Medicaid Benefits: Inpatient Hospital Services, other than in an Institution for Mental Disease

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 - 21	Included in "Limits on Services" for 2018	Not included in 2018 survey
Alabama	Yes - Mandatory	CN	$50 for each admission	No	-	-
Alaska	Yes - Mandatory	CN	$50 a day for a maximum of $200	Must be prior authorized	-	-
Arizona	Yes - Mandatory	CN	No	No	-	-
Arkansas	Yes - Mandatory	CN	NR	NR	-	-
California	Yes - Mandatory	CN	No	Limitations vary by type of admission and services rendered	-	-
Colorado	Yes - Mandatory	CN	$10/day up to 50% of payment for first day of care in case of non-emergency	Prior authorization is required for transplants and bariatric surgery	-	-
Connecticut	Yes - Mandatory	CN	No	Prior authorization on inpatient admissions	-	-
Delaware	Yes - Mandatory	CN	No	No	-	-
District of Columbia	Yes - Mandatory	CN	No	Requires UR review for elective procedures	-	-
Florida	Yes - Mandatory	CN	No	Up to 45 days per fiscal year for recipients age 21 years or older Florida Medicaid reimburses for inpatient hospital days beyond the 45 day limit for emergency services, as defined in Rule 59G-1.010, F.A.C.	-	-
Georgia	Yes - Mandatory	CN	$12.50 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	Prior approval for non-emergency admissions other than deliveries; second opinions required for specified procedures, LOS less than 24 hours considered outpatient; substance abuse treatment limited to detox.	-	-
Iowa	Yes - Mandatory	CN	NR	NR	-	-
Kansas	Yes - Mandatory	CN	$48 per admission	No	-	-
Kentucky	Yes - Mandatory	CN	$50	No	-	-
Louisiana	Yes - Mandatory	CN	No	No	-	-
Maine	Yes - Mandatory	CN	$.50 to $3/day depending on payment amount, up to $30/month	No	-	-
Maryland	Yes - Mandatory	CN	No	Utilization control for medical necessity	-	-
Massachusetts	Yes - Mandatory	CN	$3 per admission	No	-	-
Michigan	Yes - Mandatory	CN	$50/inpatient stay for elective admissions	No	-	-
Minnesota	Yes - Mandatory	CN	NR	No	-	-
Mississippi	Yes - Mandatory	CN	$10 per day up to one-half the first day per diem	NR	-	-
Missouri	Yes - Mandatory	CN	$10 per admission	Inpatient hospital admissions must be certified as medically necessary and appropriate before MO HealthNet reimburses for inpatient services. All MO HealthNet enrolled hospitals in Missouri and bordering states are subject to this admission certification requirement.	-	-
Montana	Yes - Mandatory	CN	Income at or below 100% FPL - $75 per admission; above FPL - 10% of payment amount	Prior authorization required for transplants	-	-
Nebraska	Yes - Mandatory	CN	$15 per admission	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	$30 for working disabled individuals program beneficiaries	No	-	-
New York	Yes - Mandatory	CN	NR	NR	-	-
North Carolina	Yes - Mandatory	CN	$1 - $3 depending on the service	Title 42-Public Health, Subchapter C-Medical Assistance Programs, Part 456 Utilization Control	-	-
North Dakota	Yes - Mandatory	CN	$75 per admission	No	-	-
Ohio	Yes - Mandatory	CN	$3 for non-emergency services at an emergency department	No	-	-
Oklahoma	Yes - Mandatory	CN	$10 per day for first seven days; $5 on the eighth day	General acute care inpatient hospital services are limited to 24 days per individual per State fiscal year	-	-
Oregon	Yes - Mandatory	CN	No	In Oregon limits are based upon the condition/treatment pair and not the facility type. The physician would prior authorize the service to be performed in the hospital	-	-
Pennsylvania	Yes - Mandatory	CN	$3.00 per day up to $21.00 per admission	No	-	-
Rhode Island	Yes - Mandatory	CN	No	Stays over expected LOS are reviewed. Denied if over established limit. Reviewed by Medical Director if appealed	-	-
South Carolina	Yes - Mandatory	CN	NR	NR	-	-
South Dakota	Yes - Mandatory	CN	$50 per admission	No	-	-
Tennessee	Yes - Mandatory	CN	No	No	-	-
Texas	Yes - Mandatory	CN	No	Spell of illness limitation of 30 days	-	-
Utah	Yes - Mandatory	CN	$75.00 per episode of care	No	-	-
Vermont	Yes - Mandatory	CN	No	No	-	-
Virginia	Yes - Mandatory	CN	$75 per admission	service authorization required	-	-
Washington	Yes - Mandatory	CN	No	Inpatient rehabilitation requires prior authorization and concurrent review for length of stay	-	-
West Virginia	Yes - Mandatory	CN	$35 for individuals 50-100% FPL and $75 for those 100% FPL and above	All inpatient admissions, with the exception of those related to labor and delivery, are subject to medical necessity review and certification of admission by the Utilization Management Contractor	-	-
Wisconsin	Yes - Mandatory	CN	$3 per day with a $75 cap per stay	A small number of services require prior approval to be covered or to receive enhanced reimbursement rates	-	-
Wyoming	Yes - Mandatory	CN	No	Prior authorization is required for acute psych, rehab, transplants and some other surgeries	-	-

2012

Location	Benefit Covered	Coverage Code	Copayment Required?	Limit on services days	Prior Approval Required	Reimbursement Methodology
United States	Yes - 56 No - 0		Yes - 29 No - 27
Alabama	Yes	CN	$50/admission	Payment allowed for only 16 days/year		Cost based per diem
Alaska	Yes	CN	$50/day up to $200/admission	InterQual criteria used for selected procedures and diagnoses and for stays exceeding 3 days	Non emergency admissions except maternity, admissions for specified procedures, LOS greater than 3 days	Prospective cost based per diem
American Samoa	Yes	See territory-specific FN		Most on-island services provided by LBJ Tropical Medical Center
Arizona	Yes	CN & MN		25 days/year unless in a governmentally operated burn unit or for transplant or behavioral health care	Non-emergency admissions (including psych) except maternity, emergency admissions more than 3 days, ICU care more than 1 day	Prospective tiered per diem, psych admissions paid all-inclusive per diem
Arkansas	Yes	CN & MN	10% of first day's per diem rate up to specified limit	24 days/year	Admissions for specified procedures, elective surgery admissions	Cost based payment for pediatric, teaching and critical access hospitals; cost based payment with daily cap for other acute hospitals; prospective per diem for rehab hospitals
California	Yes	CN & MN		Limitations vary by type of admission and services rendered		Competitively bid rate, negotiated rate, contracted capitation rate or prospective all-inclusive rate using historical costs and peer groups
Colorado	Yes	CN	$10/day up to 50% of payment for first day of care	45 day LOS for psych admissions		Prospective cost based per diem
Connecticut	Yes	CN & MN			Non-emergency admissions except maternity, emergency readmissions within 2 days of discharge	Cost based payment
Delaware	Yes	CN		No limit on medically necessary acute care days but inpatient psychiatric treatment limited to 30 days/year		Prospective payment/discharge or prospective per diem for psych, rehab and other special hospitals/units
District of Columbia	Yes	CN & MN		Cosmetic and oral surgery limited to emergency repair due to injury or trauma, pre-surgical days limited to 1 unless medically justified, weekend admissions must be medically justified		Prospective payment/discharge using DRGs and peer group adjustment or percentage of charge for specific hospitals and services
Florida	Yes	CN & MN	$3/admission	45 days/year	Non-emergency admissions	Prospective cost based per diem with limits, admissions for certain organ transplants paid a global fee
Georgia	Yes	CN & MN	$12.50/non-emergency admission	Transplants of some organs not covered, LOS 30 days for psych care, rehab stays unrelated to acute illness or injury not covered	Non-emergency admissions except maternity	Prospective payment/discharge using DRGs
Guam	Yes	CN				Medicare interim payment rate
Hawaii	Yes	CN & MN		LOS limited by state's Utilization Review authority, tissue and organ transplants limited to Medicare-certified transplant facilities		Prospective cost based payment
Idaho	Yes	CN			Elective surgery admissions	Cost based payment
Illinois	Yes	CN & MN	$2-$3/day unless per diem less than $275	Pre-surgical days limited to 1 unless medically justified, admissions and LOS limited by State's Utilization Review authority, inpatient detox stays must be 60 days apart		Prospective payment/discharge using DRGs or prospective per diem for psych and rehab hospitals/units or facility-specific per diem for other special hospitals/units including certain government-operated facilities and children's hospitals
Indiana	Yes	CN		Second opinions required for specified procedures, LOS less than 24 hours considered outpatient except for newborns, substance abuse treatment limited to detox	Non-emergency admissions other than deliveries and newborns	Prospective payment/discharge using DRGs, prospective per diem for rehab and burn centers
Iowa	Yes	CN & MN			Specified procedures and services	Prospective payment/discharge using DRGs
Kansas	Yes	CN & MN	$48/admission	Elective surgery limited to sterilizations, rehab therapies must be restorative and post-trauma, transplants of some organs not covered, substance abuse limited to medical detox		Prospective payment/discharge using DRGs or percentage of charge for specific hospitals and services
Kentucky	Yes	A, B & C - See state-specific FN	A - $50/admission, B & C - $10/admission	Admissions limited to maternity and management of acute or chronic illness or injury that can't be rendered on outpatient basis	Admissions for specified procedures safely rendered on outpatient basis, elective admissions, all psychiatric admissions	Prospective payment/discharge using DRGs or prospective cost based per diem for psychiatric admissions
Louisiana	Yes	CN & MN		LOS in specified hospitals limited by state's Utilization Review authority	Non-emergency admissions	Prospective per diem using peer groups, higher per diem for high intensity services
Maine	Yes	CN & MN	$.50-$3/day, depending on payment, up to $30/month	All Medicare benefits/days must be exhausted before Medicaid is billed		Prospective payment/discharge using DRGs
Maryland	Yes	CN & MN		LOS limited by state's Utilization Review authority	Elective admissions	Prospective cost set by rate commission
Massachusetts	Yes	CN & MN	$3/admission	20 days/acute care admission not applicable to stays in acute hospital psych or rehab units	Elective admissions	Acute care hospitals paid prospective payment/discharge using statewide average cost adjusted for case mix; prospective all-inclusive hospital specific per diem for specified hospitals/units
Michigan	Yes	CN & MN	$50/first day of admission - see state-specific FN		Elective admissions, readmissions within 15 days, non-emergency transfers	Prospective payment/discharge using DRGs, prospective per diem for psych hospitals/units
Minnesota	Yes	A & B - See state-specific FN	See state specific FN	B - $10,000 annual limit for some population groups - See state-specific FN		Prospective payment/discharge using DRGs
Mississippi	Yes	CN	$10/day up to 1/2 first day per diem/admission		Non-emergency admissions except maternity	Prospective payment/discharge using APR-DRGs
Missouri	Yes	CN	$10/admission, except emergencies and transfers	LOS determined by Milliman Care Guidelines	Inpatient certification required for most admissions	Prospective per diem
Montana	Yes	A & B - See state-specific FN	A - $100/admission	Adult transplant coverage based on Medicare criteria		Cost based payment using Medicare principles for critical access hospitals, prospective payment/discharge using APR-DRGs for all others
Nebraska	Yes	CN & MN	$15/admission	Psych services limited to approved facilities	Admission and continued stay	Prospective payment/discharge using DRGs and peer groups, cost based payment for critical access hospitals, prospective cost based per diem for psych and rehab hospitals/units
Nevada	Yes	CN		Continuing stay authorizations required	Non-emergency admissions except maternity; authorization for emergency and maternity admissions required within 1 day	Prospective all-inclusive per diem by type of admission, cost based payment for critical access hospitals and hospital LTC units, swing beds paid statewide average nursing facility per diem
New Hampshire	Yes	CN & MN		LOS limited by state's Utilization Review authority, transplants limited to approved facilities and 2 transplants of same type/lifetime	Admissions for specified purposes	Prospective payment/discharge using DRGs, payment ceiling for transplants
New Jersey	Yes	CN & MN - See state-specific FN		Specified procedures require a second opinion	Admissions for specified procedures and LOS	Prospective payment/discharge using DRGs
New Mexico	Yes	CN	A - $0-$30/admission, B - $30/admission - see state-specific FN	A - 25 days/year in combination with inpatient psych care, physical rehab and home health care, inpatient detox limited to 72 hours per occurrence and is included in the 25 day limit, $100,000/year limit on transplant care and only selected transplants covered		Prospective payment/discharge using DRGs for general acute care hospitals, cost based payment with limits for rehab and specialty hospitals
New York	Yes	CN & MN	$25/admission			Prospective payment/discharge using APR-DRGs, prospective per diem for specialty hospitals/units, some services may be paid on a fee for service basis
North Carolina	Yes	CN & MN		3 administrative leave days to facilitate transfer to less restrictive setting	Specified services	Prospective payment/discharge using DRGs, prospective per diem for specialty hospitals
North Dakota	Yes	CN & MN	$75/admission	30 days for rehab, 21 days for psych	Transfers to LTC hospitals	Prospective payment/discharge using DRGs, prospective per diem for psych and rehab services, prospective percentage of charge payment for long-stay hospitals, cost based payment for critical access hospitals
Northern Mariana Islands	Yes	CN & MN - See territory-specific FN
Ohio	Yes	CN				Prospective payment/discharge using DRGs and peer groups, facility specific rates for children's hospitals, cost based payment for LTACH, rehab and cancer hospitals
Oklahoma	Yes	CN	$10/day up to $90/admission			Prospective payment/discharge using DRGs
Oregon	Yes	A & B - See state-specific FN		A & B - services limited to funded conditions on the priority list, specified procedures require a second opinion	Non-emergency transfers, readmissions for specified services	Prospective payment/discharge using federal DRG rate methodology, cost based payment for small hospitals
Pennsylvania	Yes	CN & MN	$3/day up to $21/admission	1 med rehab admission/year, 30 days psych care/year, non-emergency weekend admissions must have procedures same or next day, medical/surgical patients limited to 2 periods of therapeutic leave/month of no more than 12 hours/day	Specified non-emergency admissions	Prospective payment/discharge using APR-DRGs, rehab hospitals/units and psych units paid prospective per diem, cost based payment for alcohol detox units
Puerto Rico	Yes	CN & MN	$3/admission		Specified services	Service is included in the capitated rate paid to managed care plans
Rhode Island	Yes	See state-specific FN			Admissions for state specified procedures	Negotiated prospective cost based payment with a ceiling on allowable cost increases
South Carolina	Yes	CN	$25/admission			Prospective payment/discharge using DRGs or prospective per diem
South Dakota	Yes	CN	$50/non-emergency admission	Cosmetic surgery must be post-trauma, substance abuse treatment not covered	Admissions to DRG-exempt hospitals/units	Prospective payment/discharge using DRGs, cost based payment for psych, rehab and other special hospitals/units
Tennessee	Yes	A, B & C - See state-specific FN	B1 - $5/admission B2 - $100/admission	Inpatient rehab hospital services not covered		See state-specific FN
Texas	Yes	CN & MN		$200,000/year, LOS limited to 30 days in a 90-day period	Admissions for specified procedures	Prospective payment/discharge using DRGs and peer groups
Utah	Yes	A & B - See state-specific FN	A - $220/year for non-emergency admissions, B - $220/non-emergency admission	Psych and substance abuse admissions limited to 30 days/year irrespective of setting, specified surgical procedures not covered		Prospective payment/discharge using DRGs for most urban hospitals, enhanced DRG payment for children's hospitals, rural and psych hospitals paid percentage of charge, cost based payment for state-owned hospital
Vermont	Yes	A & B - See state-specific FN			Admissions for specified purposes	Prospective payment/discharge using DRGs
U.S. Virgin Islands	Yes	CN		Services in public health facilities only		Prospective all-inclusive per diem up to Medicare cost ceiling
Virginia	Yes	CN & MN	$100/non-emergency admission	Admissions for specified procedures safely rendered on outpatient basis, weekend admissions and days before elective surgery must be medically justified; psych admissions limited to 21 days in 60 days for same or similar diagnosis	Yes	Prospective payment/discharge using DRGs for acute care; prospective per diem for psych, rehab and other special hospitals/units
Washington	Yes	CN & MN		LOS limited to medically necessary days per InterQual IS/SI criteria if admission not paid under DRG method, elective admissions in specified areas of state restricted to contracted hospitals		Prospective payment/discharge using DRGs or per diems, cost based payment for critical access hospitals using prospective percentage of charges
West Virginia	Yes	A, B & C		Inpatient rehab care not covered	Yes	Prospective payment/discharge using DRGs, transplants paid DRG up to ceiling, critical access hospitals paid Medicare per diem rates
Wisconsin	Yes	CN & MN	$3/day up to $75/admission	Weekend admissions limited to hospitals providing full services every day	Admissions for specified procedures	Prospective payment/discharge using DRGs, prospective per diem for rehab hospitals/units and for specified conditions
Wyoming	Yes	CN			Specified admission types	Prospective payment/discharge based on LOC at admission

2010

Location	Benefit Covered	Coverage Code	Copayment Required?	Limit on services days	Prior Approval Required	Reimbursement Methodology
United States	Yes - 56 No - 0		Yes - 29 No - 27
Alabama	Yes	CN	$50/admission	Payment allowed for only 16 days/year		Capitated per eligible per month payment or prospective cost based payment with rate ceilings
Alaska	Yes	CN	$50/day up to $200/admission	LOS limited to 50th percentile of published guidelines for Region	Non emergency admissions except maternity, admissions for specified procedures, LOS greater than 3 days	Prospective cost based per diem
American Samoa	Yes	See territory-specific FN
Arizona	Yes	CN & MN		Specified transplants not covered, including lung, pancreas alone or after a kidney transplant and heart, liver and stem cell transplants for specified diagnoses	Non-emergency admissions (including psych) except maternity, emergency admissions more than 3 days, ICU care more than 1 day	Prospective tiered per diem, psych admissions paid all-inclusive per diem
Arkansas	Yes	CN & MN	10% of first day's per diem rate up to specified limit	24 days/year	Admissions for specified procedures, elective surgery admissions	Cost based payment for pediatric, teaching and critical access hospitals; cost based payment with daily cap for other acute hospitals; prospective per diem for rehab hospitals
California	Yes	CN & MN		Limitations vary by type of admission and services rendered		Competitively bid rate, negotiated rate, contracted capitation rate or prospective all-inclusive rate using historical costs and peer groups
Colorado	Yes	CN	$10/day up to 50% of payment for first day of care	45 day LOS for psych admissions		Prospective cost based per diem
Connecticut	Yes	CN & MN			Non-emergency admissions except maternity, emergency readmissions within 2 days of discharge	Cost based payment
Delaware	Yes	CN		No limit on medically necessary acute care days but inpatient psychiatric treatment limited to 30 days/year		Prospective payment/discharge or prospective per diem for psych, rehab and other special hospitals/units
District of Columbia	Yes	CN & MN		Cosmetic and oral surgery limited to emergency repair due to injury or trauma, pre-surgical days limited to 1 unless medically justified, weekend admissions must be medically justified		Prospective payment/discharge using DRGs and peer group adjustment or percentage of charge for specific hospitals and services
Florida	Yes	CN & MN	$3/admission	45 days/year	Non-emergency admissions	Prospective cost based per diem with limits, admissions for organ transplants paid a global fee
Georgia	Yes	CN & MN	$12.50/non-emergency admission	Transplants of some organs not covered, LOS 30 days for psych care, rehab stays unrelated to acute illness or injury not covered	Non-emergency admissions except maternity	Prospective payment/discharge using DRGs
Guam	Yes	CN		LOS limited to 60 days		Negotiated rate/service
Hawaii	Yes	CN & MN		Psych services limited to 30 days/year, LOS limited by state's Utilization Review authority, tissue and organ transplants limited to Medicare-certified transplant facilities		Prospective cost based payment
Idaho	Yes	CN			Elective surgery admissions	Cost based payment
Illinois	Yes	CN & MN	$2-$3/day unless per diem less than $275	Pre-surgical days limited to 1 unless medically justified, admissions and LOS limited by State's Utilization Review authority		Prospective payment/discharge using DRGs or prospective per diem for psych and rehab hospitals/units or facility-specific per diem for other special hospitals/units including certain government-operated facilities and children's hospitals
Indiana	Yes	CN		Second opinions required for specified procedures, LOS less than 24 hours considered outpatient except for newborns, substance abuse treatment limited to detox	Specified admissions, including to rehab and burn centers	Prospective payment/discharge using DRGs, prospective per diem for rehab and burn centers
Iowa	Yes	CN & MN		LOS limited to 50th percentile of published guidelines for Region	Admissions for specified procedures	Prospective payment/discharge using DRGs
Kansas	Yes	CN & MN	$48/admission	Elective surgery limited to sterilizations, rehab therapies must be restorative and post-trauma, transplants of some organs not covered, psych care limited to daily therapy, substance abuse limited to detox		Prospective payment/discharge using DRGs or percentage of charge for specific hospitals and services
Kentucky	Yes	A, B & C - See state-specific FN	A - $50/admission, B & C - $10/admission	Admissions limited to maternity and management of acute or chronic illness or injury that can't be rendered on outpatient basis	Admissions for specified procedures safely rendered on outpatient basis, elective admissions, all psychiatric admissions	Prospective payment/discharge using DRGs or prospective cost based per diem for psychiatric admissions
Louisiana	Yes	CN & MN		LOS in specified hospitals limited by state's Utilization Review authority	Non-emergency admissions	Prospective per diem using peer groups, higher per diem for high intensity services
Maine	Yes	CN & MN	$3/day up to $30/month	All Medicare benefits/days must be exhausted before Medicaid is billed		Prospective payment/discharge using DRGs
Maryland	Yes	CN & MN		LOS limited by state's Utilization Review authority, 2 therapeutic leaves of less than 12 hours/admission	Elective admissions	Prospective cost set by rate commission
Massachusetts	Yes	CN & MN	$3/admission		Elective admissions	Acute care hospitals paid prospective payment/discharge using statewide average cost adjusted for case mix; prospective all-inclusive hospital specific per diem for specified hospitals/units
Michigan	Yes	CN & MN	$50/first day of admission - see state-specific FN		Elective admissions, readmissions within 15 days, non-emergency transfers	Prospective payment/discharge using DRGs, prospective per diem for psych hospitals/units
Minnesota	Yes	A & B - See state-specific FN	B - 10% copayment for childless adults	B - $10,000 annual limit for some population groups - See state-specific FN		Prospective payment/discharge using DRGs
Mississippi	Yes	CN	$10/day up to 1/2 first day per diem/admission	30 days/year, including emergency admissions but transplant admissions are exempt	Non-emergency admissions except maternity	Prospective cost based per diem, with limits
Missouri	Yes	CN	$10/admission, except emergencies and transfers	LOS limited to 75th percentile of published guidelines for admissions exempt from certification	Admissions for specified surgical procedures	Prospective per diem with limits
Montana	Yes	A & B - See state-specific FN	$100/admission			Cost based payment using Medicare principles for critical access hospitals, prospective payment/discharge using APR-DRGs for all others
Nebraska	Yes	CN & MN		Psych services limited to approved facilities	Admission and continued stay	Prospective payment/discharge using DRGs and peer groups, cost based payment for critical access hospitals, prospective cost based per diem for psych and rehab hospitals/units
Nevada	Yes	CN		Continuing stay authorizations required	Non-emergency admissions except maternity; authorization for emergency and maternity admissions required within 1 day	Prospective all-inclusive per diem by type of admission, cost based payment for critical access hospitals and hospital LTC units, swing beds paid statewide average nursing facility per diem
New Hampshire	Yes	CN & MN		LOS limited by state's Utilization Review authority, transplants limited to approved facilities and 2 transplants of same type/lifetime	Admissions for specified purposes	Prospective payment/discharge using DRGs, payment ceiling for transplants
New Jersey	Yes	CN & MN - See state-specific FN		Specified procedures require a second opinion	Admissions for specified procedures and LOS	Prospective payment/discharge using DRGs
New Mexico	Yes	CN	A - $0-$30/admission, B - $30/admission - see state-specific FN	A - 25 days/year in combination with inpatient psych care, physical rehab and home health care, inpatient detox limited to 72 hours per occurrence and is included in the 25 day limit, $100,000/year limit on transplant care and only selected transplants covered		Prospective payment/discharge using DRGs for general acute care hospitals, cost based payment with limits for rehab and specialty hospitals
New York	Yes	CN & MN	$25/admission			Prospective payment/discharge using APR-DRGs, prospective per diem for specialty hospitals/units, some services may be paid on a fee for service basis
North Carolina	Yes	CN & MN		3 administrative leave days to facilitate transfer to less restrictive setting	Specified admissions and services	Prospective payment/discharge using DRGs or prospective per diem
North Dakota	Yes	CN & MN	$75/admission	30 days for rehab, 21 days for psych	Transfers to LTC hospitals	Prospective payment/discharge using DRGs and peer groups, prospective per diem for psych and rehab services, prospective percentage of charge payment for long-stay hospitals, cost based payment for critical access hospitals
Northern Mariana Islands	Yes	CN & MN - See territory-specific FN
Ohio	Yes	CN				Prospective payment/discharge using DRGs and peer groups, facility specific rates for children's hospitals, cost based payment for LTACH, rehab and cancer hospitals
Oklahoma	Yes	CN	$10/day up to $90/admission			Prospective payment/discharge using DRGs
Oregon	Yes	A & B - See state-specific FN		A & B - services limited to funded conditions on the priority list, specified procedures require a second opinion B - limited to admissions for urgent or emergency medical care only	Non-emergency transfers, readmissions for specified services	Prospective payment/discharge using federal DRG rate methodology, cost based payment for small hospitals
Pennsylvania	Yes	CN & MN	$3/day up to $21/admission	1 med rehab admission/year, 30 days psych care/year, non-emergency weekend admissions must have procedures same or next day, medical/surgical patients limited to 2 periods of therapeutic leave/month of no more than 12 hours/day	Specified non-emergency admissions	Prospective payment/discharge using APR-DRGs, rehab hospitals/units and psych units paid prospective per diem, cost based payment for alcohol detox units
Puerto Rico	Yes	CN & MN	$3/admission		Specified services	Service is included in the capitated rate paid to managed care plans
Rhode Island	Yes	See state-specific FN			Admissions for state specified procedures	Negotiated prospective cost based payment with a ceiling on allowable cost increases
South Carolina	Yes	CN	$25/admission			Prospective payment/discharge using DRGs or prospective per diem
South Dakota	Yes	CN	$50/non-emergency admission	Cosmetic surgery must be post-trauma, substance abuse treatment not covered	Admissions to DRG-exempt hospitals/units	Prospective payment/discharge using DRGs, cost based payment for psych, rehab and other special hospitals/units
Tennessee	Yes	A & B - See state-specific FN	B1 - $5/admission B2 - $100/admission	10 days detox treatment/lifetime with $30,000 limit/lifetime on inpatient and outpatient drug and alcohol treatment, inpatient rehab hospital services not covered		See state-specific FN
Texas	Yes	CN & M		$200,000/year, LOS limited to 30 days in a 90-day period	Admissions for specified procedures	Prospective payment/discharge using DRGs and peer groups
Utah	Yes	A & B - See state-specific FN	$220/year for non-emergency admissions	Psych and substance abuse admissions limited to 30 days/year irrespective of setting, specified surgical procedures not covered		Prospective payment/discharge using DRGs for most urban hospitals, enhanced DRG payment for children's hospitals, rural and psych hospitals paid percentage of charge, cost based payment for state-owned hospital
Vermont	Yes	A & B - See state-specific FN	A - $75/admission		Admissions for specified purposes	Prospective payment/discharge using DRGs
U.S. Virgin Islands	Yes	CN		Services in public health facilities only		Prospective all-inclusive per diem up to Medicare cost ceiling
Virginia	Yes	CN & MN	$100/non-emergency admission	Admissions for specified procedures safely rendered on outpatient basis, weekend admissions and days before elective surgery must be medically justified; psych admissions limited to 21 days in two months	Yes	Prospective payment/discharge using DRGs for acute care; prospective per diem for psych, rehab and other special hospitals/units
Washington	Yes	CN & MN		LOS limited to medically necessary days per InterQual IS/SI criteria if admission not paid under DRG method, elective admissions in specified areas of state restricted to contracted hospitals		Prospective payment/discharge using DRGs or per diems, cost based payment for critical access hospitals using prospective percentage of charges
West Virginia	Yes	A, B & C		Inpatient rehab care not covered	Yes	Prospective payment/discharge using DRGs, transplants paid DRG up to ceiling, critical access hospitals paid Medicare per diem rates
Wisconsin	Yes	CN & MN	$3/day up to $75/admission	Weekend admissions limited to hospitals providing full services every day	Admissions for specified procedures	Prospective payment/discharge using DRGs, prospective per diem for rehab hospitals/units and for specified conditions
Wyoming	Yes	CN				Prospective payment/discharge based on LOC at admission

2008

Location	Benefit Covered	Coverage Code	Copayment Required?	Limit on services days	Prior Approval Required	Reimbursement Methodology
United States	Yes - 56 No - 0		Yes - 28 No - 28
Alabama	Yes	CN	$50/admission	16 days/year for other than pregnancy-related services		Capitated per eligible per month payment or prospective cost based payment with rate ceilings
Alaska	Yes	CN	$50/day up to $200/admission	LOS limited to 50th percentile of published guidelines for Region	Non emergency admissions except maternity, admissions for specified procedures, LOS greater than 3 days	Prospective cost based per diem
American Samoa	Yes	See territory-specific FN
Arizona	Yes	CN & MN			Non-emergency admissions (including psych) except maternity, emergency admissions more than 3 days, ICU care more than 1 day	Prospective tiered per diem, psych admissions paid all-inclusive per diem
Arkansas	Yes	CN & MN	10% of first day's per diem rate up to specified limit	24 days/year	Admissions for specified procedures, elective surgery admissions	Cost based payment for pediatric, teaching and critical access hospitals; cost based payment with daily cap for other acute hospitals; prospective per diem for rehab hospitals
California	Yes	CN & MN		Limitations vary by type of admission and services rendered		Competitively bid rate, negotiated rate, contracted capitation rate or prospective all-inclusive rate using historical costs and peer groups
Colorado	Yes	CN	$10/day up to 50% of payment for first day of care	Second opinions required for specified procedures, 45 day LOS for psych admissions unless court-ordered	Admissions for specified procedures, elective surgery admissions	Prospective payment/discharge using DRG or prospective per diem
Connecticut	Yes	CN & MN			Non-emergency admissions except maternity, emergency readmissions within 2 days of discharge	Cost based payment
Delaware	Yes	CN		30 inpatient psychiatric treatment days/year		Prospective payment/discharge or prospective per diem for psych, rehab and other special hospitals/units
District of Columbia	Yes	CN & MN		Cosmetic and oral surgery limited to emergency repair due to injury or trauma, pre-surgical days limited to 1 unless medically justified, weekend admissions must be medically justified		Prospective payment/discharge using DRG and peer group adjustment or percentage of charge for specific hospitals and services
Florida	Yes	CN & MN	$3/admission	45 days/year	Non-emergency admissions	Prospective cost based per diem with limits, admissions for organ transplants paid a global fee
Georgia	Yes	CN & MN	$12.50/non-emergency admission	Transplants of some organs not covered, LOS 30 days for psych care, rehab stays unrelated to acute illness or injury not covered	Non-emergency admissions except maternity	Prospective payment/discharge using DRG
Guam	Yes	CN		LOS limited to 60 days		Negotiated rate/service
Hawaii	Yes	CN & MN		Psych services limited to 30 days/year, LOS limited by state's Utilization Review authority, tissue and organ transplants limited to Medicare-certified transplant facilities		Prospective cost based payment
Idaho	Yes	CN			Elective surgery admissions	Cost based payment
Illinois	Yes	CN & MN	$2-$3/day unless per diem less than $275	Pre-surgical days limited to 1 unless medically justified, admissions and LOS limited by State's Utilization Review authority, second opinion required for specified procedures	Admissions for specified procedures safely rendered on outpatient basis, physical rehab services	Prospective payment/discharge using DRG or prospective per diem for psych and rehab hospitals/units or facility-specific per diem for other special hospitals/units including certain government-operated facilities and children's hospitals
Indiana	Yes	CN		Second opinions required for specified procedures, LOS less than 24 hours considered outpatient except for newborns, substance abuse treatment limited to detoxification	Specified admissions, including to rehab and burn centers	Prospective payment/discharge using DRG, prospective per diem for rehab and burn centers
Iowa	Yes	CN & MN		LOS limited to 50th percentile of published guidelines for Region	Non-emergency admissions, including dental and excluding maternity	Prospective payment/discharge using DRG
Kansas	Yes	CN & MN	$48/admission	Elective surgery limited to sterilizations, rehab therapies must be restorative and post-trauma, transplants of some organs not covered, psych care limited to daily therapy, substance abuse limited to detox		Prospective payment/discharge using DRG or percentage of charge for specific hospitals and services
Kentucky	Yes	A, B & C - See state-specific FN	A - $50/admission, B & C - $10/admission	Admissions limited to maternity and management of acute or chronic illness or injury that can't be rendered on outpatient basis	Admissions for specified procedures safely rendered on outpatient basis, elective admissions	Prospective payment/discharge using DRG
Louisiana	Yes	CN & MN		LOS in specified hospitals limited by state's Utilization Review authority	Non-emergency admissions	Prospective per diem using peer groups, higher per diem for high intensity services
Maine	Yes	CN & MN	$3/day up to $30/month	All Medicare benefits/days must be exhausted before Medicaid is billed		Cost based payment per discharge with limits
Maryland	Yes	CN & MN		LOS limited by state's Utilization Review authority, 2 therapeutic leaves of less than 12 hours/admission	Elective admissions	Cost based payment
Massachusetts	Yes	CN & MN	$3/admission		Admissions for specified procedures safely rendered on outpatient basis	Prospective payment/discharge using statewide average cost adjusted for case mix, prospective cost based per diem for specified hospitals/units
Michigan	Yes	CN & MN	$50/first day of admission - see state-specific FN		Elective admissions, readmissions within 15 days, non-emergency transfers	Prospective payment/discharge using DRG, prospective per diem for psych hospitals/units
Minnesota	Yes	A & B - See state-specific FN		B1 - $10,000 annual limit- See state-specific FN		Prospective payment/discharge using DRG
Mississippi	Yes	CN	$10/day	30 days/year, including emergency admissions	Non-emergency admissions except maternity	Prospective cost based per diem, with limits
Missouri	Yes	CN	$10/admission, except emergencies and transfers	LOS limited to 75th percentile of published guidelines for Region or days certified by state's Utilization Review authority, special schedule for rehab services	Admissions for specified surgical procedures	Prospective cost based per diem or reasonable charge
Montana	Yes	A & B - See state-specific FN	$100/admission			Cost based payment using Medicare principles for critical access hospitals, prospective payment/discharge using APR-DRG for all others
Nebraska	Yes	CN & MN		Psych services limited to approved facilities		Prospective payment/discharge using DRG and peer groups, cost based payment for critical access hospitals, prospective cost based per diem for psych and rehab hospitals/units
Nevada	Yes	CN		Continuing stay authorizations required	Non-emergency admissions except maternity	Prospective all-inclusive per diem by type of admission, cost based payment for critical access hospitals and hospital LTC units, swing beds paid statewide average nursing facility per diem
New Hampshire	Yes	CN & MN		LOS limited by state's Utilization Review authority, transplants limited to approved facilities and 2 transplants of same type/lifetime	Admissions for specified purposes	Prospective payment/discharge using DRG, payment ceiling for transplants
New Jersey	Yes	CN & MN - See state-specific FN		Specified procedures require a second opinion	Admissions for specified procedures and LOS	Prospective payment/discharge using DRG
New Mexico	Yes	CN	A - $25/admission, B - $30/admission - see state-specific FN			Prospective payment/discharge using DRG for general acute care hospitals, cost based payment with limits for rehab and specialty hospitals
New York	Yes	CN & MN	$25/admission			Prospective payment/discharge using DRG, prospective per diem for specialty hospitals/units, some services may be paid on a fee for service basis
North Carolina	Yes	CN & MN		3 administrative leave days to facilitate transfer to less restrictive setting	Elective admissions and other specified services	Prospective payment/discharge using DRG or prospective per diem
North Dakota	Yes	CN & MN	$75/admission	30 days for rehab, 21 days for psych	Transfers to LTC hospitals	Prospective payment/discharge using DRG and peer groups, prospective per diem for psych and rehab services, prospective percentage of charge payment for long-stay hospitals, cost based payment for critical access hospitals
Northern Mariana Islands	Yes	CN & MN - See territory-specific FN
Ohio	Yes	CN				Prospective payment/discharge using DRG and peer groups, facility specific rates for children's hospitals, cost based payment for LTC, rehab and cancer hospitals
Oklahoma	Yes	CN	$3/day up to $90/admission			Prospective payment/discharge using DRG
Oregon	Yes	A & B - See state-specific FN	A - $3/admission	A & B - specified procedures require a second opinion, B - limited to admissions for urgent or emergency medical care only	Non-emergency transfers, readmissions for specified services	Prospective payment/discharge using DRG, cost based payment for small hospitals
Pennsylvania	Yes	CN & MN	$3/day up to $21/admission	1 med rehab admission/year, 30 days psychiatric care/year, non-emergency weekend admissions must have procedures same or next day, medical/surgical patients limited to 2 periods of therapeutic leave/month of no more than 12 hours/day	Specified non-emergency admissions	Prospective payment/discharge using DRG, rehab hospitals/units and psych units paid prospective per diem, cost based payment for alcohol detox units
Puerto Rico	Yes	CN & MN			Specified services	All-inclusive per diem
Rhode Island	Yes	CN & MN - see state-specific FN			Admissions for state specified procedures	Negotiated prospective cost based payment with a ceiling on allowable cost increases
South Carolina	Yes	CN	$25/admission			Prospective payment/discharge using DRG or prospective per diem
South Dakota	Yes	CN	$50/non-emergency admission	Cosmetic surgery must be post-trauma, substance abuse treatment not covered	Admissions to DRG-exempt hospitals/units	Prospective payment/discharge using DRG, cost based payment for psych, rehab and other special hospitals/units
Tennessee	Yes	A & B - See state-specific FN	B1 - $100/admission, B2 - $200/admission	10 days detoxification treatment/lifetime with $30,000 limit/lifetime on inpatient and outpatient drug and alcohol treatment, inpatient rehab hospital services not covered
Texas	Yes	CN & M		$200,000/year, LOS limited to 30 days in a 90-day period	Admissions for specified procedures	Prospective payment/discharge using DRG and peer groups
Utah	Yes	A & B - See state-specific FN	A - $220/year for non-emergency admissions, B - $220/non-emergency admission is also annual limit	B - psych and substance abuse admissions limited to 30 days/year irrespective of setting, specified surgical procedures not covered	B - specified non-emergency admissions or complications from non-covered surgery	Prospective payment/discharge using DRG for most urban hospitals, enhanced DRG payment for children's hospitals, rural and psych hospitals paid percentage of charge, cost based payment for state-owned hospital
Vermont	Yes	A & B - See state-specific FN	A - $75/admission		Admissions for specified purposes	Prospective payment/discharge using DRG
U.S. Virgin Islands	Yes	CN		Services in public health facilities only		Prospective all-inclusive per diem up to Medicare cost ceiling
Virginia	Yes	CN & MN	$100/non-emergency admission	Admissions for specified procedures safely rendered on outpatient basis, weekend admissions and days before elective surgery must be medically justified; psych admissions limited to 21 days in two months for same diagnosis	Non-emergency admissions	Prospective payment/discharge using DRG for acute care; prospective per diem for psych, rehab and other special hospitals/units
Washington	Yes	CN & MN		LOS limited to medically necessary days per InterQual IS/SI criteria if admission not paid under DRG method, elective admissions in specified areas of state restricted to contracted hospitals		Prospective payment/discharge using DRG or per diem, cost based payment for critical access hospitals using prospective percentage of charges
West Virginia	Yes	A, B & C		A, B & C - inpatient rehab not covered, A & B - psych admissions limited to acute care facilities, B - psych admissions to distinct part psych unit limited to 30 days/year	Yes	Prospective payment/discharge using DRG, transplants paid DRG up to ceiling, critical access hospitals paid Medicare per diem rates
Wisconsin	Yes	CN & MN	$3/day up to $75/admission	Weekend admissions limited to hospitals providing full services every day	Admissions for specified procedures	Prospective payment/discharge using DRG, prospective per diem for rehab hospitals/units and for specified conditions
Wyoming	Yes	CN				Prospective payment/discharge based on LOC at admission

2006

Location	Benefit Covered	Coverage Code	Copayment Required?	Limit on services days	Prior Approval Required	Reimbursement Methodology
United States	Yes - 56 No - 0		Yes - 28 No - 28
Alabama	Yes	CN	$50/admission	16 days/year for other than pregnancy-related services		Capitated per eligible per month payment or prospective cost based payment with rate ceilings
Alaska	Yes	CN	$50/day up to $200/admission	LOS limited to 50th percentile of published guidelines for Region, vaginal delivery LOS 2 days, C-section delivery LOS 4 days, heart transplants not covered	Non emergency admissions except maternity, admissions for specified procedures, LOS greater than 3 days	Prospective cost based per diem
American Samoa	Yes	See territory-specific FN
Arizona	Yes	CN & MN			Non-emergency admissions (including psych) except maternity, emergency admissions more than 3 days, ICU care more than 1 day	Prospective tiered per diem, psych admissions paid all-inclusive per diem
Arkansas	Yes	CN & MN	10% of first day's per diem rate up to specified limit	24 days/year	Admissions for specified procedures, elective surgery admissions	Cost based payment for pediatric, teaching and critical access hospitals; cost based payment with daily cap for other acute hospitals; prospective per diem for rehab hospitals
California	Yes	CN & MN		Limitations vary by type of admission and services rendered		Competitively bid rate, negotiated rate, contracted capitation rate or prospective all-inclusive rate using historical costs and peer groups
Colorado	Yes	CN	$10/day up to 50% of payment for first day of care	Second opinions required for specified procedures, 45 day LOS for psych admissions unless court-ordered	Admissions for specified procedures, elective surgery admissions	Prospective payment/discharge using DRG or prospective per diem
Connecticut	Yes	CN & MN			Non-emergency admissions except maternity, emergency readmissions within 2 days of discharge	Cost based payment
Delaware	Yes	CN		30 inpatient psychiatric treatment days/year		Prospective payment/discharge or prospective per diem for psych, rehab and other special hospitals/units
District of Columbia	Yes	CN & MN		Cosmetic and oral surgery limited to emergency repair due to injury or trauma, pre-surgical days limited to 1 unless medically justified, weekend admissions must be medically justified		Prospective payment/discharge using DRG and peer group adjustment or percentage of charge for specific hospitals and services
Florida	Yes	CN & MN	$3/admission	45 days/year	Non-emergency admissions	Prospective cost based per diem with limits, admissions for lung transplants paid a global fee
Georgia	Yes	CN & MN	$12.50/non-emergency admission	Transplants of some organs not covered, LOS 30 days for psych care, rehab stays unrelated to acute illness or injury not covered	Non-emergency admissions except maternity	Prospective payment/discharge using DRG
Guam	Yes	CN		LOS limited to 60 days		Negotiated rate/service
Hawaii	Yes	CN & MN		Psych services limited to 30 days/year, LOS limited by state's Utilization Review authority, tissue and organ transplants limited to Medicare-certified transplant facilities	Administrative days while awaiting nursing facility placement, substitution of 1 unused inpatient day for 2 additional outpatient treatment days/year	Prospective cost based payment system using peer groups
Idaho	Yes	CN			Elective surgery admissions	Cost based payment
Illinois	Yes	CN & MN	$2-$3/day unless per diem less than $275	Pre-surgical days limited to 1 unless medically justified, admissions and LOS limited by State's Utilization Review authority, second opinion required for specified procedures	Admissions for specified procedures safely rendered on outpatient basis, physical rehab services	Prospective payment/discharge using DRG or prospective per diem for psych and rehab hospitals/units or facility-specific per diem for other special hospitals/units including certain government-operated facilities and children's hospitals
Indiana	Yes	CN		Second opinions required for specified procedures, LOS less than 24 hours considered outpatient except for newborns, substance abuse treatment limited to detoxification		Prospective payment/discharge using DRG, prospective per diem for psych, rehab and burn centers
Iowa	Yes	CN & MN		LOS limited to 50th percentile of published guidelines for Region	Non-emergency admissions, including dental and excluding maternity	Prospective payment/discharge using DRG
Kansas	Yes	CN & MN	$48/admission	Elective surgery limited to sterilizations, rehab therapies must be restorative and post-trauma, transplants of some organs not covered, psych care limited to daily therapy, substance abuse limited to detox		Prospective payment/discharge using DRG or percentage of charge for specific hospitals and services
Kentucky	Yes	A, B & C - See state-specific FN	A - $50/admission, B & C - $10/admission	Admissions limited to maternity and management of acute or chronic illness or injury that can't be rendered on outpatient basis	Admissions for specified procedures safely rendered on outpatient basis, elective admissions	Prospective payment/discharge using DRG
Louisiana	Yes	CN & MN		LOS in specified hospitals limited by state's Utilization Review authority	Non-emergency admissions	Prospective per diem using peer groups, higher per diem for high intensity services
Maine	Yes	CN & MN	$3/day up to $30/month	All Medicare benefits/days must be exhausted before Medicaid is billed		Cost based payment per discharge with limits
Maryland	Yes	CN & MN		LOS limited by state's Utilization Review authority, 2 therapeutic leaves of less than 12 hours/admission	Elective admissions	Cost based payment
Massachusetts	Yes	CN & MN	$3/admission		Admissions for specified procedures safely rendered on outpatient basis	Prospective payment/discharge using statewide average cost adjusted for case mix, prospective cost based per diem for specified hospitals/units
Michigan	Yes	CN & MN	$50/first day of admission - see state-specific FN		Elective admissions, readmissions within 15 days, non-emergency transfers	Prospective payment/discharge using DRG, prospective per diem for psych hospitals/units
Minnesota	Yes	A & B - See state-specific FN		B1 - $10,000 annual limit- See state-specific FN		Prospective payment/discharge using DRG
Mississippi	Yes	CN	$10/day	30 days/year, including emergency admissions	Non-emergency admissions except maternity	Prospective cost based per diem, with limits
Missouri	Yes	CN	$10/admission, except emergencies and transfers	LOS limited to 75th percentile of published guidelines for Region or days certified by state's Utilization Review authority	Admissions for specified surgical procedures	Prospective cost based per diem or reasonable charge
Montana	Yes	A & B - See state-specific FN	$100/admission			Prospective payment/discharge using DRG, cost based payment using Medicare principles for critical access hospitals, rehab and other special hospitals/units
Nebraska	Yes	CN & MN		Psych services limited to approved facilities		Prospective payment/discharge using DRG and peer groups, cost based payment for critical access hospitals, prospective cost based per diem for psych and rehab hospitals/units
Nevada	Yes	CN			Non-emergency admissions except maternity	Prospective all-inclusive per diem by type of admission, cost based payment for critical access hospitals and hospital LTC units, swing beds paid statewide average nursing facility per diem
New Hampshire	Yes	CN & MN		LOS limited by state's Utilization Review authority, transplants limited to approved facilities and 2 transplants of same type/lifetime		Prospective payment/discharge using DRG, payment ceiling for transplants
New Jersey	Yes	CN & MN - See state-specific FN		Specified procedures require a second opinion	Admissions for specified procedures and LOS	Prospective payment/discharge using DRG
New Mexico	Yes	CN	A - $25/admission, B - $30/admission - see state-specific FN			Prospective payment/discharge using DRG for general acute care hospitals, cost based payment with limits for rehab and specialty hospitals
New York	Yes	CN & MN	$25/admission			Prospective payment/discharge using DRG, prospective per diem for specialty hospitals/units
North Carolina	Yes	CN & MN		3 administrative leave days to facilitate transfer to less restrictive setting	Elective admissions and other specified services	Prospective payment/discharge using DRG or prospective per diem
North Dakota	Yes	CN & MN	$75/admission	30 days for rehab, 21 days for psych	Transfers to LTC hospitals	Prospective payment/discharge using DRG and peer groups, prospective per diem for psych and rehab services, prospective percentage of charge payment for long-stay hospitals, cost based payment for cancer and children's hospitals
Northern Mariana Islands	Yes	CN & MN - See territory-specific FN
Ohio	Yes	CN				Prospective payment/discharge using DRG and peer groups, facility specific rates for children's hospitals, cost based payment for LTC and rehab hospitals/units
Oklahoma	Yes	CN	$3/day up to $90/admission			Prospective payment/discharge using DRG
Oregon	Yes	A & B - See state-specific FN	A - $3/admission	A & B - specified procedures require a second opinion, B - limited to admissions for urgent or emergency medical care only	Non-emergency transfers, readmissions for specified services	Prospective payment/discharge using DRG, cost based payment for small hospitals
Pennsylvania	Yes	CN & MN	$3/day up to $21/admission	1 med rehab admission/year, 30 days psychiatric care/year, non-emergency weekend admissions must have procedures same or next day, medical/surgical patients limited to 2 periods of therapeutic leave/month of no more than 12 hours/day	Non-emergency substance abuse treatment	Prospective payment/discharge using DRG, rehab hospitals/units and psych units paid prospective per diem, cost based payment for alcohol detox units
Puerto Rico	Yes	CN & MN			Specified services	All-inclusive per diem
Rhode Island	Yes	CN & MN - see state-specific FN			Admissions for state specified procedures	Negotiated prospective cost based payment with a ceiling on allowable cost increases
South Carolina	Yes	CN	$25/admission			Prospective payment/discharge using DRG or prospective per diem
South Dakota	Yes	CN	$50/non-emergency admission	Cosmetic surgery must be post-trauma, substance abuse treatment not covered	Admissions to DRG-exempt hospitals/units	Prospective payment/discharge using DRG, cost based payment for psych, rehab and other special hospitals/units
Tennessee	Yes	A & B - See state-specific FN	B1 - $100/admission, B2 - $200/admission	10 days detoxification treatment/lifetime with $30,000 limit/lifetime on inpatient and outpatient drug and alcohol treatment, inpatient rehab hospital services not covered
Texas	Yes	CN & M		$200,000/year, LOS limited to 30 days/episode except LOS for transplants 60 days, OT not covered	Admissions for specified procedures	Prospective payment/discharge using DRG and peer groups
Utah	Yes	A & B - See state-specific FN	A - $220/year for non-emergency admissions, B - $220/non-emergency admission	B - psych and substance abuse admissions limited to 30 days/year irrespective of setting, specified surgical procedures not covered	B - specified non-emergency admissions or complications from non-covered surgery	Prospective payment/discharge using DRG for most urban hospitals, enhanced DRG payment for children's hospitals, rural and psych hospitals paid percentage of charge, cost based payment for state-owned hospital
Vermont	Yes	A & B - See state-specific FN	A - $75/admission	B - only urgent and emergency medical/surgical admissions covered	Admissions for specified purposes	Prospective per diem
U.S. Virgin Islands	Yes	CN		Services in public health facilities only		Prospective all-inclusive per diem up to Medicare cost ceiling
Virginia	Yes	CN & MN	$100/admission	Admissions for specified procedures safely rendered on outpatient basis, weekend admissions and days before elective surgery must be medically justified; psych admissions not covered for adults	Non-emergency admissions	Prospective payment/discharge using DRG for acute care; prospective per diem for psych, rehab and other special hospitals/units
Washington	Yes	CN & MN		LOS limited to medically necessary days per InterQual IS/SI criteria if admission not paid under DRG method, elective admissions in specified areas of state restricted to contracted hospitals		Prospective payment/discharge using DRG, some hospitals paid prospective percentage of charge, cost based payment for critical access hospitals
West Virginia	Yes	CN & MN				Prospective payment/discharge using DRG, transplants paid DRG up to ceiling, critical access hospitals paid Medicare per diem
Wisconsin	Yes	CN & MN	$3/day up to $75/admission	Weekend admissions limited to hospitals providing full services every day	Admissions for specified procedures	Prospective payment/discharge using DRG, prospective per diem for rehab hospitals/units and for specified conditions
Wyoming	Yes	CN				Prospective payment/discharge based on LOC, negotiated rates for specialty care

2004

Location	Benefit Covered	Coverage Code	Copayment Required?	Limit on services days	Prior Approval Required	Reimbursement Methodology
United States	Yes - 56 No - 0		Yes - 24 No - 32
Alabama	Yes	CN	$50/admission	16 days/year for other than pregnancy-related services		Capitated per eligible per month payment or prospective cost based payment with rate ceilings
Alaska	Yes	CN	$50/day up to lesser of $200/admission or 50% of first day's payment	LOS limited to 50th percentile of published guidelines for Region, vaginal delivery LOS 2 days, C-section delivery LOS 4 days, heart transplants not covered	Non emergency admissions except maternity, admissions for specified procedures, LOS greater than 3 days	Prospective cost based per diem
American Samoa	Yes	See territory-specific FN
Arizona	Yes	CN & MN			Non-emergency admissions (including psych) except maternity, emergency admissions more than 3 days, ICU care more than 1 day	Prospective tiered per diem, psych admissions paid all-inclusive per diem
Arkansas	Yes	CN & MN	10% of first day's per diem rate up to specified limit	24 days/year	Admissions for specified procedures, elective surgery admissions	Cost based payment for pediatric, teaching and critical access hospitals; cost based payment with daily cap for other acute hospitals; prospective per diem for rehab hospitals
California	Yes	CN & MN		Limitations vary by type of admission and services rendered		Competitively bid rate, negotiated rate, contracted capitation rate or prospective all-inclusive rate using historical costs and peer groups
Colorado	Yes	CN	$10/day up to 50% of payment for first day of care	Second opinions required for specified procedures, 45 day LOS for psych admissions unless court-ordered	Admissions for specified procedures, elective surgery admissions	Prospective payment/discharge using DRG or prospective per diem
Connecticut	Yes	CN & MN		Weekend admissions must be medically justified	Non-emergency admissions except maternity, emergency readmissions within 2 days of discharge	Cost based payment
Delaware	Yes	CN				Prospective payment/discharge or prospective per diem for psych, rehab and other special hospitals/units
District of Columbia	Yes	CN & MN		Cosmetic and oral surgery limited to emergency repair due to injury or trauma, pre-surgical days limited to 1 unless medically justified, weekend admissions must be medically justified		Prospective payment/discharge using DRG and peer group adjustment or percentage of charge for specific hospitals and services
Florida	Yes	CN & MN	$3/admission	45 days/year	Non-emergency admissions	Prospective cost based per diem, with limits
Georgia	Yes	CN & MN	$12.50/non-emergency admission	Transplants of some organs not covered, LOS 30 days for psych care, rehab stays unrelated to acute illness or injury not covered	Non-emergency admissions except maternity	Prospective payment/discharge using DRG
Guam	Yes	CN		LOS limited to 60 days		Negotiated rate/service
Hawaii	Yes	CN & MN		Psych services limited to 30 days/year, LOS limited by state's Utilization Review authority	Administrative days while awaiting nursing facility placement, substitution of 1 unused inpatient day for 2 additional outpatient treatment days/year	Prospective cost based payment system using peer groups
Idaho	Yes	CN			Elective surgery admissions	Cost based payment
Illinois	Yes	CN & MN	$2-$3/day unless per diem less than $275	Pre-surgical days limited to 1 unless medically justified, admissions and LOS limited by State's Utilization Review authority, second opinion required for specified procedures	Admissions for specified procedures safely rendered on outpatient basis, physical rehab services	Prospective payment/discharge using DRG or prospective per diem for psych and rehab hospitals/units or facility-specific per diem for other special hospitals/units including certain government-operated facilities and children's hospitals
Indiana	Yes	CN		Second opinions required for specified procedures, LOS less than 24 hours considered outpatient except for newborns, substance abuse treatment limited to detoxification		Prospective payment/discharge using DRG, prospective per diem for psych, rehab and burn centers
Iowa	Yes	CN & MN		LOS limited to 50th percentile of published guidelines for Region	Non-emergency admissions, including dental and excluding maternity	Prospective payment/discharge using DRG
Kansas	Yes	CN & MN	$48/admission	Elective surgery limited to sterilizations, rehab therapies must be restorative and post-trauma, transplants of some organs not covered, psych care limited to daily therapy, substance abuse limited to detox		Prospective payment/discharge using DRG or percentage of charge for specific hospitals and services
Kentucky	Yes	CN & MN		Admissions limited to maternity and management of acute or chronic illness or injury that can't be rendered on outpatient basis	Admissions for specified procedures safely rendered on outpatient basis, elective admissions	Prospective payment/discharge using DRG
Louisiana	Yes	CN & MN		LOS in specified hospitals limited by state's Utilization Review authority	Non-emergency admissions	Prospective per diem using peer groups, higher per diem for high intensity services
Maine	Yes	CN & MN	$3/day up to $30/month	All Medicare benefits/days must be exhausted before Medicaid is billed		Cost based payment per discharge with limits
Maryland	Yes	CN & MN		LOS limited by state's Utilization Review authority, 2 therapeutic leaves of less than 12 hours/admission	Elective admissions	Cost based payment
Massachusetts	Yes	CN & MN	$3/admission		Admissions for specified procedures safely rendered on outpatient basis	Prospective payment/discharge using statewide average cost adjusted for case mix, prospective cost based per diem for specified hospitals/units
Michigan	Yes	CN & MN			Elective admissions, readmissions within 15 days, non-emergency transfers	Prospective payment/discharge using DRG, prospective per diem for psych hospitals/units
Minnesota	Yes	A & B - See state-specific FN		B1 - $10,000 annual limit - See state-specific FN		Prospective payment/discharge using DRG
Mississippi	Yes	CN	$10/day up to half of first day's per diem/admission	30 days/year, including emergency admissions	Non-emergency admissions except maternity	Prospective cost based per diem, with limits
Missouri	Yes	CN	$10/admission, except emergencies and transfers	LOS limited to 75th percentile of published guidelines for Region or days certified by state's Utilization Review authority	Admissions for specified surgical procedures	Prospective cost based per diem or reasonable charge
Montana	Yes	A & B - See state-specific FN	$100/admission			Prospective payment/discharge using DRG, cost based payment using Medicare principles for critical access hospitals, rehab and other special hospitals/units
Nebraska	Yes	CN & MN		Psych services limited to approved facilities		Prospective payment/discharge using DRG and peer groups, cost based payment for critical access hospitals, prospective cost based per diem for psych and rehab hospitals/units
Nevada	Yes	CN			Non-emergency admissions except maternity	Prospective all-inclusive per diem by type of admission, cost based payment for critical access hospitals and hospital LTC units, swing beds paid statewide average nursing facility per diem
New Hampshire	Yes	CN & MN		LOS limited by state's Utilization Review authority, transplants limited to approved facilities and 2 transplants of same type/lifetime		Prospective payment/discharge using DRG, payment ceiling for transplants
New Jersey	Yes	CN & MN - See state-specific FN		Specified procedures require a second opinion	Admissions for specified procedures and LOS	Prospective payment/discharge using DRG
New Mexico	Yes	CN	B - $30/admission - see state-specific FN			Prospective payment/discharge using DRG for general acute care hospitals, cost based payment with limits for rehab and specialty hospitals
New York	Yes	CN & MN	$25/admission			Prospective payment/discharge using DRG, prospective per diem for specialty hospitals/units
North Carolina	Yes	CN & MN		3 administrative leave days to facilitate transfer to less restrictive setting	Elective admissions and other specified services	Prospective payment/discharge using DRG or prospective per diem
North Dakota	Yes	CN & MN	$75/admission	30 days for rehab, 21 days for psych	Transfers to LTC hospitals	Prospective payment/discharge using DRG and peer groups, prospective per diem for psych and rehab services, prospective percentage of charge payment for long-stay hospitals, cost based payment for cancer and children's hospitals
Northern Mariana Islands	Yes	CN & MN - See territory-specific FN
Ohio	Yes	CN				Prospective payment/discharge using DRG and peer groups, facility specific rates for children's hospitals, cost based payment for LTC and rehab hospitals/units
Oklahoma	Yes	CN	$3/day			Prospective payment/discharge using DRG
Oregon	Yes	A & B - See state-specific FN	A - $3/admission	A & B - specified procedures require a second opinion, B - limited to admissions for urgent or emergency medical care only	Non-emergency transfers, readmissions for specified services	Prospective payment/discharge using DRG, cost based payment for small hospitals
Pennsylvania	Yes	CN & MN	$3/day up to $21/admission	Non-emergency weekend admissions must have procedures same or next day, medical/surgical patients limited to 2 periods of therapeutic leave/month of no more than 12 hours/day	Non-emergency substance abuse treatment	Prospective payment/discharge using DRG, rehab hospitals/units and psych units paid prospective per diem, cost based payment for alcohol detox units
Puerto Rico	Yes	CN & MN			Specified services	All-inclusive per diem
Rhode Island	Yes	CN & MN - see state-specific FN			Admissions for state specified procedures	Negotiated prospective cost based payment with a ceiling on allowable cost increases
South Carolina	Yes	CN	$25/admission			Prospective payment/discharge using DRG or prospective per diem
South Dakota	Yes	CN		Cosmetic surgery must be post-trauma, substance abuse treatment not covered	Admissions to DRG-exempt hospitals/units	Prospective payment/discharge using DRG, cost based payment for psych, rehab and other special hospitals/units
Tennessee	Yes	A & B - See state-specific FN	B1 - $100/admission, B2 - $200/admission
Texas	Yes	CN & M		$200,000/year, LOS limited to 30 days/episode except LOS for transplants 60 days, OT not covered	Admissions for dental procedures under age 21	Prospective payment/discharge using DRG and peer groups
Utah	Yes	A & B - See state-specific FN	B - $220/admission	B - psych and substance abuse admissions limited to 30 days/year irrespective of setting, specified surgical procedures not covered	B - specified non-emergency admissions or complications from non-covered surgery	Prospective payment/discharge using DRG for most urban hospitals, enhanced DRG payment for children's hospitals, rural and psych hospitals paid percentage of charge, cost based payment for state-owned hospital
Vermont	Yes	A & B - See state-specific FN		B - Only urgent and emergency admissions covered	Some surgery, some psych admissions	Prospective per diem using peer groups and dependent on hospital participation status
U.S. Virgin Islands	Yes	CN		Services in public health facilities only		Prospective all-inclusive per diem up to Medicare cost ceiling
Virginia	Yes	CN & MN	$100/admission	Admissions for specified procedures safely rendered on outpatient basis, weekend admissions and days before elective surgery must be medically justified; psych admissions not covered for adults		Prospective payment/discharge using DRG; prospective per diem for psych, rehab and other special hospitals/units
Washington	Yes	CN & MN		LOS limited to medically necessary days per InterQual IS/SI criteria if admission not paid under DRG method, elective admissions in specified areas of state restricted to contracted hospitals		Prospective payment/discharge using DRG, some hospitals paid prospective percentage of charge, cost based payment for critical access hospitals
West Virginia	Yes	CN & MN			Yes	Prospective payment/discharge using DRG, transplants paid DRG up to ceiling, critical access hospitals paid Medicare per diem rates
Wisconsin	Yes	CN & MN	$3/day up to $75/admission	Weekend admissions limited to hospitals providing full services every day	Admissions for specified procedures	Prospective payment/discharge using DRG, prospective per diem for rehab hospitals/units and for specified conditions
Wyoming	Yes	CN				Prospective payment/discharge based on LOC, negotiated rates for specialty care

2003

Location	Benefit Covered	Coverage Code	Copayment Required?	Limit on services days	Prior Approval Required	Reimbursement Methodology
United States	Yes - 56 No - 0		Yes - 22 No - 34
Alabama	Yes	CN	$50/admission	16 days/year		Prospective cost based per diem or reasonable charge
Alaska	Yes	CN	$50/day up to $200/admission	LOS limited to 50th percentile of published guidelines for Region, vaginal delivery LOS 2 days, C-section delivery LOS 4 days, heart transplants not covered	Non emergency admissions except maternity, admissions for specified procedures	Prospective cost based per diem
American Samoa	Yes	See territory-specific FN
Arizona	Yes	CN & MN			Non-emergency admissions (including psych) except maternity, emergency admissions more than 3 days, ICU care more than 1 day	Prospective tiered per diem, psych admissions paid all-inclusive per diem
Arkansas	Yes	CN & MN	10% of first day's per diem rate up to specified limit	24 days/year	Admissions for specified procedures, elective surgery admissions	Cost based payment for pediatric, teaching and critical access hospitals; cost based payment with daily cap for other acute hospitals; prospective per diem for rehab hospitals
California	Yes	CN & MN		Limitations vary by type of admission and services rendered		Competitively bid rate or prospective all-inclusive rate using historical costs and peer groups
Colorado	Yes	CN	$15/admission	Second opinions required for specified procedures, 45 day LOS for psych admissions	Admissions for specified procedures, elective surgery admissions	Prospective payment/discharge using DRG or prospective per diem
Connecticut	Yes	CN & MN		Weekend admissions must be medically justified	Non-emergency admissions except maternity, emergency readmissions within 2 days of discharge	Cost based payment
Delaware	Yes	CN				Prospective payment/discharge or prospective per diem for psych, rehab and other special hospitals/units
District of Columbia	Yes	CN & MN		Cosmetic and oral surgery limited to emergency repair due to injury or trauma, pre-surgical days limited to 1 unless medically justified, weekend admissions must be medically justified		Prospective payment/discharge using DRG and peer group adjustment or percentage of charge for specific hospitals and services
Florida	Yes	CN & MN	$3/admission	45 days/year	Non-emergency admissions	Prospective cost based per diem
Georgia	Yes	CN & MN	$12.50/non-emergency admission	Transplants of some organs not covered, LOS 30 days for psych care, rehab stays unrelated to acute illness or injury not covered	Non-emergency admissions except maternity	Prospective payment/discharge using DRG
Guam	Yes	CN		LOS limited to 60 days		Negotiated rate/service
Hawaii	Yes	CN & MN		Psych services limited to 30 days/year, LOS limited by state's Utilization Review authority	Administrative days while awaiting nursing facility placement, substitution of 1 unused inpatient day for 2 additional outpatient treatment days/year	Prospective cost based payment system using peer groups
Idaho	Yes	CN			Elective surgery admissions	Cost based payment
Illinois	Yes	CN & MN	$2-$3/day unless per diem less than $275	Pre-surgical days limited to 1 unless medically justified, admissions and LOS limited by State's Utilization Review authority, second opinion required for specified procedures	Admissions for specified procedures safely rendered on outpatient basis, physical rehab services	Prospective payment/discharge using DRG or prospective per diem for psych and rehab hospitals/units or facility-specific per diem for other special hospitals/units including certain government-operated facilities and children's hospitals
Indiana	Yes	CN		Second opinions required for specified procedures, substance abuse treatment limited to detoxification		Prospective payment/discharge using DRG, prospective per diem for psych, rehab and burn centers
Iowa	Yes	CN & MN		LOS limited to 50th percentile of published guidelines for Region	Non-emergency admissions, including dental and excluding maternity	Prospective payment/discharge using DRG
Kansas	Yes	CN & MN	$48/admission	Elective surgery limited to sterilizations, rehab therapies must be restorative and post-trauma, transplants of some organs not covered, psych care limited to daily therapy, substance abuse limited to detox		Prospective payment/discharge using DRG or percentage of charge for specific hospitals and services
Kentucky	Yes	CN & MN		Admissions limited to maternity and management of acute or chronic illness or injury that can't be rendered on outpatient basis	Admissions for specified procedures safely rendered on outpatient basis, elective admissions	Prospective payment/discharge using DRG
Louisiana	Yes	CN & MN		LOS in specified hospitals limited by state's Utilization Review authority	Non-emergency admissions	Prospective per diem using peer groups, higher per diem for high intensity services
Maine	Yes	CN & MN	$3/day up to $30/month	All Medicare benefits/days must be exhausted before Medicaid is billed		Cost based payment per discharge with limits
Maryland	Yes	CN & MN		LOS limited by state's Utilization Review authority, 2 therapeutic leaves of less than 12 hours/admission	Elective admissions	Cost based payment
Massachusetts	Yes	CN & MN			Admissions for specified procedures safely rendered on outpatient basis	Prospective payment/discharge using statewide average cost adjusted for case mix, prospective cost based per diem for specified hospitals/units
Michigan	Yes	CN & MN			Elective admissions, readmissions within 15 days, non-emergency transfers	Prospective payment/discharge using DRG, prospective per diem for psych hospitals/units
Minnesota	Yes	A & B - See state-specific FN		B1 - $10,000 annual limit - See state-specific FN		Prospective payment/discharge using DRG
Mississippi	Yes	CN	$10/day up to half of first day's per diem/admission	30 days/year, including emergency admissions	Non-emergency admissions except maternity	Prospective cost based per diem, with limits
Missouri	Yes	CN	$10/admission, except emergencies and transfers	LOS limited to 75th percentile of published guidelines for Region or days certified by state's Utilization Review authority	Admissions for specified surgical procedures	Prospective per diem, reasonable charge or percentage of charge for specific services
Montana	Yes	CN & MN	$100/admission			Prospective payment/discharge using DRG, cost based payment using Medicare principles for critical access hospitals, rehab and other special hospitals/units
Nebraska	Yes	CN & MN		Psych services limited to approved facilities		Prospective payment/discharge using DRG and peer groups, cost based payment for critical access hospitals, prospective cost based per diem for psych and rehab hospitals/units
Nevada	Yes	CN			Non-emergency admissions except maternity	Prospective all-inclusive payment/discharge by type of admission and LOS, prospective cost based per diem after 25 days, per diem or cost based payment for psych, rehab and other special hospitals/units
New Hampshire	Yes	CN & MN		LOS limited by state's Utilization Review authority, transplants limited to approved facilities and 2 transplants of same type/lifetime		Prospective payment/discharge using DRG, payment ceiling for transplants
New Jersey	Yes	CN & MN - See state-specific FN		Specified procedures require a second opinion	Admissions for specified procedures and LOS	Prospective payment/discharge using DRG
New Mexico	Yes	CN	B - $25/admission - see state-specific FN			Prospective payment/discharge using DRG for general acute care hospitals, cost based payment with limits for rehab and specialty hospitals
New York	Yes	CN & MN	$25/admission			Prospective payment/discharge using DRG, prospective per diem for specialty hospitals/units
North Carolina	Yes	CN & MN		3 administrative leave days to facilitate transfer to less restrictive setting	Elective admissions and other specified services	Prospective payment/discharge using DRG or prospective per diem
North Dakota	Yes	CN & MN	$50/admission	30 days for rehab, 21 days for psych	Transfers to LTC hospitals	Prospective payment/discharge using DRG and peer groups, prospective per diem for psych and rehab services, prospective percentage of charge payment for long-stay hospitals, cost based payment for cancer and children's hospitals
Northern Mariana Islands	Yes	CN & MN - See territory-specific FN
Ohio	Yes	CN				Prospective payment/discharge using DRG and peer groups, facility specific rates for children's hospitals, cost based payment for LTC and rehab hospitals/units
Oklahoma	Yes	CN & MN	$3/day	15 days/year, LOS in critical access hospitals limited to 96 hours		Prospective payment/discharge using DRG
Oregon	Yes	CN & MN		Specified procedures require a second opinion	Non-emergency transfers, readmissions for specified services	Prospective payment/discharge using DRG, cost based payment for small hospitals
Pennsylvania	Yes	CN & MN	$3/day up to $21/admission	Non-emergency weekend admissions must have procedures same or next day, medical/surgical patients limited to 2 periods of therapeutic leave/month of no more than 12 hours/day	Non-emergency substance abuse treatment	Prospective payment/discharge using DRG, rehab hospitals/units and psych units paid prospective per diem, cost based payment for alcohol detox units
Puerto Rico	Yes	CN & MN			Specified services	All-inclusive per diem
Rhode Island	Yes	CN & MN - see state-specific FN			Admissions for state specified procedures	Negotiated prospective cost based payment with a ceiling on allowable cost increases
South Carolina	Yes	CN				Prospective payment/discharge using DRG or prospective per diem
South Dakota	Yes	CN		Cosmetic surgery must be post-trauma, substance abuse treatment not covered	Admissions to DRG-exempt hospitals/units	Prospective payment/discharge using DRG, cost based payment for psych, rehab and other special hospitals/units
Tennessee	Yes	A & B - See state-specific FN	B1 - $100/admission B2 - $200/admission
Texas	Yes	CN & MN		$200,000/year, LOS limited to 30 days/episode except LOS for transplants 60 days, OT not covered	Admissions for dental procedures under age 21	Prospective payment/discharge using DRG and peer groups
Utah	Yes	A, B & C - See state specific FN	B - $100/admission	B - psych and substance abuse admissions limited to 30 days/year irrespective of setting, specified surgical procedures not covered	B - specified non-emergency admissions or complications from non-covered surgery	Prospective payment/discharge using DRG for most urban hospitals, enhanced DRG payment for children's hospitals, rural and psych hospitals paid percentage of charge, cost based payment for state-owned hospital
Vermont	Yes	A & B - See state-specific FN	$50/admission	B - Only urgent and emergency admissions covered	Some surgery, some psych admissions	Prospective per diem using peer groups and dependent on hospital participation status
U.S. Virgin Islands	Yes	CN		Services in public health facilities only		Prospective all-inclusive per diem up to Medicare cost ceiling
Virginia	Yes	CN & MN	$100/admission	Admissions for specified procedures safely rendered on outpatient basis, weekend admissions and days before elective surgery must be medically justified		Prospective payment/discharge using DRG; prospective per diem for psych, rehab and other special hospitals/units
Washington	Yes	CN & MN		LOS limited to medically necessary days per InterQual IS/SI criteria if admission not paid under DRG method, elective admissions in specified areas of state restricted to contracted hospitals		Prospective payment/discharge using DRG, some hospitals paid prospective percentage of charge, cost based payment for critical access hospitals
West Virginia	Yes	CN & MN			Non-emergency admissions except maternity	Prospective payment/discharge using DRG and urban/rural adjustment, adjusted rate for sole community hospitals, negotiated rates for transplant services
Wisconsin	Yes	CN & MN	$3/day up to $75/admission	Weekend admissions limited to hospitals providing full services every day	Admissions for specified procedures	Prospective payment/discharge using DRG, prospective per diem for rehab hospitals/units and for specified conditions
Wyoming	Yes	CN				Prospective payment/discharge based on LOC, negotiated rates for specialty care

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Medicaid Benefits: Inpatient Hospital Services, other than in an Institution for Mental Disease

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Medicaid Benefits: Inpatient Hospital Services, other than in an Institution for Mental Disease

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