Limited to screening services only, specified coverage criteria for mammography | Fee for service | ||
| Nevada | Yes | CN | Limited to screening and preventive services only, specified coverage criteria for mammography and annual gynecological exams | Fee for service | ||
| New Hampshire | Yes | CN & MN | Preventive services to newborns and their mothers are counted in the 18 visit physician limit | Fee for service or negotiated rate | ||
| New Jersey | Yes | CN & MN | Specified services only | Dependent upon service and billing provider | ||
| New Mexico | No | |||||
| New York | Yes | CN & MN | Fee for service | |||
| North Carolina | Yes | CN & MN | Services limited to programs for mental illness, developmental disability and substance abuse | Specified services | Fee for service | |
| North Dakota | Yes | CN & MN | Fee for service | |||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | Limited to preventive services | Fee for service | ||
| Oklahoma | Yes | CN | Medically necessary outpatient and diagnostic x-rays and laboratory services, specified coverage criteria for mammography, limited coverage of hepatitis screening for at risk beneficiaries | Fee for service | ||
| Oregon | Yes | A & B - See state-specific FN | Fee for service | |||
| Pennsylvania | Yes | CN & MN | $1/x-ray | Diagnostic services only | Fee for service | |
| Puerto Rico | Yes | CN & MN | Capitated payment | |||
| Rhode Island | Yes | CN & MN - see state-specific FN | Yes | Fee for service | ||
| South Carolina | Yes | CN | Limited to preventive services only | Fee for service | ||
| South Dakota | Yes | CN | Fee for service or percentage of charge | |||
| Tennessee | Yes | A & B - See state-specific FN | B1 - $5/visit except preventive care and $15/specialty care visit, B2 - $10/visit except preventive care and $25/specialty care visit | |||
| Texas | Yes | CN & MN | Limited to specified screenings only | Fee for service | ||
| Utah | Yes | A, B & C - See state-specific FN | Limited to preventive services only | Dependent upon service and billing provider | ||
| Vermont | Yes | A & B - See state-specific FN | Dependent upon service and billing provider | |||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | Diagnostic services only covered as part of another service, specified coverage criteria for screening and preventive services | Fee for service | ||
| Washington | Yes | CN & MN | Limited to preventive services only | Fee for service, contracted rate for disease management services | ||
| West Virginia | Yes | A, B & C | Fee for service | |||
| Wisconsin | No | |||||
| Wyoming | No |
2006
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 44 No - 12 | Yes - 4 No - 40 | ||||
| Alabama | No | |||||
| Alaska | Yes | CN | Limited to diagnostic and screening services only, specified coverage criteria for mammography | Fee for service | ||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | Specified age and gender criteria for clinical screening, health education and immunizations | Fee for service | ||
| Arkansas | No | |||||
| California | No | |||||
| Colorado | Yes | CN | Dependent upon service and billing provider | |||
| Connecticut | Yes | CN & MN | Fee for service | |||
| Delaware | No | |||||
| District of Columbia | Yes | CN & MN | Limited to diagnostic and preventive services only | Yes | Dependent upon service and billing provider | |
| Florida | No | |||||
| Georgia | Yes | CN & MN | Fee for service at 80% of physician fee | |||
| Guam | Yes | CN | Specified coverage criteria for screening services | Fee for service | ||
| Hawaii | Yes | CN & MN | Fee for service | |||
| Idaho | Yes | CN | 1 preventive physical exam/year | Fee for service | ||
| Illinois | Yes | CN & MN | Limited to diagnostic and screening services only, specified coverage criteria for mammography | Dependent upon service and billing provider | ||
| Indiana | Yes | CN | Dependent upon service and billing provider | |||
| Iowa | Yes | CN & MN | $1-$3 depending on service | Limitations vary depending on service and provider | Specified services | Fee for service or cost based payment |
| Kansas | No | |||||
| Kentucky | Yes | A, B & C - See state-specific FN | Limited to diagnostic services only | Reasonable charge | ||
| Louisiana | Yes | CN & MN | Limited to specified screening services, including mammography | Fee for service | ||
| Maine | Yes | CN & MN | Screening services limited to sexually transmitted diseases, diagnostic and preventive services limited to beneficiaries in state mental health facilities | Dependent upon service and billing provider | ||
| Maryland | Yes | CN & MN | Fee for service | |||
| Massachusetts | Yes | CN & MN | Dependent upon service and billing provider | |||
| Michigan | No | |||||
| Minnesota | Yes | A & B - See state-specific FN | Fee for service | |||
| Mississippi | Yes | CN | Limited to annual preventive physical exams | Fee for service | ||
| Missouri | Yes | CN | Fee for service | |||
| Montana | Yes | A & B - See state-specific FN | Dependent upon service and billing provider | Dependent upon service and billing provider | ||
| Nebraska | Yes | CN & MN | Limited to screening services only, specified coverage criteria for mammography | Fee for service | ||
| Nevada | Yes | CN | Limited to screening and preventive services only, specified coverage criteria for mammography and annual gynecological exams | Fee for service | ||
| New Hampshire | Yes | CN & MN | Preventive services to newborns and their mothers are counted in the 18 visit limit | Fee for service or negotiated rate | ||
| New Jersey | Yes | CN & MN | Specified services only | Dependent upon service and billing provider | ||
| New Mexico | No | |||||
| New York | Yes | CN & MN | Fee for service | |||
| North Carolina | Yes | CN & MN | Services limited to programs for mental illness, developmental disability and substance abuse | Specified services | Fee for service | |
| North Dakota | Yes | CN & MN | Fee for service | |||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | Fee for service | |||
| Oklahoma | Yes | CN | Medically necessary outpatient and diagnostic x-rays and laboratory services, specified coverage criteria for mammography, limited coverage of hepatitis screening for at risk beneficiaries | Fee for service | ||
| Oregon | Yes | A & B - See state-specific FN | Fee for service | |||
| Pennsylvania | Yes | CN & MN | $1/x-ray or diagnostic test | Diagnostic services only | Fee for service | |
| Puerto Rico | Yes | CN & MN | Capitated payment | |||
| Rhode Island | Yes | CN & MN - see state-specific FN | Yes | Fee for service | ||
| South Carolina | Yes | CN | Limited to preventive services only | Fee for service | ||
| South Dakota | Yes | CN | Fee for service or percentage of charge | |||
| Tennessee | Yes | A & B - See state-specific FN | B1 - $5/visit except preventive care and $15/specialty care visit, B2 - $10/visit except preventive care and $25/specialty care visit | |||
| Texas | Yes | CN & MN | Limited to specified screenings only | Fee for service | ||
| Utah | Yes | A, B & C - See state-specific FN | Limited to preventive services only | Dependent upon service and billing provider | ||
| Vermont | Yes | A & B - See state-specific FN | Dependent upon service and billing provider | |||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | Limited to screening and preventive services only, specified coverage criteria for mammography | Fee for service | ||
| Washington | Yes | CN & MN | Limited to preventive services only | Fee for service, contracted rate for disease management services | ||
| West Virginia | Yes | CN & MN | Fee for service | |||
| Wisconsin | No | |||||
| Wyoming | No |
2004
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 42 No - 14 | Yes - 3 No - 39 | ||||
| Alabama | No | |||||
| Alaska | Yes | CN | Limited to diagnostic and screening services only, specified coverage criteria for mammography | Fee for service | ||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | Specified age and gender criteria for clinical screening, health education and immunizations | Fee for service | ||
| Arkansas | No | |||||
| California | No | |||||
| Colorado | Yes | CN | Dependent upon service and billing provider | |||
| Connecticut | Yes | CN & MN | Fee for service | |||
| Delaware | No | |||||
| District of Columbia | Yes | CN & MN | Limited to diagnostic and preventive services only | Yes | Dependent upon service and billing provider | |
| Florida | No | |||||
| Georgia | Yes | CN & MN | Fee for service at 80% of physician fee | |||
| Guam | Yes | CN | Specified coverage criteria for screening services | Fee for service | ||
| Hawaii | Yes | CN & MN | Fee for service | |||
| Idaho | Yes | CN | Screening services only, specified coverage criteria and limits for mammography | Fee for service | ||
| Illinois | Yes | CN & MN | Limited to diagnostic and screening services only, specified coverage criteria for mammography | Dependent upon service and billing provider | ||
| Indiana | Yes | CN | Dependent upon service and billing provider | |||
| Iowa | Yes | CN & MN | $1-$3 depending on service | Limitations vary depending on service and provider | Specified services | Fee for service or cost based payment |
| Kansas | No | |||||
| Kentucky | Yes | CN & MN | Limited to diagnostic services only | Reasonable charge | ||
| Louisiana | Yes | CN & MN | Limited to specified screening services, including mammography | Fee for service | ||
| Maine | Yes | CN & MN | Screening services limited to sexually transmitted diseases, diagnostic and preventive services limited to beneficiaries in state mental health facilities | Dependent upon service and billing provider | ||
| Maryland | Yes | CN & MN | Fee for service | |||
| Massachusetts | Yes | CN & MN | Dependent upon service and billing provider | |||
| Michigan | No | |||||
| Minnesota | Yes | A & B - See state-specific FN | Fee for service | |||
| Mississippi | No | |||||
| Missouri | No | |||||
| Montana | Yes | A & B - See state-specific FN | Dependent upon service and billing provider | Dependent upon service and billing provider | ||
| Nebraska | Yes | CN & MN | Limited to screening services only, specified coverage criteria for mammography | Fee for service | ||
| Nevada | Yes | CN | Limited to screening and preventive services only, specified coverage criteria for mammography and annual gynecological exams | Fee for service | ||
| New Hampshire | Yes | CN & MN | Preventive services to newborns and their mothers are counted in the 18 visit limit | Fee for service or negotiated rate | ||
| New Jersey | Yes | CN & MN | Specified services only | Dependent upon service and billing provider | ||
| New Mexico | No | |||||
| New York | Yes | CN & MN | Fee for service | |||
| North Carolina | Yes | CN & MN | Services limited to programs for mental illness, developmental disability and substance abuse | Specified services | Fee for service | |
| North Dakota | Yes | CN & MN | Fee for service | |||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | Fee for service | |||
| Oklahoma | Yes | CN | Medically necessary outpatient and diagnostic x-rays and laboratory services, specified coverage criteria for mammography, limited coverage of hepatitis screening for at risk beneficiaries | Fee for service | ||
| Oregon | Yes | A & B - See state-specific FN | Fee for service | |||
| Pennsylvania | Yes | CN & MN | Diagnostic services only | Fee for service | ||
| Puerto Rico | Yes | CN & MN | Fee for service | |||
| Rhode Island | Yes | CN & MN - see state-specific FN | Yes | Fee for service | ||
| South Carolina | Yes | CN | Limited to preventive services only | Fee for service | ||
| South Dakota | Yes | CN | Fee for service or percentage of charge | |||
| Tennessee | Yes | A & B - See state-specific FN | B1 - $5/visit except preventive care and $15/specialty care visit, B2 - $10/visit except preventive care and $25/specialty care visit | |||
| Texas | Yes | CN & MN | Limited to specified screenings only | Fee for service | ||
| Utah | Yes | A, B & C - See state-specific FN | Limited to preventive services only | Dependent upon service and billing provider | ||
| Vermont | Yes | A & B - See state-specific FN | Dependent upon service and billing provider | |||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | Limited to screening and preventive services only, specified coverage criteria for mammography | Fee for service | ||
| Washington | Yes | CN & MN | Limited to preventive services only | Fee for service, contracted rate for disease management services | ||
| West Virginia | Yes | CN & MN | Fee for service | |||
| Wisconsin | No | |||||
| Wyoming | No |
2003
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 41 No - 15 | Yes - 3 No - 38 | ||||
| Alabama | No | |||||
| Alaska | Yes | CN | Limited to diagnostic and screening services only, specified coverage criteria for mammography | Fee for service | ||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | Specified age and gender criteria for clinical screening, health education and immunizations | Fee for service | ||
| Arkansas | No | |||||
| California | No | |||||
| Colorado | Yes | CN | Dependent upon service and billing provider | |||
| Connecticut | Yes | CN & MN | Fee for service | |||
| Delaware | No | |||||
| District of Columbia | Yes | CN & MN | Limited to diagnostic and preventive services only | Yes | Dependent upon service and billing provider | |
| Florida | No | |||||
| Georgia | Yes | CN & MN | Fee for service at 80% of physician fee | |||
| Guam | Yes | CN | Specified coverage criteria for screening services | Fee for service | ||
| Hawaii | Yes | CN & MN | Fee for service | |||
| Idaho | Yes | CN | Screening services only, specified coverage criteria and limits for mammography | Fee for service | ||
| Illinois | Yes | CN & MN | Limited to diagnostic and screening services only, specified coverage criteria for mammography | Dependent upon service and billing provider | ||
| Indiana | Yes | CN | Dependent upon service and billing provider | |||
| Iowa | Yes | CN & MN | $1-$3 depending on service | Limitations vary depending on service and provider | Specified services | Fee for service or cost based payment |
| Kansas | No | |||||
| Kentucky | Yes | CN & MN | Limited to diagnostic services only | Reasonable charge | ||
| Louisiana | Yes | CN & MN | Limited to specified screening services, including mammography | Fee for service | ||
| Maine | Yes | CN & MN | Screening services limited to sexually transmitted diseases, diagnostic and preventive services limited to beneficiaries in state mental health facilities | Dependent upon service and billing provider | ||
| Maryland | Yes | CN & MN | Fee for service | |||
| Massachusetts | Yes | CN & MN | Dependent upon service and billing provider | |||
| Michigan | No | |||||
| Minnesota | Yes | A & B - See state-specific FN | Fee for service | |||
| Mississippi | No | |||||
| Missouri | No | |||||
| Montana | Yes | CN & MN | Dependent upon service and billing provider | Dependent upon service and billing provider | ||
| Nebraska | Yes | CN & MN | Limited to screening services only, specified coverage criteria for mammography | Fee for service | ||
| Nevada | Yes | CN | Limited to screening and preventive services only, specified coverage criteria for mammography and annual gynecological exams | Fee for service | ||
| New Hampshire | Yes | CN & MN | Preventive services to newborns and their mothers are counted in the 18 visit limit | Fee for service | ||
| New Jersey | Yes | CN & MN | Specified services only | Dependent upon service and billing provider | ||
| New Mexico | No | |||||
| New York | Yes | CN & MN | Fee for service | |||
| North Carolina | Yes | CN & MN | Services limited to programs for mental illness, developmental disability and substance abuse | Specified services | Fee for service | |
| North Dakota | Yes | CN & MN | Fee for service | |||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | Limited to diagnostic and preventive services | Dependent upon service and billing provider | ||
| Oklahoma | Yes | CN & MN | Medically necessary outpatient and diagnostic x-rays and laboratory services, specified coverage criteria for mammography, limited coverage of hepatitis screening for at risk beneficiaries | Fee for service | ||
| Oregon | Yes | CN & MN | Limited to preventive services only including immunizations and services for beneficiaries with HIV/AIDS | Fee for service | ||
| Pennsylvania | Yes | CN & MN | Diagnostic services only | Fee for service | ||
| Puerto Rico | Yes | CN & MN | Fee for service | |||
| Rhode Island | Yes | CN & MN - see state-specific FN | Yes | Fee for service | ||
| South Carolina | Yes | CN | Limited to preventive services only | Fee for service | ||
| South Dakota | Yes | CN | Fee for service or percentage of charge | |||
| Tennessee | Yes | A & B - See state-specific FN | B1 - $5/visit except preventive care and $15/specialty care visit, B2 - $10/visit except preventive care and $25/specialty care visit | |||
| Texas | Yes | CN & MN | Fee for service | |||
| Utah | Yes | A, B & C - See state specific FN | Limited to preventive services only | Dependent upon service and billing provider | ||
| Vermont | Yes | A & B - See state-specific FN | Dependent upon service and billing provider | |||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | Limited to screening and preventive services only, specified coverage criteria for mammography | Fee for service | ||
| Washington | Yes | CN & MN | Limited to preventive services only | Fee for service, contracted rate for disease management services | ||
| West Virginia | No | |||||
| Wisconsin | No | |||||
| Wyoming | No |