Primary Care E/M Codes and Medicaid-vs-Medicare Benchmarking

Among the codes CMS designates for its Medicaid-vs-Medicare comparative analysis are two of the most commonly billed office-visit codes in primary care: 99213 (established patient, low-to-moderate complexity) and 99214 (established patient, moderate complexity). Because Medicare rates are national and well-published, these two codes give a rare, genuinely comparable benchmark across states.

What the ratio actually measures

The comparison is simple in concept: take a state’s Medicaid FFS rate for a code, divide by the corresponding Medicare non-facility rate for the same code, and express it as a percentage. A ratio at or above 100% means Medicaid pays at or above Medicare for that service; well below 100% means a meaningful reimbursement gap exists between the two programs for the same visit type.

This matters beyond a compliance checkbox — the ratio is one of the more direct, apples-to-apples signals of how competitively a state’s Medicaid program reimburses primary care relative to a stable, national reference point.

What published rates look like today

Looking at current published 99213/99214 rates across states with available data:

State	99213	99214
Nebraska	$70.40	$114.62
Ohio	$82.85	$122.27
California	$82.02	$115.88
Louisiana	$77.61	$109.26
Hawaii	$66.56	$98.27
Kentucky	$64.31	$90.98
Illinois	$44.67	$65.79
New York	$21.76	$34.03

The spread here is even wider than in behavioral health — New York’s published rate for these two codes is roughly a quarter of Nebraska’s, for what CMS defines as the same service. Whether that specific comparison reflects the full picture depends on factors like managed care penetration and whether a state’s FFS rate is even the primary payment mechanism most beneficiaries experience — but the raw FFS numbers themselves are exactly this far apart.

Why this ratio specifically gets used in access discussions

Primary care access is often measured partly through whether reimbursement is adequate to sustain provider participation, and the Medicare comparison gives regulators, advocates, and researchers a consistent yardstick that doesn’t require guessing at what “adequate” means in the abstract — it’s relative to a rate structure that already exists and is well understood.

Using this data responsibly

A few things worth keeping in mind if you’re using this comparison in your own analysis:

• The Medicare side of the ratio can itself change (via the annual Physician Fee Schedule update), so a ratio can shift even if the state’s Medicaid rate hasn’t moved.
• Facility vs. non-facility Medicare rates differ, so make sure you’re comparing against the correct Medicare rate type for the setting in question.
• A single ratio for one code is a data point, not a full picture of a state’s primary care reimbursement adequacy — it’s most useful in aggregate across the full CMS-designated code set.

MedicaidBench tracks the current published FFS rate for both codes across every state where data is available, alongside the underlying Medicaid-vs-Medicare ratio for Org-tier accounts, so this comparison doesn’t require manually cross-referencing two separate fee schedules yourself.