97165 Medicaid reimbursement rate by state (2026)
Occupational therapy evaluation, level 1 of 3. Medicaid pays a median of $81.28 for 97165 across 48 states, from $16.25 in District of Columbia to $153.02 in Alaska.
- States publishing
- 48
- National median
- $81.28units vary by state
- Lowest
- $16.25District of Columbia
- Highest
- $153.02Alaska
What does Medicaid pay for 97165?
48 state Medicaid programs publish a fee-for-service rate for 97165. The national median is $81.28 (units differ between states). Alaska pays the most, $153.02, and District of Columbia the least, $16.25, a 9.4x spread. Where the billing unit matches Medicare's, Medicaid pays 37% of the 2026 Medicare physician fee schedule amount for the state.
Medicare (non-facility, 2026 physician fee schedule): $93.50–$129.28 depending on the state's Medicare locality.
97165 rate by state: highest, middle and lowest
One like-for-like fee-for-service rate per state, ranked. The workspace lists all 48 states with every variant, modifier and effective date.
How to read this table
- Order. States are listed from the highest published rate to the lowest. No single unit is shared by 8 or more states for 97165, 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. 37 of the 48 states list more than one rate for 97165, 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 48 states, 1 publish 97165 per an evaluation, 1 per unit and 1 per visit, and 45 schedules print no unit at all (a flat amount per service).
- Per hour. 97165 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. Shown only where the Medicaid rate uses the code's own billing unit and a Medicare amount exists: 1 state for 97165, at 37%.
- Source and date. Each Source link opens the state's own document; “since” is the date the rate took effect.
Why 97165 rates differ between states
Published rates for 97165 run from $16.25 in District of Columbia to $153.02 in Alaska, a 9.4x gap in the same unit. Half the states pay more than the median of $81.28 and half pay less. The usual reasons for a spread like this in therapy (PT/OT/speech) rates:
- States pay therapy by CPT code, but many pay therapy assistants a reduced percentage and some pay differently in outpatient hospital, private practice and home settings.
- Children's therapy is driven by the EPSDT benefit, so some states maintain separate pediatric rates or programs.
- Visit limits, prior authorization and annual caps vary by state and change how much a single code is worth to a practice.
Timing matters too. 29 states set the current rate for 97165 in 2026 or later, while 6 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 managed-care plans pay for 97165
Most Medicaid members are in managed-care plans, and plans don't publish their provider fee schedules. For 97165, the public signal is the rule each state sets for its plans, recorded on each rate above.
In 9 states, the published rate binds plans: a floor, a pass-through or a state-set rate. In 23 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 15 states is not classified yet.
- Plans negotiate; the published rate applies out of network (23 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 (9 states). 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.
- 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 Alaska managed care.
Units and billing for 97165
97165 is a CPT medicine code in the therapy (PT/OT/speech) line, billed mostly by physical, occupational and speech therapists and therapy practices. The medicine section runs from vaccines and psychiatry to dialysis, cardiology and therapy. Some of its codes are timed in 15-minute units, others are billed once per session or per test, so the unit matters more here than in most sections.
Medicare applies a rule for counting timed minutes into units; Medicaid programs may follow it or set their own, so check the state's therapy manual. Many treatment codes are timed in 15-minute units, while evaluations and re-evaluations are billed once per session.
Medicare's 2026 physician fee schedule pays $93.50–$129.28 for 97165 (non-facility), depending on the Medicare locality. That is a useful reference point, but Medicare and Medicaid can define the unit differently, so compare only where the units match.
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.
Frequently asked questions
What does Medicaid pay for 97165?
It depends on the state. Of the 48 states with a published fee-for-service rate, the median is $81.28. Alaska pays the most ($153.02) and District of Columbia the least ($16.25).
Which state pays the highest Medicaid rate for 97165?
Alaska, at $153.02, effective 2026-07-01.
Which state pays the lowest Medicaid rate for 97165?
District of Columbia, at $16.25, effective 2017-04-04.
What unit is 97165 billed in?
Of the 48 states, 1 publish 97165 per an evaluation, 1 per unit and 1 per visit, and 45 schedules print no unit at all (a flat amount per service).
How do Medicaid rates for 97165 compare with Medicare?
Where the billing units match, Medicaid pays 37% of the 2026 Medicare physician fee schedule amount for the state (non-facility).
Do managed-care plans pay the same rate for 97165?
Not necessarily. In 9 states, the published rate binds plans: a floor, a pass-through or a state-set rate. In 23 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 15 states is not classified yet. Each rule is cited to the plan contract, statute or notice in the workspace.