Medicaid Benefits: Outpatient Hospital 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 - 12 | Included in "Limits on Services" for 2018 | Not included in 2018 survey |
| Alabama | Yes - Mandatory | CN | $3.90 each visit | No | - | - |
| Alaska | Yes - Mandatory | CN | 5% | Must be prior authorized | - | - |
| Arizona | Yes - Mandatory | CN | No | No | - | - |
| Arkansas | Yes - Mandatory | CN | NR | NR | - | - |
| California | Yes - Mandatory | CN | $5/non-emergency visit in ER, $1/visit for other services | No | - | - |
| Colorado | Yes - Mandatory | CN | $4 per visit; $6 per non-emergent ER visit | No | - | - |
| Connecticut | Yes - Mandatory | CN | No | prior authorization on a limited number of high risk/cost procedures | - | - |
| Delaware | Yes - Mandatory | CN | No | No | - | - |
| District of Columbia | Yes - Mandatory | CN | No | No | - | - |
| Florida | Yes - Mandatory | CN | Use of the hospital emergency department for non-emergency services: 5% of the first $300.00 of the Florida Medicaid payment (maximum $15.00) | $1500 annual max for some services | - | - |
| Georgia | Yes - Mandatory | CN | $3 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 authorization for specified services. | - | - |
| Iowa | Yes - Mandatory | CN | NR | NR | - | - |
| Kansas | Yes - Mandatory | CN | $3 per visit | No | - | - |
| Kentucky | Yes - Mandatory | CN | $4 | 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 | No | - | - |
| Massachusetts | Yes - Mandatory | CN | No | No | - | - |
| Michigan | Yes - Mandatory | CN | $1/visit, $3/Non-Emergency ER Visit | No | - | - |
| Minnesota | Yes - Mandatory | CN | NR | No | - | - |
| Mississippi | Yes - Mandatory | CN | $3 per visit | NR | - | - |
| Missouri | Yes - Mandatory | CN | $3 per visit | Lab services billed by outpatient hospital are limited to the max allowed quantity and reimbursed on a fee schedule. Radiology services billed by outpatient hospital require precertification and are reimbursed on a fee schedule. | - | - |
| Montana | Yes - Mandatory | CN | Income at or below 100% FPL - $4 per visit; above 100% FPL - 10% of payment amount | Criteria required for MRI/CT of Head/Brain; Prior Authorization required on some physician administered drugs and some outpatient surgical procedures | - | - |
| Nebraska | Yes - Mandatory | CN | $3 per visit | 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 | No | No | - | - |
| New York | Yes - Mandatory | CN | NR | NR | - | - |
| North Carolina | Yes - Mandatory | CN | $1 - $3 depending on the service | 2A-1 Acute Inpatient Policy-Observation hour limitations | - | - |
| North Dakota | Yes - Mandatory | CN | No | No | - | - |
| Ohio | Yes - Mandatory | CN | $3 for non-emergency services at an emergency department. | No | - | - |
| Oklahoma | Yes - Mandatory | CN | $4 per visit | There are a variety of services that fall under this category and they have their own set of limitations | - | - |
| 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 | Sliding scale based on the Medicaid fee for the service: $0.65 - $3.80 | No | - | - |
| Rhode Island | Yes - Mandatory | CN | No | No | - | - |
| South Carolina | Yes - Mandatory | CN | NR | NR | - | - |
| South Dakota | Yes - Mandatory | CN | 5% of Medicaid Payment | No | - | - |
| Tennessee | Yes - Mandatory | CN | No | No | - | - |
| Texas | Yes - Mandatory | CN | No | No | - | - |
| Utah | Yes - Mandatory | CN | $4 per date of service; $8 for non-emergent use of the ED | No | - | - |
| Vermont | Yes - Mandatory | CN | No | No | - | - |
| Virginia | Yes - Mandatory | CN | $3 per visit | NR | - | - |
| Washington | Yes - Mandatory | CN | No | Some surgeries, advanced imaging and lab require prior authorization | - | - |
| West Virginia | Yes - Mandatory | CN | $2 for those 50-100% FPL and $4 for those 100% FPL and above. Non-emergent use of ER is $8 for all FPL levels, unless meeting a population exclusion. Partial hospitalization services may only be rendered in settings authorized by the Bureau for Medical Services and subject to all prior authorization requirements and limitations. Physical and occupational therapy rendered in the hospital outpatient setting are also subject to prior authorization by the utilization management contractor. All outpatient services must be medically necessary for the diagnosis and/or treatment of an illness or injury and ordered by a physician or other practitioner acting within their licensure and/or scope of practice as defined by state law. | No | - | - |
| Wisconsin | Yes - Mandatory | CN | $3 per visit; no copayment for emergency room visits | A small number of services require prior approval | - | - |
| Wyoming | Yes - Mandatory | CN | $3.65 for non-emergent outpatient hospital visits | No | - | - |
2012
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 56 No - 0 | Yes - 37 No - 19 | ||||
| Alabama | Yes | CN | $3/non-emergency visit in ER | 3 non-emergency visits/year unless outpatient surgery, lab, dialysis, radiation or chemotherapy, non-emergency visit to ER counts toward both outpatient and physician visit limits | Fee for service | |
| Alaska | Yes | CN | 5% of payment for non-emergency services | Outpatient psych and substance abuse not covered | Specified surgical procedures | Prospective cost based rate using percentage of charge |
| American Samoa | Yes | See territory-specific FN | Most on-island services provided by LBJ Tropical Medical Center | |||
| Arizona | Yes | CN & MN | $2.30/visit for any outpatient therapy service | Coverage of outpatient OT and SP services limited to ALTCS members | Specified surgical procedures, rehab services | All-inclusive rate per episode of care using Medicare groupings for most surgical procedures or fee for service |
| Arkansas | Yes | CN & MN | 12 non-emergency visits/year | Specified surgical procedures | Cost based payment for pediatric, teaching and critical access hospitals; fee for service for other hospitals | |
| California | Yes | CN & MN | $5/non-emergency visit in ER, $1/visit for other services | Fee for service, state may negotiate all-inclusive per visit rates with certain hospitals and all-inclusive rates for adult day health care centers | ||
| Colorado | Yes | CN | $3/visit | Cost based payment | ||
| Connecticut | Yes | CN & MN | 1 visit/day | Fee for service or percentage of charge | ||
| Delaware | Yes | CN | Fee for service | |||
| District of Columbia | Yes | CN & MN | Cosmetic and oral surgery limited to emergency repair due to injury or trauma | Cost based payment | ||
| Florida | Yes | CN & MN | 5% of payment for non-emergency visit to ER, $3/visit for other outpatient services | 6 ER visits/year for non-pregnant adults, $1,500/year limit for non-emergency services (excluding labor/delivery, chemotherapy, dialysis and surgery) in combination with OT and PT | Prospective cost based per diem or rate per service, lab and x-ray services paid fee for service | |
| Georgia | Yes | CN & MN | $3/non-emergency visit | Observation limited to less than 24 hours | Specified procedures | Cost based payment using percentage of charge |
| Guam | Yes | CN | Non-emergency therapy services, CT-scans | Medicare interim payment rate | ||
| Hawaii | Yes | CN & MN | All-inclusive rate per episode of care using Medicare groupings for most surgical procedures or fee for service with limits | |||
| Idaho | Yes | CN | $3.65/visit up to 5% of income/year across all services, $3/non-emergency visit in ER | 6 ER visits/year if no admission, varying visit limits for therapies including psych which may be included in limits with other providers | Specified services | Fee for service using hospital cost as upper limit |
| Illinois | Yes | CN & MN | Fee for service or prospective rate/visit | |||
| Indiana | Yes | CN | Specified services | Fee for service, with surgical procedures grouped using Medicare methodology | ||
| Iowa | Yes | CN & MN | $3/non-emergency visit in ER | Varying visit limits for cardiac rehab, behavioral health and substance abuse, eating disorder and pain management therapies defined as non-inpatient programs | Fee for service, with surgical procedures grouped using Medicare methodology, ancillaries paid at Medicare rates | |
| Kansas | Yes | CN & MN | $3/non-emergency visit | Non-emergency visits count toward physician visit limit, rehab must be restorative | Fee for service | |
| Kentucky | Yes | A, B & C - See state-specific FN | $3/ambulatory visit; 5% of payment for non-emergency visit in ER up to $6 | Fee for service with surgical procedures grouped using Medicare methodology or cost based payment | ||
| Louisiana | Yes | CN & MN | 3 ER visits/year and count against physician visit limit, no limit for managed care enrollees | Rehab and specified surgeries | Cost based payment or fee for service | |
| Maine | Yes | CN & MN | $.50-$3/day, depending on payment, up to $30/month | Fee for service, with surgical procedures grouped using Medicare APC methodology and payment at 93% of Medicare rate | ||
| Maryland | Yes | CN & MN | Fee for service using rates approved by cost review commission | |||
| Massachusetts | Yes | CN & MN | Hospital-specific episode-based payment/day, excludes physician and lab services | |||
| Michigan | Yes | CN & MN | $3/non-emergency visit in ER, $1/hospital clinic visit | Prospective payment system using Medicare OPPS/APC methodology and a state-determined rate reduction factor | ||
| Minnesota | Yes | A & B - See state-specific FN | $3.50/non-emergency visit in ER | Payments based on Medicare methodology, cost based payment for critical access hospitals | ||
| Mississippi | Yes | CN | $3/non-emergency visit with some exceptions | Prospective payment system using Medicare OPPS/APC methodology | ||
| Missouri | Yes | CN | $3/day except emergency and therapy services | Specified services | Percentage of charge, fee for service for certain lab and radiology services | |
| Montana | Yes | A & B - See state-specific FN | $5/visit | Fee for service using Medicare APC methodology | ||
| Nebraska | Yes | CN & MN | $3/visit | No visit payable within 3 days of inpatient admission, substance abuse treatment not covered | Percentage of charge with limits, lab services paid fee for service, cost based payment for critical access hospitals | |
| Nevada | Yes | CN | Specified services | Fee for service with surgical procedures grouped using Medicare methodology | ||
| New Hampshire | Yes | CN & MN | 4 ER visits/year, visits for OT, PT and SP count toward the eighty 15-minute time units/year for therapy providers | Percentage of charge | ||
| New Jersey | Yes | CN & MN | Cost based payment | |||
| New Mexico | Yes | CN | A - $0-$7/non-emergency visit to ER, B - $20/non-emergency visit to ER and $7/visit for other services, A - ER copays waived for admissions - see state-specific FN | A - outpatient detox limited to 10 days/year | Prospective payment system based on Medicare methodology | |
| New York | Yes | CN & MN | $3/non-emergency visit | Beneficiary Specific Utilization Thresholds apply - see state-specific FN | Prospective payment using APGs | |
| North Carolina | Yes | CN & MN | $6/non-emergency visit to ER, $3/visit for other services | 22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature | More than 8 outpatient psych visits and any therapy services | Prospective cost based rate or fee for service settled annually to 80% allowable cost |
| North Dakota | Yes | CN & MN | $3/non-emergency visit in ER | 30 therapy visits/year included in limits for other providers of therapy services | Fixed percentage of charge | |
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Ohio | Yes | CN | $3/non-emergency visit in ER | Prospective payment with surgical procedure groupings paid by level, clinic and ER visit procedures paid by level, fee for service or percentage of charge for selected services | ||
| Oklahoma | Yes | CN | $3/visit | Outpatient behavioral health services not covered for nursing facility residents | Specified surgical procedures and other services | Fee for service using surgical group rates, ancillaries paid separately |
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Services limited to funded conditions on the priority list | Specified surgical and therapy procedures | Cost based payment with limits |
| Pennsylvania | Yes | CN & MN | $.65-$3.80/service, depending on payment rate, $.50/unit of psychotherapy service | Frequency limits vary by service | Fee for service | |
| Puerto Rico | Yes | CN & MN | $1/non-emergency visit | Elective surgery requires primary care physician referral | Service is included in the capitated rate paid to managed care plans | |
| Rhode Island | Yes | See state-specific FN | $3/non-emergency visit in ER | PT, OT and SP | Medicare reimbursement rates with adjustors and utilizing Ambulatory Payment Classification codes | |
| South Carolina | Yes | CN | $3.40/non-emergency visit | Fee for service | ||
| South Dakota | Yes | CN | 5% of payment up to $50/visit, non-emergency only | Substance abuse treatment not covered, cosmetic surgery limited to emergency repair due to injury or trauma | Cost based payment | |
| Tennessee | Yes | A, B & C - See state-specific FN | B1 - $10/ER visit if not admitted B2 - $50/ER visit if not admitted | See state-specific FN | ||
| Texas | Yes | CN & MN | Specified services | Cost based payment, prospective payment with surgical procedures grouped using Medicare methodology | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B - $6/non-emergency visit in ER and $3/non-preventive care visit, C - $30/non-emergency visit in ER and $5/visit for other care | A & B - outpatient psych and substance abuse services limited to 30 days/year and included in inpatient limit, C - services limited to emergency treatment in ER | Prospective payment system | |
| Vermont | Yes | A & B - See state-specific FN | A - $3/visit, B - $25/visit in ER | Fee for service, with surgical procedures grouped using Medicare methodology; lab procedures paid fee for service, using Medicare Relative Value Units and a state conversion factor; psych services paid on per diem basis | ||
| U.S. Virgin Islands | Yes | CN | Services in public health facilities only | Fee for service | ||
| Virginia | Yes | CN & MN | $3/non-emergency service | Limits vary by service | Specified services | Cost based payment with limits |
| Washington | Yes | CN & MN | $3/non-emergency visit in ER | Specified services | Most urban hospitals paid prospective cost based rates, rural hospitals paid prospective percentage of charge | |
| West Virginia | Yes | A, B & C | Specified surgical procedures and other services | Fee for service | ||
| Wisconsin | Yes | CN & MN | $3/visit | Outpatient psych services limited to 5 hours/day up to 120 hours/month and 40 hours/year for nursing facility residents; OT, PT and SP services must be billed as if rendered by the therapist and are reimbursed accordingly | Specified surgical procedures and other services | Cost based payment with limits |
| Wyoming | Yes | CN | $3.65/non-emergency visit in ER | 12 visits/year in combination with physician, nurse practitioner and clinic visits, therapy services must be restorative and are limited to 20 visits/year across all therapy providers | Payment based on Medicare Outpatient Prospective Payment System methodology |
2010
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 56 No - 0 | Yes - 36 No - 20 | ||||
| Alabama | Yes | CN | $3/non-emergency visit in ER | 3 non-emergency visits/year unless outpatient surgery, lab, dialysis, radiation or chemotherapy, non-emergency visit to ER counts toward both outpatient and physician visit limits | Fee for service | |
| Alaska | Yes | CN | 5% of payment for non-emergency services | Outpatient psych and substance abuse not covered | Specified surgical procedures | Prospective cost based rate using percentage of charge |
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | $2.30/visit for any outpatient therapy service | Coverage of outpatient OT and SP services limited to ALTCS members | Specified surgical procedures, rehab services | All-inclusive rate per episode of care using Medicare groupings for most surgical procedures or fee for service |
| Arkansas | Yes | CN & MN | 12 non-emergency visits/year | Specified surgical procedures | Cost based payment for pediatric, teaching and critical access hospitals; fee for service for other hospitals | |
| California | Yes | CN & MN | $5/non-emergency visit in ER, $1/visit for other services | Fee for service, state may negotiate all-inclusive per visit rates with certain hospitals and all-inclusive rates for adult day health care centers | ||
| Colorado | Yes | CN | $3/visit | Cost based payment | ||
| Connecticut | Yes | CN & MN | 1 visit/day | Fee for service or percentage of charge | ||
| Delaware | Yes | CN | Fee for service | |||
| District of Columbia | Yes | CN & MN | Cosmetic and oral surgery limited to emergency repair due to injury or trauma | Cost based payment | ||
| Florida | Yes | CN & MN | $3/visit | $1,500/year for non-emergency services (excluding surgery) | Prospective cost based per diem or rate per service, lab and x-ray services paid fee for service | |
| Georgia | Yes | CN & MN | $3/non-emergency visit | Observation limited to 48 hours | Specified procedures | Cost based payment using percentage of charge |
| Guam | Yes | CN | Non-emergency therapy services, CT-scans | Negotiated rate/service | ||
| Hawaii | Yes | CN & MN | All-inclusive rate per episode of care using Medicare groupings for most surgical procedures or fee for service with limits | |||
| Idaho | Yes | CN | $3/non-emergency visit in ER | 6 ER visits/year if no admission, varying visit limits for therapies including psych which may be included in limits with other providers | Specified services | Fee for service using hospital cost as upper limit |
| Illinois | Yes | CN & MN | Specified surgical procedures | Fee for service or prospective rate/visit | ||
| Indiana | Yes | CN | Fee for service, with surgical procedures grouped using Medicare methodology | |||
| Iowa | Yes | CN & MN | Varying visit limits for cardiac rehab, behavioral health and substance abuse, eating disorder and pain management therapies defined as non-inpatient programs | Fee for service, with surgical procedures grouped using Medicare methodology, ancillaries paid at Medicare rates | ||
| Kansas | Yes | CN & MN | $3/non-emergency visit | Non-emergency visits count toward physician visit limit, rehab must be restorative | Fee for service | |
| Kentucky | Yes | A, B & C - See state-specific FN | $3/ambulatory visit; 5% of payment for non-emergency visit in ER up to $6 | Fee for service with surgical procedures grouped using Medicare methodology or cost based payment | ||
| Louisiana | Yes | CN & MN | 3 ER visits/year and count against physician visit limit, no limit for CommunityCare enrollees | Rehab and specified surgeries | Cost based payment or fee for service | |
| Maine | Yes | CN & MN | $.50-$3/day, depending on payment, up to $30/month | Fee for service, with surgical procedures grouped using Medicare APC methodology | ||
| Maryland | Yes | CN & MN | Fee for service using rates approved by cost review commission | |||
| Massachusetts | Yes | CN & MN | Hospital-specific episode-based payment/day, excludes physician and lab services | |||
| Michigan | Yes | CN & MN | $3/non-emergency visit in ER, $1/hospital clinic visit | Prospective payment system with surgical procedures grouped using Medicare methodology, satellite clinics in health shortage areas paid higher rates | ||
| Minnesota | Yes | A & B - See state-specific FN | $6/non-emergency visit in ER | Payments based on Medicare methodology, cost based payment for critical access hospitals | ||
| Mississippi | Yes | CN | $3/non-emergency visit with some exceptions | 6 ER visits/year | Cost based payment using hospital cost to charge ratio | |
| Missouri | Yes | CN | $3/day except emergency services | Specified services | Percentage of charge | |
| Montana | Yes | A & B - See state-specific FN | $5/visit | Fee for service with surgical procedures grouped using Medicare methodology, cost based payment for critical access hospitals | ||
| Nebraska | Yes | CN & MN | $3/visit | No visit payable within 3 days of inpatient admission, substance abuse treatment not covered | Percentage of charge with limits, lab services paid fee for service, cost based payment for critical access hospitals | |
| Nevada | Yes | CN | Specified services | Fee for service with surgical procedures grouped using Medicare methodology | ||
| New Hampshire | Yes | CN & MN | 12 visits/year, visits for therapy included in limits with other specified practitioners | Percentage of charge | ||
| New Jersey | Yes | CN & MN | Non-emergency services in ER not covered | Cost based payment | ||
| New Mexico | Yes | CN | A - $0-$7/non-emergency visit to ER, B - $20/non-emergency visit to ER and $7/visit for other services, A - ER copays waived for admissions - see state-specific FN | A - outpatient detox limited to 10 days/year | Cost based payment with limits | |
| New York | Yes | CN & MN | $3/non-emergency visit | Beneficiary Specific Utilization Thresholds apply - see state-specific FN | Prospective payment system with surgical procedures grouped using Medicare Ambulatory Payment Group methodology, other services paid fee for service | |
| North Carolina | Yes | CN & MN | $3/visit | 22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature | More than 8 outpatient psych visits and any therapy services | Prospective cost based rate or fee for service |
| North Dakota | Yes | CN & MN | $3/non-emergency visit in ER | 30 SP visits/year included in limits for other providers of therapy services | Fixed percentage of charge | |
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Ohio | Yes | CN | $3/non-emergency visit in ER | Prospective payment with surgical procedure groupings paid by level, clinic and ER visit procedures paid by level, fee for service or percentage of charge for selected services | ||
| Oklahoma | Yes | CN | $3/visit | Outpatient behavioral health services not covered for nursing facility residents | Specified surgical procedures and other services | Fee for service using surgical group rates, ancillaries paid separately |
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Services limited to funded conditions on the priority list | Specified surgical and therapy procedures | Cost based payment with limits |
| Pennsylvania | Yes | CN & MN | $.50-$3/service, depending on payment rate | Frequency limits vary by service | Fee for service | |
| Puerto Rico | Yes | CN & MN | $1/non-emergency visit | Elective surgery requires primary care physician referral | Service is included in the capitated rate paid to managed care plans | |
| Rhode Island | Yes | See state-specific FN | $3/non-emergency visit in ER | PT, OT and SP | Medicare reimbursement rates with adjustors and utilizing Ambulatory Payment Classification codes | |
| South Carolina | Yes | CN | $3/non-emergency visit in ER | Fee for service | ||
| South Dakota | Yes | CN | 5% of payment up to $50/visit, non-emergency only | Substance abuse treatment not covered, cosmetic surgery limited to emergency repair due to injury or trauma | Cost based payment | |
| Tennessee | Yes | A & B - See state-specific FN | B1 - $10/ER visit if not admitted B2 - $50/ER visit if not admitted | $30,000 limit/lifetime for drug and alcohol treatment across all types of providers | See state-specific FN | |
| Texas | Yes | CN & MN | Specified services | Cost based payment, prospective payment with surgical procedures grouped using Medicare methodology | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B - $6/non-emergency visit in ER and $3/non-preventive care visit, C - $30/non-emergency visit in ER and $5/visit for other care | A & B - outpatient psych and substance abuse services limited to 30 days/year and included in inpatient limit, C - services limited to emergency treatment in ER | Prospective payment system | |
| Vermont | Yes | A & B - See state-specific FN | A - $3/day, B - $25/visit in ER | Fee for service, with surgical procedures grouped using Medicare methodology; lab procedures paid fee for service, using Medicare Relative Value Units and a state conversion factor; psych services paid on per diem basis | ||
| U.S. Virgin Islands | Yes | CN | Services in public health facilities only | Fee for service | ||
| Virginia | Yes | CN & MN | $3/visit | Limits vary by service | Specified services | Cost based payment with limits |
| Washington | Yes | CN & MN | $3/non-emergency visit in ER | Specified services | Most urban hospitals paid prospective cost based rates, rural hospitals paid prospective percentage of charge | |
| West Virginia | Yes | A, B & C | Specified surgical procedures and other services | Fee for service | ||
| Wisconsin | Yes | CN & MN | $3/visit | Outpatient psych services limited to 5 hours/day up to 120 hours/month and 40 hours/year for nursing facility residents; OT, PT and SP services must be billed as if rendered by the therapist and are reimbursed accordingly | Specified surgical procedures and other services | Cost based payment with limits |
| Wyoming | Yes | CN | $3.40/non-emergency visit in ER | 12 visits/year in combination with physician office visits, therapy services must be restorative and are limited to 20 visits/year across all therapy providers | Payment based on Medicare Outpatient Prospective Payment System methodology |
2008
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 56 No - 0 | Yes - 35 No - 21 | ||||
| Alabama | Yes | CN | $3/non-emergency visit in ER | 3 non-emergency visits/year unless outpatient surgery, lab, dialysis, radiation or chemotherapy, non-emergency visit to ER counts toward both outpatient and physician visit limits | Fee for service | |
| Alaska | Yes | CN | 5% of payment for non-emergency services | Outpatient psych and substance abuse not covered | Specified surgical procedures | Prospective cost based rate using percentage of charge |
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | $5/non-emergency visit in ER | Coverage of outpatient occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN | Specified surgical procedures, rehab services | All-inclusive rate per episode of care using Medicare groupings for most surgical procedures or fee for service |
| Arkansas | Yes | CN & MN | 12 non-emergency visits/year | Specified surgical procedures | Cost based payment for pediatric, teaching and critical access hospitals; fee for service for other hospitals | |
| California | Yes | CN & MN | $5/non-emergency visit in ER, $1/visit for other services | Fee for service, state may negotiate all-inclusive per visit rates with certain hospitals | ||
| Colorado | Yes | CN | $3/visit | Cost based payment | ||
| Connecticut | Yes | CN & MN | 1 visit/day | Fee for service or percentage of charge | ||
| Delaware | Yes | CN | Cost based payment | |||
| District of Columbia | Yes | CN & MN | Cosmetic and oral surgery limited to emergency repair due to injury or trauma | Cost based payment | ||
| Florida | Yes | CN & MN | 5% of payment up to $15/visit for non-emergency services in the ER, $3/visit for other services | $1,500/year for non-emergency services (excluding surgery) | Prospective cost based per diem or rate per service, lab and x-ray services paid fee for service | |
| Georgia | Yes | CN & MN | $3/non-emergency visit | Observation limited to 48 hours | Specified procedures | Cost based payment using percentage of charge |
| Guam | Yes | CN | Non-emergency therapy services, CT-scans | Negotiated rate/service | ||
| Hawaii | Yes | CN & MN | All-inclusive rate per episode of care using Medicare groupings for most surgical procedures or fee for service with limits | |||
| Idaho | Yes | CN | $3/non-emergency visit in ER | 6 ER visits/year if no admission, varying visit limits for therapies including psych which may be included in limits with other providers | Specified services | Fee for service using hospital cost as upper limit |
| Illinois | Yes | CN & MN | Specified surgical procedures | Fee for service or prospective rate/visit | ||
| Indiana | Yes | CN | Fee for service, with surgical procedures grouped using Medicare methodology | |||
| Iowa | Yes | CN & MN | Varying visit limits for cardiac rehab, behavioral health and substance abuse, eating disorder and pain management therapies | Fee for service, with surgical procedures grouped using Medicare methodology, ancillaries paid at Medicare rates | ||
| Kansas | Yes | CN & MN | $3/non-emergency visit | Non-emergency visits count toward physician visit limit, rehab must be restorative | Fee for service | |
| Kentucky | Yes | A, B & C - See state-specific FN | $3/ambulatory visit; 5% of payment for non-emergency visit in ER up to $6 | Fee for service with surgical procedures grouped using Medicare methodology or cost based payment | ||
| Louisiana | Yes | CN & MN | 3 ER visits/year and count against physician visit limit, no limit for CommunityCare enrollees | Cost based payment or fee for service | ||
| Maine | Yes | CN & MN | $.50-$3/day, depending on payment, up to $30/month | Cost based payment with limits | ||
| Maryland | Yes | CN & MN | Fee for service using rates approved by cost review commission | |||
| Massachusetts | Yes | CN & MN | Hospital-specific episode-based payment/day, excludes physician and lab services | |||
| Michigan | Yes | CN & MN | $3/non-emergency visit in ER, $1/hospital clinic visit | Fee for service, with surgical procedures grouped using Medicare methodology, satellite clinics in health shortage areas paid higher rates | ||
| Minnesota | Yes | A & B - See state-specific FN | $6/non-emergency visit in ER | Payments based on Medicare methodology, cost based payment for critical access hospitals | ||
| Mississippi | Yes | CN | $3/non-emergency visit | 6 ER visits/year | Cost based payment using hospital cost to charge ratio | |
| Missouri | Yes | CN | $3/day | Selected elective surgeries require second opinion | Specified services | Percentage of charge |
| Montana | Yes | A & B - See state-specific FN | $5/visit | Fee for service with surgical procedures grouped using Medicare methodology, cost based payment for critical access hospitals | ||
| Nebraska | Yes | CN & MN | $3/visit | No visit payable within 3 days of inpatient admission, substance abuse treatment not covered | Percentage of charge with limits, lab services paid fee for service, cost based payment for critical access hospitals | |
| Nevada | Yes | CN | Specified services | Fee for service with surgical procedures grouped using Medicare methodology | ||
| New Hampshire | Yes | CN & MN | 12 visits/year, visits for therapy included in limits with other specified practitioners | Percentage of charge | ||
| New Jersey | Yes | CN & MN | Non-emergency services in ER not covered | Cost based payment | ||
| New Mexico | Yes | CN | A - $15/non-emergency visit to ER and $5/visit for other services, B - $20/non-emergency visit to ER and $5/visit for other services - see state-specific FN | Allergy testing and treatment, therapies | Cost based payment with limits | |
| New York | Yes | CN & MN | $3/visit | 10 outpatient visits/year in combination with other specified providers | Prospective all-inclusive rate with limits, some services fee for service | |
| North Carolina | Yes | CN & MN | $3/visit | 22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature | More than 8 outpatient psychiatric visits | Prospective cost based rate or fee for service |
| North Dakota | Yes | CN & MN | $6/non-emergency visit in ER | 30 SP visits/year included in limits for other providers of therapy services | Fixed percentage of charge | |
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Ohio | Yes | CN | $3/non-emergency visit in ER | Fee for service or prospective payment based on percentage of charge | ||
| Oklahoma | Yes | CN | $3/day | Outpatient behavioral health services not covered for nursing facility residents | Specified surgical procedures and other services | Fee for service using surgical group rates, ancillaries paid separately |
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Specified surgical and therapy procedures | Cost based payment with limits | |
| Pennsylvania | Yes | CN & MN | $.50-$3/service, depending on payment rate | Frequency limits vary by service | Fee for service | |
| Puerto Rico | Yes | CN & MN | Elective surgery requires primary care physician referral | Fee for service with capitated payment for primary care | ||
| Rhode Island | Yes | CN & MN - see state-specific FN | $3/non-emergency visit in ER | Physical and occupational therapy, speech pathology | Prospective payment with surgical procedures grouped using Medicare methodology | |
| South Carolina | Yes | CN | $3/non-emergency visit in ER | Fee for service | ||
| South Dakota | Yes | CN | 5% of payment up to $50/visit, non-emergency only | Substance abuse treatment not covered, cosmetic surgery limited to emergency repair due to injury or trauma | Cost based payment | |
| Tennessee | Yes | A & B - See state-specific FN | B1 - $25/ER visit if not admitted, B2 - $50/ER visit if not admitted | $30,000 limit/lifetime for drug and alcohol treatment across all types of providers | ||
| Texas | Yes | CN & MN | Specified services | Cost based payment, prospective payment with surgical procedures grouped using Medicare methodology | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B - $6/non-emergency visit in ER and $3/non-preventive care visit, C - $30/non-emergency visit in ER and $5/visit for other care | B - outpatient psych and substance abuse services limited to 30 days/year and included in inpatient limit, C - services limited to emergency treatment in ER | Prospective cost based rate | |
| Vermont | Yes | A & B - See state-specific FN | A - $3/day, B - $25/medically necessary visit in ER | Fee for service, with surgical procedures grouped using Medicare methodology | ||
| U.S. Virgin Islands | Yes | CN | Services in public health facilities only | Fee for service | ||
| Virginia | Yes | CN & MN | $3/visit | Limits vary by service | Specified services | Cost based payment with limits |
| Washington | Yes | CN & MN | $3/non-emergency visit in ER | Specified services | Most urban hospitals paid prospective cost based rates, rural hospitals paid prospective percentage of charge | |
| West Virginia | Yes | A, B & C | Specified surgical procedures and other services | Fee for service | ||
| Wisconsin | Yes | CN & MN | $3/visit, $.50/day for psych day treatment | Outpatient psych services limited to 5 hours/day up to 120 hours/month and 40 hours/year for nursing facility residents; occupational therapy, physical therapy and speech pathology services must be billed as if rendered by the therapist and are reimbursed accordingly | Specified surgical procedures and other services | Cost based payment with limits |
| Wyoming | Yes | CN | $6/non-emergency visit in ER | 12 visits/year in combination with physician office visits, therapy services must be restorative and are limited to 20 visits/year across all therapy providers | Payment based on Medicare Outpatient Prospective Payment System methodology |
2006
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 56 No - 0 | Yes - 34 No - 22 | ||||
| Alabama | Yes | CN | $3/non-emergency visit in ER | 3 non-emergency visits/year unless outpatient surgery, lab, dialysis, radiation or chemotherapy, non-emergency visit to ER counts toward both outpatient and physician visit limits | Fee for service | |
| Alaska | Yes | CN | 5% of payment for non-emergency services | Outpatient psych and substance abuse not covered | Specified surgical procedures | Prospective cost based rate using percentage of charge |
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | $5/non-emergency visit in ER | Coverage of outpatient occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN | Specified surgical procedures, rehab services | All-inclusive rate per episode of care using Medicare groupings for most surgical procedures or fee for service |
| Arkansas | Yes | CN & MN | 12 non-emergency visits/year | Specified surgical procedures | Cost based payment for pediatric, teaching and critical access hospitals; fee for service for other hospitals | |
| California | Yes | CN & MN | $5/non-emergency visit in ER, $1/visit for other services | Fee for service, state may negotiate all-inclusive per visit rates with certain hospitals | ||
| Colorado | Yes | CN | $3/visit | Cost based payment | ||
| Connecticut | Yes | CN & MN | 1 visit/day | Fee for service or percentage of charge | ||
| Delaware | Yes | CN | Cost based payment | |||
| District of Columbia | Yes | CN & MN | Cosmetic and oral surgery limited to emergency repair due to injury or trauma | Cost based payment | ||
| Florida | Yes | CN & MN | 5% of payment up to $15/visit for non-emergency services in the ER | $1,500/year for non-emergency services (excluding surgery) | Prospective cost based per diem or rate per service, lab and x-ray services paid fee for service | |
| Georgia | Yes | CN & MN | $3/non-emergency visit | Observation limited to 48 hours | Specified procedures | Cost based payment using percentage of charge |
| Guam | Yes | CN | Non-emergency therapy services, CT-scans | Negotiated rate/service | ||
| Hawaii | Yes | CN & MN | All-inclusive rate per episode of care using Medicare groupings for most surgical procedures or fee for service with limits | |||
| Idaho | Yes | CN | 6 ER visits/year if no admission, varying visit limits for therapies including psych which may be included in limits with other providers | Fee for service using hospital cost as upper limit | ||
| Illinois | Yes | CN & MN | Specified surgical procedures | Fee for service or prospective rate/visit | ||
| Indiana | Yes | CN | Fee for service, with surgical procedures grouped using Medicare methodology | |||
| Iowa | Yes | CN & MN | Varying visit limits for cardiac rehab, behavioral health and substance abuse, eating disorder and pain management therapies | Fee for service, with surgical procedures grouped using Medicare methodology, ancillaries paid at Medicare rates | ||
| Kansas | Yes | CN & MN | $3/non-emergency visit | Non-emergency visits count toward physician visit limit, rehab must be restorative | Fee for service | |
| Kentucky | Yes | A, B & C - See state-specific FN | $3/ambulatory visit; 5% of payment for non-emergency visit in ER up to $6 | Fee for service with surgical procedures grouped using Medicare methodology or cost based payment | ||
| Louisiana | Yes | CN & MN | 3 ER visits/year and count against physician visit limit | Cost based payment or fee for service | ||
| Maine | Yes | CN & MN | $.50-$3/day, depending on payment, up to $30/month | Cost based payment with limits | ||
| Maryland | Yes | CN & MN | Fee for service using rates approved by cost review commission | |||
| Massachusetts | Yes | CN & MN | Fee for service using rates approved by cost review commission, surgical procedures grouped using Medicare methodology | |||
| Michigan | Yes | CN & MN | $3/non-emergency visit in ER, $1/hospital clinic visit | Fee for service, satellite clinics in health shortage areas paid higher rates | ||
| Minnesota | Yes | A & B - See state-specific FN | $6/non-emergency visit in ER | Payments based on Medicare methodology, cost based payment for critical access hospitals | ||
| Mississippi | Yes | CN | $3/non-emergency visit | 6 ER visits/year | Cost based payment using hospital cost to charge ratio | |
| Missouri | Yes | CN | $3/day | Elective surgeries require second opinion | Specified services | Percentage of charge |
| Montana | Yes | A & B - See state-specific FN | $5/visit | Fee for service with surgical procedures grouped using Medicare methodology, cost based payment for critical access hospitals | ||
| Nebraska | Yes | CN & MN | $3/visit | No visit payable within 3 days of inpatient admission, substance abuse treatment not covered | Percentage of charge with limits, lab services paid fee for service, cost based payment for critical access hospitals | |
| Nevada | Yes | CN | Fee for service with surgical procedures grouped using Medicare methodology | |||
| New Hampshire | Yes | CN & MN | 12 visits/year, visits for therapy included in limits with other specified practitioners | Percentage of charge | ||
| New Jersey | Yes | CN & MN | Non-emergency services in ER not covered | Cost based payment | ||
| New Mexico | Yes | CN | A - $15/non-emergency visit to ER and $5/visit for other services, B - $20/non-emergency visit to ER and $5/visit for other services - see state-specific FN | Allergy testing and treatment, therapies | Cost based payment with limits | |
| New York | Yes | CN & MN | $3/visit | 10 outpatient visits/year in combination with other specified providers | Prospective all-inclusive rate with limits, some services fee for service | |
| North Carolina | Yes | CN & MN | $3/visit | 24 non-emergency visits/year included in limits with other specified practitioners | More than 8 outpatient psychiatric visits | Prospective cost based rate, cost based payment for state owned facilities |
| North Dakota | Yes | CN & MN | $6/non-emergency visit in ER | 30 SP visits/year included in limits for other specified providers | Fixed percentage of charge | |
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Ohio | Yes | CN | $3/non-emergency visit in ER | Fee for service or prospective payment based on percentage of charge | ||
| Oklahoma | Yes | CN | $3/day | Outpatient behavioral health services not covered for nursing facility residents | Specified surgical procedures and other services | Fee for service using surgical group rates, ancillaries paid separately |
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Specified surgical and therapy procedures | Cost based payment with limits | |
| Pennsylvania | Yes | CN & MN | $.50-$3/service, depending on payment | Frequency limits vary by service | Fee for service | |
| Puerto Rico | Yes | CN & MN | Elective surgery requires primary care physician referral | Fee for service with capitated payment for primary care | ||
| Rhode Island | Yes | CN & MN - see state-specific FN | $3/non-emergency visit in ER | Physical and occupational therapy, speech pathology | Prospective payment with surgical procedures grouped using Medicare methodology | |
| South Carolina | Yes | CN | $3/non-emergency visit in ER | Fee for service | ||
| South Dakota | Yes | CN | 5% of payment up to $50/visit, non-emergency only | Substance abuse treatment not covered, cosmetic surgery limited to emergency repair due to injury or trauma | Cost based payment | |
| Tennessee | Yes | A & B - See state-specific FN | B1 - $25/ER visit if not admitted, B2 - $50/ER visit if not admitted | $30,000 limit/lifetime for drug and alcohol treatment across all types of providers | ||
| Texas | Yes | CN & MN | Specified services | Cost based payment, prospective payment with surgical procedures grouped using Medicare methodology | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B - $6/non-emergency visit in ER and $3/non-preventive care visit, C - $30/non-emergency visit in ER and $5/visit for other care | B - outpatient psych and substance abuse services limited to 30 days/year and included in inpatient limit, C - services limited to emergency treatment in ER | Prospective cost based rate with higher rates for rural hospitals, some services paid fee for service or all-inclusive rate | |
| Vermont | Yes | A & B - See state-specific FN | A - $3/day, B - $25/medically necessary visit in ER | Non-emergency services in ER not covered | Cost based payment, some services paid fee for service or prospective per diem | |
| U.S. Virgin Islands | Yes | CN | Services in public health facilities only | Fee for service | ||
| Virginia | Yes | CN & MN | $3/visit | 24 therapy visits/year | Cost based payment with limits | |
| Washington | Yes | CN & MN | $3/non-emergency visit in ER | Specified services | Most urban hospitals paid prospective cost based rates, rural hospitals paid prospective percentage of charge | |
| West Virginia | Yes | CN & MN | Specified surgical procedures and other services | Fee for service | ||
| Wisconsin | Yes | CN & MN | $3/visit, $.50/day for psych day treatment | Outpatient psych services limited to 5 hours/day up to 120 hours/month and 40 hours/year for nursing facility residents; occupational therapy, physical therapy and speech pathology services must be billed as if rendered by the therapist and are reimbursed accordingly | Specified surgical procedures and other services | Cost based payment with limits |
| Wyoming | Yes | CN | $6/non-emergency visit in ER | 12 visits/year in combination with physician office visits, therapy services must be restorative and are limited to 20 visits/year across all therapy providers | Fee for service |
2004
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 56 No - 0 | Yes - 30 No - 26 | ||||
| Alabama | Yes | CN | $3/non-emergency visit in ER | 3 non-emergency visits/year unless outpatient surgery, lab, dialysis, radiation or chemotherapy | Fee for service | |
| Alaska | Yes | CN | 5% of payment for non-emergency services | Outpatient psych and substance abuse not covered | Specified surgical procedures | Prospective cost based rate using percentage of charge |
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | Coverage of occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN | Specified surgical procedures, rehab services | Percentage of charge | |
| Arkansas | Yes | CN & MN | 12 non-emergency visits/year | Specified surgical procedures | Cost based payment for pediatric, teaching and critical access hospitals; fee for service for other hospitals | |
| California | Yes | CN & MN | $5/non-emergency visit in ER, $1/visit for other services | Fee for service, state may negotiate all-inclusive per visit rates with certain hospitals | ||
| Colorado | Yes | CN | $3/visit | Cost based payment | ||
| Connecticut | Yes | CN & MN | 1 visit/day | Fee for service or percentage of charge | ||
| Delaware | Yes | CN | Cost based payment | |||
| District of Columbia | Yes | CN & MN | Cosmetic and oral surgery limited to emergency repair due to injury or trauma | Cost based payment | ||
| Florida | Yes | CN & MN | 5% of payment up to $15/visit for non-emergency services in the ER, $3/visit for other services | $1,500/year for non-emergency services (excluding surgery) | Prospective cost based per diem or rate per service, lab and x-ray services paid fee for service | |
| Georgia | Yes | CN & MN | $3/non-emergency visit | Observation limited to 48 hours | Specified procedures | Cost based payment using percentage of charge |
| Guam | Yes | CN | Non-emergency therapy services, CT-scans | Negotiated rate/service | ||
| Hawaii | Yes | CN & MN | All-inclusive rate per episode of care using Medicare groupings for most surgical procedures or fee for service with limits | |||
| Idaho | Yes | CN | 6 ER visits/year if no admission, varying visit limits for therapies including psych which may be included in limits with other providers | Fee for service using hospital cost as upper limit | ||
| Illinois | Yes | CN & MN | Specified surgical procedures | Fee for service or prospective rate/visit | ||
| Indiana | Yes | CN | Fee for service, with surgical procedures grouped using Medicare methodology | |||
| Iowa | Yes | CN & MN | Varying visit limits for cardiac rehab, behavioral health and substance abuse, eating disorder and pain management therapies | Fee for service, with surgical procedures grouped using Medicare methodology, ancillaries paid at Medicare rates | ||
| Kansas | Yes | CN & MN | $3/non-emergency visit | Non-emergency visits count toward physician visit limit, rehab must be restorative | Fee for service | |
| Kentucky | Yes | CN & MN | Fee for service with surgical procedures grouped using Medicare methodology or cost based payment | |||
| Louisiana | Yes | CN & MN | 3 ER visits/year and count against physician visit limit | Cost based payment or fee for service | ||
| Maine | Yes | CN & MN | $.50-$3/day, depending on payment, up to $30/month | Cost based payment with limits | ||
| Maryland | Yes | CN & MN | Fee for service using rates approved by cost review commission | |||
| Massachusetts | Yes | CN & MN | Fee for service using rates approved by cost review commission, surgical procedures grouped using Medicare methodology | |||
| Michigan | Yes | CN & MN | Fee for service, satellite clinics in health shortage areas paid higher rates | |||
| Minnesota | Yes | A & B - See state-specific FN | A - $6/non-emergency visit in ER - See state-specific FN | Payments based on Medicare methodology, cost based payment for critical access hospitals | ||
| Mississippi | Yes | CN | $3/non-emergency visit | 6 visits/year | Cost based payment using hospital cost to charge ratio | |
| Missouri | Yes | CN | $2/visit | Elective surgeries require second opinion | Specified services | Percentage of charge |
| Montana | Yes | A & B - See state-specific FN | $5/visit | Fee for service with surgical procedures grouped using Medicare methodology, cost based payment for critical access hospitals | ||
| Nebraska | Yes | CN & MN | $3/non-emergency visit in ER or for therapy services | No visit payable within 3 days of inpatient admission, substance abuse treatment not covered | Percentage of charge with limits, lab services paid fee for service, cost based payment for critical access hospitals | |
| Nevada | Yes | CN | Fee for service with surgical procedures grouped using Medicare methodology | |||
| New Hampshire | Yes | CN & MN | 12 visits/year, visits for therapy included in limits with other specified practitioners | Percentage of charge | ||
| New Jersey | Yes | CN & MN | Non-emergency services in ER not covered | Cost based payment | ||
| New Mexico | Yes | CN | B - $20/non-emergency visit to ER and $5/visit for other services - see state-specific FN | Allergy testing and treatment, therapies | Cost based payment with limits | |
| New York | Yes | CN & MN | $3/visit | 10 outpatient visits/year in combination with other specified providers | Prospective all-inclusive rate with limits, some services fee for service | |
| North Carolina | Yes | CN & MN | $3/visit | 24 non-emergency visits/year included in limits with other specified practitioners | More than 8 outpatient psychiatric visits | Prospective cost based rate, cost based payment for state owned facilities |
| North Dakota | Yes | CN & MN | $6/non-emergency visit in ER | 30 SP visits/year included in limits for other specified providers | Fixed percentage of charge | |
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Ohio | Yes | CN | Fee for service or prospective payment based on percentage of charge | |||
| Oklahoma | Yes | CN | $3/day | Outpatient behavioral health services not covered for nursing facility residents | Specified surgical procedures and other services | Fee for service using surgical group rates, ancillaries paid separately |
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Specified surgical and therapy procedures | Cost based payment with limits | |
| Pennsylvania | Yes | CN & MN | $.50/clinic visit | Varying visit limits | Fee for service | |
| Puerto Rico | Yes | CN & MN | Elective surgery requires primary care physician referral | Cost based payment using all inclusive rates | ||
| Rhode Island | Yes | CN & MN - see state-specific FN | $3/non-emergency visit in ER | Physical and occupational therapy, speech pathology | Prospective payment with surgical procedures grouped using Medicare methodology | |
| South Carolina | Yes | CN | $3/non-emergency visit in ER | Fee for service | ||
| South Dakota | Yes | CN | 5% of payment for non-emergency visit in ER up to $50 | Substance abuse treatment not covered, cosmetic surgery limited to emergency repair due to injury or trauma | Cost based payment | |
| Tennessee | Yes | A & B - See state-specific FN | B1 - $25/ER visit if not admitted, B2 - $50/ER visit if not admitted | |||
| Texas | Yes | CN & MN | Occupational therapy must be restorative | Parenteral nutrition therapy | Cost based payment or prospective payment with surgical procedures grouped using Medicare methodology | |
| Utah | Yes | A, B & C - See state-specific FN | A & B - $6/non-emergency visit in ER and $3/non-preventive care visit, C - $30/non-emergency visit in ER and $5/visit for other care | B - outpatient psych and substance abuse services limited to 30 days/year and included in inpatient limit, C - services limited to emergency treatment in ER | Prospective cost based rate with higher rates for rural hospitals, some services paid fee for service or all-inclusive rate | |
| Vermont | Yes | A & B - See state-specific FN | B - $25/medically necessary emergency visit in ER | Non-emergency services in ER not covered | Cost based payment, some services paid fee for service or prospective per diem | |
| U.S. Virgin Islands | Yes | CN | Services in public health facilities only | Fee for service | ||
| Virginia | Yes | CN & MN | $3/visit | 24 therapy visits/year | Cost based payment with limits | |
| Washington | Yes | CN & MN | $3/non-emergency visit in ER | Specified services | Most urban hospitals paid prospective cost based rates, rural hospitals paid prospective percentage of charge | |
| West Virginia | Yes | CN & MN | Specified surgical procedures and other services | Fee for service | ||
| Wisconsin | Yes | CN & MN | $3/visit, $.50/day for psych day treatment | Outpatient psych services limited to 5 hours/day up to 120 hours/month and 40 hours/year for nursing facility residents | Specified surgical procedures and other services | Cost based payment with limits |
| Wyoming | Yes | CN | $6/non-emergency visit in ER | 12 visits/year in combination with physician office visits, therapy services must be restorative and are limited to 20 visits/year across all therapy providers | Fee for service |
2003
| 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 | $3/non-emergency visit in ER | 3 non-emergency visits/year unless outpatient surgery, radiation or chemotherapy | Fee for service | |
| Alaska | Yes | CN | 5% of payment | Outpatient psych and substance abuse not covered | Specified surgical procedures | Prospective cost based rate |
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | Coverage of occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN | Specified surgical procedures, rehab services | Fee for service | |
| Arkansas | Yes | CN & MN | 12 non-emergency visits/year | Specified surgical procedures | Cost based payment for pediatric, teaching and critical access hospitals; fee for service for other hospitals | |
| California | Yes | CN & MN | $5/non-emergency visit in ER, $1/visit for other services | Fee for service, state may negotiate all-inclusive per visit rates with certain hospitals | ||
| Colorado | Yes | CN | $3/visit | Cost based payment | ||
| Connecticut | Yes | CN & MN | 1 visit/day | Fee for service or percentage of charge | ||
| Delaware | Yes | CN | Cost based payment | |||
| District of Columbia | Yes | CN & MN | Cosmetic and oral surgery limited to emergency repair due to injury or trauma | Cost based payment | ||
| Florida | Yes | CN & MN | $3/visit | $1,500/year for non-emergency services (excluding surgery) | Prospective cost based per diem or rate per service, lab and x-ray services paid fee for service | |
| Georgia | Yes | CN & MN | $3/non-emergency visit | Observation limited to 48 hours | Specified procedures | Cost based payment using percentage of charge |
| Guam | Yes | CN | Non-emergency therapy services, CT-scans | Negotiated rate/service | ||
| Hawaii | Yes | CN & MN | All-inclusive rate per episode of care using Medicare groupings for most surgical procedures or fee for service with limits | |||
| Idaho | Yes | CN | 6 ER visits/year if no admission, varying visit limits for therapies including psych which may be included in limits with other providers | Fee for service using hospital cost as upper limit | ||
| Illinois | Yes | CN & MN | Specified surgical procedures | Fee for service or prospective rate/visit | ||
| Indiana | Yes | CN | Fee for service | |||
| Iowa | Yes | CN & MN | Varying visit limits for cardiac rehab, behavioral health and substance abuse, eating disorder and pain management therapies | Fee for service, with surgical procedures grouped using Medicare methodology, ancillaries paid at Medicare rates | ||
| Kansas | Yes | CN & MN | $3/non-emergency visit | Non-emergency visits count toward physician visit limit, rehab must be restorative | Fee for service | |
| Kentucky | Yes | CN & MN | Fee for service with surgical procedures grouped using Medicare methodology or cost based payment | |||
| Louisiana | Yes | CN & MN | 3 ER visits/year and count against physician visit limit | Cost based payment or fee for service | ||
| Maine | Yes | CN & MN | $.50-$3/day, depending on payment, up to $30/month | Cost based payment | ||
| Maryland | Yes | CN & MN | Fee for service using rates approved by cost review commission | |||
| Massachusetts | Yes | CN & MN | Fee for service using rates approved by cost review commission | |||
| Michigan | Yes | CN & MN | Fee for service, satellite clinics in health shortage areas paid higher rates | |||
| Minnesota | Yes | A & B - See state-specific FN | A - $6/non-emergency visit in ER | Payments based on Medicare methodology, cost based payment for critical access hospitals | ||
| Mississippi | Yes | CN | $3/non-emergency visit | 6 visits/year | Cost based payment using hospital cost to charge ratio | |
| Missouri | Yes | CN | $2/visit | Elective surgeries require second opinion | Specified services | Percentage of charge |
| Montana | Yes | CN & MN | $5/visit | Fee for service with surgical procedures grouped using Medicare methodology, cost based payment for critical access hospitals | ||
| Nebraska | Yes | CN & MN | $3/non-emergency visit in ER or for therapy services | No visit payable within 3 days of inpatient admission, substance abuse treatment not covered | Prospective cost based rate, cost based payment for critical access hospitals | |
| Nevada | Yes | CN | Fee for service | |||
| New Hampshire | Yes | CN & MN | 12 visits/year, visits for therapy included in limits with other specified practitioners | Percentage of charge | ||
| New Jersey | Yes | CN & MN | Non-emergency services in ER not covered | Cost based payment | ||
| New Mexico | Yes | CN | B - $15/non-emergency visit to ER and $5/visit for other services - see state-specific FN | Allergy testing and treatment, therapies | Cost based payment with limits | |
| New York | Yes | CN & MN | $3/visit | 10 outpatient visits/year in combination with other specified providers | Prospective all-inclusive rate with limits, some services fee for service | |
| North Carolina | Yes | CN & MN | $3/visit | 24 non-emergency visits/year included in limits with other specified practitioners | More than 8 outpatient psychiatric visits | Prospective cost based rate, cost based payment for state owned facilities |
| North Dakota | Yes | CN & MN | $3/non-emergency visit in ER | Fixed percentage of charge | ||
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Ohio | Yes | CN | Fee for service or prospective payment based on percentage of charge | |||
| Oklahoma | Yes | CN & MN | $3/day | Specified surgical procedures and other services | Fee for service using surgical group rates, ancillaries paid separately | |
| Oregon | Yes | CN & MN | $3/visit | Specified surgical and therapy procedures | Prospective cost based rate, cost based payment for some rural hospitals | |
| Pennsylvania | Yes | CN & MN | $.50/clinic visit | Varying visit limits | Fee for service | |
| Puerto Rico | Yes | CN & MN | Elective surgery requires primary care physician referral | Cost based payment using all inclusive rates | ||
| Rhode Island | Yes | CN & MN - see state-specific FN | $3/non-emergency visit in ER | Physical and occupational therapy, speech pathology | Prospective payment with surgical procedures grouped using Medicare methodology | |
| South Carolina | Yes | CN | Fee for service | |||
| South Dakota | Yes | CN | 5% of payment for non-emergency visit in ER up to $50 | Substance abuse treatment not covered, cosmetic surgery limited to emergency repair due to injury or trauma | Cost based payment | |
| Tennessee | Yes | A & B - See state-specific FN | B1 - $25/ER visit if not admitted, B2 - $50/ER visit if not admitted | |||
| Texas | Yes | CN & MN | Occupational therapy must be restorative | Parenteral nutrition therapy | Cost based payment with limits | |
| Utah | Yes | A, B & C - See state specific FN | A - $2/visit, B - $3/visit, A & B - $6/non-emergency visit in ER, C - $30/visit | B - outpatient psych and substance abuse services limited to 30 days/year and included in inpatient limit, C - services limited to emergency treatment in ER | Prospective cost based rate with higher rates for rural hospitals, some services paid fee for service or all-inclusive rate | |
| Vermont | Yes | A & B - See state-specific FN | B - $25/medically necessary emergency visit in ER | Non-emergency services in ER not covered | Cost based payment, some services paid fee for service or prospective per diem | |
| U.S. Virgin Islands | Yes | CN | Services in public health facilities only | Fee for service | ||
| Virginia | Yes | CN & MN | $3/visit | 24 therapy visits/year | Cost based payment | |
| Washington | Yes | CN & MN | $3/non-emergency visit in ER | Specified services | Fee for service | |
| West Virginia | Yes | CN & MN | Specified surgical procedures and other services | Fee for service | ||
| Wisconsin | Yes | CN & MN | $3/visit, $.50/day for psych day treatment | Outpatient psych services limited to 5 hours/day up to 120 hours/month and 40 hours/year for nursing facility residents | Specified surgical procedures and other services | Cost based payment with limits |
| Wyoming | Yes | CN | $6/non-emergency visit in ER | 12 visits/year in combination with physician office visits, therapy services must be restorative and are limited to 20 visits/year across all therapy providers | Fee for service |