Ensuring Access to Medicaid Services — Comparative Rate Analysis (CY2025)
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Governs the Comparative Rate Analysis of Calendar Year 2025 Medicaid Fee‑For‑Service rates compared to Medicare non‑facility payments across CPT evaluation & management and preventive visit codes statewide for West Virginia Medicaid beneficiaries and providers.
No material clinical or coverage changes in this revision.
Coverage stance and applicability
Coverage stance
The document lists CY2025 Medicaid fee‑for‑service payment rates and corresponding Medicare non‑facility payments for numerous CPT codes statewide; it does not assert coverage limits, exclusions, or prior authorization requirements within the provided text.
ALL of the following
- Calendar Year 2025 Base Medicaid Fee‑For‑Service Fee Schedule values are reported for multiple CPT codes (statewide).
- Calendar Year 2025 Medicare Non‑Facility Payment amounts are reported as comparators for many of the same CPT codes.
- The analysis is statewide and covers multiple population groups (All Ages and age bands for preventive codes).
ALL of the following
- This is an informational Comparative Rate Analysis (Ensuring Access to Medicaid Services) that reports payment rates; it does not specify coverage determinations, medical necessity criteria, service exclusions, or prior authorization requirements in the provided excerpts.
ALL of the following
ANY of the following
- 99202 — Office/outpatient new, 15 minutes; CY2025 Medicaid FFS = 49.51; Medicare non‑facility = 65.44.
- 99203 — Office/outpatient new, 30 minutes; CY2025 Medicaid FFS = 78.43; Medicare non‑facility = 103.54.
- 99212 — Office/outpatient established, 10 minutes; CY2025 Medicaid FFS = 38.97; Medicare non‑facility = 51.29.
- 99215 — Office/outpatient established, high complexity, 40 minutes; CY2025 Medicaid FFS = 126.72; Medicare non‑facility = 167.10 (where reported).
ALL of the following
- 99381–99398 — Preventive medicine E/M initial and periodic visit codes reported with CY2025 Medicaid and Medicare rates for multiple age bands (example: 99381 for <1 year, Medicaid FFS = 75.49).
This document functions as a comparative payment-rate report. For coverage, medical necessity, or authorization requirements, providers should refer to West Virginia Medicaid coverage policies and billing guidance; such details are not provided in the analyzed excerpts.
Codes and payment comparisons
| 99381-99398 | Preventive medicine E/M codes for age-based periodic visits (various age bands) |
Required actions and notable determinations
Comparative Rate Analysis (July 1, 2026)
Comparative Rate Analysis — Ensuring Access to Medicaid Services (July 1, 2026).
Key term definitions
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