T4542 Medicaid reimbursement rate by state (2026)

• Order. States are listed from the highest published rate to the lowest. No single unit is shared by 8 or more states for T4542, so the order is by published amount and is not a like-for-like rank.
• Medicaid rate. The most the state's fee-for-service program pays for one unit, as published. 5 of the 23 states list more than one rate for T4542, by modifier, provider type or setting; the table shows the one that matches the provider level and setting used across states, without add-ons.
• Unit. Of the 23 states, 3 publish T4542 per unit, and 20 schedules print no unit at all (a flat amount per service).
• Per hour. T4542 is not billed in time units in these states, so no hourly figure is shown.
• Managed-care plans. The rule the state sets for its plans on this rate. What each rule means is explained below.
• % of Medicare. No Medicare physician fee schedule amount is on file for T4542, so there is no percentage.
• Source and date. Each Source link opens the state's own document; “since” is the date the rate took effect.

Published rates for T4542 run from $0.16 in Maine to $30.00 in Virginia, a 187.5x gap in the same unit. Half the states pay more than the median of $0.29 and half pay less. The usual reasons for a spread like this in equipment & supplies rates:

• Some items are priced individually from the manufacturer's price or the supplier's invoice, so fewer states publish a fixed fee.
• Many states set equipment and supply fees as a percentage of the Medicare DMEPOS fee schedule, at different percentages and from different years.
• A single code can carry separate purchase, rental and used-equipment amounts, and states publish different subsets of them.

Timing matters too. 3 states set the current rate for T4542 in 2026 or later, while 11 states still pay a rate that took effect in 2022 or earlier. A state that has not updated its rate in years will drift down the ranking as others raise theirs.

What a plan pays for T4542 is negotiated privately, but the state decides how much room there is to negotiate. Here is how the rules break down across the 23 states.

In 2 states, the published rate binds plans: a floor, a pass-through or a state-set rate. In 12 states, plans negotiate and the published rate is a benchmark or out-of-network default. In 1 state, the service is paid outside the plans or through a state-directed payment. The rule for the remaining 8 states is not classified yet.

• Plans negotiate; the published rate applies out of network (12 states). In-network rates can be above or below the published rate. The published rate is the benchmark both sides know, and the fallback if no contract is signed.
• Plans must pay at least the published rate (1 state). The published rate is your floor. Negotiate up from it, and if a plan pays less, the contract provision is the basis for a payment dispute.
• The state sets the plan rate (1 state). There is little to negotiate on price. Contracting is about network participation, authorization and billing terms.
• Paid by the state, outside the plans (1 state). Bill the state's Medicaid program, not the plan, at the published rate. There is no plan contract to negotiate for this service.

Plan-negotiated rates are never estimated here. To see the rule and its citation for a particular state, open that state's managed-care page, for example Virginia managed care.

T4542 is a HCPCS Level II state Medicaid agency code in the equipment & supplies line, billed mostly by durable medical equipment suppliers, orthotists, prosthetists and pharmacies. T codes were created for state Medicaid agencies, for services such as personal care, private duty nursing, case management and waiver services. Each state defines how the code is used and paid, so units vary from 15 minutes to a month.

Units follow the code: per item, per pair, per box or per month of rental, so a per-unit comparison only holds when the states use the same unit. Pricing modifiers decide which amount applies: NU for a new purchase, RR for a monthly rental and UE for used equipment.

Before billing, confirm the rate, unit and any modifier with the state's current schedule or the plan: the amounts here are as published, not a guarantee of payment.