State Plan Under Title XIX of the Social Security Act (Base plan pages)

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

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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.

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TN: ______ Approval Date ___ Effective Date______

Supersedes TN:_____