| Is the Benefit Covered? |
Copayment Requirement |
Prior Approval Requirement |
Coverage Limitations |
Reimbursement Methodology |
Populations Covered |
|
|
Alabama
|
|
Yes
|
$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
|
CN
|
|
Alaska
|
|
Yes
|
$3/visit
|
|
|
Fee for service, second and subsequent surgeries performed at same time paid at lesser rate
|
CN
|
|
Arizona
|
|
Yes
|
$1/office visit
|
|
|
Fee for service
|
CN & MN
|
|
Arkansas
|
|
Yes
|
|
Specified surgical procedures
|
12 visits/year irrespective of setting included in limits for other specified practitioners, 2 in-person and 2 telemedicine consultations/year
|
Fee for service
|
CN & MN
|
|
California
|
|
Yes
|
$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
|
CN & MN
|
|
Colorado
|
|
Yes
|
$2/office or home visit, $.50/15 minute psych service
|
|
|
Fee for service
|
CN
|
|
Connecticut
|
|
Yes
|
|
Specified surgical procedures
|
1 psych evaluation/year, 1 psych therapy/day
|
Fee for service
|
CN & MN
|
|
Delaware
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
District of Columbia
|
|
Yes
|
|
Specified surgical procedures
|
|
Fee for service
|
CN & MN
|
|
Florida
|
|
Yes
|
$2/day for office or non-emergency outpatient hospital visit
|
Specified services
|
1 non-emergency visit/day, 1 routine physical exam/year, 10 prenatal visits/pregnancy, 2 postpartum visits/pregnancy
|
Fee for service
|
CN & MN
|
|
Georgia
|
|
Yes
|
$.50-$3 for selected services dependng on payment rate
|
Specified surgical procedures
|
12 office visits/year, 12 nursing facility visits/year
|
Fee for service at 84.645% of CMS RBRVS rates for 2000, services performed in outpatient hospital rather than office paid lower fees
|
CN & MN
|
|
Hawaii
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Idaho
|
|
Yes
|
|
|
1 wellness exam/year
|
Fee for service
|
CN
|
|
Illinois
|
|
Yes
|
$2/visit
|
Specified surgical procedures
|
Home visits limited to homebound
|
Fee for service, certified cost for certain government-employed practitioners
|
CN & MN
|
|
Indiana
|
|
Yes
|
|
Specified surgical procedures, procedures exceeding specified cost limits
|
30 visits/year
|
Fee for service, services performed with assistance of second surgeon or in outpatient setting rather than office paid reduced fee
|
CN
|
|
Iowa
|
|
Yes
|
$3/day, limited to office visits
|
Specified surgical procedures
|
|
Fee for service
|
CN & MN
|
|
Kansas
|
|
Yes
|
$2/visit - see state-specific FN
|
|
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
|
CN & MN
|
|
Kentucky
|
|
Yes
|
A, B, C & D - no copays for preventive services; A - $2/visit except maternity care; B - $2/visit for allergy testing
|
|
4 psychotherapy visits/year
|
Fee for service
|
A, B, C & D - See state-specific FN
|
|
Louisiana
|
|
Yes
|
|
Specified surgical procedures including those to be performed on inpatient basis that are normally rendered on outpatient basis
|
12 ambulatory visits/year irrespective of setting, 1 preventive care visit/.year, 1 inpatient hospital visit/day
|
Fee for service
|
CN & MN
|
|
Maine
|
|
Yes
|
$.50-$2/day, depending on payment, up to $20/month
|
Specified procedures and services
Specified procedures and services
|
|
Fee for service
|
CN & MN
|
|
Maryland
|
|
Yes
|
|
Specified surgical procedures
|
|
Fee for service
|
CN & MN
|
|
Massachusetts
|
|
Yes
|
|
Specified surgical procedures
|
1 office, inpatient hospital or home visit/day, 1 nursing facility visit/month
|
Fee for service
|
CN & MN
|
|
Michigan
|
|
Yes
|
$2/visit - see state-specific FN
|
Selected procedures
|
10 psychiatric visits/year
|
Fee for service
|
CN & MN
|
|
Minnesota
|
|
Yes
|
$3/visit for non-preventive service
|
|
3 telemedicine consultations/week
|
Fee for service
|
A & B - See state-specific FN
|
|
Mississippi
|
|
Yes
|
$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
|
CN
|
|
Missouri
|
|
Yes
|
$1/day
|
|
Specified procedures require a second opinion
|
Fee for service
|
CN & MN
|
|
Montana
|
|
Yes
|
$4/visit
|
Specified services
|
null
|
Fee for service
|
A & B - See state-specific FN
|
|
Nebraska
|
|
Yes
|
$2/visit, not applicable to primary care services - see state-specific FN
|
|
Telemedicine consultations require minimum 30 mile distance
|
Fee for service
|
CN & MN
|
|
Nevada
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
New Hampshire
|
|
Yes
|
|
|
18 ambulatory visits/year
|
Fee for service with payment ceiling for transplants
|
CN & MN
|
|
New Jersey
|
|
Yes
|
|
|
Psych services up to $900/year or $400 for nursing facility residents
|
Fee for service, cost based payment for vaccines
|
CN & MN
|
|
New Mexico
|
|
Yes
|
A - $5/visit, B - $7/visit non-preventive services - see state-specific FN
|
Specified surgical procedures, allergy testing and treatment
|
2 inpatient hospital or NF visits/day, 3 physical medicine or manipulative therapy visits/month
|
Fee for service, some services performed in hospital setting paid 60% of fee
|
CN
|
|
New York
|
|
Yes
|
|
|
10 visits/year in combination with other specified providers
|
Fee for service
|
CN & MN
|
|
North Carolina
|
|
Yes
|
$3/visit
|
Specified services
|
22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature
|
Fee for service
|
CN & MN
|
|
North Dakota
|
|
Yes
|
$2/visit
|
|
40 psychotherapy visits/year
|
Fee for service
|
CN & MN
|
|
Ohio
|
|
Yes
|
|
|
24 visits/year irrespective of setting
|
Fee for service
|
CN
|
|
Oklahoma
|
|
Yes
|
$1/service
|
|
1 inpatient hospital visit/day, 4 non-emergency ambulatory visits/month irrespective of setting
|
Fee for service
|
CN
|
|
Oregon
|
|
Yes
|
A - $3/visit
|
Specified surgical and therapy procedures
|
A & B - specified procedures require a second opinion, B - osteopathic manipulative therapy not covered
|
Fee for service, second and subsequent surgeries performed at same time paid a reduced fee
|
A & B - See state-specific FN
|
|
Pennsylvania
|
|
Yes
|
$.50-$3/specified service, depending on payment rate
|
|
Frequency limits vary by service
|
Fee for service
|
CN & MN
|
|
Rhode Island
|
|
Yes
|
|
Specified surgical procedures, MN only - multiple visits for chronic and acute diagnoses, psych visits after evaluation
|
3 patients/home visit, 6 patients/group care facility, MN limited 37 inpatient hospital visits/year
|
Fee for service
|
CN & MN - see state-specific FN
|
|
South Carolina
|
|
Yes
|
$2/visit - applicable to specified E&M services only
null
|
|
12 visits/year including visits and services provided by other specified practitioners
|
Fee for service
|
CN
|
|
South Dakota
|
|
Yes
|
$3/visit
|
|
Substance abuse treatment not covered
|
Fee for service for high volume procedures, percentage of charge for low volume procedures and for supplies
|
CN
|
|
Tennessee
|
|
Yes
|
B1 - $5/visit except preventive care and $15/specialty care visit, B2 - $10/visit except preventive care and $25/specialty care visit
|
|
|
|
A & B - See state-specific FN
|
|
Texas
|
|
Yes
|
|
Specified services
|
|
Fee for service
|
CN & MN
|
|
Utah
|
|
Yes
|
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
|
A, B & C - See state-specific FN
|
|
Vermont
|
|
Yes
|
|
|
5 office or home visits/month, 1 inpatient hospital visit/day, 1 nursing facility visit/week
|
Fee for service
|
A & B - See state-specific FN
|
|
Virginia
|
|
Yes
|
$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
|
CN & MN
|
|
Washington
|
|
Yes
|
|
Specified surgical procedures
|
1 inpatient hospital visit/day unless payment is all-inclusive fee, 2 nursing facility visits/month, routine physical exams limited
|
Fee for service
|
CN & MN
|
|
West Virginia
|
|
Yes
|
|
Specified surgical procedures
|
|
Fee for service
|
A & B
|
|
Wisconsin
|
|
Yes
|
$.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
|
CN & MN
|
|
Wyoming
|
|
Yes
|
$2/office or home visit
|
|
12 visits/year in combination with outpatient hospital visits
|
Fee for service
|
CN
|
|
American Samoa
|
|
Yes
|
|
|
|
|
See territory-specific FN
|
|
Guam
|
|
Yes
|
|
|
1 inpatient hospital visit/day, 20 psych visits/year, routine physical exams and acupuncture not covered
|
Fee for service
|
CN
|
|
Northern Mariana Islands
|
|
Yes
|
|
|
|
|
CN & MN - See territory-specific FN
|
|
Puerto Rico
|
|
Yes
|
|
|
Specialist care requires primary care physician referral
|
Fee for service with capitated payment for primary care
|
CN & MN
|
|
Virgin Islands
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
