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Benefits by Service: Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center (October 2008) Definition/Notes

Note: Totals include 50 states and D.C.

"Benefits Covered" Totals

"Benefits Not Covered" Totals

Is the benefit covered?

Is there a co-payment requirement?

Yes: 16

No: 32

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Alabama
Yes	$3/visit		3 surgical procedures/year if hospitalization not required	Reasonable charge	CN
Alaska
Yes	$3/visit	Specified surgical procedures		Prospective cost based rate	CN
Arizona
Yes		Yes		Fee for service	CN & MN
Arkansas
Yes		Specified surgical procedures		Fee for service, all-inclusive rate for surgical procedures	CN & MN
California
Yes	$1/visit	Specified surgical procedures		Fee for service	CN & MN
Colorado
Yes			Limited to procedures safely performed in ambulatory setting, as approved by CMS	Fee for service using lower of a percentage of Medicare allowable payment and inpatient hospital payment rates as ceiling	CN
Connecticut
Yes		null	null	Prospective cost based rate per episode of care using Medicare payment rates as ceiling	CN & MN
Delaware
Yes				Prospective cost based rate per episode of care using Medicare payment rates as ceiling	CN
District of Columbia
Yes			Limited to procedures safely performed in ambulatory setting, as approved by CMS	Negotiated rate	CN & MN
Florida
Yes		Yes	Limited to procedures safely performed in ambulatory setting, as approved by CMS	Medicare payment rates adjusted by county wage index	CN & MN
Georgia
Yes	$3/visit	Specified surgical procedures	Limited to procedures safely performed in ambulatory setting, as approved by CMS	Prospective cost based rate per episode of care using Medicare payment rates as ceiling	CN & MN
Hawaii
Yes		Specified services and procedures		All-inclusive rate per episode of care using Medicare groupings for most procedures	CN & MN
Idaho
Yes			Limited to procedures safely performed in ambulatory setting, as approved by CMS, facilities must be certified	Fee for service	CN
Illinois
Yes				Fee for service at 75% of rate paid in outpatient hospital setting	CN & MN
Indiana
Yes				Fee for service, with surgical procedures grouped using Medicare methodology	CN
Iowa
Yes		Specified surgical procedures	Limited to procedures safely performed in ambulatory setting, as approved by CMS	Fee for service, with surgical procedures grouped using Medicare methodology, ancillaries paid at Medicare rates	CN & MN
Kansas
Yes	$3/date of service		Limited to specified surgical procedures	Fee for service	CN & MN
Kentucky
Yes	A, C & D - $3/visit		Limited to procedures safely performed in ambulatory setting, as approved by CMS	Prospective cost based rate per episode of care using Medicare payment rates as ceiling or 45% of charge	A, B, C & D - See state-specific FN
Louisiana
Yes				Fee for service, using an all-inclusive payment per episode of care	CN & MN
Maine
Yes				Fee for service	CN & MN
Maryland
Yes				Cost based payment	CN & MN
Massachusetts
Yes				Fee for service	CN & MN
Michigan
Yes				Fee for service, using physician reimbursement rates	CN & MN
Minnesota
Yes	null			Fee for service or percentage of charge	A & B - See state-specific FN
Mississippi
Yes				Fee for service using a percentage of Medicare allowable payment as ceiling	CN
Missouri
Yes			Coverage limited to specified procedures	Fee for service, using an all-inclusive payment per episode of care	CN & MN
Montana
Yes	$5/visit			Prospective cost based rate per episode of care using Medicare payment rates	A & B - See state-specific FN
Nebraska
Yes				Medicare methodology for grouping and reimbursing covered surgical procedures	CN & MN
Nevada
Yes		Specified services		Prospective cost based rate per episode of care using Medicare methodology and upper limits, ancillaries paid fee for service	CN
New Hampshire
No
New Jersey
Yes				Fee for service, using an all-inclusive payment per episode of care	CN & MN
New Mexico
Yes				Fee for service using Medicare methodology for grouping surgical procedures	CN
New York
Yes	$3/visit clinic services excluding ambulatory surgery		10 clinic visits/year in combination with other specified providers	Prospective cost based rate	CN & MN
North Carolina
Yes		Specified services	Services limited to published ASC procedure codes	Fee for service	CN & MN
North Dakota
Yes				Fee for service	CN & MN
Ohio
Yes				Fee for service using surgical group rates, ancillaries paid separately	CN
Oklahoma
Yes	$3/day			Fee for service using surgical group rates	CN
Oregon
Yes	A - $3/visit	Specified surgical procedures	Specified procedures require a second opinion	Fee for service, second and subsequent surgeries performed at same time paid a lesser rate	A - See state-specific FN
Pennsylvania
Yes	$.50-$3/service, depending on payment rate		Limits vary by service	Fee for service	CN & MN
Rhode Island
No
South Carolina
Yes	$2/episode of care			Fee for service	CN
South Dakota
Yes	5% of payment up to $50/visit			Prospective cost based rate per episode of care using Medicare payment rates as ceiling	CN
Tennessee
Yes					A & B - See state-specific FN
Texas
Yes		Specified services		Prospective cost based rate per episode of care using Medicare payment rates as ceiling	CN & MN
Utah
Yes	$3/visit			Fee for service	A & B - See state-specific FN
Vermont
No
Virginia
Yes	$3/visit	Specified services	Limits vary by service	Fee for service	CN & MN
Washington
Yes				Fee for service	CN & MN
West Virginia
Yes				Fee for service using a percentage of Medicare allowable payment as ceiling	A & B
Wisconsin
Yes	$3/surgical procedure	Specified surgical procedures	Specified surgical procedures require second opinion	Fee for service	CN & MN
Wyoming
Yes				Prospective rate per episode of care at 90% of Medicare rate	CN
American Samoa
No
Guam
Yes			Limited to services unavailable at Guam Memorial Hospital	Fee for service	CN
Northern Mariana Islands
No
Puerto Rico
Yes			Primary care physician referral required	All-inclusive per diem or capitated payment	CN & MN
Virgin Islands
No

Definition/Notes: Link to Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center Footnote


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