| Is the Benefit Covered? |
Copayment Requirement |
Prior Approval Requirement |
Coverage Limitations |
Reimbursement Methodology |
Populations Covered |
|
|
Alabama
|
|
Yes
|
|
|
14 visits/year included in physician visit limitation
|
Fee for service
|
CN
|
|
Alaska
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
Arizona
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Arkansas
|
|
Yes
|
|
|
12 visits/year irrespective of setting included in limits for other specified practitioners
|
Fee for service
|
CN & MN
|
|
California
|
|
Yes
|
$1/visit
|
Specified services
|
|
Fee for service
|
CN & MN
|
|
Colorado
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
Connecticut
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Delaware
|
|
Yes
|
|
|
Limited to extraction of bony impacted wisdom teeth
|
Fee for service
|
CN
|
|
District of Columbia
|
|
Yes
|
|
|
Limited to trauma care
|
Fee for service
|
CN & MN
|
|
Florida
|
|
Yes
|
$2/day for oral surgery
|
|
|
Fee for service
|
CN & MN
|
|
Georgia
|
|
Yes
|
$.50-$3 for selected services dependng on payment rate
|
Specified services
|
|
Fee for service
|
CN & MN
|
|
Hawaii
|
|
Yes
|
|
|
Limited to trauma care and emergency treatment for relief of pain and infection
|
Fee for service
|
CN & MN
|
|
Idaho
|
|
Yes
|
|
Specified services
|
Limited to preventative and restorative services
|
Fee for service
|
CN
|
|
Illinois
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Indiana
|
|
Yes
|
|
Specified services including non-emergency services provided on an inpatient hospital basis and oral surgery
|
Second opinions required for specified procedures, ambulatory services limited
|
Fee for service
|
CN
|
|
Iowa
|
|
Yes
|
$3/day
|
|
Services limited to what a physician would provide
|
Fee for service
|
CN & MN
|
|
Kansas
|
|
Yes
|
$3/date of service
|
Specified services
|
|
Fee for service
|
CN & MN
|
|
Kentucky
|
|
Yes
|
A - $2/visit
|
|
|
Fee for service
|
A, B, C & D - See state-specific FN
|
|
Louisiana
|
|
Yes
|
|
Services provided on an inpatient hospital basis
|
Services limited to what a physician would provide and are included in physician 12 visit/year limit unless provided on an inpatient hospital basis
|
Fee for service
|
CN & MN
|
|
Maine
|
|
Yes
|
|
Specified services
|
|
Fee for service
|
CN & MN
|
|
Maryland
|
|
Yes
|
|
|
Services for non-pregnant adults limited to trauma care and emergency treatment rendered in a hospital emergency department
|
Fee for service
|
CN & MN
|
|
Massachusetts
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Michigan
|
|
Yes
|
|
Specified services
|
|
Fee for service using physician fee schedule
|
CN & MN
|
|
Minnesota
|
|
Yes
|
|
Specified services
|
|
Fee for service
|
A & B - See state-specific FN
|
|
Mississippi
|
|
Yes
|
$3/visit
|
|
Limited to trauma care and emergency treatment for relief of pain and infection, maximum annual payments for specified services
|
Fee for service
|
CN
|
|
Missouri
|
|
Yes
|
$.50-$3/service depending on payment
|
|
|
Fee for service
|
CN & MN
|
|
Montana
|
|
Yes
|
$3/visit
|
Oral surgery
|
|
Fee for service or percentage of charge
|
A & B - See state-specific FN
|
|
Nebraska
|
|
Yes
|
$2/visit, not applicable to primary care services - see state-specific FN
|
|
Services limited to what a physician would provide
|
Fee for service
|
CN & MN
|
|
Nevada
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
New Hampshire
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
New Jersey
|
|
Yes
|
|
Specified services, x-ray services costing more than $35
|
Specified procedures require a second opinion
|
Fee for service
|
CN & MN
|
|
New Mexico
|
|
Yes
|
A - $5/visit, B - $7/visit - see state-specific FN
|
Services provided on an inpatient hospital basis
|
|
Fee for service
|
CN
|
|
New York
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
North Carolina
|
|
Yes
|
$3/episode of treatment
|
Specified services including complex oral surgeries
|
|
Fee for service
|
CN & MN
|
|
North Dakota
|
|
Yes
|
$2/visit
|
|
|
Fee for service
|
CN & MN
|
|
Ohio
|
|
Yes
|
|
|
Limited to extractions, surgical excisions and incisions
|
Fee for service
|
CN
|
|
Oklahoma
|
|
Yes
|
|
|
Services limited to what a physician would provide
|
Fee for service
|
CN
|
|
Oregon
|
|
Yes
|
A - $3/visit
|
Specified services
|
A - specified procedures require a second opinion, B - limited to emergency treatment for pain and infection
|
Fee for service
|
A & B - See state-specific FNN
|
|
Pennsylvania
|
|
Yes
|
$.50-$3/service, depending on payment rate
|
|
|
Fee for service
|
CN & MN
|
|
Rhode Island
|
|
Yes
|
|
Specified services
|
|
Fee for service
|
CN & MN - see state-specific FN
|
|
South Carolina
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
South Dakota
|
|
Yes
|
null
|
|
Cosmetic surgery limited to post-trauma conditions
|
Fee for service, or percentage of charge for unlisted services
|
CN
|
|
Tennessee
|
|
Yes
|
B1 - $15/visit, B2 - $25/visit
|
|
|
|
A & B - See state-specific FN
|
|
Texas
|
|
Yes
|
|
Specified surgical procedures and services
|
Adult coverage lfor other than ICF/MR residents limited to trauma or cancer-related care
|
Fee for service
|
CN & MN
|
|
Utah
|
|
Yes
|
C - 10% of payment
|
|
B & C - Limited to trauma care and emergency treatment for relief of pain and infection
|
Fee for service
|
A, B & C - See state-specific FN
|
|
Vermont
|
|
Yes
|
|
|
1 inpatient hospital visit/day
|
Fee for service
|
A & B - See state-specific FN
|
|
Virginia
|
|
Yes
|
|
Hospital-based care
|
Limited to medically necessary oral surgery and associated diagnostic services
|
Fee for service
|
CN & MN
|
|
Washington
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
West Virginia
|
|
Yes
|
|
|
Limited to trauma care including maxillofacial surgery and emergency treatment for relief of pain and infection
|
Fee for service
|
A & B
|
|
Wisconsin
|
|
Yes
|
$.50-$3/service depending on payment
|
Specified services
|
|
Fee for service
|
CN & MN
|
|
Wyoming
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
American Samoa
|
|
Yes
|
|
|
|
|
See territory-specific FN
|
|
Guam
|
|
Yes
|
|
|
1 inpatient hospital visit/day
|
Fee for service
|
CN
|
|
Northern Mariana Islands
|
|
Yes
|
|
|
1 inpatient hospital visit/day
|
|
CN & MN - See territory-specific FN
|
|
Puerto Rico
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Virgin Islands
|
|
Yes
|
|
|
Services in public health facilities only
|
Fee for service
|
CN
|
