FMG4 19b preprint 7-29-08

Revision:

(MB)

OMB No.:

State/Territory: _______________
Citation: 42 CFR 447.201, 42 CFR 447.302, 52 FR 286648, 1902(a)(15), 1902(bb), 1903(a)(1) and (n), and 1920 of
the Act.
Section 4.19(b): In addition to the services specified in paragraphs 4.19(a),(d),(k),(1), and (m), the Medicaid
agency meets the following requirements: Sections 1902(a)(15) and 1902(bb) of the Act regarding payment for
services furnished by Federally Qualified Health Center (FQHCS) under section 1905(a)(2)(C) of the Act.
ATTACHMENT 4.19-B: Describes the method of payment and how the agency determines the reasonable costs of
the services (for example, cost-reports, cost or budget reviews, or sample surveys). Also, describes the methods and
standards used for the payment of each of these services except for inpatient hospital, nursing facility services and
services in intermediate care facilities for the mentally retarded that are described in other attachments.
Citation: Section 1902(a)(10) and 1902(a)(30) of the Act.
SUPPLEMENT 1 to ATTACHMENT 4.19-B: Describes the general methods and standards used for establishing
payment for Medicare Part A and B deductible/coinsurance.

______________________________________________________________________________
TN No.
Supersedes
TN No.

Approval Date

Effective Date______________

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
State/Territory: ________________________
Attachment 4.19-B –Reimbursement Methodology: Non-institutional Services
The following items specify the method of payment and how the agency determines the reasonable costs of the
services for each service.
1. Outpatient hospital services, rural health clinic and federally qualified health center
services. Applicable reimbursement limitations described at 42 CFR 447.321.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
2. Rural health clinic services and other ambulatory services furnished by a rural
health clinic, which are otherwise included in the state plan.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
3. Federally-qualified health center (FQHC) services and other ambulatory services that are offered
by a Federally-qualified health center and which are otherwise included in the plan.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
4. Other laboratory and x ray services.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.

5. Early and periodic screening, diagnostic and treatment services for individuals who are eligible
under the plan and are under the age of 21.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
6. Family planning services and supplies for individuals of child bearing age.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
7. Physicians’ services and medical and surgical services of a dentist.
a. Physicians’ services furnished by a physician, whether furnished in the office,
the patient’s home, a hospital, or a nursing facility, or elsewhere.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
b. Medical and surgical services furnished by a dentist.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
9.

Medical care and any other type of remedial care provided by licensed practitioners within
their scope of practice.

Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency

determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
10. Home health services
a. Home health services provided by a home health agency and/or registered nurse.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
b. Medical supplies, equipment, and appliances suitable for use in home.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
c. Physical therapy, occupational therapy, or speech pathology and audiology services provided by a
home health agency or by a facility licensed by the State to provided medical rehabilitation services.
Instructions:
C Comprehensively describe all methods of payment used to reimburse service providers and how the
agency determines the reasonable costs for the services (for example, cost reports, cost review, or sample
surveys). Unless otherwise specified, please confirm that governmental and private providers are paid
according to the same published fee schedule, include the publication reference for the services (i.e. State
agency website address), and include the effective date for the fee schedule. If the agency increases rates
based upon inflation, please include the exact percentage increase applicable to the rate year.
11. Private duty nursing services.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
12. Clinic services. Applicable reimbursement limitations described at 42 CFR 447.321.

Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year. If the agency
reimburses an exact percentage of the Medicare fee schedule, please indicate the percentage in the
reimbursement methodology.
13. Dental services.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
14. Physical therapy and related services
a. Physical therapy.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
b. Occupational therapy.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
c. Services for individuals with speech, hearing, and language disorders.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based

upon inflation, please include the exact percentage increase applicable to the rate year.
15. Prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a
physician skilled in diseases of the eye or by an optometrist.
a.

Prescribed Drugs.

Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
b. Dentures.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
c. Prosthetic devices.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
d. Eyeglasses.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
16. Other diagnostic, screening, preventive, and rehabilitative services.
a.
Instructions:

Other diagnostic services.

Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
b. Screening services.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
c. Preventive services.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
d. Rehabilitative services.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
17. Nurse-midwife services.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
18. Hospice care.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency

determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
19. Case management services.
Instructions:
For each target group, comprehensively describe all methods of payment used to reimburse service
providers and how the agency determines the reasonable costs for the services (for example, cost reports,
cost review, or sample surveys). Unless otherwise specified, please confirm that governmental and private
providers are paid according to the same published fee schedule, include the publication reference for the
services (i.e. State agency website address), and include the effective date for the fee schedule. If the
agency increases rates based upon inflation, please include the exact percentage increase applicable to the
rate year.
b. Special tuberculosis (TB) related services.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
20. Respiratory care services.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
21. Certified pediatric nurse practitioner or certified family nurse practitioner services.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
22. Reserved
23. Reserved

24. Personal care services.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
25. Primary care case management services.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
26. PACE program services.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
27. Sickle Cell Disease services.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
28. Any other medical care, and any other type of remedial care recognized under State law,
specified by the Secretary.
a. Transportation, excluding “school-based” transportation.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency

website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
 Non-emergency transportation is provided through a brokerage program as an
optional medical service.
Instructions:
(A) The State will pay the contracted broker by the following method:
 (i) risk capitation
 (ii) non-risk capitation
 (iii) other (e.g., brokerage fee and direct payment to providers)
(If the State attests to “other” then a text box will appear with the instructions to describe the other
payment methodology.)

(B) Who will pay the transportation provider?
 (i) Broker
 (ii) State
 (iii)

other

(If the State attests to “other” then a text box will appear with the instructions to describe who other
than the state will pay the transportation provider.)



(7) The broker is a non-governmental entity:


The broker is not itself a provider of transportation nor does it refer to or
subcontract with any entity with which it has a prohibited financial
relationship as described at 45 CFR 440.170(4)(ii).



The broker is itself a provider of transportation or subcontracts with or
refers to an entity with which it has a prohibited financial relationship and:
(i)

 transportation is provided in a rural area as defined at 412.62(f) and there is
no other available Medicaid participating provider or other provider determined
by the State to be qualified except the non-governmental broker

(ii)

 transportation is so specialized that there is no other available Medicaid
participating provider or other provider determined by the State to be qualified
except the non-governmental broker.

(iii)

 the availability of other non-governmental Medicaid participating providers or
other providers determined by the State to be qualified is insufficient to meet the
need for transportation.

 (8) The broker is a governmental entity and provides transportation itself or refers to or
subcontracts with another governmental entity for transportation. The governmental broker
will:


Maintain an accounting system such that all funds allocated to the Medicaid
brokerage program and all costs charged to the Medicaid brokerage will be
completely separate from any other program.



Document that with respect to each individual beneficiary’s specific
transportation needs, the government provider is the most appropriate and
lowest cost alternative.



Document that the Medicaid program is paying no more for fixed route
public transportation than the rate charged to the general public and no
more for public paratransit services than the rate charged to other
State human services agencies for the same service.

b. Services furnished in a religious non-medical health care institution.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
e. Emergency hospital services.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
f. Reserved
g. Critical access hospital (CAH)
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency

website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
29. Enhanced services for pregnant women.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
30. State Plan Home and Community Based Service Reimbursement.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
31. Self-Directed Personal Assistance Service Reimbursement.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
32. Benchmark Benefit Reimbursement and Benchmark Equivalent Benefit Reimbursement.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to
the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.
33. Organ transplant services.
Instructions:
Comprehensively describe all methods of payment used to reimburse service providers and how the agency
determines the reasonable costs for the services (for example, cost reports, cost review, or sample surveys).
Unless otherwise specified, please confirm that governmental and private providers are paid according to

the same published fee schedule, include the publication reference for the services (i.e. State agency
website address), and include the effective date for the fee schedule. If the agency increases rates based
upon inflation, please include the exact percentage increase applicable to the rate year.