| Is the Benefit Covered? |
Copayment Requirement |
Prior Approval Requirement |
Coverage Limitations |
Reimbursement Methodology |
Populations Covered |
|
|
Alabama
|
|
Yes
|
$1/visit
|
|
14 visits/year included in physician visit limitation - limit doesn't apply to family planning
|
Prospective cost based rate per service with ancillaries paid fee for service
|
CN
|
|
Alaska
|
|
Yes
|
$3/visit
|
|
|
Prospective cost based rate/visit with ancillaries paid fee for service
|
CN
|
|
Arizona
|
|
Yes
|
|
Yes
|
Coverage of outpatient occupational therapy and speech pathology services limited to ALTCS members - see state-specific FN
|
Fee for service
|
CN & MN
|
|
Arkansas
|
|
Yes
|
|
|
12 ambulatory encounters/year irrespective of setting
|
Greater of prospective rate/encounter or allowable cost
|
CN & MN
|
|
California
|
|
Yes
|
$1/visit
|
Specified services
|
|
Provider based: prospective cost based rate/visit with ancillaries paid fee for service, Independent: cost based payment
|
CN & MN
|
|
Colorado
|
|
Yes
|
$2/visit
|
|
|
Prospective cost based rate/visit with ancillaries paid fee for service, or alternative reimbursement methodology
|
CN
|
|
Connecticut
|
|
Yes
|
|
|
|
Prospective cost based rate/visit with ancillaries paid fee for service
|
CN & MN
|
|
Delaware
|
|
Yes
|
|
|
|
Cost based payment, ancillary services paid fee for service
|
CN
|
|
District of Columbia
|
|
Yes
|
|
|
|
Prospective cost based rate/visit with ancillaries paid fee for service
|
CN & MN
|
|
Florida
|
|
Yes
|
$3/day
|
|
1 encounter/day except mental health services limited to 26 encounters/year
|
On site: prospective cost based rate/encounter, Off-site: fee for service
|
CN & MN
|
|
Georgia
|
|
Yes
|
$2/visit
|
|
|
Prospective cost based rate/visit
|
CN & MN
|
|
Hawaii
|
|
Yes
|
|
|
|
Prospective cost based payment
|
CN & MN
|
|
Idaho
|
|
Yes
|
|
|
|
Prospective cost based rate/visit
|
CN
|
|
Illinois
|
|
Yes
|
|
|
|
Prospective cost based rate/visit or certified cost/encounter
|
CN & MN
|
|
Indiana
|
|
Yes
|
|
|
|
Prospective cost based rate/encounter
|
CN
|
|
Iowa
|
|
Yes
|
|
|
|
Cost based payment
|
CN & MN
|
|
Kansas
|
|
Yes
|
$3/encounter
|
|
|
Prospective cost based rate/visit
|
CN & MN
|
|
Kentucky
|
|
Yes
|
A - $2/visit
|
|
|
Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment
|
A, B, C & D - See state-specific FN
|
|
Louisiana
|
|
Yes
|
|
|
15 visits/year, visits count toward physician visit limit where applicable
|
Prospective all-inclusive rate/encounter
|
CN & MN
|
|
Maine
|
|
Yes
|
|
|
|
Prospective cost based rate/visit
|
CN & MN
|
|
Maryland
|
|
Yes
|
|
|
1 non-emergency visit/day
|
Prospective cost based rate/visit
|
CN & MN
|
|
Massachusetts
|
|
Yes
|
|
|
|
Prospective cost based rate/visit
|
CN & MN
|
|
Michigan
|
|
Yes
|
null
|
|
|
Prospective cost based rate/visit
|
CN & MN
|
|
Minnesota
|
|
Yes
|
$3/visit for non-preventive service
|
|
|
Prospective cost based rate/visit or alternative reimbursement methodology using cost based payment
|
A & B - See state-specific FN
|
|
Mississippi
|
|
Yes
|
$3/visit
|
|
12 visits/year, visits count toward physician visit limit
|
Prospective cost based rate/visit
|
CN
|
|
Missouri
|
|
Yes
|
$2/day
|
|
|
Cost based payment
|
CN & MN
|
|
Montana
|
|
Yes
|
$5/visit
|
|
|
Prospective cost based rate/visit
|
A & B - See state-specific FN
|
|
Nebraska
|
|
Yes
|
|
|
|
Prospective cost based rate/visit
|
CN & MN
|
|
Nevada
|
|
Yes
|
|
|
|
Prospective all-inclusive cost based rate/visit
|
CN
|
|
New Hampshire
|
|
Yes
|
|
|
|
Cost based payment, with limits
|
CN & MN
|
|
New Jersey
|
|
Yes
|
|
|
|
Prospective cost based rate/visit
|
CN & MN
|
|
New Mexico
|
|
Yes
|
A - $5/visit, B - $7/visit non-preventive services - see state-specific FN
|
|
|
Prospective cost based rate/encounter
|
CN
|
|
New York
|
|
Yes
|
$3/visit
|
|
10 clinic visits/year in combination with other specified providers
|
Prospective cost based rate
|
CN & MN
|
|
North Carolina
|
|
Yes
|
$1-$3/visit for specified non-core services
|
Specified services
|
22 ambulatory visits/year included in limits with other specified practitioners - limits set annually by the legislature
|
Prospective or cost based rate/visit up to Medicare PPS rate
|
CN & MN
|
|
North Dakota
|
|
Yes
|
$3/visit
|
|
|
Prospective cost based rate/visit for medical services, cost based payment for dental services
|
CN & MN
|
|
Ohio
|
|
Yes
|
|
|
24 visits/year included in physician visit limit
|
Prospective cost based rate/visit
|
CN
|
|
Oklahoma
|
|
Yes
|
$1/service
|
|
|
Prospective rate/visit
|
CN
|
|
Oregon
|
|
Yes
|
A - $3/visit
|
|
|
Prospective cost based rate/visit
|
A & B - See state-specific FN
|
|
Pennsylvania
|
|
Yes
|
$.50-$3/service, depending on payment rate
|
|
Frequency limits vary by service
|
Provider based: prospective cost based rate/visit, Independent: prospective cost based rate/visit with ancillaries paid fee for service
|
CN & MN
|
|
Rhode Island
|
|
Yes
|
|
|
|
Prospective cost based rate/visit
|
CN & MN - see state-specific FN
|
|
South Carolina
|
|
Yes
|
$2/encounter
|
|
12 visits/year, visits count toward physician visit limit
|
Prospective cost based rate/visit or cost based payment
|
CN
|
|
South Dakota
|
|
Yes
|
$3/visit
|
|
Substance abuse treatment not covered
|
Prospective cost based rate/visit
|
CN
|
|
Tennessee
|
|
Yes
|
|
|
|
Cost based through combination of MCO and State payments
|
A & B - See state-specific FN
|
|
Texas
|
|
Yes
|
|
Specified services
|
|
Prospective cost based rate/visit
|
CN & MN
|
|
Utah
|
|
Yes
|
A & B- $3/visit, C - $5/visit
|
|
C - Primary care only, including routine physical exams
|
Cost based payment
|
A, B & C - See state-specific FN
|
|
Vermont
|
|
Yes
|
|
|
1 visit/day up to 5 visits/month
|
Cost based payment
|
A & B - See state-specific FN
|
|
Virginia
|
|
Yes
|
$1/visit
|
|
|
Cost based payment
|
CN & MN
|
|
Washington
|
|
Yes
|
|
|
|
Prospective cost based rate/visit
|
CN & MN
|
|
West Virginia
|
|
Yes
|
|
|
|
Prospective cost based rate/visit
|
A & B
|
|
Wisconsin
|
|
Yes
|
$.50-$3/encounter, depending on services provided, maximum $30/year/provider
|
|
|
Prospective cost based rate/visit
|
CN & MN
|
|
Wyoming
|
|
Yes
|
$2/visit
|
|
|
Prospective cost based rate/visit
|
CN
|
|
American Samoa
|
|
Yes
|
|
|
|
|
See territory-specific FN
|
|
Guam
|
|
No
|
|
|
|
|
|
|
Northern Mariana Islands
|
|
No
|
|
|
|
|
|
|
Puerto Rico
|
|
Yes
|
|
|
|
Capitated payment
|
CN & MN
|
|
Virgin Islands
|
|
No
|
|
|
|
|
|
