Medicaid Benefits: Rural Health Clinic 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 | $3.90 each visit | limit of 14 office visits and 16 inpatient hospital visits | - | - |
| Alaska | Yes - Mandatory | CN | $3 | No | - | - |
| Arizona | Yes - Mandatory | CN | No | Prior authorization only | - | - |
| Arkansas | Yes - Mandatory | CN | NR | NR | - | - |
| California | Yes - Mandatory | CN | $1/visit | No | - | - |
| Colorado | Yes - Mandatory | CN | $2 per visit | No | - | - |
| Connecticut | Yes - Mandatory | CN | - | - | ||
| Delaware | Yes - Mandatory | CN | No | No | - | - |
| District of Columbia | Yes - Mandatory | CN | No | No | - | - |
| Florida | Yes - Mandatory | CN | Rural health clinic visit, per clinic, $3.00 per day | Up to one visit per recipient, per day for urgent care, primary and preventive care services, dental, an behavioral health services. Must Comply with Title 42, Code of Federal Regulations, parts 440 & 491. | - | - |
| Georgia | Yes - Mandatory | CN | $2 copay | Must be medically necessary. | - | - |
| Hawaii | Yes - Mandatory | CN | No | No | - | - |
| Idaho | Yes - Mandatory | CN | No | No | - | - |
| Illinois | Yes - Mandatory | CN | NR | NR | - | - |
| Indiana | Yes - Mandatory | CN | No | Limitations vary by service. | - | - |
| Iowa | Yes - Mandatory | CN | NR | NR | - | - |
| Kansas | Yes - Mandatory | CN | $2.00 per visit | Allow one encounter per day | - | - |
| Kentucky | Yes - Mandatory | CN | $3 | No | - | - |
| Louisiana | Yes - Mandatory | CN | No | No | - | - |
| Maine | Yes - Mandatory | CN | $.50 to $3/day depending on payment amount, up to $30/month | Service limits in the RHCs are the same as for providers in other settings | - | - |
| Maryland | Yes - Mandatory | CN | No | No | - | - |
| Massachusetts | Yes - Mandatory | CN | No | No | - | - |
| Michigan | Yes - Mandatory | CN | No | No | - | - |
| Minnesota | Yes - Mandatory | CN | $3 copay for non-preventive office visits | No | - | - |
| Mississippi | Yes - Mandatory | CN | $3 per visit | NR | - | - |
| Missouri | Yes - Mandatory | CN | $2 | There are daily quantity limits on services. | - | - |
| Montana | Yes - Mandatory | CN | Income at or below 100% FPL - $4 per visit; above FPL - 10% of payment amount | No | - | - |
| Nebraska | Yes - Mandatory | CN | No | No | - | - |
| Nevada | Yes - Mandatory | CN | NR | NR | - | - |
| New Hampshire | Yes - Mandatory | CN | No | NR | - | - |
| New Jersey | Yes - Mandatory | CN | No | No | - | - |
| New Mexico | Yes - Mandatory | CN | $7 for WDI recipients | No | - | - |
| New York | Yes - Mandatory | CN | NR | NR | - | - |
| North Carolina | Yes - Mandatory | CN | $1 - $3 depending on the service | 22 visits per year | - | - |
| North Dakota | Yes - Mandatory | CN | $3 per visit | No | - | - |
| Ohio | Yes - Mandatory | CN | If the RHC has an on-site pharmacy, co-pay amounts range from $0-$3. | Limits for psychology services rendered at an RHC are shown below. If the RHC holds a DME contract, there are also DME limitations (shown below). | - | - |
| Oklahoma | Yes - Mandatory | CN | $4 per visit | Payment is limited to one visit per 24 hour period. Payment is also subject to the existing visit limitation of 4 visits per month. | - | - |
| Oregon | Yes - Mandatory | CN | No | No | - | - |
| Pennsylvania | Yes - Mandatory | CN | Sliding scale based on the Medicaid fee for the service: $0.65 - $3.80 | Dental services provided by RHCs are limited as follows: Dentures 1 per lifetime Exams/pro phylaxis 1 per 180 days Crowns, Periodontics and Endodontics only via approved Benefit Limit Exception | - | - |
| Rhode Island | Yes - Mandatory | CN | No | No | - | - |
| South Carolina | Yes - Mandatory | CN | NR | NR | - | - |
| South Dakota | Yes - Mandatory | CN | $3/visit | No | - | - |
| Tennessee | Yes - Mandatory | CN | No | No | - | - |
| Texas | Yes - Mandatory | CN | No | No | - | - |
| Utah | Yes - Mandatory | CN | $4 per visit | No | - | - |
| Vermont | Yes - Mandatory | CN | No | 1 visit/encounter per day up to 5 visits/encounters per month | - | - |
| Virginia | Yes - Mandatory | CN | $1 per visit | NR | - | - |
| Washington | Yes - Mandatory | CN | No | PA may be required if the service being delivered in this setting require PA | - | - |
| West Virginia | Yes - Mandatory | CN | Office visits are $2 for those 50-100% FPL and $4 for those 100% FPL and above | Professional services other than physician services must be furnished by Physician Assistant (PA), Nurse Practitioner (NP), Certified Nurse-Midwife (CNM), or Certified Nurse Specialist (CNS), Licensed Psychologist (LP), Licensed Independent Clinical Social Worker (LICSW), Licensed Certified Social Worker (LCSW), Licensed Graduate Social Worker (LGSW) under the supervision of the LICSW or LCSW, and Licensed Professional Counselor (LPC) to the WV Medicaid member and include diagnosis, therapy, and consultation. These practitioners work under the medical supervision of a physician and in accordance with any medical orders for the care and treatment of a WV Medicaid member prepared by a physician. The professional conditions are specified in 42 CFR §491.8(b) and are to be within their scope | - | - |
| Wisconsin | Yes - Mandatory | CN | $0.50 - $3/encounter depending on the service provided, maximum of $30 per year, per provider | A small number of services require prior approval. | - | - |
| Wyoming | Yes - Mandatory | CN | $2.45 for non - emergent | Prior authorization is required after the first 12 visits to confirm medical necessity. | - | - |
2012
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 48 No - 8 | Yes - 28 No - 20 | ||||
| Alabama | Yes | CN | $1/visit | 14 visits/year | Provider based: prospective cost based rate/service with ancillaries paid fee for service, Independent: prospective cost based rate/visit with ancillaries paid fee for service | |
| Alaska | Yes | CN | $3/visit | Prospective cost based rate | ||
| American Samoa | No | |||||
| Arizona | Yes | CN & MN | OT and SP services not covered in this setting | Specified services | Fee for service | |
| Arkansas | Yes | CN & MN | 12 visits/year irrespective of setting included in limits for other specified practitioners | Prospective cost based rate/encounter | ||
| California | Yes | CN & MN | $1/visit | Provider based: prospective cost based rate/visit with ancillaries paid fee for service, Independent: cost based payment | ||
| Colorado | Yes | CN | $2/visit | Prospective cost based rate/visit with ancillaries paid fee for service or alternative reimbursement methodology | ||
| Connecticut | No | |||||
| Delaware | No | |||||
| District of Columbia | No | |||||
| Florida | Yes | CN & MN | $3/day | 1 encounter/day except mental health services limited to 26 encounters/year | On site: prospective cost based rate/encounter, Off-site: fee for service | |
| Georgia | Yes | CN & MN | $2/visit | Prospective cost based rate/visit | ||
| Guam | Yes | CN | Fee for service using Medicare fee schedule | |||
| Hawaii | Yes | CN & MN | Cost based payment | |||
| Idaho | Yes | CN | $3.65/visit up to 5% of income/year across all services` | Prospective cost based rate/visit | ||
| Illinois | Yes | CN & MN | $3.65 | Prospective cost based rate/visit or certified cost/encounter | ||
| Indiana | Yes | CN | Limitations vary by service | Prospective cost based rate/encounter | ||
| Iowa | Yes | CN & MN | Services limited to those covered by Medicare | Specified services | Cost based payment | |
| Kansas | Yes | CN & MN | $2/encounter | Prospective cost based rate/visit | ||
| Kentucky | Yes | A, B & C - See state-specific FN | A - $2/visit | Prospective cost based rate/visit | ||
| Louisiana | Yes | CN & MN | 12 visits/year, visits count toward physician visit limit | Prospective all-inclusive rate/encounter | ||
| Maine | Yes | CN & MN | $.50-$3/day, depending on payment, up to $30/month | Same limitations as for providers in other settings | Same requirements as for providers in other settings | Prospective cost based rate/visit |
| Maryland | Yes | CN & MN | Prospective cost based rate/visit | |||
| Massachusetts | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Michigan | Yes | CN & MN | Prospective cost based rate/visit | |||
| Minnesota | Yes | A & B - See state-specific FN | $3/visit for non-preventive service | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | ||
| Mississippi | Yes | CN | $3/visit | 12 visits/year, visits count toward physician visit limit | All-inclusive rate per encounter | |
| Missouri | Yes | CN | $2/day | Prospective cost based rate/visit or certified cost/encounter depending on service provider | ||
| Montana | Yes | A & B - See state-specific FN | $5/visit | Prospective cost based rate/visit | ||
| Nebraska | Yes | CN & MN | Prospective cost based rate/visit | |||
| Nevada | Yes | CN | Prospective all-inclusive cost based rate/visit | |||
| New Hampshire | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| New Jersey | No | |||||
| New Mexico | Yes | CN | A - $0-$7/visit depending on income, B - $7/visit non-preventive services - see state-specific FN | Prospective cost based rate/encounter | ||
| New York | Yes | CN & MN | $3/visit | Beneficiary Specific Utilization Thresholds apply - see state-specific FN | Prospective cost based rate or alternate payment methodology using APGs | |
| North Carolina | Yes | CN & MN | $3/visit for specified non-core services | 22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature | Specified services | Prospective payment or settled to cost up to Medicare PPS rate |
| North Dakota | Yes | CN & MN | $3/visit | Prospective cost based rate/visit | ||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | 24 visits/year that count toward physician visit limit | Prospective cost based rate/visit | ||
| Oklahoma | Yes | CN | $3/visit | Prospective rate/visit | ||
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Prospective cost based rate/visit | ||
| Pennsylvania | Yes | CN & MN | $.65-$3.80/service, depending on payment rate | Limited to one physical health encounter and one mental health encounter per day | Provider based: prospective cost based rate/visit, Independent: prospective cost based rate/visit with cost based payment for ancillaries | |
| Puerto Rico | Yes | CN & MN | Service is included in the capitated rate paid to managed care plans | |||
| Rhode Island | No | |||||
| South Carolina | Yes | CN | $3.30/encounter | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit or cost based payment | |
| South Dakota | Yes | CN | $3/visit | Substance abuse treatment not covered | Prospective cost based rate/visit | |
| Tennessee | Yes | A, B & C - See state-specific FN | See state-specific FN | |||
| Texas | Yes | CN & MN | Specified services | Prospective cost based rate/visit | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B - $3/non-preventive care visit, C - $5/visit | C - Primary care only, including routine physical exams | Prospective cost based rate/visit | |
| Vermont | Yes | A & B - See state-specific FN | 1 visit/day up to 5 visits/month | Cost based payment | ||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | $1/visit | Limits vary by service | Specified services | Cost based payment |
| Washington | Yes | CN & MN | Prospective cost based rate/encounter or fee for service | |||
| West Virginia | Yes | A, B & C | Prospective cost based rate/visit | |||
| Wisconsin | Yes | CN & MN | $.50-$3/encounter, depending on services provided, maximum $30/year/provider | Prospective cost based rate/visit | ||
| Wyoming | Yes | CN | $3.65/visit | 12 visits/year, in combination with physician, nurse practitioner and outpatient hosp visits | Prospective cost based rate/visit |
2010
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 48 No - 8 | Yes - 26 No - 22 | ||||
| Alabama | Yes | CN | $1/visit | 14 visits/year | Provider based: prospective cost based rate/service with ancillaries paid fee for service, Independent: prospective cost based rate/visit with ancillaries paid fee for service | |
| Alaska | Yes | CN | $3/visit | Prospective cost based rate/visit with ancillaries paid fee for service | ||
| American Samoa | No | |||||
| Arizona | Yes | CN & MN | OT and SP services not covered in this setting | Specified services | Fee for service | |
| Arkansas | Yes | CN & MN | 12 visits/year irrespective of setting included in limits for other specified practitioners | Prospective cost based rate/encounter | ||
| California | Yes | CN & MN | $1/visit | Provider based: prospective cost based rate/visit with ancillaries paid fee for service, Independent: cost based payment | ||
| Colorado | Yes | CN | $2/visit | Prospective cost based rate/visit with ancillaries paid fee for service or alternative reimbursement methodology | ||
| Connecticut | No | |||||
| Delaware | No | |||||
| District of Columbia | No | |||||
| Florida | Yes | CN & MN | $3/day | 1 encounter/day except mental health services limited to 26 encounters/year | On site: prospective cost based rate/encounter, Off-site: fee for service | |
| Georgia | Yes | CN & MN | $2/visit | Prospective cost based rate/visit | ||
| Guam | Yes | CN | Prospective rate/visit | |||
| Hawaii | Yes | CN & MN | Cost based payment | |||
| Idaho | Yes | CN | Prospective cost based rate/visit | |||
| Illinois | Yes | CN & MN | Prospective cost based rate/visit or certified cost/encounter | |||
| Indiana | Yes | CN | Prospective cost based rate/encounter | |||
| Iowa | Yes | CN & MN | Services limited to those covered by Medicare | Specified services | Cost based payment | |
| Kansas | Yes | CN & MN | $2/encounter | Prospective cost based rate/visit | ||
| Kentucky | Yes | A, B & C - See state-specific FN | A - $2/visit | Prospective cost based rate/visit | ||
| Louisiana | Yes | CN & MN | 12 visits/year, visits count toward physician visit limit | Prospective all-inclusive rate/encounter | ||
| Maine | Yes | CN & MN | $.50-$3/day, depending on payment, up to $30/month | Specified procedures and services | Prospective cost based rate/visit | |
| Maryland | Yes | CN & MN | Prospective cost based rate/visit | |||
| Massachusetts | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Michigan | Yes | CN & MN | Cost based payment | |||
| Minnesota | Yes | A & B - See state-specific FN | B - $3/visit for non-preventive service | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | ||
| Mississippi | Yes | CN | $3/visit | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit | |
| Missouri | Yes | CN | $2/day | Prospective cost based rate/visit or certified cost/encounter depending on service provider | ||
| Montana | Yes | A & B - See state-specific FN | $5/visit | Prospective cost based rate/visit | ||
| Nebraska | Yes | CN & MN | Prospective cost based rate/visit | |||
| Nevada | Yes | CN | Prospective all-inclusive cost based rate/visit | |||
| New Hampshire | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| New Jersey | No | |||||
| New Mexico | Yes | CN | A - $0-$7/visit depending on income, B - $7/visit non-preventive services - see state-specific FN | Prospective cost based rate/encounter | ||
| New York | Yes | CN & MN | $3/visit | Beneficiary Specific Utilization Thresholds apply - see state-specific FN | Prospective cost based rate/visit | |
| North Carolina | Yes | CN & MN | $3/visit for specified non-core services | 22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature | Specified services | Prospective or cost based rate/visit up to Medicare PPS rate |
| North Dakota | Yes | CN & MN | $3/visit | Prospective cost based rate/visit | ||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | 24 visits/year that count toward physician visit limit | Prospective cost based rate/visit | ||
| Oklahoma | Yes | CN | $3/visit | Prospective rate/visit | ||
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Prospective cost based rate/visit | ||
| Pennsylvania | Yes | CN & MN | $.50-$3/service, depending on payment rate | Limited to one physical health encounter and one mental health encounter per day | Provider based: prospective cost based rate/visit, Independent: prospective cost based rate/visit with cost based payment for ancillaries | |
| Puerto Rico | Yes | CN & MN | Service is included in the capitated rate paid to managed care plans | |||
| Rhode Island | No | |||||
| South Carolina | Yes | CN | $2/encounter | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit or cost based payment | |
| South Dakota | Yes | CN | $3/visit | Substance abuse treatment not covered | Prospective cost based rate/visit | |
| Tennessee | Yes | A & B - See state-specific FN | See state-specific FN | |||
| Texas | Yes | CN & MN | Specified services | Prospective cost based rate/visit | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B - $3/visit, C - $5/visit | C - Primary care only, including routine physical exams | Prospective cost based rate/visit | |
| Vermont | Yes | A & B - See state-specific FN | 1 visit/day up to 5 visits/month | Cost based payment | ||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | $1/visit | Limits vary by service | Specified services | Cost based payment |
| Washington | Yes | CN & MN | Prospective cost based rate/visit | |||
| West Virginia | Yes | A, B & C | Prospective cost based rate/visit | |||
| Wisconsin | Yes | CN & MN | $.50-$3/encounter, depending on services provided, maximum $30/year/provider | Prospective cost based rate/visit | ||
| Wyoming | Yes | CN | $2/visit | Prospective cost based rate/visit |
2008
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 49 No - 7 | Yes - 26 No - 23 | ||||
| Alabama | Yes | CN | $1/visit | 14 visits/year | Provider based: prospective cost based rate/service with ancillaries paid fee for service, Independent: prospective cost based rate/visit with ancillaries paid fee for service | |
| Alaska | Yes | CN | $3/visit | Prospective cost based rate/visit with ancillaries paid fee for service | ||
| American Samoa | No | |||||
| Arizona | Yes | CN & MN | Coverage of occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN | Specified services | Fee for service | |
| Arkansas | Yes | CN & MN | 12 visits/year irrespective of setting included in limits for other specified practitioners | Prospective cost based rate/encounter | ||
| California | Yes | CN & MN | $1/visit | Provider based: prospective cost based rate/visit with ancillaries paid fee for service, Independent: cost based payment | ||
| Colorado | Yes | CN | $2/visit | Prospective cost based rate/visit with ancillaries paid fee for service or alternative reimbursement methodology | ||
| Connecticut | No | |||||
| Delaware | Yes | CN | Cost based payment, ancillary services paid fee for service | |||
| District of Columbia | No | |||||
| Florida | Yes | CN & MN | $3/day | 1 encounter/day except mental health services limited to 26 encounters/year | On site: prospective cost based rate/encounter, Off-site: fee for service | |
| Georgia | Yes | CN & MN | $2/visit | Prospective cost based rate/visit | ||
| Guam | No | |||||
| Hawaii | Yes | CN & MN | Cost based payment | |||
| Idaho | Yes | CN | Prospective cost based rate/visit | |||
| Illinois | Yes | CN & MN | Prospective cost based rate/visit or certified cost/encounter | |||
| Indiana | Yes | CN | Prospective cost based rate/encounter | |||
| Iowa | Yes | CN & MN | Services limited to those covered by Medicare | Specified services | Cost based payment | |
| Kansas | Yes | CN & MN | $2/encounter | Prospective cost based rate/visit | ||
| Kentucky | Yes | A, B & C - See state-specific FN | A - $2/visit | Prospective cost based rate/visit | ||
| Louisiana | Yes | CN & MN | 12 visits/year, visits count toward physician visit limit | Prospective all-inclusive rate/encounter | ||
| Maine | Yes | CN & MN | $.50-$3/day, depending on payment, up to $30/month | Specified procedures and services | Prospective cost based rate/visit | |
| Maryland | Yes | CN & MN | Prospective cost based rate/visit | |||
| Massachusetts | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Michigan | Yes | CN & MN | Cost based payment | |||
| Minnesota | Yes | A & B - See state-specific FN | $3/visit for non-preventive service | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | ||
| Mississippi | Yes | CN | $3/visit | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit | |
| Missouri | Yes | CN | $2/day | Prospective cost based rate/visit or certified cost/encounter | ||
| Montana | Yes | A & B - See state-specific FN | $5/visit | Prospective cost based rate/visit | ||
| Nebraska | Yes | CN & MN | Prospective cost based rate/visit | |||
| Nevada | Yes | CN | Prospective all-inclusive cost based rate/visit | |||
| New Hampshire | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| New Jersey | No | |||||
| New Mexico | Yes | CN | A - $5/visit, B - $7/visit non-preventive services - see state-specific FN | Prospective cost based rate/encounter | ||
| New York | Yes | CN & MN | $3/visit | 10 clinic visits/year in combination with other specified providers | Prospective cost based rate/visit | |
| North Carolina | Yes | CN & MN | $1-$3/visit for specified non-core services | 22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature | Specified services | Prospective or cost based rate/visit up to Medicare PPS rate |
| North Dakota | Yes | CN & MN | $3/visit | Prospective cost based rate/visit | ||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | 24 visits/year that count toward physician visit limit | Prospective cost based rate/visit | ||
| Oklahoma | Yes | CN | $1/service | Prospective rate/visit | ||
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Prospective cost based rate/visit | ||
| Pennsylvania | Yes | CN & MN | $.50-$3/service, depending on payment rate | Frequency limits vary by service | Provider based: prospective cost based rate/visit, Independent: prospective cost based rate/visit with cost based payment for ancillaries | |
| Puerto Rico | Yes | CN & MN | Capitated payment | |||
| Rhode Island | Yes | CN & MN - see state-specific FN | Prospective cost based rate/visit | |||
| South Carolina | Yes | CN | $2/encounter | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit or cost based payment | |
| South Dakota | Yes | CN | $3/visit | Substance abuse treatment not covered | Prospective cost based rate/visit | |
| Tennessee | Yes | A & B - See state-specific FN | ||||
| Texas | Yes | CN & MN | Specified services | Prospective cost based rate/visit | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B - $3/visit, C - $5/visit | C - Primary care only, including routine physical exams | Prospective cost based rate/visit | |
| Vermont | Yes | A & B - See state-specific FN | 1 visit/day up to 5 visits/month | Cost based payment | ||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | $1/visit | Limits vary by service | Specified services | Cost based payment |
| Washington | Yes | CN & MN | Prospective cost based rate/visit | |||
| West Virginia | Yes | A, B & C | Prospective cost based rate/visit | |||
| Wisconsin | Yes | CN & MN | $.50-$3/encounter, depending on services provided, maximum $30/year/provider | Prospective cost based rate/visit | ||
| Wyoming | Yes | CN | $2/visit | Prospective cost based rate/visit |
2006
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 49 No - 7 | Yes - 26 No - 23 | ||||
| Alabama | Yes | CN | $1/visit | 14 visits/year | Provider based: prospective cost based rate/service with ancillaries paid fee for service, Independent: prospective cost based rate/visit with ancillaries paid fee for service | |
| Alaska | Yes | CN | $3/visit | Prospective cost based rate/visit with ancillaries paid fee for service | ||
| American Samoa | No | |||||
| Arizona | Yes | CN & MN | Coverage of occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN | Specified services | Fee for service | |
| Arkansas | Yes | CN & MN | 12 visits/year irrespective of setting included in limits for other specified practitioners | Prospective cost based rate/encounter | ||
| California | Yes | CN & MN | $1/visit | Provider based: prospective cost based rate/visit with ancillaries paid fee for service, Independent: cost based payment | ||
| Colorado | Yes | CN | $2/visit | Prospective cost based rate/visit with ancillaries paid fee for service or alternative reimbursement methodology | ||
| Connecticut | No | |||||
| Delaware | Yes | CN | Cost based payment, ancillary services paid fee for service | |||
| District of Columbia | No | |||||
| Florida | Yes | CN & MN | $3/day | 1 encounter/day except mental health services limited to 26 encounters/year | On site: prospective cost based rate/encounter, Off-site: fee for service | |
| Georgia | Yes | CN & MN | $2/visit | Prospective cost based rate/visit | ||
| Guam | No | |||||
| Hawaii | Yes | CN & MN | Cost based payment | |||
| Idaho | Yes | CN | Prospective cost based rate/visit | |||
| Illinois | Yes | CN & MN | Prospective cost based rate/visit or certified cost/encounter | |||
| Indiana | Yes | CN | Prospective cost based rate/encounter | |||
| Iowa | Yes | CN & MN | Services limited to those covered by Medicare | Specified services | Cost based payment | |
| Kansas | Yes | CN & MN | $2/encounter | Prospective cost based rate/visit | ||
| Kentucky | Yes | A, B & C - See state-specific FN | A - $2/visit | Prospective cost based rate/visit | ||
| Louisiana | Yes | CN & MN | 12 visits/year, visits count toward physician visit limit | Prospective all-inclusive rate/encounter | ||
| Maine | Yes | CN & MN | $.50-$3/day, depending on payment, up to $30/month | Specified procedures and services | Prospective cost based rate/visit | |
| Maryland | Yes | CN & MN | Prospective cost based rate/visit | |||
| Massachusetts | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Michigan | Yes | CN & MN | Cost based payment | |||
| Minnesota | Yes | A & B - See state-specific FN | $3/visit for non-preventive service | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | ||
| Mississippi | Yes | CN | $3/visit | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit | |
| Missouri | Yes | CN | $2/day | Prospective cost based rate/visit with ancillaries paid fee for service | ||
| Montana | Yes | A & B - See state-specific FN | $5/visit | Prospective cost based rate/visit | ||
| Nebraska | Yes | CN & MN | Prospective cost based rate/visit | |||
| Nevada | Yes | CN | Prospective all-inclusive cost based rate/visit | |||
| New Hampshire | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| New Jersey | No | |||||
| New Mexico | Yes | CN | A - $5/visit, B - $7/visit non-preventive services - see state-specific FN | Prospective cost based rate/encounter | ||
| New York | Yes | CN & MN | $3/visit | 10 clinic visits/year in combination with other specified providers | Prospective cost based rate/visit | |
| North Carolina | Yes | CN & MN | $1-$3/visit for specified non-core services | 24 ambulatory visits/year included in limits with other specified practitioners | Specified services | Prospective cost based rate/visit |
| North Dakota | Yes | CN & MN | $3/visit | Prospective cost based rate/visit | ||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | 24 visits/year that count toward physician visit limit | Prospective cost based rate/visit | ||
| Oklahoma | Yes | CN | $1/service | Prospective rate/visit | ||
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Prospective cost based rate/visit | ||
| Pennsylvania | Yes | CN & MN | $.50-$3/service, depending on payment | Frequency limits vary by service | Provider based: prospective cost based rate/visit, Independent: prospective cost based rate/visit with cost based payment for ancillaries | |
| Puerto Rico | Yes | CN & MN | Capitated payment | |||
| Rhode Island | Yes | CN & MN - see state-specific FN | Prospective cost based rate/visit | |||
| South Carolina | Yes | CN | $2/encounter | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit or cost based payment | |
| South Dakota | Yes | CN | $3/visit | Substance abuse treatment not covered | Prospective cost based rate/visit | |
| Tennessee | Yes | A & B - See state-specific FN | ||||
| Texas | Yes | CN & MN | Specified services | Prospective cost based rate/visit | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B - $3/visit, C - $5/visit | C - Primary care only, including routine physical exams | Prospective cost based rate/visit | |
| Vermont | Yes | A & B - See state-specific FN | 1 visit/day up to 5 visits/month | Cost based payment | ||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | $1/visit | Cost based payment | ||
| Washington | Yes | CN & MN | Prospective cost based rate/visit | |||
| West Virginia | Yes | CN & MN | Prospective cost based rate/visit | |||
| Wisconsin | Yes | CN & MN | $.50-$3/encounter, depending on services provided, maximum $30/year/provider | Prospective cost based rate/visit | ||
| Wyoming | Yes | CN | $2/visit | Prospective cost based rate/visit |
2004
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 49 No - 7 | Yes - 23 No - 26 | ||||
| Alabama | Yes | CN | $1/visit | 14 visits/year | Provider based: prospective cost based rate/service with ancillaries paid fee for service, Independent: prospective cost based rate/visit with ancillaries paid fee for service | |
| Alaska | Yes | CN | $3/visit | Prospective cost based rate/visit with ancillaries paid fee for service | ||
| American Samoa | No | |||||
| Arizona | Yes | CN & MN | Coverage of occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN | Specified services | Fee for service | |
| Arkansas | Yes | CN & MN | 12 visits/year irrespective of setting included in limits for other specified practitioners | Prospective cost based rate/encounter | ||
| California | Yes | CN & MN | $1/visit | Provider based: prospective cost based rate/visit with ancillaries paid fee for service, Independent: cost based payment | ||
| Colorado | Yes | CN | $2/visit | Prospective cost based rate/visit with ancillaries paid fee for service or alternative reimbursement methodology | ||
| Connecticut | No | |||||
| Delaware | Yes | CN | Cost based payment, ancillary services paid fee for service | |||
| District of Columbia | No | |||||
| Florida | Yes | CN & MN | $3/day | 1 encounter/day except mental health services limited to 26 encounters/year | On site: prospective cost based rate/encounter, Off-site: fee for service | |
| Georgia | Yes | CN & MN | $2/visit | Prospective cost based rate/visit | ||
| Guam | No | |||||
| Hawaii | Yes | CN & MN | Cost based payment | |||
| Idaho | Yes | CN | Prospective cost based rate/visit | |||
| Illinois | Yes | CN & MN | Prospective cost based rate/visit or certified cost/encounter | |||
| Indiana | Yes | CN | Prospective cost based rate/encounter | |||
| Iowa | Yes | CN & MN | Services limited to those covered by Medicare | Specified services | Cost based payment | |
| Kansas | Yes | CN & MN | $2/encounter | Prospective cost based rate/visit | ||
| Kentucky | Yes | CN & MN | Prospective cost based rate/visit | |||
| Louisiana | Yes | CN & MN | 12 visits/year, visits count toward physician visit limit | Prospective all-inclusive rate/encounter | ||
| Maine | Yes | CN & MN | $.50-$3/day, depending on payment, up to $30/month | Specified procedures and services | Prospective cost based rate/visit | |
| Maryland | Yes | CN & MN | Prospective cost based rate/visit | |||
| Massachusetts | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Michigan | Yes | CN & MN | Cost based payment | |||
| Minnesota | Yes | A & B - See state-specific FN | A - $3/visit for non-preventive service | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | ||
| Mississippi | Yes | CN | $3/visit | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit | |
| Missouri | Yes | CN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Montana | Yes | A & B - See state-specific FN | $5/visit | Prospective cost based rate/visit | ||
| Nebraska | Yes | CN & MN | Provider based: prospective cost based rate/visit, Independent: fee for service | |||
| Nevada | Yes | CN | Prospective all-inclusive cost based rate/visit | |||
| New Hampshire | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| New Jersey | No | |||||
| New Mexico | Yes | CN | B - $7/visit non-preventive services - see state-specific FN | Prospective cost based rate/encounter | ||
| New York | Yes | CN & MN | $3/visit | 10 clinic visits/year in combination with other specified providers | Prospective cost based rate/visit | |
| North Carolina | Yes | CN & MN | $1-$3/visit for specified non-core services | 24 ambulatory visits/year included in limits with other specified practitioners | Specified services | Prospective cost based rate/visit |
| North Dakota | Yes | CN & MN | $3/visit | Prospective cost based rate/visit | ||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | 24 visits/year that count toward physician visit limit | Prospective cost based rate/visit | ||
| Oklahoma | Yes | CN | $1/service | Prospective rate/visit | ||
| Oregon | Yes | A & B - See state-specific FN | A - $3/visit | Prospective cost based rate/visit | ||
| Pennsylvania | Yes | CN & MN | Provider based: prospective cost based rate/visit, Independent: prospective cost based rate/visit with cost based payment for ancillaries | |||
| Puerto Rico | Yes | CN & MN | Capitated payment | |||
| Rhode Island | Yes | CN & MN - see state-specific FN | Prospective cost based rate/visit | |||
| South Carolina | Yes | CN | $2/encounter | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit or cost based payment | |
| South Dakota | Yes | CN | $2/visit | Substance abuse treatment not covered | Prospective cost based rate/visit | |
| Tennessee | Yes | A & B - See state-specific FN | ||||
| Texas | Yes | CN & MN | Specified services | Prospective cost based rate/visit | ||
| Utah | Yes | A, B & C - See state-specific FN | A & B - $3/visit, C - $5/visit | C - Primary care only, including routine physical exams | Prospective cost based rate/visit | |
| Vermont | Yes | A & B - See state-specific FN | 1 visit/day up to 5 visits/month | Cost based payment | ||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | $1/visit | Cost based payment | ||
| Washington | Yes | CN & MN | Prospective cost based rate/visit | |||
| West Virginia | Yes | CN & MN | Prospective cost based rate/visit | |||
| Wisconsin | Yes | CN & MN | $.50-$3/encounter, depending on services provided, maximum $30/year/provider | Prospective cost based rate/visit | ||
| Wyoming | Yes | CN | $2/visit | Prospective cost based rate/visit with ancillaries paid fee for service |
2003
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 49 No - 7 | Yes - 21 No - 28 | ||||
| Alabama | Yes | CN | $1/visit | 14 visits/year | Provider based: prospective cost based rate/service with ancillaries paid fee for service, Independent: prospective cost based rate/visit with ancillaries paid fee for service | |
| Alaska | Yes | CN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| American Samoa | No | |||||
| Arizona | Yes | CN & MN | Coverage of occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN | Specified services | Fee for service | |
| Arkansas | Yes | CN & MN | 12 ambulatory encounters/year irrespective of setting and included in physician limits | Prospective cost based rate/encounter | ||
| California | Yes | CN & MN | $1/visit | Provider based: prospective cost based rate/visit with ancillaries paid fee for service, Independent: cost based payment | ||
| Colorado | Yes | CN | $2/visit | Prospective cost based rate/visit with ancillaries paid fee for service or alternative reimbursement methodology | ||
| Connecticut | No | |||||
| Delaware | Yes | CN | Cost based payment, ancillary services paid fee for service | |||
| District of Columbia | No | |||||
| Florida | Yes | CN & MN | $3/day | 1 encounter/day except mental health services limited to 26 encounters/year | On site: prospective cost based rate/encounter, Off-site: fee for service | |
| Georgia | Yes | CN & MN | $2/visit | Prospective cost based rate/visit with ancillaries paid fee for service | ||
| Guam | No | |||||
| Hawaii | Yes | CN & MN | Cost based payment | |||
| Idaho | Yes | CN | Prospective cost based rate/visit | |||
| Illinois | Yes | CN & MN | Prospective cost based rate/visit or certified cost/encounter | |||
| Indiana | Yes | CN | Prospective cost based rate/encounter | |||
| Iowa | Yes | CN & MN | Services limited to those covered by Medicare | Specified services | Cost based payment | |
| Kansas | Yes | CN & MN | $2/encounter | Prospective cost based rate/visit | ||
| Kentucky | Yes | CN & MN | Prospective cost based rate/visit | |||
| Louisiana | Yes | CN & MN | 12 visits/year, visits count toward physician visit limit | Prospective all-inclusive rate/encounter | ||
| Maine | Yes | CN & MN | Specified procedures and services | Prospective cost based rate/visit | ||
| Maryland | Yes | CN & MN | Prospective cost based rate/visit | |||
| Massachusetts | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Michigan | Yes | CN & MN | Cost based payment | |||
| Minnesota | Yes | A & B - See state-specific FN | A - $3/visit for non-preventive service | Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment | ||
| Mississippi | Yes | CN | $3/visit | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit | |
| Missouri | Yes | CN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| Montana | Yes | CN & MN | $5/visit | Prospective cost based rate/visit | ||
| Nebraska | Yes | CN & MN | Provider based: prospective cost based rate/visit, Independent: fee for service | |||
| Nevada | Yes | CN | Prospective cost based rate/visit | |||
| New Hampshire | Yes | CN & MN | Prospective cost based rate/visit with ancillaries paid fee for service | |||
| New Jersey | No | |||||
| New Mexico | Yes | CN | B - $5/visit non-preventive services - see state-specific FN | Prospective cost based rate/encounter | ||
| New York | Yes | CN & MN | $3/visit | 10 clinic visits/year in combination with other specified providers | Prospective cost based rate/visit | |
| North Carolina | Yes | CN & MN | $1-$3/visit for specified non-core services | 24 ambulatory visits/year included in limits with other specified practitioners | Specified services | Prospective cost based rate/visit |
| North Dakota | Yes | CN & MN | $2/visit | Prospective cost based rate/visit | ||
| Northern Mariana Islands | No | |||||
| Ohio | Yes | CN | 24 ambulatory visits/year, 20 physical medicine visits/year, visits count toward physician visit limit | Provider based: cost based payment with ancillaries paid fee for service, Independent: prospective cost based rate/visit with ancillaries paid fee for service | ||
| Oklahoma | Yes | CN & MN | $1/service | Prospective rate/visit | ||
| Oregon | Yes | CN & MN | $3/visit | Prospective cost based rate/visit | ||
| Pennsylvania | Yes | CN & MN | Provider based: prospective cost based rate/visit, Independent: prospective cost based rate/visit with cost based payment for ancillaries | |||
| Puerto Rico | Yes | CN & MN | Capitated payment | |||
| Rhode Island | Yes | CN & MN - see state-specific FN | Prospective cost based rate/visit | |||
| South Carolina | Yes | CN | 12 visits/year, visits count toward physician visit limit | Prospective cost based rate/visit or cost based payment | ||
| South Dakota | Yes | CN | $2/visit | Substance abuse treatment not covered | Prospective cost based rate/visit | |
| Tennessee | Yes | A & B - See state-specific FN | ||||
| Texas | Yes | CN & MN | Specified services | Prospective cost based rate/visit | ||
| Utah | Yes | A, B & C - See state specific FN | A - $2/visit, B - $3/visit, C - $5/visit | C - Primary care only, including routine physical exams | Prospective cost based rate/visit | |
| Vermont | Yes | A & B - See state-specific FN | B - $7/visit | 1 visit/day up to 5 visits/month | Cost based payment | |
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | $1/visit | Cost based payment | ||
| Washington | Yes | CN & MN | Prospective cost based rate/visit | |||
| West Virginia | Yes | CN & MN | Prospective cost based rate/visit | |||
| Wisconsin | Yes | CN & MN | $2/visit | Prospective cost based rate/visit | ||
| Wyoming | Yes | CN | $2/visit | Prospective cost based rate/visit |