Pennsylvania Medicaid Fee Schedule (Pennsylvania Medical Assistance)
Pennsylvania Medical Assistance pays $35.00 for an established-patient office visit (99213): lowest of 45 Medicaid programs, at 49% of the median. Its rates for the most-billed codes are below, ranked against every state.
- Schedule as of
- October 2026
- Codes priced
- 6,593
- 99213 vs. median
- 49% of median
Current Pennsylvania Medical Assistance rates for common codes
Each amount is the unmodified non-facility rate in the October 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 |
|---|---|---|
| 99213 | Office visit, established patient (low complexity)5 rate types
| $35.00In effect since Feb 17, 2025Lowest of 45 · 49% of median |
| 99214 | Office visit, established patient (moderate complexity)4 rate types
| $54.42In effect since Feb 17, 20252nd-lowest of 45 · 54% of median |
| 99203 | Office visit, new patient (low complexity)3 rate types
| $54.25In effect since Feb 17, 20252nd-lowest of 45 · 61% of median |
| 99204 | Office visit, new patient (moderate complexity)3 rate types
| $90.37In effect since Feb 17, 20253rd-lowest of 45 · 67% of median |
| 99285 | Emergency department visit, high severity with threat to function1 rate type
| $138.74In effect since Sep 1, 202121st-highest of 42 · 100% of median |
Dot: Pennsylvania. Tick: median across state programs. Line: lowest to highest state. Base fee-for-service rates; supplemental payments some states add are not included.
Pennsylvania is lowest of 45 for 99213. See where all 6,593 Pennsylvania Medical Assistance codes rank.
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Compare any other code across state programs. The free view shows a few states per code; Pennsylvania's full schedule is in the complete dataset.
What to know about the Pennsylvania Medical Assistance fee schedule
- Pennsylvania sets one statewide maximum fee per code, and 55 Pa. Code 1150.62 caps rates at the Medicare upper limit. 55 Pa. Code 1150.62 Pennsylvania Bulletin fee schedule notice, April 2025
- KFF's 2024 index puts obstetric care at 1.06 of Medicare, among the few states above it, but primary care at only 0.49. KFF Medicaid-to-Medicare fee index
- Southeast zone academic medical center practice plans get a directed increase from HealthChoices plans, capped at the average commercial rate. CMS approval: PA academic medical center directed payment (2024)
- Anesthesia for multiple procedures pays 100% for the highest-paying procedure, 25% for the second and nothing beyond that. 55 Pa. Code 1150.52
Pennsylvania Medical Assistance fee schedule FAQ
Does a listed code mean the service is covered by Pennsylvania Medical Assistance?
No. A listed Pennsylvania Medical Assistance fee is not a coverage, authorization, or payment guarantee. Coverage limits and prior authorization rules are set in DHS's Medical Assistance bulletins and provider handbooks.
Does this Pennsylvania rate apply to Medicaid managed-care plans?
Pennsylvania's Physical HealthChoices is the state's mandatory managed care program for Medical Assistance, and CMS reports 95.1% of Pennsylvania Medicaid enrollees were in some form of managed care in 2024. MCO rates are negotiated with providers and are not on this fee-for-service schedule. The fee-for-service rates apply when Pennsylvania Medical Assistance pays a claim directly.
Why might my actual payment differ from the displayed rate?
These are the October 2026 Pennsylvania Medical Assistance 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?
Where Pennsylvania lists a $0 fee, DHS asks providers to contact the program office for the amount. Codes marked "Please See Details" are priced by modifier. A code may also be bundled into another service or priced on a different Pennsylvania Medical Assistance schedule. A missing rate does not mean the service is noncovered or pays $0.
Where can I find other Pennsylvania Medical Assistance fee schedules?
Pennsylvania Medical Assistance publishes separate fee schedules by provider type alongside the Medical Assistance Outpatient Fee Schedule, physicians, and its provider manual sets the coverage and billing rules.
How does Pennsylvania set Medical Assistance physician fees?
DHS establishes a statewide maximum fee for each procedure code and pricing modifier, and 55 Pa. Code 1150.62 caps those rates at 'the Medicare upper limit.' Under 1150.61, DHS publishes notice in the Pennsylvania Bulletin when fees change or codes are added or deleted; recent notices pair fee changes with prior authorization and NCCI-based unit and limit changes.
How do Pennsylvania Medicaid fees compare to Medicare?
KFF's 2024 Medicaid-to-Medicare fee index puts Pennsylvania at 0.68 of Medicare for all services, but the categories diverge sharply: obstetric care pays 1.06 of Medicare while primary care pays 0.49, among the lowest primary care ratios in the country. The index covers fee-for-service fees only.
Do HealthChoices MCOs pay the fee-for-service fee schedule?
No state rule ties HealthChoices physician rates to the fee schedule; MCOs negotiate them. The main exception is a CMS-approved directed payment: practice plans affiliated with state-related academic medical centers in the Southeast zone get a uniform increase on MCO professional payments, paid quarterly and capped at their average commercial rate (up to $38 million for 2024).
How is anesthesia paid by Pennsylvania Medical Assistance?
Anesthesia is governed by 55 Pa. Code 1150.52, not a per-code amount on the physician listing. When two or more surgical procedures are performed under anesthesia by the same anesthesiologist during the same hospitalization, the anesthesiologist is paid 100% of the highest allowable payment for one procedure and 25% for the second, with no payment for additional procedures. No payment is made for local anesthesia.
What does a $0 fee mean on the Pennsylvania schedule?
It does not mean the service pays nothing. DHS says that for procedures showing $0, providers should 'contact the appropriate program office for specific fee information', because the amount is set outside the published schedule.
Does the Pennsylvania MA fee schedule apply to waiver services and program exceptions?
No. DHS states the schedule 'does not apply to Home and Community Based waiver services or those services approved by the Department under the 1150 Administrative Waiver (Program Exception) process.' Services approved through a program exception are paid at the amount DHS approves for that case, not the listed fee.
Neighboring and high-enrollment Medicaid fee schedules
States bordering Pennsylvania first, then the largest programs.