425 Medicaid reimbursement rates by state
Inpatient DRG pricing input (outlier, cost ratio, stay). 5 state Medicaid programs publish a fee-for-service rate for 425. Rates run from $0.0038 in Illinois to $4.00 in New York, with a median of $1.31.
Data as of 2026-10-05. Every rate links to the official document it came from.
- States publishing
- 5
- Median rate
- $1.31units vary by state
- Highest
- $4.00New York
- Medicare (non-facility)
- —not on the physician fee schedule
425 rate in every state
One like-for-like fee-for-service rate per state, highest first. Units can differ between states; the per-hour column converts time-based units.
| State | Medicaid rate | Unit | Per hour | Managed-care plans | % of Medicare | Source |
|---|---|---|---|---|---|---|
| New YorkAny qualified provider (rate does not vary by provider) · New York Medicaid (fee-for-service and managed care default rates) | $4.00since 2018-07-01 | days (average length of stay) | — | Suggested schedule for plans | — | NYS DOH Final APR-DRG Service Intensity |
| North CarolinaAny qualified provider (rate does not vary by provider) · North Carolina Medicaid Direct (fee-for-service) | $2.90since 2026-10-01 | — | — | Plans must pay at least this | — | NC Medicaid fee schedule 'Grouper DRG We |
| GeorgiaAny qualified provider (rate does not vary by provider) · Georgia Medicaid (fee-for-service) | $1.31since 2024-01-01 | weight | — | Plans negotiate; applies out of network | — | Georgia Inpatient DRG System - DRG Weigh |
| VirginiaAny qualified provider (rate does not vary by provider) · Virginia Medicaid (fee-for-service, DMAS) | $0.0043since 2019-07-01 | EAPG WEIGHT | — | Plans negotiate; applies out of network | — | EAPG Weights Version 3.13 |
| IllinoisAny qualified provider (rate does not vary by provider) · Illinois Medicaid (HFS fee-for-service) | $0.0038since 2019-10-01 | — | — | Plans negotiate; applies out of network | — | Outpatient Calculator Effective July 1, |
Rates are per the unit shown for each state; units can differ between states. Medicare amounts are computed from the CMS relative value file and locality cost indices with the CMS formula; states with several Medicare localities show a range. Confirm rates with the payer before billing.
Frequently asked questions
What does Medicaid pay for 425?
It depends on the state. Of the 5 states with a published fee-for-service rate, the median is $1.31. New York pays the most ($4.00 per days (average length of stay)) and Illinois the least ($0.0038).
Which state pays the highest Medicaid rate for 425?
New York, at $4.00 per days (average length of stay), effective 2018-07-01.
Do managed-care plans pay the same rate for 425?
Not necessarily. Each state's plan contracts decide whether plans must pay at least the fee-for-service rate, pay a state-set rate, or negotiate their own. The table shows the rule for each state, cited to the contract or statute.