| Is the Benefit Covered? |
Copayment Requirement |
Prior Approval Requirement |
Coverage Limitations |
Reimbursement Methodology |
Populations Covered |
|
|
Alabama
|
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Yes
|
|
|
Services for the following populations: 2, 4, 5, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN
|
|
Alaska
|
|
Yes
|
|
|
Services for the following populations: 2, 4, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN
|
|
Arizona
|
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Yes
|
|
|
See state-specific FN and service-specific FN
|
See state-specific FN
|
CN & MN
|
|
Arkansas
|
|
Yes
|
|
|
Services for the following populations: 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
California
|
|
Yes
|
|
|
Services for the following populations: 2, 4, 5, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Colorado
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 3, 4, 5, 7 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN
|
|
Connecticut
|
|
Yes
|
|
|
Services for the following populations: 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Delaware
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4, 5 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN
|
|
District of Columbia
|
|
Yes
|
|
|
Services for the following populations: 2, 4, 5 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Florida
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4, 5, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Georgia
|
|
Yes
|
|
|
Services for the following populations: 2, 4, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Hawaii
|
|
Yes
|
|
|
Services for the following populations: 2, 4, 5, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Idaho
|
|
Yes
|
|
|
Services limited to Enhanced Plan and for the following populations: 1, 2, 4 & 8 - See both state-specific FN and service-specific FN
|
Dependent upon the services provided
|
CN
|
|
Illinois
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4, 5, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Indiana
|
|
Yes
|
|
Yes
|
Services for the following populations: 1, 2, 3, 4, 6, 7 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN
|
|
Iowa
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4, 5 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN
|
|
Kansas
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4, 6, 7 & 8 - see service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Kentucky
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
C & D - See state-specific FN
|
|
Louisiana
|
|
Yes
|
|
|
Services for the following populations: 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Maine
|
|
Yes
|
|
|
Services for the following populations: 2 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Maryland
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 3, 4, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Massachusetts
|
|
Yes
|
|
|
Services for the following populations: 1, 2 & 4 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Michigan
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Minnesota
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
A - See state-specific FN
|
|
Mississippi
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN
|
|
Missouri
|
|
Yes
|
|
|
Services for the following populations: 2, 4, 5 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Montana
|
|
Yes
|
|
|
Services for the following populations: 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
A - See state-specific FN
|
|
Nebraska
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Nevada
|
|
Yes
|
|
|
Services for the following populations: 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN
|
|
New Hampshire
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
New Jersey
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4, 5, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
New Mexico
|
|
Yes
|
|
|
Services for the following populations: 2, 4, 5 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN
|
|
New York
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4, 6, 7 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
North Carolina
|
|
Yes
|
|
|
Services for the following populations: 2, 4, 5, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
North Dakota
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Ohio
|
|
Yes
|
|
|
Services for the following populations: 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN
|
|
Oklahoma
|
|
Yes
|
|
|
Services for the following populations: 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN
|
|
Oregon
|
|
Yes
|
|
|
Services for the following populations: 2, 4, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
A & B - See state-specific FN
|
|
Pennsylvania
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4, 5, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Rhode Island
|
|
Yes
|
|
|
Services for the following populations: 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN - see state-specific FN
|
|
South Carolina
|
|
Yes
|
|
|
Services for the following populations: 2, 4, 5, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN
|
|
South Dakota
|
|
Yes
|
|
|
Services for the following populations: 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN
|
|
Tennessee
|
|
Yes
|
|
Specified services
|
Services for the following populations: 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
A - See state-specific FN
|
|
Texas
|
|
Yes
|
|
|
Services for the following populations: 2, 4, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN
|
|
Utah
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
A, B & C - See state-specific FN
|
|
Vermont
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4, 7 & 8 - See service-specific FN
|
Dependent upon the services provided
|
A - See state-specific FN
|
|
Virginia
|
|
Yes
|
|
|
Services for the following populations: 2, 3, 4, 5, 6 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Washington
|
|
Yes
|
|
|
Services for the following populations: 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
West Virginia
|
|
Yes
|
|
|
Services for the following populations: 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Wisconsin
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4, 7 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN & MN
|
|
Wyoming
|
|
Yes
|
|
|
Services for the following populations: 1, 2, 4 & 8 - See service-specific FN
|
Dependent upon the services provided
|
CN
|
|
American Samoa
|
|
No
|
|
|
|
|
|
|
Guam
|
|
No
|
|
|
|
|
|
|
Northern Mariana Islands
|
|
No
|
|
|
|
|
|
|
Puerto Rico
|
|
No
|
|
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Virgin Islands
|
|
No
|
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