MEDICAID REIMBURSEMENT REPORTS

Notes and Caveats

ï¿½(Updated July 2008)

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Fees shown in this report series represent fee-for-service (FFS) payments reported by states for state-administered Medicaid programs only.ï¿½ Nationally, the majority of children enrolled in Medicaid programs are enrolled in managed care plans, which may or may not benchmark provider payment rates to fees shown in this report. ï¿½In fact, payment levels are known to vary widely between state-administered plans and managed care plans in some states. ï¿½As examples, some of New York Stateï¿½s Medicaid managed care plans reportedly pay substantially higher than its state-administered FFS plan, whereas the opposite has been observed in Hawaii.

Important:

Depending on managed care penetration levels, the impact of state-administered fee-for-service Medicaid payment rates varies by state.

Medicaid managed care penetration rate and state effort to monitor plan-to-provider payment are described in a set of notes at the beginning of each report, and in the table below.ï¿½ It is important to note that state-administered FFS rates shown in this report may not apply to children in managed care Medicaid plans, or may apply to certain carved-out services only for these children.

State	Medicaid Managed Care Penetration Rate, State Effort to Monitor Medicaid Managed Care Payments
Alabama	All children in Alabama's Medicaid program were covered by a state-administered fee-for-service plan for non-hospital care according to state reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Alaska	All children in Alaska's Medicaid program were covered by a state-administered fee-for-service plan according to state reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Arizona	90.3% of children enrolled in AZ Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not monitor any plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Arkansas	All children in Arkansas's Medicaid program were covered by a state-administered fee-for-service plan according to state reply to the 2007/8 AAP Medicaid Reimbursement Survey.
California	70.8% of children enrolled in CA Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State monitored both FFS and capitated plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.

Colorado	93.7% of children enrolled in CO Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State monitored capitated plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Connecticut	95.5% of children enrolled in CT Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State monitored FFS plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey. Note: Pediatric payments for preventive visits, office visits and mental health services (rates shown in this report for CT) are 80%-120% higher than regular (non-pediatric rates) rates.
Delaware	95.1% of children enrolled in DE Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not monitor plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Dist of Columbia	88.1% of children enrolled in DC Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State monitored FFS plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Florida	65.6% of children enrolled in FL Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not monitor plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey. Note: Rates shown in this report represent regular rates paid by FL Medicaid. Board-certified pediatric surgeons and certain other specialties receive enhanced pediatric specialty rates at 124% of regular rates for certain procedures.
Georgia	88.2% of children enrolled in GA Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State monitored capitated plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Hawaii	State did not respond to 2007/8 AAP Medicaid Reimbursement Survey. FFS payment rates shown in this report are based on a search of state Medicaid website (URL: http://www.med-quest.us/) conducted by AAP staff. 95.5% of children enrolled in HI Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. Note: Rates shown in this report for HI are either for EPSDT or "Mandated Services", which are higher than regular Medicaid rates.
Idaho	100% of children enrolled in ID Medicaid were in a state-administered FFS plan according to FY2005 CMS data.

Illinois	15.1% of children enrolled in IL Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State monitored capitated plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Indiana	76.2% of children enrolled in IN Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not monitor plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Iowa	93.4% of children enrolled in IA Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State monitored FFS plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Kansas	43.3% of children enrolled in KS Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not indicate whether it monitored plan-to-provider payment rates in its Medicaid managed care plan(s) in its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Kentucky	98.7% of children enrolled in KY Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State monitored both FFS and capitated plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Louisiana	All children in Louisiana's Medicaid program were covered by a state-administered fee-for-service plan according to state reply to the 2007/8 AAP Medicaid Reimbursement Survey. Note: Where available, enhanced rates reimbursed for Professional Services (Physician) and/or Community Care/EPSDT programs are shown in this report.
Maine	All children in Maine's Medicaid program were covered by a state-administered fee-for-service plan according to state reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Maryland	94.1% of children enrolled in MD Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State indicated that FFS plan-to-provider payment rates in its Medicaid managed care plan(s) were about 110% of state-administered FFS rates in its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Massachusetts	81.6% of children enrolled in MA Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State monitored both FFS and capitated plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Michigan	94.3% of children enrolled in MI Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not monitor plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.

Minnesota	82.8% of children enrolled in MN Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not monitor plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Mississippi	All children enrolled in MS Medicaid were covered by a state-administered FFS program according to state reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Missouri	59.3% of children enrolled in MO Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not monitor plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Montana	All children enrolled in MT Medicaid were covered by a state-administered FFS program according to FY2005 CMS/MSIS data. Note: Dental rates shown in this report for MT are EPSDT rates, which are higher than regular Medicaid rates.
Nebraska	18.8% of children enrolled in NE Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State monitored FFS plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Nevada	93.1% of children enrolled in NV Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not monitor plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey. Note: Rates shown in this report for NV include regular Medicaid rates and, if available, enhanced pediatric rates.
New Hampshire	All children enrolled in NH Medicaid were covered by a state-administered FFS program according to state reply to the 2007/8 AAP Medicaid Reimbursement Survey.
New Jersey	87.6% of children enrolled in NJ Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not indicate whether it monitored plan-to-provider payment rates in its Medicaid managed care plan(s) in its reply to the 2007/8 AAP Medicaid Reimbursement Survey. Note: Rates shown in this report for NJ are regular FFS rates. Payments for specialists are typically 14%-29% above regular rate.
New Mexico	91.5% of children enrolled in NM Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not monitor plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.

New York	State did not respond to 2007/8 AAP Survey. FFS payment rates shown in this report are based on a search of state Medicaid website (URL: http://www.emedny.org/ProviderManuals/ Physician/index.html) conducted by AAP staff. Information posted on this website suggests that payment varies by provider specialty. Rates shown in this report reflect rates paid primary care providers, which are typically lower than payment for specialists. 78.0% of children enrolled in NY Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. Payment levels in some of NY's Medicaid managed care plans are, reportedly, substantially higher than rates paid by state-administered FFS plan(s).
North Carolina	All children enrolled in NC Medicaid were covered by a state-administered FFS program according to state reply to the 2007/8 AAP Medicaid Reimbursement Survey.
North Dakota	All children enrolled in ND Medicaid were covered by a state-administered FFS program according to state reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Ohio	44.7% of children enrolled in OH Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not monitor plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Oklahoma	All children enrolled in OK Medicaid were covered by a state-administered FFS program according to state reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Oregon	91.4% of children enrolled in OR Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not monitor plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Pennsylvania	75.7% of children enrolled in PA Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State monitored both FFS and capitated plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Rhode Island	90.1% of children enrolled in RI Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not monitor plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
South Carolina	17.4% of children enrolled in SC Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State monitored both FFS and capitated plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey. Note: Payments shown in this report for SC are regular rates. Reimbursement to pediatric sub-specialists is generally higher, paid at 120% of Medicare for E&M codes and 100% of Medicare for most other codes.

South Dakota	100% of children enrolled in SD Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not indicate whether it monitored plan-to-provider payment rates in its Medicaid managed care plan(s) in its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Tennessee	TN's Medicaid program, TennCare, is 100% managed care. All TN Medicaid children were covered in TennCare (Medicaid managed care) according to state response to 2007/8 AAP Medicaid Reimbursement Survey. State did not indicate whether it monitored plan-to-provider payment rates in its Medicaid managed care plan(s) in its reply to the same survey.
Texas	43.6% of children enrolled in TX Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State monitored both FFS and capitated plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Utah	91.2% of children enrolled in UT Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State monitored FFS plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Vermont	All children enrolled in VT Medicaid were covered by a state-administered FFS program according to state reply to the 2007/8 AAP Medicaid Reimbursement Survey. Note: Pediatric payments for E&M codes are enhanced (20% above regular level, as shown in this report for VT).
Virginia	64.5% of children enrolled in VA Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State monitored capitated plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Washington	75.2% of children enrolled in WA Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not monitor plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
West Virginia	62.3% of children enrolled in WV Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State did not monitor plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey.
Wisconsin	64.7% of children enrolled in WI Medicaid were in prepaid plans according to FY2005 CMS data - state-administered FFS rates shown in this report may apply to certain carved-out services only for these children. State monitored capitated plan-to-provider payment rates in its Medicaid managed care plan(s) according to its reply to the 2007/8 AAP Medicaid Reimbursement Survey. Note: Enhanced reimbursement for pediatric office and ED visits (rates shown in this report for WV) can be coupled with a 20% health professional service area (HPSA) bonus when patient or provider comes from a HPSA eligible zip code.
Wyoming	All children enrolled in WY Medicaid were covered by a state-administered fee-for-service program according to state reply to the 2007/8 AAP Medicaid Reimbursement Survey.

Attempts by the AAP to collect plan-to-provider payment rates in Medicaid managed care plans have been unsuccessful since such information has typically been classified as ï¿½confidential and proprietaryï¿½ by the states and the plans with which they contract. ï¿½In part to compensate for this information gap, the AAP had, most recently in 2006, contracted with the actuarial firm of Reden & Anders to provide the AAP Pediatric Medical Cost Model, a state-by-state report on pediatric medical cost in both commercial and Medicaid/SCHIP plans.ï¿½ (URL: http://www.aap.org/research/pedmedcostmodel.cfm) ï¿½ï¿½State and national medical cost data for Medicaid/SCHIP programs as presented in the Model are based on physician payment for pediatric services averaged across both state-administered fee-for-service programs and managed care plans.

Finally, fees included in this report series may represent enhanced pediatric fees in state-administered fee-for-service Medicaid instead of regular Medicaid rates if the former are available and reported or published by the state.ï¿½ As an example, rates shown in this report for HI are either for EPSDT or "Mandated Services", which are higher than regular Medicaid rates."ï¿½ States may and often do impose additional requirements for providers to qualify for the enhanced payments.ï¿½ Please see notes related to enhanced payment rates in the reports and inquire with states for further information.ï¿½