Illinois Medicaid Fee Schedule
Illinois Medicaid pays $44.67 for an established-patient office visit (99213): 6th-lowest of 45 Medicaid programs, at 63% of the median. Its rates for the most-billed codes are below, ranked against every state.
- Schedule as of
- July 2026
- Codes priced
- 9,319
- 99213 vs. median
- 63% of median
Current Illinois Medicaid rates for common codes
Each amount is the unmodified non-facility rate in the July 2026 schedule. Where a code appears under more than one rate type, it is the state's ordinary statewide rate when its rules name one, and otherwise the median across rate types. Modifier-specific and facility-only rows are listed separately under the service.
| Code | Service | Non-facility rate | Prior auth |
|---|---|---|---|
| 99213 | Office visit, established patient (low complexity)1 rate type
| $44.67In effect since Apr 1, 20246th-lowest of 45 · 63% of median | Not published |
| 99214 | Office visit, established patient (moderate complexity)1 rate type
| $65.79In effect since Apr 1, 20244th-lowest of 45 · 65% of median | Not published |
| 99203 | Office visit, new patient (low complexity)1 rate type
| $55.95In effect since Apr 1, 20243rd-lowest of 45 · 63% of median | Not published |
| 99204 | Office visit, new patient (moderate complexity)1 rate type
| $90.81In effect since Apr 1, 20244th-lowest of 45 · 68% of median | Not published |
| 99285 | Emergency department visit, high severity with threat to function | $121.28In effect since Apr 1, 202412th-lowest of 42 · 87% of median | Not published |
Dot: Illinois. Tick: median across state programs. Line: lowest to highest state. Base fee-for-service rates; supplemental payments some states add are not included.
Illinois is 6th-lowest of 45 for 99213. See where all 9,319 Illinois Medicaid codes rank.
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Compare any other code across state programs. The free view shows a few states per code; Illinois's full schedule is in the complete dataset.
What to know about the Illinois Medicaid fee schedule
- Since April 1, 2024, practitioner codes first set at 60% of Medicare pay 70% of the January 2024 Medicare rate, capped at 100% of Medicare. HFS provider notice, April 2, 2024 SPA 24-0007 (CMS)
- Primary care still pays just 0.47 of Medicare on KFF's 2024 fee index, against 0.66 nationally. KFF Medicaid-to-Medicare fee index
- Maternal and Child Health Program rates, Medicare-level psychiatry rates and $75 postpartum visit add-ons pay above the base fee. SPA 24-0007 (CMS) HFS Practitioner Fee Schedule Key
- Physicians are exempt from the SMART Act's 2.7% cut, which still reduces other practitioner types billing the same codes. Practitioner Fee Schedule Key (07/01/2026) Public Act 097-0689 (SMART Act)
Illinois Medicaid fee schedule FAQ
Does a listed code mean the service is covered by Illinois Medicaid?
No. A listed Illinois Medicaid fee is not a coverage, authorization, or payment guarantee. Coverage, prior approval and billing rules are set in the HFS Handbook for Practitioners Rendering Medical Services and the Practitioner Fee Schedule Key.
Does this Illinois rate apply to Medicaid managed-care plans?
About 2.4 million of Illinois's 3.1 million Medicaid members are in HealthChoice Illinois managed care. Each plan negotiates its own rates with its network providers. The fee-for-service rates apply when Illinois Medicaid pays a claim directly. Plans must pay non-network providers the fee-for-service rate for covered services during a member's transition period.
Why might my actual payment differ from the displayed rate?
These are the July 2026 Illinois Medicaid rates. A claim can pay a different amount because of the date of service, modifier, place of service, units billed, provider enrollment or taxonomy, bundling with another service, coverage policy, prior authorization, and claim edits.
Why is there no published rate for this code?
Illinois hand-prices some codes: anesthesia follows the Practitioner Handbook, and practitioner-administered drugs and some procedures are priced from what is submitted with the claim. A code may also be bundled into another service or priced on a different Illinois Medicaid schedule. A missing rate does not mean the service is noncovered or pays $0.
Where can I find other Illinois Medicaid fee schedules?
Illinois Medicaid publishes separate fee schedules by provider type alongside the HFS Practitioner Fee Schedule, and its provider manual sets the coverage and billing rules.
How does Illinois set Medicaid practitioner rates?
Illinois pays the lesser of the provider's usual charge or the statewide maximum, and sets those maximums as a percentage of Medicare. From April 1, 2024, codes first priced at 60% of Medicare moved to 70% of the January 1, 2024 Medicare rate, mammography to 80%, under a 100% of Medicare ceiling. CMS approved the change as SPA IL 24-0007 in June 2024; assistant surgeon, anesthesia, add-on and bonus rates were excluded.
How do Illinois Medicaid rates compare to Medicare?
Illinois is one of the lower-paying states for primary care. The KFF Medicaid-to-Medicare fee index for 2024 puts Illinois at 0.47 for primary care, 0.80 for obstetric care, 0.85 for other services and 0.63 overall, against a national average of 0.66 for primary care and 0.75 overall. Obstetric and behavioral health codes are the main exceptions, since HFS lets some of them stay above 100% of Medicare.
Does the SMART Act 2.7% reduction apply to physicians?
No. The 2012 SMART Act (PA 097-0689) cut many Illinois practitioner rates by 2.7%, but HFS exempts physicians, physician assistants, advanced practice nurses, dentists, genetic counselors, FQHCs, RHCs, ERCs, LEAs and local health departments. Other practitioner types billing the same codes are paid the reduced amount.
Which Illinois physicians get enhanced or add-on payments?
Physicians who meet the Maternal and Child Health Program requirements receive enhanced rates for pregnant women and children through age 20. Since July 1, 2019, psychiatrists and psychiatric APNs have been paid the July 2019 Medicare rate for certain office and behavioral health codes, and since January 1, 2023 physicians, APNs and PAs can earn $75 add-ons for postpartum visits within 26 days and again at 27-89 days after delivery.
Do HealthChoice Illinois plans have to pay the Medicaid fee-for-service rate?
Not in general. About 2.4 million of Illinois's 3.1 million Medicaid enrollees (June 2026) are in HealthChoice Illinois plans, which negotiate rates with their network providers. HFS requires plans to pay the fee-for-service rate only to non-network providers treating a member during the transition period after enrollment.
Where does Illinois announce Medicaid rate changes?
HFS announces rate changes in provider notices, and under 42 CFR 447.205 it publishes a public notice of proposed changes in payment methods before they take effect. Rate changes can take effect before CMS approves them; in April 2024 HFS held affected claims until CMS approved the amendment and then reprocessed them.
Neighboring and high-enrollment Medicaid fee schedules
States bordering Illinois first, then the largest programs.