Benefits by Service: Inpatient Hospital Services, other than in an Institution for Mental Diseases (October 2006) Definition/Notes

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Elaine Short
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1 Page 1 of 9 Benefits by Service: Inpatient Hospital Services, other than in an Institution for Mental Diseases (October 2006) Definition/Notes Note: Totals include 50 states and D.C. "Benefits Covered" Totals "Benefits Not Covered" Totals Is the benefit covered? 51 0 Is there a co-payment requirement? : 28 No: 23 Is the Benefit Covered? Copayment Requirement Prior Approval Requirement Coverage Limitations Reimbursement Methodology Populations Covered Alabama Alaska $50/admission 16 days/year for other than pregnancy-related Capitated per eligible per month payment or prospective cost based payment with rate ceilings $50/day up to $200/admission Non emergency except maternity, for procedures, LOS greater than 3 days LOS limited to 50th percentile of published guidelines for region, vaginal delivery LOS 2 days, C-section delivery LOS 4 days, heart transplants not covered cost based per Arizona (including psych) except maternity, emergency more than 3 days, ICU care more than 1 day tiered per, psych paid allinclusive per Arkansas 10% of first day's per rate up to limit procedures, elective surgery 24 days/year Cost based payment for pediatric, teaching and critical access

2 Page 2 of 9 hospitals; cost based payment with daily cap for other acute hospitals; for rehab hospitals California Limitations vary by type of admission and rendered Competitively bid rate, negotiated rate, contracted capitation rate or prospective allinclusive rate using historical costs and peer groups Colorado $10/day up to 50% of payment for first day of care procedures, elective surgery Second opinions required for procedures, 45 day LOS for psych unless court-ordered or Connecticut except maternity, emergency re within 2 days of discharge Cost based payment Delaware 30 inpatient psychiatric treatment days/year or for psych, rehab and other special District of Columbia Cosmetic and oral surgery limited to emergency repair due to injury or trauma, pre-surgical days limited to 1 unless medically justified, weekend must be medically justified and peer group adjustment or percentage of charge for specific hospitals and Florida $3/admission 45 days/year cost based per with limits, for lung transplants paid a global fee

3 Page 3 of 9 Georgia $12.50/nonemergency admission except maternity Transplants of some organs not covered, LOS 30 days for psych care, rehab stays unrelated to acute illness or injury not covered Hawaii Administrative days while awaiting nursing facility placement, substitution of 1 unused inpatient day for 2 additional outpatient treatment days/year Psych limited to 30 days/year, LOS limited by state's Utilization Review authority, tissue and organ transplants limited to Medicare-certified transplant facilities cost based payment system using peer groups Idaho Elective surgery Cost based payment Illinois $2-$3/day unless per less than $275 safely rendered on outpatient basis, physical rehab Pre-surgical days limited to 1 unless medically justified, and LOS limited by State's Utilization Review authority, second opinion required for or for psych and rehab or facility-specific per for other special including certain governmentoperated facilities and children's hospitals Indiana Second opinions required for procedures, LOS less than 24 hours considered outpatient except for newborns, substance abuse treatment limited to detoxification, for psych, rehab and burn centers Iowa, including dental and excluding maternity LOS limited to 50th percentile of published guidelines for region

4 Page 4 of 9 Kansas $48/admission Elective surgery limited to sterilizations, rehab therapies must be restorative and post-trauma, transplants of some organs not covered, psych care limited to daily therapy, substance abuse limited to detox or percentage of charge for specific hospitals and Kentucky A - $50/admission, C & D - $10/admission safely rendered on outpatient basis, elective Admissions limited to maternity and management of acute or chronic illness or injury that can't be rendered on outpatient basis A, B, C & D - See state-specific FN Louisiana LOS in hospitals limited by state's Utilization Review authority per using peer groups, higher per for high intensity Maine $3/day up to $30/month All Medicare benefits/days must be exhausted before Medicaid is billed Cost based payment per discharge with limits Maryland Elective LOS limited by state's Utilization Review authority, 2 therapeutic leaves of less than 12 hours/admission Cost based payment Massachusetts $3/admission safely rendered on outpatient basis Michigan using statewide average cost adjusted for case mix, prospective cost based per for $50/first day of admission - see Elective, re within 15 days, nonemergency transfers, for psych

5 Page 5 of 9 Minnesota B1 - $10,000 annual limit- See Mississippi $10/day except maternity 30 days/year, including emergency cost based per, with limits Missouri $10/admission, except emergencies and transfers surgical procedures LOS limited to 75th percentile of published guidelines for region or days certified by state's Utilization Review authority cost based per or reasonable charge Montana $100/admission, cost based payment using Medicare principles for critical access hospitals, rehab and other special Nebraska Psych limited to approved facilities and peer groups, cost based payment for critical access hospitals, prospective cost based per for psych and rehab Nevada except maternity allinclusive per by type of admission, cost based payment for critical access hospitals and hospital LTC units, swing beds paid statewide average nursing facility per New Hampshire LOS limited by state's Utilization Review authority,,

6 Page 6 of 9 transplants limited to approved facilities and 2 transplants of same type/lifetime payment ceiling for transplants New Jersey and LOS Specified procedures require a second opinion - See New Mexico A - $25/admission, B - $30/admission - see state-specific FN for general acute care hospitals, cost based payment with limits for rehab and specialty hospitals New York $25/admission, for specialty North Carolina Elective and other 3 administrative leave days to facilitate transfer to less restrictive setting or North Dakota $75/admission Transfers to LTC hospitals 30 days for rehab, 21 days for psych and peer groups, prospective per for psych and rehab, prospective percentage of charge payment for long-stay hospitals, cost based payment for cancer and children's hospitals Ohio and peer groups, facility specific rates for children's hospitals, cost based payment for LTC and rehab Oklahoma

7 Page 7 of 9 $3/day Oregon A - $3/admission transfers, re for A & B - procedures require a second opinion, B - limited to for urgent or emergency medical care only, cost based payment for small hospitals Pennsylvania $3/day up to $21/admission substance abuse treatment 1 med rehab admission/year, 30 days psychiatric care/year, nonemergency weekend must have procedures same or next day, medical/surgical patients limited to 2 periods of therapeutic leave/month of no more than 12 hours/day, rehab and psych units paid, cost based payment for alcohol detox units Rhode Island state procedures Negotiated prospective cost based payment with a ceiling on allowable cost increases - see South Carolina $25/admission or South Dakota $50/nonemergency admission Admissions to DRG-exempt Cosmetic surgery must be posttrauma, substance abuse treatment not covered, cost based payment for psych, rehab and other special Tennessee B1 - $100/admission, B2 - $200/admission 10 days detoxification treatment/lifetime with $30,000 limit/lifetime for drug and alcohol

8 Page 8 of 9 treatment across all types of providers Texas $200,000/year, LOS limited to 30 days/episode except LOS for transplants 60 days, OT not covered and peer groups & M Utah A - $220/year for non-emergency, B - $220/nonemergency admission B - nonemergency or complications from non-covered surgery B - psych and substance abuse limited to 30 days/year irrespective of setting, surgical procedures not covered for most urban hospitals, enhanced DRG payment for children's hospitals, rural and psych hospitals paid percentage of charge, cost based payment for stateowned hospital Vermont A - $75/admission purposes B - only urgent and emergency medical/surgical covered per Virginia $100/admission safely rendered on outpatient basis, weekend and days before elective surgery must be medically justified; psych not covered for adults for acute care; prospective per for psych, rehab and other special Washington LOS limited to medically necessary days per InterQual IS/SI criteria if admission not paid under DRG method, elective in areas of state restricted to contracted hospitals, some hospitals paid prospective percentage of charge, cost based payment for critical access hospitals West Virginia except maternity and urban/rural adjustment,

9 Page 9 of 9 adjusted rate for sole community hospitals, negotiated rates for transplant Wisconsin $3/day up to $75/admission, includes psych Weekend limited to hospitals providing full every day, for rehab and for conditions Wyoming based on LOC, negotiated rates for specialty care American Samoa See territoryspecific FN Guam LOS limited to 60 days Northern Mariana Islands Puerto Rico Negotiated rate/service - See territory-specific FN Specified All-inclusive per Virgin Islands Services in public health facilities only allinclusive per up to Medicare cost ceiling Definition/Notes: Link to Inpatient Hospital Services, other than in an Institution for Mental Diseases Footnote

Benefits by Service: Outpatient Hospital Services (October 2006)

Page 1 of 8 Benefits by Service: Outpatient Hospital Services (October 2006) Definition/Notes Note: Totals include 50 states and D.C. "Benefits Covered" Totals "Benefits Not Covered" Totals Is the benefit