The following Benefit Grids outline service codes, service limits, level of care and documentation requirements needed for service authorization requests (SARs). They also outline requirements for unmanaged services.
Please note that new benefit plans effective October 1, 2023 for Tailored Plan/PIHP/State funds will be available for view September 1, 2023.
Medicaid Benefit Grids
- Medicaid Adult Mental Health/Substance Use Services Benefit Grid
- Medicaid Child Mental Health/Substance Use Services Benefit Grid
- Medicaid MH, SU, I/DD Specialty Services Benefit Grid
- Medicaid Adult and Child B3 Services Benefit Grid
- Medicaid Inpatient Services Benefit
- 1915(i) State Plan Amendment Services Benefit Grid
Updated: August 23, 2023