| Is the Benefit Covered? |
Copayment Requirement |
Prior Approval Requirement |
Coverage Limitations |
Reimbursement Methodology |
Populations Covered |
|
|
Alabama
|
|
No
|
|
|
|
|
|
|
Alaska
|
|
Yes
|
|
|
Limited to diagnostic and screening services only, specified coverage criteria for mammography
|
Fee for service
|
CN
|
|
Arizona
|
|
Yes
|
|
|
Specified age and gender criteria for clinical screening, health education and immunizations
|
Fee for service
|
CN & MN
|
|
Arkansas
|
|
No
|
|
|
|
|
|
|
California
|
|
No
|
|
|
|
|
|
|
Colorado
|
|
Yes
|
|
|
|
Dependent upon service and billing provider
|
CN
|
|
Connecticut
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Delaware
|
|
No
|
|
|
|
|
|
|
District of Columbia
|
|
Yes
|
|
Yes
|
Limited to diagnostic and preventive services only
|
Dependent upon service and billing provider
|
CN & MN
|
|
Florida
|
|
Yes
|
$1-$3 dependng on service
|
Specified services
|
Limitations vary depending on service and provider
|
Fee for service
|
CN & MN
|
|
Georgia
|
|
Yes
|
|
|
|
Fee for service at 84.645% of CMS RBRVS rates for 2000
|
CN & MN
|
|
Hawaii
|
|
Yes
|
|
Specified services
|
|
Fee for service
|
CN & MN
|
|
Idaho
|
|
Yes
|
|
|
1 preventive physical exam/year
|
Fee for service
|
CN
|
|
Illinois
|
|
Yes
|
|
|
Limited to diagnostic and screening services only, specified coverage criteria for mammography
|
Dependent upon service and billing provider
|
CN & MN
|
|
Indiana
|
|
Yes
|
|
|
|
Dependent upon service and billing provider
|
CN
|
|
Iowa
|
|
Yes
|
$1-$3 depending on service
|
Specified services
|
Limitations vary depending on service and provider
|
Fee for service or cost based payment
|
CN & MN
|
|
Kansas
|
|
No
|
|
|
|
|
|
|
Kentucky
|
|
Yes
|
|
|
Limited to diagnostic services only
|
Reasonable charge
|
A, B, C & D - See state-specific FN
|
|
Louisiana
|
|
Yes
|
|
|
Limited to specified screening services, including mammography
|
Fee for service
|
CN & MN
|
|
Maine
|
|
Yes
|
|
|
Screening services limited to sexually transmitted diseases, diagnostic and preventive services
|
Fee for service
|
CN & MN
|
|
Maryland
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Massachusetts
|
|
Yes
|
|
|
|
Dependent upon service and billing provider
|
CN & MN
|
|
Michigan
|
|
No
|
|
|
|
|
|
|
Minnesota
|
|
Yes
|
|
|
|
Fee for service
|
A & B - See state-specific FN
|
|
Mississippi
|
|
Yes
|
|
|
Limited to annual preventive physical exams
|
Fee for service
|
CN
|
|
Missouri
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Montana
|
|
Yes
|
Dependent upon service and billing provider
|
|
|
Dependent upon service and billing provider
|
A & B - See state-specific FN
|
|
Nebraska
|
|
Yes
|
|
|
Limited to screening services only, specified coverage criteria for mammography
|
Fee for service
|
CN & MN
|
|
Nevada
|
|
Yes
|
|
|
Limited to screening and preventive services only, specified coverage criteria for mammography and annual gynecological exams
|
Fee for service
|
CN
|
|
New Hampshire
|
|
Yes
|
|
|
Preventive services to newborns and their mothers are counted in the 18 visit physician limit
|
Fee for service or negotiated rate
|
CN & MN
|
|
New Jersey
|
|
Yes
|
|
|
Specified services only
|
Dependent upon service and billing provider
|
CN & MN
|
|
New Mexico
|
|
No
|
|
|
|
|
|
|
New York
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
North Carolina
|
|
Yes
|
|
Specified services
|
Services limited to programs for mental illness, developmental disability and substance abuse
|
Fee for service
|
CN & MN
|
|
North Dakota
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Ohio
|
|
Yes
|
|
|
Limited to preventive services
|
Fee for service
|
CN
|
|
Oklahoma
|
|
Yes
|
|
|
Medically necessary outpatient and diagnostic x-rays and laboratory services, specified coverage criteria for mammography, limited coverage of hepatitis screening for at risk beneficiaries
|
Fee for service
|
CN
|
|
Oregon
|
|
Yes
|
|
|
|
Fee for service
|
A & B - See state-specific FN
|
|
Pennsylvania
|
|
Yes
|
$1/x-ray
|
|
Diagnostic services only
|
Fee for service
|
CN & MN
|
|
Rhode Island
|
|
Yes
|
|
Yes
|
|
Fee for service
|
CN & MN - see state-specific FN
|
|
South Carolina
|
|
Yes
|
|
|
Limited to preventive services only
|
Fee for service
|
CN
|
|
South Dakota
|
|
Yes
|
|
|
|
Fee for service or percentage of charge
|
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
|
|
|
Limited to specified screenings only
|
Fee for service
|
CN & MN
|
|
Utah
|
|
Yes
|
|
|
Limited to preventive services only
|
Dependent upon service and billing provider
|
A, B & C - See state-specific FN
|
|
Vermont
|
|
Yes
|
|
|
|
Dependent upon service and billing provider
|
A & B - See state-specific FN
|
|
Virginia
|
|
Yes
|
|
|
Diagnostic services only covered as part of anothr service, specified coverage criteria for screening and preventive services
|
Fee for service
|
CN & MN
|
|
Washington
|
|
Yes
|
|
|
Limited to preventive services only
|
Fee for service, contracted rate for disease management services
|
CN & MN
|
|
West Virginia
|
|
No
|
|
|
|
|
|
|
Wisconsin
|
|
No
|
|
|
|
|
|
|
Wyoming
|
|
No
|
|
|
|
|
|
|
American Samoa
|
|
Yes
|
|
|
|
|
See territory-specific FN
|
|
Guam
|
|
Yes
|
|
|
Specified coverage criteria for screening services
|
Fee for service
|
CN
|
|
Northern Mariana Islands
|
|
No
|
|
|
|
|
|
|
Puerto Rico
|
|
Yes
|
|
|
|
Capitated payment
|
CN & MN
|
|
Virgin Islands
|
|
No
|
|
|
|
|
|
