S0265 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 S0265, 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. 2 of the 5 states list more than one rate for S0265, 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. All 5 states publish S0265 per 15 min, so the amounts compare directly.
• Per hour. Time-based units are converted to an hour of service (four 15-minute units make an hour). 5 of the 5 states bill S0265 by time, with a median of $64.48 per hour.
• 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 S0265, 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 S0265 run from $15.00 in California to $67.88 in South Carolina, a 4.5x gap in the same unit. Half the states pay more than the median of $16.12 per 15 min and half pay less. The usual reasons for a spread like this in physician & professional rates:

• Primary-care and pediatric add-ons, enhanced rates for certain specialties and targeted increases for access problems change individual codes without moving the rest of the schedule.
• Modifiers such as professional or technical component, bilateral, multiple procedure and assistant at surgery change the amount paid, and states apply them with their own percentages.
• Some states pay physician services as a percentage of the Medicare fee schedule; others keep a schedule of their own that may not have been rebased for years.

Timing matters too. 3 states set the current rate for S0265 in 2026 or later, while 2 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 S0265 is negotiated privately, but the state decides how much room there is to negotiate. Here is how the rules break down across the 5 states.

In 3 states, plans negotiate and the published rate is a benchmark or out-of-network default. The rule for the remaining 2 states is not classified yet.

• Plans negotiate; the published rate applies out of network (3 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.

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 South Carolina managed care.

S0265 is a HCPCS Level II temporary national code in the physician & professional line, billed mostly by physicians, nurse practitioners, physician assistants and other licensed practitioners. S codes were created for private payers and are widely used by Medicaid programs for services Medicare does not cover, such as home nursing and home infusion. Units range from 15 minutes to a day.

Where a state publishes separate facility and non-facility amounts, the non-facility (office) amount is usually higher because the practice carries the overhead. Physician-fee-schedule codes are billed per service: one unit is one occurrence unless the code itself is defined by time or quantity.

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.