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