Medicaid Benefits: Physician 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 - 25 | Yes - 17 | Included in "Limits on Services" for 2018 | Not included in 2018 survey |
| Alabama | Yes - Mandatory | CN | $1.30 - $3.90 each visit | limit of 14 office visits and 16 inpatient hospital visits | - | - |
| Alaska | Yes - Mandatory | CN | $3 | No | - | - |
| Arizona | Yes - Mandatory | CN | $4 for beneficiaries with Transitional Medical Assistance | Prior authorization only | - | - |
| Arkansas | Yes - Mandatory | CN | NR | NR | - | - |
| California | Yes - Mandatory | CN | $1/visit | Specified surgical procedures including those to be performed on inpatient basis that are normally rendered on outpatient basis, respiratory therapy. | - | - |
| Colorado | Yes - Mandatory | CN | $2 per visit | No | - | - |
| Connecticut | Yes - Mandatory | CN | No | prior authorization on a limited number of high risk/cost procedures | - | - |
| Delaware | Yes - Mandatory | CN | No | no experimental procedures | - | - |
| District of Columbia | Yes - Mandatory | CN | No | Some procedures require a PA | - | - |
| Florida | Yes - Mandatory | CN | Physician services, per provider or group provider, $2.00 per day | Adult Health Screening Services: One adult health screening every 365 days, for recipients age 21 years and older. Nursing Facility Services: One evaluation and management visit per month, per recipient. Office Visits: Up to two office visits per month, per specialty, for recipients age 21 years and older (pregnant women are exempt). | - | - |
| Georgia | Yes - Mandatory | CN | $2 copay | Over 12 visits per year must be prior authorized. | - | - |
| 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 surgical procedures. 4 visits/month; up to 30 visits/year | - | - |
| Iowa | Yes - Mandatory | CN | NR | NR | - | - |
| Kansas | Yes - Mandatory | CN | $2.00 per service date | No | - | - |
| Kentucky | Yes - Mandatory | CN | $3 | Psychiatry services limited to 4 visits per year; one E&M service per physician per member per year | - | - |
| Louisiana | Yes - Mandatory | CN | No | NR | - | - |
| Maine | Yes - Mandatory | CN | No | No | - | - |
| Maryland | Yes - Mandatory | CN | No | No | - | - |
| Massachusetts | Yes - Mandatory | CN | No | No | - | - |
| Michigan | Yes - Mandatory | CN | $2/visit | No | - | - |
| Minnesota | Yes - Mandatory | CN | $3 copay for non-preventive office visits | No | - | - |
| Mississippi | Yes - Mandatory | CN | $3 per visit with some exceptions | NR | - | - |
| Missouri | Yes - Mandatory | CN | $1 | There are daily quantity limits on services. | - | - |
| Montana | Yes - Mandatory | CN | Income at or below 100% FPL - $4 per visit; above FPL - 10% of payment amount | No | - | - |
| Nebraska | Yes - Mandatory | CN | $2 per visit, excluding primary care physicians, family practice, general practice, pediatricians, internists and physician extenders who provide primary care services | No | - | - |
| Nevada | Yes - Mandatory | CN | NR | NR | - | - |
| New Hampshire | Yes - Mandatory | CN | No | NR | - | - |
| New Jersey | Yes - Mandatory | CN | No | No | - | - |
| New Mexico | Yes - Mandatory | CN | $7 for WDI recipients | No | - | - |
| New York | Yes - Mandatory | CN | NR | NR | - | - |
| North Carolina | Yes - Mandatory | CN | $1 - $3 depending on the service | NR | - | - |
| North Dakota | Yes - Mandatory | CN | $2 per visit | No | - | - |
| Ohio | Yes - Mandatory | CN | No | No | - | - |
| Oklahoma | Yes - Mandatory | CN | $4 per visit | Services are subject to the existing visit limitation of 4 visits per month. | - | - |
| Oregon | Yes - Mandatory | CN | No | Coverage is based upon Oregon's 1115 waiver and Health Evidence Review Commission's prioritized list of health services | - | - |
| 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 | $3/visit | No | - | - |
| Tennessee | Yes - Mandatory | CN | No | No | - | - |
| Texas | Yes - Mandatory | CN | No | No | - | - |
| Utah | Yes - Mandatory | CN | $4 per visit | No | - | - |
| Vermont | Yes - Mandatory | CN | No | 5 office visits per month; 1 acute care hospital visit per day; 1 nursing facility visit per week; prior authorization required for certain services and to exceed stated visit limits | - | - |
| Virginia | Yes - Mandatory | CN | $1 per visit | NR | - | - |
| Washington | Yes - Mandatory | CN | No | Some may require prior authorization | - | - |
| West Virginia | Yes - Mandatory | CN | No | No | - | - |
| Wisconsin | Yes - Mandatory | CN | $0.50 - $3, depending on the service. Capped at $30 per physician or clinic, per calendar year. | A small number of services require prior approval. | - | - |
| Wyoming | Yes - Mandatory | CN | $2.45 for non - emergent | Prior authorization is required after the first 12 visits to confirm ongoing medical necessity | - | - |
2012
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 51 No - 0 | Yes - 35 No - 21 | ||||
| Alabama | Yes | CN | $1/office visit - See state-specific FN | 14 ambulatory or nursing facility visits/year; 16 inpatient hospital visits/year; pregnancy, family planning and mental health visits excluded from limit; non-emergency visit to ER counts toward both outpatient and physician visit limits | Fee for service | |
| Alaska | Yes | CN | $3/visit | Fee for service, second and subsequent surgeries performed at same time paid at lesser rate | ||
| Arizona | Yes | CN & MN | $3.40/office visit | Wellness exams not covered; specified transplants not covered, including lung, pancreas alone or after a kidney transplant and heart, liver and stem cell transplants for specified diagnoses | Fee for service | |
| Arkansas | Yes | CN & MN | 12 visits/year irrespective of setting included in limits for other specified practitioners, 2 in-person and 2 telemedicine consultations/year | Specified surgical procedures | Fee for service | |
| California | Yes | CN & MN | $1/visit | Specified surgical procedures including those to be performed on inpatient basis that are normally rendered on outpatient basis, respiratory therapy | Fee for service, some services performed in outpatient hospital setting paid 80% of fee | |
| Colorado | Yes | CN | $2/visit, $.50/15 minute psych service | Specified services | Fee for service | |
| Connecticut | Yes | CN & MN | 1 psych evaluation/year, 1 psych therapy/day | Specified surgical procedures | Fee for service | |
| Delaware | Yes | CN | Fee for service | |||
| District of Columbia | Yes | CN & MN | Specified surgical procedures | Fee for service | ||
| Florida | Yes | CN & MN | $2/day for office or non-emergency outpatient hospital visit | 2 primary care visits/month for non-pregnant adults, 1 non-emergency visit/specialty/day, 1 routine physical exam/year, 1 visit/specialty/month for supervision of chronic illness, 10 prenatal visits/normal pregnancy and 2 postpartum visits within 90 days of delivery /pregnancy | Specified services | Fee for service |
| Georgia | Yes | CN & MN | $.50-$3 for selected services depending on payment rate | 12 office visits/year, 12 nursing facility visits/year | Specified surgical procedures | Fee for service at 84.645% of CMS RBRVS rates for 2000 |
| Hawaii | Yes | CN & MN | Fee for service | |||
| Idaho | Yes | CN | $3.65/non-preventive care visit up to 5% of income/year across all services | 1 wellness exam/year | Fee for service | |
| Illinois | Yes | CN & MN | $3.65/visit | Specified surgical procedures | Fee for service, certified cost for certain government-employed practitioners | |
| Indiana | Yes | CN | 4 visits/month up to 30 visits/year | Specified surgical procedures | Fee for service, services performed with assistance of second surgeon or in outpatient setting rather than office paid reduced fee | |
| Iowa | Yes | CN & MN | $3/office visit/day | Specified procedures and services | Fee for service | |
| Kansas | Yes | CN & MN | $2/visit | 12 office visits/year, 1 inpatient hospital visit/day, 1 nursing facility visit/month, 1 office consultation/2 months, 1 inpatient hospital consultation/10 days | Fee for service | |
| Kentucky | Yes | A, B & C - See state-specific FN | A - $2/visit except maternity care and preventive services | 4 psychotherapy visits/year | Fee for service | |
| Louisiana | Yes | CN & MN | 12 ambulatory visits/year irrespective of setting, 1 preventive care visit/.year, 1 inpatient hospital visit/day | Specified surgical procedures including those to be performed on inpatient basis that are normally rendered on outpatient basis | Fee for service | |
| Maine | Yes | CN & MN | Specified procedures and services | Fee for service | ||
| Maryland | Yes | CN & MN | Specified surgical procedures | Fee for service | ||
| Massachusetts | Yes | CN & MN | 1 office, inpatient hospital or home visit/day, 1 nursing facility visit/month; limits do not apply to emergency services | Specified surgical procedures | Fee for service | |
| Michigan | Yes | CN & MN | $2/office visit not associated with pregnancy or family planning | 10 psychiatric visits/year | Selected procedures | Fee for service |
| Minnesota | Yes | A & B - See state-specific FN | $3/visit for non-preventive and non-maternity service | 3 telemedicine consultations/week | Fee for service | |
| Mississippi | Yes | CN | $3/visit with some exceptions | 12 office, clinic or outpatient hospital visits/year plus a physical exam, 36 nursing facility visits/year, and an additional 12 psych office visits/year | Fee for service using a percentage of Medicare allowable payment as ceiling | |
| Missouri | Yes | CN | $1/day | Fee for service | ||
| Montana | Yes | A & B - See state-specific FN | $4/visit | Specified services | Fee for service | |
| Nebraska | Yes | CN & MN | $2/visit, not applicable to primary care services - see state-specific FN | Fee for service | ||
| Nevada | Yes | CN | Fee for service | |||
| New Hampshire | Yes | CN & MN | Fee for service with payment ceiling for transplants | |||
| New Jersey | Yes | CN & MN | Psych services beyond $900/year, or $400/year for nursing facility residents | Fee for service, cost based payment for vaccines | ||
| New Mexico | Yes | CN | A - $0-$7/visit depending on income, B - $7/visit non-preventive services - see state-specific FN | 2 inpatient hosp or nursing facility visits/day, 3 physical medicine or manipulative therapy visits/month | Specified surgical procedures, allergy testing and treatment | Fee for service, some services performed in hospital setting paid 60% of fee |
| New York | Yes | CN & MN | Beneficiary Specific Utilization Thresholds apply - see state-specific FN, arthroscopic knee surgery limited to specified medical conditions, specified treatments for low back pain considered ineffective not covered | 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 | Specified services | Fee for service |
| North Dakota | Yes | CN & MN | $2/visit | 40 psychotherapy visits/year | Fee for service | |
| Ohio | Yes | CN | 24 visits/year irrespective of setting | Fee for service | ||
| Oklahoma | Yes | CN | $3/visit | 1 inpatient hospital visit/day, 4 non-emergency ambulatory visits/month irrespective of setting | Fee for service | |
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | A & B - services limited to funded conditions on the priority list, specified procedures require a second opinion B - osteopathic manipulative therapy not covered | Specified surgical and therapy procedures | Fee for service, using Medicare Relative Value Units and a state conversion factor |
| Pennsylvania | Yes | CN & MN | $.65-$3.80/service, depending on payment rate | Frequency limits vary by service | Fee for service | |
| Rhode Island | Yes | See state-specific FN | Fee for service | |||
| South Carolina | Yes | CN | 12 visits/year including visits and services provided by other specified practitioners | Fee for service | ||
| South Dakota | Yes | CN | $3/visit | Substance abuse treatment not covered | Fee for service for high volume procedures, percentage of charge for low volume procedures and for supplies | |
| Tennessee | Yes | A, B & C - See state-specific FN | B1 - $5/visit except preventive care and $15/specialty care visit B2 - $15/visit except preventive care and $20/specialty care visit | See state-specific FN | ||
| Texas | Yes | CN & MN | 1 comprehensive preventive exam/year including preventive testing and necessary vaccines | Specified services | Fee for service | |
| Utah | Yes | A, B & C - See state-specific FN | A & B- $3/non-preventive care visit, C - $5/visit | Circumcision not covered, C - primary care only, including routine physical exams | Fee for service, second and subsequent surgeries performed at same time paid a reduced fee, rural physicians may be paid higher fees | |
| Vermont | Yes | A & B - See state-specific FN | 5 office or home visits/month, 1 inpatient acute hospital visit/day and 1 subacute hospital visit/month, 1 nursing facility visit/week | Fee for service, using Medicare Relative Value Units and a state conversion factor | ||
| Virginia | Yes | CN & MN | $1/visit including refractive eye exams, $3/service other than visits | Elective surgical procedures must restore body function, inpatient hosp admissions for specified surgical procedures normally rendered on outpatient basis must be medically justified, routine physical exams not covered, immunizations limited to flu and pneumonia and only for those at risk | Specified services | Fee for service |
| Washington | Yes | CN & MN | 1 inpatient hosp visit/day unless payment is all-inclusive fee, 2 nursing facility visits/month, routine physical exams limited | Specified surgical procedures | Fee for service | |
| West Virginia | Yes | A, B & C | Specified surgical procedures | Fee for service | ||
| Wisconsin | Yes | CN & MN | $.50-$3, depending on service, maximum $30/year/provider except copayment for psychotherapy limited to 15 hours or $825 | Specified surgical procedures require second opinion, 1 nursing facility visit/month | Fee for service | |
| Wyoming | Yes | CN | $2.45/office or home visit | 12 visits/year in combination with nurse practitioner, outpatient hosp and clinic visits | Fee for service | |
| American Samoa | Yes | See territory-specific FN | ||||
| Guam | Yes | CN | 1 inpatient hospital visit/day, 20 psych visits/year, routine physical exams and acupuncture not covered | Fee for service using Medicare fee schedule | ||
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Puerto Rico | Yes | CN & MN | $1/visit | Specialist care requires primary care physician referral, osteopathic physician services not available | Service is included in the capitated rate paid to managed care plans | |
| U.S. Virgin Islands | Yes | CN | Fee for service |
2010
| 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 | $1/office visit - See state-specific FN | 14 ambulatory or nursing facility visits/year; 16 inpatient hospital visits/year; 1 psych evaluation/year; pregnancy, family planning and mental health visits excluded from limit; non-emergency visit to ER counts toward both outpatient and physician visit limits | Fee for service | |
| Alaska | Yes | CN | $3/visit | Fee for service, second and subsequent surgeries performed at same time paid at lesser rate | ||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | $3.40/office visit | Wellness exams not covered; specified transplants not covered, including lung, pancreas alone or after a kidney transplant and heart, liver and stem cell transplants for specified diagnoses | Fee for service | |
| Arkansas | Yes | CN & MN | 12 visits/year irrespective of setting included in limits for other specified practitioners, 2 in-person and 2 telemedicine consultations/year | Specified surgical procedures | Fee for service | |
| California | Yes | CN & MN | $1/visit | Specified surgical procedures including those to be performed on inpatient basis that are normally rendered on outpatient basis, respiratory therapy not personally rendered | Fee for service, some services performed in outpatient hospital setting paid 80% of fee | |
| Colorado | Yes | CN | $2/visit, $.50/15 minute psych service | Specified services | Fee for service | |
| Connecticut | Yes | CN & MN | 1 psych evaluation/year, 1 psych therapy/day | Specified surgical procedures | Fee for service | |
| Delaware | Yes | CN | Fee for service | |||
| District of Columbia | Yes | CN & MN | Specified surgical procedures | Fee for service | ||
| Florida | Yes | CN & MN | $2/day for office or non-emergency outpatient hospital visit | 1 non-emergency visit/day, 1 routine physical exam/year, 10 prenatal visits/pregnancy, 2 postpartum visits/pregnancy | Specified services | Fee for service |
| Georgia | Yes | CN & MN | $.50-$3 for selected services depending on payment rate | 12 office visits/year, 12 nursing facility visits/year | Specified surgical procedures | Fee for service at 84.645% of CMS RBRVS rates for 2000, services performed in outpatient hospital rather than office paid lower fees |
| Guam | Yes | CN | 1 inpatient hospital visit/day, 20 psych visits/year, routine physical exams and acupuncture not covered | Fee for service | ||
| Hawaii | Yes | CN & MN | Fee for service | |||
| Idaho | Yes | CN | 1 wellness exam/year | Fee for service | ||
| Illinois | Yes | CN & MN | $2/visit | Home visits limited to homebound | Specified surgical procedures | Fee for service, certified cost for certain government-employed practitioners |
| Indiana | Yes | CN | 30 visits/year | Specified surgical procedures, procedures exceeding specified cost limits | Fee for service, services performed with assistance of second surgeon or in outpatient setting rather than office paid reduced fee | |
| Iowa | Yes | CN & MN | $3/day, limited to office visits | Specified surgical procedures | Fee for service | |
| Kansas | Yes | CN & MN | $2/visit | 12 office visits/year, 1 inpatient hospital visit/day, 1 nursing facility visit/month, 1 office consultation/2 months, 1 inpatient hospital consultation/10 days | Fee for service | |
| Kentucky | Yes | A, B & C - See state-specific FN | A - $2/visit except maternity care and preventive services | 4 psychotherapy visits/year | Fee for service | |
| Louisiana | Yes | CN & MN | 12 ambulatory visits/year irrespective of setting, 1 preventive care visit/.year, 1 inpatient hospital visit/day | Specified surgical procedures including those to be performed on inpatient basis that are normally rendered on outpatient basis | Fee for service | |
| Maine | Yes | CN & MN | Specified procedures and services | Fee for service | ||
| Maryland | Yes | CN & MN | Specified surgical procedures | Fee for service | ||
| Massachusetts | Yes | CN & MN | 1 office, inpatient hospital or home visit/day, 1 nursing facility visit/month; limits do not apply to emergency services | Specified surgical procedures | Fee for service | |
| Michigan | Yes | CN & MN | $2/visit - see state-specific FN | 10 psychiatric visits/year | Selected procedures | Fee for service |
| Minnesota | Yes | A & B - See state-specific FN | B - $3/visit for non-preventive service | 3 telemedicine consultations/week | Fee for service | |
| Mississippi | Yes | CN | $3/visit | 12 office, clinic or outpatient hospital visits/year, 36 nursing facility visits/year | Fee for service using a percentage of Medicare allowable payment as ceiling | |
| Missouri | Yes | CN | $1/day | Fee for service | ||
| Montana | Yes | A & B - See state-specific FN | $4/visit | Specified services | Fee for service | |
| Nebraska | Yes | CN & MN | $2/visit, not applicable to primary care services - see state-specific FN | Fee for service | ||
| Nevada | Yes | CN | Fee for service | |||
| New Hampshire | Yes | CN & MN | 18 ambulatory visits/year | Fee for service with payment ceiling for transplants | ||
| New Jersey | Yes | CN & MN | Psych services up to $900/year or $400/year for nursing facility residents | Fee for service, cost based payment for vaccines | ||
| New Mexico | Yes | CN | A - $0-$7/visit depending on income, B - $7/visit non-preventive services - see state-specific FN | 2 inpatient hosp or nursing facility visits/day, 3 physical medicine or manipulative therapy visits/month | Specified surgical procedures, allergy testing and treatment | Fee for service, some services performed in hospital setting paid 60% of fee |
| New York | Yes | CN & MN | Beneficiary Specific Utilization Thresholds apply - see state-specific FN | 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; 30 visits/year for PT, OT or SP, with exceptions | Specified services | Fee for service |
| North Dakota | Yes | CN & MN | $2/visit | 40 psychotherapy visits/year | Fee for service | |
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Ohio | Yes | CN | 24 visits/year irrespective of setting | Fee for service | ||
| Oklahoma | Yes | CN | $3/visit | 1 inpatient hospital visit/day, 4 non-emergency ambulatory visits/month irrespective of setting | Fee for service | |
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | A & B - services limited to funded conditions on the priority list, specified procedures require a second opinion B - osteopathic manipulative therapy not covered | Specified surgical and therapy procedures | Fee for service, using Medicare Relative Value Units and a state conversion factor |
| Pennsylvania | Yes | CN & MN | $.50-$3/specified service, depending on payment rate | Frequency limits vary by service | Fee for service | |
| Puerto Rico | Yes | CN & MN | $1/visit | Specialist care requires primary care physician referral, osteopathic physician services not available | Service is included in the capitated rate paid to managed care plans | |
| Rhode Island | Yes | See state-specific FN | Fee for service | |||
| South Carolina | Yes | CN | 12 visits/year including visits and services provided by other specified practitioners | Fee for service | ||
| South Dakota | Yes | CN | $3/visit | Substance abuse treatment not covered | Fee for service for high volume procedures, percentage of charge for low volume procedures and for supplies | |
| Tennessee | Yes | A & B - See state-specific FN | B1 - $5/visit except preventive care and $10/specialty care visit B2 - $10/visit except preventive care and $20/specialty care visit | See state-specific FN | ||
| Texas | Yes | CN & MN | 1 comprehensive preventive exam/year including preventive testing and necessary vaccines | Specified services | Fee for service | |
| Utah | Yes | A, B & C - See state-specific FN | A & B - $3/visit, C - $5/visit | Circumcision not covered, C - primary care only, including routine physical exams | Fee for service, second and subsequent surgeries performed at same time paid a reduced fee, rural physicians may be paid higher fees | |
| Vermont | Yes | A & B - See state-specific FN | 5 office or home visits/month, 1 inpatient acute hospital visit/day and 1 subacute hospital visit/month, 1 nursing facility visit/week | Fee for service, using Medicare Relative Value Units and a state conversion factor | ||
| U.S. Virgin Islands | Yes | CN | Fee for service | |||
| Virginia | Yes | CN & MN | $1/visit including refractive eye exams, $3/service other than visits | Elective surgical procedures must restore body function, inpatient hosp admissions for specified surgical procedures normally rendered on outpatient basis must be medically justified, routine physical exams not covered | Specified services | Fee for service |
| Washington | Yes | CN & MN | 1 inpatient hosp visit/day unless payment is all-inclusive fee, 2 nursing facility visits/month, routine physical exams limited | Specified surgical procedures | Fee for service | |
| West Virginia | Yes | A, B & C | Specified surgical procedures | Fee for service | ||
| Wisconsin | Yes | CN & MN | $.50-$3, depending on service, maximum $30/year/provider except copayment for psychotherapy limited to 15 hours or $825 | Specified surgical procedures require second opinion, 1 nursing facility visit/month | Fee for service | |
| Wyoming | Yes | CN | $2/office or home visit | 12 visits/year in combination with outpatient hosp visits | Fee for service |
2008
| 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 | $1/office visit - See state-specific FN | 14 ambulatory or nursing facility visits/year; 16 inpatient hospital visits/year; 1 psych evaluation/year; pregnancy, family planning and mental health visits excluded from limit; non-emergency visit to ER counts toward both outpatient and physician visit limits | Fee for service | |
| Alaska | Yes | CN | $3/visit | Fee for service, second and subsequent surgeries performed at same time paid at lesser rate | ||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | $1/office visit | Fee for service | ||
| Arkansas | Yes | CN & MN | 12 visits/year irrespective of setting included in limits for other specified practitioners, 2 in-person and 2 telemedicine consultations/year | Specified surgical procedures | Fee for service | |
| California | Yes | CN & MN | $1/visit | Specified surgical procedures including those to be performed on inpatient basis that are normally rendered on outpatient basis, respiratory therapy not personally rendered | Fee for service, some services performed in outpatient hospital setting paid 80% of fee | |
| Colorado | Yes | CN | $2/office or home visit, $.50/15 minute psych service | Fee for service | ||
| Connecticut | Yes | CN & MN | 1 psych evaluation/year, 1 psych therapy/day | Specified surgical procedures | Fee for service | |
| Delaware | Yes | CN | Fee for service | |||
| District of Columbia | Yes | CN & MN | Specified surgical procedures | Fee for service | ||
| Florida | Yes | CN & MN | $2/day for office or non-emergency outpatient hospital visit | 1 non-emergency visit/day, 1 routine physical exam/year, 10 prenatal visits/pregnancy, 2 postpartum visits/pregnancy | Specified services | Fee for service |
| Georgia | Yes | CN & MN | $.50-$3 for selected services depending on payment rate | 12 office visits/year, 12 nursing facility visits/year | Specified surgical procedures | Fee for service at 84.645% of CMS RBRVS rates for 2000, services performed in outpatient hospital rather than office paid lower fees |
| Guam | Yes | CN | 1 inpatient hospital visit/day, 20 psych visits/year, routine physical exams and acupuncture not covered | Fee for service | ||
| Hawaii | Yes | CN & MN | Fee for service | |||
| Idaho | Yes | CN | 1 wellness exam/year | Fee for service | ||
| Illinois | Yes | CN & MN | $2/visit | Home visits limited to homebound | Specified surgical procedures | Fee for service, certified cost for certain government-employed practitioners |
| Indiana | Yes | CN | 30 visits/year | Specified surgical procedures, procedures exceeding specified cost limits | Fee for service, services performed with assistance of second surgeon or in outpatient setting rather than office paid reduced fee | |
| Iowa | Yes | CN & MN | $3/day, limited to office visits | Specified surgical procedures | Fee for service | |
| Kansas | Yes | CN & MN | $2/visit | 12 office visits/year, 1 inpatient hospital visit/day, 1 nursing facility visit/month, 1 office consultation/2 months, 1 inpatient hospital consultation/10 days | Fee for service | |
| Kentucky | Yes | A, B & C - See state-specific FN | A - $2/visit except maternity care and preventive services | 4 psychotherapy visits/year | Fee for service | |
| Louisiana | Yes | CN & MN | 12 ambulatory visits/year irrespective of setting, 1 preventive care visit/.year, 1 inpatient hospital visit/day | Specified surgical procedures including those to be performed on inpatient basis that are normally rendered on outpatient basis | Fee for service | |
| Maine | Yes | CN & MN | $.50-$2/day, depending on payment, up to $20/month | Specified procedures and services | Fee for service | |
| Maryland | Yes | CN & MN | Specified surgical procedures | Fee for service | ||
| Massachusetts | Yes | CN & MN | 1 office, inpatient hospital or home visit/day, 1 nursing facility visit/month | Specified surgical procedures | Fee for service | |
| Michigan | Yes | CN & MN | $2/visit - see state-specific FN | 10 psychiatric visits/year | Selected procedures | Fee for service |
| Minnesota | Yes | A & B - See state-specific FN | $3/visit for non-preventive service | 3 telemedicine consultations/week | Fee for service | |
| Mississippi | Yes | CN | $3/visit | 12 office, clinic or outpatient hospital visits/year, 36 nursing facility visits/year | Fee for service using a percentage of Medicare allowable payment as ceiling | |
| Missouri | Yes | CN | $1/day | Specified procedures require a second opinion | Fee for service | |
| Montana | Yes | A & B - See state-specific FN | $4/visit | Specified services | Fee for service | |
| Nebraska | Yes | CN & MN | $2/visit, not applicable to primary care services - see state-specific FN | Telemedicine consultations require minimum 30 mile distance | Fee for service | |
| Nevada | Yes | CN | Fee for service | |||
| New Hampshire | Yes | CN & MN | 18 ambulatory visits/year | Fee for service with payment ceiling for transplants | ||
| New Jersey | Yes | CN & MN | Psych services up to $900/year or $400 for nursing facility residents | Fee for service, cost based payment for vaccines | ||
| New Mexico | Yes | CN | A - $5/visit, B - $7/visit non-preventive services - see state-specific FN | 2 inpatient hospital or NF visits/day, 3 physical medicine or manipulative therapy visits/month | Specified surgical procedures, allergy testing and treatment | Fee for service, some services performed in hospital setting paid 60% of fee |
| New York | Yes | CN & MN | 10 visits/year in combination with other specified providers | 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 | Specified services | Fee for service |
| North Dakota | Yes | CN & MN | $2/visit | 40 psychotherapy visits/year | Fee for service | |
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Ohio | Yes | CN | 24 visits/year irrespective of setting | Fee for service | ||
| Oklahoma | Yes | CN | $1/service | 1 inpatient hospital visit/day, 4 non-emergency ambulatory visits/month irrespective of setting | Fee for service | |
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | A & B - specified procedures require a second opinion, B - osteopathic manipulative therapy not covered | Specified surgical and therapy procedures | Fee for service, second and subsequent surgeries performed at same time paid a reduced fee |
| Pennsylvania | Yes | CN & MN | $.50-$3/specified service, depending on payment rate | Frequency limits vary by service | Fee for service | |
| Puerto Rico | Yes | CN & MN | Specialist care requires primary care physician referral | Fee for service with capitated payment for primary care | ||
| Rhode Island | Yes | CN & MN - see state-specific FN | 3 patients/home visit, 6 patients/group care facility, MN limited 37 inpatient hospital visits/year | Specified surgical procedures, MN only - multiple visits for chronic and acute diagnoses, psych visits after evaluation | Fee for service | |
| South Carolina | Yes | CN | 12 visits/year including visits and services provided by other specified practitioners | Fee for service | ||
| South Dakota | Yes | CN | $3/visit | Substance abuse treatment not covered | Fee for service for high volume procedures, percentage of charge for low volume procedures and for supplies | |
| Tennessee | Yes | A & B - See state-specific FN | B1 - $5/visit except preventive care and $15/specialty care visit, B2 - $10/visit except preventive care and $25/specialty care visit | |||
| Texas | Yes | CN & MN | Specified services | Fee for service | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B - $3/visit, C - $5/visit | Circumcision not covered, C - primary care only, including routine physical exams | Fee for service, second and subsequent surgeries performed at same time paid a reduced fee, rural physicians may be paid higher fees | |
| Vermont | Yes | A & B - See state-specific FN | 5 office or home visits/month, 1 inpatient hospital visit/day, 1 nursing facility visit/week | Fee for service | ||
| U.S. Virgin Islands | Yes | CN | Fee for service | |||
| Virginia | Yes | CN & MN | $1/visit including refractive eye exams, $3/service other than visits | Elective surgical procedures must restore body function, inpatient hospital admissions for specified surgical procedures normally rendered on outpatient basis must be medically justified, routine physical exams not covered | Fee for service | |
| Washington | Yes | CN & MN | 1 inpatient hospital visit/day unless payment is all-inclusive fee, 2 nursing facility visits/month, routine physical exams limited | Specified surgical procedures | Fee for service | |
| West Virginia | Yes | A, B & C | Specified surgical procedures | Fee for service | ||
| Wisconsin | Yes | CN & MN | $.50-$3, depending on service, $1/EPSDT screening for beneficiary over age 18, maximum $30/year/provider except copayment for psychotherapy limited to 15 hours or $500 | Specified surgical procedures require second opinion, 1 nursing facility visit/month | Fee for service | |
| Wyoming | Yes | CN | $2/office or home visit | 12 visits/year in combination with outpatient hospital visits | Fee for service |
2006
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 56 No - 0 | Yes - 31 No - 25 | ||||
| Alabama | Yes | CN | $1/office visit - See state-specific FN | 14 ambulatory or nursing facility visits/year; 16 inpatient hospital visits/year; 1 psych evaluation/year; pregnancy, family planning and mental health visits excluded from limit; non-emergency visit to ER counts toward both outpatient and physician visit limits | Fee for service | |
| Alaska | Yes | CN | $3/visit | Fee for service, second and subsequent surgeries performed at same time paid at lesser rate | ||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | $1/office visit | Fee for service | ||
| Arkansas | Yes | CN & MN | 12 visits/year irrespective of setting included in limits for other specified practitioners, 2 in-person and 2 telemedicine consultations/year | Specified surgical procedures | Fee for service | |
| California | Yes | CN & MN | $1/visit | Specified surgical procedures including those to be performed on inpatient basis that are normally rendered on outpatient basis, respiratory therapy not personally rendered | Fee for service, some services performed in outpatient hospital setting paid 80% of fee | |
| Colorado | Yes | CN | $2/office or home visit, $.50/15 minute psych service | Fee for service | ||
| Connecticut | Yes | CN & MN | 1 psych evaluation/year, 1 psych therapy/day | Specified surgical procedures | Fee for service | |
| Delaware | Yes | CN | Fee for service | |||
| District of Columbia | Yes | CN & MN | Specified surgical procedures | Fee for service | ||
| Florida | Yes | CN & MN | $2/day for office or non-emergency outpatient hospital visit | 1 non-emergency visit/day, 1 routine physical exam/year, 10 prenatal visits/year, 2 postpartum visits/year | Specified services | Fee for service |
| Georgia | Yes | CN & MN | $.50-$3 for selected services depending on payment rate | 12 office visits/year, 12 nursing facility visits/year | Specified surgical procedures | Fee for service, services performed in outpatient hospital clinic rather than office paid lower fees |
| Guam | Yes | CN | 1 inpatient hospital visit/day, 20 psych visits/year, routine physical exams and acupuncture not covered | Fee for service | ||
| Hawaii | Yes | CN & MN | 2 nursing facility visits/month | Fee for service | ||
| Idaho | Yes | CN | 1 wellness exam/year, naturopathic services not covered | Fee for service | ||
| Illinois | Yes | CN & MN | $2/visit | Home visits limited to homebound | Specified surgical procedures | Fee for service, certified cost for certain government-employed practitioners |
| Indiana | Yes | CN | 30 office visits/year/provider or provider group | Specified surgical procedures, procedures exceeding specified cost limits | Fee for service, services performed with assistance of second surgeon or in outpatient setting rather than office paid reduced fee | |
| Iowa | Yes | CN & MN | $3/day, limited to office visits | Specified surgical procedures | Fee for service | |
| Kansas | Yes | CN & MN | $2/visit | 12 office visits/year, 32 hours psychotherapy/year in combination with other providers, 1 inpatient hospital visit/day, 1 nursing facility visit/month, 1 office consultation/2 months, 1 inpatient hospital consultation/10 days | Fee for service | |
| Kentucky | Yes | A, B & C - See state-specific FN | A - $2/visit except maternity care and preventive services | 4 psychotherapy visits/year | Fee for service | |
| Louisiana | Yes | CN & MN | 12 ambulatory visits/year irrespective of setting, 1 inpatient hospital visit/day | Specified surgical procedures including those to be performed on inpatient basis that are normally rendered on outpatient basis | Fee for service | |
| Maine | Yes | CN & MN | $.50-$2/day, depending on payment, up to $20/month | Specified procedures and services | Fee for service | |
| Maryland | Yes | CN & MN | Specified surgical procedures | Fee for service | ||
| Massachusetts | Yes | CN & MN | 1 office, inpatient hospital or home visit/day, 1 nursing facility visit/month | Specified surgical procedures | Fee for service | |
| Michigan | Yes | CN & MN | $2/visit - see state-specific FN | 10 psychiatric visits/year | Fee for service | |
| Minnesota | Yes | A & B - See state-specific FN | $3/visit for non-preventive service | 3 telemedicine consultations/week | Fee for service | |
| Mississippi | Yes | CN | $3/visit | 12 office, clinic or outpatient hospital visits/year, 36 nursing facility visits/year | Fee for service using a percentage of Medicare allowable payment as ceiling | |
| Missouri | Yes | CN | $1/day | Specified procedures require a second opinion | Fee for service | |
| Montana | Yes | A & B - See state-specific FN | $4/visit | Specified services | Fee for service | |
| Nebraska | Yes | CN & MN | $2/visit, not applicable to primary care services - see state-specific FN | Telemedicine consultations require minimum 30 mile distance | Fee for service | |
| Nevada | Yes | CN | Fee for service | |||
| New Hampshire | Yes | CN & MN | 18 ambulatory visits/year irrespective of setting, surgical procedures include pre- and post-operative care | Fee for service with payment ceiling for transplants | ||
| New Jersey | Yes | CN & MN | Psych services up to $900/year or $400 for nursing facility residents | Fee for service, cost based payment for vaccines | ||
| New Mexico | Yes | CN | A - $5/visit, B - $7/visit non-preventive services - see state-specific FN | 2 inpatient hospital or NF visits/day, 3 physical medicine or manipulative therapy visits/month | Specified surgical procedures, allergy testing and treatment | Fee for service, some services performed in hospital setting paid 60% of fee |
| New York | Yes | CN & MN | 10 visits/year in combination with other specified providers | Fee for service | ||
| North Carolina | Yes | CN & MN | $3/visit | 24 ambulatory visits/year included in limits with other specified practitioners, 1 routine health assessment exam/year | Specified services | Fee for service |
| North Dakota | Yes | CN & MN | $2/visit | 40 psychotherapy visits/year | Fee for service | |
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Ohio | Yes | CN | 24 visits/year irrespective of setting | Fee for service | ||
| Oklahoma | Yes | CN | $1/service | 1 inpatient hospital visit/day, 4 non-emergency ambulatory visits/month irrespective of setting | Fee for service | |
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | A & B - specified procedures require a second opinion, B - osteopathic manipulative therapy not covered | Specified surgical and therapy procedures | Fee for service, second and subsequent surgeries performed at same time paid a reduced fee |
| Pennsylvania | Yes | CN & MN | $.50-$3/specified service, depending on payment | Frequency limits vary by service | Fee for service with maximums/day dependent on setting, anesthesia paid using Medicare methodology | |
| Puerto Rico | Yes | CN & MN | Specialist care requires primary care physician referral | Fee for service with capitated payment for primary care | ||
| Rhode Island | Yes | CN & MN - see state-specific FN | 3 patients/home visit, 6 patients/group care facility, MN limited 37 inpatient hospital visits/year | Specified surgical procedures, MN only - multiple visits for chronic and acute diagnoses, psych visits after evaluation | Fee for service | |
| South Carolina | Yes | CN | $2/visit | 12 visits/year including initial psych visits and specified services provided by nurse practitioners | Fee for service | |
| South Dakota | Yes | CN | $3/visit | Substance abuse treatment not covered | Fee for service for high volume procedures, percentage of charge for low volume procedures and for supplies | |
| Tennessee | Yes | A & B - See state-specific FN | B1 - $5/visit except preventive care and $15/specialty care visit, B2 - $10/visit except preventive care and $25/specialty care visit | |||
| Texas | Yes | CN & MN | Specified services | Fee for service | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B - $3/visit, C - $5/visit | Circumcision not covered, C - primary care only, including routine physical exams | Fee for service, second and subsequent surgeries performed at same time paid a reduced fee, rural physicians may be paid higher fees | |
| Vermont | Yes | A & B - See state-specific FN | 5 office or home visits/month, 1 inpatient hospital visit/day, 1 nursing facility visit/week, $500/year limit on psychotherapy | Fee for service | ||
| U.S. Virgin Islands | Yes | CN | Fee for service | |||
| Virginia | Yes | CN & MN | $1/visit including refractive eye exams, $3/service other than visits | Elective surgical procedures must restore body function, inpatient hospital admissions for specified surgical procedures normally rendered on outpatient basis must be medically justified, routine physical exams not covered | Fee for service, some services performed in outpatient hospital setting paid 50% of fee, assistant surgeons paid 20% of fee | |
| Washington | Yes | CN & MN | 1 inpatient hospital visit/day unless payment is all-inclusive fee, 2 nursing facility visits/month, routine physical exams limited | Specified surgical procedures | Fee for service | |
| West Virginia | Yes | CN & MN | Specified surgical procedures | Fee for service | ||
| Wisconsin | Yes | CN & MN | $.50-$3, depending on service, $1/EPSDT screening for beneficiary over age 18, maximum $30/year/provider except copayment for psychotherapy limited to 15 hours or $500 | Specified surgical procedures require second opinion, 1 nursing facility visit/month | Fee for service | |
| Wyoming | Yes | CN | $2/office or home visit | 12 visits/year in combination with outpatient hospital visits | 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 | $1/office visit - See state-specific FN | 14 ambulatory or nursing facility visits/year; 16 inpatient hospital visits/year; 1 psych evaluation/year; pregnancy, family planning and mental health visits excluded from limit | Fee for service | |
| Alaska | Yes | CN | $3/visit | Fee for service, second and subsequent surgeries performed at same time paid at lesser rate | ||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | $1/office or home visit | Fee for service | ||
| Arkansas | Yes | CN & MN | 12 visits/year irrespective of setting included in limits for other specified practitioners, 2 in-person and 2 telemedicine consultations/year | Specified surgical procedures | Fee for service | |
| California | Yes | CN & MN | $1/visit | Specified surgical procedures including those to be performed on inpatient basis that are normally rendered on outpatient basis, respiratory therapy not personally rendered | Fee for service, some services performed in outpatient hospital setting paid 80% of fee | |
| Colorado | Yes | CN | $2/office or home visit, $.50/15 minute psych service | Fee for service | ||
| Connecticut | Yes | CN & MN | 1 psych evaluation/year, 1 psych therapy/day | Specified surgical procedures | Fee for service | |
| Delaware | Yes | CN | Fee for service | |||
| District of Columbia | Yes | CN & MN | Specified surgical procedures | Fee for service | ||
| Florida | Yes | CN & MN | $2/day for office or non-emergency outpatient hospital visit | 1 non-emergency visit/day, 1 routine physical exam/year, 10 prenatal visits/year, 2 postpartum visits/year | Fee for service or prospective cost based rate | |
| Georgia | Yes | CN & MN | $2/office visit | 12 office visits/year, 1 inpatient hospital visit/day, 12 nursing facility visits/year | Specified surgical procedures | Fee for service |
| Guam | Yes | CN | 1 inpatient hospital visit/day, 20 psych visits/year, routine physical exams and acupuncture not covered | Fee for service | ||
| Hawaii | Yes | CN & MN | 2 nursing facility visits/month | Fee for service | ||
| Idaho | Yes | CN | Naturopathic services not covered | Fee for service | ||
| Illinois | Yes | CN & MN | $2/visit | Home visits limited to homebound | Specified surgical procedures | Fee for service, certified cost for certain government-employed practitioners |
| Indiana | Yes | CN | 20 office visits/year/provider or provider group | Specified surgical procedures, procedures exceeding specified cost limits | Fee for service, services performed with assistance of second surgeon or in outpatient setting rather than office paid reduced fee | |
| Iowa | Yes | CN & MN | $3/day, limited to office visits | Specified surgical procedures | Fee for service | |
| Kansas | Yes | CN & MN | $2/visit | 12 office visits/year, 32 hours psychotherapy/year in combination with other providers, 1 inpatient hospital visit/day, 1 nursing facility visit/month, 1 office consultation/2 months, 1 inpatient hospital consultation/10 days | Fee for service | |
| Kentucky | Yes | CN & MN | $2/visit for specified vision services only | 4 psychotherapy visits/year | Fee for service | |
| Louisiana | Yes | CN & MN | 12 ambulatory visits/year irrespective of setting, 1 inpatient hospital visit/day | Specified surgical procedures including those to be performed on inpatient basis that are normally rendered on outpatient basis | Fee for service | |
| Maine | Yes | CN & MN | $.50-$2/day, depending on payment, up to $20/month | Specified procedures and services | Fee for service | |
| Maryland | Yes | CN & MN | Specified surgical procedures | Fee for service | ||
| Massachusetts | Yes | CN & MN | 1 office, inpatient hospital or home visit/day, 1 nursing facility visit/month | Specified surgical procedures | Fee for service | |
| Michigan | Yes | CN & MN | 1 nursing facility visit/month, 5 psych visits/year by general practitioner and 10 visits/year by psychiatrist | Fee for service | ||
| Minnesota | Yes | A & B - See state-specific FN | $3/visit for non-preventive service | 3 telemedicine consultations/week | Fee for service | |
| Mississippi | Yes | CN | $3/visit | 12 office, clinic or outpatient hospital visits/year, 36 nursing facility visits/year | Fee for service using a percentage of Medicare allowable payment as ceiling | |
| Missouri | Yes | CN | $1/visit (non-emergency outpatient hospital service only) - See state-specific FN | Specified procedures require a second opinion | Fee for service | |
| Montana | Yes | A & B - See state-specific FN | $4/visit | Specified services | Fee for service | |
| Nebraska | Yes | CN & MN | $2/visit (specialist only) - see state-specific FN | Telemedicine consultations require minimum 30 mile distance | Fee for service | |
| Nevada | Yes | CN | Fee for service | |||
| New Hampshire | Yes | CN & MN | 18 ambulatory visits/year irrespective of setting, surgical procedures include pre- and post-operative care | Fee for service with payment ceiling for transplants | ||
| New Jersey | Yes | CN & MN | Psych services up to $900/year or $400 for nursing facility residents | Fee for service, cost based payment for vaccines | ||
| New Mexico | Yes | CN | B - $7/visit non-preventive services - see state-specific FN | 2 inpatient hospital or NF visits/day, 3 physical medicine or manipulative therapy visits/month | Specified surgical procedures, allergy testing and treatment | Fee for service, some services performed in hospital setting paid 60% of fee |
| New York | Yes | CN & MN | 10 visits/year in combination with other specified providers | Fee for service | ||
| North Carolina | Yes | CN & MN | $3/visit | 24 ambulatory visits/year included in limits with other specified practitioners, 1 routine health assessment exam/year | Specified services | Fee for service |
| North Dakota | Yes | CN & MN | $2/visit | 40 psychotherapy visits/year | Fee for service | |
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Ohio | Yes | CN | 24 visits/year irrespective of setting | Fee for service | ||
| Oklahoma | Yes | CN | $1/service | 1 inpatient hospital visit/day, 4 non-emergency ambulatory visits/month irrespective of setting | Fee for service | |
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | A & B - specified procedures require a second opinion, B - osteopathic manipulative therapy not covered | Specified surgical and therapy procedures | Fee for service, second and subsequent surgeries performed at same time paid a reduced fee |
| Pennsylvania | Yes | CN & MN | $.50-$3/specified service, depending on payment | Specified limits dependent upon care setting | Fee for service with maximums/day dependent on setting, second and subsequent surgeries performed at same time paid a reduced fee | |
| Puerto Rico | Yes | CN & MN | Specialist care requires primary care physician referral | Fee for service for contracted staff, cost based payment for public health staff | ||
| Rhode Island | Yes | CN & MN - see state-specific FN | 3 patients/home visit, 6 patients/group care facility, MN limited 37 inpatient hospital visits/year | Specified surgical procedures, MN only - multiple visits for chronic and acute diagnoses, psych visits after evaluation | Fee for service | |
| South Carolina | Yes | CN | $2/visit | 12 visits/year including initial psych visits and specified services provided by nurse practitioners | Fee for service | |
| South Dakota | Yes | CN | $2/visit | Substance abuse treatment not covered | Fee for service for high volume procedures, percentage of charge for low volume procedures and for supplies | |
| Tennessee | Yes | A & B - See state-specific FN | B1 - $5/visit except preventive care and $15/specialty care visit, B2 - $10/visit except preventive care and $25/specialty care visit | |||
| Texas | Yes | CN & MN | Specified services | Fee for service | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B - $3/visit, C - $5/visit | Circumcision not covered, C - primary care only, including routine physical exams | Fee for service, second and subsequent surgeries performed at same time paid a reduced fee, rural physicians may be paid higher fees | |
| Vermont | Yes | A & B - See state-specific FN | 5 office or home visits/month, 1 inpatient hospital visit/day, 1 nursing facility visit/week, $500/year limit on psychotherapy with some exceptions | Fee for service | ||
| U.S. Virgin Islands | Yes | CN | Fee for service | |||
| Virginia | Yes | CN & MN | $1/visit including refractive eye exams, $3/service other than visits | Elective surgical procedures must restore body function, inpatient hospital admissions for specified surgical procedures normally rendered on outpatient basis must be medically justified, routine physical exams not covered | Fee for service, some services performed in outpatient hospital setting paid 50% of fee, assistant surgeons paid 20% of fee | |
| Washington | Yes | CN & MN | 1 inpatient hospital visit/day unless payment is all-inclusive fee, 2 nursing facility visits/month, routine physical exams limited | Specified surgical procedures | Fee for service | |
| West Virginia | Yes | CN & MN | Specified surgical procedures | Fee for service | ||
| Wisconsin | Yes | CN & MN | $.50-$3, depending on service, $1/EPSDT screening for beneficiary over age 18, maximum $30/year/provider except copayment for psychotherapy limited to 15 hours or $500 | Specified surgical procedures require second opinion, 1 nursing facility visit/month | Fee for service | |
| Wyoming | Yes | CN | $2/office or home visit | 12 visits/year in combination with outpatient hospital 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 | $1/office visit - See state-specified FN | 14 ambulatory visits/year irrespective of setting including psychotherapy, 16 inpatient hospital visits/year, 1 psych evaluation/year | Fee for service | |
| Alaska | Yes | CN | $3/day | Fee for service, second and subsequent surgeries performed at same time paid at lesser rate | ||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | $1/office or home visit | Fee for service | ||
| Arkansas | Yes | CN & MN | 12 visits/year irrespective of setting included in limits for other specified practitioners, 2 in-person and 2 telemedicine consultations/year | Specified surgical procedures | Fee for service | |
| California | Yes | CN & MN | $1/visit | Specified surgical procedures including those to be performed on inpatient basis that are normally rendered on outpatient basis, respiratory therapy not personally rendered | Fee for service, some services performed in outpatient hospital setting paid 80% of fee | |
| Colorado | Yes | CN | $2/office or home visit, $.50/15 minute psych service | Fee for service | ||
| Connecticut | Yes | CN & MN | 1 psych evaluation/year, 1 psych therapy/day | Specified surgical procedures | Fee for service | |
| Delaware | Yes | CN | Fee for service | |||
| District of Columbia | Yes | CN & MN | Specified surgical procedures | Fee for service | ||
| Florida | Yes | CN & MN | $2/day for office or non-emergency outpatient hospital visit | 1 non-emergency visit/day, 1 routine physical exam/year, 10 prenatal visits/year, 2 postpartum visits/year | Fee for service or prospective cost based rate | |
| Georgia | Yes | CN & MN | $2/office visit | 12 office visits/year, 1 inpatient hospital visit/day, 12 nursing facility visits/year | Specified surgical procedures | Fee for service |
| Guam | Yes | CN | 1 inpatient hospital visit/day, 20 psych visits/year, routine physical exams and acupuncture not covered | Fee for service | ||
| Hawaii | Yes | CN & MN | 2 nursing facility visits/month | Fee for service | ||
| Idaho | Yes | CN | Naturopathic services not covered | Fee for service | ||
| Illinois | Yes | CN & MN | $2/visit | Home visits limited to homebound | Specified surgical procedures | Fee for service, certified cost for certain government-employed practitioners |
| Indiana | Yes | CN | 20 office visits/year/provider or provider group | Specified surgical procedures, procedures exceeding specified cost limits | Fee for service, services performed with assistance of second surgeon or in outpatient setting rather than office paid reduced fee | |
| Iowa | Yes | CN & MN | $3/day, limited to office visits | Specified surgical procedures | Fee for service | |
| Kansas | Yes | CN & MN | $2/visit | 12 office visits/year, 32 hours psychotherapy/year in combination with other providers, 1 inpatient hospital visit/day, 1 nursing facility visit/month, 1 office consultation/2 months, 1 inpatient hospital consultation/10 days | Fee for service | |
| Kentucky | Yes | CN & MN | 4 psychotherapy visits/year | Fee for service | ||
| Louisiana | Yes | CN & MN | 12 ambulatory visits/year irrespective of setting, 1 inpatient hospital visit/day | Specified surgical procedures including those to be performed on inpatient basis that are normally rendered on outpatient basis | Fee for service | |
| Maine | Yes | CN & MN | $.50-$2/day, depending on payment, up to $20/month | Specified procedures and services | Fee for service | |
| Maryland | Yes | CN & MN | Specified surgical procedures | Fee for service | ||
| Massachusetts | Yes | CN & MN | 1 office, inpatient hospital or home visit/day, 1 nursing facility visit/month | Specified surgical procedures | Fee for service | |
| Michigan | Yes | CN & MN | 1 nursing facility visit/month, 5 psych visits/year by general practitioner and 10 visits/year by psychiatrist | Fee for service | ||
| Minnesota | Yes | A & B - See state-specific FN | A - $3/visit for non-preventive service | 3 telemedicine consultations/week | Fee for service | |
| Mississippi | Yes | CN | $3/visit | 12 office, clinic or outpatient hospital visits/year, 36 nursing facility visits/year | Fee for service using a percentage of Medicare allowable payment as ceiling | |
| Missouri | Yes | CN | $1/visit (non-emergency outpatient hospital service only) | Specified procedures require a second opinion | Fee for service | |
| Montana | Yes | CN & MN | $4/visit | Specified services | Fee for service | |
| Nebraska | Yes | CN & MN | $2/visit (specialist only) - see state-specific FN | Telemedicine consultations require minimum 30 mile distance | Fee for service | |
| Nevada | Yes | CN | Fee for service | |||
| New Hampshire | Yes | CN & MN | 18 ambulatory visits/year irrespective of setting, surgical procedures include pre- and post-operative care | Fee for service with payment ceiling for transplants | ||
| New Jersey | Yes | CN & MN | Psych services up to $900/year or $400 for nursing facility residents | Fee for service, cost based payment for vaccines | ||
| New Mexico | Yes | CN | B - $5/visit non-preventive services - see state-specific FN | 2 inpatient hospital visits/day | Specified surgical procedures, allergy testing and treatment | Fee for service, some services performed in hospital setting paid 60% of fee |
| New York | Yes | CN & MN | 10 visits/year in combination with other specified providers | Fee for service | ||
| North Carolina | Yes | CN & MN | $3/visit | 24 ambulatory visits/year included in limits with other specified practitioners, 1 routine health assessment exam/year | Specified services | Fee for service |
| North Dakota | Yes | CN & MN | $2/visit | Fee for service | ||
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Ohio | Yes | CN | 24 ambulatory visits/year irrespective of setting, 20 physical medicine visits/year | Fee for service | ||
| Oklahoma | Yes | CN & MN | $1/service | 1 inpatient hospital visit/day, 2 non-emergency ambulatory visits/month irrespective of setting | Fee for service | |
| Oregon | Yes | CN & MN | $3/visit | Specified procedures require a second opinion | Specified surgical and therapy procedures | Fee for service, second and subsequent surgeries performed at same time paid a reduced fee |
| Pennsylvania | Yes | CN & MN | $.50-$3/specified service, depending on payment | Specified limits dependent upon care setting | Fee for service with maximums/day dependent on setting, second and subsequent surgeries performed at same time paid a reduced fee | |
| Puerto Rico | Yes | CN & MN | Specialist care requires primary care physician referral | Fee for service for contracted staff, cost based payment for public health staff | ||
| Rhode Island | Yes | CN & MN - see state-specific FN | 3 patients/home visit, 6 patients/group care facility, MN limited 37 inpatient hospital visits/year | Specified surgical procedures, MN only - multiple visits for chronic and acute diagnoses, psych visits after evaluation | Fee for service | |
| South Carolina | Yes | CN | 12 visits/year including initial psych visits and specified services provided by nurse practitioners | Fee for service, physician case manager can opt for alternative method with volume incentives | ||
| South Dakota | Yes | CN | $2/visit | Substance abuse treatment not covered | Fee for service for high volume procedures, percentage of charge for low volume procedures and for supplies | |
| Tennessee | Yes | A & B - See state-specific FN | B1 - $5/visit except preventive care and $15/specialty care visit, B2 - $10/visit except preventive care and $25/specialty care visit | |||
| Texas | Yes | CN & MN | Specified services | Fee for service | ||
| Utah | Yes | A, B & C - See state specific FN | A - $2/visit, B - $3/visit, C - $5/visit | C - primary care only, including routine physical exams | Fee for service, second and subsequent surgeries performed at same time paid a reduced fee, rural physicians may be paid higher fees | |
| Vermont | Yes | A & B - See state-specific FN | B - $7/visit | 5 office or home visits/month, 1 inpatient hospital visit/day, 1 nursing facility visit/week, $500/year limit on psychotherapy with some exceptions | Fee for service | |
| U.S. Virgin Islands | Yes | CN | Fee for service | |||
| Virginia | Yes | CN & MN | $1/visit, $3/service other than visits | Elective surgical procedures must restore body function, inpatient hospital admissions for specified surgical procedures normally rendered on outpatient basis must be medically justified, routine physical exams not covered | Fee for service, some services performed in outpatient hospital setting paid 50% of fee, assistant surgeons paid 20% of fee | |
| Washington | Yes | CN & MN | 1 inpatient hospital visit/day unless payment is all-inclusive fee, 2 nursing facility visits/month, routine physical exams limited | Specified surgical procedures | Fee for service | |
| West Virginia | Yes | CN & MN | Specified surgical procedures | Fee for service | ||
| Wisconsin | Yes | CN & MN | $.50-$3, depending on service up to $30/year | Specified surgical procedures require second opinion, 1 nursing facility visit/month | Fee for service | |
| Wyoming | Yes | CN | $2/office or home visit | 12 visits/year in combination with outpatient hospital visits | Fee for service |