States post first Medicaid-to-Medicare E/M rate comparisons; CMS seeks to renew access reporting, comments due Nov. 13

In Pennsylvania’s Medicaid fee-for-service program, a 99213 office visit paid $35.00 in 2025, 39% of what Medicare’s fee schedule paid [3]. In South Carolina, a physician billing the same code got $90.22, or 107% of the Medicare rate the state used [4]. What is new is that both states had to post those figures, code by code, on a public website.

What changed

The postings are the first round of a requirement in the Centers for Medicare & Medicaid Services (CMS) Ensuring Access to Medicaid Services final rule (CMS-2442-F), published May 10, 2024 and effective July 9, 2024 [2]. By July 1, 2026, each state had to publish all of its Medicaid fee-for-service (FFS) fee schedule rates and a comparative payment rate analysis setting certain Medicaid fees against Medicare’s [2].

On September 14, CMS published a Paperwork Reduction Act notice asking for comment on extending the information collection that documents states’ compliance with those access provisions, 42 CFR 447.203 and 447.204 (form CMS-10391, OMB control number 0938-1134) [1]. CMS estimates 51 respondents, 346 annual responses and 15,305 hours a year [1]. Comments must be received by November 13, 2026 [1].

The notice says CMS will use the information to monitor compliance with section 1902(a)(30)(A) of the Social Security Act and “to make informed approval decisions on State plan amendments that propose to make Medicaid rate reductions or restructure payment rates” [1]. It adds that providers and beneficiaries “may use the information to raise access issues to state Medicaid agencies” [1].

Who it affects

Primary care, OB/GYN and behavioral health practices. The comparison covers evaluation and management (E/M) codes CMS identifies for three categories: primary care, obstetrical and gynecological services, and outpatient mental health and substance use disorder services [2]. For each code, the state must show its base Medicaid rate, the Medicare non-facility rate for the same period and location, the Medicaid rate as a percentage of Medicare, and the number of paid claims and beneficiaries [2].

Home care agencies. A separate disclosure covers personal care, home health aide, homemaker and habilitation services, expressed as average hourly rates rather than as a percentage of Medicare [2].

Practices paid mostly by managed care plans. The rule reaches only FFS fee schedule rates [2]. In 2021, 85% of Medicaid beneficiaries were enrolled in a managed care program, according to the rule [2]. CMS still requires every state to comply, however much of its program runs through managed care [2].

How do Medicaid office-visit rates compare with Medicare?

It depends heavily on the state, the code and who bills it.

Pennsylvania’s report, dated June 25, pays one rate per code regardless of age, provider type or location [3]. Its 99214 rate was $54.42 against a Medicare rate of $125.59, or 43%, across 31,613 paid claims [3]. Preventive visits showed the widest gaps: codes 99381 through 99397 paid $20.00 each, between 13% and 21% of Medicare [3]. One line ran the other way. A 99211 billed under OB/GYN paid $32.50, which was 144% of Medicare’s $22.56 [3]. Pennsylvania’s Medicare figures are an average of its Metropolitan Philadelphia and Rest of State localities [3].

South Carolina splits its rates by provider type [4]. Physicians billing 99214 in primary care received $127.50, 107% of a Medicare rate of $119.23, on 131,318 claims [4]. Nurse practitioners and physician assistants billing the same code received $79.07, which the state compares with a lower Medicare rate of $101.35, for 78% [4]. In outpatient behavioral health, psychiatrists billing 99213 through 99215 were paid at the 107% level while other physicians were listed at 83% [4].

The national picture the rule cited came from a 2021 Health Affairs study, which found that “Medicaid physician fees were 72 percent of Medicare physician fees for twenty-seven common procedures in 2019,” with primary care lower than obstetric care [2].

What it means for your practice

You have a public benchmark. The rule requires the rates to be organized so “a member of the public can readily determine the amount that Medicaid would pay for a given service,” and the page must be easily reached from a hyperlink on the state Medicaid agency’s website [2]. The state has to update the published rates within one month after a rate change is approved or takes effect [2].

The numbers are a year old by design. The first comparison uses rates in effect as of July 1, 2025, even though it was due a year later [2]. Pennsylvania and South Carolina both report calendar year 2025 rates and claims [3, 4]. Any increase your state adopted since then won’t appear until the next comparison, which states must update at least every two years [2].

Your managed care contracts are a separate question. Pennsylvania’s notes say its utilization counts exclude managed care and that “MCO payment rates may differ from the base FFS fee schedule rates” [3]. If most of your Medicaid volume comes through plans, the state table describes FFS rates, not what your plans pay you.

Rate cuts now come with a paper trail. When a state proposes to cut or restructure FFS rates in a way that could reduce access, it gets a lighter review only if three tests are met: aggregate payments stay at or above 80% of Medicare for the affected category, the cuts total no more than 4% of FFS spending in that category over the state fiscal year, and the public process turns up no significant access concerns it cannot resolve [2]. Otherwise the state must give CMS three years of data on actively participating providers, beneficiaries and services by geographic area, plus a summary of the access complaints it received [2]. Using a Medicaid-to-Medicare fee index for 2019, CMS estimated that only 15 states could have cut primary care rates by up to 4% and still met the 80% threshold [2].

What to do now

1. Pull your state’s comparative analysis from the Medicaid agency website and find the E/M codes you bill most [2].
2. Check which line applies to you. States must separate rates by population, provider type and location where they differ, as South Carolina’s physician and nurse practitioner rows show [2, 4].
3. Set the FFS figures beside your managed care contract rates rather than assuming they match [3].
4. Report access problems through the state’s channel. States must keep ongoing mechanisms for provider input, such as hotlines, surveys or an ombudsman, and must keep a record of what they received and how they responded [2].
5. Comment on CMS-10391 by November 13 if your practice or society wants to weigh in on the reporting [1].

The policy fight

The comment record on the 2024 rule was lopsided. CMS reported that commenters “overwhelmingly supported” the rate transparency provision [2]. A couple opposed it, arguing it would burden states and “would not result in a meaningful access analysis,” and one questioned whether section 1902(a)(30) gives CMS authority to require the publication [2]. Several commenters raised the strain on state staff and budgets of meeting this rule alongside a separate managed care rule [2].

Some commenters wanted more. A couple asked CMS to require states to raise rates when the analysis found shortfalls, or when rates fell below a threshold such as 50% of Medicare [2]. CMS declined, saying the provisions “do not require States to change their payment rates” [2]. It said it expects states to weigh the data when evaluating their rates, and that it will use the same information in its own oversight and rate approvals [2].

CMS also set a penalty for states that do not publish: future grant awards may be reduced by the federal share CMS attributes to administrative spending on the affected service categories, until the state complies [2]. And when a state identifies an access deficiency, it must submit a corrective action plan within 90 days, with fixes that can include higher rates [2].

The data arrive as states weigh other financing changes, including the provider tax limits covered in our July report on CMS’s proposal. Whether a published 39% changes any state’s next rate decision is not something the rule settles. The renewal notice leaves the reporting itself in place, and its comment period closes November 13 [1].