Medicaid Benefits: Online Database

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Benefits by Service: Outpatient Hospital Services (October 2006) 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: 36

No: 15

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

Alabama
Yes	$3/non-emergency visit in ER		3 non-emergency visits/year unless outpatient surgery, lab, dialysis, radiation or chemotherapy, non-emergency visit to ER counts toward both outpatient and physician visit limits	Fee for service	CN
Alaska
Yes	5% of payment for non-emergency services	Specified surgical procedures	Outpatient psych and substance abuse not covered	Prospective cost based rate using percentage of charge	CN
Arizona
Yes	$5/non-emergency visit in ER	Specified surgical procedures, rehab services	Coverage of outpatient occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN	All-inclusive rate per episode of care using Medicare groupings for most surgical procedures or fee for service	CN & MN
Arkansas
Yes		Specified surgical procedures	12 non-emergency visits/year	Cost based payment for pediatric, teaching and critical access hospitals; fee for service for other hospitals	CN & MN
California
Yes	$5/non-emergency visit in ER, $1/visit for other services			Fee for service, state may negotiate all-inclusive per visit rates with certain hospitals	CN & MN
Colorado
Yes	$3/visit			Cost based payment	CN
Connecticut
Yes			1 visit/day	Fee for service or percentage of charge	CN & MN
Delaware
Yes				Cost based payment	CN
District of Columbia
Yes			Cosmetic and oral surgery limited to emergency repair due to injury or trauma	Cost based payment	CN & MN
Florida
Yes	5% of payment up to $15/visit for non-emergency services in the ER		$1,500/year for non-emergency services (excluding surgery)	Prospective cost based per diem or rate per service, lab and x-ray services paid fee for service	CN & MN
Georgia
Yes	$3/non-emergency visit	Specified procedures	Observation limited to 48 hours	Cost based payment using percentage of charge	CN & MN
Hawaii
Yes				All-inclusive rate per episode of care using Medicare groupings for most surgical procedures or fee for service with limits	CN & MN
Idaho
Yes			6 ER visits/year if no admission, varying visit limits for therapies including psych which may be included in limits with other providers	Fee for service using hospital cost as upper limit	CN
Illinois
Yes		Specified surgical procedures		Fee for service or prospective rate/visit	CN & MN
Indiana
Yes	$3/non-emergency visit in ER			Fee for service, with surgical procedures grouped using Medicare methodology	CN
Iowa
Yes			Varying visit limits for cardiac rehab, behavioral health and substance abuse, eating disorder and pain management therapies	Fee for service, with surgical procedures grouped using Medicare methodology, ancillaries paid at Medicare rates	CN & MN
Kansas
Yes	$3/non-emergency visit		Non-emergency visits count toward physician visit limit, rehab must be restorative	Fee for service	CN & MN
Kentucky
Yes	A, C & D - $3/ambulatory visit; A, B, C & D - 5% of payment for non-emergency visit in ER up to $6			Fee for service with surgical procedures grouped using Medicare methodology or cost based payment	A, B, C & D - See state-specific FN
Louisiana
Yes			3 ER visits/year and count against physician visit limit	Cost based payment or fee for service	CN & MN
Maine
Yes	$.50-$3/day, depending on payment, up to $30/month			Cost based payment with limits	CN & MN
Maryland
Yes	$6/non-emergency visit in ER			Fee for service using rates approved by cost review commission	CN & MN
Massachusetts
Yes	$3/non-emergency visit in ER			Fee for service using rates approved by cost review commission, surgical procedures grouped using Medicare methodology	CN & MN
Michigan
Yes	$3/non-emergency visit in ER, $1/hospital clinic visit			Fee for service, satellite clinics in health shortage areas paid higher rates	CN & MN
Minnesota
Yes	$6/non-emergency visit in ER, $3/visit for non-preventive service			Payments based on Medicare methodology, cost based payment for critical access hospitals	A & B - See state-specific FN
Mississippi
Yes	$3/non-emergency visit		6 ER visits/year	Cost based payment using hospital cost to charge ratio	CN
Missouri
Yes	$3/day	Specified services	Elective surgeries require second opinion	Percentage of charge	CN & MN
Montana
Yes	$5/visit			Fee for service with surgical procedures grouped using Medicare methodology, cost based payment for critical access hospitals	A & B - See state-specific FN
Nebraska
Yes	$3/visit		No visit payable within 3 days of inpatient admission, substance abuse treatment not covered	Percentage of charge with limits, lab services paid fee for service, cost based payment for critical access hospitals	CN & MN
Nevada
Yes				Fee for service with surgical procedures grouped using Medicare methodology	CN
New Hampshire
Yes			12 visits/year, visits for therapy included in limits with other specified practitioners	Percentage of charge	CN & MN
New Jersey
Yes			Non-emergency services in ER not covered	Cost based payment	CN & MN
New Mexico
Yes	A - $15/non-emergency visit to ER and $5/visit for other services, B - $20/non-emergency visit to ER and $5/visit for other services - see state-specific FN	Allergy testing and treatment, therapies		Cost based payment with limits	CN
New York
Yes	$3/visit		10 outpatient visits/year in combination with other specified providers	Prospective all-inclusive rate with limits, some services fee for service	CN & MN
North Carolina
Yes	$3/visit	More than 8 outpatient psychiatric visits	24 non-emergency visits/year included in limits with other specified practitioners	Prospective cost based rate, cost based payment for state owned facilities	CN & MN
North Dakota
Yes	$6/non-emergency visit in ER		30 SP visits/year included in limits for other specified providers	Fixed percentage of charge	CN & MN
Ohio
Yes				Fee for service or prospective payment based on percentage of charge	CN
Oklahoma
Yes	$3/day	Specified surgical procedures and other services	Outpatient behavioral health services not covered for nursing facility residents	Fee for service using surgical group rates, ancillaries paid separately	CN
Oregon
Yes	A - $3/visit	Specified surgical and therapy procedures		Cost based payment with limits	A & B - See state-specific FN
Pennsylvania
Yes	$.50-$3/service, depending on payment		Frequency limits vary by service	Fee for service	CN & MN
Rhode Island
Yes	$3/non-emergency visit in ER	Physical and occupational therapy, speech pathology		Prospective payment with surgical procedures grouped using Medicare methodology	CN & MN - see state-specific FN
South Carolina
Yes	$3/non-emergency visit in ER			Fee for service	CN
South Dakota
Yes	5% of payment up to $50/visit, non-emergency only		Substance abuse treatment not covered, cosmetic surgery limited to emergency repair due to injury or trauma	Cost based payment	CN
Tennessee
Yes	B1 - $25/ER visit if not admitted, B2 - $50/ER visit if not admitted		$30,000 limit/lifetime for drug and alcohol treatment across all types of providers		A & B - See state-specific FN
Texas
Yes		Specified services		Cost based payment, prospective payment with surgical procedures grouped using Medicare methodology	CN & MN
Utah
Yes	A & B - $6/non-emergency visit in ER, C - $30/non-emergency visit in ER		B - outpatient psych and substance abuse services limited to 30 days/year and included in inpatient limit, C - services limited to emergency treatment in ER	Prospective cost based rate with higher rates for rural hospitals, some services paid fee for service or all-inclusive rate	A, B & C - See state-specific FN
Vermont
Yes	A - $3/day, B - $25/medically necessary visit in ER		Non-emergency services in ER not covered	Cost based payment, some services paid fee for service or prospective per diem	A & B - See state-specific FN
Virginia
Yes	$3/visit		24 therapy visits/year	Cost based payment with limits	CN & MN
Washington
Yes	$3/non-emergency visit in ER	Specified services		Most urban hospitals paid prospective cost based rates, rural hospitals paid prospective percentage of charge	CN & MN
West Virginia
Yes		Specified surgical procedures and other services		Fee for service	CN & MN
Wisconsin
Yes	$3/visit, $.50/day for psych day treatment	Specified surgical procedures and other services	Outpatient psych services limited to 5 hours/day up to 120 hours/month and 40 hours/year for nursing facility residents; occupational therapy, physical therapy and speech pathology services must be billed as if rendered by the therapist and are reimbursed accordingly	Cost based payment with limits	CN & MN
Wyoming
Yes	$6/non-emergency visit in ER		12 visits/year in combination with physician office visits, therapy services must be restorative and are limited to 20 visits/year across all therapy providers	Fee for service	CN
American Samoa
Yes					See territory-specific FN
Guam
Yes		Non-emergency therapy services, CT-scans		Negotiated rate/service	CN
Northern Mariana Islands
Yes					CN & MN - See territory-specific FN
Puerto Rico
Yes			Elective surgery requires primary care physician referral	Fee for service with capitated payment for primary care	CN & MN
Virgin Islands
Yes			Services in public health facilities only	Fee for service	CN

Definition/Notes: Link to Outpatient Hospital Services Footnote


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