Exhibit N

Exhibit N.DOC

State Plan Under Title XIX of the Social Security Act (Base plan pages, Attachments, Supplements to Attachments)

Exhibit N

OMB: 0938-0193

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Revision: ATTACHMENT 4.19-B

Section 24, Page 1a


STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT


State: __________________


METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES-

OTHER TYPES OF CARE

­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­______________________________________________________________________________


Item VIII: Payment of Title XVIII Part B Outpatient Psychiatric Services


Except for a nominal recipient co-payment, if applicable, the Medicaid agency makes payment for Medicare cost-sharing based on the following:

Group

State Plan Rates *

Medicare Allowable

amount based

on 62.5% of charges

QMB



QMB Plus



FBDE




* For Medicare services which are not otherwise covered by this State plan, the Medicaid agency uses the methodology specified on page 3 of this supplement.













______________________________________________________________________________

TN: ______ Approval Date ___ Effective Date______

Supersedes TN:_____

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AuthorCMS
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File Modified2008-05-20
File Created2008-05-20

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