Medicaid Benefits: Federally Qualified Health Center 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 - 51 | 2018 data limited to CN | Yes - 24 | Yes - 16 | Included in "Limits on Services" for 2018 | Not included in 2018 survey |
| Alabama | Yes - Mandatory | CN | $3.90 each visit | limit of 14 office visits and 16 inpatient hospital visits | - | - |
| Alaska | Yes - Mandatory | CN | $3 | No | - | - |
| Arizona | Yes - Mandatory | CN | No | Prior authorization only | - | - |
| Arkansas | Yes - Mandatory | CN | NR | NR | - | - |
| California | Yes - Mandatory | CN | $1/visit | No | - | - |
| Colorado | Yes - Mandatory | CN | $2 per visit | No | - | - |
| Connecticut | Yes - Mandatory | CN | No | No | - | - |
| Delaware | Yes - Mandatory | CN | No | No | - | - |
| District of Columbia | Yes - Mandatory | CN | No | No | - | - |
| Florida | Yes - Mandatory | CN | Federally qualified health center visit, per clinic, $3.00 per day | Up to one visit per recipient, per day for urgent care, primary and preventive care services, dental, an behavioral health services. Must Comply with Title 42, Code of Federal Regulations, parts 440 & 491. | - | - |
| Georgia | Yes - Mandatory | CN | $2 copay | Must be medically necessary. | - | - |
| Hawaii | Yes - Mandatory | CN | No | No | - | - |
| Idaho | Yes - Mandatory | CN | No | No | - | - |
| Illinois | Yes - Mandatory | CN | NR | NR | - | - |
| Indiana | Yes - Mandatory | CN | No | Limitations dependent upon services rendered. | - | - |
| Iowa | Yes - Mandatory | CN | NR | NR | - | - |
| Kansas | Yes - Mandatory | CN | $3.00 per visit | Allow one encounter per day | - | - |
| Kentucky | Yes - Mandatory | CN | $3 | No | - | - |
| Louisiana | Yes - Mandatory | CN | No | No | - | - |
| Maine | Yes - Mandatory | CN | $.50 to $3/day depending on payment amount, up to $30/month | Service limits in the FQHCs are the same as for providers in other settings | - | - |
| Maryland | Yes - Mandatory | CN | No | No | - | - |
| Massachusetts | Yes - Mandatory | CN | No | No | - | - |
| Michigan | Yes - Mandatory | CN | No | No | - | - |
| Minnesota | Yes - Mandatory | CN | $3 copay for non-preventive office visits | No | - | - |
| Mississippi | Yes - Mandatory | CN | $3 per visit | NR | - | - |
| Missouri | Yes - Mandatory | CN | $2 | There are daily quantity limits on services. | - | - |
| Montana | Yes - Mandatory | CN | Income at or below 100% FPL - $4 per visit; above FPL - 10% of payment amount | No | - | - |
| Nebraska | Yes - Mandatory | CN | No | No | - | - |
| Nevada | Yes - Mandatory | CN | NR | NR | - | - |
| New Hampshire | Yes - Mandatory | CN | No | NR | - | - |
| New Jersey | Yes - Mandatory | CN | No | No | - | - |
| New Mexico | Yes - Mandatory | CN | $7 for WDI recipients | No | - | - |
| New York | Yes - Mandatory | CN | NR | NR | - | - |
| North Carolina | Yes - Mandatory | CN | $1 - $3 depending on the service | 22 visits per year | - | - |
| North Dakota | Yes - Mandatory | CN | $3 per visit | No | - | - |
| Ohio | Yes - Mandatory | CN | Some FQHC dental services have a $3 co-pay; Some FQHC vision services have a $2 co-pay and there is a $1 co-pay for eyeglasses; If the FQHC has an on-site pharmacy, co-pay amounts range from $0-$3. | Limits for dental, vision, OT/PT, psychology, audiology, and chiropractic services rendered at an FQHC are shown below. If the FQHC holds a DME contract, there are also DME limitations | - | - |
| Oklahoma | Yes - Mandatory | CN | $4 per visit | Payment is limited to one visit per 24 hour period. Payment is also subject to the existing visit limitation of 4 visits per month. | - | - |
| Oregon | Yes - Mandatory | CN | No | No | - | - |
| Pennsylvania | Yes - Mandatory | CN | Sliding scale based on the Medicaid fee for the service: $0.65 - $3.80 | Dental services provided by FQHCs are limited as follows: Dentures 1 per lifetime; Exams/prophylaxis 1 per 180 days; Crowns, Periodontics and Endodontics only via approved Benefit Limit Exception | - | - |
| Rhode Island | Yes - Mandatory | CN | No | No | - | - |
| South Carolina | Yes - Mandatory | CN | NR | NR | - | - |
| South Dakota | Yes - Mandatory | CN | $3/visit | No | - | - |
| Tennessee | Yes - Mandatory | CN | No | No | - | - |
| Texas | Yes - Mandatory | CN | No | No | - | - |
| Utah | Yes - Mandatory | CN | $4 per visit | No | - | - |
| Vermont | Yes - Mandatory | CN | No | 1 visit/encounter per day up to 5 visits/encounters per month | - | - |
| Virginia | Yes - Mandatory | CN | NR | NR | - | - |
| Washington | Yes - Mandatory | CN | No | PA may be required if the service being delivered in this setting require PA | - | - |
| West Virginia | Yes - Mandatory | CN | Office visits are $2 for those 50-100% FPL and $4 for those 100% FPL and above | No | - | - |
| Wisconsin | Yes - Mandatory | CN | $0.50 - $3/encounter depending on the service provided, maximum of $30 per year, per provider | A small number of services require prior approval. | - | - |
| Wyoming | Yes - Mandatory | CN | $2.45 for non - emergent | 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-54 No-2 | Yes - 28 No - 26 | ||||
| Alabama | Yes | CN | $1/visit | 14 visits/year included in physician visit limitation - limit does not apply to family planning | Prospective cost based rate per service with ancillaries paid fee for service | |
| Alaska | Yes | CN | $3/visit | Prospective cost based rate/visit with ancillaries paid fee for service | ||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | Coverage of outpatient OT and SP services limited to ALTCS members | Yes | Fee for service | |
| Arkansas | Yes | CN & MN | 12 ambulatory encounters/year irrespective of setting for other than OB/GYN or family planning services | Greater of prospective rate/encounter or allowable cost | ||
| California | Yes | CN & MN | $1/visit | Provider based: prospective cost based rate/visit with ancillaries paid fee for service, Independent: cost based payment | ||
| Colorado | Yes | CN | $2/visit | Prospective cost based rate/visit with ancillaries paid fee for service, or alternative reimbursement methodology | ||
| Connecticut | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Delaware | Yes | CN | Cost based payment, ancillary services paid fee for service | |||
| District of Columbia | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Florida | Yes | CN & MN | $3/day | 3 encounters/day - 1 medical, 1 dental and 1 mental health | On site: prospective cost based rate/encounter, Off-site: fee for service | |
| Georgia | Yes | CN & MN | $2/visit | Prospective cost based rate/visit | ||
| Guam | Yes | CN | Fee for service using Medicare fee schedule | |||
| Hawaii | Yes | CN & MN | Prospective cost based payment | |||
| Idaho | Yes | CN | $3.65/visit up to 5% of income/year across all services | Prospective cost based rate/visit | ||
| Illinois | Yes | CN & MN | $3.65/visit | Prospective cost based rate/visit or certified cost/encounter | ||
| Indiana | Yes | CN | Limitations dependent upon service rendered | Prospective cost based rate/encounter | ||
| Iowa | Yes | CN & MN | Cost based payment | |||
| Kansas | Yes | CN & MN | $3/encounter | Prospective cost based rate/visit | ||
| Kentucky | Yes | A, B & C - See state-specific FN | A - $2/visit | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | ||
| Louisiana | Yes | CN & MN | 12 visits/year, visits count toward physician visit limit where applicable | Prospective all-inclusive rate/encounter | ||
| Maine | Yes | CN & MN | $.50-$3/day, depending on payment, up to $30/month | Same limitations as for providers in other settings | Same requirements as for providers in other settings | Prospective cost based rate/visit |
| Maryland | Yes | CN & MN | 1 non-emergency somatic visit/day, additional visits allowed for behavioral health and dental services | Prospective cost based rate/visit | ||
| Massachusetts | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Michigan | Yes | CN & MN | Prospective cost based rate/visit | |||
| Minnesota | Yes | A & B - See state-specific FN | $3/visit for non-preventive service | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | ||
| Mississippi | Yes | CN | $3/visit | 12 visits/year, visits count toward physician visit limit | All-inclusive rate per encounter | |
| Missouri | Yes | CN | $2/day | Cost based payment | ||
| Montana | Yes | A & B - See state-specific FN | $5/visit | Prospective cost based rate/visit | ||
| Nebraska | Yes | CN & MN | Prospective cost based rate/visit | |||
| Nevada | Yes | CN | Prospective all-inclusive cost based rate/visit | |||
| New Hampshire | Yes | CN & MN | Cost based payment, with limits | |||
| New Jersey | Yes | CN & MN | Prospective cost based rate/visit | |||
| New Mexico | Yes | CN | A - $0-$7/visit depending on income, B - $7/visit non-preventive services - see state-specific FN | Prospective cost based rate/encounter | ||
| New York | Yes | CN & MN | $3/visit | 10 clinic visits/year in combination with other specified providers | Prospective cost based rate or alternate payment methodology using APGs | |
| North Carolina | Yes | CN & MN | $3/visit for specified non-core services | 22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature | Specified services | Prospective payment or settled to cost up to Medicare PPS rate |
| North Dakota | Yes | CN & MN | $3/visit | Prospective cost based rate/visit for medical services, cost based payment for dental services | ||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | 24 visits/year included in physician visit limit | Prospective cost based rate/visit | ||
| Oklahoma | Yes | CN | $3/visit | Prospective rate/visit | ||
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Services limited to funded conditions on the priority list | Prospective cost based rate/visit | |
| Pennsylvania | Yes | CN & MN | $.65-$3.80/service, depending on payment rate | Limited to one physical health encounter and one mental health encounter per day | Provider based: prospective cost based rate/visit, Independent: prospective cost based rate/visit with ancillaries paid 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 | Prospective cost based rate/visit | |||
| South Carolina | Yes | CN | $3.30/encounter | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit or cost based payment | |
| South Dakota | Yes | CN | $3/visit | Substance abuse treatment not covered | Prospective cost based rate/visit | |
| Tennessee | Yes | A, B & C - See state-specific FN | Cost based through combination of managed care organization and State payments | |||
| Texas | Yes | CN & MN | Specified services | Prospective cost based rate/visit | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B- $3/non-preventive care visit, C - $5/visit | C - Primary care only, including routine physical exams | Prospective cost based rate/visit | |
| Vermont | Yes | A & B - See state-specific FN | 1 visit/day up to 5 visits/month | Cost based payment | ||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | $1/visit | Cost based payment | ||
| Washington | Yes | CN & MN | Prospective cost based rate/visit | |||
| West Virginia | Yes | A, B & C | Prospective cost based rate/visit | |||
| Wisconsin | Yes | CN & MN | $.50-$3/encounter, depending on services provided, maximum $30/year/provider | Prospective cost based rate/visit | ||
| Wyoming | Yes | CN | $3.65/visit | Prospective cost based rate/visit |
2010
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 54 No - 2 | Yes - 26 No - 28 | ||||
| Alabama | Yes | CN | $1/visit | 14 visits/year included in physician visit limitation - limit does not apply to family planning | Prospective cost based rate per service with ancillaries paid fee for service | |
| Alaska | Yes | CN | $3/visit | Prospective cost based rate/visit with ancillaries paid fee for service | ||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | Coverage of outpatient OT and SP services limited to ALTCS members | Yes | Fee for service | |
| Arkansas | Yes | CN & MN | 12 ambulatory encounters/year irrespective of setting | Greater of prospective rate/encounter or allowable cost | ||
| California | Yes | CN & MN | $1/visit | Specified services | Provider based: prospective cost based rate/visit with ancillaries paid fee for service, Independent: cost based payment | |
| Colorado | Yes | CN | $2/visit | Prospective cost based rate/visit with ancillaries paid fee for service, or alternative reimbursement methodology | ||
| Connecticut | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Delaware | Yes | CN | Cost based payment, ancillary services paid fee for service | |||
| District of Columbia | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Florida | Yes | CN & MN | $3/day | 1 encounter/day except mental health services limited to 26 encounters/year | On site: prospective cost based rate/encounter, Off-site: fee for service | |
| Georgia | Yes | CN & MN | $2/visit | Prospective cost based rate/visit | ||
| Guam | Yes | CN | Prospective rate/visit | |||
| Hawaii | Yes | CN & MN | Prospective cost based payment | |||
| Idaho | Yes | CN | Prospective cost based rate/visit | |||
| Illinois | Yes | CN & MN | Prospective cost based rate/visit or certified cost/encounter | |||
| Indiana | Yes | CN | Prospective cost based rate/encounter | |||
| Iowa | Yes | CN & MN | Cost based payment | |||
| Kansas | Yes | CN & MN | $3/encounter | Prospective cost based rate/visit | ||
| Kentucky | Yes | A, B & C - See state-specific FN | A - $2/visit | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | ||
| Louisiana | Yes | CN & MN | 12 visits/year, visits count toward physician visit limit where applicable | Prospective all-inclusive rate/encounter | ||
| Maine | Yes | CN & MN | $.50-$3/day, depending on payment, up to $30/month | Prospective cost based rate/visit | ||
| Maryland | Yes | CN & MN | 1 non-emergency visit/day | Prospective cost based rate/visit | ||
| Massachusetts | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Michigan | Yes | CN & MN | Prospective cost based rate/visit | |||
| Minnesota | Yes | A & B - See state-specific FN | B - $3/visit for non-preventive service | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | ||
| Mississippi | Yes | CN | $3/visit | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit | |
| Missouri | Yes | CN | $2/day | Cost based payment | ||
| Montana | Yes | A & B - See state-specific FN | $5/visit | Prospective cost based rate/visit | ||
| Nebraska | Yes | CN & MN | Prospective cost based rate/visit | |||
| Nevada | Yes | CN | Prospective all-inclusive cost based rate/visit | |||
| New Hampshire | Yes | CN & MN | Cost based payment, with limits | |||
| New Jersey | Yes | CN & MN | Prospective cost based rate/visit | |||
| New Mexico | Yes | CN | A - $0-$7/visit depending on income, B - $7/visit non-preventive services - see state-specific FN | Prospective cost based rate/encounter | ||
| New York | Yes | CN & MN | $3/visit | 10 clinic visits/year in combination with other specified providers | Prospective cost based rate | |
| North Carolina | Yes | CN & MN | $3/visit for specified non-core services | 22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature | Specified services | Prospective or cost based rate/visit up to Medicare PPS rate |
| North Dakota | Yes | CN & MN | $3/visit | Prospective cost based rate/visit for medical services, cost based payment for dental services | ||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | 24 visits/year included in physician visit limit | Prospective cost based rate/visit | ||
| Oklahoma | Yes | CN | $3/visit | Prospective rate/visit | ||
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Services limited to funded conditions on the priority list | Prospective cost based rate/visit | |
| Pennsylvania | Yes | CN & MN | $.50-$3/service, depending on payment rate | Limited to one physical health encounter and one mental health encounter per day | Provider based: prospective cost based rate/visit, Independent: prospective cost based rate/visit with ancillaries paid 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 | Prospective cost based rate/visit | |||
| South Carolina | Yes | CN | $2/encounter | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit or cost based payment | |
| South Dakota | Yes | CN | $3/visit | Substance abuse treatment not covered | Prospective cost based rate/visit | |
| Tennessee | Yes | A & B - See state-specific FN | Cost based through combination of managed care organization and State payments | |||
| Texas | Yes | CN & MN | Specified services | Prospective cost based rate/visit | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B- $3/visit, C - $5/visit | C - Primary care only, including routine physical exams | Prospective cost based rate/visit | |
| Vermont | Yes | A & B - See state-specific FN | 1 visit/day up to 5 visits/month | Cost based payment | ||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | $1/visit | Cost based payment | ||
| Washington | Yes | CN & MN | Prospective cost based rate/visit | |||
| West Virginia | Yes | A, B & C | Prospective cost based rate/visit | |||
| Wisconsin | Yes | CN & MN | $.50-$3/encounter, depending on services provided, maximum $30/year/provider | Prospective cost based rate/visit | ||
| Wyoming | Yes | CN | $2/visit | Prospective cost based rate/visit |
2008
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 53 No - 3 | Yes - 25 No - 28 | ||||
| Alabama | Yes | CN | $1/visit | 14 visits/year included in physician visit limitation - limit doesn't apply to family planning | Prospective cost based rate per service with ancillaries paid fee for service | |
| Alaska | Yes | CN | $3/visit | Prospective cost based rate/visit with ancillaries paid fee for service | ||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | Coverage of outpatient occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN | Yes | Fee for service | |
| Arkansas | Yes | CN & MN | 12 ambulatory encounters/year irrespective of setting | Greater of prospective rate/encounter or allowable cost | ||
| California | Yes | CN & MN | $1/visit | Specified services | Provider based: prospective cost based rate/visit with ancillaries paid fee for service, Independent: cost based payment | |
| Colorado | Yes | CN | $2/visit | Prospective cost based rate/visit with ancillaries paid fee for service, or alternative reimbursement methodology | ||
| Connecticut | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Delaware | Yes | CN | Cost based payment, ancillary services paid fee for service | |||
| District of Columbia | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Florida | Yes | CN & MN | $3/day | 1 encounter/day except mental health services limited to 26 encounters/year | On site: prospective cost based rate/encounter, Off-site: fee for service | |
| Georgia | Yes | CN & MN | $2/visit | Prospective cost based rate/visit | ||
| Guam | No | |||||
| Hawaii | Yes | CN & MN | Prospective cost based payment | |||
| Idaho | Yes | CN | Prospective cost based rate/visit | |||
| Illinois | Yes | CN & MN | Prospective cost based rate/visit or certified cost/encounter | |||
| Indiana | Yes | CN | Prospective cost based rate/encounter | |||
| Iowa | Yes | CN & MN | Cost based payment | |||
| Kansas | Yes | CN & MN | $3/encounter | Prospective cost based rate/visit | ||
| Kentucky | Yes | A, B & C - See state-specific FN | A - $2/visit | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | ||
| Louisiana | Yes | CN & MN | 15 visits/year, visits count toward physician visit limit where applicable | Prospective all-inclusive rate/encounter | ||
| Maine | Yes | CN & MN | Prospective cost based rate/visit | |||
| Maryland | Yes | CN & MN | 1 non-emergency visit/day | Prospective cost based rate/visit | ||
| Massachusetts | Yes | CN & MN | Prospective cost based rate/visit | |||
| Michigan | Yes | CN & MN | Prospective cost based rate/visit | |||
| Minnesota | Yes | A & B - See state-specific FN | $3/visit for non-preventive service | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | ||
| Mississippi | Yes | CN | $3/visit | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit | |
| Missouri | Yes | CN | $2/day | Cost based payment | ||
| Montana | Yes | A & B - See state-specific FN | $5/visit | Prospective cost based rate/visit | ||
| Nebraska | Yes | CN & MN | Prospective cost based rate/visit | |||
| Nevada | Yes | CN | Prospective all-inclusive cost based rate/visit | |||
| New Hampshire | Yes | CN & MN | Cost based payment, with limits | |||
| New Jersey | Yes | CN & MN | Prospective cost based rate/visit | |||
| New Mexico | Yes | CN | A - $5/visit, B - $7/visit non-preventive services - see state-specific FN | Prospective cost based rate/encounter | ||
| New York | Yes | CN & MN | $3/visit | 10 clinic visits/year in combination with other specified providers | Prospective cost based rate | |
| North Carolina | Yes | CN & MN | $1-$3/visit for specified non-core services | 22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature | Specified services | Prospective or cost based rate/visit up to Medicare PPS rate |
| North Dakota | Yes | CN & MN | $3/visit | Prospective cost based rate/visit for medical services, cost based payment for dental services | ||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | 24 visits/year included in physician visit limit | Prospective cost based rate/visit | ||
| Oklahoma | Yes | CN | $1/service | Prospective rate/visit | ||
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Prospective cost based rate/visit | ||
| Pennsylvania | Yes | CN & MN | $.50-$3/service, depending on payment rate | Frequency limits vary by service | Provider based: prospective cost based rate/visit, Independent: prospective cost based rate/visit with ancillaries paid fee for service | |
| Puerto Rico | Yes | CN & MN | Capitated payment | |||
| Rhode Island | Yes | CN & MN - see state-specific FN | Prospective cost based rate/visit | |||
| South Carolina | Yes | CN | $2/encounter | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit or cost based payment | |
| South Dakota | Yes | CN | $3/visit | Substance abuse treatment not covered | Prospective cost based rate/visit | |
| Tennessee | Yes | A & B - See state-specific FN | Cost based through combination of MCO and State payments | |||
| Texas | Yes | CN & MN | Specified services | Prospective cost based rate/visit | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B- $3/visit, C - $5/visit | C - Primary care only, including routine physical exams | Cost based payment | |
| Vermont | Yes | A & B - See state-specific FN | 1 visit/day up to 5 visits/month | Cost based payment | ||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | $1/visit | Cost based payment | ||
| Washington | Yes | CN & MN | Prospective cost based rate/visit | |||
| West Virginia | Yes | A, B & C | Prospective cost based rate/visit | |||
| Wisconsin | Yes | CN & MN | $.50-$3/encounter, depending on services provided, maximum $30/year/provider | Prospective cost based rate/visit | ||
| Wyoming | Yes | CN | $2/visit | Prospective cost based rate/visit |
2006
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 53 No - 3 | Yes - 25 No - 28 | ||||
| Alabama | Yes | CN | $1/visit | 14 visits/year included in physician visit limitation - limit doesn't apply to family planning | Prospective cost based rate per service with ancillaries paid fee for service | |
| Alaska | Yes | CN | $3/visit | Prospective cost based rate/visit with ancillaries paid fee for service | ||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | Coverage of outpatient occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN | Yes | Fee for service | |
| Arkansas | Yes | CN & MN | 12 ambulatory encounters/year irrespective of setting | Greater of prospective rate/encounter or allowable cost | ||
| California | Yes | CN & MN | $1/visit | Specified services | Provider based: prospective cost based rate/visit with ancillaries paid fee for service, Independent: cost based payment | |
| Colorado | Yes | CN | $2/visit | Prospective cost based rate/visit with ancillaries paid fee for service, or alternative reimbursement methodology | ||
| Connecticut | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Delaware | Yes | CN | Cost based payment, ancillary services paid fee for service | |||
| District of Columbia | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Florida | Yes | CN & MN | $3/day | 1 encounter/day except mental health services limited to 26 encounters/year | On site: prospective cost based rate/encounter, Off-site: fee for service | |
| Georgia | Yes | CN & MN | $2/visit | Prospective cost based rate/visit | ||
| Guam | No | |||||
| Hawaii | Yes | CN & MN | Cost based payment | |||
| Idaho | Yes | CN | Prospective cost based rate/visit | |||
| Illinois | Yes | CN & MN | Prospective cost based rate/visit or certified cost/encounter | |||
| Indiana | Yes | CN | Prospective cost based rate/encounter | |||
| Iowa | Yes | CN & MN | Cost based payment | |||
| Kansas | Yes | CN & MN | $3/encounter | Prospective cost based rate/visit | ||
| Kentucky | Yes | A, B & C - See state-specific FN | A - $2/visit | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | ||
| Louisiana | Yes | CN & MN | 15 visits/year, visits count toward physician visit limit where applicable | Prospective all-inclusive rate/encounter | ||
| Maine | Yes | CN & MN | Prospective cost based rate/visit | |||
| Maryland | Yes | CN & MN | 1 non-emergency visit/day | Prospective cost based rate/visit | ||
| Massachusetts | Yes | CN & MN | Prospective cost based rate/visit | |||
| Michigan | Yes | CN & MN | Prospective cost based rate/visit | |||
| Minnesota | Yes | A & B - See state-specific FN | $3/visit for non-preventive service | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | ||
| Mississippi | Yes | CN | $3/visit | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit | |
| Missouri | Yes | CN | $2/day | Cost based payment | ||
| Montana | Yes | A & B - See state-specific FN | $5/visit | Prospective cost based rate/visit | ||
| Nebraska | Yes | CN & MN | Prospective cost based rate/visit | |||
| Nevada | Yes | CN | Prospective all-inclusive cost based rate/visit | |||
| New Hampshire | Yes | CN & MN | Cost based payment, with limits | |||
| New Jersey | Yes | CN & MN | Prospective cost based rate/visit | |||
| New Mexico | Yes | CN | A - $5/visit, B - $7/visit non-preventive services - see state-specific FN | Prospective cost based rate/encounter | ||
| New York | Yes | CN & MN | $3/visit | 10 clinic visits/year in combination with other specified providers | Prospective cost based rate | |
| North Carolina | Yes | CN & MN | $1-$3/visit for specified non-core services | 24 ambulatory visits/year included in limits with other specified practitioners | Specified services | Prospective cost based rate/visit |
| North Dakota | Yes | CN & MN | $3/visit | Prospective cost based rate/visit for medical services, cost based payment for dental services | ||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | 24 visits/year included in physician visit limit | Prospective cost based rate/visit | ||
| Oklahoma | Yes | CN | $1/service | Prospective rate/visit | ||
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Prospective cost based rate/visit | ||
| Pennsylvania | Yes | CN & MN | $.50-$3/service, depending on payment | Frequency limits vary by service | Provider based: prospective cost based rate/visit, Independent: prospective cost based rate/visit with ancillaries paid fee for service | |
| Puerto Rico | Yes | CN & MN | Capitated payment | |||
| Rhode Island | Yes | CN & MN - see state-specific FN | Prospective cost based rate/visit | |||
| South Carolina | Yes | CN | $2/encounter | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit or cost based payment | |
| South Dakota | Yes | CN | $3/visit | Substance abuse treatment not covered | Prospective cost based rate/visit | |
| Tennessee | Yes | A & B - See state-specific FN | Cost based through combination of MCO and State payments | |||
| Texas | Yes | CN & MN | Specified services | Prospective cost based rate/visit | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B- $3/visit, C - $5/visit | C - Primary care only, including routine physical exams | Cost based payment | |
| Vermont | Yes | A & B - See state-specific FN | 1 visit/day up to 5 visits/month | Cost based payment | ||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | $1/visit | Cost based payment | ||
| Washington | Yes | CN & MN | Prospective cost based rate/visit | |||
| West Virginia | Yes | CN & MN | Prospective cost based rate/visit | |||
| Wisconsin | Yes | CN & MN | $.50-$3/encounter, depending on services provided, maximum $30/year/provider | Prospective cost based rate/visit | ||
| Wyoming | Yes | CN | $2/visit | Prospective cost based rate/visit |
2004
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 52 No - 4 | Yes - 22 No - 30 | ||||
| Alabama | Yes | CN | $1/visit | 14 visits/year | Prospective cost based rate per service with ancillaries paid fee for service | |
| Alaska | Yes | CN | $3/visit | Prospective cost based rate/visit with ancillaries paid fee for service | ||
| American Samoa | No | |||||
| Arizona | Yes | CN & MN | Coverage of occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN | Yes | Fee for service | |
| Arkansas | Yes | CN & MN | 12 ambulatory encounters/year irrespective of setting | Greater of prospective cost based rate/encounter or allowable cost | ||
| California | Yes | CN & MN | $1/visit | Specified services | Provider based: prospective cost based rate/visit with ancillaries paid fee for service, Independent: cost based payment | |
| Colorado | Yes | CN | $2/visit | Prospective cost based rate/visit with ancillaries paid fee for service, or alternative reimbursement methodology | ||
| Connecticut | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Delaware | Yes | CN | Cost based payment, ancillary services paid fee for service | |||
| District of Columbia | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Florida | Yes | CN & MN | $3/day | 1 encounter/day except mental health services limited to 26 encounters/year | On site: prospective cost based rate/encounter, Off-site: fee for service | |
| Georgia | Yes | CN & MN | $2/visit | Prospective cost based rate/visit | ||
| Guam | No | |||||
| Hawaii | Yes | CN & MN | Cost based payment | |||
| Idaho | Yes | CN | Prospective cost based rate/visit | |||
| Illinois | Yes | CN & MN | Prospective cost based rate/visit or certified cost/encounter | |||
| Indiana | Yes | CN | Prospective cost based rate/encounter | |||
| Iowa | Yes | CN & MN | Cost based payment | |||
| Kansas | Yes | CN & MN | $3/encounter | Prospective cost based rate/visit | ||
| Kentucky | Yes | CN & MN | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | |||
| Louisiana | Yes | CN & MN | 12 visits/year, visits count toward physician visit limit | Prospective all-inclusive rate/encounter | ||
| Maine | Yes | CN & MN | Prospective cost based rate/visit | |||
| Maryland | Yes | CN & MN | 1 non-emergency visit/day | Prospective cost based rate/visit | ||
| Massachusetts | Yes | CN & MN | Prospective cost based rate/visit | |||
| Michigan | Yes | CN & MN | Prospective cost based rate/visit | |||
| Minnesota | Yes | A & B - See state-specific FN | A - $3/visit for non-preventive service | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | ||
| Mississippi | Yes | CN | $3/visit | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit | |
| Missouri | Yes | CN | Cost based payment | |||
| Montana | Yes | A & B - See state-specific FN | $5/visit | Prospective cost based rate/visit | ||
| Nebraska | Yes | CN & MN | Provider based: prospective cost based rate/visit, Independent: fee for service | |||
| Nevada | Yes | CN | Prospective all-inclusive cost based rate/visit | |||
| New Hampshire | Yes | CN & MN | Cost based payment, with limits | |||
| New Jersey | Yes | CN & MN | Prospective cost based rate/visit | |||
| New Mexico | Yes | CN | B - $7/visit non-preventive services - see state-specific FN | Prospective cost based rate/encounter | ||
| New York | Yes | CN & MN | $3/visit | 10 clinic visits/year in combination with other specified providers | Prospective cost based rate | |
| North Carolina | Yes | CN & MN | $1-$3/visit for specified non-core services | 24 ambulatory visits/year included in limits with other specified practitioners | Specified services | Prospective cost based rate/visit |
| North Dakota | Yes | CN & MN | $3/visit | Prospective cost based rate/visit for medical services, cost based payment for dental services | ||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | 24 visits/year that count toward physician visit limit | Prospective cost based rate/visit | ||
| Oklahoma | Yes | CN | $1/service | Prospective rate/visit | ||
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Prospective cost based rate/visit | ||
| Pennsylvania | Yes | CN & MN | Provider based: prospective cost based rate/visit, Independent: prospective cost based rate/visit with ancillaries paid fee for service | |||
| Puerto Rico | Yes | CN & MN | Capitated payment | |||
| Rhode Island | Yes | CN & MN - see state-specific FN | Prospective cost based rate/visit | |||
| South Carolina | Yes | CN | $2/encounter | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit or cost based payment | |
| South Dakota | Yes | CN | $2/visit | Substance abuse treatment not covered | Prospective cost based rate/visit | |
| Tennessee | Yes | A & B - See state-specific FN | Cost based through combination of MCO and State payments | |||
| Texas | Yes | CN & MN | Specified services | Prospective cost based rate/visit | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B- $3/visit, C - $5/visit | C - Primary care only, including routine physical exams | Cost based payment | |
| Vermont | Yes | A & B - See state-specific FN | 1 visit/day up to 5 visits/month | Cost based payment | ||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | $1/visit | Cost based payment | ||
| Washington | Yes | CN & MN | Prospective cost based rate/visit | |||
| West Virginia | Yes | CN & MN | Prospective cost based rate/visit | |||
| Wisconsin | Yes | CN & MN | $.50-$3/encounter, depending on services provided, maximum $30/year/provider | Prospective cost based rate/visit | ||
| Wyoming | Yes | CN | $2/visit | Prospective cost based rate/visit |
2003
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 52 No - 4 | Yes - 21 No - 31 | ||||
| Alabama | Yes | CN | $1/visit | 14 visits/year | Prospective cost based rate/service with ancillaries paid fee for service | |
| Alaska | Yes | CN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| American Samoa | No | |||||
| Arizona | Yes | CN & MN | Coverage of occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN | Yes | Fee for service | |
| Arkansas | Yes | CN & MN | 12 ambulatory encounters/year irrespective of setting and included in physician limits | Greater of prospective rate/encounter or allowable cost | ||
| California | Yes | CN & MN | $1/visit | Specified services | Provider based: prospective cost based rate/visit with ancillaries paid fee for service, Independent: cost based payment | |
| Colorado | Yes | CN | $2/visit | Prospective cost based rate/visit with ancillaries paid fee for service, or alternative reimbursement methodology | ||
| Connecticut | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Delaware | Yes | CN | Cost based payment, ancillary services paid fee for service | |||
| District of Columbia | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Florida | Yes | CN & MN | $3/day | 1 encounter/day except mental health services limited to 26 encounters/year | On site: prospective cost based rate/encounter, Off-site: fee for service | |
| Georgia | Yes | CN & MN | $2/visit | Prospective cost based rate/visit | ||
| Guam | No | |||||
| Hawaii | Yes | CN & MN | Cost based payment | |||
| Idaho | Yes | CN | Prospective cost based rate/visit | |||
| Illinois | Yes | CN & MN | Prospective cost based rate/visit or certified cost/encounter | |||
| Indiana | Yes | CN | Prospective cost based rate/encounter | |||
| Iowa | Yes | CN & MN | Cost based payment | |||
| Kansas | Yes | CN & MN | $3/encounter | Prospective cost based rate/visit | ||
| Kentucky | Yes | CN & MN | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | |||
| Louisiana | Yes | CN & MN | 12 visits/year, visits count toward physician visit limit | Prospective all-inclusive rate/encounter | ||
| Maine | Yes | CN & MN | Prospective cost based rate/visit | |||
| Maryland | Yes | CN & MN | 1 non-emergency visit/day | Prospective cost based rate/visit | ||
| Massachusetts | Yes | CN & MN | Prospective cost based rate/visit | |||
| Michigan | Yes | CN & MN | Prospective cost based rate/visit | |||
| Minnesota | Yes | A & B - See state-specific FN | A - $3/visit for non-preventive service | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | ||
| Mississippi | Yes | CN | $3/visit | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit | |
| Missouri | Yes | CN | Cost based payment | |||
| Montana | Yes | CN & MN | $5/visit | Prospective cost based rate/visit | ||
| Nebraska | Yes | CN & MN | Provider based: prospective cost based rate/visit, Independent: fee for service | |||
| Nevada | Yes | CN | Prospective cost based rate/visit | |||
| New Hampshire | Yes | CN & MN | Cost based payment, with limits | |||
| New Jersey | Yes | CN & MN | Prospective cost based rate/visit | |||
| New Mexico | Yes | CN | B - $5/visit non-preventive services - see state-specific FN | Prospective cost based rate/encounter | ||
| New York | Yes | CN & MN | $3/visit | 10 clinic visits/year in combination with other specified providers | Prospective cost based rate/visit | |
| North Carolina | Yes | CN & MN | $1-$3/visit for specified non-core services | 24 ambulatory visits/year included in limits with other specified practitioners | Specified services | Prospective cost based rate/visit |
| North Dakota | Yes | CN & MN | $2/visit | Prospective cost based rate/visit for medical services, cost based payment for dental services | ||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | 24 ambulatory visits/year, 20 physical medicine visits/year, visits count toward physician visit limit | Cost based payment | ||
| Oklahoma | Yes | CN & MN | $1/service | Prospective rate/visit | ||
| Oregon | Yes | CN & MN | $3/visit | Prospective cost based rate/visit | ||
| Pennsylvania | Yes | CN & MN | Provider based: prospective cost based rate/visit, Independent: prospective cost based rate/visit with ancillaries paid fee for service | |||
| Puerto Rico | Yes | CN & MN | Capitated payment | |||
| Rhode Island | Yes | CN & MN - see state-specific FN | Prospective cost based rate/visit | |||
| South Carolina | Yes | CN | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit or cost based payment | ||
| South Dakota | Yes | CN | $2/visit | Substance abuse treatment not covered | Prospective cost based rate/visit | |
| Tennessee | Yes | A & B - See state-specific FN | Cost based through combination of MCO and State payments | |||
| Texas | Yes | CN & MN | Specified services | Prospective cost based rate/visit | ||
| Utah | Yes | A, B & C - See state specific FN | A - $2/visit, B- $3/visit, C - $5/visit | C - Primary care only, including routine physical exams | Cost based payment | |
| Vermont | Yes | A & B - See state-specific FN | B - $7/visit | 1 visit/day up to 5 visits/month | Cost based payment | |
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | $1/visit | Cost based payment | ||
| Washington | Yes | CN & MN | Prospective cost based rate/visit | |||
| West Virginia | Yes | CN & MN | Prospective cost based rate/visit | |||
| Wisconsin | Yes | CN & MN | $.50-$3, depending on service | Prospective cost based rate/visit | ||
| Wyoming | Yes | CN | $2/visit | Prospective cost based rate/visit |