[XLS]Fee Schedules - macpac · Web viewCNP- All CNP services are reimbursed at 100 percent of the...

Medicaid Fee-for-Service Physician Payment Policy Landscapes*

State

Fee Schedules:Adjustments to Payment

Yes NF Yes 80% Yes NF

RBRVS Yes Yes NF 85% NF NFRBRVS Yes NF Yes No NF Yes

Yes Yes NF NF NF

Yes NF Yes No NF NF

Yes NF Yes No NF NF

% of Medicare Yes NF Yes 90% NF NF

RBRVS Yes NF NF NF NF NF

% of Medicare Yes NF NF 80% NF Yes

Fee Schedule Basis(See state details)

Advanced Practitioners(See state details.)

Geo-graphic

Site of Service

Physicians(General)

NP, PA, and MW

Other Specialty

Alabama

State determined based on internal process

AlaskaArizona

Arkansas

State determined based on market assessment

Separate Fee Schedules

California


Colorado

State determined based on market value

Connecticut

Delaware

District of Columbia

RBRVS Yes Yes Yes NF NF

% of Medicare Yes NF NF 90% NF Yes

% of Medicare Yes NF NF NF NF Yes

% of Medicare Yes NF Yes 85% NF Yes

Yes NF NF No NF NF

RBRVS Yes NF NF 75% NF Yes

% of Medicare Yes Yes Yes 85% NF Yes

% of Medicare Yes Yes NF 75% NF NFRBRVS Yes NF NF 75% NF No

% of Medicare Yes NF NF 80% NF NF

% of Medicare Yes NF NF NF Yes

% of Medicare Yes NF NF NF NF Yes

RBRVS Yes NF NF 85% NF Yes

Yes Yes Yes Up to 100% NF Yes

FloridaRanges from 12.8% to 80%

Georgia

Hawaii

Idaho

Illinois


Indiana

Iowa

KansasKentucky

Louisiana

Maine

Lesser of charges, Medicare rate, or fee schedule*

Maryland

Massachusetts

Michigan


RBRVS Yes NF NF No Yes


% of Medicare Yes Yes NF NF No NFRBRVS Yes No Yes 90% NF YesRBRVS Yes Yes Yes Up to 100% NF Yes

RBRVS Yes Yes Yes NF NF

% of Medicare Yes Yes NF NF NF NF

NF Yes NF Yes NF NF

Yes NF NF NF Yes

% of Medicare Yes Yes Yes NF Yes

% of Medicare Yes Yes Yes No NF Yes

RBRVS Yes NF NF NF NF

RBRVS Yes NF NF NF YesRBRVS Yes NF NF No NF NFRBRVS Yes NF NF No NF Yes

MinnesotaRanges from 65% to 90%

Mississippi

MissouriMontanaNebraska

NevadaRanges from 69% to 88%

New Hampshire

New JerseyRanges from 70% to 100%

New Mexico


Ranges from 77% to 90%

New YorkSeparate Fee Schedules

North Carolina

North DakotaRanges from 15% to 75%

OhioRanges from 85% to 100%

OklahomaOregon

Yes Yes Yes NF NF NF

RBRVS Yes NF Yes NF NF NF

% of Medicare Yes NF Yes NF Yes


NF NF NF NF NF NF

RBRVS Yes Yes Yes No YesRBRVS Yes Yes Yes No Yes NFRBRVS Yes NF NF No NF Yes

RBRVS Yes NF NF NF No YesRBRVS Yes NF NF NF NF YesRBRVS Yes NF NF No NF Yes

Yes Yes NF NF NF

Yes NF NF No NF NF

clarify policies which could not be found or were unclear. Every attempt was made to find the most recent and up-to-date data, however, not all recent data was publicly available and many ofthe policies may have been developed years earlier and may not be in current practice.

Pennsylvania


Rhode Island

South CarolinaRanges from 65% to 100%

South Dakota

Tennessee

85% Medicare or 100% Medicaid FS

TexasRanges from 70% to 92%

UtahVermont

VirginiaWashingtonWest Virginia

Wisconsin



Wyoming


*Note: Data is based on publicly available policy documentation identified in July and August 2013. Follow-up contact was made with state Medicaid employees (primarily policy staff) to

Many of the sources are best accessed through Internet Explorer.Any errors or changes, please contact MACPAC at 202-350-2000.NF=None Found

Source: Data collected by George Washington University for MACPAC

Medicaid Fee-for-Service Physician Payment Policy Landscapes*Adjustments to Payment Incentive or Add-on Payments

Out-of-State Other

NF In-State Yes NF Yes Yes Yes

Yes No NF No NF NFNF NF NF No NF Yes NF NF

NF NF No Yes Yes Yes Yes

Yes In-State NF No NF Yes Yes NF

NF In-State Anesthesia No NF Yes Yes NF

Yes In-State NF No NF Yes Yes NF

NF NF No NF Yes NF NF

NF In-State NF No NF Yes NF NF

Children vs. Adults

Health Home

Quality or P4P

Primary Care

Primary Care Case Mgmt (PCCM)

Academic Health Center

Public vs. Private

Lesser of charges, 70% of in-state fee schedule, or out-of-state fee schedule

AnesthesiaSurgery

AnesthesiaAssistant Surgery

Lesser of charges or in-state fee schedule

Yes Negotiated No NF Yes Yes Yes

NF NF No NF Yes NF Yes

Yes NF NF No NF Yes NF NF

NF In-State NF Yes NF Yes Yes NF

NF NF No NF Yes Yes Yes

Yes Negotiated No NF Yes Yes NF

Yes NF NF Yes NF Yes Yes NF

No NF NF No NF Yes Yes NFYes NF NF No NF Yes Yes Yes

Yes NF NF No NF Yes Yes Yes

NF In-State NF Yes Yes Yes Yes NF

NF NF NF No NF Yes NF NF

NF In-State NF No NF Yes Yes Yes

NF In-State No NF Yes` NF Yes

AnesthesiaAssistant SurgeryAA

Lesser of in-state fee schedule, 45% charges, or out-of-state fee schedule

Maternal and Child Health Program

Breast Cancer Quality Screening and Treatment Initiative

Anesthesia, CRNA, AA

Children with Special Health Care Needs

NF In-State Anesthesia No Yes Yes NF NF

Yes NF NF No NF Yes NF NF

Yes In-State NF Yes NF Yes NF NFYes NF NF No NF Yes Yes NFYes Negotiated CRNA, AA No No Yes Yes Yes

Yes NF No NF Yes NF Yes



NF In-State NF No NF Yes NF Yes

Yes In-State No NF Yes No NF

Yes In-State Yes NF Yes Yes Yes

NF In-State NF No NF No Yes NF

NF In-State NF Yes NF Yes NF NFYes NF CRNA, AA No NF Yes Yes NFNF In-State NF Yes NF Yes No Yes


HIV, PPAC, & MOMS programs


NF NF NF No NF Yes Yes NF

NF NF Yes No Yes No No

Yes Surgery No NF Yes Yes Yes

NF NF NF No NF Yes Yes NF

No NF CRNA No NF Yes NF NF

Yes CRNA No NF Yes No NFNF In-State Anesthesia No No Yes Yes NFNF NF NF No NF Yes Yes Yes

Yes In-State Anesthesia No NF Yes NF NFYes In-State NF No NF Yes NF YesNo In-State Anesthesia No NF Yes Yes Yes

Yes NF Yes NF Yes NF Yes

Yes In-State Surgery No NF Yes NF NF

clarify policies which could not be found or were unclear. Every attempt was made to find the most recent and up-to-date data, however, not all recent data was publicly available and many ofthe policies may have been developed years earlier and may not be in current practice.

Lesser of charges or the out-of-state fee schedule - NTE lesser of FS or Medicare charge


Lesser of in-state fee schedule or Medicare rate

HPSA (+20%) Primary Care

Data is based on publicly available policy documentation identified in July and August 2013. Follow-up contact was made with state Medicaid employees (primarily policy staff) to

Incentive or Add-on Payments

Other

NF

NF $3NF $0.00

NF NF

NF $1.00

NF $2.00

NF NF

NF NF

NF $0.00

Enrollee Cost Sharing

Ranges from $1.30 to $3.90

NF $2.00

NF

NF $0.00

NF $3.65

NF

NF $0.00

NF $3.00

NF $2.00NF $2.00

NF $0.00

NF

NF NF

NF NF

NF $2.00

Ranges from $0.50-$3.00 max

Ranges from $0 to $3.90

Ranges from $0.50 to $3

NF $3.00

NF $3.00

NF $1.00NF $4.00NF $2.00

NF NF

NF NF

NF NF

No NF

$0.00

NF $2.00

NFNF $3.00NF $3.00

(A) E-Prescription Incentive(B) Adirondack Medical Home Multipayor Program

Pregnancy Medical Home

$3 (NCHC $0)

Office/Clinic Incentive Program

NF

No No

NF $3.30

NF NF

NF

NF $0.00NF $3.00NF NF

NFNF NoNF $0.00

NF $2.45

clarify policies which could not be found or were unclear. Every attempt was made to find the most recent and up-to-date data, however, not all recent data was publicly available and many of


Ranges from $0 to $20


BMI Reimbursement


Data is based on publicly available policy documentation identified in July and August 2013. Follow-up contact was made with state Medicaid employees (primarily policy staff) to

States' Medicaid Fee-for-Service Physician Payment Policies - Alabama

Every attempt was made to find the most recent and up-to-date data, however, not all recent data was publicly available and many of the policies may have been developed years earlier and may not be in current practice.Many of the sources are best accessed through Internet Explorer.Any errors or changes, please contact MACPAC at 202-350-2000.NF=None Found

CategoryAdjustments

Basic Payment Policy

Fee Schedule Basis

Note: Data is based on publicly available policy documentation identified in July and August 2013. Follow-up contact was made with state Medicaid employees (primarily policy staff) to clarify policies which could not be found or were unclear.

Source: Data collected by George Washington University for MACPACBack to Summary

Advanced Practitioner Adjustments

Fee Schedules: General Physicians

Children vs. Adults

Out-of-State

Fee Schedules: NP, PA, and MW

Fee Schedules: Other Specialties

Geographic Adjustments

Site of Service Adjustments


OtherIncentive or Add-on Payments

Health Home

Primary Care

Quality or P4P Incentives

Primary Care Case Management (PCCM)


Other (Includes Supplemental Payments)

States' Medicaid Fee-for-Service Physician Payment Policies - Alabama

Every attempt was made to find the most recent and up-to-date data, however, not all recent data was publicly available and many of the policies may have been developed years earlier and may not be in current practice.Many of the sources are best accessed through Internet Explorer.Any errors or changes, please contact MACPAC at 202-350-2000.

AlabamaAdjustments

Payment for physician services is based on a state-developed fee schedule.

Physician Fee Schedule

Data is based on publicly available policy documentation identified in July and August 2013. Follow-up contact was made with state Medicaid employees (primarily policy staff) to clarify policies which could not be found or were unclear.

Data collected by George Washington University for MACPAC

A statewide maximum payment will be calculated for each service designated by a procedure code recognized by the Alabama Medicaid Agency as designating a covered service. To determine payments for procedures codes without an established Medicaid rate, the Alabama Medicaid Agency will base rates on the current Medicare rate, and if not available the average commercial rate. Payment rates are the same for both governmental and non-governmental providers except as noted below.

(A) CRNPs and PAs are reimbursed at 80% of the allowed amount for all services except lab and injectables, which should pay at 100%.The covered services for PAs and CRNPs are limited to injectable drugs, laboratory services in which the laboratory is CLIA certified to perform, and the CPT codes identified in Appendix O, CRNP & PA Services. (B) Nurse Midwives are generally reimbursed at 80% of the allowed amount for all services except lab and injectables, which should pay at 100%.

None Found

None Found

None Found

(A) Physician Rural Rate Fee Schedule for E&M and Maternity(B) Teaching Physician Fee Schedule

1. Rural Physician (Supplemental/Enhanced) Payment:

(i) Providers in rural counties whose specialty is OB/GYN, Family Practice, General practice or Pediatrics, will be paid an enhanced rate for global delivery codes and delivery codes only. (ii) In order to increase provider participation and improve access to care, both governmental and non-governmental providers of all specialties in rural counties will be paid an additional $1.00 per office visit or hospital visit.

An out-of-state medical provider must agree to enroll as a provider with the Alabama Medicaid Agency. Some services must be approved before the service can be given by an out-of-state provider.


None Found

The copayment amount for office visit including crossovers is:$3.90 for procedure codes reimbursed $50.01 and greater$2.60 for procedure codes reimbursed between $25.01 and $50.00$1.30 for procedure codes reimbursed between $10.01 and $25.00There are exceptions.

Rule No. 560-X-11-.10. Reimbursement - EPSDT: (1) Governmental screening providers (including physicians) will be paid on a negotiated rate basis which will not exceed their actual costs. Non-governmental screening providers will be paid their usual and customary charge which is not to exceed the maximum allowable rate established by Medicaid.

PMPs provided a monthly payment of $8.50 if certain criteria is met.PMPs receive the standard Medicaid FFS payment for other state Plan non-health home direct services.For Health home activities, they receive an overlaying per-member-per-month payment of $8.50.The PMPM health home network payment will be $9.50 for each patient who meets the chronic conditions eligibility.PMPs receive a payment of $.50 PMPM to participate in the 1915(b) waiver. Since Patient 1st case management fee pays for health home care management services, the PMP will receive an additional $8.00 to avoid payment duplication.

(A) Primary Care Physicians will be paid the lesser of the following:· The provider’s submitted charge· The enhanced fee schedule rate(B) Physician ACA Primary Care Fee Schedule

None Found

Monthly Case Management Fee in Pilot Counties:If the PMP meets the guidelines specified in Section 39.3, then $1.00 will be built into the monthly case management fee. Participation in PCNA (optional): $0.50 PMPM will be added to the case management fee AND For PMPs with a patient acuity level case mix value of 0.9 or greater, $1.60 PMPM is added. Less than 0.9, $1.00 PMPM is added.Monthly Case Management Fee in Non-Pilot Counties:If the PMP meets the guidelines specified in Section 39.3, then $1.00 will be built into the monthly case management fee. For PMPs with a patient case mix (using ACG weights) value of 0.9 or greater, $1.60 PMPM is added to the case management fee. Less than 0.9, $1.00 PMPM is added.

Additional monies may be paid to the PMPs meeting performance measurements as defined by the Agency. The additional monies will be based on the total amount of savings and the percentage of measures met by the PMP.

Physician Access (Supplemental/Enhanced) Payment: In order to maintain adequate access to specialty faculty physician (all specialties including general practice, family practice, and general pediatrics) services as required by 42 USC 1396(a) (30) and 42 CFR 447.204, enhanced rates will be paid to teaching physicians. Teaching physicians are defined as doctors of medicine or osteopathy employed by or under contract with (a) a medical school that is part of the public university system (The University of Alabama at Birmingham and The University of South Alabama) or (b) a children’s hospital healthcare system which meets the criteria and receives funding under Section 340E (a) of the U.S. Public Health Service Act (42 USC 256e), and which operates and maintains a state license for specialty pediatric beds. Payments will be added to the fee-for-service rate and reconciled annually. The provider’s average commercial rate demonstration will be updated annually. Enhanced rates have been established based on 2011 Medicare rates.

Every attempt was made to find the most recent and up-to-date data, however, not all recent data was publicly available and many of the policies may have been developed years earlier and may not be in current practice.

Source Sites Searched for None Found Summary dataAdjustments

Staff at Alabama Medicaid Office NA Fee Schedule

NA

NA 80%

NA Yes


Staff at Alabama Medicaid Office (State Plan, Attachment 4.19-B, Page 2)


(A) AL Physician Provider Manual Chapter 28:http://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.7_Provider_Manuals_2013/6.7.7.3_July_2013/Jul13_28.pdf(B) AL Nurse Midwife Provider Manual Chapter 25: http://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.7_Provider_Manuals_2013/6.7.7.3_July_2013/Jul13_25.pdf

AL Fee Schedules: http://medicaid.alabama.gov/CONTENT/6.0_Providers/6.6_Fee_Schedules.aspx

NA NF

NA Yes

NA Yes

NA NF

NA NF

NA In-State




AL Entire Provider Manual:http://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.7_Provider_Manuals_2013/6.7.7.3_July_2013/provman.pdfAL Administrative Code:http://medicaid.alabama.gov/CONTENT/5.0_resources/5.2_Administrative_Code.aspxAdditional search of key terms in Google.

Entire AL Provider Manual:http://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.7_Provider_Manuals_2013/6.7.7.3_July_2013/provman.pdfAL Administrative Code:http://medicaid.alabama.gov/CONTENT/5.0_resources/5.2_Administrative_Code.aspxAdditional search of key terms in Google.

AL Out-of-State Services:http://medicaid.alabama.gov/CONTENT/4.0_Programs/4.2.1_Out-of-State_Services.aspx

NA

NA Public vs. Private

NA Yes

NA NF

NA Yes

Alabama Provider Manual, Chapter 28, Section 28.5:http://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.7_Provider_Manuals_2013/6.7.7.3_July_2013/Jul13_28.pdf


AL Administrative Code, EPSDT, Chapter 11 :http://medicaid.alabama.gov/documents/5.0_Resources/5.2_Administrative_Code/Chapters_11_20/5.2_Adm_Code_Chap_11_EPSDT_Under_21_2-15-13.pdf

Alabama Approved Health Home SPA: http://www.chcs.org/usr_doc/Alabama_HH_SPA_040913.pdf


(A) Alabama Medicaid Agency Alert: http://medicaid.alabama.gov/news_detail.aspx?ID=7657(B) ACA Primary Care Physician Fee Schedule:http://medicaid.alabama.gov/documents/6.0_Providers/6.6_Fee_Schedules/6.6_Physician_ACA%20_Primary_Care_Fee_Schedule_Revised_7-3-13.pdf

NA Yes

NA Yes

NA NF

AL Medicaid Provider Manual - PCCM - Patient 1sthttp://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.7_Provider_Manuals_2013/6.7.7.3_July_2013/Jul13_39.pdf




Adjustments

NA 8/21/2013

1/1/2012 8/21/2013

7/1/2013 7/1/2013

4/9/2013 7/1/2013


Documentation date

Date Last Searched

NA 7/1/2013

7/1/2013

1/1/2012 8/21/2013

NA 7/1/2013

NA 7/1/2013

NA 7/9/2013

(A) 5/1/2013(B) 3/25/2013

7/1/2013 7/1/2013

2/15/2013 7/1/2013

4/9/2013 7/1/2013

NA 7/1/2013

7/9/2013(A) 3/6/2013(B) 7/3/2013

7/1/2013 7/1/2013

1/1/2012 8/21/2013

NA 7/1/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Alaska


CategoryAdjustments


Fee Schedule Basis





Children vs. Adults

Out-of-State







Health Home

Primary Care



States' Medicaid Fee-for-Service Physician Payment Policies - Alaska


Alaska



Alaska Medical Assistance reimburses in-state providers at the lesser of• The provider’s billed charges• The rate identified for the specific type of provider• The provider’s lowest charge advertised, quoted, posted, billed, or discounted for any other person or patient at the same time, excluding– A sliding fee scale in place as a written policy for patients who earn no more than 250 percent of the federal policy level– Contracts for a service or services at a discounted rate (cannot exceed 20 percent of the provider’s gross income)– Discounts given as a part of an employer benefit package– Contracts with a federal or state government agency (including Medicare).

Alaska Medical Assistance reimburses physicians, advanced nurse practitioners and physician assistants using the resource-based relative value scale (RBRVS) methodology. Services for which the Centers for Medicare and Medicaid Services (CMS) has not established Relative Value Units (RVU) are manually priced by the department in accordance with 7 AAC 145.050(e).

Advanced nurse practitioners and physician assistants are reimbursed at 85 % of the established rate for physicians. *Nurse Midwives have the same fee schedule as nurse practitioners.

Physician Fee ScheduleEPSDT Fee Schedule

ANP/NW Fee Schedule

None Found

None Found

None Found

EPSDT fee schedule

Pricing Methodology for Out of State ServicesAlaska Medicaid recipients may be eligible for coverage of medical benefits while outside the state of Alaska. This eligibility exists when the individual is temporarily absent and intends to return to Alaska. Payment for professional services provided to Alaska Medicaid recipients outside the state of Alaska is limited to the lesser of:• The provider’s billed charges• 70 percent of the in-state Alaska Medicaid rate identified for the specific type of provider• The rate established by the Medicaid agency in the jurisdiction where the service was provided.


No Health Home Listed

$3 per day for physician servicesExceptions noted.

(A) Co-Surgeons: When medical necessity requires co-surgeons to perform a surgical procedure, Alaska Co-Surgeons: Medical Assistance reimburses at the lesser of billed charges or the rate calculated using RBRVS methodology x 125 percent. The reimbursement is divided equally between the surgeons.Surgical Assistants: Alaska Medicaid covers physicians, advanced nurse practitioners and physician assistants acting as surgical assistants for selected procedures. Surgical assistants are reimbursed at the lesser of billed charges or 25 percent of the rate established by the provider’s RBRVS methodology. (B) Surgical reimbursement is in accordance with the Resource Based Relative Value Scale methodology except that multiple surgeries performed on the same day are reimbursed at 100 percent of the RBRVS rate for the highest procedure and 50 percent of the RBRVS rate for each additional surgery; bilateral surgeries are reimbursed at 150 percent of the RBRVS rate; co-surgeons are reimbursed by increasing the RBRVS rate by 25 percent and splitting payment between the surgeons; and supplies associated with surgical procedures performed in a physician's office are reimbursed at the lesser of billed charges or the state maximum allowable. Payment is made to surgical assistants at the lesser of billed charges or 25 percent of the Resource Based Relative Value Scale methodology. Laboratory services are reimbursed at the lesser of the amount billed the general public or the Medicare fee schedule. Payment is made to independently enrolled hospital-based physician for certain services at the lessor of the amount billed the general public or 100 percent of the Resource Based Relative Value Scale methodology. Anesthesia services are reimbursed using base units and time units and a state determined conversion factor.

None Found

None Found

None Found

None Found

None Found


Source Sites Searched for None Found

NA

NA RBRVS

NA 85%

NA Yes


Summary Data

Alaska Medical Assistance Provider Billing ManualSection II: Professional Claims Management, Page II-25:http://www.medicaidalaska.com/dnld/PBM_Prof_Claim_Mgmt.pdf

Lesser of charges or max allowable

Billing manuals for the Alaska Medical Assistance Program, Page I-25: http://www.medicaidalaska.com/dnld/PBM_MD_ANP_PA.pdf

Billing manuals for the Alaska Medical Assistance Program, Page I-25:http://www.medicaidalaska.com/dnld/PBM_MD_ANP_PA.pdf

Alaska Fee Schedule:https://medicaidalaska.com/providers/FeeSchedule.asp

NA Yes

NA NF

NA NF

NA NF

NA Yes

NA


Alaska Fee Schedule (Select Applicable Option) https://medicaidalaska.com/providers/FeeSchedule.asp

Alaska Medical Assistance Provider Billing Manual: http://www.medicaidalaska.com/dnld/PBM_Prof_Claim_Mgmt.pdf Alaska State Plan Amendment:http://dhss.alaska.gov/Commissioner/Pages/MedicaidStatePlan/default.aspx#TOCBulletins, NewslettersAdditional search of key terms in Google



Alaska Medical Assistance Provider Billing ManualsSection II: Professional Claims Management, Page II-25:http://www.medicaidalaska.com/dnld/PBM_Prof_Claim_Mgmt.pdf

Lesser of charges, 70% of in-state fee schedule, or out-of-state fee schedule

NA $3

NA

NA No

Alaska Medical Assistance Provider Billing Manual. Section II: Professional Claims Management, Page II-26: https://medicaidalaska.com/dnld/PBM_Prof_Claim_Mgmt.pdf

(A) Alaska Billing Manual, Section I: Physician, ANP, PA Services, Policies and Procedures http://www.medicaidalaska.com/dnld/PBM_MD_ANP_PA.pdf(B) Alaska State Plan Amendment 4.19-B Page 6:http://dhss.alaska.gov/Commissioner/Documents/medicaidstateplan/PDF_SP/SP_pgs/SP_att4.19b.pdf

AnesthesiaSurgery

Medicaid Approved Health Home State Plan Amendments:http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Approved-Health-Home-State-Plan-Amendments.html

NA NF

NA No

NA NF

Alaska Medical Assistance Provider Billing Manual: http://www.medicaidalaska.com/dnld/PBM_Prof_Claim_Mgmt.pdf Alaska State Plan Amendment:http://dhss.alaska.gov/Commissioner/Pages/MedicaidStatePlan/default.aspx#TOCBulletins, NewslettersAdditional searches of key terms in GoogleAlaska Primary Care Programs: http://dhss.alaska.gov/dph/HealthPlanning/Pages/primarycare/pc_home.aspx

Alaska Medical Assistance Provider Billing Manual: http://www.medicaidalaska.com/dnld/PBM_Prof_Claim_Mgmt.pdf Alaska State Plan Amendment:http://dhss.alaska.gov/Commissioner/Pages/MedicaidStatePlan/default.aspx#TOCBulletins, NewslettersAdditional searches of key terms in GoogleAlaska Primary Care Programs: http://dhss.alaska.gov/dph/HealthPlanning/Pages/primarycare/pc_home.aspx


NA NF

NA NF




5/10/2013

5/10/2013

5/10/2013 7/1/2013

11/5/2012 7/1/2013


Documentation Date

Date Last Accessed

7/3/2013

7/01/2013

8/9/2012 7/10/2013

NA 7/10/2013

NA 7/2/2013

NA 7/2/2013

7/31/2012 7/8/2013

5/10/2013 7/1/2013

6/1/2012 7/8/2013

7/8/2013

NA 7/2/2013

(A) 5/10/2013(B) 11/30/2012

NA 7/2/2013

NA 7/8/2013

NA 7/2/2013

NA 7/2/2013

NA 7/2/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Arizona


CategoryAdjustments


Fee Schedule Basis







Children vs. Adults



Out-of-State



Health Home


Primary Care


States' Medicaid Fee-for-Service Physician Payment Policies - Arizona


Arizona

Licensed midwife services: Reimbursement is the lesser of billed charges or the AHCCCS capped fee.

Medicine and Professional Medical Services Fee Schedule

None Found



The Administration shall pay providers, including noncontracting providers, at the lesser of billed charges or the capped fee-for-service rates specified in subsections (A)(3)(a) through (d) unless a different fee is specified in a contract between the Administration and the provider, or is otherwise required by law.

Arizona CMS RVU's and an assortment of conversion factors with concern to budget and provider type need. Rather than one conversion factor like Medicare, several are used.

AnesthesiaRadiologySurgery

None Found

Facility and non-facility pricing in fee schedule for certain procedures

None Found

None Found

All services paid on a fee-for-service basis are exempt from copayments for all members.

None FoundIncentive or Add-on Payments


None Found

None Found

(A) On July 2, 2013, CMS approved AHCCCS’ financial methodologies. AHCCCS anticipates that enhanced payments for qualifying claims by qualifying providers with dates of service on or after January 1, 2013 will not begin until after August 1, 2013, but will be made retroactively to January 1, 2013 or the individual provider attestation date if attestation was made on or after 5/1/2013.

(B) Primary Care Enhanced Fee Schedule

None Found

None Found



NA

Staff at Arizona Medicaid Office NA

NA

NA

NA

NA


AZ Admin Code R9-22-710. Payments for Non-hospital Services: http://www.azsos.gov/public_services/Title_09/9-22.htm#Article_7

AZ FFS Provider Manual, Chapter 10, Page 10-25:http://www.azahcccs.gov/commercial/Downloads/FFSProviderManual/FFS_Chap10.pdf

AZ FFS Fee Schedules: http://www.azahcccs.gov/commercial/ProviderBilling/rates/Physicianrates/2013July/2013PhysicianRates.aspx



NA

NA

NA

Medicaid State Plan: http://www.azahcccs.gov/reporting/PoliciesPlans/stateplan.aspx#State_Plan_for_MedicaidA.A.C. R9-22: http://www.azsos.gov/public_services/Title_09/9-22.htm#Article_7Medical Policy Manual: http://www.azahcccs.gov/shared/MedicalPolicyManual/MedicalPolicyManual.aspx?ID=policymanualsAZ FFS Provider Manual, Chapter 10 - Professional and Technical Services:http://www.azahcccs.gov/commercial/Downloads/FFSProviderManual/FFS_Chap10.pdf


AZ Medicaid State Plan: http://www.azahcccs.gov/reporting/PoliciesPlans/stateplan.aspx#State_Plan_for_MedicaidA.A.C. R9-22: http://www.azsos.gov/public_services/Title_09/9-22.htm#Article_7AZ Medical Policy Manual: http://www.azahcccs.gov/shared/MedicalPolicyManual/MedicalPolicyManual.aspx?ID=policymanuals

NA

NA

NA

NA


AZ Admin Code R9-22-711. Copayments: http://www.azsos.gov/public_services/Title_09/9-22.htm#Article_7



NA

NA

NA


(A) AZ AHCCCS FFS Rates: Rates for Primary Care Services: http://www.azahcccs.gov/commercial/ProviderBilling/rates/PCSrates.aspx(B) AZ Primary Care Enhanced Fee Schedule:http://www.azahcccs.gov/commercial/Downloads/FFSrates/Physician/2013/2013_PCP_RATES_Enhanced.xls

AZ Medicaid State Plan: http://www.azahcccs.gov/reporting/PoliciesPlans/stateplan.aspx#State_Plan_for_MedicaidA.A.C. R9-22: http://www.azsos.gov/public_services/Title_09/9-22.htm#Article_7AZ Medical Policy Manual: http://www.azahcccs.gov/shared/MedicalPolicyManual/MedicalPolicyManual.aspx?ID=policymanuals

NA

NA



Summary Data

5/5/2007 7/17/2013

RBRVS NA 8/15/2013

No 2/19/2013 8/27/2013

Yes 7/1/2013 7/17/2013

NF NA 7/17/2013

Yes 7/1/2013 7/17/2013


Documentation Date

Date Last Searched


NF 6/1/2013 7/17/2013

Yes 7/1/2013 7/17/2013

NF NA 7/17/2013

NF 2/10/1987 7/17/2013

$0 4/1/2012 7/17/2013

NF

No NA 7/17/2013

NF NA 7/17/2013

Yes 7/17/2013

NF NA 7/17/2013

(A) 7/2/2013(B) 7/2/2013

NF NA 7/17/2013

NF NA 7/17/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Arkansas


CategoryAdjustments


Fee Schedule Basis





Children vs. Adults





Out-of-State



Health Home


Primary Care




States' Medicaid Fee-for-Service Physician Payment Policies - Arkansas


Arkansas

None Found




The methodology used by the Arkansas Medicaid Program to determine reimbursement rates for all physicians, except anesthesiology, is a “fee schedule.” Under the fee schedule methodology, reimbursement is based on the lesser of the billed charge for each procedure or the maximum allowable for each procedure. The maximum allowable for a procedure is the same for all physicians regardless of specialty.

Reimbursement rates (payments) shall be as ordered by the United States District Court for the Eastern District of Arkansas in the case of Arkansas Medical Society v. Reynolds. Reimbursement rates are increased by 10% up to a maximum or benchmark rate of 80% of the 2003 Arkansas Blue Cross/Blue Shield (BC/BS) fee schedule. For rates that as of March 31,2004, are equal to or greater than 80% of the 2003 BC/BS fee schedule rate, no increase will be given. A minimum rate or floor amount of 45% of the 2003 BC/BS fee schedule rate will be reimbursed. For those rates that after the 10 % increase is applied are still less than the floor amount, an additional increase will be given to bring these rates up to the floor amount.

NP and CNW

None Found

None Found

None Found

None Found

None Found

None Found



272.100 Anesthesia:Payment for anesthesiology is determined by the provider’s base charge times the A.S.A. surgery base units plus one (1) unit for each 15 minutes (or fraction thereof) of surgery plus additional units for other factors such as risk, emergency, etc.272.200 Assistant Surgery:Assistant surgery payment is 20% of the maximum allowed for the procedure.

Episodes of Care where the Principal Accountable Provider (PAP) could be a physician: URI, Perinatal Cara, ADHDQuality measures “to pass”: Measures for which a PAPs must meet or exceed a minimum threshold in order to qualify for a full positive supplemental payment for that episode type. Quality measures “to track”: Measures for which a PAP’s performance is not linked to supplemental payments. Performance on these measures may result in a program integrity review.

Supplemental payments vary by episode type and can be positive or negative supplemental payments. Payments take into account an acceptable threshold, a commendable threshold, a gain sharing limit and a risk sharing percentage. There are exclusions and adjustments.

IV. INCENTIVE ADJUSTMENTS: The Program promotes efficient and economic care utilization by makingincentive adjustments based on the aggregate valid and paid claims (“paid claims”) across a PAP’s episodes of careending during the twelve (12) month performance period specified for the episode. Unless provided otherwise fora specific episode of care, incentive adjustments are made annually in the form of gain sharing (positive incentiveadjustments) or provider risk sharing payments to Medicaid (negative incentive adjustments), and equal 50% of thedifference between the average adjusted episode expenditures and the applicable threshold.

None Found

(A) Supplemental Payments to PCPs Fee Schedule(B) Arkansas Medicaid reimbursement amounts will be determined based upon the difference between Medicare Part B rates Medicare Physician Fee Schedule (MPFS) for January 2009 OR 2013 and 2014 respectively (whichever is larger), and the Arkansas Medicaid rates, on a code by code basis

Arkansas Medicaid’s Primary Care Case Management (PCCM) Program, ConnectCare, operates statewide.171.230 Primary Care Case Management Fee:A. In addition to reimbursing PCPs on a fee for service basis for physician services, Arkansas Medicaid pays them a monthly case management fee for each enrollee on their caseloads.B. The amount due for each month is determined by multiplying the established case management fee by the number of enrollees on the PCP’s caseload on the last day of the month.

Effective January 1,2008, certain medical professional providers employed by the University ofArkansas for Medical Sciences (UAMS) shall be eligible for a supplemental payment that equalsthe difference between the regular, base Medicaid rate and an estimate of the averagecommercial rate paid for each billing code.



NA

NA

NA

NA


Arkansas Medicaid Provider Manual, Section II, 270.000 Reimbursement, Page II-85: https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/physicn.aspx#manual

Arkansas State Plan Amendment, Attachment 4.19-B, Page 2:https://www.medicaid.state.ar.us/Download/general/units/pdqa/ARMedStatePlan-Sec4.pdf

Arkansas Provider Manual - Physician (Sections I-V) :https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/physicn.aspxTransmittal Letters, Notices of Rule Making, Official Notices, and RA:https://www.medicaid.state.ar.us/Download/provider/provdocs/Manuals/PHYSICN/PHYSICN_O.doc

Physician Fee Schedule https://www.medicaid.state.ar.us/Download/provider/provdocs/Manuals/PHYSICN/PHYSICN-fees.pdf

NA

NA

NA

NA

NA

(A) Nurse Practitioner Fee Schedule:https://www.medicaid.state.ar.us/Download/provider/provdocs/Manuals/NURSEPRA/NURSEPRA-fees.pdf(B) Certified Nurse Midwife Fee Schedule:https://www.medicaid.state.ar.us/Download/provider/provdocs/Manuals/CNM/CNM-fees.pdf

Provider Documents:https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/docs.aspx




NA

NA

NA

NA

NA


Arkansas Medicaid Program Overview, SFY 2012, Page 7:http://humanservices.arkansas.gov/reportDocuments/Medicaid%20Program%20Overview.pdf

Arkansas Medicaid Provider Manual, Section II:https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/physicn.aspx#manual


AR Episodes of Care Provider Manual, Section II:https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/episode.aspx

NA

NA

NA

NA

(A) AR Enhanced Fee Schedule for E&M Codes and Vaccine Admin Codes:https://www.medicaid.state.ar.us/Download/provider/provdocs/Manuals/PHYSICN/PHYSICN-Supplement-fees.pdf (B) Arkansas Medicaid Provider Manual, Section II, 272.011:https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/pcp.aspx

Arkansas Medicaid Provider Manual, Section 1, 171.230: https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/physicn.aspx

Arkansas State Plan Amendment, Attachment 4.19-B, Page 2a:https://www.medicaid.state.ar.us/Download/general/units/pdqa/ARMedStatePlan-Sec4.pdf


Summary Data

10/13/2003 7/16/2013

2/7/2007 7/16/2013

NA 7/3/2013

Yes 3/28/2013 7/2/2013


Documentation Date

Date Last Accessed


State determined based on market assessment


Yes 7/2/2013

NF NA 7/2/2013

NF NA 7/10/2013

NF NA 7/10/2013

NF NA 7/10/2013

(A) 4/12/2013(B) 4/16/2013

NF NA 7/2/2013

NF SFY 2012 7/10/2013

10/13/2003 7/16/2013

No 4/5/2013 7/2/2013

Yes 10/1/2012 7/17/2013

AnesthesiaAssistant Surgery

Yes 1/1/2013 7/10/2013

Yes 2/1/2010 7/10/2013

Yes 2/28/2008 8/9/2013

NF NA 8/9/2013

States' Medicaid Fee-for-Service Physician Payment Policies - California


CategoryAdjustments


Fee Schedule Basis





Children vs. Adults

Out-of-State







Health Home


Primary Care



States' Medicaid Fee-for-Service Physician Payment Policies - California


California

Global Fee Schedule "Medi-Cal Rates"



(A) The policy of the State Agency is that reimbursement for each of the other types of care or service listed in Section 1905(a) of the Act that are included in the program under the plan will be at the lesser of usual charges or the limits specified in the California Code of Regulations (CCR), Title 22, Division 3, Chapter 3, Article 7 (commencing with Section 51 501) and CCR, Title 17, Chapter 4, Subchapter 13, Sections 6800-6874, for EPSDT health assessment services, or as specified by any other means authorized by state law.(B) CCR- Except as otherwise provided, reimbursement for physician services shall be the usual charges made to the general public not to exceed the maximum reimbursement rates listed in this section for each procedure performed by a physician.Except as set forth in (d), (e), (h), (k) and (l), the maximum reimbursement rates for physician services shall be the rates set forth in the “Schedule of Medi-Cal Physician Rates”, published by the Department of Health Services, June 2002, herein incorporated by reference in its entirety.

Effective August 1, 2000, Medi-Cal’s physician fee schedule is no longer based upon the 1969 California Relative Value Studies (CRVS). Medi-Cal assigns its own unit values for all physician services, except pathology (which generally uses 1974 CRVS values or Medicare’s Maximum Allowance), and anesthesia (which uses 90.3 percent of the Uniform Relative Value Guide values). To determine the basic reimbursement rate for a service, multiply the assigned unit value by the conversion factor on the following pages.

PA- Payment is made at the lesser of the amount billed or 100 percent of the amount payable to a physician for the same service.NP- Payment is made at the lesser of the amount billed or 100 percent of the amount payable to a physician for the same service. CNP- All CNP services are reimbursed at 100 percent of the amount paid to physicians for the same service.

None Found

Procedure Type Codes in Fee Schedule for: Anesthesia, Primary Surgeon, Assistant Surgeon

None Found

None Found

$1 co-pay on physician services for medically needy.

None found Incentive or Add-on Payments

Selected primary care and preventive medicine services are reimbursed at a higher rate for children aged 17 years or under than adults. For these services, rates for child patients are about 9 percent higher than rates for adult patients. For these services, the rates for adults are included in the “Basic Rate” column and the higher rates for children are listed in the “Child Rate” column.

The Out-of-State Provider Unit may enroll certain out-of-state providers and allow payment for up to $599.99, or 10 paid claim lines per calendar year, before they are required to complete the standard enrollment forms. Once this billing limit is reached, the provider is informed through a system-generated letter that enrollment as a permanent provider in the Medi-Cal program is necessary prior to receiving further payment.


None Found

None Found

The increased minimum payment level applies to specified primary care services and to services rendered by these provider types paid by Medicaid managed care plans that are contracted by states to provide the primary care services. The payment provides for 100 percent federal financial participation for any increase in payment above the amounts that would be due for these services under the provisions of the approved Medicaid state plan, as of July 1, 2009.

Increased payments are anticipated to begin in the summer of 2013, and will be retroactive for dates of service on or after January 1, 2013.

AIDS Healthcare Centers, Los Angeles County, is a PCCM program specializing in the care of recipients with Acquired Immune Deficiency Syndrome (AIDS). AIDS Healthcare Centers is paid a capitation rate per person per month to cover the cost of rendering all Medi-Cal services except the noncapitated services listed on the following pages.

None Found



NA

NA

NA

NA


(A) CA Medicaid State Plan, Attachment 4.19-B: http://www.dhcs.ca.gov/formsandpubs/laws/Documents/State%20Plan%20Attachment%204.19B%201-5.pdf(B) 22 CCR § 51503: http://weblinks.westlaw.com/result/default.aspx?cite=22CAADCS51503&db=1000937&findtype=L&fn=_top&pbc=DA010192&rlt=CLID_FQRLT6613481815177&rp=%2FSearch%2Fdefault.wl&rs=WEBL13.04&service=Find&spa=CCR-1000&sr=TC&vr=2.0

Medi-Cal Provider Manual: Max Rates: http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/ratesmax_m00o03.doc

Medi-Cal Provider Manual- Non-Physician Medical Practitioners (NMP): http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/nonph_m00o03o11.doc

Medi-Cal Fee Schedule: http://files.medi-cal.ca.gov/pubsdoco/Rates/rates_download.asp

NA

NA

NA

NA

NA

NA

NA

NA

Medi-Cal Fee Schedule - Rates Notes: http://files.medi-cal.ca.gov/pubsdoco/Rates/rates_download.asp

Medi-Cal Fee Schedule: http://files.medi-cal.ca.gov/pubsdoco/Rates/rates_download.asp

Medi-Cal Provider Manual: online search function: http://files.medi-cal.ca.gov/pubsdoco/manuals_menu.asp?pg=&PgDwn=Yes&hURL=&qu=geographic&Action=Go#top_search


Medi-Cal Fee Schedule - Rates Notes: http://files.medi-cal.ca.gov/pubsdoco/Rates/rates_download.asp

Medi-Cal: Out-of-State Providers FAQs:http://files.medi-cal.ca.gov/pubsdoco/contact/docs/oos_faq.asp

California Medicaid State Plan. §4.18-C: http://www.dhcs.ca.gov/formsandpubs/laws/Pages/SPdocs.aspx

(A) Medi-Cal Rates Home: http://files.medi-cal.ca.gov/pubsdoco/rates/rateshome.asp(B) Medi-Cal Payment Reduction Update: http://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_21158.asp

NA

NA

NA

NA

NA



Additional search of key terms in Google.

Medi-Cal: ACA Increased Medicaid Payment for Primary Care Physicians: http://files.medi-cal.ca.gov/pubsdoco/aca/aca_form_landing.aspMCP: Primary Care Case Management (PCCM): http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part1/mcpprim_z01.doc

CA Medicaid State Plan. Attachment 4.19-B: http://www.dhcs.ca.gov/formsandpubs/laws/Documents/State%20Plan%20Attachment%204.19B%201-5.pdfMedi-Cal Provider Manual: online search function: http://files.medi-cal.ca.gov/pubsdoco/manuals_menu.asp?pg=&PgDwn=Yes&hURL=&qu=geographic&Action=Go#top_search Additional search of key terms in Google.

NA

CA Medicaid State Plan. Attachment 4.19-B: http://www.dhcs.ca.gov/formsandpubs/laws/Documents/State%20Plan%20Attachment%204.19B%201-5.pdfMedi-Cal Provider Manual: online search function: http://files.medi-cal.ca.gov/pubsdoco/manuals_menu.asp?pg=&PgDwn=Yes&hURL=&qu=geographic&Action=Go#top_search Additional search of key terms in Google.

Summary Data

7/17/2013

9/2009 7/17/2013

No 2/1/2009 7/17/2013

Yes 7/15/2013 7/17/2013


Documentation Date

Date Last Searched


(A) 12/30/2003(B) 7/16/02


NF 7/15/2013 7/17/2013

Yes NA 7/17/2013

NF NA 7/17/2013

NF NA 7/17/2013

Yes 7/15/2013 7/17/2013

In-State Not Listed 7/23/2013

$1 2/18/1986 7/17/2013

NF NA 7/23/2013

No NA 7/17/2013

NF NA 7/17/2013

Yes NA 7/17/2013

Yes NA 7/17/2013

NF NA 7/17/2013

NF NA 7/17/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Colorado


CategoryAdjustments

Basic payment policy

Fee schedule basis








Site of Service Adjustments:

Children vs. Adults:

Out-of-State:

Enrollee cost sharing


Health Home


Primary Care



States' Medicaid Fee-for-Service Physician Payment Policies - Colorado


Colorado



Payment for practitioner services is based on whichever of the following two calculations results in a lesser amount: -The maximum allowable price for the submitted HCPCS code multiplied by the number of units of service.- The provider's submitted charge.

Previously based on % of Medicare. In more recent years, has become based on legislative action dictating increases in certain codes. Planning on returning to % of Medicare based system in the future.

Services provided by non-physician practitioners consisting of certified nurse midwives, certified registered nurse anesthetists, certified nurse practitioners, clinical nurse specialists, physician assistants, and psychologists shall be reimbursed at the lower of the following:

1. Submitted charges or2. Fee schedule as determined by the Department of Health Care Policy and Financing.

Except as otherwise noted in the State Plan, state-developed fee schedule rates are the same for both governmental and private providers. Reimbursement rates for dates of service on or after July 1, 2010 and dates of service on or after July 1, 2011 for these services can be found on the official Web site of the Department of Health Care Policy and Financing at www.colorado.gov/hcpf.

Medicaid Fee Schedule

None Found

Conversion Factors for: Anesthesia, Surgery

None Found

None Found

None Found



Out-of-State providers enroll in the Colorado Medical Assistance Program under the same rules and regulations applied to Colorado providers.

Clients in Regular Medicaid must pay the co-payment listed below when getting services, refer to 10 CCR 2505-10 Section 8.754:Practitioner Services - $2.00 per visit.With exceptions.

Anesthesia payments are based on whichever of the following two calculations results in a lesser amount: The number of units multiplied by the established anesthesia base unit rate. The number of units multiplied by the provider's submitted charge.

None Found

None Found

The state reimburses for services provided by physicians meeting the requirements of 42 CFR 447.400(a) at the Medicare Part B fee schedule rate using the Medicare physician fee schedule rate as provided by Deloitte that is identified as being in effect in calendar years 2013 and 2014 or, if greater, the payment rates that would be applicable in those years using the calendar year 2009 Medicare physician fee schedule conversion factor. If there is no applicable rate established by Medicare, the state uses the rate specified in a fee schedule established and announced by CMS.

The target rate would be calculated as outlined in the 1202 final , corrected rule and will be determined to be the lesser of the two values described below:1.the greater of the 2009 Medicaid rate & the applicable 2013 or 2014 Medicare rate (depending on date of service); or 2.the provider billed charges.

(A) As part of the State of Colorado's efforts to reform Medicaid, the Department of Health Care Policy and Financing will implement the Accountable Care Collaborative (ACC). ACC is a patient-centered approach to managing the care of Medicaid members. The State has described the ACC initiative as an enhancement of Medicaid’s Primary Care Case Management program. The goals of the program are to improve health outcomes and to control costs.(B) Effective November 1, 2012, the PMPM rate is $10.50 with adjustments made based on contract differences between RCCOs. This includes the additional dollar PMPM that can be earned by meeting performance targets.

None Found



NA

Staff at Colorado Medicaid Office NA

NA


Colorado Medical Assistance Program- General Provider Information and Requirements (Practitioners Services), Page 30:http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251856630893&ssbinary=true

State of Colorado MAP State Plan Attachment 4.19-B: Methods and Standards for Establishing Payment Rates - Section 6: Other Types of Non-Physician Practitioners:http://downloads.cms.gov/cmsgov/archived-downloads/MedicaidGenInfo/downloads/CO-11-020-179.pdf

NA

NA

NA

NA

CO Medicaid Fee Schedule:http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=application%2Fvnd.ms-excel&blobkey=id&blobtable=MungoBlobs&blobwhere=1251855734497&ssbinary=true

CO Medicaid Fee Schedule:http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=application%2Fvnd.ms-excel&blobkey=id&blobtable=MungoBlobs&blobwhere=1251855734497&ssbinary=true

Colorado Medicaid Fee Schedule Instructions:http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251861202035&ssbinary=true

Code of Colorado Regulations:http://www.sos.state.co.us/CCR/Welcome.doGeneral Provider Information:http://www.colorado.gov/cs/Satellite?c=Document_C&childpagename=HCPF%2FDocument_C%2FHCPFAddLink&cid=1251568908511&pagename=HCPFWrapperColorado Medicaid State Plan:http://www.colorado.gov/cs/Satellite/HCPF/HCPF/1197969486289


NA

NA

NA

NA

NA



Regular Medicaid Co-payments:http://www.colorado.gov/cs/Satellite/HCPF/HCPF/1212398230851



NA

NA

NA

NA

State of Colorado MAP State Plan Attachment 4.19-B:http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251856997783&ssbinary=true

State of Colorado MAP State Plan Attachment 4.19-B: http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251856997783&ssbinary=true

(A) Colorado Access -Accountable Care Collaborative:http://www.coaccess.com/accountable-care-collaborative(B) Accountable Care Collaborative Annual Report, Page 7:http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251864215634&ssbinary=true


NA


Summary data

6/2013 7/2/2013

NA 8/22/2013

No 7/29/2011 7/8/2013


Documentation Date

Date Last Searched



Yes 6/1/2013 7/3/2013

NF NA 7/10/2013

Yes 1/1/2013 7/10/2013

NF NA 7/8/2013

NF NA 7/8/2013

NF NA 7/8/2013

In-State NA 7/10/2013

$2 Not listed 7/8/2013

Anesthesia 6/2013 7/30/2013

No NA 7/8/2013

NF 7/11/2012 7/30/2013

Yes 6/4/2013 7/24/2013

Yes 7/30/2013

NF NA 7/30/2013

(A) Not listed(B) 11/01/2012

NF NA 7/10/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Connecticut

Every attempt was made to find the most recent and up-to-date data, however, not all recent data was publicly available and many of the policies may have been developed years earlier and may not be in current practice.Many of the sources are best accessed through Internet ExplorerAny errors or changes, please contact MACPAC at 202-350-2000.NF=None Found

CategoryAdjustments


Fee Schedule Basis





Children vs. Adults

Out-of-State







Health Home


Primary Care

States' Medicaid Fee-for-Service Physician Payment Policies - Connecticut

Every attempt was made to find the most recent and up-to-date data, however, not all recent data was publicly available and many of the policies may have been developed years earlier and may not be in current practice.Many of the sources are best accessed through Internet ExplorerAny errors or changes, please contact MACPAC at 202-350-2000.

Connecticut

Physician Office and Out Patient Services Fee Schedule



Payment shall be made at the lowest of:(1) The billing provider’s usual and customary charge;(2) the lowest Medicare rate;(3) the amount in the applicable fee schedule as published by the department pursuant to section 4-67c of the Connecticut General Statutes; or(4) the amount billed by the billing provider.

For services provided by physicians, the fee-for-service rate in the state of CT is typically based on a percentage of the Medicare Fee Schedule and the percentage varies by the nature of the service (which may range from 57% to 100% of Medicare). The rates are determined by the Commissioner each year.

Nurse Practitioners/Nurse Midwives - Nurse practitioner and nurse midwives should bill for procedures at their usual and customary fee. Reimbursement will be limited to 90% of the fee that appears on the Physician Fee Schedule.

None Found

None Found

None Found

Pediatric Pricing in Fee Schedule for certain procedures.

Fees shall be the same for in-state, border and out-of-state providers.

Physician AnesthesiaPhysician RadiologyPhysician Surgical

None Found



None Found

(A) Pursuant to section 1202 of the Affordable Care Act the Department is in the process of analyzing and implementing the provisions outlined in the Federal Final Rule for Increased Payments for Medicaid Primary Care Services. (B) ACA Primary Care Payment Increase Fee Schedule

None Found

None Found

HUSKY Primary Care, Connecticut’s Primary Care Case Management (PCCM) Pilot Program. The Pilot pays participating primary care providers $7.50 per member per month (in addition to fees paid for direct service) to coordinate the care of patients who enroll with their primary care provider (PCP) directly, rather than with a HUSKY managed care health plan.



NA

Staff at CT Medicaid Office NA

NA

NA


Connecticut interChange MMIS Provider Manual Chapter 7 – Physician , Page 9: https://www.ctdssmap.com/CTPortal/Information/Get%20Download%20File/tabid/44/Default.aspx?Filename=ch7_iC_physician_V2.1.pdf&URI=Manuals/ch7_iC_physician_V2.1.pdf&PopUp=Y

CT Provider Manual – Chapter 8 – Professional Services Claim Submission Instructions V 2.4, Page 34: https://www.ctdssmap.com/CTPortal/Information/Get%20Download%20File/tabid/44/Default.aspx?Filename=ch8_iC_professional_v2.4.pdf&URI=Manuals/ch8_iC_professional_v2.4.pdf&PopUp=Y

Connecticut Provider Fee Schedule Download:https://www.ctdssmap.com/CTPortal/Provider%20Fee%20Schedule%20Download/tabid/54/Default.aspx

NA

NA

NA

NA

NA

NA



Connecticut Department of Social Services, Providers Manuel, Chapters 1-12. Also reviewed the newsletters listed. https://www.ctdssmap.com/CTPortal/Information/Publications/tabId/40/Default.aspx


Connecticut Provider Fee Schedule Download:https://www.ctdssmap.com/CTPortal/Provider%20Fee%20Schedule%20Download/tabid/54/Default.aspx (scroll to bottom and press "I accept")


Connecticut interChange MMIS Provider Manual Chapter 7 – Physician , Page 9: https://www.ctdssmap.com/CTPortal/Information/Get%20Download%20File/tabid/44/Default.aspx?Filename=ch7_iC_physician_V2.1.pdf&URI=Manuals/ch7_iC_physician_V2.1.pdf&PopUp=Y

NA

NA

NA

NA

NA

Connecticut interChange MMIS Provider Manual Chapter 7 – Physician: https://www.ctdssmap.com/CTPortal/Information/Get%20Download%20File/tabid/44/Default.aspx?Filename=ch7_iC_physician_V2.1.pdf&URI=Manuals/ch7_iC_physician_V2.1.pdf&PopUp=Y

Connecticut interChange MMIS Provider Manual Chapter 7 – Physician: https://www.ctdssmap.com/CTPortal/Information/Get%20Download%20File/tabid/44/Default.aspx?Filename=ch7_iC_physician_V2.1.pdf&URI=Manuals/ch7_iC_physician_V2.1.pdf&PopUp=Y



(A) Connecticut Medical Assistance Program PB 2012-69 Policy Transmittal 2012-26 December 2012: https://www.ctdssmap.com/CTPortal/Information/Get%20Download%20File/tabid/44/Default.aspx?Filename=pb12_69_4.pdf&URI=Bulletins/pb12_69_4.pdf&PopUp=Y 2013 (B) Fee Table for ACA Section 1202,Page 17: https://www.ctdssmap.com/CTPortal/portals/0/StaticContent/Publications/Fee_Schedule_Instructions.pdf

NA

NA

NA

HUSKY Primary Care (PCCM): Providers Invited: http://www.ct.gov/dss/cwp/view.asp?a=2345&q=423906State of Connecticut - Invitation to Join HUSKY Primary Care/PCCM Pilot Program: http://www.ct.gov/dss/lib/dss/pdfs/pccm/pccmproviderinvitation.pdf



Summary Data

3/2013 7/31/2013

% of Medicare NA 9/13/2013

90% 3/1/2013 7/31/2013

Yes Not listed 7/31/2013


Documentation Date

Date Last Searched

Lesser of charges, Medicare rate, or fee schedule

NF NA 7/31/2013


NF NA 7/31/2013

NF NA 7/31/2013


In-State 3/1/2013 7/31/2013

NF NA 7/31/2013

NF NA 7/31/2013

No NA 7/31/2013

NF NA 7/31/2013

Yes 7/31/2013(A) 1/1/2013(B) Not Listed

Yes 10/17/2012 7/31/2013

NF NA 7/31/2013

NF NA 7/31/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Delaware


CategoryAdjustments


Fee Schedule Basis






Children vs. Adults

Out-of-State






Health Home


Primary Care




States' Medicaid Fee-for-Service Physician Payment Policies - Delaware


Delaware

None Found

CPT/HCPCS Fee Schedule

None Found



The DMAP will reimburse the lower of the provider’s U&C or the prospectively determined rate, unless federal policy proscribes that a particular rate or payment amount be used, in which case the federal policy will govern the payment. Specific methods of charging the DMAP are addressed in the subsequent sections of this manual. The provider must inform the DMAP of payments from any other source for the same services for which the provider is billing the DMAP.

Reimbursement rates shall be based on the Medicare Relative Value (RVU) adjusted by Geographic Practice Cost Indices (GPCI) representing the medical economic conditions specific to Delaware. Each CPT code has a unique RVU consisting of a Work Unit (WRVU), an Overhead Unit (ORVU) and a Malpractice Unit (MRVU). Delaware Medicaid may adjust the weight of each RVU up to, but not exceed, 100% of the Medicare value.

None Found

None Found

None Found

None Found

The DMAP reimburses non-institutional out-of-state services for those individuals not covered under a managed care plan as follows: Services provided out-of-state, for which Delaware has established a universal rate or cap, will be reimbursed at the provider’s usual and customary charge or Delaware’s rate/cap, whichever is lower. Where there is no established rate or cap (i.e., providers are paid a provider-specific rate/cap), the DMAP will establish a rate or cap that is consistent with its reimbursement methodology for the specific service.

None Found



None Found

None Found

None Found

NA

Follows federal guidelines; The rates do not reflect site of service adjustments, but reimburse at the Medicare rate applicable to the office setting. Delaware Medicaid will maintain the Medicare rates throughout the year without any adjustments mirroring Medicare changes. Delaware is using a Deloitte fee schedule (which was based on the November 2012 Medicare release and the 2009 conversion factor). The methodology will also recognize Delaware's sole Medicare geographic locality. The state has adjusted its fee schedule to make payment at the higher rate for each E&M and vaccine administration code.



NA

NA

NA

NA

NA


Delaware General Policy Manual §1.13.2, Page 26: http://www.dmap.state.de.us/downloads/manuals.html

Delaware State Plan, Attachment 4.19-B:Provided directly from Delaware Medicaid Office

Delaware General Policy and Practitioner Manuals:http://www.dmap.state.de.us/downloads/manuals/General.Policy.Manual.pdf

Delaware Admin Code Title 16:http://regulations.delaware.gov/AdminCode/title16/Department%20of%20Health%20and%20Social%20Services/Division%20of%20Social%20Services/Delaware%20Social%20Services%20Manual/index.shtml

Physician Fee Schedule: http://www.dmap.state.de.us/downloads/hcpcs.html

Fee Schedules: http://www.dmap.state.de.us/downloads/hcpcs.html

NA

NA

NA

NA

NA

Fee Schedules: http://www.dmap.state.de.us/downloads/hcpcs.html

Delaware General Policy Manual:http://www.dmap.state.de.us/downloads/manuals/General.Policy.Manual.pdf

Delaware Admin Code Title 16: http://regulations.delaware.gov/AdminCode/title16/Department%20of%20Health%20and%20Social%20Services/Division%20of%20Social%20Services/Delaware%20Social%20Services%20Manual/index.shtml

Physician Fee Schedule: http://www.dmap.state.de.us/downloads/hcpcs.html


Delaware Admin Code. Title 16:http://regulations.delaware.gov/AdminCode/title16/Department%20of%20Health%20and%20Social%20Services/Division%20of%20Social%20Services/Delaware%20Social%20Services%20Manual/index.shtml

Delaware General Policy Manual §1.13.3 Page 26: http://www.dmap.state.de.us/downloads/manuals.html

NA

NA

NA

NA



Additional search of key terms in Google






NA

NA

NA

NA

CMS Delaware State Plan Attachment 4.19-B: Amendment DE-13-002: Page 1:http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Plan-Amendments/Medicaid-State-Plan-Amendments.html?filterBy=delaware


Admin Code:http://regulations.delaware.gov/AdminCode/title16/Department%20of%20Health%20and%20Social%20Services/Division%20of%20Social%20Services/Delaware%20Social%20Services%20Manual/index.shtml



Admin Code:http://regulations.delaware.gov/AdminCode/title16/Department%20of%20Health%20and%20Social%20Services/Division%20of%20Social%20Services/Delaware%20Social%20Services%20Manual/index.shtml





Summary Data

NA 7/26/2013

RBRVS 6/22/1995 8/19/2013

NF NA 7/26/2013

Yes 1/1/2013 7/26/2013

NF NA 7/26/2013


Documentation Date

Date Last Searched


NF NA 7/26/2013

NF NA 7/26/2013

NF 1/1/2013 7/26/2013

NF NA 7/26/2013

NA 7/26/2013


NF NA 7/26/2013

NF NA 7/30/2013

No NA 7/26/2013

NF NA 7/26/2013

Yes 6/24/2013 7/26/2013

NF NA 7/26/2013

NF NA 7/30/2013

NF NA 7/30/2013

States' Medicaid Fee-for-Service Physician Payment Policies - District of Columbia


CategoryAdjustments


Fee Schedule Basis



Children vs. Adults

Out-of-State



Health Home


Primary Care

States' Medicaid Fee-for-Service Physician Payment Policies - District of Columbia


District of ColumbiaAdjustments



For services where the procedure code falls within the Medicare (Title XVIII) fee schedule, payment will be the lesser of the Medicare rate; the actual charges to the general public; or the rate listed in the state agency fee schedule. Effective January I, 20 II, the Department will use the Medicare rates to determine the Medicaid rates for services on or after that date. Beginning January I, 20 II, physician and specialty services rates will be reimbursed at eighty percent (80%) of the Medicare rate. All rates will be updated annually pursuant to the Medicare fee schedule. Except as otherwise noted in the Plan, the District developed fee schedule rates are the same for both governmental and private. Effective January 1,2011, for services where the procedure code does not fall within the Medicare fee schedule, the District will apply the lowest of the following: (1) usual and customary charges; (2) rates paid by the surrounding states of Maryland or Virginia; or (3) rates set by national benchmark compendiums when available.

995 MEDICAID PHYSICIAN AND SPECIALTY SERVICES RATE METHODOLOGY:995.1 For services rendered on or after January 1, 2011, Medicaid reimbursement rates for fee-for-service physician and specialist services shall be eighty percent (80%) of the rates paid by the Medicare Program as set forth in this section. 995.2 For services where the physician and specialist service procedure code falls within the Medicare (Title XVIII) fee schedule, payment shall be the lesser of the Medicare rate established pursuant to subsection 995.1 or the providers’ actual charges to the general public. 995.3 For services where the procedure code does not fall within the Medicare fee schedule, an alternative method, as set forth in § 995.4, shall be used to establish the Medicaid reimbursement rate.995.4 When making a determination to establish the Medicaid reimbursement rate using an alternative method for physician and specialty services, in addition to using professional judgment, the following factors may be considered:(a) Practitioner fees;(b) Fee schedules from other states;(c) Similar procedures with established fees; or(d) Private insurance payments.995.5 Beginning Fiscal Year 2010, and annually thereafter, all rates for physician and specialty services shall be updated on January 1st pursuant to the rate schedules in effect on the first day of the District of Columbia fiscal year or October 1st.995.6 All physician and specialty services reimbursement rates shall be located on the Department of Health Care Finance website.

Medical Fee Schedule

None Found

None Found

None Found


Private Clinics: Rates provided by non-physicians for Medicaid services will be reimbursed at eighty percent (80%) of the physician and specialty services rate.

None Found


Providers whose practice address is located outside of the geographic boundaries of the District of Columbia are eligible to request consideration for participation in the DC Medicaid program if licensed in the state of the practice address.

DC Medicaid does not charge a fee for covered health care services, except for co-payments for prescriptiondrugs and eyeglasses.


None Found

Increased payments (including retroactive payments) will not be made until DCHF receives approval from the Centers for Medicare and Medicaid Services (CMS). DHCF estimates this will occur in late summer, 2013.

None Found

None Found

None Found


Source Sites Searched for None FoundAdjustments

NA

NA


DC Medicaid State Plan: Attachment 4.19B: Page 4: http://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/DHCFStatePlanAttach4-19bPt1_0.pdf

DC Municipal Regulations. Rule: 29-995, ID 3879920: http://www.dcregs.dc.gov/Gateway/RuleHome.aspx?RuleNumber=29-995

NA

NA

NA

NA

NA

DC Medicaid State Plan: Attachment 4.19B, Part 1: Page 6b: http://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/DHCFStatePlanAttach4-19bPt1_0.pdf

DC Medical Fee Schedule: https://www.dc-medicaid.com/dcwebportal/nonsecure/feeScheduleDownload



DC Medicaid Provider Billing Manual - Physician:https://www.dc-medicaid.com/dcwebportal/documentInformation/getDocument/7243DC Medicaid State Plan:http://dhcf.dc.gov/page/medicaid-state-planDHCF Medicaid Regulations:http://dhcf.dc.gov/page/dhcf-medicaid-regulationsAdditional search of key terms in Google and dhcf.dc.gov

DC Medical Fee Schedule:https://www.dc-medicaid.com/dcwebportal/nonsecure/feeScheduleDownload. Click on “Medical_Fee_Schedule.pdf” or “Medical_Fee_Schedule.csv”

NA

NA

NA

NA


DC Medicaid Provider Manual - Physician: §3.3.2. Version 2.07: https://www.dc-medicaid.com/dcwebportal/documentInformation/getDocument/7243

DC DHCF FFS Member Manual: Volume 13: http://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/DHCF%20FFS%20Medicaid%20Version%2013_red.pdf


NA

NA

NA



DC Office of the Senior Deputy Director. Transmittal Number: 13-09. " Increased Medicaid Reimbursement for Primary Care Services under the Affordable Care Act: https://www.dc-medicaid.com/dcwebportal/documentInformation/getDocument/8164

NA

NA

DC Medicaid Provider Billing Manual - Physician:https://www.dc-medicaid.com/dcwebportal/documentInformation/getDocument/7243DC Medicaid State Plan:http://dhcf.dc.gov/page/medicaid-state-planDHCF Medicaid Regulations:http://dhcf.dc.gov/page/dhcf-medicaid-regulationsAdditional search of key terms in Google and dhcf.dc.govKaiser State Health Facts: Providers Recognized as Primary Care Providers (PCPs) in Primary Care Case Management (PCCM) Programs. Available at: http://kff.org/medicaid/state-indicator/primary-care-providers-in-pccm-programs/


NA


Summary DataAdjustments

1/1/2011 6/24/2013

% of Medicare 1/13/2012 7/15/2013


Documentation Date

Date Last Searched


80% 1/1/2011 6/24/2013

Yes 6/17/2013 6/24/2013

NF NA 6/24/2013

NF NA 6/24/2013

NF NA 6/24/2013

Yes NA 6/24/2013

NF NA 7/15/2013

In-State 12/20/2012 6/24/2013

$0 8/31/2012 7/11/2013

NF NA 7/15/2013

No NA 7/11/2013

NF NA 6/24/2013

Yes 5/15/2013 7/11/2013

NF NA 7/11/2013

NF NA 7/11/2013

NF NA 7/11/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Florida


CategoryAdjustments


Fee Schedule Basis





Children vs. Adults

Out-of-State



Health Home


Primary Care



States' Medicaid Fee-for-Service Physician Payment Policies - Florida


Florida

Physician Medical Services Fee Schedule



Medicaid reimbursement for services is the lesser of the Medicaid fee or the provider’s usual and customary charge, except for cost-based or capitation reimbursed providers.

(b) The agency shall adopt a fee schedule, subject to any limitations or directions provided for in the General Appropriations Act, based on a resource-based relative value scale for pricing Medicaid physician services. Under this fee schedule, physicians shall be paid a dollar amount for each service based on the average resources required to provide the service, including, but not limited to, estimates of average physician time and effort, practice expense, and the costs of professional liability insurance. The fee schedule shall provide increased reimbursement for preventive and primary care services and lowered reimbursement for specialty services by using at least two conversion factors , one for cognitive services and another for procedural services. The fee schedule shall not increase total Medicaid physician expenditures unless moneys are available. The Agency for Health Care Administration shall seek the advice of a 16-member advisory panel in formulating and adopting the fee schedule. The panel shall consist of Medicaid physicians licensed under chapters 458 and 459 and shall be composed of 50 percent primary care physicians and 50 percent specialty care physicians.

ARNPs are reimbursed at 80% of the physician rate. When performing as an assistant to the surgeon, the ARNP is reimbursed at 12.8% of the physician rate. For services provided to children age 20 and younger, reimbursement is increased by 4%.PAs are reimbursed at 80% of the physician rate. When performing as an assistant to the surgeon, the PA is reimbursed at 12.8% of the physician rate. For services provided to children age 20 and younger reimbursement is increased by 4%.RNFAs (Registered Nurse First Assistants) are reimbursed at 12.8% of the physician rate. For services provided to children age 20 and younger, reimbursement is increased by 4%.

ARNP, PA, and Licensed MW Fee Schedules

Various Other Specialty Fee Schedules

None Found

None Found

Florida Medicaid will reimburse for out-of-state services at a rate mutually agreed upon rate by the provider and Florida Medicaid.

Physician services, per provider or group provider, per day = $2.00



For services provided to children age 20 and younger, the reimbursement is increased by 4%. The exceptions are: Regional Perinatal Intensive Care Centers (RPICC), injectable medications, supplies, devices, laboratory and pathology services.The following specialty types receive a 24% fee increase in addition to the above mentioned 4% fee increase for services provided to children age 20 and younger: 002, 003, 004, 005, 008, 010, 014, 015, 017, 021, 022, 023, 029, 030, 031, 036, 037, 038, 039, 043, 046, 051, 053, 055, 057, 058, 060, 062.

Florida Medicaid reimburses an enhanced fee to board-certified pediatric surgeons and urologists for certain procedures provided to Medicaid recipients under age 21. Providers requesting the enhanced fees for pediatric surgery or urology must be certified by the American Board of Pediatrics or American Board of Urology and must submit copies of their board certification to the Medicaid fiscal agent.

The calculation for reimbursement of anesthesia services is:Anesthesia Base Rate + (time/15 x $ conversion factor) = maximum reimbursement.• The Anesthesia Base Rate is listed on the Physician Anesthesia and ARNP fee schedule.• Time is reported in total minutes, not units. During claim processing, the total time is divided by 15 minute increments and rounded down to the nearest whole unit.• Time less than 15 minutes is rounded up to one 15 minute increment and will pay base fee.

When performing as an assistant to a surgeon, the assisting physician is reimbursed at 16% of the physician rate.AAs are reimbursed at 80% of anesthesiology physician rate and the increase reimbursement for children age 20 and younger does not apply.

Various pricing modifiers with some having different reimbursement rates.

None Found

(A) Physician Primary Care Rate Increase Fee Schedule(B) The state reimburses for services provided by physicians meeting the requirements of 42 CFR 447.400(a) at the Medicare Part B fee schedule rate using the Medicare physician fee schedule rate in effect in calendar years 2013 and 2014 or, if greater, the payment rates that would be applicable in those years using the calendar year 2009 Medicare physician fee schedule conversion factor. If there is no applicable rate established by Medicare, the state uses the rate specified in a fee schedule established and announced by CMS. Rates do not reflect site of service adjustments, but reimburse at the Medicare rate applicable to the office setting. The rates reflect all Medicare geographic/locality adjustments.

Method of Payment1. Management Fee. It is agreed that the Agency or Medicaid program will pay each primary care provider or group provider a management fee of $2 monthly for each MediPass patient the provider has as of the first day of each month. 2. Service Reimbursement. It is agreed that the Agency or Medicaid program will provide Medicaid reimbursement for medical services rendered by the MediPass provider in accordance with the standard Medicaid fee for service schedules and policy.

Supplemental Payments:The agency may provide for supplemental payments for services provided by doctors of medicine and osteopathy employed by or under contract with either (1) a medical school that is part of the public university system (Florida State University, The University of Florida, and The University of South Florida); (2) a private medical school that places over fifty percent (50%) of their residents with a public hospital (The University of Miami); (3) Nova Southeastern University. The supplemental payments will be based on the difference between the lower of fifty-four and thirty-four one hundredths percent (54.34%) of the provider's usual and customary charges or fifty-four and thirty-four one hundredths percent (54.34%) of the charge ceiling established by the Agency and the actual payment by Medicaid to the physician or osteopathic physician under the current physician fee schedule.

None Found



NA

NA

NA

NA


Florida Medicaid Provider General Handbook, Page I-5:http://b.ahca.myflorida.com/Medicaid/review/handbooks/Provider_General_Handbook_July_2012.pdf

Florida State Statutes, Title XXX, Chapter 409, Section 908 (12)(b):http://flsenate.gov/Laws/Statutes/2013/409.908

Florida Medicaid Practitioner Services Handbook, Page 3-6:http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/HANDBOOKS/CL_12_12-12-01_Practitioner_Services_Handbook.pdf

FL Fee Schedules: http://portal.flmmis.com/FLPublic/Provider_ProviderSupport/Provider_ProviderSupport_FeeSchedules/tabId/44/Default.aspx

NA

NA

NA

NA

FL Fee Schedules: http://portal.flmmis.com/FLPublic/Provider_ProviderSupport/Provider_ProviderSupport_FeeSchedules/tabId/44/Default.aspxFL Fee Schedules:http://portal.flmmis.com/FLPublic/Provider_ProviderSupport/Provider_ProviderSupport_FeeSchedules/tabId/44/Default.aspx

Florida Medicaid Provider General Handbook:http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/HANDBOOKS/GH_12_12-07-01_Provider_General_Handbook.pdfFlorida State Plan:http://ahca.myflorida.com/Medicaid/stateplan.shtmlFlorida Medicaid Practitioner Services Handbook:http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/HANDBOOKS/CL_12_12-12-01_Practitioner_Services_Handbook.pdf


NA

NA

NA

NA

NA

Florida Medicaid Practitioner Services Handbook:http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/HANDBOOKS/CL_12_12-12-01_Practitioner_Services_Handbook.pdf

Florida Medicaid Provider General Handbook, Page 2-39:http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/HANDBOOKS/GH_12_12-07-01_Provider_General_Handbook.pdf

Florida Medicaid Provider General Handbook, Page I-10:http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/HANDBOOKS/GH_12_12-07-01_Provider_General_Handbook.pdf

Florida Medicaid Practitioner Services Handbook:http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/HANDBOOKS/CL_12_12-12-01_Practitioner_Services_Handbook.pdf


NA

NA

NA

NA


(A) FL Physician Primary Care Rate Increase Fee Schedule:http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/FEE%20SCHEDULES/2013_07_01_Phys_Primary_Care_Rates.pdf(B) Florida State Plan Amendment 4.19-B, Page 28b:http://ahca.myflorida.com/Medicaid/stateplanpdf/attachment_4-19-B.pdf

FL Agreement for Participation in MediPass:http://www.fdhc.state.fl.us/Medicaid/MediPass/pdf/Agreement_for_Participation_in_MediPass.pdf

Florida State Plan Amendment 4.19B, Page 28a:http://ahca.myflorida.com/Medicaid/stateplanpdf/attachment_4-19-B.pdf

NA


Summary Data

7/2012 7/16/2013

RBRVS 2013 8/27/2013

12/2012 7/16/2013

Yes 7/1/2013 7/11/2013


Documentation Date

Date Last Searched


Ranges from 12.8% to 80%

Yes 7/1/2013 7/11/2013

Yes NA 7/11/2013

NF NA 7/11/2013

NF 7/16/2013

Yes 7/1/2013 7/16/2013

Negotiated 7/1/2003 7/16/2013

$2 7/2013 7/16/2013

12/2012 7/16/2013

No NA 7/11/2013

AnesthesiaAssistant SurgeryAA

NF NA 7/11/2013

Yes 7/16/2013

Yes 10/2008 7/11/2013

Yes 7/23/2004 7/16/2013

(A) 7/1/2013(B) 4/1/2013

NF NA 7/16/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Georgia


CategoryAdjustments


Fee Schedule Basis



Children vs. Adults

Out-of-State





Health Home

Primary Care



States' Medicaid Fee-for-Service Physician Payment Policies - Georgia


Georgia



The Division will pay the lower of the physician's lowest price regularly and routinely offered to any segment of the general public for the same service or item on the same date(s) of service, the lowest price charged to other third party payers, or the statewide maximum allowable reimbursement amount allowed for the procedure code reflecting the service rendered.

Effective with dates of service July 1, 2003, the statewide maximum allowable reimbursement is 84.645% of the 2000 Resource Based Relative Value Scale (RBRVS) as specified by Medicare for Georgia Area 1 (Atlanta). All procedure codes recognized and adopted after the 2000 RBRVS are subject to the same level of reimbursement.

Physician Services Fee Schedule of Maxim Allowable April 2013 XCEL

None Found

None Found

(A) ANPs: The Division will pay the lower of the nurse practitioner’s lowest price regularly and routinely offered to any segment of the general public for the same service or item on the same date(s) of service, the lowest price charged to other third party payers, or 90% of the statewide maximum allowable reimbursement is 84.645% of the 2000 Resource Based Relative Value Scale(RBRVS) as specified by Medicare for Georgia Area 1(Atlanta).(B) Nurse Midwifery: The Division will pay the lower of the nurse-midwife’s lowest price regularly and routinely offered to any segment of the general public for the same service or item on the same date(s) of service, the lowest price charged to other third party payers, or the statewide maximum allowable reimbursement a mount allowed for the procedure code reflecting the service rendered. (C) PAs: Services provided by a physician's assistant will be limited to no more than 90% of the maximum allowable amount paid to a physician.

None Found

None Found

Services that are primarily performed in office settings will be subject to a reimbursement reduction when performed in an inpatient, outpatient, emergency, or ambulatory surgery setting. The reduced reimbursement is calculated as part of RBRVs and is updated annually. See Appendix K for specifics on link.

Reimbursement and coverage of out-of-state services is determined in accordance with current policies and procedures of the Georgia Division of Medicaid and are contingent on the patient's eligibility at the time services are provided. Reimbursement shall include the lesser of the Medicaid reimbursement amount for the state in which the service was rendered, or 45% of the billed charges, or the current reimbursement for Georgia Medicaid enrolled physicians, as cited in Section 1001- Reimbursement Methodology.

State‘s payment for the service. Maximum co-payment chargeable to recipient:$10.00 or less: $0.50$10.01 to $25.00 : $1.00$25.01 to $50.00 : $2.00$50.01 or more : $3.00(With exceptions)



None Found

None Found

The state reimburses for services provided by physicians meeting the requirements of 42 CFR 447.4 at the Medicare Part B fee schedule rate using the Medicare physician fee schedule rate in effect in calendar years 2013 and 2014 or, if greater, the payment rates that would be applicable in those years using the calendar year 2009 Medicare physician fee schedule conversion factor. If there is no applicable rate established by Medicare, the state uses the rate specified in a fee schedule established and announced by CMS.

The rates do not reflect site of service adjustments, but reimburse at the Medicare rate applicable to the office setting. The rates are statewide and reflect the mean value over all counties for each of the specified evaluation and management and vaccine billing codes. The state has adjusted its fee schedule to make payment at the higher rate for each E&M and vaccine administration code.

None Found

All physician services provided on and after August 1, 2006, by faculty practices affiliated with governmental teaching hospitals located in MSAs will be eligible for a supplemental payment. The methodology for calculating physician supplemental payments will be the difference between the Medicare equivalent of the average commercial rate and the Medicaid payment.



NA

NA % of Medicare


Summary Data

Physician Services Manual. PART II, CHAPTER 1000, Page X-1: https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Physician%20Services%2018-07-2013%20143746.pdf


Physician Services Manual. PART II-CHAPTER 1000, Page X-1: https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Physician%20Services%2018-07-2013%20143746.pdf

NA 90%

NA Yes

NA NF

NA NF

(A) ANP Provider Manual. PART II, CHAPTER 1000, Page X-1:https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Advanced%20Nurse%20Practitioner%20Services%2001-07-2013%20144117.pdf(B) Nurse Midwifery Services Manual, Part II, Chapter 2000, Page X-1:https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Nurse%20Midwifery%20Services%2001-07-2013%20144130.pdf (C) Physician Services Manual. PART II-CHAPTER 1000, Page X-1: https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Provider%20Manuals/tabId/54/Default.aspx

Fee Schedules: https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Fee%20Schedules/tabId/56/Default.aspx



NA NF

NA Yes

NA NF

NA

NA

GA Medicaid State Plan: http://dch.georgia.gov/medicaid-state-planPhysician Services Manual: https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Physician%20Services%2018-07-2013%20143746.pdfFee Schedules: https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Fee%20Schedules/tabId/56/Default.aspx

Physician Services Manual. PART II, Chapter 903.24, Page IX 40:https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Physician%20Services%2018-07-2013%20143746.pdf

GA Medicaid State Plan: http://dch.georgia.gov/medicaid-state-planPhysician Services Manual. PART II:https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Physician%20Services%2018-07-2013%20143746.pdfFee Schedules: https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Fee%20Schedules/tabId/56/Default.aspx

Physician Service Manual, Part II, Page IX 34: https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Physician%20Services%2018-07-2013%20143746.pdf

Lesser of in-state fee schedule, 45% charges, or out-of-state fee schedule

Physician Services Manual. PART II, Appendix Q, Page Q-1: https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Physician%20Services%2018-07-2013%20143746.pdf

Ranges from $0.50-$3.00 max

NA NF

NA No

NA NF

NA Yes

NA NF

GA Medicaid State Plan: http://dch.georgia.gov/medicaid-state-planPhysician Services Manual: https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Physician%20Services%2018-07-2013%20143746.pdf


GA Medicaid State Plan: http://dch.georgia.gov/medicaid-state-planPhysician Services Manual: https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Provider%20Manuals/tabId/54/Default.aspx

GA Medicaid State Plan. Attachment 4.19-B. Page 4.007. Available at: http://dch.georgia.gov/sites/dch.georgia.gov/files/related_files/document/13-004_Enhanced_Primary_Care_Service_Payment.pdf

GA Medicaid State Plan. Attachment 4.19-B: http://dch.georgia.gov/medicaid-state-plan.


NA Yes

NA NF

GA Medicaid State Plan, Attachment 4.19-B, Page 4.002: http://dch.georgia.gov/sites/dch.georgia.gov/files/related_files/document/State_Plan_Attachment_4.pdf

GA Medicaid State Plan: http://dch.georgia.gov/medicaid-state-planPhysician Services Manual: https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Physician%20Services%2018-07-2013%20143746.pdfFee Schedules: https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Fee%20Schedules/tabId/56/Default.aspx


7/23/2013

7/1/2013 7/23/2013


Documentation Date

Date Last Searched

7/1/2013

7/2013 7/23/2013

4/1/2013 7/23/2013

NA 7/23/2013

NA 7/23/2013

NA 7/23/2013

NA 7/23/2013

NA 7/23/2013

NA 7/25/2013

4/2013 8/5/2013

NA 8/5/2013

NA 7/23/2013

NA 7/25/2013

6/4/2013 7/25/2013

NA 7/23/2013

5/15/2008 8/2/2013

NA 8/2/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Hawaii


CategoryAdjustments


Fee Schedule Basis







Children vs. Adults

Out-of-State



Health Home



Primary Care





States' Medicaid Fee-for-Service Physician Payment Policies - Hawaii


Hawaii

None Found

Global Fee Schedule

None Found

None Found



(A) 4.4.4 Pricing and Payment Processing As mandated by state law, non-institutional services will be paid using a fee schedule. All services that were paid on usual and customary charges will be paid on a fee schedule.(B) Payment to physicians is the lesser of charges or the Hawaii Medicaid fee schedule.

Services are paid based off of the Medicare fee schedule. No less than 60% of Medicare and no higher than 100% of Medicare.

None Found

Facility and office rates based on modifier. Facility rates are lower than the office rates.

None Found

$0



EPSDT pricing for certain codes.The enhanced reimbursement ($120 for FFS in 2009*) for comprehensive EPSDT exams.The enhanced reimbursement ($30 for FFS in 2009*) for EPSDT catch-up/follow-up immunizations and screenings.

None Found

None Found

None Found

None Found

Follows federal guidelines. Health plans will not make increased reimbursement payments until MQD receives approval by CMS.



NA

Staff at Hawaii Medicaid Office NA % of Medicare

NA NF

NA Yes

NA NF

NA NF


Summary Data

(A) Hawaii Provider Manual, Page 19:http://www.med-quest.us/providers/ProviderManual.html(B) Staff at Hawaii Medicaid Office


Hawaii Department of Health Services:http://www.med-quest.us/index.htmlProvider Manual:http://www.med-quest.us/providers/ProviderManual.html

Medicaid Fee Schedule:http://www.med-quest.us/PDFs/Provider%20Memos/Medicaid%20Fee%20Schedule.pdf



NA NF

Staff at Hawaii Medicaid Office NA Yes

NA Yes

NA NF

Staff at Hawaii Medicaid Office NA $0

NA NF

NA No


Hawaii Medicaid Provider Manual: EPSDT, Chapter 5:http://www.med-quest.us/PDFs/Provider%20Manual/PMChp0511.pdf




NA NF

NA Yes

NA NF

NA NF

NA NF


Hawaii MedQUEST Division, PCP Increase:http://www.med-quest.us/providers/PrimaryCarePhysician.html

Hawaii Department of Health Services:http://www.med-quest.us/index.htmlKaiser Family Foundation:http://kff.org/medicaid/state-indicator/primary-care-providers-in-pccm-programs/




9/13/2013

NA 8/14/2013

1/1/2012 7/15/2013

7/1/2009 7/15/2013

NA 7/15/2013

NA 7/15/2013


Documentation Date

Date Last Searched

(A) 3/2011(B) NA

1/1/2012 7/15/2013

8/14/2013 8/14/2013

7/15/2013

1/1/2012 7/15/2013

NA 8/14/2013

NA 7/15/2013

1/1/2012 7/15/2013

3/1/2011

1/1/2012 7/15/2013

NA 7/15/2013

NA 7/15/2013

NA 7/15/2013

NA 7/15/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Idaho


CategoryAdjustments


Fee Schedule Basis






Children vs. Adults




Out-of-State



Health Home

Primary Care




States' Medicaid Fee-for-Service Physician Payment Policies - Idaho


Idaho

Numerical Fee Schedule

None Found



Section 2.2: Reimbursement:Idaho Medicaid reimburses physician services on a fee-for-service basis. Medicaid reimbursement will be either the lowest of the provider’s actual charge for the service, the other insurance allowable, or Medicaid’s established maximum allowable reimbursement from its pricing file, minus the payment from Medicare or other insurance.

Pay 90% of Medicare when our Legislature approves a rate change. For primary procedure codes, pay no more than 100% of the Medicare rate. The last rate change was 7/1/12, and used the 1/1/12 Idaho fee schedule for Medicare.

PA/APN/LM: Medicaid reimburses midlevel practitioner services on a fee-for-service basis. Usual and customary fees are paid up to the Medicaid maximum allowance.Idaho Medicaid will reimburse the lowest of the following rates:• Provider’s actual charge for the service• Medicaid’s established maximum allowable reimbursement from its pricing file for the service. Most mid-level reimbursement is 85% (percent) of the physician fee schedule as posted on the DHW Web site: www.idmedicaid.com

Anesthesia Fee Schedule

None Found

None Found

Section 2.2.1 Site of Service Differential:(A) Idaho Medicaid reduces physician reimbursement when certain procedures are provided in a facility setting. For these procedure codes there is a 30 percent reduction of the Idaho Medicaid fee schedule.(B) Site of Service Reduction Codes


Out-of-state providers who are enrolled in the Idaho Medicaid Program and have an active Idaho Medicaid provider number may render services to Idaho Medicaid participants without receiving out-of-state prior approval.

The co-pay starts at $3.65 and co-pay ratio to the Medicaid reimbursement for the visit (according to the Medicaid Fee Schedule) is more than 10%. -- With exceptions.

Provider reimbursement for Idaho Medicaid Health Home(IMHH) participants will be $15.50 per member per month as enrolled on the first day of the month. The IMHH per member per month payment is in lieu of any other primary care case management reimbursement and is in addition to fee-for-service reimbursements

None Found

Primary Care Physician Incentive Payment Fee Schedule

None Found

Healthy Connections is a mandatory Primary Care Case Management program for Idaho Medicaid. The PCCM Fee paid to Health Connections Primary Care Providers shall be:$2.50 per member per month for enrollees in the Basic Benefit Plan$3.00 per member per month for enrollees in the Enhanced Benefit PlanThe fee is increased by 50 cents PMPM when the Healthy Connections Primary Care Provider offers extended hours of service equal to or greater than 46 hours per week.

None Found



NA

Staff at Idaho Medicaid Office NA % of Medicare

NA 85%

NA Yes

NA NF


Summary Data

Idaho MMIS Provider Handbook - Allopathic and Osteopathic Physicians, Page 3:https://www.idmedicaid.com/Provider%20Guidelines/Allopathic%20and%20Osteopathic%20Physicians.pdf


Idaho MMIS Provider Handbook - PA and ANP, Page 2:https://www.idmedicaid.com/Provider%20Guidelines/Physician%20Assistants,%20Advanced%20Practice%20Nursing.pdfIdaho MMIS Provider Handbook - Licensed Midwife, Page 3:https://www.idmedicaid.com/Provider%20Guidelines/Licensed%20Midwife.pdfIdaho Numerical Fee Schedule:http://www.healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/FeeSchedule070113.pdf

Idaho Fee Schedules:http://www.healthandwelfare.idaho.gov/Providers/MedicaidProviders/MedicaidFeeSchedule/tabid/268/

NA Yes

NA NF

NA Yes

NA NF

Idaho Medicaid Fee Schedule -Anesthesia:http://www.healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/Anesthesia%208-10.pdf

Idaho MMIS Provider Handbook - Allopathic and Osteopathic Physicians, Page 3:https://www.idmedicaid.com/Provider%20Guidelines/Allopathic%20and%20Osteopathic%20Physicians.pdfIdaho Administrative Code, 16, Dept. of Health and Welfare:http://adminrules.idaho.gov/rules/current/16/0309.pdfIdaho Medicaid Provider Manual 2013:http://www.qualishealth.org/sites/default/files/ID-Medicaid-Provider-Manual.pdf

(A)Idaho MMIS Provider Handbook - Allopathic and Osteopathic Physicians, Page 3:https://www.idmedicaid.com/Provider%20Guidelines/Allopathic%20and%20Osteopathic%20Physicians.pdf(B) Idaho Idaho Site of Service Reduction Codes:https://www.idmedicaid.com/Reference/Site%20of%20Service%20Reduction%20Codes.pdf


NA In-State

NA $3.65

NA NF

NA Yes

Idaho MMIS Provider Handbook - Allopathic and Osteopathic Physicians, Page 4:https://www.idmedicaid.com/Provider%20Guidelines/Allopathic%20and%20Osteopathic%20Physicians.pdf

Idaho MMIS Provider Handbook - General Billing Instructions, Page 17:https://www.idmedicaid.com/General%20Information/General%20Billing%20Instructions.pdf


Idaho MMIS Provider Handbook - General Provider and Participant Information, Page 44:https://www.idmedicaid.com/General%20Information/General%20Provider%20and%20Participant%20Information.pdf

NA NF

NA Yes

NA Yes

NA NF


Primary Care Physician Rates for Incentive Payments Fee Schedule: http://www.healthandwelfare.idaho.gov/LinkClick.aspx?fileticket=ww1LthuekxI%3d&tabid=268&portalid=0&mid=1994

Idaho Dept. of Health and Welfare Website:http://healthandwelfare.idaho.gov/Default.aspx?TabId=216Coordinated Care Provider Agreement-Addenda A, PCCM Fee:http://healthandwelfare.idaho.gov/Portals/0/Medical/MedicaidCHIP/AddendaA.pdf


NA NF



5/1/2013 7/29/2013

8/19/2013 7/29/2013

7/29/2013

7/1/2013 7/29/2013

NA 7/29/2013


Documentation Date

Date Last Searched

8/1/2010 (PA/APN)2/1/2012 (LM)

8/1/2010 7/31/2013

NA 7/29/2013

7/29/2013

NA 7/29/2013

(A) 5/2013(B) Not Listed

NA 7/29/2013

6/1/2013 7/29/2013

NA 7/29/2013

NA 7/29/2013

NA 7/29/2013

NA 7/29/2013

6/2011 7/29/2013

NA 7/29/2013

NA 7/29/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Illinois


CategoryAdjustments


Fee Schedule Basis





Children vs. Adults

Out-of-State







Health Home

Primary Care


States' Medicaid Fee-for-Service Physician Payment Policies - Illinois


Illinois

Practitioner Fee Schedules



Payment made by the department for allowable services will be made at the lower of the provider's usual and customary charge or the maximum rate as established by the department.

Except as described otherwise in this Section, payments will be made according to a schedule of statewide pricing screens established by the Department. The pricing screens are to be established based on consideration of the market value of the service. In considering the market value, the Department will examine the costs of operations and material. Input from advisory groups designated by statute, generally recognized provider interest groups and the general public will be taken into consideration in determining the allocation of available funds to rate adjustments. Increases in rates are contingent upon funds appropriated by the General Assembly. Reductions or increases may be affected by changes in the market place or changes in funding available for the Medical Assistance Program. Screens will be related to the average statewide charge. Except as described otherwise in this Section, the upper limit for services shall not exceed the lowest Medicare charge levels.

All Certified Nurse Practitioners (CNP) and Clinical Nurse Specialists (CNS), may enroll with the department. With the exception of psychiatric services (CPT code range 90801 through 90899), which must be rendered by a physician, all services rendered by an APN are reimbursed at 100 percent of the physician’s rate. In addition, APNs may enroll as a primary care provider under the Maternal and Child Health (MCH) program.

None Found

None Found

None Found

None Found

None Found

None Found



None Found

Medicaid Adults (0-133%)CPT Codes 99201–99215: $3.90/visitCPT Codes 99241–99245: $3.90/visitCPT Codes 90791 – 90911: $3.90/visitCPT Codes 92002–92014: $3.90/visitCPT Codes 98940–98943: Not CoveredT1015 (Medical or Dental Encounter): $3.90/visitT1015 (Behavioral Health Encounter): $0With exceptions.

Practitioners who meet the qualifications for and enter into a Primary Care Provider Agreement for participation in the Maternal and Child Health Program, as described in Subpart G, will receive enhanced reimbursement in accordance with Section 140.930(a)(1).

For services rendered on or after June 1, 2013, a practitioner (radiologist) that meets the qualifications for and participates in the Department's Breast Cancer Quality Screening and Treatment Initiative shall be paid for mammography services at the effective Chicago Metropolitan Area Medicare Level established rate (Established Rate).

For providers identified as eligible for the rate increase, payment will be made on the qualified procedure codes at the Medicare Physician Fee Schedule rates for calendar year 2013 and 2014 or, if higher, the rate that would be applicable using the calendar year 2009 Medicare conversion factor.

The increased rates will be paid as an “add-on” through an adjustment process, and the adjustment will be paid separately from the payment for the service.

None Found

Illinois Health Connect:Illinois Health Connect PCPs receive a monthly care management fee. The monthly care management fee is paid to Illinois Health Connect PCPs on a capitated basis for each person whose care they are responsible to manage. The fees are: $2.00 per child (under age 21), $3.00 per adult, and $4.00 per senior or adult with disabilities. This care management fee will be paid monthly, even if the enrollee does not utilize a service that month. PCPs will continue to receive reimbursement from HFS for their services using current established rates. PCPs are to bill their usual and customary rate for the given service and will be reimbursed for covered services the lesser of the provider’s usual and customary rate or the State’s maximum reimbursement rate.

Supplemental payments to universities for certain practitioner services

1) Supplemental payments are available for services that are provided by practitioners who are employed by an Illinois public university and are services eligible under Titles XIX and XXI of the Social Security Act.A) For dates of service on or after April 1, 2009, supplemental payment will be made on a quarterly basis as described in this subsection (e).B) Supplemental payments under this subsection (e) are subject to federal approval.C) Supplemental payments shall be funded through cooperative agreements between the Department and the State university.



NA

NA

NA No

NA Yes


Summary Data

IL Handbook for PractitionersRendering Medical Services, Chapter A-200, Page HFS A-202 (5):http://www.hfs.illinois.gov/assets/a200.pdf


IL Admin. Code Title 89, Page 140.400: http://www.ilga.gov/commission/jcar/admincode/089/089001400D04000R.html


IL DHF. Medicaid Reimbursement - Individual Practitioner:http://www.hfs.illinois.gov/reimbursement/practitioner.html

IL Practitioner Fee Schedule: http://www2.illinois.gov/hfs/MedicalProvider/FeeSchedule/Pages/default.aspx

NA NF

NA NF

NA NF

NA NF

NA NF

NA NF

IL DHF. Medicaid Reimbursement - Individual Practitioner: http://www.hfs.illinois.gov/reimbursement/




IL DHFS Medical Provider Handbook:http://www.hfs.illinois.gov/handbooks/

IL DHF. Medicaid Reimbursement - Individual Practitioner: http://www.hfs.illinois.gov/reimbursement/practitioner.html



IL Provider Fee Schedule: http://www2.illinois.gov/hfs/MedicalProvider/FeeSchedule/Pages/default.aspx


NA

NA

NA No

NA NF

NA Yes

IL DHFS Medical Provider Handbook: Appendix 12: Cost Sharing: www.hfs.illinois.gov/handbooks/

Ranges from $0 to $3.90


Maternal and Child Health Program

Breast Cancer Quality Screening and Treatment Initiative




IL HFS Informational Notice: Increased Payment For Primary Care Services: http://www.hfs.illinois.gov/assets/030413n.pdf

NA Yes

NA Yes

NA NF

IL Handbook for Providers of Healthy Kids Services. Chapter HK-201.1.2:http://www.hfs.illinois.gov/assets/hk200.pdf





8/1/2010 7/29/2013

5/29/2013 7/29/2013

Not Listed 8/6/2013

7/1/2013 7/29/2013


Documentation Date

Date Last Searched

NA 7/29/2013

NA 7/29/2013

NA 7/29/2013

NA 7/29/2013

NA 7/29/2013

NA

4/1/2013 7/26/2013

5/29/2013 8/2/2013

NA 7/29/2013

NA 7/29/2013

3/4/2013 7/26/2013

3/1/2008 8/2/2013

5/29/2013 8/2/2013

NA 8/2/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Indiana


CategoryAdjustments


Fee Schedule Basis



Children vs. Adults







Out-of-State



Health Home

Primary Care



States' Medicaid Fee-for-Service Physician Payment Policies - Indiana


Indiana



Physicians, limited license practitioners, and other nonphysician medical practitioners that bill on a fee-for-service basis receive a resource-based relative value scale (RBRVS) method of reimbursement.

With the exception of providers contracted with a risk-based managed care (RBMC) plan, practitioners are reimbursed at the lower of the submitted charge or the established statewide RBRVS fee schedule allowance for the procedure.

The RBRVS reimbursement methodology is used in the IHCP Fee Schedule for physician services. RBRVS was designed to represent the resource costs associated with providing physician services for a more equitable reimbursement structure.

The components of the RBRVS reimbursement methodology include the Medicare-based relative value units (RVUs) and a conversion factor. Individual RVUs for each procedure have been developed to represent the resource use associated with individual procedures. The RBRVS IHCP Fee Schedule is based on statewide RVUs. The RVUs were adjusted to reflect work, practice, and malpractice costs in Indiana. Indiana specifically developed a statewide geographic practice cost index (GPCI) as follows:•Physician work–0.980•Practice expense–0.905•Malpractice expense–0.516

Once the total base RVUs are calculated, the payment rate can be determined according to this formula: total Base RVUs x RBRVS Conversion Factor

None Found

None Found

None Found

Payment Differentials for Nonphysician Practitioners:Reimbursement for the following provider types under the RBRVS IHCP Fee Schedule is based on less than 100% of the physician fee schedule amount.

• Independently practicing advance practice nurses (enrolled as type 09, specialty 090-095)

• Certified registered nurse anesthetists (CRNAs) (enrolled as type 09, specialty 094)

The fee schedule is based on claims data from physicians and limited license practitioners. Nonphysician providers are reimbursed at 75% of the physician fee to reflect differences in education and training. Certified registered nurse anesthetists are reimbursed at 60% of the physician fee allowance.

Global Fee Schedule for all providers

Providers that perform procedures in an outpatient setting or place of service 22, 23, or 62, which are normally provided in a physician’s office, are subject to a site of service payment adjustment that is 80% of the practice expense component of the statewide RBRVS IHCP Fee Schedule. These procedures are identified with a site of service indicator on the Medicare Fee Schedule database.

HealthWatch/EPSDT services are available to Indiana Health Coverage Programs (IHCP) members. The methods and standards for payment are consistent with the current program: not less than one of the following:• The federal Medicare reimbursement rate for the services provided• A rate of 130% of the Medicaid reimbursement rate for a service that does not have a Medicare reimbursement rate



None Found

Payments for services to an out-of-state-provider will be negotiated on a case-by-case basis to obtain the lowest possible rate, not to exceed 100% of the provider’s reasonable and customary charges, and may differ from the reimbursement methodology or amounts set out in the Indiana Administrative Code when such payments are required because the services are not available in-state or are necessary due to unique medical circumstances requiring care that is available only from a limited number of qualified providers

Co-pay: This is the amount you may have to pay at the time you receive services. You may owe co-pays for rides to and from the doctor's office, at the pharmacy and/or the dentist office as well as some pharmacy supplies and drugs.

The reimbursement rates for anesthesiology procedures were developed using the total base and time units for each procedure multiplied by the Indiana Medicaid conversion factor for anesthesiology, $13.88. Anesthesia reimbursement rate = (Base Units + Time Units + Additional Units for age (if applicable) + Additional Units for physical status modifiers (as applicable)) x anesthesia conversion factor.

Certified registered nurse anesthetists (CRNAs) and anesthesiologist assistants (AAs) are reimbursed at 60% of the allowable physician rate.

Follows federal guidelines; The rates do not reflect site of service adjustments, but reimburse at the Medicare rate applicable to the office setting. Rates reflect all Medicare geographic/locality adjustments. The state reimburses a supplemental amount equal to the difference between the Medicaid rate in effect on the date of service as published in the agency’s fee schedule described in Attachment 4.19-B, page 1c.4b Physician Services of the State plan and the minimum payment required at 42 CFR 447.405. Applies to select E&M codes.

Care Select operates as a fee-for-service (FFS) delivery system with a gatekeeper approach. Each Care Select member is linked to a Care Select-enrolled Primary Medical Provider (PMP), who provides or arranges for most of the members' medical care.

Care Select is similar to Traditional Medicaid in that services are reimbursed on an FFS basis. In addition, a $6 per-member, per-month administration fee is paid to PMPs, with the exception of rural health clinics and Federally Qualified Healthcare Centers.

None Found

None Found



NA

NA RBRVS


Summary Data

Indiana Medicaid Provider Manual Chapter 7, Reimbursement Methodologies, Section 4. Pages 7-38 & 7-39: http://provider.indianamedicaid.com/ihcp/manuals/chapter07.pdf


Indiana Medicaid Provider Manual Chapter 7, Reimbursement Methodologies, Section 4. Pages 7-38 & 7-39: http://provider.indianamedicaid.com/ihcp/manuals/chapter07.pdf

NA 75%

NA Yes

NA NF

NA NF

NA NF

NA Yes

NA Yes

Indiana Medicaid Provider Manual Chapter 7, Reimbursement Methodologies, Section 4 Page 7-41: http://provider.indianamedicaid.com/ihcp/manuals/chapter07.pdf

Indiana Health Coverage Programs Fee Schedule: http://provider.indianamedicaid.com/ihcp/Publications/MaxFee/fee_schedule.asp



Indiana Medicaid Manuals: http://provider.indianamedicaid.com/general-provider-services/manuals.aspx

Indiana Medicaid Manual Chapter 7, Reimbursement Methodologies, Section 4. Page 7-42: http://provider.indianamedicaid.com/ihcp/manuals/chapter07.pdf

HealthWatch/Early Periodic Screening, Diagnosis andTreatment Provider Manual. Page 2-1:http://provider.indianamedicaid.com/ihcp/manuals/epsdt_healthwatch.pdf

NA Negotiated

NA $0

NA

NA No

NA NF

NA Yes

NA Yes

Indiana State Plan, Attachment 4.19-B, Page 1B:http://provider.indianamedicaid.com/general-provider-services/state-plan.aspxIndiana Medicaid FAQ:http://member.indianamedicaid.com/resource-center/faq-member-.aspx

Indiana State Plan, Attachment 4.19-B, Page 1a:http://provider.indianamedicaid.com/general-provider-services/state-plan.aspx



Indiana Medicaid Manual: http://provider.indianamedicaid.com/general-provider-services/manuals.aspx

Indiana State Plan:http://provider.indianamedicaid.com/general-provider-services/state-plan.aspx

Indiana State Plan, Attachment 4.19-B, Page 1c.4b:http://provider.indianamedicaid.com/general-provider-services/state-plan.aspx

Indiana Medicaid For Providers: About Indiana Medicaid: http://provider.indianamedicaid.com/about-indiana-medicaid.aspx

NA NF

NA NF






10/1/2012 7/9/2013

10/1/2012 7/9/2013


Documentation Date

Date Last Searched

10/1/2012 7/9/2013

6/23/2013 7/9/2013

NA 7/31/2013

NA 7/31/2013

NA 7/9/2013

10/1/2012 7/9/2013

6/6/2013 7/9/2013

4/1/2005 7/9/2013

Not Listed 8/23/2013

3/17/2011 9/15/2013

NA 7/9/2013

NA 7/9/2013

6/24/2013 8/19/2013

NA 7/9/2013

NA 7/9/2013

NA 7/9/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Iowa


CategoryAdjustments


Fee Schedule Basis







Children vs. Adults

Out-of-State





Health Home

Primary Care


States' Medicaid Fee-for-Service Physician Payment Policies - Iowa


Iowa

Physician MD and Physician DO Fee Schedule

NP and Certified MW Fee Schedule

CRNA, Podiatrist, Psychologist Fee Schedule



The Department has established a fee schedule with advice and consultation from the Iowa Medical Society and the Iowa Osteopathic Medical Association. Physicians will be reimbursed the lower level of customary charges and the fee schedule amount.

The Iowa Medicaid fee schedule is generally based on a percentage of the federal Medicare fee schedule specific to Iowa and can fluctuate up or down. There are no set conversion factors. The changes to the fee schedule are decreed to Legislature yearly.

(A) NP: The fee schedule is based on 85% of the physician fee schedule.(B) Nurse-Midwife fee schedule is based on 85% of the physician fee schedule.

None found


EPSDT pricing in fee schedule

None Found

Copay: $3 for services rendered in a physician (MD/DO) office visitWith exceptions.


None Found

The payment methodology for Health Homes is in addition to the existing fee-for-service or Managed Care plan payments for direct services, and is structured as follows:

The PMPM payment is a reflection of the added value provided to members receiving this level of care and will be risk adjusted based on the level of acuity assigned to each patient with no distinction between public or private health home providers. The health home provider will tier the eligible members into one of four tiers with a PMPM payment assigned to each tier.

The State will inform Health Home providers prior to the start of each performance year the target performance (also known as the minimum performance or benchmark) for each measure. The Health Home Provider must achieve the target performance for each measure in the category to achieve the bonus for that category.

Formula:20% of Patient Management Payments for Measurement Year = Maximum Incentive Payment (MIP)Category 1 Assigned Value = 35% of MIPCategory 2 Assigned Value = 30% of MIPCategory 3 Assigned Value = 20% of MIPCategory 4 Assigned Value = 15% of MIP

Follows federal guidelines. The rates reflect all Medicare site of service and locality adjustments, geographic/locality adjustments. State has adjusted is fee schedule to make payment at the higher rate for each E&M and vaccine administration code.

None Found

None Found

The Iowa Medicaid Patient Access to Service System (hereinafter referred to as MediPASS) is a primary care patient management system implemented in accordance with Title XIX of the Social Security Act and is subject to the provisions of the Iowa Administrative Code.

The Iowa Department of Human Services agrees to:A. Pay the PM a management fee of $2.00 monthly for each enrolled recipient, subject to a maximum monthly fee for each provider providing patient management of $3,000.00, regardless of the number of recipients enrolled with the PM.B. Pay the PM for medical services covered under the Iowa Medicaid program provided to enrollees according to the fee for service reimbursement system in place in the Iowa Medicaid program.



NA

Staff at Iowa Medicaid Office NA % of Medicare

NA 85%

NA Yes

NA Yes

NA Yes


Summary Data

Iowa Medicaid Provider Manual: Physician Services: Chapter E-92: http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/Manual_Documents/Provman/phys.pdf


(A) Iowa Medicaid State Plan, Attachment 4.19-B, Page 15: http://www.ime.state.ia.us/StatePlan/(B) Iowa Medicaid State Plan, Attachment 4.19-B, Page 14: http://www.ime.state.ia.us/StatePlan/

Iowa Medicaid Fee Schedule: https://secureapp.dhs.state.ia.us/MedicaidFeeSched/



NA NF

NA Yes

NA Yes

NA NF

NA $3

Iowa Medicaid Provider Manual:http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/Manual_Documents/Provman/phys.pdf

Iowa Medicaid State Plan: Attachment 4.19-B: http://www.ime.state.ia.us/StatePlan/


Iowa Medicaid Fee Schedule: Factor Code Explanation: http://www.dhs.state.ia.us/uploads/FactorCodeExplanation.pdf

Iowa Medicaid Fee Schedule: Factor Code Explanation: http://www.dhs.state.ia.us/uploads/FactorCodeExplanation.pdf

Iowa Medicaid Provider Manual: Physician Services: http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/Manual_Documents/Provman/phys.pdf



Iowa Policy Manuals-Medicaid Provider: All Providers: Chapter 1; General Program Policies: Page 50:http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/Manual_Documents/Provman/all-i.pdf

NA NF

NA Yes

NA NF

NA Yes



Iowa Health Home SPA: Pages 27-28: http://www.ime.state.ia.us/docs/ApprovedHHSPA_20120608.pdf



Iowa Medicaid State Plan, Attachment 4.19-B, Page 22: http://www.ime.state.ia.us/StatePlan/

NA Yes

NA NF

NA NF

Iowa Department of Human Services: "Agreement for Participation as a Patient Manager In the Iowa Medicaid Patient Access Service System (MediPASS)": http://www.ime.state.ia.us/Providers/medipass.html






1/1/1997 7/11/2013


8/12/2013

4/1/2013 7/11/2013

4/1/2013 7/11/2013

4/1/2013 7/11/2013


Documentation Date

Date Last Searched

(A) 1/25/2008(B) 6/24/2011

NA 7/11/2013

1/1/2013 7/11/2013

1/1/2013 7/11/2013

NA 8/7/2013

9/1/2011 7/11/2013

NA 8/7/2013

6/18/2012 7/11/2013

NA 7/11/2013

4/30/2013 8/12/2013

11/1/2003 8/8/2013

NA 8/8/2013

NA 7/11/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Kansas


CategoryAdjustments


Fee Schedule Basis







Children vs. Adults

Out-of-State





Health Home

Primary Care



States' Medicaid Fee-for-Service Physician Payment Policies - Kansas


Kansas

ARNPs and PAs are reimbursed at 75% of the Medicaid allowed amount for services provided.

Medicaid Fee Schedule Under TXIX or MediKan plan.

None Found



Physician's services are reimbursed on the basis of reasonable fees as related to Medicaid customary charges, except no fee is reimbursed in excess of a range maximum. The range of charges provides the base for computation of range maximums.

Kansas normally prices at 65% of Medicare, but sometimes other factors are taken into consideration.

An allowed amount is normally established at 65% of Medicare; however, that allowed amount is not reviewed in the future to determine if Medicare changed their allowed amount. Once the original price is set, that price is utilized unless there is a lot of feedback from the provider community stating that the amount does not cover their costs.

Mid Level Practitioners (PA/ARNP) pricing in Medicaid Fee Schedule under TXIX or MediKan plan.Separate Fee Schedule for Mid Level Practitioner under TXIX or MediKan plan.

None Found

None Found

None Found

EPSDT screens are reimbursed on the basis of reasonable fees as related to Medicaid customary charges except no fee is reimbursed in excess of a Statewide maximum. Provider representatives and the EPSDT Advisory Committee are consulted in reviewing the maximum rate.

Physician services require a copayment of $2.00 per office visit.ARNP and local health department services are exempt from copayment requirements.



None Found

PCP Rate Increase Fee Schedule

HealthConnect Kansas (HCK) is a primary care case management program established in 1994to provide Medicaid beneficiaries increased access to quality care and continuity of service, while controlling costs for specialty care. Case management was instituted by contracting with Primary Care Case Managers (PCCMs) to provide primary care to HCK members and coordinate their specialty care. In the HCK program, PCCMs receive a $2 per member per month (PMPM) fee to provide primary care to HCK members and to coordinate their specialty care. Medical services obtained by HCK members are reimbursed on a FFS basis.

None Found

None Found



NA

Staff at Kansas Medicaid Office NA % of Medicare

NA 75%

NA Yes

NA Yes

NA NF


Summary Data

KS State Plan Volume 2 Amendment 4.19B #5 (page 326 out of 650) :http://www.kdheks.gov/hcf/Medicaid/download/StatePlan/Kansas_SPA_Volume2.pdf


KS Fee-for-Service Provider Manual, Section 7010, Page 7-4: https://www.kmap-state-ks.us/Documents/Content/Provider%20Manuals/Professional_07242013_13080.pdf

KS Medicaid Fee Schedule:https://www.kmap-state-ks.us/Provider/PRICING/ScheduleList.asp

KS Medicaid Fee Schedule:https://www.kmap-state-ks.us/Provider/PRICING/ScheduleList.asp

KS Fee Schedule:https://www.kmap-state-ks.us/Provider/PRICING/ScheduleList.asp

NA NF

NA NF

NA No

NA NF

NA $2

KS State Plan Volume 2 Amendment 4.19B :http://www.kdheks.gov/hcf/Medicaid/download/StatePlan/Kansas_SPA_Volume2.pdfProvider Manual:https://www.kmap-state-ks.us/Documents/Content/Provider%20Manuals/Professional_04062010_10021.pdf


KS State Plan Volume 2 Amendment 4.19B (Page 323 out of 650):http://www.kdheks.gov/hcf/Medicaid/download/StatePlan/Kansas_SPA_Volume2.pdf


KS Medicaid Provider Manual, Page 8-1:https://www.kmap-state-ks.us/Documents/Content/Provider%20Manuals/Professional_07022013_13077.pdf

NA NF

NA No

NA NF

NA Yes

NA Yes




PCP Rate Increase Fee Schedule:https://www.kmap-state-ks.us/Documents/Content/Provider/PCP_rate_increase.pdf

Program Review of HealthConnect Kansas, Page 1:http://www.kdheks.gov/hcf/program_improvements/downloads/HealthConnect%20KS%20ProgReview2009_version%2031_2%2023%2010.pdf

NA NF

NA NF




4/5/1985 7/31/2013

NA 8/23/2013

7/1/2013 7/15/2013

8/1/2013 8/2/2013

7/1/2013 7/31/2013

NA 7/31/2013


Documentation Date

Date Last Searched

NA 7/15/2013

NA 7/15/2013

10/18/2006 7/31/2013

NA 7/15/2013

7//2013 7/15/2013

NA 7/15/2013

NA 7/31/2013

NA 7/15/2013

6/1/2013 7/31/2013


NA 7/31/2013

NA 7/31/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Kentucky


CategoryAdjustments


Fee Schedule Basis





Children vs. Adults





Out-of-State



Health Home

Primary Care




States' Medicaid Fee-for-Service Physician Payment Policies - Kentucky


Kentucky

Global Physician Fee Schedule



(2) Except as provided in subsections (3) to (9) of this section, reimbursement for a covered service shall be the lesser of: (a) The physician’s usual and customary charge; or (b) The amount specified in the Medicaid Physician Fee Schedule established in accordance with Section 3 of this administrative regulation.(3) If there is not an established fee in the Medicaid Physician Fee Schedule, the reimbursement shall be forty-five (45) percent of the usual and customary billed charge.

Section 3. Reimbursement Methodology. (1) Except for a service specified in subsections (3) through (7) of this section: (a) The rate for a nonanesthesia related covered service shall be established by multiplying RVU by a dollar conversion factor to obtain the RBRVS maximum amount specified in the Medicaid Physician Fee Schedule.

NP: Except as specified in subsection c of this section or Section 2 below, reimbursement for a procedure provided by an ARNP shall be at the lesser of the following:I. The ARNPs actual billed charge for the service; or2. Seventy-five (75) percent of the amount reimbursable to a Medicaid participating physician for the same service.Midwife: Participating nurse- midwife providers shall be paid only for covered services rendered to eligible recipients, and services provided shall be within the scope of practice of the nurse-midwife. For services provided on or after July 1, 1990, payments to nurse - midwives shall be at usual and customary actual billed charges on a procedure-by-procedure basis, with reimbursement for each procedure to be the lesser of the actual billed charge or at seventy- five (75) percent of the fixed upper limit per procedure for physicians.

None Found

None Found

None Found

None Found

For the services listed above in section XXIX subsection (I), the department shall reimburse for an expanded EPSDT service based upon the established methodology for other similar services under the Kentucky Medicaid Program. The reimbursement of the expanded EPSDT service shall not exceed 100 percent of the usual and customary charges. If the item is covered under Medicare, the payment amount shall not exceed the amount the at would be paid using the Medicare payment methodology and upper limits. If an expanded EPSDT service is provided before prior authorization is received, the provider shall assume the financial risk that the prior authorization may not be subsequently approved.

None Found

$2.00 Physician Office Services



None Found

Effective January 1, 2013, certain healthcare providers who provide eligible primary care services to Medicaid clients are eligible to be paid the Medicare rates in effect in calendar years (CY) 2013 and 2014 instead of their usual state-established Medicaid rates. The enhanced rate is available for providers who are fee for service providers with Kentucky Medicaid, as well as eligible providers who are enrolled in the Kentucky managed care program. This enhanced rate will only be available for the limited periods of the calendar years 2013 and 2014. At the end of this period, the enhanced federal funding for this program sunsets and the enhanced rate for Medicaid services will end.

The purpose of this agreement is to obtain primary care case management services for beneficiaries participating in the Kentucky Patient Access and Care System (KenPAC). The goal of KenPAC as a primary care case management system of Medicaid is to increase access to primary and preventive care services, thereby enhancing the health status of enrollees and reducing future health care expenditures. This agreement is made pursuant to Title XIX of the Social Security Act and amendments thereto and Title 907, chapter 1, Section 320, of the Kentucky Administrative Regulations.

Section 5. Supplemental Payments. (1) In addition to a reimbursement made pursuant to Sections 2 through 4 of this administrative regulation, the department shall make a supplemental payment to a medical school faculty physician employed by a state-supported school of medicine that is part of a university health care system that includes a: (a) Teaching hospital; and (b) Pediatric teaching hospital. (2) A supplemental payment plus other reimbursements made in accordance with this administrative regulation shall not exceed the physician’s charge for the service provided and shall be paid directly or indirectly to the medical school. (3) A supplemental payment made in accordance with this section shall be: (a) Based on the funding made available through an intergovernmental transfer of funds for this purpose by a state-supported school of medicine meeting the criteria established in subsection (1) of this section; (b) Consistent with the requirements of 42 C.F.R. 447.325; and (c) Made on a quarterly basis.

None Found



NA

NA RBRVS

NA 75%

NA Yes


Summary Data

Kentucky Regulations, 907 KAR 3:010. Reimbursement for physicians' services, Section 2:http://www.lrc.state.ky.us/kar/907/003/010.htm



Kentucky State Plan Attachment 4.19B, Pages 20.24 & 20.18:http://chfs.ky.gov/NR/rdonlyres/2F65FC25-9F1D-48CC-9F9F-41C364883A5A/0/Attachment419B.pdf

Physician Fee Schedule: http://chfs.ky.gov/NR/rdonlyres/0A89E75D-8B03-46D6-B4D4-C1B3795FD4D2/0/2013physicianFEESCHEDULEweb.pdf

NA NF

NA NF

NA NF

NA No

NA Yes



Provider Manual: http://www.kymmis.com/kymmis/Provider%20Relations/..%5Cpdf%5CbillingInstr%5CPT64-65withMedicare_v6.1_%2807-09-2013%29.pdfKentucky State Plan Attachment 4.19B:http://chfs.ky.gov/NR/rdonlyres/2F65FC25-9F1D-48CC-9F9F-41C364883A5A/0/Attachment419B.pdf

KY Medicaid Provider Billing Instructions -Physician:http://www.kymmis.com/kymmis/Provider%20Relations/..%5Cpdf%5CbillingInstr%5CPT64-65withMedicare_v6.1_%2807-09-2013%29.pdf

Kentucky State Plan Attachment 4.19B, Page 20.37:http://chfs.ky.gov/NR/rdonlyres/2F65FC25-9F1D-48CC-9F9F-41C364883A5A/0/Attachment419B.pdf

NA NF

NA $2

NA NF

NA No

Provider Manual: http://www.kymmis.com/kymmis/Provider%20Relations/..%5Cpdf%5CbillingInstr%5CPT64-65withMedicare_v6.1_%2807-09-2013%29.pdfKentucky State Attachment 4.19B:http://chfs.ky.gov/NR/rdonlyres/2F65FC25-9F1D-48CC-9F9F-41C364883A5A/0/Attachment419B.pdf

KY Medicaid Member Handbook, Pages 7-10:http://chfs.ky.gov/NR/rdonlyres/F6B5F330-EE69-4CC8-83A8-1A1C0DC4BF46/0/MemberHandbookRevisedFeb2011.pdf



NA NF

NA Yes

NA Yes

NA Yes


KY Medicaid Enhanced PC Payments Bulletin:http://chfs.ky.gov/NR/rdonlyres/EE85CEC1-7649-46A6-AF21-9E402A5C8E9C/0/KentuckyMedicaidEnhancedPrimaryCarePayments.pdf

KenPAC PCCP Agreement:http://chfs.ky.gov/NR/rdonlyres/51EA085B-F04D-4E58-A1F6-0AB5BA5D9825/0/MAP811ADDDMedicaid.pdf


NA NF



4/11/2012 7/17/2013

4/11/2012 7/17/2013

6/12/2008 7/31/2013

1/1/2013 7/17/2013


Documentation Date

Date Last Searched

NA 7/31/2013

5/16/2013 7/17/2013

3/25/2013 7/17/2013

NA 7/17/2013

6/12/2008 7/17/2013

NA 7/17/2013

1/22/2009 7/31/2013

NA 8/1/2013

NA 8/1/2013

NA 7/17/2013

Not listed 8/1/2013

Not listed 8/1/2013

4/11/2012 8/1/2013

NA 8/1/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Louisiana


CategoryAdjustments




Fee Schedule Basis





Children vs. Adults



Out-of-State



Health Home

Primary Care




States' Medicaid Fee-for-Service Physician Payment Policies - Louisiana


Louisiana



Recipients 16+ years of age:Effective for dates of service on or after January 22, 20I0, physician services rendered to recipients 16 years of age or older shall be reduced to 75 percent of the 2009 Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount.Effective for dates of service on or after January 22, 20 I0, those services rendered to recipients 16 years of age or older that are currently reimbursed at a rate below 75 percent of the 2009 Louisiana Medicare Region 99 allowable will be reimbursed at a rate of 75 percent of the 2009 Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount.

Recipients below 16 years of age:Effective for dates of service on or after January 22, 20I0, physician services rendered to recipients under the age of 16 shall be reimbursed at 90 percent of the 2009 Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount.Effective for dates of service on or after January 22, 2010, those services rendered to recipients under the age of 16 that are currently reimbursed at a rate below 90 percent of the 2009 Louisiana Medicare Region 99 allowable will be reimbursed at a rate of 90 percent of the 2009 Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount.

Professional Services Fee Schedule

None Found

None Found

(A) Effective February l, 1987, the Louisiana Medical Assistance Program began implementation of a statewide flat fee-for-service reimbursement methodology for services provided by physicians, osteopaths, optometrists, dentists, and nurse midwives. In order to determine flat-fee amounts, we compared billed charges, maximum allowable prices on file, and average amounts paid for the full service aspect of all payable CPT procedure codes for calendar year 1984 . This review vas conducted by Medical Assistance Program staff and consultant physicians .

(B) Recipients 16+ years of age:Effective for dates of service on or after January 22, 20I0, physician services rendered to recipients 16 years of age or older shall be 75 percent of the 2009 Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount.Recipients below 16 years of age:Effective for dates of service on or after January 22, 20I0, physician services rendered to recipients under the age of 16 shall be reimbursed at 90 percent of the 2009 Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount.

The reimbursement for services rendered by a physician assistant or advance practice registered nurses (CNS/CNP/CNM) shall be 80% of the professional services fee schedule and 100% of the fee for immunizations and Early and Periodic Screening, Diagnosis and Treatment (EPSDT) medical, vision, and hearing screenings.

None Found

None Found

(A) EPSDT Fee Schedule(B) Recipients 16+ years of age:Effective for dates of service on or after January 22, 20 I 0, physician services rendered to recipients 16 years of age or older shall be reduced to 75 percent of the 2009 Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount. Services currently reimbursed at a rate below 75 percent of the 2009 Louisiana Medicare Region 99 allowable will be reimbursed at a rate of 75 percent of the 2009 Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount.Recipients below 16 years of age:Effective for dates of service on or after January 22, 20 I 0, physician services rendered to recipients under the age of 16 shall be reimbursed at 90 percent of the 2009 Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount. Services currently reimbursed at a rate below 90 percent of the 2009 Louisiana Medicare Region 99 allowable will be reimbursed at a rate of90 percent of the 2009 Louisiana Medicare Region 99 allowable or billed charges, whichever is the lesser amount.

None Found

No physician office visit copays



None Found

ACA Primary Care Enhanced Reimbursement Fee Schedule

(A) It was previously announced that the department’s current PCCM program, CommunityCARE, would end as structured presently on Dec. 1 as part of reductions necessitated by a mid-year spending deficit in Medicaid. Under the new system announced today, CommunityCARE will now end Jan. 1, and the new Enhanced PCCM will begin at the same time.Physicians will receive a flat rate of $1.50 per month for each child enrolled in Medicaid on their patient panels, and $3 per month for each SSI child. Physicians will have an opportunity to earn an additional rate of up to $3 per member per month for reaching certain health quality measures that gauge how well they are coordinating the care of their patients.

(B) Louisiana Medicaid implemented an immunization pay-for-performance (P4P) initiative which includes supplemental payments to providers. This initiative was implemented to promote up-to-date immunizations of Louisiana Medicaid eligible children and to increase the number of providers utilizing the Louisiana Immunization Network for Kids Statewide (LINKS) immunization registry.

Supplemental Payments for Services at State-owned or Operated EntityPhysicians and other eligible professional service practitioners may qualify for supplemental payments if they are employed by a state-owned or operated entity, such as a state-operated hospital or other state entity, including a state academic health system. The supplemental payment to each qualifying physician or other eligible professional services practitioner in the practice plan will equal the difference between the Medicaid payments otherwise made to these qualifying providers for professional services and the average amount that would have been paid at the equivalent community rate defined as the average amount that would have been paid by commercial insurers for the same services.

Supplemental Payments for Services at Non-State Owned or Operated Entity with Tulane School of MedicinePhysicians and other professional service practitioners (physician assistants, certified registered nurse practitioners and certified registered nurse anesthetists) who are employed by, or under contract with, a non-state owned or operated governmental entity, such as a non-state owned or operated public hospital, may qualify for supplemental payments for services rendered to Medicaid recipients. To qualify for the supplemental payment, the physician or professional service practitioner must be identified as a physician or other professional service practitioner that is employed by, or under contract to provide services for, Tulane University School of Medicine. The supplemental payment will be determined in a manner to bring payments for these services up to the community rate level defined as the rates paid by commercial payers for the same service.

None Found



NA


Summary Data

LA State Plan Amendment 4.19-B, item 5, Page 2a: http://bhsfweb.dhh.louisiana.gov/onlinemanualspublic/stateplan/gpa/attachment%204.19-b%20item%205.pdf

Lesser of charges or % of Medicare rate

NA % of Medicare

NA 80%

NA Yes

NA NF

NA NF

(A)(B) LA State Plan Amendment, Attachment 4.19-B, Item 5, Page 1 & 2a: http://bhsfweb.dhh.louisiana.gov/onlinemanualspublic/stateplan/gpa/attachment%204.19-b%20item%205.pdf

Louisiana Professional Services Provider Manual, Chapter 5, Section 5.1, Advance Practice Registered Nurses and Section 5.1 Physician Assistants:http://www.lamedicaid.com/provweb1/Providermanuals/manuals/PS/PS.pdf

LA Medicaid Fee Schedule: http://www.lamedicaid.com/provweb1/fee_schedules/ProfServ_FS.htm

LA Medicaid Fee Schedule: http://www.lamedicaid.com/provweb1/fee_schedules/feeschedulesindex.htm

LA Medicaid Fee Schedule: http://www.lamedicaid.com/provweb1/fee_schedules/feeschedulesindex.htm

NA NF

NA NF

NA Yes

Louisiana Professional Services: Provider Manual, Chapter 5, Section 5.1:http://www.lamedicaid.com/provweb1/Providermanuals/manuals/PS/PS.pdf

LA Administrative Code: http://doa.louisiana.gov/osr/lac/lac50.htm

LA Medicaid State Plan:http://bhsfweb.dhh.louisiana.gov/onlinemanualspublic/




(A) EPSDT Early Intervention Services (Early Steps) Fee Schedule: http://www.lamedicaid.com/provweb1/fee_schedules/EPSDTFEE.pdf(B) LA State Plan Amendment 4.19b, item 5, Page 2a: http://bhsfweb.dhh.louisiana.gov/onlinemanualspublic/stateplan/gpa/attachment%204.19-b%20item%205.pdf

NA NF

LA Medicaid Office NA $0

NA NF

NA No








NA NF

NA Yes

NA Yes

NA Yes

Louisiana Professional Services Provider Manual, Chapter 5, Section 5.1:http://www.lamedicaid.com/provweb1/Providermanuals/manuals/PS/PS.pdf

LA ACA Fee schedule: http://www.lamedicaid.com/provweb1/fee_schedules/ACA_Fee_Scheldule_02_20_13.PDF

(A) Department of Health & Hospitals LA:http://dhh.louisiana.gov/index.cfm/newsroom/detail/1353(B) CommunityCARE Immunization Pay-for-Performance Initiative Louisianahttp://www.lamedicaid.com/provweb1/P4P_Rev_Jan_11.pdf

Louisiana Professional Services Provider Manual, Chapter 5, Section 5.1, Physician Supplemental Payments:http://www.lamedicaid.com/provweb1/Providermanuals/manuals/PS/PS.pdf

NA NF





3/11/2011 8/2/2013


Documentation Date

Date Last Searched

8/20/2013

9/28/2012 8/7/2013

2/1/2013 8/5/2013

NA 7/11/2013

NA 7/11/2013

(A) 5/4/1987(B) 3/11/2011

NA 7/11/2013

2/1/2013 7/11/2013

8/2/2013(A) 7/28/2013(B) 3/11/2011

NA 7/11/2013

NA 8/20/2013

NA 7/11/2013

NA 8/5/2013

NA 7/11/2013

7/26/2013 7/11/2013

7/11/2013

11/2/2012 8/7/2013

(A) 11/19/2010(B) 1/2011

NA 8/7/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Maine


CategoryAdjustments


Fee Schedule Basis





Children vs. Adults

Out-of-State







Health Home

Primary Care





States' Medicaid Fee-for-Service Physician Payment Policies - Maine


Maine

Global Fee Schedule



MaineCare will reimburse the lowest of the following for covered services:

A. The MaineCare rates of reimbursement as found in this Section and posted in the fee schedule on the MaineCare websiteB. The lowest amount allowed by Medicare Part B for Maine area “99” fee schedule and upon the implementation of MIHMS this will include appropriate Medicare fee adjustments for place of service and modifiers; orC. The provider’s usual and customary charges; orD. The amount, if any, by which the MaineCare rate of reimbursement for services billed exceeds the amount of the third party payment as set in MBM, Chapter I. MaineCare considers a claim paid in full if the insurance amount received exceeds the MaineCare rate of reimbursement.

For services provided on or after March 1, 2010, the fee for service rate is set at 70% of the lowest level in the 2009 Medicare fee schedule for Maine area. Upon implementation of MIHMS, this rate will include appropriate Medicare fee adjustments for place of service and modifiers in effect at that time.

Advanced Practice Registered Nursing Services: (includes CNP, CNM, CRNA, CNS)For independent practitioners billing for services not billed through hospitals, physicians, or dentists, reimbursement for covered services shall be the lowest of the following:

A. The amount listed on the Office of MaineCare Services’ website, for services as described in Chapters II and III, Section 90, Physician Services, of this manual. A.P.R.N.s providing psychological or psychiatric services shall receive sixty percent (60%) of the amount reimbursed for physician’s services as set forth in the MaineCare Benefits Manual, Chapter II, Section 90, Physician Services; orB. The lowest amount allowed by the Medicare - Part B carrier, when applicable; orC. The provider’s usual and customary charge.

None Found

None Found

None Found

Facility and Non-Facility Pricing in Fee Schedule

None Found

Out-of-state providers, within fifteen (15) miles of the Maine/New Hampshire border are treated the same as Maine providers in all aspects of policy requirements, enrollment, rates of reimbursement, and payment methodologies with the exception of out-of-state hospitals, which are excluded from in-state reimbursement methodology as described in Chapter III, Section 45. MaineCare will not provide payment to any entity outside the United States.

Maine-based providers who are providing services out-of-state are considered out-of-state providers and as such are bound by the same requirements as for out-of-state providers, including prior authorization and proper licensure within the state in which services are being provided.


When MaineCare pays . . . the member co-payment is $10.00 or less $0.50$10.01 - $25.00 $1.00$25.01 - $50.00 $2.00$50.01 – more $3.00With Exceptions.

Practice PMPM care management payment:Maine will pay for reimbursement of the cost of staff associated with the delivery of Health Homes services to Health Homes-eligible members not covered by other reimbursement under MaineCare.

CCT PMPM add-on payment:Maine will pay for reimbursement of the cost of staff associated with the delivery of care management support for Individuals with special health needs served by the Health Home practices, not covered by other reimbursement under MaineCare. The state will provide add-on payments for no more than 5% of the total number of Health Home enrollees associated with Health Home practices.

Practice PMPM care management payment = $12.00CCT PMPM Add-On Payment = $129.50

None Found

None Found

The Primary Care Physician Incentive Payment (PCPIP) rewards physicians who have provided quality primary care to MaineCare members. Physicians receive scores in various categories such as the number of MaineCare patients, emergency room utilization and prevention/quality. Each physician’s practices are compared to other physicians in his/her primary care specialty and then are given an overall ranking. Physicians ranking above the twentieth percentile will receive a monetary share of their specialty pool, based on percentile. The twentieth percentile and below do not receive a monetary share of their specialty pool.

Group 1 Percentile- Sixty Percent (60%) Of Total Payment Octal 1 90 - 100 Thirty percent (30%) of Group 1 payment Octal 2 80 - 89 Twenty percent (20%) of Group 1 payment Octal 3 70 - 79 Ten percent (10%) of Group 1 paymentGroup 2 Percentile - Twenty-Five Percent (25%) Of Total Payment Octal 4 60 - 69 Ten percent (10%) of Group 2 payment Octal 5 50 - 59 Eight percent (8%) of Group 2 payment Octal 6 40 - 49 Seven percent (7%) of Group 2 paymentGroup 3 Percentile - Fifteen Percent (15%) Of Total Payment Octal 7 30 - 39 Ten percent (10%) of Group 3 payment Octal 8 20 - 29 Five percent (5%) of Group 3 payment

No Payment for 0 - 19 Percentile

Follows federal guidelines. Rates reflect Medicare site of service, are statewide, and reflect the mean value over all counties for each of the specified E&M and vaccine billing codes. The state has adjusted its fee schedule to make payment at the higher rate for each E&M and vaccine administration code.

PCP sites receive a $3.50 management fee per PCCM member-patient per month, even if they do not see the patient during that particular month.



NA

NA % of Medicare

NA

NA Yes


Summary Data

MaineCare Benefits Physician Manual: Chapter 2 § 90.0 Page 42-43: http://www.maine.gov/sos/cec/rules/10/ch101.htm


MaineCare Benefits Physician Manual: Chapter 2 § 90.0 Page 42: http://www.maine.gov/sos/cec/rules/10/ch101.htm

MaineCare Benefits Advanced Practice Registered Nursing Services Manual: Chapter 2 § 14.06 (Page 4): http://www.maine.gov/sos/cec/rules/10/ch101.htm


MaineCare Services: Health PAS: Fee Schedules: https://mainecare.maine.gov/Provider%20Fee%20Schedules/Forms/Publication.aspx

NA NF

NA NF

NA NF

NA Yes

NA NF

NA In-State



MaineCare Benefits Physician Manual. Available at: http://www.maine.gov/sos/cec/rules/10/ch101.htm

MaineCare Benefits Advanced Practice Registered Nursing Services Manual: Available at: http://www.maine.gov/sos/cec/rules/10/ch101.htm


MaineCare Benefits Physician Manual: http://www.maine.gov/sos/cec/rules/10/ch101.htm

MaineCare Benefits Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) Manual: Chapter 2 § 94.06(Page 9): http://www.maine.gov/sos/cec/rules/10/ch101.htm

MaineCare Benefits General Administrative Policies and Procedures Manual: Chapter 1 § 1.03E, Page 9: http://www.maine.gov/sos/cec/rules/10/ch101.htm

NA

NA NF

NA Yes

Maine Co-Pay Schedule: http://www.maine.gov/dhhs/oms/pdfs_doc/member/co_pay_sched_033111.doc

Ranges from $0.50 to $3

MaineCare Benefits Physician Manual. Available at: http://www.maine.gov/sos/cec/rules/10/ch101.htm

MaineCare Benefits Advanced Practice Registered Nursing Services Manual: Available at: http://www.maine.gov/sos/cec/rules/10/ch101.htm

Maine Health Home State Plan Amendment:http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Downloads/Maine-SPA-4.pdf

NA Yes

NA Yes

NA Yes

NA NF

NA NF

MaineCare Benefits Physician Manual: Chapter 2 § 90.09-4,Page 43-45: http://www.maine.gov/sos/cec/rules/10/144/ch101/c2s090.doc

Maine State Plan Amendment, Attachment 4.19B, Page 7a:http://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/ME/ME-13-001-Att.pdf

MaineCare Services: Health PAS: Provider Handbooks: State PCCM Manual. Page 3: https://mainecare.maine.gov/Provider%20Handbooks/PCCM_Manual_v3.0_20110315.pdf

MaineCare Benefits Physician Manual: http://www.maine.gov/sos/cec/rules/10/ch101.htm

MaineCare Benefits Manual:http://www.maine.gov/sos/cec/rules/10/ch101.htm


8/9/2010 7/25/2013

8/9/2010 7/25/2013

10/15/2006 7/26/2013

7/15/2013 7/26/2013


Documentation Date

Date Last Searched

NA 7/26/2013

NA 7/26/2013

NA 7/26/2013

7/15/2013 7/26/2013

NA 7/26/2013

7/1/2013 7/26/2013

3/2011 8/1/2013

NA 8/1/2013

1/22/2013 7/26/2013

8/9/2010 7/25/2013

6/5/2013 8/9/2013

3/16/2011 7/26/2013

NA 8/1/2013

NA 8/1/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Maryland


CategoryAdjustments


Fee Schedule Basis






Children vs. Adults

Out-of-State






Health Home

Primary Care




States' Medicaid Fee-for-Service Physician Payment Policies - Maryland


Maryland

Providers are paid either the lesser of their charge or the maximum allowable fee.

Physicians Fee Schedule

None Found



Reimbursement rates are based on a percent of Medicare, however, Maryland does not peg rates to Medicare rates. Old codes use the standard rates, new codes are based on 79.9% of Medicare rates. Only time raised or lower based on legislative action.

(A) CNPS: The Department shall pay for applicable covered services the lower of the provider's customary fees or the maximum rates according to COMAR 10.09.02.07.

(B) Nurse Midwives: The Department will pay for applicable covered services the lower of the provider's amount billed to the Program or the maximum rates according to COMAR 10.09.02.07.

None Found

None Found

Facility and non-facility pricing in fee schedule

None Found

None Found

None Found



None Found

None Found

None Found

Maryland and other states will increase rates to 100% of the Medicare rates for eligible primary care services delivered by eligible primary care providers between January 1, 2013 and December 31, 2014. The increased rate is applicable to previously covered Evaluation and Management (E&M) codes 99201-99499 and Vaccine for Children (VFC) administration codes, billed using the –SE modifier. Maryland is handling the Medicaid payment increase for these important primary care services differently from every other state. The rates in Maryland apply to most Medicaid providers who bill for these services, including specialists and nurse practitioners. As always, Medicaid pays the lesser of the provider's usual and customary charge or the Physicians' Fee Schedule. Providers who submit specialty mental health claims through Value Options are excluded from the fee increase.

None Found



NA

Staff at Maryland Medicaid Office NA % of Medicare

NA NF

NA Yes

NA NF


Summary Data

Maryland Medical Assistance Program, Physicians' Services Provider Fee Manual, COMAR 10.09.02, Page 2-7: https://mmcp.dhmh.maryland.gov/docs/Phys-svcs-prov-fee-man_2013.pdf


(A) COMAR 10.09.01.06(D): http://www.dsd.state.md.us/comar/getfile.aspx?file=10.09.01.06.htm

(B) COMAR 10.09.21.07(D): http://www.dsd.state.md.us/comar/getfile.aspx?file=10.09.21.07.htm

MD DHMH. 2013 Physician Fee Schedule: https://mmcp.dhmh.maryland.gov/SitePages/Provider%20Information.aspx


NA NF

NA NF

NA Yes

NA NF

NA NF

NA NF


COMAR Title 10: http://www.dsd.state.md.us/comar/searchall.aspx



COMAR 10.09.23.08: http://www.dsd.state.md.us/comar/getfile.aspx?file=10.09.23.08.htm


MD DHMH. 2013 Physicians Services Provider Fee Manual: https://mmcp.dhmh.maryland.gov/SitePages/Provider%20Information.aspx


MD DHMH. 2013 Physicians Services Provider Fee Manual: https://mmcp.dhmh.maryland.gov/SitePages/Provider%20Information.aspx


NA NF

NA No

NA NF

NA Yes

NA NF

NA NF






Maryland Department of Health and Mental Hygiene. PCP Fee Increase: https://mmcp.dhmh.maryland.gov/SitePages/PCPFeeIncrease.aspx





NA NF




8/1/2013

NA 8/22/2013

Not Listed 8/1/2013

4/1/2013 7/19/2013

NA 7/19/2013


Documentation Date

Date Last Searched

1/1/2013

NA 7/19/2013

NA 7/19/2013

4/1/2013 7/19/2013

NA 7/19/2013

NA 7/19/2013

NA 7/19/2013

NA 7/19/2013

NA 7/19/2013

NA 7/19/2013

NA 8/1/2013

NA 7/19/2013

NA 8/23/2013

NA 8/23/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Massachusetts


CategoryAdjustments


Fee Schedule Basis






Children vs. Adults

Out-of-State






Health Home

Primary Care


States' Medicaid Fee-for-Service Physician Payment Policies - Massachusetts


Massachusetts

Global fee schedule

None Found



Rates of payment to which 101 CMR 317.00 applies shall be the lowest of:(a)The eligible provider's usual fee to patients other than publicly-aided; or(b)The eligible provider's actual charge submitted; or(c)The schedule of allowable fees set forth in 101 CMR 317.04(4) in accordance with 101 CMR 317.03; or(d)The current Medicare Outpatient Prospective Payment System (OPPS) cap payment amounts, if applicable.

Regulations 114.3 CMR 16.00, 17.00 and 18.00 govern the rates of payment used by governmental units for physician surgery and anesthesia care, office visits and other general medicine, and radiology services rendered to publicly aided individuals by eligible providers, including physicians and mid-level practitioners (nurse practitioners and physician assistants). These regulations consist of a fee schedule based on the Medicare resource based relative value scale (RBRVS). Most of the 9,000 rates are derived by applying one of the four conversion factors (CF) used as a standard dollar value to convert Medicare assigned relative value units (RVUs) into a rate for each procedure code.

Allowable Mid-level Fee for Qualified Mid-Level Practitioners. Payment for services provided by eligible licensed nurse practitioners, eligible licensed nurse midwives, eligible licensed physician assistants, eligible registered nurses, eligible tobacco cessation counselors, eligible pharmacies which utilize pharmacists or other health care professionals certified in accordance with Massachusetts Department of Public Health regulations at 105 CMR 700.000: Implementation of M.G.L. c. 94C, and eligible home health agencies as specified in 101 CMR317.02 is 85% of the fees contained in 101 CMR 317.04(4).

None Found

None Found

None Found

Payments for certain services that can be routinely furnished in physicians' offices are reduced when such services are furnished in facility settings. 101 CMR 317.04 establishes facility setting fees applied to services rendered in a facility when a practice site differential is warranted.

Facility and non-facility pricing in fee schedule.

The MassHealth agency pays for all medically necessary physician services for EPSDT-eligible members in accordance with 130 CMR 450.140 et seq., without regard to service limitations described in 130 CMR 433.000, and with prior authorization.

Except as provided in 130 CMR 450.233(D), payment to an out-of-state noninstitutional provider for any medical service payable under MassHealth is made in accordance with the applicable fee schedule established by DHCFP or the MassHealth agency, subject to any applicable federal payment limit (see 42 CFR 447.304).



None Found

For calendar years 2013 and 2014, Section 1202 of the federal Affordable Care Act requires Medicaid agencies to provide payment for certain primary care services delivered by eligible physicians, consistent with federal rules set forth in 42 CFR Part 447, Subpart G and 101 CMR 317.

Services provided by nonphysician practitioners, such as physician assistants, nurse practitioners, and nurse midwives, are eligible for payment of 85% of the Section 1202 rates,

(A) The Prospective Interim Payment (PIP)is an optional monthly cash advance for physicians, nurse practitioners, group practices, and community health centers that are Primary Clinician (PCC) Plan providers. This payment is a monthly advance equal to 25% of the monthly average of the previous quarter’s actual paid claims, including enhancements, for services provided to your PCC Plan members.

(B) Primary Care Clinicians (PCCs) receive an enhanced rate for certain types of primary and preventive care visits provided to PCC Plan members enrolled with the PCC on the date of service. Ten dollars is added to the rate for the procedure code billed. The MassHealth agency pays PCCs an enhanced fee for delivering primary care services in accordance with the terms of the PCC provider contract.

(C) (2) PCC Plan Pay for Performance (P4P) Incentive Payments. Subject to MassHealth's determination of the availability of funds, PCCs receive incentive payments through the PCC Plan Pay for Performance (P4P) Program as described in MassHealth regulation at 130 CMR 450.118 and as follows:(a) Practice Infrastructure Survey. The MassHealth agency pays PCCs a $2,000 Practice Infrastructure incentive payment. The MassHealth agency pays PCCs for each of their Service Locations that returns a completed Practice Infrastructure Survey within the time specified by the MassHealth agency.Payment Eligibility. To be eligible for a payment for the Practice Infrastructure Survey, a PCC must be enrolled as a MassHealth PCC as of a certain date, the date to be established by MassHealth agency on an annual basis.

2) Supplemental Payment. (a) Eligibility. An eligible provider may receive a supplemental payment for services to publicly aided individuals eligible under Titles XIX and XXI of the Social Security Act if the following conditions are met: 1. the eligible provider is employed by a non-profit group practice that was established in accordance with St. 1997, c.163 and is affiliated with a Commonwealth-owned medical school; 2. such non-profit group practice shall have been established on or before January 1, 2000 in order to support the purposes of a teaching hospital affiliated with and appurtenant to a Commonwealth-owned medical school; and 3. the services are provided at a teaching hospital affiliated with and appurtenant to a Commonwealth-owned medical school. (b) Payment Method. This supplemental payment may not exceed the difference between: 1. payments to the eligible provider made pursuant to the rates applicable under 101 CMR 317.03(1), and 2. the Federal upper payment limit set forth in 42 CFR 447.325: Other Inpatient and Outpatient Facility Services: Upper Limits Of Payment.

None Found



NA

NA RBRVS

NA 85%

NA Yes

NA NF


Summary Data

Code of MA Regulation (CMR) 101 CMR 317.03(1): http://www.lawlib.state.ma.us/source/mass/cmr/cmrtext/101CMR317.pdf


Staff at Massachusetts Medicaid Office


Code of MA Regulation (CMR) 101 CMR 317.04: Maximum Allowable Fees (4): http://www.lawlib.state.ma.us/source/mass/cmr/cmrtext/101CMR317.pdf

101 CMR 317: http://www.lawlib.state.ma.us/source/mass/cmr/cmrtext/101CMR317.pdf

NA NF

NA NF

NA Yes

NA NF

NA In-State

NA NF



130 CMR 433.000: http://www.mass.gov/eohhs/docs/masshealth/regs-provider/regs-physician.pdf

Code of MA Regulation 101 CMR 317.03(3) and 317.04(4): http://www.lawlib.state.ma.us/source/mass/cmr/cmrtext/101CMR317.pdf

MA MassHealth Provider Manual 130 CMR 450.433.412(Page2-21): http://www.mass.gov/eohhs/docs/masshealth/regs-provider/regs-allprovider.pdf

MA MassHealth Provider Manual 130 CMR 450.233(C)(Page 4-13): http://www.mass.gov/eohhs/docs/masshealth/regs-provider/regs-allprovider.pdf

Code of MA Regulation 130 CMR 450.130: Copayments Required by the MassHealth Agency:http://www.lawlib.state.ma.us/source/mass/cmr/cmrtext/130CMR450.pdf

NA NF

NA No

NA NF

NA Yes

(A) Massachusetts PCC Plan FAQ: http://www.mass.gov/eohhs/docs/masshealth/provider-services/pip-qa.pdf

(B) Code of MA Regulation (CMR 101 CMR 317.03(9): http://www.lawlib.state.ma.us/source/mass/cmr/cmrtext/101CMR317.pdf

(C) Code of MA Regulation (CMR) 114 CMR 53.03(2a): http://www.lawlib.state.ma.us/source/mass/cmr/cmrtext/114.3CMR53.pdf


Code of MA Regulation (CMR) 101 CMR 317: http://www.lawlib.state.ma.us/source/mass/cmr/cmrtext/101CMR317.pdf 114 CMR -Division of Health Care Finance & Policy: http://www.lawlib.state.ma.us/source/mass/cmr/114cmr.html130 CMR 433.000: http://www.mass.gov/eohhs/docs/masshealth/regs-provider/regs-physician.pdf

MassHealth All provider Bulletin 235, Section 1202 Rats for Physicians Who Provide Primary Care Services: http://www.mass.gov/eohhs/docs/masshealth/bull-2013/all-235.pdf

NA Yes

NA Yes





NA NF





NA 7/19/2013

NA 8/14/2013

NA 7/19/2013

NA 7/19/2013

NA 7/19/2013


Documentation Date

Date Last Searched

NA 7/19/2013

NA 7/19/2013

NA 7/19/2013

12/26/2008 8/2/2013

6/20/2013 8/2/2013

6/20/2013 7/19/2013

NA 7/19/2013

NA 7/19/2013

NA 8/2/2013

8/2013 7/19/2013

7/19/2013


(A) 11/1/2009(B)(C) Not Listed

NA 8/12/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Michigan


CategoryAdjustments


Fee Schedule Basis





Children vs. Adults





Out-of-State



Health Home


Primary Care



States' Medicaid Fee-for-Service Physician Payment Policies - Michigan


Michigan

Nurse Practitioners – Up to 100% of fee schedule except assistant at surgery at 85% of fee schedule

Global Fee Schedule



For beneficiaries with no Medicare or commercial insurance coverage, providers are reimbursed the lesser of: • the Medicaid fee screen minus any applicable Medicaid co-payment, patient pay, or spend-down amounts. • the provider's usual and customary charge minus any applicable Medicaid copayment, patient pay, or spend-down amounts. For beneficiaries with Medicare and/or commercial insurance coverage, providers are reimbursed the lesser of: • the Medicaid beneficiary's liability for Medicare/commercial insurance coinsurance, co-payments, and/or deductibles minus any applicable Medicaid co-payment, patient pay, or spend-down amounts. • the Medicaid fee screen minus any third party payments, contractual adjustments, and any applicable Medicaid co-payment, patient pay, or spend-down amounts. • the provider's usual and customary charge minus any third party payments, contractual adjustments, and any applicable Medicaid co-payment, patient pay, or spend-down amounts.

Payment rates are established by the Medical Services Administration as a fee screen for each procedure. The fee schedule is designed to enlist the participation of an adequate number of providers. The Medicare prevailing fees, the Resource Based Relative Value Scale (RBRVS) and other relative value information, other state Medicaid fee screens, and providers' charges may be utilized as guidelines or reference in determining the maximum fee screens for individual procedures.

CNMW Fee Schedule


None Found

None Found

Medicaid reduces payment for specified procedures provided in a facility setting. This policy is consistent with the Centers for Medicare & Medicaid Services (CMS) facility and nonfacility reimbursement determination. When a provider performs services in a facility setting, costs for certain procedures are reduced because the practitioner does not incur certain overhead expenses (such as clinical staff, supplies, equipment) necessary to provide the service. When a service is performed in a nonfacility setting, the payment rate is based on the nonfacility relative value units (RVUs). When the service is provided in a facility setting, the payment rate is based on the facility RVUs. The payment difference takes into account the higher expenses for the provider in the nonfacility setting.



None Found

Reimbursement for services rendered to beneficiaries is normally limited to Medicaid-enrolled providers.MDCH reimburses out of state providers who are beyond the borderland area (defined below) if the service meets one of the following criteria:- Emergency services as defined by the federal Emergency Medical Treatment and Active Labor Act (EMTALA) and the Balanced Budget Act of 1997 and its regulations; or- Medicare and/or private insurance has paid a portion of the service and the provider is billing MDCH for the coinsurance and/or deductible amounts; or- The service is prior authorized by MDCH. MDCH will only prior authorize non-emergency services to out of state/beyond borderland providers if the service is not available within the state of Michigan and borderland areas.

A copayment of $2 may be required for physician office (evaluation and management) visits forbeneficiaries age 21 years and older.

Payment Adjustments for Children with Special Health Care Needs Approved Specialty Physicians.Effective April 1, 2009, the payment adjustment method determined by the Medical Services Administration is the lesser of:• The difference between the fee-for-service (FFS) Medicaid fee screens and the average commercial rate.• The difference between the FFS Medicaid fee screens and the physician’s customary charge.

None Found

(A) For providers identified as eligible for the rate increase, payment will be made on the qualified procedure codes at the Medicare Physician Fee Schedule (MPFS) rates for CYs 2013 and 2014 or, if higher, the rate that will be applicable using the CY 2009 Medicare conversion factor. MDCH will apply the Medicare site of service (Facility vs. Non-Facility) differential and the Medicare geographic adjustment. MDCH will also apply Medicare’s two-tiered rates for locality 01 and locality 99 as defined by Medicare. Payment for the locality differential for services paid under this incentive will be determined by using the validated 9-digit ZIP code on the claim for where the service was performed. MDCH will provide a separate fee schedule database for the two-year rate increase which will be located on the MDCH website.

(B) Physician Primary Care Rate Increase Initiative Database

A) Payment adjustments will be made for practitioner services provided through the following public entities:• University of Michigan Health System, • Wayne State University,• Hurley Hospital, • Michigan State University,• Oakland University,• Western Michigan University,• Central Michigan UniversityAdjustments apply to both public and private practitioners and practitioner groups. Practitioners and practitioner groups are either employees of the public entity or are under a contract with the public entity.

The payment adjustment will be the lesser of: • The difference between 95.7% of the average commercial rate for services provided on or after January 17, 2010. • The difference between the practitioner FFS Medicaid fee screens and the practitioner's customary charge.

None Found



NA

NA

NA Up to 100%

NA Yes


Summary Data

Michigan State Plan Attachment 4.19B, Page 1 (Sheet 738 from 952):http://www.mdch.state.mi.us/dch-medicaid/manuals/MichiganStatePlan/MichiganStatePlan.pdf





Practitioner and Medical Clinic Database: http://www.michigan.gov/documents/mdch/Practitioner-072013_426620_7.pdf

NA Yes

NA Yes

NA NF

NA Yes

NA NF

CNMW Fee Schedule: http://www.michigan.gov/documents/mdch/CertNurse-012013_409361_7.pdf

Michigan Fee Schedules: http://www.michigan.gov/mdch/0,1607,7-132-2945_42542_42543_42546_42551-151022--,00.html

Michigan Medicaid Website:http://www.michigan.gov/mdch/0,1607,7-132-2945_42542_42543_42546_42551-151022--,00.htmlMichigan Provider Manual:http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdfMichigan State Plan Attachment 4.19B:http://www.mdch.state.mi.us/dch-medicaid/manuals/MichiganStatePlan/MichiganStatePlan.pdfAdditional Key terms in Google

Michigan Provider Manual - Practitioner, Section 1, 1.4 Facility and Nonfacility Reimbursement:http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf


NA In-State

NA $2

NA

NA No

NA NF

Michigan Provider Manual (Sheets 24 &25 from 1756):http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf

Michigan Provider Manual - Practitioner, Section 1.3 Copayments, Page 2:http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf

Michigan State Plan Attachment 4.19B, page 1b.1 (Sheet 743 from 952):http://www.mdch.state.mi.us/dch-medicaid/manuals/MichiganStatePlan/MichiganStatePlan.pdf

Children with Special Health Care Needs



NA Yes`

NA NF

NA Yes

(A) Michigan Provider Manual - Practitioner, Section 3, 3.3 Enhanced Rates for Primary Care, Page A3 (Sheets 1441 & 1442 from 1756):http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf

(B)Physician Primary Care Rate Increase Initiative Database (1/1/2013): http://www.michigan.gov/documents/mdch/Phys_PC_Increase-012013_410620_7.pdf


Michigan State Plan Attachment 4.19B, page 1a-1b (Sheet 741 from 952): http://www.mdch.state.mi.us/dch-medicaid/manuals/MichiganStatePlan/MichiganStatePlan.pdf

NA NF



8/8/2011 8/8/2013

8/8/2011 8/8/2013

8/8/2011 7/18/2013

7/1/2013 7/18/2013


Documentation Date

Date Last Searched

1/1/2013 7/18/2013

1/1/2013 8/8/2013

NA 7/18/2013

7/1/2013 8/8/2013

NA 7/18/2013

7/1/2013 8/8/2013

7/1/2013 7/18/2013

8/16/2013

NA 8/8/2013

NA 7/18/2013

3/15/2010

8/8/2013

NA 8/8/2013

8/16/2011 8/16/2013

(A) 7/1/2013(B) 1/2013

NA 8/8/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Minnesota


CategoryAdjustments


Fee Schedule Basis



Children vs. Adults

Out-of-State



Health Home



Primary Care



States' Medicaid Fee-for-Service Physician Payment Policies - Minnesota


Minnesota



Effective for physician/clinic services rendered on or after October 1, 1992, the payment rate is follows:Payment for level I HCPCS codes titled: "Office or other outpatient Services", "Preventive Medicine Services (new patient and established patient)", "Delivery, Antepartum, and Postpartum Care", "Cesarean Delivery", "Critical Care Services", “Pharmacological Management” provided to psychiatric patients, and HCPCS level III codes for enhanced services for prenatal at risk, will be paid at the lower of the:• Provider's submitted charge• 25% above the rate in effect on June 30, 1992If the rate on any procedure code within these categories is different than the rate that would have been paid under the methodology in MS 256B.74, subd. 2, then the larger rate shall be paid. All physician rates (except anesthesia, laboratory, medical supplies and equipment, orthotics and prosthetics, injections and immunizations) shall be converted from the 50th percentile of 1982 to the 50th percentile of 1989, less the percent in aggregate necessary to equal the above increases. Payments for all other services (except anesthesia, laboratory, medical supplies and equipment, orthotics and prosthetics, and injections and immunizations) shall be paid at the lower of the following:• Provider’s submitted charge• 5.4% above the rate in effect on June 30, 1992

Reimbursement rates is based on the Medicare Relative Value (RVU) adjusted by Geographic Practice Cost Indices (GPCI) times a state conversion factor.

Minnesota Health Care Programs Fee Schedule

None Found

None Found

All geographic regions within the state are subject to the same maximum reimbursement rate.

Services provided by a physician assistant (PA). advanced practice registered nurse (APRN), clinical nurse specialist (CNS) shall be paid to the supervising enrolled provider at the lower of the following:• Provider's submitted charge• 90% of the allowableServices provided by non-psychiatric physician extenders shall be paid to the supervising enrolled provider at the lower of the following:• Provider's submitted charge• 65% of the reference file allowable


None Found



MHCP covers services provided by an out-of-state provider to MHCP recipients who are outside of Minnesota or their local trade area under certain circumstances. To receive MHCP payment for services to MHCP recipients, eligible providers, including out-of-state providers, must enroll.

$3 copay for nonpreventive visits.With exceptions

Rates paid for anesthesiology services provided by physicians shall be according to the formula utilized in the Medicare program and shall use a conversion factor "at percentile of calendar year set by legislature, "except that rates paid to physicians for the medical direction of a certified registered nurse anesthetist shall be the same as the rate paid to the certified registered nurse anesthetist under medical direction.

In 2008, MHCP implemented a Pay for Performance (P4P) program for MHCP fee-for-service (FFS) providers. The program awards $250 up to two times every 12 months when physicians or advance practice registered nurses (APRNs) render optimal chronic disease care to their qualifying MHCP recipients with cardiovascular disease or diabetes or both. MHCP will use a combination of four clinical results for cardiovascular disease and five treatment measures for diabetes to determine if the provider is eligible for a results payment.

None Found

None Found

MHCP will reimburse the lesser of the following:• The provider’s submitted charge• The amount based on the appropriate enhanced rate method identified below

Enhanced rates for eligible Primary Care services will be determined as the higher of the following:• Medicare Physician Fee Schedule (MPFS) rate in effect for the calendar year (CY) in which the service was performed• Applicable rate using the Relative Value Unit (RVU) for the CY in which the service was performed, multiplied by CY 2009 MPFS conversion factor.

With exceptions

None Found



NA

Staff at Minnesota Medicaid Office NA RBRVS


Summary Data

MN Provider Manual, Billing Policy, Payment Methodology - Nonhospital:http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_146898#

Lesser of charges or % of rate

NA

NA Yes

NA NF

NA NF

NA No

MN Provider Manual- Physicians and Professional Services: http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=id_008926#P549_40137MN Provider Manual, Billing Policy, Payment Methodology - Nonhospital:http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_146898#


MN Fee Schedule:http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_FILE&RevisionSelectionMethod=LatestReleased&Rendition=Primary&allowInterrupt=1&noSaveAs=1&dDocName=dhs_id_017675

Fee Schedule:http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_FILE&RevisionSelectionMethod=LatestReleased&Rendition=Primary&allowInterrupt=1&noSaveAs=1&dDocName=dhs_id_017675

Fee Schedule:http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_FILE&RevisionSelectionMethod=LatestReleased&Rendition=Primary&allowInterrupt=1&noSaveAs=1&dDocName=dhs_id_017675

MN House of Representatives Information Brief, Page 19: http://www.house.leg.state.mn.us/hrd/pubs/medastib.pdf

NA Yes

NA NF

NA In-State

NA $3

NA Anesthesia

NA No

NA Yes

MN Fee Schedule:http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_FILE&RevisionSelectionMethod=LatestReleased&Rendition=Primary&allowInterrupt=1&noSaveAs=1&dDocName=dhs_id_017675

MN C&TC Provider Guide https://edocs.dhs.state.mn.us/lfserver/Public/DHS-4212-ENG

MN Provider Manual - Physicians and Professional Services, Out of State Providers http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_146899

Summary of MN coverage, cost sharing and limits:https://edocs.dhs.state.mn.us/lfserver/public/DHS-3860-ENG

2012 MN Statue 256B.0625 Covered Services:Subd. 3.Physicians' services: https://www.revisor.mn.gov/statutes/?id=256B.0625&year=2012


MN Dept. of Human Services Pay for Performance: http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_142133#

NA Yes

NA NF

NA NF

MN -Payment for PCP & VFC Programhttp://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_174018#P73_5581



NA NF



8/6/2013 8/16/2013

NA 8/26/2013


Documentation Date

Date Last Searched

8/6/2013 8/16/2013

7/15/2013 7/23/2013

NA 7/23/2013

NA 7/23/2013

NA 8/27/2013

7/15/2013 7/23/2013

NA 7/23/2013

12/6/2012 7/23/2013

1/1/2013 7/23/2013

1/1/2012 7/23/2013

NA 7/23/2013

5/10/2013 7/23/2013

3/13/2013 7/23/2013

NA 7/23/2013

NA 7/23/2013

NA 7/23/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Mississippi


CategoryAdjustments


Fee Schedule Basis




Children vs. Adults

Out-of-State








Health Home

Primary Care



States' Medicaid Fee-for-Service Physician Payment Policies - Mississippi


Mississippi



Rule 1.2: Physician FeesEffective for dates of services on and after June 1, 2005, and as authorized in House Bill 1104 during the 2005 Legislative Session, Medicaid covers physicians’ services at ninety percent (90%) of the rate established on January 1, 1999 and as may be adjusted each July thereafter, under Medicare (Title XVIII of the federal Social Security Act, as amended).

All fees for physicians' services that are covered only by Medicaid shall be reimbursed at ninety percent (90%) of the rate established on January 1, 1999, and as adjusted each January thereafter, under Medicare (Title XVIII of the Social Security Act, as amended), and which shall in no event be less than seventy percent (70%) of the rate established on January 1, 1994. All fees for physicians' services that are covered by both Medicare and Medicaid shall be reimbursed at ten percent (10%) of the adjusted Medicare payment established on January 1, 1999, and as adjusted each January thereafter, under Medicare (Title XVIII of the Social Security Act, as amended), and which shall in no event be less than seventy percent (70%) of the adjusted Medicare payment established on January 1, 1994.

(A) Medicaid reimbursement for nurse practitioners or physician assistants is ninety percent (90%) of the amount allowed by physicians for procedures.(B) The reimbursement for certified nurse midwifery services shall not exceed ninety percent (90%) of the reimbursement rate for comparable services rendered by a physician.


None Found

Anesthesia

None Found

None Found

EPSDT Pricing in Fee Schedule

None Found

Physician: $3.00 per visit.



None Found

Increased Primary Care Provider Fee Schedule

None Found

None Found

None Found



NA 90% of Medicare

NA % of Medicare

NA 90%


Summary Data

Miss. Code Ann. § 43-13-121: 43-13-117 in MS Medicaid Admin Code Manual, Title 23, Part 203, Chapter 1, Page 1:http://www.medicaid.ms.gov/Manuals/Title_23_Part_203_Physician_Services_Eff04012013.pdf

Miss. Code Ann. § 43-13-117, 6. Physician Services: http://www.mscode.com/free/statutes/43/013/0117.htm

(A) Miss. Code Ann. § 43-13-121 in MS Medicaid Admin Code Manual, Title 23, Part 203, Chapter 8, Rule 8.2, Pages 46 and Chapter 7, Rule 7.2, Page 45:http://www.medicaid.ms.gov/Manuals/Title_23_Part_203_Physician_Services_Eff04012013.pdf(B) MS State Plan, Attachment 4.19-B, Page 17:http://www.medicaid.ms.gov/MsStatePlan/Attachment_4.19B.pdf

NA Yes

NA NF

NA Yes

NA NF

NA NF

NA Yes

NA NF

NA $3

MS Fee Schedule:https://msmedicaid.acs-inc.com/FeeSchedule.csv

MS Fee Schedule Main Page: http://www.medicaid.ms.gov/FeeScheduleLists.aspx

MS Fee Schedule Main Page: http://www.medicaid.ms.gov/FeeScheduleLists.aspx

MS Provider Manual:http://www.medicaid.ms.gov/Manuals/Title_23_Part_203_Physician_Services_Eff04012013.pdfMS State Plan:http://www.medicaid.ms.gov/MsStatePlan/Attachment_4.19B.pdfAdditional Key Search Terms in Google


MS Fee Schedule:https://msmedicaid.acs-inc.com/FeeSchedule.csv


What MS Medicaid Can Do For You:http://www.medicaid.ms.gov/Pamphlets/WhatMississippiMedicaidCanDoForYou.pdf

NA NF

NA No

NA NF

NA Yes

NA NF




MS Fee Schedule: http://www.medicaid.ms.gov/FeeScheduleLists.aspx


NA NF

NA NF




4/1/2013 8/2/2013

4/21/2003 8/13/2013

8/13/2013


Documentation Date

Date Last Searched

(A) 4/1/2013(B) 6/10/2002

8/2/2013 7/18/2013

NA 7/18/2013

7/1/2013 7/18/2013

NA 7/18/2013

NA 7/18/2013

8/2/2013 8/13/2013

NA 7/18/2013

11/1/2012 8/3/2013

NA 8/3/2012

NA 8/2/2013

NA 7/18/2013

7/1/2009 7/18/2013

NA 8/2/2013

NA 8/2/2103

NA 8/2/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Missouri


CategoryAdjustments


Fee Schedule Basis








Children vs. Adults

Out-of-State



Health Home


Primary Care





States' Medicaid Fee-for-Service Physician Payment Policies - Missouri


Missouri

None Found

None Found

No



12.2 Physician services - Reimbursement for physician services is made on a fee-for-service basis. The maximum allowable fee for a unit of service has been determined by the MO HealthNet Agency to be a reasonable fee, consistent with efficiency, economy, and quality of care. Payment for covered services is the lower of the provider’s actual billed charge (should be the provider’s usual and customary charge to the general public for the service), or the maximum allowable per unit of service.In general, MO HealthNet reimburses physicians in fee-for-service at the rate of 62.5% of the Missouri Medicare fee schedule Locality 01 for newly added procedure codes. Prior to 2007, it was 50%, in 2007 it was 55% and 2008 forward it was 62.5%.

Medical Services Fee ScheduleEPSDT Other Services Fee Schedule

Medical Services Fee Schedule (Includes ANP and Physicians)Other Medical Fee Schedule (Includes ANP)Nurse/Midwife Fee Schedule

None Found


EPSDT Other Services Fee ScheduleEPSDT Pricing in Fee Schedule

The out-of-state medical provider must agree to complete an enrollment application and accept MO HealthNet reimbursement.

Unless an exemption applies, each provider providing treatment for each date of service on which the participant receives services shall charge the following copayments: Physician, MD or DO $1.00 ; Nurse Practitioner $1.00

(A) Community Mental Health Center Health Home: Total PMPM Payment = $78.74(B) Primary Care Health Home: Total PMPM Payment = $58.87

None Found

None Found

None Found

None Found

The MO HealthNet Division’s (MHD) reimbursement rates for the identified services will be the lower of the provider’s usual and customary charges to the general public or MHD’s allowable amount based upon Medicare Part B rates for office site of service using the mean value over all counties.



NA

Staff at MO Medicaid Office NA % of Medicare

NA NF

NA Yes

NA Yes

NA NF

Staff at MO Medicaid Office NA No


Summary Data

MO Physician Provider Manual, Section 12.2:http://manuals.momed.com/collections/collection_phy/Physician_Section12.pdf


MO Medicaid Physician and Nurse Midwife Provider Manuals: http://manuals.momed.com/manuals/ MO Medicaid Fee Schedules: https://dssapp3.dss.mo.gov/FeeSchedules/dlfiles/MedSrvcs.doc

MO Fee Schedules:https://dssapp3.dss.mo.gov/FeeSchedules/maindisclaimer.shtml MO Fee Schedules:https://dssapp3.dss.mo.gov/FeeSchedules/maindisclaimer.shtml

MO Medicaid Fee Schedules and Price Key: https://dssapp3.dss.mo.gov/FeeSchedules/dlfiles/MedSrvcs.doc

NA NF

NA Yes

NA In-State

NA $1

NA NF

NA Yes

MO Medicaid Physician and Nurse Midwife Provider Manuals: http://manuals.momed.com/manuals/ MO Medicaid Fee Schedules: https://dssapp3.dss.mo.gov/FeeSchedules/dlfiles/MedSrvcs.doc Additional search of key terms in Google

MO Fee Schedules:https://dssapp3.dss.mo.gov/FeeSchedules/maindisclaimer.shtml

Physician Provider Manual: § 8.10 and 13.25, Page 35: http://manuals.momed.com/collections/collection_phy/Physician_Section13.pdf

Physician Provider Manual: § 13.16.B: http://manuals.momed.com/collections/collection_phy/Physician_Section13.pdf


(A) MO Community Mental Health Center Health Home State Plan Amendment:http://www.chcs.org/usr_doc/Missouri_Health_Home_SPA_Approved_on_10-20-2011.pdf(B) MO Primary Care Practice Health Home (PCP-HH) Clinic - State Plan Amendment:http://www.chcs.org/usr_doc/MO_11-15_APPROVED.pdf

NA NF

NA Yes

NA NF

NA NF

NA NF


Provider Bulletin: Physician Primary Care Rate Increase For Certain Services. 35(31): http://dss.mo.gov/mhd/providers/pdf/bulletin35-31_2013may07.pdf





3/14/2013 6/24/2013

9/9/2013 9/9/2013

NA 7/11/2013

4/11/2013 6/24/2013

4/11/2013 7/11/2013

NA 7/11/2013

NA 9/9/2013


Documentation Date

Date Last Searched

NA 7/11/2013

NA 7/11/2013

4/15/2013 6/24/2013

4/15/2013 6/24/2013

NA 6/24/2013

7/19/2013(A) 10/20/2011(B) 12/22/2011

NA 7/11/2013

5/10/2013 6/24/2013

NA 7/11/2013

NA 7/19/2013

NA 7/19/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Montana


CategoryAdjustments


Fee Schedule Basis




Children vs. Adults

Out-of-State








Health Home

Primary Care




States' Medicaid Fee-for-Service Physician Payment Policies - Montana


Montana



When Medicaid payment differs from the fee schedule, The Department pays the lower of the established Medicaid fee or the provider’s charge.

Most services by provider types covered in this manual are reimbursed for using the Department’s RBRVS fee schedule. RBRVS stands for Resource-Based Relative Value Scale. The fee schedule includes several thousand CPT codes and HCPCS Level II codes. Within the CPT coding structure, only anesthesia services (00100–01999) and clinical lab services (almost the entire 80000–89999 range) are not reimbursed for using the RBRVS fee schedule. Each fee is the product of a relative value times a conversion factor. When Medicaid payment differs from the fee schedule, The Department pays the lower of the established Medicaid fee or the provider’s charge.

For almost all services, Medicaid uses the same relative values as Medicare in Montana. Nationally, Medicare adjusts the relative values for differences in practice costs between localities, but Montana is considered a single locality. For fewer than 1% of codes, relative values are not available from Medicare. For these codes, the Department has set the relative values.

APRNs and PAs: In general, mid-level practitioners receive 90% of the fee that a physician would receive for the same service.

Mid-level practitioners include physician assistants licensed to practice medicine by the Montana Board of Medical Examiners and advanced practice registered nurses licensed to practice medicine by the Montana Board of Nursing. Advanced practice registered nurses include nurse anesthetists, nurse practitioners, clinical nurse specialists, and certified nurse midwives. Mid-level practitioners also include practitioners outside Montana who hold appropriate licenses in their own states.

Mid-Level Practitioner Fee Schedule

Oral Surgeon, Psychiatrist, Psychologist

None Found


EPSDT Fee Schedule

None Found

(A) Physician Services Fee Schedule(B) EPSDT Fee Schedule

Client Cost Sharing (ARM 37.85.204 and 37.85.402)Provider Type AmountMid-level practitioner $4.00 per visitPhysician $4.00 per visitWith exceptions.



None Found

Primary Care Enhanced Fee Schedule

None Found

Passport to Health Primary Care Case Management(ARM 37.86.5101–5120)The client’s Passport provider is also referred to as the PCP. The Department actively recruits these providers. Passport providers receive a primary case management fee of $3.00 a month for each enrollee.

None Found



NA

NA RBRVS

NA 90%


Summary Data

MT Physician Manual, Section 10.1, Page 100: http://medicaidprovider.hhs.mt.gov/pdf/manuals/physician.pdf Lesser of charges

or max allowable

MT Physician Manual, Section 10.1, Page 100: http://medicaidprovider.hhs.mt.gov/pdf/manuals/physician.pdf

MT Physician Manual: Section 10.4: Page 103: http://medicaidprovider.hhs.mt.gov/pdf/manuals/physician.pdf

NA Yes

NA No

NA Yes

NA NF

NA Yes

NA Yes

NA NF

NA $4

MT Physician Fee Schedule: http://medicaidprovider.hhs.mt.gov/providerpages/providertype/providertype.shtml

MT Mid-Level Practitioner Fee Schedule: http://medicaidprovider.hhs.mt.gov/providerpages/providertype/providertype.shtml

MT Medicaid Fee Schedules: http://medicaidprovider.hhs.mt.gov/providerpages/providertype/providertype.shtml

MT Annotated Code: Title 53: Social Services and Institutions: Chapter 6: Health Care Services, Part 1: Medical Assistance: http://leg.mt.gov/bills/mca_toc/53_6_1.htmAdditional search of key terms in Google

MT Physician Fee Schedule: http://medicaidprovider.hhs.mt.gov/providerpages/providertype/providertype.shtml

MT Physician Manual: Section 10.4: Page 103 http://medicaidprovider.hhs.mt.gov/pdf/manuals/physician.pdf

MT Physician Manual: Section 2.3: Page 21: http://medicaidprovider.hhs.mt.gov/pdf/manuals/physician.pdfAdditional search of key terms in Google

MT Physician Manual, Section 7.3, Page 61: http://medicaidprovider.hhs.mt.gov/pdf/manuals/physician.pdf

NA NF

NA No

NA NF

NA Yes

NA Yes

NA NF

MT Physician Manual: http://medicaidprovider.hhs.mt.gov/pdf/manuals/physician.pdfMT Annotated Code: Title 53: Social Services and Institutions: Chapter 6: Health Care Services, Part 1: Medical Assistance: http://leg.mt.gov/bills/mca_toc/53_6_1.htm


MT Physician Manual: http://medicaidprovider.hhs.mt.gov/pdf/manuals/physician.pdf

PCP Enhanced Fee Schedule: http://medicaidprovider.hhs.mt.gov/pdf/enhanced%20payment/primarycareenhancedpaymentfs012013.pdf

MT Medicaid Provider Manual: Section 4: Pages 35 & 42: http://medicaidprovider.hhs.mt.gov/pdf/manuals/physician.pdf


NA NF



3/1/2013 7/15/2013

3/1/2012 8/8/2013

3/1/2012 7/15/2013


Documentation Date

Date Last Searched

8/19/2013

7/17/2013 8/19/2013

8/19/2013

NA 7/15/2013

7/1/2013 7/15/2013

7/1/2013 7/15/2013

NA 8/8/2013

5/1/2013 7/15/2013

(A) 8/9/2013(B) 7/8/2013

7/8/2013 or 7/17/2013

NA 8/8/2013

NA 7/15/2013

NA 7/15/2013

1/1/2013 7/15/2013

3/1/2012 7/15/2013

NA 8/8/2013

NA 8/8/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Nebraska


CategoryAdjustments

Basic Payment PolicyFee Schedule Basis








Children vs. Adults

Out-of-State



Health Home


Primary Care




States' Medicaid Fee-for-Service Physician Payment Policies - Nebraska


Nebraska

Based on Medicare RVUs times state conversion factor.


RN/LPN Fee Schedule

Anesthesiologist and CRNA Fee Schedule

None Found



For dates of service on or after August 1, 1989, NMAP pays for covered physicians' services at thelower of:1. The provider's submitted charge; or2. The allowable amount for that procedure code in the Nebraska Medicaid PractitionerFee Schedule in effect for that date of service.

Payment for nurse-midwife or nurse practitioner services is made at the lower of -1. The provider's submitted charge; or2. The Medicaid allowable amount for the procedure code billed.

Payment for CPNP or CFNP services is made at the lower of -1. The provider's submitted charge; or2. A percentage, determined by the Department, of the amount allowable under the Nebraska Medicaid Practitioner Fee Schedule if the service was provided by a physician.

$2 per Office Visit (MDs and DOs)



Physicians and non-physician care providers are subject to a site-of-service payment adjustment. A site-of-service differential that reduces the fee schedule amount for specific CPT/HCPCS codes will be applied when the service is provided in the facility setting. Based on the Medicare differential, NMAP will reimburse specific CPT/HCPCS codes with adjusted rates based on the site-of-service.

(A) For services reimbursed under the Nebraska Medicaid Practitioner Fee Schedule, NMAP paysfor EPSDT services (except for clinical diagnostic laboratory services) at the lower of:

1. The provider's submitted charge; or2. The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule for that date of service.

(B) EPSDT Pricing in Fee Schedule.

The Director of the Division of Medicaid and Long-Term Care or designee may enter into an agreement for a negotiated rate with an out-of-state provider which will be based on a percentage of billed charges, not to exceed 100%, only when the Medical Director of the Division has determined that:a. The client requires specialized services that are not available in Nebraska; andb. No other source of the specialized service can be found.

The Nebraska Medical Assistance Program calculates payment for Certified Registered Nurse Anesthetists (CRNA/AA) services as follows: The total of the units assigned to the CPT/ASA procedure plus the appropriate number of time units are multiplied by the appropriate conversion factor for medically directed or non-medically directed services. This amount must not exceed the amount allowable for physicians' services for the procedure. These services are paid according to the Nebraska Medicaid Practitioner Fee Schedule.

None Found

Effective January 1, 2013, certain physicians who provide eligible primary care services to Medicaid clients are eligible to be paid the Medicare rates in effect in calendar years (CY) 2013 and 2014 instead of their usual state-established Medicaid rates.

The State of Nebraska enrolls Medicaid beneficiaries on a mandatory basis into managed care entities (managed care organization (MCOs) and/or primary care case managers (PCCMs)) in the absence of section 1115 or section 1915(b) waiver authority. The payment method to the contracting entity will be fee for service, a case management fee and/or a bonus/incentive payment for the Enhanced PCCM. For states that pay a PCCM on a fee-for-service basis, incentive payments are permitted as an enhancement to the PCCM’s case management fee, if certain conditions are met.

Supplemental payments will be made for services provided by practitioners who are acting in the capacity of an employee or contractor of the University of Nebraska Medical Center or its affiliated medical practices; UNMC Physicians and Nebraska Pediatric Practice, Inc. These payments are made in addition to payments otherwise provided under the state plan to practitioners that qualify for such payments.For practitioners qualifying under this section, a supplemental payment will be made. The payment amount will be the difference between payments otherwise made to these practitioners and the average rate paid for the services by commercial insurers.

None Found



NAStaff at Nebraska Medicaid Office NA RBRVS

NA Up to 100%

NA Yes

NA Yes

NA Yes

NA NF


Summary Data

NE Medicaid State Plan Part 3: Attachment 4.19B: Item 5: Page 1:http://dhhs.ne.gov/medicaid/Documents/Part3.pdf


Nebraska HHS Finance and Support Manual, Title 471, Chapter 18, 18-004.42, 18-004.43, and 18-004.43A3:http://www.sos.state.ne.us/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-471/Chapter-18.pdf

NE Physician Fee Schedule:http://dhhs.ne.gov/medicaid/Documents/471-000-518-7-13.pdf

NE RN/LPN Fee Schedule: http://dhhs.ne.gov/medicaid/Documents/471-000-513-13.pdf

NE Anesthesia Fee Schedule: http://dhhs.ne.gov/medicaid/Documents/471-000-521-13.pdf

NE Medicaid State Plan Part 3: http://dhhs.ne.gov/medicaid/Pages/med_xixstateplan.aspx

NA Yes

NA Yes

NA Negotiated

NA $2

NA CRNA, AA

NA No

NE Medicaid State Plan Part 3: Attachment 4.19B: Item 5: Page 1:http://dhhs.ne.gov/medicaid/Documents/Part3.pdf

(A) NE Medicaid State Plan Part 3 Attachment 4.19B: Item 4b: Page 1:http://dhhs.ne.gov/medicaid/Documents/Part3.pdf(B) NE Medicaid Practitioner Fee Schedule for Physician Services:http://dhhs.ne.gov/Documents/471-000-518.pdf

NE Medicaid State Plan Part 3 Attachment 4.19B, Item 5, Page 1:http://dhhs.ne.gov/medicaid/Documents/Part3.pdf

NE Medicaid State Plan, Part 3, Attachment 4.18-A, Page 1:http://dhhs.ne.gov/medicaid/Documents/Part3.pdf

NE Medicaid State Plan Part 3: Attachment 4.19B: Item 6d: http://dhhs.ne.gov/medicaid/Documents/Part3.pdf


NA No

NA Yes

NA Yes

NA Yes

NE Medicaid State Plan Attachment 3.1-F: Page 2:https://www.statereforum.org/system/files/ne_medicaid_state_plan_-_att_3.1-f.pdf

NE Medicaid Provider Handbook: Chapters 1, 3, & 18: http://dhhs.ne.gov/medicaid/Pages/med_phphys.aspx

NE Rules and Regulations: Titles 471 and 482: http://dhhs.ne.gov/medicaid/Pages/med_regs.aspx

NE Enhanced PC Payments:http://dhhs.ne.gov/medicaid/Pages/Nebraska-Medicaid-Enhanced-Primary-Care-Payments.aspx

Nebraska State Plan, Attachment 3.1-F, Page 1-16:http://dhhs.ne.gov/medicaid/Documents/Part2.pdf

NE Medicaid State Plan Part 3: Attachment 4.19B, Item 5, Page 3:http://dhhs.ne.gov/medicaid/Documents/Part3.pdf

NA NF

NE Medicaid State Plan Attachment 3.1-F: Page 2:https://www.statereforum.org/system/files/ne_medicaid_state_plan_-_att_3.1-f.pdf

NE Medicaid Provider Handbook: Chapters 1, 3, & 18: http://dhhs.ne.gov/medicaid/Pages/med_phphys.aspx

NE Rules and Regulations: Titles 471 and 482: http://dhhs.ne.gov/medicaid/Pages/med_regs.aspx


3/6/2012 7/26/2013NA 8/13/2013

10/15/2003 8/13/2013

7/1/2013 7/26/2013

7/1/2013 7/26/2013

7/1/2013 7/26/2013

NA 7/26/2013


Documentation Date

Date Last Searched

3/6/2012 7/26/2013

7/26/2013

3/6/2012 7/26/2013

3/6/2012 7/26/2013

1/11/2013 7/26/2013

NA 7/26/2013

(A) 3/6/2012(B) 7/1/2013

NA 7/26/2013

12/14/2012 7/26/2013

1/27/2011 8/26/2013

8/25/2010 7/26/2013

8/25/2010 7/26/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Nevada


CategoryAdjustments


Fee Schedule Basis



Children vs. Adults

Out-of-State



Health Home

Primary Care





States' Medicaid Fee-for-Service Physician Payment Policies - Nevada


Nevada



Payment will be the lower of billed charges, or the amounts specified below:a. Surgical codes 10000 – 58999 and 60000 - 69999 will be reimbursed at 100% of the Medicare facility rate.b. Radiology codes 70000 – 79999 will be reimbursed at 100% of the Medicare facility rate. Effective February 15, 2012, Radiopharmaceutical and Contrast codes will be reimbursed at the 2012 Medicare Mean Unit Cost plus 5%.c. Medicine codes 90000 – 99199 and Evaluation and Management codes 99201 - 99499 will be reimbursed at 85% of the Medicare non-facility rate. Vaccine Products 90476 – 90749 will be reimbursed at 85% of the Medicare non-facility rate.d. Obstetrical service codes 59000 – 59999 will be reimbursed at 100% of the Medicare non facility rate.e. Anesthesia codes 00100 – 01999 will be reimbursed based on the Centers for Medicare and Medicaid Services (CMS) 2009 base units for anesthesia. Payment is determined by adding the base units plus time units and multiplying the result by the CMS 2009 anesthesia conversion factor of $21.12. Anesthesia codes 01967 – 01969 are occurrence based codes that are paid a flat rate. Anesthesia codes 99100 – 99140 are not covered.f. Medicine codes 90281-90399, and all other pharmaceuticals that are not identified above, will be reimbursed according to the drug reimbursement algorithm set forth on page 3 of Attachment 4.19-B.g. Increased Primary Care Services Payment 42 CFR 447.405, 447.410, 447.415.

Payments for services billed by Physicians using Current Procedural Terminology (CPT) codes will be calculated using the April 1, 2002 unit values for the Nevada-specific resource based relative value scale (RBRVS) and the 2002 Medicare Physician Fee Schedule conversion factor.

Provider Type 20 Physician, MD., Osteopath Fee Schedule

None Found

None Found

d. Payment for services billed by an Advanced Practitioner of Nursing/Physician Assistant/Nurse-Midwife will be calculated using the April 1, 2002 unit values for the Nevada specific resource based relative value scale (RBRVS) and the 2002 Medicare Physicians Fee Schedule conversion factor. Payment will be the lower of billed charges, or the amounts specified below:1. Surgical codes will be reimbursed at 69% of the Medicare facility rate.2. Medicine codes and Evaluation and Management codes will be reimbursed at 74% of the Medicare non-facility rate. Vaccine Products will be reimbursed at 85% of the Medicare non-facility rate.3. Obstetrical service codes will be reimbursed at 88% of the Medicare non-facility rate.4. When codes 90465-90468, 90471-90474, 99381-99385 and 99391-99395 are used for EPSDT services, the reimbursement will be 85% of the Medicare non-facility rate.

Provider Type 24 Certified Nurse PractitionerProvider Type 74 Nurse MidwifeProvider Type 77 Physician's Assistant

Provider Type 72 Nurse AnesthetistProvider Type 26 Psychologist

None Found



Early and periodic screening, diagnosis and treatment (EPSDT) services will be reimbursed the lower of a) billed charge, or b) fixed fee per unit as indicated for specific services listed elsewhere in this attachment.

The out-of-state payment rate for services provided by an out-of-state provider is based on one of the following criteria:a. The out-of-state provider will be paid the lesser of the provider’s billed charges or the fee for service rate that is paid to an in-state provider for the service.b. If the out-of-state provider refuses to accept this rate, then the out-of-state provider may be paid the lesser of the provider’s billed charges or the same fee-for-service rate as it would be paid by its home state Medicaid program.c. For services that cannot be provided by a provider that accepts payment under (A) or (B), the State will maintain a list of other qualified out-of-state providers, and will negotiate competitive rates that will not exceed the provider’s customary charge.

None Found

None Found

None Found

(A) Follows federal guidelines. The rates do not reflect site of service adjustments, but reimburse at the Medicare rate applicable to the office setting. The rates reflect all Medicare geographic/locality adjustments. The rates are statewide and reflect the mean value over all counties for each of the specified evaluation and management and vaccine billing codes.

The State reimburses a supplemental amount equal to the difference between the Medicaid rate in effect on the date of service as published in the agency's fee schedule described in Attachment 4.19-B, Page 1c Physician Services of the State Plan and the minimum payment required at 42 CFR 447.405. Payment is made for specific E&M codes.

(B) Primary Care Physician Rates

In order to ensure access to University of Nevada School of Medicine (UNSOM) Practitioner Services by needy individuals in the state of Nevada and to recognize the higher cost of providing Practitioner Services in a teaching environment, UNSOM shall be paid a Supplemental Payment for such services to Medicaid recipients which is in addition to the Medicaid Base Rate(s) normally paid for said services. The Supplemental Payment for any quarterly Service Period shall be calculated as: ((Medicare Equivalent Ratio X (sum of Medicaid Services paid for during the Service Period X Medicare Reimbursement Rates)) - (Medicaid Services paid for during the Service Period X Medicaid Base Rates) provided, however, that in no event shall total reimbursements (i.e., Medicaid Base Rate plus Supplemental Payments) during any Service Period exceed the Reimbursement Ceiling for that Service Period.



NA

NA RBRVS


Summary Data

Nevada State Plan Attachment 4.19B, Page 1c: http://dhcfp.nv.gov/MStatePlan/Section%204/Section%204.19%20Attachment%20B.pdf

Lesser of charges or % of Medicare rate

Nevada State Plan Attachment 4.19B, Page 1c: http://dhcfp.nv.gov/MStatePlan/Section%204/Section%204.19%20Attachment%20B.pdf

NA

NA Yes

NA Yes

NA Yes

NA NF

NA NF

Nevada State Plan Attachment 4.19B, Page 1d: http://dhcfp.nv.gov/MStatePlan/Section%204/Section%204.19%20Attachment%20B.pdf


Nevada Fee Schedules:http://dhcfp.state.nv.us/RatesUnit.htm?Accept

NP Fee Schedule:https://dhcfp.nv.gov/Rates/PT/PT%2024%20Certified%20Nurse%20Practitioner%2011-7-11.pdfPA fee schedule: https://dhcfp.nv.gov/Rates/PT/PT%2077%20Physician%27s%20Assistant%2011-9-11.pdfMW Fee Schedule:https://dhcfp.nv.gov/Rates/PT/PT%2074%20Nurse%20Midwife%20101019.pdf

Nevada Fee Schedules: http://dhcfp.state.nv.us/RatesUnit.htm?Accept

Nevada State Plan Attachment 4.19B: http://dhcfp.nv.gov/MStatePlan/Section%204/Section%204.19%20Attachment%20B.pdf

Nevada State Plan Attachment 4.19B: http://dhcfp.nv.gov/MStatePlan/Section%204/Section%204.19%20Attachment%20B.pdf

Nevada Medicaid Services Manual-Physician:https://dhcfp.nv.gov/MSM/CH0600/MSM%20Ch%20600%20FINAL%205-16-13.pdf

NA Yes

NA

NF

NA NF

NA No

Nevada State Plan Attachment 4.19B (Page 1b): http://dhcfp.nv.gov/MStatePlan/Section%204/Section%204.19%20Attachment%20B.pdf

Nevada State Plan Attachment 4.19B (Page 3i &3j): http://dhcfp.nv.gov/MStatePlan/Section%204/Section%204.19%20Attachment%20B.pdf


Nevada State Plan Attachment 4.18, Page 54: http://dhcfp.nv.gov/MStatePlan/Section%204/Section%204.18%20Cost%20Sharing%20and%20Similar%20Charges%2009-04.pdfNevada Medicaid Services Manual-Physician:https://dhcfp.nv.gov/MSM/CH0600/MSM%20Ch%20600%20FINAL%205-16-13.pdf

Nevada State Plan Attachment 4.19B (Page 1d) : http://dhcfp.nv.gov/MStatePlan/Section%204/Section%204.19%20Attachment%20B.pdf


NA NF

NA Yes

NA NF

NA Yes

NA NF

Nevada State Plan: http://dhcfp.nv.gov/MStatePlan/Section%204/Section%204.19%20Attachment%20B.pdf


(A) Nevada State Plan Attachment 4.19B (Page 1c-1 to 1c-2): http://dhcfp.nv.gov/MStatePlan/Section%204/Section%204.19%20Attachment%20B.pdf

(B) Primary Care Physician Rates:https://dhcfp.nv.gov/Rates/2013%20PCP%20Rates%20for%20Eligible%20Providers.pdf

Nevada DHHS: http://dhcfp.nv.gov/caremgmt.htm

Nevada State Plan Attachment 4.19B, Page 8: http://dhcfp.nv.gov/MStatePlan/Section%204/Section%204.19%20Attachment%20B.pdf

Nevada State Plan: http://dhcfp.nv.gov/MStatePlan/Section%204/Section%204.19%20Attachment%20B.pdf



6/10/2013 8/16/2013

6/10/2013 7/22/2013


Documentation Date

Date Last Searched

5/1/2009 7/22/2013

8/1/2013 8/19/2013

8/2/2013

8/2/2013

NA 7/22/2013

NA 8/2/2013

NP: 7/11/2011PA:9/11/2011MW: 10/19/2010

(A) 10/19/2010(B) 11/8/2011

5/1/2009 7/22/2013

11/1/2008 8/2/2013

NA 8/19/2013

NA 7/22/2013

NA 7/22/2013

NA 7/22/2013

8/16/2013

NA 8/2/2013

12/21/2007 8/19/2013

NA 8/19/2013

(A) 6/10/2013(B) 2013

States' Medicaid Fee-for-Service Physician Payment Policies - New Hampshire


CategoryAdjustments


Fee Schedule Basis




Children vs. Adults

Out-of-State




Health Home

Primary Care



States' Medicaid Fee-for-Service Physician Payment Policies - New Hampshire


New Hampshire

Rates developed by the state which is typically 60% of Medicare, however, occasionally some are higher than that.

None Found



(A) Payment to physicians shall be made in accordance with rates established by the department in accordance with RSA 161:4, VI(a)

(B) Payment to physicians will be the lesser of charges or the maximum allowable rate.

Modifier Codes, Covered Procedures and Manually Priced Procedures Fee Schedules

Certified Midwives Fee Schedule

None Found

None Found

None Found

None Found

None found

None found

None foundIncentive or Add-on Payments


None Found

None Found

The Affordable Care Act (ACA) authorized Medicaid reimbursement for eligible primary care services at parity with Medicare for calendar years 2013 and 2014. NH Medicaid primary care providers (PCPs) who meet requirements for this enhanced reimbursement for certain primary care services must complete an attestation form.

None Found

None Found



NA

NA % of Medicare

NA NF


Summary Data

(A) NH Administrative Rules, CHAPTER He-W 500 MEDICAL ASSISTANCE, He-W 531.10 Payment for Services:http://www.gencourt.state.nh.us/rules/state_agencies/he-w500.html(B) Staff at RI Medicaid Office


Staff at New Hampshire Medicaid Office

NH Billing & provider Manuals:https://nhmmis.nh.gov/portals/wps/portal/!ut/p/c5/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hXX-cwF3cfQwMLAz9LAyNjC0fvIFcDg0ALI6B8pFm8AQ7gaEBAdzjIPtwq3M0h8njM9_PIz03VL8iNMMgycVQEADqTPrw!/dl3/d3/L2dJQSEvUUt3QS9ZQnZ3LzZfUVNMOE81MjYxTzM4QzBJOUpMVDdONDIwODQ!/

NA Yes

Yes

NF

NA NF

Fee Schedules:https://nhmmis.nh.gov/portals/wps/portal/!ut/p/c5/jZHLDoIwEEU_qQN9UJYVCSLP8hLZGBaGkAi4MH6_bdholMaZ5clJZu5FHVI7989x6B_jMvc31KKOXfzEa_ZBbAGH1AUbcxEVPgArQfHzJpeB848NGyNA27KMeUZtZnGSCAgpq92CYaz4ahv4h51JDGFO8Y7SCn7YX9xweUSMf2u-bUthmVNT3JzaSbf0dnuGuQehe4wrJyU2cLJyUyuaG3JPD8t0Rfep1tPCmA8v1ZMCZQ!!/dl3/d3/L2dJQSEvUUt3QS9ZQnZ3LzZfRU1DVkRHTDEwODBOOTAyMzhBS1JFMDA2NTY!/

Certified Midwives Fee Schedule 2012:https://nhmmis.nh.gov/portals/wps/wcm/connect/223df2004ec4d2f3852da7054277da38/Certified+Midwives+2012.xls?MOD=AJPERES

Fee Schedules:https://nhmmis.nh.gov/portals/wps/portal/!ut/p/c5/jZHLDoIwEEU_qQN9UJYVCSLP8hLZGBaGkAi4MH6_bdholMaZ5clJZu5FHVI7989x6B_jMvc31KKOXfzEa_ZBbAGH1AUbcxEVPgArQfHzJpeB848NGyNA27KMeUZtZnGSCAgpq92CYaz4ahv4h51JDGFO8Y7SCn7YX9xweUSMf2u-bUthmVNT3JzaSbf0dnuGuQehe4wrJyU2cLJyUyuaG3JPD8t0Rfep1tPCmA8v1ZMCZQ!!/dl3/d3/L2dJQSEvUUt3QS9ZQnZ3LzZfRU1DVkRHTDEwODBOOTAyMzhBS1JFMDA2NTY!/


NA NF

NA NF

NA NF

NA NF

NA NF




NH Medicaid Services Fact Sheethttp://www.dhhs.nh.gov/ombp/medicaid/documents/med77l.pdf


NA No

NA NF

NA Yes

NA NF


New Hampshire State Health CareInnovation Model- Report by Deloitte:http://www.dhhs.nh.gov/ocom/documents/sim-presentation06272013.pdfNH Billing & provider Manuals:https://nhmmis.nh.gov/portals/wps/portal/!ut/p/c5/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hXX-cwF3cfQwMLAz9LAyNjC0fvIFcDg0ALI6B8pFm8AQ7gaEBAdzjIPtwq3M0h8njM9_PIz03VL8iNMMgycVQEADqTPrw!/dl3/d3/L2dJQSEvUUt3QS9ZQnZ3LzZfUVNMOE81MjYxTzM4QzBJOUpMVDdONDIwODQ!/

Enhanced Primary Care Service Rates:https://nhmmis.nh.gov/portals/wps/wcm/connect/8d5b48004ff7b3919e98bec1c7e9749a/primary+care+rate+increase+table+word+for+Xerox.doc?MOD=AJPERES


NA NF

NA NF




9/13/2013

NA 8/22/2013

NA 7/16/2013


Documentation Date

Date Last Searched

(A) 11/14/2011(B) NA

1/16/2013 8/7/2013

5/1/2012 7/16/2013

NA 7/16/2013

NA 7/16/2013

7/16/2013

NA 7/16/2013

NA 7/16/2013

NA 7/16/2013

NA 7/16/2013

NA 7/16/2013

6/27/2013 7/16/2013

6/12/2013 8/14/2013

9/23/2013 7/16/2013

NA 8/16/2013

NA 7/16/2013

States' Medicaid Fee-for-Service Physician Payment Policies - New Jersey


CategoryAdjustments


Fee Schedule Basis






Children vs. Adults

Out-of-State






Health Home

Primary Care




States' Medicaid Fee-for-Service Physician Payment Policies - New Jersey


New JerseyAdjustments

None Found

None Found



10:54-4.1 General payment methodology (a) Payment for physician services covered under the New Jersey Medicaid or NJ FamilyCare program is based upon the customary charge prevailing in the community for the same service but shall not exceed a "Maximum Fee Allowance Schedule" which has been determined reasonable by the Commissioner and set forth in N.J.A.C. 10:54-9 and as limited by Federal policy relative to the payment of physicians and other licensed health care practitioners.

APNS:(A) Payment for APN services covered under the New Jersey Medicaid and NJ FamilyCare fee-for-service programs is based upon the customary charge prevailing in the community for the same service but shall not exceed the "Maximum Fee Allowance Schedule" specified in N.J.A.C. 10:58A-4. In no event shall the charge to the New Jersey Medicaid/NJ FamilyCare fee-for-service program exceed the charge by the provider for identical services to other individuals, groups or governmental agencies.Nurse Midwives: (B) Reimbursement for nurse midwifery services is made on a fee-for-service basis using the HCPCS procedure code system and is based on payment of 70 percent of the physician's specialist fee for the same procedure.

(A) General Medicaid Fee For Service Schedule

(B) Children's Rates

None Found

None Found

Children's Rates Fee Schedule

None Found


(A) Reimbursement rates for physician services are differentiated as specialist or non-specialist according to the criteria for specialist designation.

(B) Anesthesia

A New Jersey Medicaid beneficiary is not required to pay any additional fee or co-payment to service providers such as a physician, dentist, or pharmacy.


None Found

None Found

None Found

(A) Follows federal guidelines. Rates do NOT reflect site of service adjustments, but reimburse at the Medicare rate applicable to the office setting. Rates are statewide and reflect mean value over all counties for each E&M. NJ will use the March 28,2013 Deloitte fee schedule rates. Payment applies to select E&M codes.

(B) ACA Enhanced Rates Fee Schedule

None Found



NA

NA NF

NA

NA Yes

NA NF


Summary Data

N.J.A.C. 10:54-4.1: http://www.lexisnexis.com/hottopics/njcode/


(A) NJ State Medicaid Plan. Attachments 3 & 4: http://www.state.nj.us/humanservices/dmahs/info/state_plan.html

Additional search of key terms in N.J.A.C. via Lexis Nexus

(A) N.J.A.C. 10:58A-1.5:http://www.lexisnexis.com/hottopics/njcode/

(B) NJ State Plan, Attachment 4.19-B, Page 16: http://www.state.nj.us/humanservices/dmahs/info/state_plan/Attachment4_Payments_and_Rates.pdf


NJ Procedure Master Listing - Medicaid Fee for Service:https://www.njmmis.com/downloadDocuments/CPTHCPCSCODES.pdf

Procedure Code Listings:https://www.njmmis.com/hospitalinfo.aspx

NA Yes

NA NF

NA NF

NA NF

NA NF

NA NF

NA NFIncentive or Add-on Payments

(A) N.J.A.C. 10:54-1.4: http://www.lexisnexis.com/hottopics/njcode/

(B) Procedure Master Listing - Anesthesia: https://www.njmmis.com/downloadDocuments/CPTCodesAA.pdf

NJ State Medicaid Plan. Attachments 3 & 4: http://www.state.nj.us/humanservices/dmahs/info/state_plan.html


NJ Procedure Master Listing - Children's Rates:https://www.njmmis.com/documentDownload.aspx?document=childrensrates.pdf


Additional search of key terms in N.J.A.C. via Lexis Nexus

NJ Office of the Medicaid Inspector General. FAQs: http://www.state.nj.us/njomig/faqs.html

(A) NJ State Plan, Amendment 4.19-B:http://www.state.nj.us/humanservices/dmahs/info/state_plan/Attachment4_Payments_and_Rates.pdf

NA No

NA NF

NA Yes

NA NF

NA NF




(A) NJ State Plan, Amendment 4.19-B, Page 29:http://www.state.nj.us/humanservices/dmahs/info/state_plan/Attachment4_Payments_and_Rates.pdf(B) NJ Procedure Master Listing - ACA Enhanced Rates:https://www.njmmis.com/downloadDocuments/CPTCodesACA.pdf

Kaiser State Health Facts: Primary Care Case Management. (2010 data is latest available): http://kff.org/medicaid/state-indicator/primary-care-providers-in-pccm-programs/

NJ State Medicaid Plan. Attachment 4.19-B: http://www.state.nj.us/humanservices/dmahs/info/state_plan/Attachment4_Payments_and_Rates.pdf

Additional search of key terms in GoogleNJ State Plan, Amendment 4.19-B:http://www.state.nj.us/humanservices/dmahs/info/state_plan/Attachment4_Payments_and_Rates.pdf

NA NF

NJ State Plan, Amendment 4.19-B:http://www.state.nj.us/humanservices/dmahs/info/state_plan/Attachment4_Payments_and_Rates.pdf


Adjustments

7/3/2006 8/7/2013

NA 8/7/2013

8/7/2013

(A & B) 8/1/2012 8/7/2013

NA 8/7/2013


Documentation Date

Date Last Searched

(A) 4/18/11

(B) 10/14/05

8/7/2013

NA 8/7/2013

NA 8/7/2013

8/1/2012 8/7/2013

NA 8/7/2013

6/17/2013 8/7/2013

NA 8/7/2013Incentive or Add-on Payments

(A) 7/2/2012(B) 8/1/2012

NA 8/7/2013

NA 8/7/2013

8/13/2013

NA 8/7/2013

NA 8/7/2013

(A) 6/11/2013(B) 2013

NA 8/7/2013

States' Medicaid Fee-for-Service Physician Payment Policies - New Mexico


CategoryAdjustments


Fee Schedule Basis




Children vs. Adults

Out-of-State








Health Home

Primary Care


States' Medicaid Fee-for-Service Physician Payment Policies - New Mexico


New MexicoAdjustments



Payment to providers on a fee for service basis is limited to the lesser of the actual charge or the fee schedule established by the Department.

Providers reimbursed on a fee for service basis include physicians, dentists, radiologists, and radiological laboratories, pathologists and clinical pathology laboratories, free-standing clinics (other than rural health clinics or federally qualified health centers), podiatrists, psychologists, optometrists, audiologists, and therapy providers.

The payment rates result in public and private providers receiving the same payment for the same service.

The fee schedule was established using the following: 1. Relative Value Scale - Relative Values for Physicians, 2nd Edition, 1986 was used to assign unit values to physician procedures. The unit value established an appropriate relativity between the procedures and was used as initial base upon which to begin constructing the fee schedule. 2. Groups for Calculation of Reimbursement - frequently billed procedures were identified and divided into groups and groupings were used to establish appropriate reimbursement for a procedure relative to other procedures in the same group3. Billed Charges.4. History of Paid Claims5. Weighted Conversion Factors

Licensed Midwives: Payments to licensed midwives are made at the lesser of the actual billed charge or 77% of the amount allowed by the fee schedule for the same service when provided by a physician.

Certified Nurse Practitioners: Certified nurse practitioners and clinical nurse specialists will be reimbursed at 90% of the payment made to physicians.

CPT Code and HCPCS Code Based General Fee Schedules

None found

None found

None found

None found

Reimbursement for office visits, diagnostic procedures, or surgical services furnished in hospital settings that are ordinarily furnished in a provider’s office is paid at sixty percent (60%) of the fee schedule allowed amount for each professional service.

Reimbursement to an out-of-state or border area provider is made at the same rate as for an in-state provider except as otherwise stated in the relevant specific providers and services sections of the MAD program rules manual.

A. Unless payment for a service is made using a diagnosis related group or outpatient prospective payment system rate, reimbursement to a provider for covered services is made at the lesser of the following:(1) the billed change which must be the provider’s usual and customary charge for service; “usual and customary charge” refers to the amount which the individual provider charges the general public in the majority of cases for a specific procedure or service; or(2) the MAD fee schedule for the specific service or procedure.

None Found



None Found

Follows federal guidelines. MAD will use the higher of either the existing Medicaid rate or the 2013 Medicare or CMS determined rate to calculate the increased payments. MAD intends to present a plan to CMS that follows the provisions stated in the notice.

None Found

None Found

Supplemental Payments will be made in addition to payments otherwise provided under the state plan to physicians. dentists and mental health professionals who qualify for such payments under the criteria outlined below in part (a) of this section. The payment methodology for establishing and making the supplemental payments is provided below:a. To qualify for a supplemental payment under this section. the provider must meet the following criteria: Be a licensed physician, dentist or mental health professional enrolled in the New Mexico Medicaid program: and be a member of a practice plan under contract to provide professional services at a State-owned academic medical center as determined by the Department.b. For qualifying providers, a quarterly supplemental payment will be made equal to the difference between Medicaid payments otherwise made to these providers and the average rate paid for the services by commercial insurers.



NA

NA

NA


Summary Data

NM Medicaid State Plan. Attachment 4.19b, Page 1: http://www.hsd.state.nm.us/mad/pdf_files/State%20Plan%20Attachments.pdf


NM Medicaid State Plan. Attachment 4.19b, Page 1: http://www.hsd.state.nm.us/mad/pdf_files/State%20Plan%20Attachments.pdf


NM Medicaid State Plan. Attachment 4.19b. Page 3a. Available at: http://www.hsd.state.nm.us/mad/pdf_files/State%20Plan%20Attachments.pdf


NA Yes

NA NF

NA NF

NA NF

NA Yes

NA NF

NA In-State

CPT Codes Schedule: http://www.hsd.state.nm.us/mad/PCptDisclaimer.htmlHSPCS Codes Schedule: http://www.hsd.state.nm.us/mad/Phcpcdisclaimer.html

New Mexico Medicaid Fee Schedules:http://www.hsd.state.nm.us/mad/PFeeSchedules.html

New Mexico Medicaid Fee Schedules:http://www.hsd.state.nm.us/mad/PFeeSchedules.html

Provider Manual (http://www.hsd.state.nm.us/mad/RPolicyManual.html) State Plan (http://www.hsd.state.nm.us/mad/RPublicInformation.html)Additional search of key terms in Google

Medicaid Policy Manual, Chapter 310 - Health Care Professional Services, Page 4, Section 8.310.2.17 http://www.hsd.state.nm.us/mad/pdf_files/provmanl/prov83102.pdf


Medicaid Policy Manual, Chapter 302, Section 8.302.4.17:http://www.hsd.state.nm.us/mad/pdf_files/provmanl/8%20302%204.pdf

NF


NA No

NA NF

NA Yes

Provider Manual (http://www.hsd.state.nm.us/mad/RPolicyManual.html) State Plan (http://www.hsd.state.nm.us/mad/RPublicInformation.html)Additional search of key terms in GoogleSCI Benefit Package: http://www.hsd.state.nm.us/mad/pdf_files/salud_rfp/Exhibit%202%20-%20SCI%20Benefit%20Package%20-%20FINAL.pdf



NM Provider Manual: (http://www.hsd.state.nm.us/mad/RPolicyManual.html) NM State Plan: (http://www.hsd.state.nm.us/mad/RPublicInformation.html)Additional search of key terms in Google

MAD Policy Supplement 13-03: http://nmaap.org/wp-content/uploads/2013/02/Supplement-13-03.pdf

NA NFNA Yes

No No

Provider Manual: (http://www.hsd.state.nm.us/mad/RPolicyManual.html) State Plan: (http://www.hsd.state.nm.us/mad/RPublicInformation.html)Additional search of key terms in Google

NM Medicaid State Plan. Attachment 4.19b. Page 3a-3b Available at: http://www.hsd.state.nm.us/mad/pdf_files/State%20Plan%20Attachments.pdf

NM Provider Manual: (http://www.hsd.state.nm.us/mad/RPolicyManual.html) NM State Plan: (http://www.hsd.state.nm.us/mad/RPublicInformation.html)Additional search of key terms in Google


Adjustments

12/2/2005 7/8/2013

12/2/2005 7/8/2013

12/2/2005 7/8/2013


Documentation Date

Date Last Searched

4/9/2013 7/8/2013

NA 7/8/2013

NA 7/8/2013

NA 7/8/2013

3/5/2001 7/8/2013

NA 7/8/2013

11/1/2010 7/8/2013

NA 7/8/2013


NA 7/8/2013

NA 7/8/2013

2/19/2013 7/24/2013

NA 7/8/201312/2/2005 7/8/2013

NA 7/8/2013

States' Medicaid Fee-for-Service Physician Payment Policies - New York


CategoryAdjustments







Children vs. Adults

Out-of-State






Health Home

Primary Care





States' Medicaid Fee-for-Service Physician Payment Policies - New York


New York

New York benchmarks the physician fee schedule to Medicare. 60% office-based services. 50% facility based services.

None Found

General Physician Fee Schedule



Payment for physician services will not exceed the maximum fee established by the DOH and promulgated by the NYS Director of the Budget. The fee schedule for physician services is available online at: http://www.emedny.org/ProviderManuals/Physician/index.html. Physicians who are enrolled in the Preferred Physicians and Children Program, the Medicaid Obstetrical and Maternal Services Program or the HIV Enhanced Fees for Physicians Program will be paid in accordance with the enhanced fees for those programs.

NP and MW have separate Fee Schedules. PA included in Physician Schedule.

Anesthesia

None Found



EPSDT Services: Fees will be established for each service or procedure and, except for Special Transportation, such fees shall be set at 75% of the 2010 Medicare fee schedule for the Mid Hudson Region.

Those providers who meet their state's licensure/certification requirements are reimbursed chargesup to the appropriate New York State fee, for services rendered.

There is no co-payment on private practicing physician services (including laboratory and/or x-ray services, home health services, personal care services or long term home health care services).

(A) HIV Enhanced Fess for Physicians Fee Schedule(B) The HIV Enhanced Fees for Physicians (HIV-EFP) Program recognizes the need to encourage primary care for persons with HIV disease by increasing fees for primary care and specialty physicians who provide HIV counseling, testing and follow-up care. The new fees are comparable to those paid by commercial insurers. (C) For primary care and specialty physicians meeting the eligibility and practice criteria of and enrolled in the HIV Enhanced Fees for Physicians (HIV-EFP) program, and the Preferred Physicians and Children's program (PPAC), fees for visits are based on the Products of Ambulatory Care (PAC) structure: fees are based on recipient diagnosis, service location and visit categories which reflect the average amount of physician time and resources for that level of visit The PAC fee structure incorporates a regional adjustment for upstate and downstate physicians. Reimbursement for the initial and subsequent prenatal care and postpartum visit for MOMS is (the same as PPAC) based on the Products of Ambulatory Care (PAC) rate structure. Reimbursement for delivery only services and total obstetrical services for physicians enrolled in MOMS is fixed at 90% of the fees paid by private insurers. For services provided on or after June 1, 2003, a single fee, regionally adjusted (upstate and downstate) and based on program specific average cost per visit shall be established for the HIV-EFP and PPAC programs, respectively, and shall be paid for each visit.


None Found

Primary Care Rate Increase (PCRI) Fee Schedule

None Found

A) PCCMs may be reimbursed on a capitated or fee-for-service basis and may be paid case management fees. If capitated, the capitation will cover primary care services routinely provided in a primary care practitioner's office.

B) Partial risk programs were an option for Medicaid recipients from 1987 until August 31, 2012, when the last PCPCPs were phased out. The original programs were capitated primary care case management programs called Physician Case Management Programs. Chapter 649 of the Laws of 1996 added a new Section 4403e to Public Health Law that authorized the certification of Primary Care Partial Capitation Providers and grandfathered the Physician Case Management Programs then in existence under 4403e.

Medicaid recipients enrolled with a partially capitated provider were assigned to a primary care practitioner who was responsible for providing primary and preventive care and coordinating, locating and monitoring access to other medically necessary services. The providers of the other services were reimbursed fee-for-service. In 2012, the three remaining PCPCPs were closed when a choice of full risk managed care plans became available.

(A) An e-prescription financial incentive will be paid to physicians and nurse practitioners for the purpose ofencouraging the electronic transmission of prescriptions and fiscal orders for select over-the counter medications prescribed and dispensed in accordance with State and federal requirements. Reimbursement is determined by the State Department of Health at 80 cents per electronic prescription/fiscal order dispensed.(B) Adirondack Medical Home Multipayor Program. The Adirondack Medical Home Multipayor Program is a primary care medical home collaborative of health care service providers. Incentive payments to physicians and/ornurse practitioner practices that meet "medical home" standards will be established. The participating payers agreed to a per member per month(PMPM) incentive payment of $7. The per visit incentive payment is $28.



NA NTE max feesStaff at NY Medicaid office NA % of Medicare

NA

NA Yes

NA Yes


Summary Data

Physician Provider Manual, Page 17 : https://www.emedny.org/ProviderManuals/Physician/PDFS/Physician_Manual_Policy_Guidelines.pdf

MW Manual: https://www.emedny.org/ProviderManuals/Midwife/PDFS/Midwife_Manual_Policy_Section.pdf

NP Manual: https://www.emedny.org/ProviderManuals/NursePractitioner/PDFS/Nurse_Practitioner_Policy_Guidelines.pdf


Physician schedule: https://www.emedny.org/ProviderManuals/Physician/index.aspx

MW: https://www.emedny.org/ProviderManuals/Midwife/index.aspxNP: https://www.emedny.org/ProviderManuals/NursePractitioner/index.aspx

NA Yes

NA NF

NA Yes

NA Yes

In-State

NA $0

NA

Anesthesia Fee Schedule:https://www.emedny.org/ProviderManuals/Physician/index.aspx

New York State Plan:http://www.health.ny.gov/regulations/state_plans/docs/nys_medicaid_plan.pdf

New York Physician Fee Schedule: https://www.emedny.org/ProviderManuals/Physician/index.aspx

New York State Plan (Sheet 1199 from 1768):http://www.health.ny.gov/regulations/state_plans/docs/nys_medicaid_plan.pdf

New York State Plan, Attachment 4.19B, Page 6(a):http://www.health.ny.gov/regulations/state_plans/docs/nys_medicaid_plan.pdf

Medicaid in New York State FAQs:http://www.health.ny.gov/health_care/medicaid/#copay

(A) Enhanced Program Fee Schedule: https://www.emedny.org/ProviderManuals/Physician/index.aspx(B) Physician Provider Manual, Page 13 : https://www.emedny.org/ProviderManuals/Physician/PDFS/Physician_Manual_Policy_Guidelines.pdf(C) New York State Plan, Attachment 4.19B:http://www.health.ny.gov/regulations/state_plans/docs/nys_medicaid_plan.pdf

HIV, PPAC, & MOMS programs

NA No

NA NF

NA Yes

NA No

NA NF

NA



Physician Primary Care Fee Schedule: https://www.emedny.org/ProviderManuals/Physician/index.aspx

A) New York State Plan, Page 16 (Sheet 1191 from 1768):http://www.health.ny.gov/regulations/state_plans/docs/nys_medicaid_plan.pdf

B) New York Medicaid State Site: http://www.health.ny.gov/health_care/managed_care/mcodefs.htm


(A) New York State Plan, Attachment 4.19-B, Page 1(A)(viii) for NPs, Page 1(A)(iii) for physicians:http://www.health.ny.gov/regulations/state_plans/docs/nys_medicaid_plan.pdf(B) New York State Plan, Attachment 4.19-B, Page 1(A)(ii)-(iii) :http://www.health.ny.gov/regulations/state_plans/docs/nys_medicaid_plan.pdf

(A) E-Prescription Incentive(B) Adirondack Medical Home Multipayor Program


4/15/2008 8/9/2013NA 12/2/2013

NA 8/9/2013

4/1/2013 8/9/2013

4/1/2013 8/9/2013


Documentation Date

Date Last Searched

11/18/2010 8/9/2013

NA 7/24/2013

4/1/2013 8/9/2013

4/26/2010 8/9/2013

9/8/2008 8/19/2013


8/9/2013

(A) 4/1/2010(B) 4/15/2008(C) 2/20/2004

NA 7/24/2013

NA 7/24/2013

1/1/2013 7/24/2013

8/9/2013

NA 7/24/2013

8/23/2013

A) 3/28/2002B) 10/1/2012

(A) 7/19/2010 (Physicians) & 4/8/2010 (NPs)(B) 7/19/2010

States' Medicaid Fee-for-Service Physician Payment Policies - North Carolina


CategoryAdjustments


Fee Schedule Basis





Children vs. Adults

Out-of-State







Health Home

Primary Care




States' Medicaid Fee-for-Service Physician Payment Policies - North Carolina


North Carolina

Physician Services Fee Schedule



A maximum fee is established for each service and is applicable to all specialties and settings in which theservice is rendered. Payment is equal to the lower of the maximum fee or the provider’s customary charge tothe general public for the particular service rendered.

Physicians’ services whether furnished in the office, the patient’s home, a hospital, a nursing facility or elsewhere, shall be reimbursed based on the North Carolina Medicaid Fee Schedule which is based on 86 percent of the Medicare Fee Schedule Resource Based Relative Value System (RBRVS) in effect January 1 of each year, but with some clarifications and modifications.

A) Payments for Physician Assistant Services covered under Attachment 3.1-A.1 are equal to the lower of the submitted charge or the appropriate fee from the North Carolina Medicaid Physician Assistant Services Fee Schedule. Physician Assistant Services are reimbursed at 100 percent of the Medicaid Physician Assistant Services Fee Schedule in effect.

B) Payments for Nurse Practitioner Services covered under Attachment 3.1-A.1 are equal to the lower ofthe submitted charge or the appropriate fee from the North Carolina Medicaid Nurse Practitioner ServicesFee Schedule. Effective November 1, 2011 Nurse Practitioner Services shall be set at 100 % percent ofNorth Carolinas’ Medicaid Physician Services Fee Schedule in effect on November 1, 2011.

C) Payments for Nurse-Midwife Services covered under Attachment 3.1-A.1 are equal to the lower of thesubmitted charge or the appropriate fee from the North Carolina Medicaid Nurse-Midwife ServicesFee Schedule. The agency’s rates were set as of November 1, 2011 and are effective on or after that date. Rates forNurse-Midwife Services are adjusted annually in accordance with the physician services fee schedule.

NP, PA, MW: Separate Fee Schedules


None Found



The rate for services contained in 1905 (a) (Health Check/EPSDT) will be reimbursed at 80% of Medicare’s fee. If no Medicare rate exists, the State will reimburse a rate equal to similar services in the state plan. If no similar serviceexists, the State will review the rates of surrounding Medicaid states. If the surrounding Medicaid State’sfees are not available, the State will reimburse 80% of usual and customary charges or negotiate the feewith the provider. Providers will be reimbursed the lower of the fee schedule rate or their usual and customary charge.

Out-of-state providers are required to adhere to all North Carolina, rules, regulations, laws and statutes governing healthcare delivery under the North Carolina Medicaid program.

$3.00 per professional for service visits($0.00 per professional service visit for NC Health Choice for Children [NCHC])

Certified Registered Nurse Anesthetists Services (CRNA's).Payments for Certified Registered Nurse Anesthetist Services covered under Attachment 3.1-A.1 are equal to the lower of the submitted charge or the appropriate fee from the North Carolina Medicaid CRNA Fee Schedule. Effective November 1, 2011 CRNA’s rates shall be set at 97.33% percent of North Carolinas’ Medicaid Physician Services Fee Schedule in effect on October 1 of 2009. Effective July 1, 2012 CRNA’s rates shall be set at 98% percent of North Carolinas’ Medicaid Physician Services Fee Schedule in effect on October 1 of 2009.

Effective, October 1, 2008, fees for anesthesiologist assistants (AAs) are established at 50% of Anesthesiologist rates for DMA approved procedures (CPT and HCPCS). Anesthesiologists are reimbursed the same as physician services, which are based on the current Medicaid Physician.

None found

The Health Home per member per month (PMPM) is distributed to the members of the Team of Healthcare Professionals using the methodologies described below. The Pregnancy Care Management payment is an add-on payment supporting care management services for high-risk pregnancies. The add-on rate was developed through the integration of a state plan Targeted Case Management program into the CCNC framework, based on an actuarial analysis of state plan TCM costs. Health Home service payments will not duplicate any other payment either through the State Plan or waiver of the State Plan.

The North Carolina Division of Medical Assistance will prevent duplication of payments and of roles and responsibilities on an ongoing basis.

Tiered based on Aged, Blind and Disabled (ABD)or non-Aged, Blind and Disabled status. Tiering of payments by ABD status Is based on ongoing analysis of the number and duration of care management interventions in the Primary care practice setting. We have determined that care management costs for ABDs are significantly higher than for other Medicaid eligibility categories.

Increased Primary Care Service Payment 42 CFR 447.405, 447.410, 447.415Primary Care Services as defined in section 1902 whether furnished in the office, the patient’s home, a hospital, a nursing facility or elsewhere, shall be reimbursed based on the North Carolina Affordable Care Act (ACA) Medicaid Fee Schedule.

Follows federal guidelines; providers will be reimbursed at no less than the Medicare Cost Share rates in effect January 1, 2013 – December 31, 2014 or, if greater, the Medicare Fee Schedule Resource Based Relative Value System (RBRVS) in effect as of July 1, 2009.

Community Care of North Carolina/Carolina ACCESS (CCNC/CA) is a primary care case management health care plan for a majority of Medicaid recipients of this state.

Supplemental payments will be made to Eligible Medical Professional Providers. These supplementalpayments will equal the difference between the Medicaid payments otherwise made under this state plan andthe Average Commercial Rate Payment. These supplemental payments will, for the same dates of service, bereduced by any other supplemental payments for professional services found elsewhere in the state plan.Eligible Medical Professional Providers must be employed by, contracted to provide a substantial amount of teaching services, or locum tenens of the state-operated school of medicine (SOM) at East Carolina University or the University of North Carolina at Chapel Hill, or employed or locum tenens within the University of North Carolina Health Care System.

Two enhanced payments may be made to a Pregnancy Medical Home provider. Upon completion of the high risk screening, an enhanced payment of $50.00 will be made to the PMH. Upon completion of the recipient’s post partum visit, an enhanced payment of $150.00 will be made to the PMH provider. The PMH providers will receive a maximum of $200 enhanced payments per recipient per pregnancy even if there are multiple births. PMH providers receive an enhanced rate for a vaginal delivery by paying the same rate for the vaginal delivery as for an uncomplicated C-section



NA

NA % of Medicare

No

NA Yes


Summary Data

NC State Plan Attachment 4.19B Section 5, Page 1 :http://www.ncdhhs.gov/dma/plan/x.pdf


NC State Plan Attachment 4.19B Section 5, Page 1:http://www.ncdhhs.gov/dma/plan/x.pdf

NC State Plan Attachment 4.19B(A) Section 5, Page 1f, (B) Section 6, Page 1c (C) Section 17, Page 1http://www.ncdhhs.gov/dma/plan/x.pdf

PA - lesser of charges or fee from PA FSNP - 100%NMW - lesser of charges or fee from NMW FS

NC Physician Services Fee Schedule: http://www.ncdhhs.gov/dma/fee/phy_fee/phy_fee_sch030113.pdf

NA Yes

NA Yes

NA NF

NA Yes

NA Yes

NA In-State

NA $3 (NCHC $0)

NA

NP Fee Schedule: http://www.ncdhhs.gov/dma/fee/nurse_prac/nurse_prac_130101.pdfPA Fee Schedule: http://www.ncdhhs.gov/dma/fee/pa_fee/pa_fee_010113.pdfMW Fee Schedule: http://www.ncdhhs.gov/dma/fee/nurse_midwife/nurse_midwife_010113.pdf

Anesthesia Fee Schedule:http://www.ncdhhs.gov/dma/fee/anesthesia/anesth_fee_0712.pdf

NC State Plan Amendment 4.19b:http://www.ncdhhs.gov/dma/plan/x.pdf

NC Physician Services Fee Schedule: http://www.ncdhhs.gov/dma/fee/index.htm

NC State Plan Attachment 4.19b Section 4, Page 2:http://www.ncdhhs.gov/dma/plan/x.pdf

Basic Medicaid and NC Health Choice Billing Guide, Section 4, Page 4-3:http://www.ncdhhs.gov/dma/basicmed/SECTION4_1012.pdf

A Consumer’s Guide to North Carolina Health Care Coverage Programs for Families and Children. (Page 17-18): http://www.ncdhhs.gov/dma/forms/famchld.pdf



NA Yes

NA NF

NA Yes

NA Yes

NA Yes

North Carolina Health Home State Plan Amendment, Page 30:http://www.chcs.org/usr_doc/NC-11-050_Approved_Atch_3_1-H_pages_(2).pdf

NC State Plan Amendment 4.19b:http://www.ncdhhs.gov/dma/plan/x.pdf

NC State Plan Attachment 4.19b Section 5, Page 1a:http://www.ncdhhs.gov/dma/plan/x.pdf

NC DHHS Division of Medical Assistance Website: http://www.ncdhhs.gov/dma/ca/ccncproviderinfo.htm


NA


Pregnancy Medical Home


12/21/2011 8/2/2103

12/21/2011 7/12/2011

8/2/2013

3/1/2013 7/24/2013


Documentation Date

Date Last Searched

(A) 12/22/11(B) 10/31/2011(C) 11/2/2011

1/1/2013 7/24/2013

7/1/2012 8/6/2013

NA 8/6/2013

3/1/2013 7/24/2013

5/16/2011 8/6/2013

10/2012 8/6/2013

Not Listed 8/6/2013

11/2/2011 8/2/2013

5/25/2012 8/2/2013

NA 7/24/2013

6/12/2013 8/6/2013

7/11/2013 8/6/2013

6/6/2011 8/2/2013

3/21/2011 8/2/2013

States' Medicaid Fee-for-Service Physician Payment Policies - North Dakota


CategoryAdjustments








Children vs. Adults

Out-of-State





Health Home

Primary Care


States' Medicaid Fee-for-Service Physician Payment Policies - North Dakota


North Dakota

Fee schedule based on Medicare RVUs times state conversion factor.

Basic Fee Schedule

None Found

None Found



For most services, North Dakota Medicaid reimburses providers the lesser of the billed amount or the maximum allowable fee established by North Dakota Medicaid. North Dakota Medicaid requires all providers to bill their usual and customary charge for services provided to Medicaid recipients.

Nurse practitioners must always bill their usual and customary charge. Services will be paid the lower of billed charges or 75% of the Medicaid fee schedule. When assisting at surgery, Nurse Practitioner services are reimbursed at 15% of the Medicaid fee schedule.

None Found

None Found

None Found

$2 co-pay

Service provided to a North Dakota Medicaid recipient by an out-of-state provider must be medically necessary and be a billable Medicaid service. The provider of the service must enroll as a North Dakota Medicaid provider and abide by all program provisions. In addition, out-of-state providers will receive payment only under certain circumstances.



None Found

North Dakota Medicaid currently reimburses above the Medicare payment rate for E&M codes, so the enhanced payment only applies to vaccine administration codes.

None Found

None Found

Certain groups within Medicaid are required to enroll in a managed care program. The Primary Care Case Management (PCCM) program is the only Statewide managed care program serving Medicaid recipients.



NAStaff at ND Medicaid Offices NA RBRVS

NA

NA Yes

NA NF

NA NF


Summary Data

ND Medicaid Basic Fee Schedule:http://www.nd.gov/dhs/services/medicalserv/medicaid/provider-fee-schedules.htmlNote: Scroll to the bottom of the page


ND Provider Manual, Page 48:http://www.nd.gov/dhs/services/medicalserv/medicaid/docs/gen-info-providers.pdf


ND Medicaid Fee Schedules:http://www.nd.gov/dhs/services/medicalserv/medicaid/provider-fee-schedules.html



NA NF

NA NF

NA NF

NA In-State

$2

ND Provider Manual:http://www.nd.gov/dhs/services/medicalserv/medicaid/docs/gen-info-providers.pdfND Admin Code:http://www.legis.nd.gov/agency-rules/north-dakota-administrative-codeND Medicaid Policy Manual:http://www.nd.gov/dhs/policymanuals/51005/51005.htm


ND Provider Manual:http://www.nd.gov/dhs/services/medicalserv/medicaid/docs/gen-info-providers.pdf

ND Admin Code:http://www.legis.nd.gov/agency-rules/north-dakota-administrative-code

ND Medicaid Policy Manual:http://www.nd.gov/dhs/policymanuals/51005/51005.htm

ND Provider Manual, Pages 132 & 133:http://www.nd.gov/dhs/services/medicalserv/medicaid/docs/gen-info-providers.pdf

ND Provider Manual, Page 19:http://www.nd.gov/dhs/services/medicalserv/medicaid/docs/gen-info-providers.pdf

NF

NA No

NA NF

NA No




ND Memo to Primary Care Providers participating in North Dakota Medicaid:http://www.nd.gov/dhs/services/medicalserv/medicaid/docs/enhanced-payments-pcp-memo-may2013.pdf

NA Yes

NA NF

NA NF

Medicaid - Primary Care Case Management Program, Service Chapter 510-06:http://www.nd.gov/dhs/policymanuals/51006/Content/PD/Microsoft%20Word%20-%20MASTER%20COPY%20DO%20NOT%20DELETE%20510-06%20PCCM.pdf




Not Listed 8/9/2013NA 8/14/2013

1/2012 8/9/2013

7/1/2012 8/9/2013

NA 7/25/2013

NA 7/25/2013


Documentation Date

Date Last Searched

NA 8/9/2013

NA 7/25/2013

NA 7/25/2013

10/1/2004 8/9/2013

7/1/2012 8/9/2013

NA 8/9/2013

NA 7/25/2013

NA 7/25/2013

5/17/2013 8/9/2013

6/1/2010 8/9/2013

NA 8/9/2013

NA 8/9/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Ohio


CategoryAdjustments


Fee Schedule Basis





Children vs. Adults

Out-of-State







Health Home

Primary Care


States' Medicaid Fee-for-Service Physician Payment Policies - Ohio


Ohio

Medicaid Fee Schedule



Providers are expected to bill the department their usual and customary charge (i.e., the amount they charge the general public). If the amount billed to the department exceeds the department's maximum, the amount paid will automatically be reduced to the maximum permitted.

Based on Medicare RVU units. Ceiling is 95-100% of Medicare RVUs and the floor is 40-45%.Each year, rates are reviewed to see if RVUs have changed in Medicare. No separate conversion factor. Look at RVUs of Medicare and base it on group code group average.

The department will reimburse physician assistants, physicians, physician group practices, and fee-for-service clinic for services provided by a physician assistant:(a) The lesser of the provider's billed charge or eighty-five per cent of the Medicaid maximum for all services billed in accordance with paragraph (C)(3) of this rule; and(b) The lesser of the provider's billed charge or one hundred per cent of the Medicaid maximum for all services billed in accordance with paragraph (C)(4) of this rule.

None Found

None Found

None Found

None Found

5101:3-4-02.2 Site Differential Payments and Place of ServiceThe site differential percentages are listed in appendix A to this rule. When the services identified in appendix A to this rule are provided in a hospital setting (i.e., inpatient, outpatient or emergency department), the maximum reimbursement will be either the lesser of the provider's billed charge or the product of the site differential percentage and the Medicaid maximum set forth in appendix DD to rule 5101:3-1-60 of the Administrative Code.

Out-of-state providers must be licensed, accredited, or certified by their respective states to be considered eligible to provide services to Ohio Medicaid consumers. Out-of-state providers must enroll as Ohio Medicaid providers in order to obtain reimbursement and must follow appropriate billing procedures in accordance with Chapter 5101:3-1 of the Administrative Code and Chapter 5101:3-3 of the Administrative Code for long term care nursing facility services.

None Found


None Found

Effective for dates of service on or after October 1, 2012, health home services are reimbursed using a monthly case rate based on cost information provided in accordance with guidance in OMB Circular A-87 or OMB Circular A-122 or the Medicare Provider Reimbursement Manual, Part 1The health home must provide the following information for the purposes of determining the monthly case rate:1. Medicaid Health Home Enrollee Caseload. 2. Medicaid Dedicated Health Home Staffing Costs3. Indirect Costs Related to the Provision of Health Home Services of Medicaid Enrollees.B. Calculation of the monthly case rate. The Medicaid Dedicated Health Home Staffing Costs for each team member role added to the Indirect Costs Related to the Provision of Health Home Services of Medicaid Enrollees equals the Medicaid Health Homes enrollee total annual cost. The monthly case rate for Medicaid Health Homes is calculated as follows:1. Divide the Medicaid Health Homes enrollee total annual cost by the caseload; then2. Divide the result of the calculation in paragraph B.1. of this rule by twelve.

(A) 5101:3-1-60.3 Primary care physician rate increase Except for circumstances described in paragraph (D) of this rule, the reimbursement to be paid to a qualified provider specified in paragraph (A) of this rule for rendering a service specified in paragraph (B) of this rule shall be the greater of two amounts:(1) The allowed amount applicable to the site of service that is derived from the "Medicare Part B Physician Fee Schedule" for the calendar year in which the service was rendered (www.cms.gov) ; or(2) The same allowed amount calculated with the conversion factor (CF) for calendar year 2009 in place of the CF for the calendar year in which the service was rendered.(D) If the provider's billed charge is less than the amount described in paragraph (C) of this rule, the reimbursement to be paid to a qualified provider shall be the billed charge.

(B) Primary Care Rate Increase Fee Schedule

None Found

None Found

5101:3-4-09 Office and Clinic Incentive Program(A) In order to encourage physicians and clinics to perform certain services and procedures in office or clinic settings instead of hospital settings, the department will make a payment of fifteen dollars, twenty-five dollars, or fifty dollars in addition to the normal payment made for the services or procedures listed in appendix A to this rule. The purpose of the additional payment is to compensate physicians for the additional cost they incur in performing services and procedures in a nonhospital setting.



Staff at Ohio Medicaid Office NA RBRVS

Yes


Summary Data

Ohio Administrative Code Rule 5101:3-1-60, Medicaid Reimbursement, Section J & L: http://emanuals.odjfs.state.oh.us/emanuals/GetDocument.do?doc=Document%28storage%3DREPOSITORY%2CdocID%3D%23Ref_OAC5101_3_1_60%29&locSource=input&docLoc=%24REP_ROOT%24%23Ref_OAC5101_3_1_60&username=guest&password=guest&publicationName=emanuals


Ohio Physician Services eManual, 5101:3-4-03 Physician Assistants, Section c.5: http://emanuals.odjfs.state.oh.us/emanuals/DataImages.srv/emanuals/pdf/pdf_books/PhysicianServices.pdf


Ohio Medicaid Fee Schedulehttp://emanuals.odjfs.state.oh.us/emanuals/DataImages.srv/emanuals/pdf/pdf_forms/3160APXDD.PDF

NA NF

NA NF

NA NF

NA Yes

NA NF

NA In-State

Ohio Medicaid Fee Schedulehttp://emanuals.odjfs.state.oh.us/emanuals/DataImages.srv/emanuals/pdf/pdf_forms/3160APXDD.PDFOhio Medicaid Fee Schedulehttp://emanuals.odjfs.state.oh.us/emanuals/DataImages.srv/emanuals/pdf/pdf_forms/3160APXDD.PDF

Ohio Administrative Code:http://codes.ohio.gov/oac/5101:3-4Ohio Physician Services eManual: http://emanuals.odjfs.state.oh.us/emanuals/DataImages.srv/emanuals/pdf/pdf_books/PhysicianServices.pdf

Ohio Physician Services eManual: (page 174)http://emanuals.odjfs.state.oh.us/emanuals/DataImages.srv/emanuals/pdf/pdf_books/PhysicianServices.pdf

Healthcheck Services(EPSTD) for Children Under Age 21http://jfs.ohio.gov/ohp/consumers/Healthchek.stmOhio Administrative Code:http://codes.ohio.gov/oac/5101:3-4Ohio Physician Services eManual: http://emanuals.odjfs.state.oh.us/emanuals/DataImages.srv/emanuals/pdf/pdf_books/PhysicianServices.pdf

Ohio Administrative Code, 5101:3-1-11, Out of State Coverage:http://emanuals.odjfs.state.oh.us/emanuals/GetDocument.do?docLoc=C%3A%2Fodjfs%2FReady4Build%2F99_GEN.htm%3ASRC%23%2F1%2F2%2F1%2F4%2F11%2F1&locSource=input&doc=Document(storage%3DREPOSITORY%2CdocID%3D%23Ref_OAC5101_3_1_60)&titleIndx=10&version=8.0.0

NA NF

NA NF

NA Yes

NA NF

NA Yes

Ohio Medicaid Copayments:http://jfs.ohio.gov/OHP/consumers/copay.stm


Ohio Home Health State Plan Amendment, Page 30-31: http://medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Approved-Health-Home-State-Plan-Amendments.html


(A) Appendix DD of Ohio Administrative Code Rule 5101:3-1-60.3 Primary care physician rate increase:http://codes.ohio.gov/oac/5101:3-1-60.3(B) Primary Rate Increase

NA NF

NA NF

NA



Ohio Admin. Code, Chapter 5101:3-4 Physician Services, 5101:3-4-09 Office incentive program.http://codes.ohio.gov/oac/5101:3-4-09

Office/Clinic Incentive Program


3/28/2013 8/12/2013

NA 8/15/2013

2/16/2009 7/16/2013

3/29/2013 8/12/2013


Documentation Date

Date Last Searched

NA

NA 7/16/2013

NA 7/16/2013

8/2/2011 8/12/2013

Not listed 7/16/2013

7/1/2005 8/12/2013

NA 7/16/2013

NA 8/12/2013

10/1/2012 7/16/2013

NA 7/16/2013

7/16/2013(A) 1/1/2013(B) Not Listed

NA 7/16/2013

NA 7/16/2013

3/30/2011 7/16/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Oklahoma


CategoryAdjustments


Fee Schedule Basis






Children vs. Adults

Out-of-State


Other





Health Home

Primary Care





States' Medicaid Fee-for-Service Physician Payment Policies - Oklahoma


Oklahoma

Title XIX Schedule

None found



Providers may not charge SoonerCare a higher fee than they charge non-SoonerCare patients even if the SoonerCare allowable is greater than the provider's usual and customary fee. Unless otherwise permitted by SoonerCare reimbursement methodology, individual claim payments are limited to the lesser of their usual and customary charge or the SoonerCare allowable.

Oklahoma has adopted the Medicare Resource Based Relative Value Scale (RBRVS) methodology as a benchmark for establishing fee-for-service payments to physicians and other limited licensed practitioners who bill the same as physicians.

Oklahoma uses the geographically adjusted relative value units (RVU) and two (2) conversion factors (CF) to determine the payment rates for all available CPT and HCPCS codes, with the exception of anesthesia.

(A) Certified Pediatric Nurse Practitioners (known as Advanced Practice Nurses under the Nurse Practice Act of Oklahoma) services payments are made in accordance with the established fee schedule rates described in Attachment 4.19-B. Page 3, (Payment for physicians' services {including remedial care and services}).

(B) Physician Assistants - Payment is made for services provided by licensed Physician Assistants within the current practice guidelines for the State of Oklahoma.

None found

None found

None Found

None Found

Copay is $3.00 for Physician Services

For each state fiscal year, the state will reimburse no more than 100% of the Medicare practitioner fee schedule rates in effect at the start of the year. As needed, rates will be adjusted to reflect changes in the Medicare rates at the beginning of each new state fiscal year. Except as otherwise noted in the plan, state developed fee schedule rates are the same for both governmental and private providers of EPSDT services and the fee schedule and any annual/periodic adjustments to the fee schedule are maintained on the Agency computer database, the Agency library, and are available to the public.

Certified Registered Nurse Anesthetists: Modifiers must be reported for each anesthesia service billed and will determine the rate of reimbursement to each provider for anesthesia services. Payment is made to Certified Registered Nurse Anesthetists at a rate of 80 percent of the allowable for physicians for anesthesia services without medical direction and at a rate of 50 percent of the allowable when medically directed.

Anesthesiologist Assistants: Modifiers must be reported for each anesthesia service billed and will determine the rate of reimbursement to each provider for anesthesia services. Payment is made to Anesthesiologist Assistants at a rate of 80 percent of the allowable for physicians for anesthesia services without medical direction and at a rate of 50 percent of the allowable when medically directed.



None Found

ACA Primary Care Fee Schedule

None found

None found

SoonerCare Choice is a Primary Care Case Management (PCCM) program in which each member has a medical home. The medical home provider will coordinate all health care services to qualifying Oklahomans.



NA RBRVS

NA No

NA Yes

NA NF


Summary Data

OHCA Policies and Rules, Part I General Scope and Administration, Section 317:30-3-5.1. Usual and Customary fees:https://okhca.org/xPolicyPart.aspx?id=538&chapter=30&subchapter=3&part=1&title=GENERAL%20SCOPE%20AND%20ADMINISTRATION


Oklahoma Medicaid Website: http://www.okhca.org/providers.aspx?id=646&menu=74

Oklahoma State Plan Attachment 4.19B (A) Page 32 (sheet 619 from 711) , (B) Page 3a-1(sheet 375 from 711):http://www.okhca.org/providers.aspx?id=122

Fee schedules: http://www.okhca.org/providers.aspx?id=102


NA NF

NA NF

NA NF

NA Yes

NA NF

NA $3.00

NA CRNA, AA


Oklahoma State Plan:http://www.okhca.org/providers.aspx?id=122OHCA Policies & Rules:https://okhca.org/xPolicyPart.aspx?id=538&chapter=30&subchapter=3&part=1&title=GENERAL%20SCOPE%20AND%20ADMINISTRATION

Oklahoma State Plan:http://www.okhca.org/providers.aspx?id=122OHCA Policies & Rules:https://okhca.org/xPolicyPart.aspx?id=538&chapter=30&subchapter=3&part=1&title=GENERAL%20SCOPE%20AND%20ADMINISTRATION

Oklahoma State Plan Attachment 4.19B (Page 16-Sheet 586 from 711):http://www.okhca.org/providers.aspx?id=122

Oklahoma State Plan :http://www.okhca.org/providers.aspx?id=122OHCA Policies & Rules:https://okhca.org/xPolicyPart.aspx?id=538&chapter=30&subchapter=3&part=1&title=GENERAL%20SCOPE%20AND%20ADMINISTRATION

Oklahoma State Plan Attachment 4.18A (Page 1-Sheet 499 from 711):http://www.okhca.org/providers.aspx?id=122

Oklahoma State Plan Attachment 4.18A (Page 20a)-Sheet 595 from 711):http://www.okhca.org/providers.aspx?id=122

NA No

NA NF

NA Yes

NA Yes

NA NF

NA NF


Oklahoma State Plan:http://www.okhca.org/providers.aspx?id=122Oklahoma Medicaid Website:http://www.okhca.org/providers.aspx?id=644&menu=74&parts=7747_7749

ACA Primary Care Fee Schedule:http://www.okhca.org/providers.aspx?id=102

OK Health Care Authority:http://www.okhca.org/individuals.aspx?id=548&menu=42




10/1/2008 8/19/2013


8/6/2013

7/1/2013 7/25/2013

NA 7/25/2013


Documentation Date

Date Last Searched

(A) 12/22/2000(B) 5/5/2010

NA 7/25/2013

NA 7/25/2013

NA 7/25/2013

6/8/2007 8/6/2013

NA 7/25/2013

10/13/2010 7/25/2013

9/2/2010 8/6/2013

NA 8/6/2013

NA 7/25/2013

1/1/2013 7/25/2013

NA 8/6/2013

NA 8/6/2013

NA 8/6/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Oregon


CategoryAdjustments


Fee Schedule Basis




Children vs. Adults

Out-of-State



Health Home

Primary Care



States' Medicaid Fee-for-Service Physician Payment Policies - Oregon


OregonAdjustments

Payment for services is a state-wide fee schedule which utilizes the RBRVS Scale, times the Oregon specific conversion factor.



The division pays the lesser of the usual and customary charge or a fee based on the methods outlined for the program according to Attachment 4.19-B. The provider‘s usual and customary fee is the fee charged by the provider to the general public for the particular service rendered.

Where applicable, the maximum allowable fees are established using the CMS Resource Based Relative Value (RBRVS) Scale methodology as published in the Federal Register annually, times an Oregon specific conversion factor. Except as otherwise noted in the plan, the agency‘s rates were set as of 8/1/11 and are effective for dates of services on or after that date.

State developed fee schedule rates are the same for both governmental and private providers.

Nurse Midwives: Payment for services by nurse midwives and other licensed nurse practitioners will be atthe same level as for physicians and independent clinical labs.

None Found

None Found

None Found

March 2013 Fee Schedule

(6) The Division’s maximum allowable rate setting process uses the following methodology for:(a) Relative Value Unit (RVU) weight-based rates: For all CPT/HCPCS codes assigned an RVU weight, the 2013 Total RVU weights published in the Federal Register, Vol. 77, November 16, 2012 with technical corrections published Dec. 14, 2012, to be effective for dates of services on or after January 1, 2013.

(A) For professional services not typically performed in a facility, the Non-Facility Total RVU weight;(B) For professional services typically performed in a facility, the Facility Total RVU weight;

None Found


FFS: For Contiguous out-of-state providers- The Division reimburses enrolled out-of-State providers in the same manner and at the same rates as in-state providers unless otherwise specified in the individual provider rules or by contract or service agreement with the individual provider.

Restrictions apply on non-contiguous out-of-state providers and services

Copayments only apply to adults (age 19 and over) who receive OHP Plus (BMH) or OHP with Limited Drug (BMM/BMD) benefits. With exceptions. DMAP charges a $3 copayment for certain types of outpatient services. Provider types and services subject to OHP Plus copayments include office visits.

None Found

None Found - Oregon has implemented Coordinated Care Organizations instead.

(3) Payment: The Division shall make per member per month (PMPM) payments based on the PCPCH clinic’s recognized tier and on the patient’s ACA status.(a) PCPCH payments are made as follows:(A) For fee-for-service (FFS) ACA-qualified patients, the amount of the PMPM shall be based on the PCPCH tier:(i) $ 10 for tier 1; (ii) $15 for tier 2 and; (iii) $24 for tier 3.(B) For FFS non-ACA-qualified patients, the amount of the PMPM shall be based on the PCPCH tier:(i) $2 for tier 1; (ii) $4 for tier 2 and; (iii) $6 for tier 3.

(A) Division of Medical Assistance Programs (DMAP) will apply the FFS rates based on the dates qualified providers submit their attestations. Only services rendered on or after Jan. 1, 2013 qualify for the new rates

(B) Primary Care ACA Increase Fee Schedule

None Found

Enhanced Teaching Physician and Other Practitioners Fee-For-Service Reimbursement:Effective April 1, 2005, physician services and other practitioner services provided by physicians and other practitioners affiliated with a public academic medical center that meets the following eligibility standards shall be eligible for a supplemental teaching physician and other practitioners payment for services provided to eligible recipients and paid for directly on a fee-for-service basis. Other practitioners include Clinical Psychologists and Psychiatrists, Dentists, Optometrists, Physician Assistants, Nurse Practitioners and Registered Nurses, Physical Therapists, and Occupational Therapists. Payment shall be equal to the difference between the physicians‘ and other practitioners‘ Medicare allowable for such services and Medicaid reimbursement received.



NA

NA RBRVS

NA No


Summary Data

OR State Plan Attachment 4-19B. Page 1(Sheet 82 from 240): http://www.oregon.gov/oha/healthplan/DataReportsDocs/Medicaid%20State%20Plan%20Attachment%204.10A%20through%204.42A%20%28248%20pages%29.pdf


OR State Plan Attachment 4-19B. Page 1 (Sheet 82 from 240):: http://www.oregon.gov/oha/healthplan/DataReportsDocs/Medicaid%20State%20Plan%20Attachment%204.10A%20through%204.42A%20%28248%20pages%29.pdf

OR State Plan Attachment 4-19B. Page 2 (Sheet 89 from 240): http://www.oregon.gov/oha/healthplan/DataReportsDocs/Medicaid%20State%20Plan%20Attachment%204.10A%20through%204.42A%20%28248%20pages%29.pdf

NA Yes

NA NF

NA NF

NA NF

Yes

Oregon Health Plan. OHP Fee Schedule for Fee-for-Service Providers: http://www.oregon.gov/oha/healthplan/pages/data_pubs/feeschedule/main.aspx

Oregon Health Plan. OHP Fee Schedule for Fee-for-Service Providers. Available at: http://www.oregon.gov/oha/healthplan/pages/data_pubs/feeschedule/main.aspx

Oregon Health Plan. OHP Fee Schedule for Fee-for-Service Providers. Available at: http://www.oregon.gov/oha/healthplan/pages/data_pubs/feeschedule/main.aspx

State Plan and State Plan Attachments: http://www.oregon.gov/oha/healthplan/Pages/reports.aspx

Oregon Admin Rules: http://arcweb.sos.state.or.us/pages/rules/oars_400/oar_410/410_120.html

Oregon Admin Rules 410-120-1340 : http://arcweb.sos.state.or.us/pages/rules/oars_400/oar_410/410_120.html

NA NF

NA In-State

NA $3



Oregon HealthyKids:http://www.oregonhealthykids.gov/families/cost.html


OAR: 410-120-1180 Medical Assistance Benefits: Out-of-State Services: http://arcweb.sos.state.or.us/pages/rules/oars_400/oar_410/410_120.html

Oregon Health Plan. Client Frequently Asked Questions, Client Copayments: http://www.oregon.gov/oha/healthplan/pages/data_pubs/faqs/copay.aspx


Oregon HealthyKids:http://www.oregonhealthykids.gov/families/cost.html


NA Yes

NA NF

NA Yes

NA No

A) Patient Centered Primary Care Homes (PCPCH). OAR 410-141-0860. Available at: http://www.oregon.gov/oha/healthplan/Pages/tools_prov/main.aspx#pcpchMedicaid Approved Health Home State Plan Amendments B) http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Approved-Health-Home-State-Plan-Amendments.html


Oregon Admin Rules: http://www.dhs.state.or.us/policy/healthplan/guides/genrules/main.html

(A) Primary care reimbursement changes under the Affordable Care Act: http://www.oregon.gov/oha/healthplan/pages/tools_prov/pcp-rates.aspx(B) Primary Care ACA Increase Fee Schedule: http://www.oregon.gov/oha/healthplan/tools/Federal%20primary%20care%20codes%20and%20rates%20-%20Updated%205-7-2013.pdf

Oregon Health Policy Board:http://www.oregon.gov/oha/OHPB/pages/health-reform/ccos.aspx

NA Yes

NA NF

OR State Plan Attachment 4-19B. Page 11 (Sheet 121 from 240):: http://www.oregon.gov/oha/healthplan/DataReportsDocs/Medicaid%20State%20Plan%20Attachment%204.10A%20through%204.42A%20%28248%20pages%29.pdf


Oregon Admin Rules: http://www.dhs.state.or.us/policy/healthplan/guides/genrules/main.html


Adjustments

8/6/2103

8/6/2013

8/6/2013


Documentation Date

Date Last Searched

3/9/2012

3/9/2012

2/4/2005

3/2013 8/6/2013

NA 7/26/2013

NA 7/26/2013

NA 7/26/2013

NA 8/7/2103

NA 8/7/2013

6/15/2013 7/5/2013

Not Listed 7/5/2013


8/7/2013

NA 7/26/2013

7/26/2013

Not Listed 8/7/2013

A) 3/22/2012B) 3/13/2012

(A) Not Listed(B) 1/1/2013

6/5/2006 8/6/2013

NA 7/26/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Pennsylvania


CategoryAdjustments


Fee Schedule Basis




Children vs. Adults

Out-of-State




Health Home


Primary Care




States' Medicaid Fee-for-Service Physician Payment Policies - Pennsylvania


Pennsylvania

None Found



Please note that MA pays the lesser of the following: the provider’s usual charge or the established MA fee for the service/item.

Defined by state through an internal process. Do not use Medicare RVU. Pennsylvania has a rate setting group and updates the fee schedule yearly, comparing rates with CMS provider rates and analyzing rates to make sure they pay less than Medicare (95% ceiling).


Certified Registered Nurse Anesthetist

None Found

Certified Registered Nurse Practitioner Fee ScheduleNurse Fee ScheduleCertified Nurse Midwife Fee Schedule

None Found

None Found

None Found

For all other MA covered services, the amount of the copayment is based on the MA fee for the service.For all recipients except for adult General Assistance MA recipients:If the MA fee is $2.00 through $10.00, the copayment is $.65.If the MA fee is $10.01 through $25.00, the copayment is $1.30.If the MA fee is $25.01 through $50.00, the copayment is $2.55.If the MA fee is $50.01 or more, the copayment is $3.80.For adult General Assistance MA recipients:If the MA fee is $2.00 through $10.00, the copayment is $1.30.If the MA fee is $10.01 through $25.00, the copayment is $2.60.If the MA fee is $25.01 through $50.00, the copayment is $5.10.If the MA fee is $50.01 or more, the copayment is $7.60.With exceptions.



None

None

None Found

(A) The Department of Public Welfare (Department) is implementing Section 1202 of the Patient Protection and Affordable Care Act (ACA). Section 1202 of the ACA requires state Medicaid programs to pay increased fees to qualifying physicians that are no less than the Medicare rates in effect in calendar years (CYs) 2013 and 2014, or if greater, the rates that would be applicable in those CYs using the CY 2009 Medicare Physician Fee Schedule conversion factor (CF). As such, the Department will increase fees for certain Evaluation and Management (E&M) and vaccine administration procedure codes to the extent covered by the Department.

(B) ACA Primary Care Services Fee for Service Fee Schedule - Statewide Average Office Rates 2013

ACCESS Plus provides physical health services to eligible MA recipients who are not enrolled in a voluntary Managed Care Organization (MCO) in the 42 Pennsylvania counties not serviced by HealthChoices. ACCESS Plus includes enhanced Primary Care Case Management and Disease Management.



Staff at Pennsylvania Medicaid Office NA

NA NF


Summary Data

PA PROMISE Provider Handbook, Page 111:http://www.dpw.state.pa.us/ucmprd/groups/webcontent/documents/form/s_001840.pdf



PA PROMISE Provider Handbook:http://www.dpw.state.pa.us/ucmprd/groups/webcontent/documents/form/s_001840.pdfPA Medical Assistance Eligible Handbookhttp://services.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ma/index.htmPA Provider Publications:http://www.dpw.state.pa.us/publications/forproviders/QuickTips/PA Admin Code:http://www.pacode.com/secure/data/055/chapter1141/055_1141.pdf

NA Yes

Yes

Yes

NF

Fee Schedule Rates: http://www.dpw.state.pa.us/publications/forproviders/schedules/mafeeschedules/outpatientfeeschedule/index.htmNote: Scroll down to "31-Physician"

Fee Schedule Rates: http://www.dpw.state.pa.us/publications/forproviders/schedules/mafeeschedules/outpatientfeeschedule/index.htmNote: Scroll down to "09-Certified registered Nurse Practitioner", "16-Nurse","33-Certified Nurse Midwife"

Fee Schedule Rates: http://www.dpw.state.pa.us/publications/forproviders/schedules/mafeeschedules/outpatientfeeschedule/index.htmNote: Scroll down to "32-Certified Registered Nurse Anesthetist"


NA NF

NA NF

NA NF

NA

PA PROMISE Provider Handbook:http://www.dpw.state.pa.us/ucmprd/groups/webcontent/documents/form/s_001840.pdfPA Medical Assistance Eligible Handbookhttp://services.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ma/index.htmPA Provider Publications:http://www.dpw.state.pa.us/publications/forproviders/QuickTips/

PA Medical Assistance Eligible Handbook, Section 338.61 EPSTD: http://services.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ma/index.htm


Chapter 338: Medical Assistance Benefits, Appendix D, Copayment Guidelines:http://services.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ma/index.htm


NA NF

NA No

NA NF




NA Yes

NA Yes

NA NF

NA NF

(A) PA Medical Assistance Bulletin on PA DPW Website:http://www.dpw.state.pa.us/provider/acaphysicianfeeincreasesforpcs/index.htm(B) Primary care Fee Schedule: http://www.dpw.state.pa.us/ucmprd/groups/webcontent/documents/bulletin_admin/p_034447.pdf

PA Medical Assistance Eligible Handbook, Section 309.521 - Access Plus:http://services.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ma/index.htm




7/29/2013 8/16/2013

NA 8/15/2013


Documentation Date

Date Last Searched




7/1/2013 7/17/2013

NA 7/17/2013

1/1/2011 7/17/2013

NA 7/17/2013

5/15/2012 7/17/2013

NA 7/17/2013

NA 8/12/2013

NA 8/12/2013



NA 8/12/2013

NA 7/17/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Rhode Island


CategoryAdjustments


Fee Schedule Basis






Children vs. Adults

Out-of-State






Health Home

Primary Care




States' Medicaid Fee-for-Service Physician Payment Policies - Rhode Island


Rhode Island

None Found

None Found



(A) 300.20.25 Medical Assistance (MA) Payment PolicyPayments to physicians and other providers of medical services and supplies are made on a fee for service basis in accordance with applicable federal and state rules and regulations, and established rates of reimbursement governing the Rhode Island Medical Assistance Program. Payments to physicians and other providers of medical services and supplies represent full and total payment. No supplementary payments are allowed. Direct reimbursement to recipients is prohibited except in the specific circumstances set forth in Section 0302.30.10 to correct an erroneous denial which is reversed on appeal.(B) Payment to physicians is the lesser of charges or the Rhode Island Medicaid Fee Schedule for Fee-for-Service.

Rhode Island has more than 50% capitated managed care. For Fee-for-Service, Rhode Island utilizes multiple conversion factors based on Medicare RVUs from 4 to 6 years ago.

90000 Series Codes - Medical Management Fee ScheduleG Codes - Procedure/Professional Services Fee ScheduleM Codes - Medical Services Fee Schedule

Surgery Fee Schedule

None Found

None Found

None Found

There is no co-pay required of recipients for physician services.


Payments to out-of-state providers enrolled in the Rhode Island Medical Assistance Program are made according to the usual, customary and reasonable (UCR) charges or the other state Medical Assistance Program fee for services, as appropriate for the provider of care. Payments made on a UCR basis may not exceed the least of: (1) the Medical Assistance fee determination for the same service in the State of Rhode Island or the other state Medical Assistance Program fee; or (2) the Medicare reasonable charge determination for the same service in the state where the service was provided.

None Found

None Found

None Found

(A) Community Mental Health Organization Health Home:The State will establish a fee structure designed to enlist participation of a sufficient number of providers in the Health Homes program so that eligible persons can receive the services included in the plan, at least to the extent that these are available to the general population. The State will pay for services under this section on the basis of a cost-related case rate encompassing all Health Home services. Basic Case Rate Methodology. The overall Community Mental Health Medicaid program utilizes a set of cost-related fees. In general, the process is based on a CMS approved methodology that utilizes reliable estimates of the actual costs to the provider agencies for staff and operating/support and then feeding those costs into a fee model. For Health Homes, the process also included the development of a standard core Health Home team composition and suggested caseload based on estimates of available staff hours and client need. (B) Rhode Island CEDARR Family Center Health Home:In 2009 Fixed Rates were developed for three CEDARR Services; Initial Family Intake and Needs Assessment (IFIND), Family Care Plan development (FCP), and Family Care Plan Review (FCPR). IFIND = $366.00 Family Care Plan (FCP) = $347 Family Care Plan Review (FCPR) = $397

Follows federal guidelines; The final details of this program are being worked out by Medicaid and our RI Medicaid Managed Care Organizations, Neighborhood Health Plan of Rhode Island and United Health Care.

None Found



NA

Staff at RI Medicaid Office NA RBRVS

NA NF

NA Yes

NA NF


Summary Data

(A) RI DHS Rules and Regulations Section 300.20.25 Medical Assistance Payment Policy:https://www.policy.dhs.ri.gov/0300.htm#_Toc361634374(B) Staff at RI Medicaid Office


RI Physician Coverage Policyhttp://www.dhs.ri.gov/ForProvidersVendors/ServicesforProviders/ProviderManuals/Physician/PhysicianPolicy/tabid/666/Default.aspx#15.5

RI Fee Schedule:http://www.dhs.ri.gov/ForProvidersVendors/MedicalAssistanceProviders/FeeSchedules/tabid/170/Default.aspx

RI Fee Schedules:http://www.dhs.ri.gov/ForProvidersVendors/MedicalAssistanceProviders/FeeSchedules/tabid/170/Default.aspx

NA Yes

NA NF

NA NF

NA NF

NA

NA No

NA NF

RI Surgery Fee Schedule:http://www.dhs.ri.gov/ForProvidersVendors/MedicalAssistanceProviders/FeeSchedules/tabid/170/Default.aspx

RI Medical Assistance Policy Guide:https://www.policy.dhs.ri.gov/0300.htm

RI Medical Assistance Policy Guide:https://www.policy.dhs.ri.gov/0300.htmRI Physician Coverage Policy EPSTD:http://www.dhs.ri.gov/ForProvidersVendors/ServicesforProviders/ProviderManuals/Physician/PhysicianPolicy/tabid/666/Default.aspx#15.9

Out-of-State and Emergency Claims:http://www.dhs.ri.gov/ForProvidersVendors/MedicalAssistanceProviders/ReferenceGuides/Waiver/OutofStateEmergencyClaims/tabid/691/Default.aspx

Lesser of charges or the out-of-state fee schedule - NTE lesser of FS or Medicare chargeRI Physician Coverage Policy:

http://www.dhs.ri.gov/ForProvidersVendors/ServicesforProviders/ProviderManuals/Physician/PhysicianPolicy/tabid/666/Default.aspx#15.5


NA Yes

NA No

Yes

No

NA No

(A) Rhode Island Community Mental Health Organization Health Home State Plan Amendment: http://www.chcs.org/usr_doc/Rhode_Island_2_-_Community_Mental_Health_Organization_Health_Homes.pdf(B) Rhode Island CEDARR Family Center Health Home State Plan Amendment:http://www.chcs.org/usr_doc/Rhode_Island_1_-_CEDARR_Family_Center_Health_Homes.pdf


Summary of Rhode Island Medicaid’s 2013-2014 Primary Care Rate Increase: http://www.dhs.ri.gov/Portals/0/Uploads/Documents/Public/Whats%20New/Memo%20to%20Providers%20re%20PCP%20bump_final_122112.pdf

Rite Care Fact Sheet: http://www.dhs.ri.gov/Portals/0/Uploads/Documents/Public/RCRS/rcrs_factsheet_eng.pdf


NA No




NA 9/10/2013

NA 7/17/2013

11/2012 8/8/2013

NA 8/8/2013


Documentation Date

Date Last Searched

Not listed 8/8/2013

NA 8/8/2013

NA 7/17/2013

NA 7/17/2013


Not Listed 8/8/2013

NA 7/17/2013

11/23/2011 8/8/2013

NA 8/8/2013

12/28/2012 8/8/2013

NA 8/8/2013

NA 8/8/2013

NA 8/8/2013

States' Medicaid Fee-for-Service Physician Payment Policies - South Carolina


CategoryAdjustments


Fee Schedule Basis







Children vs. Adults

Out-of-State



Health Home



Primary Care





States' Medicaid Fee-for-Service Physician Payment Policies - South Carolina


South Carolina

Family Practice, General Practice, Osteopath, Internal Medicine, Pediatrics, Geriatrics Fee Schedule

None Found



Providers may not charge Medicaid any more for services to a beneficiary than they would customarily charge the general public. Providers should bill their usual and customary charges and not the Medicaid reimbursement rate. Retroactive adjustments can only be made up to the billed amount. Medicaid will generally pay the lower of the established Medicaid reimbursement rate, determined by the program, or the provider’s charges.

(A) SCDHHS pays a percentage of Medicare for most claims and an enhanced percentage for an approved Specialist that provide services to children under the age of 18.

(B) All physician services will be reimbursed based on a Fee Schedule that in the aggregate will not exceed 100 percent of Medicare. For those procedures that are non-covered by Medicare, reimbursement is based on data collected within the Medicaid Management Information System or by a review conducted by medical personnel to establish the relative value.

PA: The reimbursement rate will be consistent with the South Carolina State Plan, which currently reflects 75% of the Medicare physician assistant’s fee schedule.CNMW: Reimbursement is 100% of the physician rate.Licensed MW: Reimbursement is 65% of the physician rate.NP: Reimbursement is 80% of the physician’s fee schedule for evaluation and management codes and all professional codes, and 100% for supplies and pathology services.

Obstetrics, OB/GYN, Maternal Fetal Medicine Fee ScheduleAll other physicians excluding Obstetrics, OB/GYN, Maternal Fetal Medicine Fee ScheduleAnesthesiologist Fee SchedulePediatric Subspecialist Fee Schedule

None Found

Facility and non-facility pricing for certain procedures in fee schedules

$3.30 for physician services



(A) EPSDT screening will be reimbursed at a uniform rate. Although screening services vary according to age and schedule, the reimbursement is intended to be an equitable average fee. Any other test or treatment service performed should be billed separately.

(B) Approved specialists receive an enhanced rate for services provided to children under the age of 18.

Payments to out-of-state providers shall be made based on the lesser of the fixed fee specified for the service or the charge for the service in the case of surgery, nonsurgery or treatment, therapy and testing services.

Surgical services shall be compensated based on the lesser of the charge for services or an all-inclusive fee. ICD-9-CM surgical procedures shall be classified by procedures of similar complexity which consume a like amount of resources. An all-inclusive fee shall be established for each class.

None Found

None Found

SCDHHS will implement 42 CFR Part 438, 441, and 447 for services provided January 1, 2013 through December 31, 2014. This action implements the Affordable Care Act (ACA) requirement that increases payments to physicians with a specialty designation of family medicine, general internal medicine, pediatric medicine, and related subspecialists for specified primary care services and charges for vaccine administration under the Vaccines for Children Program.

The Medical Homes Network (MHN) Program is a Primary Care Case Management (PCCM) program. An MHN is composed of a Care Coordination Services Organization (CSO) and the primary care providers (PCPs) enrolled in that network. The CSO supports the member physicians by providing care coordination, disease management, and data management. The PCPs manage the health care of their patient members either by directly providing medically necessary health care services or authorizing another provider to treat the beneficiary. The Network receives a per-member-per-month (PMPM) care coordination fee. Reimbursement for medical services provided is made on a fee-for-service basis.

South Carolina Medical University Providers – Supplemental Medicaid Payments:South Carolina Medical University providers are defined as those providers who are employed by or under contract with South Carolina Medical Universities and/or their component units. In Addition to fee for service payments, the SCDHHS will pay a quarterly, enhanced teaching fee to each participating South Carolina Medical University. The enhanced teaching payment will be equal to 35% of the actual, billed Medicaid charges. Total Medicaid reimbursement, which includes the fee for service payment and the enhanced teaching fee adjustment, shall not exceed the prevailing charges in the locality for comparable services under comparable circumstances for physician practices. For clinics, total Medicaid reimbursement, which includes the fee for service payment and the enhanced teaching fee adjustment, shall not exceed costs.



NA

NA % of Medicare

NA

NA Yes

NA NF

NA Yes


Summary Data

SC Medicaid Physicians Provider Manual, Section 1, Page 17:https://www.scdhhs.gov/sites/default/files/Section%201_97.pdf


(A) Staff at SC Medicaid Office(B) South Carolina State Plan Attachment 4.19b, Page 2a.2:https://www.scdhhs.gov/sites/default/files/ATTACHMENT%204.19-B_0.pdf

SC Medicaid Physicians Provider Manual, Section 2, Page 2-4 & 2-6:https://www.scdhhs.gov/sites/default/files/Section%202_21.pdf Ranges from 65%

to 100%

Fee Schedule:https://www.scdhhs.gov/resource/fee-schedules



NA NF

NA Yes

NA Yes

NA

NA $3.30

NA Surgery

NA No

A)Provider Manual:https://www.scdhhs.gov/internet/pdf/manuals/Physicians/Manual.pdfB) South Carolina State Plan Attachment 4.19b:https://www.scdhhs.gov/sites/default/files/ATTACHMENT%204.19-B_0.pdf


(A) SC Health Connections (Medicaid) Provider Manual, Page 2-64:https://www.scdhhs.gov/internet/pdf/manuals/Physicians/Manual.pdf(B) Staff at SC Medicaid Office

South Carolina State Plan Attachment 4.19b (Page 1e):https://www.scdhhs.gov/sites/default/files/ATTACHMENT%204.19-B_0.pdf


SC Healthy Connections (Medicaid) Provider Manual, Appendix 3 Copayment Schedule:https://www.scdhhs.gov/internet/pdf/manuals/Appendix%203.pdf

South Carolina State Plan Attachment 4.19b (Page 1c):https://www.scdhhs.gov/sites/default/files/ATTACHMENT%204.19-B_0.pdf


NA NF

NA Yes

NA Yes

Yes

NA NF

A) Provider Manual:https://www.scdhhs.gov/internet/pdf/manuals/Physicians/Manual.pdfB) South Carolina State Plan Attachment 4.19b:https://www.scdhhs.gov/sites/default/files/ATTACHMENT%204.19-B_0.pdf

SC Physicians Provider Manual, Section 2, Page 2-13:https://www.scdhhs.gov/sites/default/files/Section%202_21.pdf

SC Healthy Connections (Medicaid) Provider Manual, Page 1-1 to 1-2:https://www.scdhhs.gov/internet/pdf/manuals/Physicians/Manual.pdf

South Carolina State Plan Attachment 4.19b, Page 2c:https://www.scdhhs.gov/sites/default/files/ATTACHMENT%204.19-B_0.pdf

SC Admin Codes:http://www.scstatehouse.gov/code/t44c007.php

A) Provider Manual:https://www.scdhhs.gov/internet/pdf/manuals/Physicians/Manual.pdfB) South Carolina State Plan Attachment 4.19b:https://www.scdhhs.gov/sites/default/files/ATTACHMENT%204.19-B_0.pdf


4/1/2013 8/19/2013

9/11/2013

4/1/2013 8/7/2013

1/1/2013 7/26/2013

NA 7/26/2013

1/1/2013 7/26/2013


Documentation Date

Date Last Searched

(A) NA(B) 4/1/2011

NA 7/26/2013

NA 7/26/2013

9/11/2013

4/1/2011 7/26/2013

8/1/2011 8/7/2013

7/22/2011 8/7/2013

NA 8/7/2013

(A) 4/1/2013(B) Not listed

NA 7/26/2013

4/1/2013 8/7/2013

4/1/2013 8/7/2013

9/20/2002 8/7/2013

NA 7/26/2013

States' Medicaid Fee-for-Service Physician Payment Policies - South Dakota


CategoryAdjustments


Fee Schedule Basis






Children vs. Adults

Out-of-State






Health Home

Primary Care



States' Medicaid Fee-for-Service Physician Payment Policies - South Dakota


South Dakota

Physician Fee Schedule - Non-Laboratory and Laboratory Procedures - Other and Primary Care

None Found



A claim submitted must be submitted at the physician’s usual and customary charge. Payment is limited to the lesser of the physician’s usual and customary charge or the fee established under the following provisions:▪ For non-laboratory procedures not listed in the physician fee schedule, 40% of the physician’s usual and customary charge.▪For laboratory procedures not listed in the physician fees schedule, 60% of the physician’s usual and customary charge.

Based on a % of Medicare. For rates not included in Medicare (e.g., Pregnancy), look at surrounding state's fee schedules and the historical data on U&C charges provider's have submitted for payment in SD.

Services Provided By Nurse Midwife Or Nurse Anesthetist Services provided by a nurse midwife or a nurse anesthetist are reimbursed at the same rate as when a physician provides the service. Services Provided By Nurse Practitioner Or Physician's AssistantExcept for laboratory services, radiological services, immunizations, and supplies, services provided by a nurse practitioner or a physician’s assistant are reimbursed at 90% of the physician’s established fee. Reimbursement for laboratory services, radiological services, immunizations, and supplies provided by a nurse practitioner or a physician’s assistant are reimbursed according to ARSD § 67:16:02:03

Podiatric Services Fee Schedule

None Found

None Found

None Found

None Found

None Found



None Found

Enhanced Primary Care Payments Fee Schedule

South Dakota Medicaid’s Managed Care Program, Provider and Recipient in MedicaidEfficiency Program (PRIME), is based on the primary care case management (PCCM) model.The Program is operational statewide, is applicable for recipients eligible under Title XIX and Title XXI of the Social Security Act and is administered by the South Dakota Department of Social Services Division of Medical Services. Reimbursement is based on fee-for-servicemethodology plus a monthly case management fee.

Case management fee of $3.00 for each recipient who is enrolled with that physician, regardless of whether the physician has provided services to that recipient during the month. Moreover, for services rendered by primary care physicians to recipients who have chosen that physician (e.g., recipients on that physician’s monthly primary care caseload) the Program has made an additional provision to include any applicable cost-share amount into the payment for services.

None Found

None Found



NA

Staff at SD Medicaid Office NA % of Medicare

NA 90%

NA Yes

NA NF


Summary Data

SD Medicaid Professional Services Billing Manual: Pages 21-22:http://dss.sd.gov/sdmedx/includes/providers/billingmanuals/docs/Professional%208.12.13.pdf


SD Professional Services Provider Billing Manual, Page 25: http://dss.sd.gov/sdmedx/includes/providers/billingmanuals/

SD Medicaid Fee Schedule: http://dss.sd.gov/sdmedx/includes/providers/feeschedules/dss/index.aspx


NA Yes

NA NF

NA NF

NA NF

NA NF

NA NF

NA NF


SD Medicaid Professional Services Billing Manual:http://dss.sd.gov/sdmedx/includes/providers/billingmanuals/docs/Professional%205.6.13.pdf





South Dakota Medicaid Report: Page 14:http://dss.sd.gov/SDMedicaidReport.pdf


NA No

NA NF

NA Yes

NA Yes


SD Providers: Become a Provider: https://dss.sd.gov/sdmedx/includes/providers/becomeprovider/index.aspxSD Medicaid State Plan Attachment 4.19-B: http://dss.sd.gov/medicalservices/medicaidstateplan/index.aspSD Profession Services Provider Manual: http://dss.sd.gov/sdmedx/includes/providers/billingmanuals/SD Admin Code:http://legis.state.sd.us/rules/TextSearch.aspx


SD Medicaid Professional Services Billing Manual: Pages 40-41:http://dss.sd.gov/sdmedx/includes/providers/billingmanuals/docs/Professional%208.12.13.pdf

NA NF

NA NF




8/12/2013 7/18/2013

NA 8/22/2013

8/12/2013 8/14/2013

7/1/2013 7/18/2013

NA 7/18/2013


Documentation Date

Date Last Searched

7/1/2013 7/18/2013

NA 8/7/2013

NA 7/18/2013

NA 7/18/2013

NA 7/18/2013

NA 7/18/2013

NA 8/6/2013

NA 7/18/2013

NA 7/18/2013

6/11/2013 7/18/2013

8/12/2013 8/14/2013

NA 8/7/2013

NA 8/7/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Tennessee


CategoryAdjustments


Fee Schedule Basis






Children vs. Adults

Out-of-State






Health Home

Primary Care





States' Medicaid Fee-for-Service Physician Payment Policies - Tennessee


Tennessee

NF

Not available - available through individual MCO plans




Physician service payment is not to exceed the lesser of :(1) the billed amount,(2) 85% of the usual and customary charges accumulated by each individual physician, or(3) 85% of the 75th percentile of the range of weighted customary charges by physicians in the state (Physicians profile) for the 1984 calendar year .

This methodology applies only to services which were formerly covered under the TennCare managed care program:

Physician Assistant or Nurse Midwife or Certified Pediatric or Family Nurse Practitioner (only during designated emergency period): Payment is not to exceed the lesser of:For Services Covered by Medicare: 1. Billed amount or 2. 85% of the Medicare rate for the procedureFor Services Not Covered by Medicare: 1. Billed amount or 2. State Fee Schedule


None Found

None Found

None Found


(Emergency Payment Methodology) For EPSD&T services which are covered by Medicare, payment is not to exceed the lesser of (1) the billed amount; or (2) 85% of the Medicare rate for the procedure. For EPSD&T services which are not covered by Medicare, EPSD&T services payment is not to exceed the lesser of: (1) the billed amount; or (2) an amount established under a state fee schedule. Aggregate payment will not exceed amounts that could reasonably be estimated would have been paid under Medicare payment principles.

TennCare Medicaid adults have pharmacy co-pays only . You don't pay co-pays for other TennCare services. But, TennCare Standard members with incomes at or above 100% of poverty do have co-pays for other kinds of services.100-199% of Poverty:$5.00, Primary Care Provider and Community Mental Health Agency Services Other Than Preventive Care$5.00, Physician Specialists (including Psychiatrists)200% and above:$15.00, Primary Care Provider and Community Mental Health Agency Services Other Than Preventive Care$20.00, Physician Specialists (including Psychiatrists)

CRNA: Payment for services provided with medical direction will be the lesser of billed charges or forty-four percent (44%) of what would have been paid to a physician for similar services.Payment for services provided without medical direction will be the lesser of billed charges or eighty percent (60%) of what would have been paid to a physician for similar services.


None Found

None Found

None Found

None Found

Follows federal guidelines. Rates do not reflect site of service adjustments, but reimburse at the Medicare rate applicable to the office setting. Rates are statewide and reflect the mean value over all counties for each of the specified E&M and vaccine billing codes. The state has adjusted its FS to make payment at the higher rate for each E&M and vaccine admin code. Payment is made for certain E&M codes.



NA

NA NF

NA

NA NF

NA NF


Summary Data

State Plan Attachment 4.19b (Sheet 23 from 156): http://www.tn.gov/tenncare/forms/4-19-b.pdf


TN State Plan MCO Waiver, Page 46:http://www.tn.gov/tenncare/forms/tenncarewaiver.pdf

State Plan Attachment 4.19b: http://www.tn.gov/tenncare/forms/4-19-b.pdf

85% Medicare or 100% Medicaid FS

State Plan Attachment 4.19b:http://www.tn.gov/tenncare/pol-stateplan.shtmlAdditional search of key terms in Google


NA NF

NA NF

NA NF

NA No

NA NF

NA

NA CRNA






TennCare. For Members/Applicants: http://www.tn.gov/tenncare/mem-copayments.shtml


State Plan Attachment 4.19b: http://www.tn.gov/tenncare/forms/4-19-b.pdf

NA No

NA NF

NA Yes

NA NF

NA NF

NA NF


State Plan Attachment 4.19b: http://www.tn.gov/tenncare/forms/4-19-b.pdfAdditional search of key terms in Google

TennCare Primary Care Physician Enhanced Rates: http://www.tn.gov/tenncare/pro-enhancedrates.shtmlState Plan Attachment 4.19b, Page 672(c): http://www.tn.gov/tenncare/forms/4-19-b.pdf





4/1/1990 8/8/2013

NA 8/22/2013

9/21/2000 8/15/2013

NA 7/15/2013

NA 7/15/2013


Documentation Date

Date Last Searched

NA 7/15/2013

NA 7/15/2013

NA 7/15/2013

9/21/2000 7/15/2013

NA 7/15/2013


8/29/1989 7/15/2013

NA 7/15/2013

NA 7/15/2013

5/29/2013 8/15/2013

NA 7/15/2013

NA 8/15/2013

NA 8/15/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Texas


CategoryAdjustments


Fee Schedule Basis



Children vs. Adults







Out-of-State



Health Home


Primary Care




States' Medicaid Fee-for-Service Physician Payment Policies - Texas


Texas



Texas Medicaid reimburses certain providers based on rates published in the OFL (Online Fee Lookup) and static fee schedules. These rates are uniform statewide and by provider type. According to this type of reimbursement methodology, the provider is paid the lower of the billed charges or the Medicaid rate published in the applicable static fee schedule or OFL. The Medicaid rates for physicians and other practitioners are calculated in accordance with 1 TAC §355.8085.

Resource-based fees (RBFs) are based on actual resources required by an economically efficient provider to deliver each individual service and are calculated by multiplying the applicable RVU times a conversion factor. HHSC will review any changes to or revisions to the various Medicare RVUs and, if applicable, adopt the changes as part of the RBF fee schedule.HHSC may develop and apply multiple conversion factors for various classes of service, such as obstetrics, pediatrics, general surgeons, and/or primary care services. The following conversion factors are applied and are reflected on the fee schedule for services provided by physicians and other practitioners on the agency's website: $26.7305- physicians and other practitioners primarily applied to adult procedure codes $28.0672 - physicians and other practitioners applied to children's procedure codesAccess-based fees (ABFs) are developed to account for deficiencies in RBFs relating to adequacy of access to health care services for Medicaid clients and are based upon: (1) historical charges; (2) current total Medicare fee (i.e. RVU times Conversion Factor) for the individual service; (3) review of Medicaid fees paid in other states; (4) survey of providers' costs to provide the individual service; (5) Medicaid fees paid for similar services; and/or (6) some combination or percentage thereof. General guidelines used when updating Medicaid fees for services provided by physicians and other practitioners, include, but not limited to the following: updating the Medicaid relative value units (RVUs) to those currently in effect for Medicare and multiplying the updated RVUs by the current Medicaid conversion factor to result in an updated resource-based fee; increasing the Medicaid conversion factor to increase RBFs for which no RVU update is required in order to increase access to services; changing an existing RBF to an access-based fee (ABF) when the RBF methodology does not provide sufficient access to care; and changing an existing ABF to a RBF as appropriate.


CNW,MW, and PA Fee Schedules

There is no geographical or specialty reimbursement differential for individual services.


(A) NPs: Effective for services delivered on and after March 1, 2006, covered professional services provided by a nurse practitioner (NP) or a clinical nurse specialist (CNS) and billed under the NP's or CNS' own provider number are reimbursed the lesser of the NP's or CNS' billed charges or 92% of the reimbursement for the same professional service paid to a physician (M.D. or D.O.). NPs and CNSs are reimbursed at the same reimbursement level as physicians for laboratory services, x-ray services, and injections.(B) Nurse Midwives : (a) Certified Nurse Midwives. (1) Effective for services delivered on and after March 1, 2006, covered professional services provided by a certified nurse midwife (CNM) and billed under the CNM's own provider number are reimbursed the lesser of the CNM's billed charges or 92% of the reimbursement for the same professional service paid to a physician (M.D. or D.O.). (2) CNMs are reimbursed at the same reimbursement level as physicians for laboratory services, x-ray services, and injections. (b) Licensed Midwives. Effective for services delivered on and after January 1, 2013, covered professional services provided by a licensed midwife (LM) and billed under the LM's own provider number are reimbursed the lesser of the LM's billed charges or 70% of the reimbursement for the same professional service paid to a physician (M.D. or D.O.).

Certified Registered Nurse Anesthetist, Allergy, Anesthesiology, Cardiovascular Disease, Dermatology, Gastroenterology, General Surgery, Genetics, Geriatrics, Internal Medicine, Nephrology, Neurology, Neurosurgery, Nuclear Medicine, Ob/Gyn, Ophthalmology, Orthopedic Surgery, Other, Otorhinolaryngology, Pathologist, Pediatrics, Physical Medicine And Rehabilitation, Plastic Surgery, Proctology, Pulmonary Disease, Radiation Therapy, Radiologist, and Thoracic Surgery

The following conversion factors are applied and are reflected on the fee schedule for services provided by physicians and other practitioners on the agency's website: $26.7305- physicians and other practitioners primarily applied to adult procedure codes $28.0672 - physicians and other practitioners applied to children's procedure codes



None Found

Payments to out-of-state providers enrolled in Texas Medicaid are made according to the usual, customary, and reasonable charges or the stipulated fee for services as appropriate for the provided care.Reimbursement may not exceed the lesser of:• The Medicaid reasonable charge or fee determined for the same services in Texas; or• If agreed to by HHSC, 100 percent of the Medicare reasonable charge determination for the same service in the state where the service was provided.

Medicaid Copayment by FPL Current Max Allowable<100% FPL $0 $2.45101-150% FPL $0 $3.00151-185% FPL $0 $6.00

Nurse Anesthetist (CRNA):Effective for services delivered on and after March 1, 2006, covered anesthesia services provided by a certified registered nurse anesthetist (CRNA) are reimbursed the lesser of the CRNA's billed charges or 92% of the reimbursement for the same anesthesia service paid to a physician (M.D. or D.O.) anesthesiologist.

The state is working with CMS to get federal approval for the state’s plan to increase primary care rates.

None Found

None Found

No; "As of March 1, 2012, the PCCM program is no longer available. Medicaid clients who were covered by PCCM have been assigned to Medicaid managed care organizations (MCOs).



NA

NA RBRVS


Summary Data

Texas Medicaid Provider Procedures Manual, Volume 1, Section 2.2.1 Online Fee Lookup (OFL) and Static Fee Schedules, Page 2-2:http://www.tmhp.com/pages/medicaid/Medicaid_Publications_Provider_Manual.aspx


Texas State Medicaid Plan, Attachment 4.19-B, page 1a-1a.2: http://www.hhsc.state.tx.us/medicaid/StatePlanDocs/BasicStatePlanAttachments.pdf

NA

NA Yes

NA Yes

NA Yes

NA No

NA Yes

NA Yes

(A) Tex. Admin. Code tit. 1, Part 15, Chapter 355, Subchapter J, Division 15, Rule § 355.8281: http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=1&pt=15&ch=355&rl=8281(B) Tex. Admin. Code tit. 1, Part 15, Chapter 355, Subchapter J, Division 9, Rule § 355.8161: http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=4&ti=1&pt=15&ch=355


Fee Schedules: http://public.tmhp.com/FeeSchedules/StaticFeeSchedule/FeeSchedules.aspx



Tex. Admin. Code tit. 1, Part 15, Chapter 355, Subchapter J, Division 5, Rule §355.8085http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=1&pt=15&ch=355&rl=8085


Texas State Medicaid Plan. Attachment 4.19-B, page 1a-1a.2: http://www.hhsc.state.tx.us/medicaid/StatePlanDocs/BasicStatePlanAttachments.pdf

NA

NA $0

NA CRNA

NA No

NA NF

TX Medicaid Provider Manual. June 2013: http://www.tmhp.com/pages/medicaid/Medicaid_Publications_Provider_Manual.aspx

Lesser of in-state fee schedule or Medicare rate

Presentation to Senate Finance Committee on Cost Savings Proposals for Medicaid and CHIP Cost Sharing:http://www.hhsc.state.tx.us/news/presentations/2011/sfc-co-pay-0211.pdf

(A) Tex. Admin. Code tit. 1, Part 15, Chapter 355, Subchapter J, Division 12, Rule § 355.8221: http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=1&pt=15&ch=355&rl=8221


Texas Administrative Code:http://www.sos.state.tx.us/tac/index.shtmlTexas State Plan Amendment:http://www.hhsc.state.tx.us/medicaid/StatePlan.htmlProvider Manual:http://www.tmhp.com/pages/medicaid/Medicaid_Publications_Provider_Manual.aspxAdditional search of key terms in Google

NA Yes

NA No

NA NF

NA NF

TMHP Attestation Form: http://www.tmhp.com/News_Items/2013/03-Mar/03-08-13%20Attestation%20Form%20Now%20Available%20for%20Qualified%20Primary%20Care%20Providers%20to%20Receive%20ACA%20Rate%20Increase.pdf

Texas Primary Care Case Management Website: http://www.tmhp.com/Pages/PCCM/PCCM_Home.aspx




8/2013 8/23/2013

8/30/2012 7/5/2013


Documentation Date

Date Last Searched

7/11/2013 7/15/2013

7/11/2013 7/15/2013

7/11/2013 7/15/2013

4/30/2013 7/3/2013

4/4/2013 7/5/2013

8/30/2012 7/5/2013

(A) 7/01/2006 (B) 1/01/2013

(A) 7/15/2013

(B) 7/15/2013

6/1/2013 7/5/2013

2/23/2011 8/27/2013

7/1/2006 7/15/2013

NA 7/5/2013

NA 7/5/2013

3/8/2013 7/9/2013

Not Listed 7/5/2013

NA 7/5/2013

NA 7/5/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Utah


CategoryAdjustments


Fee Schedule Basis



Children vs. Adults

Out-of-State




Health Home

Primary Care



States' Medicaid Fee-for-Service Physician Payment Policies - Utah


Utah



Physicians (Except Anesthesiologists)Payment will be based on the established fee schedule unless a lesser amount is billed. The amount billed cannot exceed usual and customary charges to private pay patients. Generally, a single fee is established for each procedure code regardless of provider specialty.

Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers.

All rates are published and maintained on the agency’s website. Specifically, the fee schedule and any annual/periodic adjustments to the fee schedule are published at http://health.utah.gov/medicaid/.

Fee Schedule Based on Relative ValuesThe physician fee schedule is based on relative value units unless otherwise specified in this Section D.

The physician fee schedule is re-based July 1, 2013, using then current relative value units (RVUs). The agency's rates were set as of July 1, 2013, and are effective for services delivered on or after that date. The total RVUs for any procedure code will be based on the Medicare formula for that calendar year. A corresponding conversion factor will also be established such that total projected payments to physicians will not increase or decrease as a result of the annual rate update. The conversion factor may also include any changes established by the economic index discussed in Subsection 4.

Physician (Traditional Medicaid Practice)

Certified Nurse Midwife, Nurse Practitioner, Nurse Anesthetist

Podiatrist

(A) Licensed Certified Nurse Midwife ServicesPayments are based on the established fee schedule for selected HCPCS codes unless a lower amount is billed. Selected HCPCS codes are established in compliance with HIPAA requirements. The amount billed cannot exceed usual and customary charges to private-pay patients. (B) Pediatric and Family Nurse PractitionersApproved codes listed in the physicians’ Current Procedural Terminology (CPT) manual may be billed by licensed pediatric and family nurse practitioners. The approved codes will be designated by the Division of Health Care Financing. Payment for approved services will be made at the lower of the usual and customary charge or the established physician’s fee schedule.

(A) Enhanced Payment Rates in Rural Areas:Physicians, including persons providing services under the direct supervision of a physician as allowed by state law, providing services in rural areas of the state are paid a rate differential equal to 112 percent of the physician fee schedule. Rural areas are defined as areas of the State of Utah outside of Weber, Davis, Salt Lake and Utah counties.

(B) CRNW: Effective October 1, 1991, Licensed Certified Registered Nurse-Midwives who provide services in rural areas of the State will be paid the lower of usual and customary charges or rate equal to 112% of the established Medicaid fee schedule. Rural areas are defined as areas of the State outside of Weber, Davis, Salt Lake and Utah counties.

Pediatric and Family Nurse Practitioners: Rate Adjustment for Rural Areas -The 12% rate differential, not to exceed usual and customary charges, will be paid for services rendered in rural Utah. Rural Utah is defined as areas of the State outside of Weber, Davis, Salt Lake and Utah counties.

None Found

None Found


Reimbursement For Out-of-State Providers Payment For ServicesExcept as otherwise specified in this Attachment, 4.19-B, out-of-state providers are reimbursed using the reimbursement methodology in effect for those services; however, as needed, the state will negotiate rates directly with out-of-state providers in order to secure access to care for clients needing specialized services through an out-of-state provider.

$3 Copay for Office Visit & Outpatient Services. No copay for preventative care or immunizations. With exceptions.

Utah Medicaid Anesthesia Fee ScheduleUse this information to determine the applicable fee for anesthesia codes billed to Utah Medicaid based on anesthesia base units. To determine the anesthesia base units for any given code please use the Fee Schedule Lookup Tool.Use the formula below to calculate the total reimbursement amount for anesthesia codes billed to Utah Medicaid. Use the table below to determine the conversion factor for the applicable date of service.Date Factor: 7/1/2013 $18.27


None found

Follows federal guidelines; Rates do not reflect site of service adjustments, but reimburse at the Medicare rate applicable to the office setting. The rates reflect all Medicare geographic/locality adjustments. The state reimburses a supplemental amount equal to the difference between the Medicaid rate in effect on the date of service as published in the agency’s fee schedule described in Attachment 4.19-B, Section D Physician Services, of the State Plan and the minimum payment required at 42 CFR 447.405. Only covers select E&M codes.

R414-140-7. Reimbursement Methodology: The PIHPs are paid under a non-risk arrangement as described in 42 CFR 447.362. The Department's payments to the health plans may not exceed what the Department would have paid on a fee-for-service basis for services furnished to health plan enrollees plus the net savings of administrative costs the Department achieves by contracting with the health plans instead of purchasing the services on a fee-for-service basis. The PCCM providers are paid under a fee- for-service arrangement. In addition, a fee is paid to cover the provision of case management services.

None found

None found



NA

NA RBRVS


Summary Data

Utah Medicaid State Plan Attachment 4.19B, Section D-1, Page 4:http://www.health.utah.gov/medicaid/stplan/A_4-19-B.pdf


Utah Medicaid State Plan Attachment 4.19B, Section D-2, Page 4: http://www.health.utah.gov/medicaid/stplan/A_4-19-B.pdf

NA No

NA Yes

NA Yes

NA Yes

NA Yes

Utah Medicaid State Plan Attachment 4.19B, Section D-2, Pages 21 & 21a:http://www.health.utah.gov/medicaid/stplan/A_4-19-B.pdf

Utah Medicaid Fee Schedule Lookup & Download (Excel Sheet):http://health.utah.gov/medicaid/stplan/lookup/FeeScheduleDownload.php

Utah Medicaid Fee Schedule Lookup & Download (Excel Sheet): http://health.utah.gov/medicaid/stplan/lookup/FeeScheduleDownload.php

Utah Medicaid Fee Schedule Lookup & Download (Excel Sheet): http://health.utah.gov/medicaid/stplan/lookup/FeeScheduleDownload.php

(A) Utah Medicaid State Plan Attachment 4.19B, Section D-7: Enhanced Physician Rates, Page 4c:http://www.health.utah.gov/medicaid/stplan/A_4-19-B.pdf

(B) Utah Medicaid State Plan Attachment 4.19B, Section D-2, Pages 21 & 21a:http://www.health.utah.gov/medicaid/stplan/A_4-19-B.pdf

NA NF

NA NF

NA In-State

NA $3

NA Anesthesia

Utah Medicaid State Plan Attachment 4.19B, Section D: Physicians:http://www.health.utah.gov/medicaid/stplan/A_4-19-B.pdf & Utah Medicaid Physician Manual:http://www.health.utah.gov/medicaid/manuals/pdfs/Medicaid%20Provider%20Manuals/Physician%20And%20Anesthesiology/SECTION%202%20-%20Physician%20Services/physician7-13.pdf


Utah Medicaid State Plan Attachment 4.19B, Section D: Physicians, Page 32:http://www.health.utah.gov/medicaid/stplan/A_4-19-B.pdf

Utah Medicaid Member Guide, NonPregnant Adults Copay Chart, Page 25:http://health.utah.gov/umb/forms/pdf/mg_w_cover.pdf

Utah Medicaid Anesthesia Fee Schedule:http://health.utah.gov/medicaid/stplan/physician.htm

NA No

NA No

NA Yes

NA Yes



Utah Medicaid State Plan Attachment 4.19-B, Page 4e:http://www.health.utah.gov/medicaid/stplan/A_4-19-B.pdf

Utah Admin. Code: Rule R414-140. Choice of Health Care Delivery Program, R414-140-7. Reimbursement Methodology: http://www.rules.utah.gov/publicat/code/r414/r414-140.htm#E11

NA NF

NA NF

Utah Medicaid State Plan Attachment 4.19B, Section D: Physicians:http://www.health.utah.gov/medicaid/stplan/A_4-19-B.pdf & Utah Medicaid Physician Manual:http://www.health.utah.gov/medicaid/manuals/pdfs/Medicaid%20Provider%20Manuals/Physician%20And%20Anesthesiology/SECTION%202%20-%20Physician%20Services/physician7-13.pdfUtah Medicaid Provider Manual: Sections 1 and 2: http://www.health.utah.gov/medicaid/provhtml/table_of_contents.htm

Utah Medicaid State Plan Attachment 4.19B, Section D: Physicians:http://www.health.utah.gov/medicaid/stplan/A_4-19-B.pdf & Utah Medicaid Physician Manual:http://www.health.utah.gov/medicaid/manuals/pdfs/Medicaid%20Provider%20Manuals/Physician%20And%20Anesthesiology/SECTION%202%20-%20Physician%20Services/physician7-13.pdfUtah Medicaid Provider Manual: Sections 1 and 2: http://www.health.utah.gov/medicaid/provhtml/table_of_contents.htm


5/16/2013 7/18/2013

5/16/2013 7/18/2013


Documentation Date

Date Last Searched

7/18/2013

NA 7/18/2013

NA 7/18/2013

NA 7/18/2013

7/23/2013

A) 2/4/2004B) 2/28/1992

Physicians: 2/13/2013

CRNW: 2/4/2004

NA 7/23/2013

NA 7/18/2013

11/22/2011 7/23/2013

7/2012 7/18/2013


NA 7/23/2013

NA 7/23/2013

6/17/2013 8/19/2013

9/9/2009 7/23/2013

NA 7/23/2013

NA 7/23/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Vermont


CategoryAdjustments


Fee Schedule Basis







Children vs. Adults

Out-of-State





Health Home

Primary Care




States' Medicaid Fee-for-Service Physician Payment Policies - Vermont


Vermont

Global "Provider" Fee Schedule

None Found

None Found



Payment for a service rendered by a physician (M.D or D.O.) is made at the lower of the actual charge for theservice or the Medicaid rate on file. Except as otherwise noted in the plan, State developed fee schedule rates are the same for both governmental and private.

Most rates were set using the Medicare Resource Based Relative Value Scale payment methodology. For services payable in Medicare’s Resource Based Relative Values Scale payment methodology, the DVHA is utilizing the Medicare RBRVS RVUs, the Medicare GPCIs and State determined conversion factors as specified in Section 26.

Certified pediatric or family nurse practitioner services are reimbursed at the lower of the actual charge orthe Medicaid rate on file for a physician providing the same service.

Licensed nurse-midwife services are reimbursed at the lower of the actual charge or the Medicaid rate on filefor a physician providing the same service.

None Found


None Found

None Found

None Found

None foundIncentive or Add-on Payments


None found

(A) Follows federal guidelines. Rates do not reflect site of service adjustments, but reimburse at the Medicare rate applicable to the office setting. Rates reflect all Medicare geographic/locality adjustments. The state has adjusted its fee schedule to make payment at the higher rate for each E&M and vaccine administration code. Applies to select E&M codes.

(B) PCP Enhanced Rate Fee Schedule

Primary Care Plus (PC PLUS): In addition to fee-for-service reimbursement, PCPs will be paid a monthly case management fee for each member assigned to their practice. PCPs receive a monthly case management fee for each member enrolled with the PCP. This fee is for coordinating members’ health care services, regardless of whether the member is seen. When services are provided, the Medicaid fee-for-service reimbursement applies.

In addition to fee-for-service reimbursement, PCPs will be paid a monthly case management fee for each member assigned to their practice. The PCP does not need to file a claim for the case management fee. Claims for the monthly fee will be generated by HPES based on the number of members enrolled in the practice and payment will appear on the Remittance Advice (RA). Actual services provided to members will be reimbursed on a fee-for-service basis in accordance with Vermont Medicaid fee-for-service payment policies and procedures.

A supplemental payment will be made for services provided by Qualified Teaching Physicians (QTP) in an amount equal to the difference between the Medicaid payments otherwise made for the services and payments at the Average Commercial Rate. Only the professional component of a procedure is eligible for a supplemental payment. Payment will be made quarterly and will not be made prior to the delivery of services.

QTPs include physicians who hold salaried appointments on the faculty of the UVM College of Medicine and are employed by UVM Medical Group.

None found



NA

NA RBRVS

NA No

NA Yes

NA NF

NA NF


Summary Data

Vermont State Plan Attachment 4.19B, Page 3:http://dvha.vermont.gov/administration/7attachment-4.19-b.pdf




Fee Schedule: http://dvha.vermont.gov/for-providers/2013-fee-schedules



NA NF

NA Yes

NA NF

NA NF

NA NF

NA NF

Vermont State Plan Attachment 4.19B:http://dvha.vermont.gov/administration/7attachment-4.19-b.pdf

Vermont Provider Manual: http://www.vtmedicaid.com/Downloads/manuals/New%20Consolidated%20Manual/ProvManual%20Consolidated%207-1-13.pdf


Vermont State Plan:http://dvha.vermont.gov/administration/7attachment-4.19-b.pdf


Vermont State Plan:http://dvha.vermont.gov/administration/7attachment-4.19-b.pdf


Vermont State Plan, Attachment 4.18-A, Page 1:http://dvha.vermont.gov/administration/attachment-4.18-a.pdf

Provider Manual:http://www.vtmedicaid.com/Downloads/manuals/New%20Consolidated%20Manual/ProvManual%20Consolidated%207-1-13.pdf

Vermont State Attachment 4.19B: http://dvha.vermont.gov/administration/7attachment-4.19-b.pdf

NA No

NA NF

NA Yes

NA Yes

NA Yes




(A) Vermont State Plan, Attachment 4.19-B, Page 21:http://dvha.vermont.gov/administration/7attachment-4.19-b.pdf

(B) Fee Schedule(Click on PCP Enhanced rates tab in Excel file):http://dvha.vermont.gov/for-providers/2013-fee-schedules

Vermont Provider Manual, Pages 19-25: http://www.vtmedicaid.com/Downloads/manuals/New%20Consolidated%20Manual/ProvManual%20Consolidated%207-1-13.pdf

Vermont State Plan Amendment 4.19B, Page 3:http://dvha.vermont.gov/administration/7attachment-4.19-b.pdf

NA NF




1/1/2012 7/25/2013

1/1/2012 7/25/2013

6/27/2013 7/25/2013

8/8/2013 8/20/2013

NA 7/25/2013

NA 7/25/2013


Documentation Date

Date Last Searched

NA 7/25/2013

7/2013 7/25/2013

NA 7/25/2013

NA 7/25/2013

NA 7/25/2013

NA 7/25/2013

NA 7/25/2013

NA 7/25/2013

8/20/2013

8/1/2011 7/25/2013

6/27/2013 7/25/2013

(A) 6/5/2013(B) 8/8/2013

NA 7/25/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Virginia


CategoryAdjustments


Fee Schedule Basis







Children vs. Adults

Out-of-State



Health Home




Primary Care




States' Medicaid Fee-for-Service Physician Payment Policies - Virginia


Virginia

None Found

CPT Codes Fee Schedule

None Found

None Found



Payments for covered services submitted by physicians are based on the individual physician's usual and customary fees, within Program limitations. Payment for physician services is the lowest of the Program's fee schedule, actual charge, or Medicare allowances.

The fee schedule effective July 1, 1995 was based in many respects on the Medicare Resource Based Relative Value Scale (RBRVS) fee schedule. The calculation of RBRVS fees for Virginia Medicaid uses Medicare’s Relative Value Units (RVUs) and Conversion Factors (CFs).

EPSTD Pricing in Fee Schedule (Flag Codes I & S)



None Found

Adjusting fees for Geographic Practice Cost Indices (GPCIs) is not part of the Medicaid fee schedule. Medicaid fees will continue to be applied on a statewide basis.

Effective July 1, 2008, the Medicaid fee schedule reflects different rates for services depending on the site of service, facility or non-facility, based on the relative value units for procedure codes published by the Medicare.

Effective April 1, 2012, out of state providers (non-participating, enrolled) are held to the same service authorization processing rules as in state (participating, enrolled) providers and must be enrolled with Virginia Medicaid prior to submitting a request for out of state services to DMAS Service Authorization contractor, KePRO.

Physician office visit = 1.00 per visitOther physician visit = 3.00 per visit

The reimbursement for physician anesthesia service is based on a conversion factor and base and time units. The conversion factor is multiplied by the sum of the base and time units. The base units are Medicaid specific, not Medicare base units, and are available in the procedure fee file. Effective October 1, 2010, the Medicaid Conversion factor (CF) is $12.84. The physician manual describes the coverage and billing policies for physician anesthesia services.

Follows Federal Guidelines. The enhanced rates will go into effect upon federal approval of VA's state plan.

None Found

None Found

None Found



NA

NA RBRVS

NA NF

NA Yes

NA NF

NA NF


Summary Data

VA Medicaid Physician/Practitioner-Manual Chapter IV, page 72: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManual



VA Medicaid Physician/Practitioner-Manual: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManual

PROCEDURE FEE FILES & CPT CODES: http://www.dmas.virginia.gov/Content_pgs/pr-ffs.aspx



NA No

NA Yes

NA Yes

NA In-State

NA

NA Anesthesia

NA No

NA NF



Procedure Rate File Layouts: http://www.dmas.virginia.gov/Content_atchs/pr-rates/ff-layout.pdf




VA - Anesthesia reimbursement for Physicians: http://www.dmas.virginia.gov/Content_atchs/pr/pr-arp.pdf


VA Medicaid: http://www.dmas.virginia.gov/default.aspx

http://www.dmas.virginia.gov/Content_atchs/pr/pr-arp.pdf

NA Yes

NA NF

NA NF

NA NF

Letter from CMS to VA Dept.,. Of Medical Assistance Services:http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Plan-Amendments/Downloads/VA/VA-13-01-Ltr.pdf

VA Medicaid: http://www.dmas.virginia.gov/default.aspxOverview of VA Medicaid Managed Care: http://www.dmas.virginia.gov/Content_pgs/mc-home.aspx




4/2/2012 7/24/2013

4/2/2012 8/8/2013

NA 7/24/2013


NA 7/24/2013

NA 7/24/2013


Documentation Date

Date Last Searched

NA 7/24/2013

4/2/2012 7/24/2013


4/2/2012 7/24/2013

4/2/2012 7/24/2013

10/1/2010 7/24/2013

NA 7/24/2013

NA 7/24/2013

5/23/2013 7/24/2013

NA 7/24/2013

NA 7/24/2013

NA 7/24/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Washington


CategoryAdjustments


Fee Schedule Basis



Children vs. Adults

Out-of-State









Health Home

Primary Care



States' Medicaid Fee-for-Service Physician Payment Policies - Washington


WashingtonAdjustments



For physician services, the department pays the lesser of the usual and customary charge or a fee based on a published department fee schedule. The usual and customary charge is the fee charged by a physician to his/her patients. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of physician services.

Maximum allowable fees are established and updated using the Resource Based Relative Value Scale (RBRVS) methodology as adopted in the Medicare Fee Schedule Data Base (MFSDB).

The MFSDB relative value units (RVU) are geographically adjusted each year by the statewide average Geographic Practice Cost Indices (GPCI) for Washington State as published annually in the Federal Register. The adjusted RVU are multiplied by a service-specific conversion factor to derive a fee for each procedure.

The department currently has unique conversion factors for Children’s primary health care services, including office visits and EPSDT screens; Adult primary health care, including office visits; Maternity services, including antepartum care, deliveries, and postpartum care; Anesthesia services; Laboratory services; Radiological services; Surgical services; Consultations; etc. The department establishes budget neutrality each year when determining its conversion factors, then updates the conversion factors by any increase or decrease mandated by the Legislature. C. When no MFSDB RVU exists, the department may apply a set fee to the procedure or determine payment based on documentation by the provider.

None Found

Physician-Related/Professional Fee Schedule

None Found

None Found

None Found


EPSDT Fee Schedule

For medically necessary treatment of emergencies that occur while a client is out-of-state, DSHS pays the lesser of the usual and customary charge or a fee based on a published department fee schedule.

None Found



None Found

Primary Care Physician ACA Enhanced Rates Fee Schedule

None Found

None Found

Supplemental Payments for Certain Professional ServicesThe purpose of the supplemental payments is to ensure access to essential professional services for Medicaid beneficiaries through the care provided by the University of Washington Medicine and the University of Washington School of Medicine, and at public hospitals or other public entities.

A supplemental payment will be made for services provided by qualified licensed professionals and billed by a component or affiliate of the University of Washington or another public entity, including a public hospital, equal to the difference between the Medicaid payments otherwise made for the services and payments at the Average Commercial Rate. Only the professional component of a procedure is eligible for a supplemental payment. Payment will be made quarterly and will not be made prior to the delivery of services.

D. The Medicaid Supplemental Payment to Qualified Licensed Professionals equals the difference between the Average Commercial Payment Ceiling for the quarter and the total Medicaid payments for the applicable procedure codes paid to qualified licensed professionals in the quarter on behalf of Medicaid beneficiaries, as reported from the MMIS. Medicaid volume and payments includes all available payments and adjustments.



NA

NA RBRVS


Washington State Plan, Attachment 4.19-B, Page 6: http://www.hca.wa.gov/medicaid/medicaidsp/Pages/index.aspx


Washington State Plan: Amendment 4.19-B: Page 6:http://www.hca.wa.gov/medicaid/medicaidsp/Pages/index.aspx

NA NF

NA Yes

NA NF

NA NF

NA NF

NA Yes

NA Yes

NA In-State

Washington State Plan: Attachment 4:http://www.hca.wa.gov/medicaid/medicaidsp/Pages/index.aspxPhysician-Related Services/Health Care Professional Services Provider Manual: http://www.hca.wa.gov/medicaid/billing/pages/physician-related_services.aspxPhysician-Related/Professional Fee Schedule:http://www.hca.wa.gov/medicaid/rbrvs/Pages/index.aspx

Physician-Related/Professional Fee Schedule:http://www.hca.wa.gov/medicaid/rbrvs/Pages/index.aspx



Washington State Plan: Attachment 4.19-B: Page 6http://www.hca.wa.gov/medicaid/medicaidsp/Pages/index.aspx


EPSDT Fee Schedule:http://www.hca.wa.gov/medicaid/rbrvs/Pages/index.aspx

Washington State Plan: Attachment 4.19-B: Page 7:http://www.hca.wa.gov/medicaid/medicaidsp/Pages/index.aspx

NA No


NA No

Washington State Plan: Attachment 4:http://www.hca.wa.gov/medicaid/medicaidsp/Pages/index.aspx

Physician Fee Schedule:http://www.hca.wa.gov/medicaid/rbrvs/Pages/index.aspx



NA NF

NA Yes

NA NF


Washington Medicaid: Provider Rate Changes Under the Affordable Care Act: http://www.hca.wa.gov/medicaid/Documents/aca_rates_eligible_codes.xls


NA Yes

NA NF

Washington State Plan: Attachment 4.19-B: Pages 43-44:http://www.hca.wa.gov/medicaid/medicaidsp/Pages/index.aspx



Adjustments

8/20/2012 7/10/2013

8/20/2012 7/10/2013


Documentation date

Date Last Searched

7/1/2013 7/10/2013

7/1/2013 7/10/2013

NA 7/10/2013

NA 7/10/2013

8/20/2012 7/10/2013

7/1/2013 7/10/2013

7/1/2013 7/10/2013

8/20/2012 7/10/2013

NA 7/10/2013


NA 7/10/2013

8/20/2012 7/10/2013

NA 7/10/2013

States' Medicaid Fee-for-Service Physician Payment Policies - West Virginia


CategoryAdjustments


Fee Schedule Basis





Children vs. Adults

Out-of-State







Health Home

Primary Care



States' Medicaid Fee-for-Service Physician Payment Policies - West Virginia


West Virginia

Payment will be the lesser of the upper limit or the provider's customary charge for the service to the general public.

Same conversion factors apply to ARNPs and CRNAs.

Physician RBRVS



An upper limit is established using a resource-based relative value for the procedure times a conversion factor as determined by the type of service. The conversion factors were developed using utilization and payment level data for the defined service group.

Medicare's RVUs multiplied by a state-determined conversion factor. Used for certain services furnished by:• Physicians• Audiologists • Advanced registered nurse practitioners • Certified registered nurse anesthetists • Chiropractors • Occupational therapists • Optometrists • Physical therapists • Podiatrists

None Found

None Found

None Found

None Found

There are two different practice expenses for many services. That explains why there are two total weights for most services. The weight that applies to a particular service depends on where the service is provided. • The “facility practice expense” weight applies if the service was provided in a hospital or other facility setting • The “non-facility practice expense” weight applies if the service was provided in a practitioner office setting. The “facility practice expense” weight, if applicable, is often lower than the “non-facility practice expense” weight. The reason is so because the facility absorbs part of the cost of providing the service when the service is provided in a facility setting. The physician is not paid for costs absorbed by the facility. Services that cannot be performed in a non-facility setting do not have a non-facility practice weight and no total weight is shown for these services. Such services are often surgical procedures that require the physician to have access to equipment and personnel that are not available in outpatient settings.

Out-of-state physicians are subject to the same fee and payment regulations as instate physicians and must enroll with WV Medicaid in order to receive reimbursement for services rendered.

No cost sharing for physician services.



None Found

Medicaid fees for anesthesiology services are calculated somewhat differently from the fees paid for all other physician services. The fee equals the conversion factor for anesthesia services multiplied by the sum of the base units and time units for a service and not relative value units.

Follows federal guidelines. Reimburse eligible primary care providers at parity with Medicare rates in calendar years 2013 and 2014 for certain E&M and vaccination codes.

The State of WV operates a managed care program, known as the Physician Assured Access System (PAAS), a Primary Care Case Management (PCCM) program. Medicaid covered services delivered by the PCP are reimbursed at the Medicaid Fee-For-Service rate for the particular service rendered.WV pays a monthly Care Management Fee every month for each enrollee on the PCP’s panel in addition to fee for service or cost-based payment methods specified by regulations.

None Found

A supplemental payment will be made for services provided by qualifying essential state-owned physicians or dentists who are members of a group practice organized by or under the control of a state academic health system or an academic health system that operates under a state authority based on the following methodology. The supplemental payment to each qualifying physician or dentist will equal the difference between the Medicaid payments otherwise made to these qualifying providers for physician and dental services and the average amount that would have been paid by commercial insurers for the same services. The average amount that private commercial insurers would have paid for Medicaid services will become the maximum Medicaid reimbursable amount for total Medicaid reimbursement, i.e., regular Medicaid payments and the supplemental payments made under this plan amendment. To determine this maximum Medicaid reimbursable amount, the Medicaid Agency will determine what all private commercial insurance companies paid for at least 80% of the commercial claims from the public physician providers affected by this plan amendment and divide that amount by the respective charges for those same claims.(The claims payments and charges will be obtained from the year preceding the reimbursement year.) The resulting ratio of payments to charges will be multiplied by the actual charges for the Medicaid services provided by the public physician providers, and the product will be the maximum Medicaid reimbursable amount. The actual non-supplemental Medicaid payments to the public physician providers will be subtracted from the maximum Medicaid.



NA

NA RBRVS

NA No

NA Yes


Summary Data

State Plan Amendment, 4.19-B, Page 3a:http://www.dhhr.wv.gov/bms/smp/Documents/Searchable/A4/4.19-B.pdf


Provider Manual, Chapter 600 - Reimbursement Methodologies, Page 11: http://www.dhhr.wv.gov/bms/Documents/bms_manuals_Chapter_600.pdf

WV Provider Manual, Chapter 600 - Reimbursement Methodologies, Page 11: http://www.dhhr.wv.gov/bms/Documents/bms_manuals_Chapter_600.pdf

WV Medicaid Physician's Fee Schedules:http://www.dhhr.wv.gov/bms/Pages/FeeSchedule.aspx

NA NF

NA NF

NA NF

NA Yes

NA No

In-State



WV Provider Manual, Chapter 600 - Reimbursement Methodologies, Page 11: http://www.dhhr.wv.gov/bms/Documents/bms_manuals_Chapter_600.pdfState Plan, Attachment 4.19-B:http://www.dhhr.wv.gov/bms/smp/Documents/Searchable/A4/4.19-B.pdf



Provider Manual, Chapter 300 - Provider Participation Requirements, Page 15:http://www.dhhr.wv.gov/bms/Documents/Chap300%20061413.pdf

NA $0

NA Anesthesia

NA No

NA NF

NA Yes

NA Yes

State Plan Amendment 4.18-A:http://www.dhhr.wv.gov/bms/smp/Documents/Searchable/A4/4.18-A.pdf




Enhanced Primary Care Payment - News and Announcements: http://www.dhhr.wv.gov/bms/news/Pages/epc.aspx

Physician Assured Access System (PAAS) Provider Agreement:http://www.dhhr.wv.gov/bms/mco/documents/bms_mancare_paas_prov_agree_final.pdf

NA Yes

NA NF

State Plan Amendment 4.19-B, Page 3b:http://www.dhhr.wv.gov/bms/smp/Documents/Searchable/S4/4.19.pdf



4/1/2003 7/2/2013

1/1/2006 7/2/2013

1/1/2006 7/2/2013

11/1/2012 7/2/2013


Documentation Date

Date Last Searched

NA 7/2/2013

NA 7/2/2013

NA 7/2/2013

1/1/2006 7/2/2013

NA 7/2/2013

9/1/2003 7/2/2013

2/13/2006 7/2/2013

1/1/2006 7/5/2013

NA 7/2/2013

NA 7/2/2013

Not Listed 7/2/2013

Not Listed 7/2/2013

4/1/2003 7/2/2013

NA 7/2/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Wisconsin

Every attempt was made to find the most recent and up-to-date data, however, not all recent data was publicly available and many of the policies may have been developed years earlier and may not be in current practice.Many of the sources are best accessed through Internet Explorer. Any errors or changes, please contact MACPAC at 202-350-2000.NF=None Found

CategoryAdjustments


Fee Schedule Basis




Children vs. Adults

Out-of-State



Health Home

Primary Care


States' Medicaid Fee-for-Service Physician Payment Policies - Wisconsin

Every attempt was made to find the most recent and up-to-date data, however, not all recent data was publicly available and many of the policies may have been developed years earlier and may not be in current practice.Many of the sources are best accessed through Internet Explorer. Any errors or changes, please contact MACPAC at 202-350-2000.

Wisconsin



Wisconsin Medicaid reimburses physicians the lesser of the physician's billed amount for a service or Wisconsin Medicaid's maximum allowable fee.

Maximum allowable fees are based on various factors, including a review of usual and customary charges submitted, the Wisconsin State Legislature's Medicaid budgetary constraints, and other relevant economic limitations. Maximum allowable fees may be adjusted to reflect reimbursement limits or limits on the availability of federal funding as specified in federal law.

For most professional services, ForwardHealth reimburses no more than Medicare rates. However, for select professional services, the rate for the service is greater than the Medicare rate when provided to members 18 years of age and younger on the date of service.

(A) Wisconsin Medicaid generally reimburses physician assistants 90 percent of the payment allowed for the physician who would have otherwise performed the service. Physician assistants are paid 100 percent of the physician's maximum fee for HealthCheck screens, injections, immunizations, lab handling fees, and select diagnostic procedures.

(B) Nurse Midwife: Reimbursement for nurse midwife services is made at a percentage of a physician's payment for each specific procedure. Specifically, the nurse midwife maximum allowable fee is based on 90 percent of a physician's maximum allowable fee for that procedure. Nurse midwives are paid at a percentage of physician fees because they have less training, require physician supervision under state licensure, have a limited scope of practice and lower overhead costs.

(C) Nurse practitioners are reimbursed the lesser of the nurse practitioner's usual and customary charge for a service or the physician's maximum allowable fee for the procedure. Nurse practitioners use the physician maximum allowable fee schedule.

Nurse Midwives Fee Schedule

None Found

None Found

Physician/Independent Lab/X-Ray/Nurse Practitioners/Physician Assistant FeeHealthCheck (EPSTD) Fee Schedule

ForwardHealth reduces reimbursement to physicians and other professional service providers for services that are typically provided in an office-based setting when those services are instead provided in a hospital (POS code 21 or 22) or an ASC (POS code 24). The reduced reimbursement is intended to account for the lower overhead costs typically realized by physicians and other professional services providers when services are provided in a hospital or an ASC.

Refer to the table below for the affected codes. The reduced reimbursement for these services when provided in a hospital or an ASC equals 80 percent of maximum allowable fees.

None Found


(A) Wisconsin Medicaid provides an enhanced reimbursement rate for office and other outpatient services (CPT codes 99201-99215) and emergency department services (CPT codes 99281-99285) for members 18 years of age and younger. The enhanced reimbursement rates are indicated on the physician services maximum allowable fee schedule.(B) Health Check (EPSTD) Fee Schedule

E&M services (each office visit, hospital admission, or consultation), based on the maximum allowable feeUp to $10.00 = $0.50$10.01 to $25.00 = $1.00$25.01 to $50.00 = $2.00Over $50.00 = $3.00With exceptions.

Health Personnel Shortage Area (HPSA) Reimbursement for Primary Care Services

Enhanced reimbursement is provided to Medicaid-enrolled primary care providers and emergency medicine providers for selected services when one or both of the following apply:

The rendering or billing provider is located in a HPSA-eligible ZIP code.The member has a residential address (according to enrollment records) within a HPSA-eligible ZIP code.Standard enhanced reimbursement for HPSA-eligible primary care procedures is an additional 20 percent of the physician maximum allowable fee. The enhanced reimbursement for HPSA-eligible obstetrical procedures is an additional 50 percent of the physician maximum allowable fee.

None Found

Health Homes for AIDS Service Organizations:Reimbursement will be limited to a monthly case rate. The reimbursement will be the same regardless of the frequency or intensity of care management activities provided within the month, except that health home providers will be required to provide at least one care management activity during the billable month. Health home providers must submit a claim to receive payment. Reimbursement will be limited to the lesser of the amount billed or the established maximum fee. Reimbursement willbe the same for private and public providers.Health home providers will receive a flat fee for the initial, comprehensive assessment of needs and the development of the integrated care plan. This initial fee is reimbursable only for members who meet the eligibility criteria and who agree to participate in the health home. The member’s agreement to participate in the health home is determined by their active participation in the assessment and care plan development process.

Effective January 1, 2013, through December 31, 2014, certain providers who are identified as primary care practitioners may be eligible to receive a temporary rate increase for certain E&M and vaccine administration services. This increase is provided for under CFR 447.400(a), as instituted by the ACA. The federally funded, temporary rate increase is authorized only for two calendar years, after which the rate will return to its previous level, assuming there is no additional federal action. Eligible services are those rendered by attested physicians on dates of service between January 1, 2013, and December 31, 2014.

None Found

Supplemental payments to certain physicians(1) Supplemental payments are available under this paragraph to physicians who are recognized as essential to the Wisconsin Medicaid program. To be identified as an essential physician and qualify for a supplemental payment, the physicianmust be:(i) A physician licensed by the State of Wisconsin;(ii) A certified Wisconsin Medicaid provider; and(iii) Employed by an eligible physician group practice that is state-owned or operated.

The eligible physician group practice, the University of Wisconsin Medical Foundation is affiliated with the state academic teaching facility, the University of Wisconsin Hospital and Clinics.

(2) For services rendered by physicians affiliated with the practice at paragraph (1), a supplemental payment will be made that is equal to the difference between the Medicaid payments otherwise made and payments at the Medicare Equivalent (specifically the Medicare non-facility rate equivalent) of the Average Commercial Rate Payment. This supplemental payment will, for the same dates of service, be reduced by any other supplemental payment found elsewhere in the state plan.

Additional Reimbursement for Reporting Body Mass IndexForwardHealth is collecting BMI data on children enrolled in the BadgerCare Plus Standard Plan, the BadgerCare Plus Benchmark Plan, or Medicaid to gather baseline information for future policy initiatives.

ForwardHealth will reimburse an additional $10.00 to providers and clinics for reporting BMI on professional claims for routine office visits and preventive services for members two to 18 years old on the DOS.



NA

NA

NA


Summary Data

ForwardHealth, Reimbursement, Topic #652:https://www.forwardhealth.wi.gov/kw/archive/Physician080113.pdf


ForwardHealth, Reimbursement, Topic #260 & #7777:https://www.forwardhealth.wi.gov/kw/archive/Physician080113.pdf


(A) ForwardHealth, Reimbursement, Topic #651:https://www.forwardhealth.wi.gov/kw/archive/Physician080113.pdf(B) WI Medicaid State Plan Attachment 4.19B : Methods and Standards for Establishing Non-Institutional Reimbursement Rates, Page 15 http://www.dhs.wisconsin.gov/aboutdhs/DHCF/MAStatePlan/Section4/4.19BNon-Institutional.pdf(C) ForwardHealth, Reimbursement, Topic #866:https://www.forwardhealth.wi.gov/kw/archive/Physician080113.pdf


NA Yes

NA Yes

NA NF

NA NF

NA NF

WI Medicaid Fee Schedule - Click on Physician & Health Check (EPSTD):https://www.forwardhealth.wi.gov/WIPortal/Tab/42/icscontent/provider/maxFee/maxFeeDownloadsPdfVersions.htm.spage

WI Medicaid Fee Schedule:https://www.forwardhealth.wi.gov/WIPortal/Tab/42/icscontent/provider/maxFee/maxFeeDownloadsPdfVersions.htm.spage

WI Medicaid Fee Schedule:https://www.forwardhealth.wi.gov/WIPortal/Tab/42/icscontent/provider/maxFee/maxFeeDownloadsPdfVersions.htm.spage

WI Medicaid State Plan Attachment 4.19-B: http://www.dhs.wisconsin.gov/aboutdhs/DHCF/MAStatePlan/Section4/4.19BNon-Institutional.pdfWI Statutes: Chapter 46: Social Services. http://docs.legis.wisconsin.gov/statutes/statutes/46.pdfWI Provider Handbook: Physician: https://www.forwardhealth.wi.gov/WIPortal/Online%20Handbooks/Display/tabid/152/Default.aspx?ia=1&p=1&sa=50&s=5&c=30

ForwardHealth, Reimbursement - Amounts, Topic #13297:https://www.forwardhealth.wi.gov/kw/archive/Physician080113.pdf

NA Yes

NA NF

NA

NA

(A) ForwardHealth, Reimbursement -Amounts, Topic #650:https://www.forwardhealth.wi.gov/kw/archive/Physician080113.pdf(B) WI Health Check (EPSTD) Fee Schedule (Click on Health Check): https://www.forwardhealth.wi.gov/WIPortal/Tab/42/icscontent/provider/maxFee/maxFeeDownloadsPdfVersions.htm.spage


ForwardHealth, Reimbursement-Copayments, Topic #555:https://www.forwardhealth.wi.gov/kw/archive/Physician080113.pdf



HPSA (+20%) Primary Care

NA Yes

NA NF

NA Yes

Medicaid Approved Health Home State Plan Amendments:http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Downloads/Wisconsin-SPA.pdf


ACA PCP Temporary Rate Increase: https://www.forwardhealth.wi.gov/WIPortal/Online%20Handbooks/Display/tabid/152/Default.aspx?ia=1&p=1&sa=50&s=5&c=30&nt=Affordable+Care+Act+Primary+Care+Rate+Increase

NA NF

NA Yes

NA

WI Case Management Services Handbook: https://www.forwardhealth.wi.gov/kw/pdf/casemanagement.pdfWI Medicaid State Plan Attachment 4.19-B: http://www.dhs.wisconsin.gov/aboutdhs/DHCF/MAStatePlan/Section4/4.19BNon-Institutional.pdfWI Statutes: Chapter 46: Social Services. http://docs.legis.wisconsin.gov/statutes/statutes/46.pdfWI Provider Handbook: Physician: https://www.forwardhealth.wi.gov/WIPortal/Online%20Handbooks/Display/tabid/152/Default.aspx?ia=1&p=1&sa=50&s=5&c=30

WI Medicaid State Plan Attachment 4.19B, Page 4,Methods and Standards for Establishing Non-Institutional Reimbursement Rates: http://www.dhs.wisconsin.gov/aboutdhs/DHCF/MAStatePlan/Section4/4.19BNon-Institutional.pdf


BMI Reimbursement




8/19/2013


Documentation Date

Date Last Searched

(A) & (C ) 7/31/2013B) 12/15/1993



NA 7/25/2013

NA 7/25/2013

7/31/2013 8/19/2013

8/1/2013

NA 7/25/2013

7/31/2013 8/19/2013

7/31/2013 8/19/2013

(A) 7/31/2013(B) Not Listed

1/29/2013 7/25/2013

NA 7/25/2013


NA 7/25/2013

7/24/2007 8/19/2013

8/19/20137/31/2013

States' Medicaid Fee-for-Service Physician Payment Policies - Wyoming


CategoryAdjustments

Basic payment policy

Fee schedule basis







Children vs. Adults:

Out-of-State:

Enrollee cost sharing



Site of Service Adjustments:

Health Home

Primary Care




States' Medicaid Fee-for-Service Physician Payment Policies - Wyoming


WyomingAdjustments

Standard Fee Schedule

None Found

None Found



Reimbursement for physician services is the lesser of charges or the Medicaid fee schedule amount. A maximum allowable fee is established by procedure code regardless of provider location. All public and private providers are reimbursed according to the same fee schedule.

Physician fees were determined by an RBRVS analysis of customary charges, prevailing charges, and average commercial rates. Charges were inflated to the SFY 2007 rate year using the Medicare Economic Index. The reasonable charge was identified as the lower of the inflated charges or the newly computed rate under each of the three approaches.

(A) Nurse midwife: Reimbursement is the lessor of charges or the physician fee schedule amount.(B) Certified Pediatric or Family Nurse Practitioner : Reimbursement is the lessor of charges or the physician fee schedule amount.

None Found

None Found


4.b. EARLY PERIODIC SCREENING, DIAGNOSIS AND TREATMENT SERVICES:Medical Screening Examination Dental and Optometric services are reimbursed at the lessor of charges or the established Medicaid fee schedule amount. Reimbursement for expanded EPSDT services is based on a rate negotiated with the provider not to exceed the rate paid for a comparable covered Medicaid service or 70% of the usual and customary charge.

A) Medicaid compensates out-of-state providers within the Wyoming Medical Service Area (WMSA) when:• The service is not available locally and the border city is closer for the Wyoming resident than a major city in Wyoming; and• The out-of-state provider in the selected border city is enrolled in Medicaid.If you are an out-of-state, non-enrolled provider and render services to a Medicaid client, you may choose to enroll in the Medicaid Program and submit your claim according to Medicaid billing instructions, or bill the client.

$2.45 Co-Payment ScheduleWith exceptions.

Assistant Surgeons - 20% of allowed feePhysician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant at surgery - 15% of allowed fee


None Found

None Found

None Found

10.15.9 Incentive Payment Program: Affordable Care Act required payment by State Medicaid agencies of at least the Medicare rates in effect in calendar years 2013 and 2014 for primary care services furnished by the physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine.From [the approval] date, the provider will receive an additional 10% over the Medicaid allowed fee for the specific procedure codes listed. In no case will the Medicaid reimbursement exceed the billed charge.

None Found



NA

NA

NA No

Yes

NA NF

NA NF


WY State Plan Attachment 4.19-B (Sheet 55 from 83):http://www.health.wyo.gov/healthcarefin/medicaid/spa.html




(A) WY State Plan Attachment 4.19-B (Sheet 73 from 83):http://www.health.wyo.gov/healthcarefin/medicaid/spa.html(B) WY State Plan Attachment 4.19-B (Sheet 78 from 83):http://www.health.wyo.gov/healthcarefin/medicaid/spa.html

Standard Fee schedule: http://wyequalitycare.acs-inc.com/fee_schedule.html



NA NF

NA NF

NA Yes

NA In-State

NA $2.45

NA SurgeryIncentive or Add-on Payments

Wyoming Provider Manual:http://wyequalitycare.acs-inc.com/manuals/Manual_CMS-1500.pdfWY State Amendment 4.19b:http://www.health.wyo.gov/healthcarefin/medicaid/spa.htmlStandard Fee schedule: http://wyequalitycare.acs-inc.com/fee_schedule.html

Wyoming Provider Manual:http://wyequalitycare.acs-inc.com/manuals/Manual_CMS-1500.pdfWY State Amendment 4.19b:http://www.health.wyo.gov/healthcarefin/medicaid/spa.htmlStandard Fee schedule: http://wyequalitycare.acs-inc.com/fee_schedule.html


Wyoming Provider Manual, 3.5 Out-of-State Service Limitations, Page 3-7:http://wyequalitycare.acs-inc.com/manuals/Manual_CMS-1500.pdf

Wyoming Provider Manual, 6.8 Co-payment Schedule, Page 6-25:http://wyequalitycare.acs-inc.com/manuals/Manual_CMS-1500.pdf

Wyoming Provider Manual, 10.15.23.9 Modifiers, Page 10-108:http://wyequalitycare.acs-inc.com/manuals/Manual_CMS-1500.pdf

NA No

NA NF

NA Yes

NA NF

NA NF


Wyoming Provider Manual:http://wyequalitycare.acs-inc.com/manuals/Manual_CMS-1500.pdfWY State Plan Attachment 4.19-B:http://www.health.wyo.gov/healthcarefin/medicaid/spa.html

Wyoming Provider Manual, 10.15.9 Incentive Payment Program, Pages 10-70 & 10-71:http://wyequalitycare.acs-inc.com/manuals/Manual_CMS-1500.pdf

Wyoming Provider Manual:http://wyequalitycare.acs-inc.com/manuals/Manual_CMS-1500.pdfState Plan Attachment 4.19B:http://www.health.wyo.gov/healthcarefin/medicaid/spa.htmlAdditional search of key terms in Google.


NA NF



Adjustments

9/14/2010 7/8/2013

9/14/2010 7/8/2013

6/26/1995 8/8/2013

Not Listed 8/7/2013

NA 8/8/2013

NA 8/7/2013


Documentation date

Date Last Searched

NA 7/8/2013

NA 7/8/2013

5/2/1995 8/7/2013

8/1/2013 8/8/2013

8/1/2013 8/8/2013

8/1/2013 8/8/2013Incentive or Add-on Payments

NA 7/8/2013

NA 7/8/2013

8/1/2013 8/8/2013

NA 8/8/2013

NA 8/8/2013

NA 8/8/2013

[XLS]Fee Schedules - macpac · Web viewCNP- All CNP services are reimbursed at 100 percent of the...

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