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 covered? 51 0 Is there a co- requirement? : 36 No: 15 Is the Benefit Covered? Co Requirement Prior Approval Requirement Coverage Limitations Reimbursement Methodology Populations Covered Alabama 3 non-emergency visits/year unless outpatient surgery, lab, dialysis, radiation or chemotherapy, nonemergency visit to ER counts toward both outpatient and physician visit limits Alaska 5% of for non-emergency services Outpatient psych and substance abuse not covered Prospective cost based rate using Arizona $5/non-emergency, rehab services Coverage of outpatient occupational therapy and speech pathology services limited to ALTCS members - see state-specific All-inclusive rate per episode of care groupings for most surgical or fee for service Arkansas 12 non-emergency visits/year for pediatric, teaching and critical access ; fee for
Page 2 of 8 service for other California $5/non-emergency, $1/visit for other services, state may negotiate all-inclusive per visit rates with certain Colorado $3/visit Connecticut 1 visit/day or Delaware District of Columbia Cosmetic and oral surgery limited to emergency repair due to injury or trauma Florida 5% of up to $15/visit for nonemergency services in the ER $1,500/year for non-emergency services (excluding surgery) Prospective cost based per diem or rate per service, lab and x-ray services paid fee for service Georgia visit Specified Observation limited to 48 hours using Hawaii All-inclusive rate per episode of care groupings for most surgical or fee for service with limits Idaho 6 ER visits/year if no admission, varying visit limits for therapies including psych which may be using hospital cost as upper limit
Page 3 of 8 included in limits with other providers Illinois or prospective rate/visit Indiana, grouped Iowa Varying visit limits for cardiac rehab, behavioral health and substance abuse, eating disorder and pain management therapies, grouped, ancillaries paid at Medicare rates Kansas visit Non-emergency visits count toward physician visit limit, rehab must be restorative Kentucky A, C & D - $3/ambulatory visit; A, B, C & D - 5% of for nonemergency visit in ER up to $6 grouped or cost based A, B, C & D - See state-specific Louisiana 3 ER visits/year and count against physician visit limit or fee for service Maine $.50-$3/day, depending on, up to $30/month with limits Maryland $6/non-emergency using rates approved by cost review commission Massachusetts
Page 4 of 8 using rates approved by cost review commission, surgical grouped using Medicare Michigan, $1/hospital clinic visit, satellite clinics in health shortage areas paid higher rates Minnesota $6/non-emergency, $3/visit for non-preventive service Payments based on Medicare, cost based for critical access A & B - See Mississippi visit 6 ER visits/year using hospital cost to ratio Missouri $3/day Specified services Elective surgeries require second opinion Percentage of Montana $5/visit grouped, cost based for critical access A & B - See Nebraska Nevada $3/visit No visit payable within 3 days of inpatient admission, substance abuse treatment not covered New Hampshire Percentage of with limits, lab services paid fee for service, cost based for critical access grouped
Page 5 of 8 12 visits/year, visits for therapy included in limits with other specified practitioners Percentage of New Jersey Non-emergency services in ER not covered New Mexico A - $15/nonemergency visit to ER and $5/visit for other services, B - $20/nonemergency visit to ER and $5/visit for other services - see statespecific Allergy testing and treatment, therapies with limits New York $3/visit 10 outpatient visits/year in combination with other specified providers North Carolina Prospective allinclusive rate with limits, some services fee for service $3/visit More than 8 outpatient psychiatric visits 24 non-emergency visits/year included in limits with other specified practitioners Prospective cost based rate, cost based for state owned facilities North Dakota $6/non-emergency 30 SP visits/year included in limits for other specified providers Fixed percentage of Ohio or prospective based on Oklahoma $3/day and other services Outpatient behavioral health services not covered for nursing facility residents using surgical group rates, ancillaries paid separately Oregon A - $3/visit A & B - See
Page 6 of 8 and therapy with limits Pennsylvania $.50-$3/service, depending on Frequency limits vary by service Rhode Island Physical and occupational therapy, speech pathology Prospective with surgical grouped using Medicare - see South Carolina South Dakota 5% of up to $50/visit, nonemergency only Substance abuse treatment not covered, cosmetic surgery limited to emergency repair due to injury or trauma Tennessee B1 - $25/ER visit if not admitted, B2 - $50/ER visit if not admitted $30,000 limit/lifetime for drug and alcohol treatment across all types of providers A & B - See Texas Specified services, prospective with surgical grouped using Medicare Utah A & B - $6/nonemergency visit in ER, C - $30/nonemergency visit in ER B - outpatient psych and substance abuse services limited to 30 days/year and included in inpatient limit, C - services limited to emergency treatment in ER Prospective cost based rate with higher rates for rural, some services paid fee for service or all-inclusive rate A, B & C - See Vermont A - $3/day, B - Non-emergency A & B - See
Page 7 of 8 $25/medically necessary services in ER not covered, some services paid fee for service or prospective per diem Virginia $3/visit 24 therapy visits/year Washington with limits Specified services Most urban paid prospective cost based rates, rural paid prospective West Virginia and other services Wisconsin $3/visit, $.50/day for psych day treatment and other services Outpatient psych services limited to 5 hours/day up to 120 hours/month and 40 hours/year for nursing facility residents; occupational therapy, physical therapy and speech pathology services must be billed as if rendered by the therapist and are reimbursed accordingly with limits Wyoming $6/non-emergency 12 visits/year in combination with physician office visits, therapy services must be restorative and are limited to 20 visits/year across all therapy providers American Samoa See territoryspecific Guam Non-emergency therapy services, Negotiated rate/service
Page 8 of 8 CT-scans Northern Mariana Islands - See territory-specific Puerto Rico Elective surgery requires primary care physician referral with capitated for primary care Virgin Islands Services in public health facilities only Definition/Notes: Link to Outpatient Hospital Services Footnote