| Is the Benefit Covered? |
Copayment Requirement |
Prior Approval Requirement |
Coverage Limitations |
Reimbursement Methodology |
Populations Covered |
|
|
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center |
|
Yes
|
|
|
|
Fee for service at 75% of rate paid in outpatient hospital setting
|
CN & MN
|
|
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics |
|
Yes
|
|
|
|
Fee for service, encounter rates for specified clinics
|
CN & MN
|
|
Federally Qualified Health Center Services |
|
Yes
|
|
|
|
Prospective cost based rate/visit or certified cost/encounter
|
CN & MN
|
|
Inpatient Hospital Services, other than in an Institution for Mental Diseases |
|
Yes
|
$2-$3/day unless per diem less than $275
|
Admissions for specified procedures safely rendered on outpatient basis, physical rehab services
|
Pre-surgical days limited to 1 unless medically justified, admissions and LOS limited by State's Utilization Review authority, second opinion required for specified procedures
|
Prospective payment/discharge using DRG or prospective per diem for psych and rehab hospitals/units or facility-specific per diem for other special hospitals/units including certain government-operated facilities and children's hospitals
|
CN & MN
|
|
Outpatient Hospital Services |
|
Yes
|
|
Specified surgical procedures
|
|
Fee for service or prospective rate/visit
|
CN & MN
|
|
Rehabilitation Services: Mental Health and Substance Abuse |
|
Yes
|
|
Residential-based services, active community treatment
|
|
Fee for service, cost based per diem or certified cost
|
CN & MN
|
|
Rural Health Clinic Services |
|
Yes
|
|
|
|
Prospective cost based rate/visit or certified cost/encounter
|
CN & MN
|
|
Certified Registered Nurse Anesthetist Services |
|
Yes
|
|
|
|
Fee for service at physician fee
|
CN & MN
|
|
Chiropractor Services |
|
Yes
|
$2/visit
|
|
|
Fee for service
|
CN & MN
|
|
Dental Services |
|
Yes
|
|
Specified services
|
Periodontia, posterior root canals and preventive services including exams and cleanings not covered; coverage limited to exams and x-rays necessary to assess oral health, to diagnose oral problems and to develop a treatment plan
|
Fee for service through contracted intermediary
|
CN & MN
|
|
Medical and Remedial Care - Other Practitioners
|
|
|
|
|
|
|
|
|
Medical/Surgical Services of a Dentist |
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Nurse Midwife Services |
|
Yes
|
|
|
|
Fee for service at physician fee
|
CN & MN
|
|
Nurse Practitioner Services |
|
Yes
|
|
|
|
Fee for service at physician fee
|
CN & MN
|
|
Optometrist Services |
|
Yes
|
$2/visit
|
Specified items, including visual aids
|
1 refractive exam/year
|
Fee for service or certified cost
|
CN & MN
|
|
Physician Services |
|
Yes
|
$2/visit
|
Specified surgical procedures
|
Home visits limited to homebound
|
Fee for service, certified cost for certain government-employed practitioners
|
CN & MN
|
|
Podiatrist Services |
|
Yes
|
$2/visit
|
Specified services or unusual procedures
|
|
Fee for service
|
CN & MN
|
|
Psychologist Services |
|
No
|
|
|
|
|
|
|
Prescription Drugs |
|
Yes
|
$3/brand Rx
|
|
3 brand Rx/month
|
AWP-12%, plus $3.40 dispensing fee for brand Rx, AWP-25%, plus $4.60 dispensing fee for generic Rx
|
CN & MN
|
|
Occupational Therapy Services |
|
Yes
|
|
Services other than to continue therapy provided in previous 30 days on inpatient basis
|
|
Fee for service or certified cost
|
CN & MN
|
|
Physical Therapy Services |
|
Yes
|
|
Services other than to continue therapy provided in previous 30 days on inpatient basis
|
|
Fee for service or certified cost
|
CN & MN
|
|
Services for Speech, Hearing and Language Disorders |
|
Yes
|
|
Services other than to continue therapy provided in previous 30 days on inpatient basis
|
Physician order required for specified services
|
Fee for service or certified cost
|
CN & MN
|
|
Dentures |
|
Yes
|
|
Yes
|
1 full upper and/or lower denture/5 years, partial dentures not covered but may be adjusted
|
Fee for service through contracted intermediary
|
CN & MN
|
|
Eyeglasses |
|
Yes
|
|
|
1 pair eyeglasses/year with specified exceptions
|
Products provided by state's volume purchase contractor, dispensing provider paid fee for service
|
CN & MN
|
|
Hearing Aids |
|
Yes
|
|
Other than monaural hearing aids
|
|
Acquisition cost plus dispensing fee
|
CN & MN
|
|
Medical Equipment and Supplies |
|
Yes
|
|
Specified med equipment and med supply items
|
|
Fee for service
|
CN & MN
|
|
Prosthetic and Orthotic Devices |
|
Yes
|
|
Specified services or items
|
|
Lower of charge or acquisition cost
|
CN & MN
|
|
Ambulance Services |
|
Yes
|
|
Specified services
|
|
Fee for service
|
CN & MN
|
|
Non-Emergency Medical Transportation Services |
|
Yes
|
|
All transports other than nursing facility residents
|
|
See service-specific FN
|
CN & MN
|
|
Diagnostic, Screening and Preventive Services |
|
Yes
|
|
|
Limited to diagnostic and screening services only, specified coverage criteria for mammography
|
Dependent upon service and billing provider
|
CN & MN
|
|
Early and Periodic Screening, Diagnosis and Treatment
|
|
See service-specific FN.
|
|
|
|
|
|
|
Extended Services for Pregnant Women
|
|
|
|
|
|
|
|
|
Family Planning Services
|
|
See service-specific FN.
|
|
|
|
|
|
|
Laboratory and X-Ray Services, outside Hospital or Clinic |
|
Yes
|
|
|
Total body scans limited to inpatient hospital setting
|
Fee for service using Medicare payment ceilings
|
CN & MN
|
|
Targeted Case Management |
|
Yes
|
|
|
Quantity and frequency limits vary by group served
|
Fee for service
|
CN & MN
|
