538 Medicaid reimbursement rates by state
Inpatient DRG pricing input (outlier, cost ratio, stay). 5 state Medicaid programs publish a fee-for-service rate for 538. Rates run from $0.7235 in Virginia to $2.50 in North Carolina, with a median of $0.7602.
Data as of 2026-10-05. Every rate links to the official document it came from.
- States publishing
- 5
- Median rate
- $0.7602units vary by state
- Highest
- $2.50North Carolina
- Medicare (non-facility)
- —not on the physician fee schedule
538 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 |
|---|---|---|---|---|---|---|
| North CarolinaAny qualified provider (rate does not vary by provider) · North Carolina Medicaid Direct (fee-for-service) | $2.50since 2026-10-01 | — | — | Plans must pay at least this | — | NC Medicaid fee schedule 'Grouper DRG We |
| WisconsinAny qualified provider (rate does not vary by provider) · Wisconsin Medicaid and BadgerCare Plus (fee-for-service, ForwardHealth maximum allowable fees) | $1.88since 2026-01-01 | — | — | Plans negotiate; applies out of network | — | ForwardHealth Rate Year 2026 EAPG weight |
| IllinoisAny qualified provider (rate does not vary by provider) · Illinois Medicaid (HFS fee-for-service) | $0.7602since 2023-08-01 | — | — | Plans negotiate; applies out of network | — | Outpatient Calculator Effective August 1 |
| New YorkAny qualified provider (rate does not vary by provider) · New York Medicaid (fee-for-service) | $0.7425since 2026-01-01 | relative weight | — | Plans negotiate; applies out of network | — | NYS DOH APG-Based Weights History File ( |
| VirginiaAny qualified provider (rate does not vary by provider) · Virginia Medicaid (fee-for-service, DMAS) | $0.7235since 2022-07-01 | EAPG WEIGHT | — | Plans negotiate; applies out of network | — | EAPG Weights Version 3.16 |
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 538?
It depends on the state. Of the 5 states with a published fee-for-service rate, the median is $0.7602. North Carolina pays the most ($2.50) and Virginia the least ($0.7235 per EAPG WEIGHT).
Which state pays the highest Medicaid rate for 538?
North Carolina, at $2.50, effective 2026-10-01.
Do managed-care plans pay the same rate for 538?
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.