CMS-179 Attachment 4.19-B, Section 24

Form Approved CMS-179
OMB No. 0938-0193
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 RATESOTHER 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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