Health Care Reimbursement

Resources that explain the various aspects of health care reimbursement and help researchers find sources of information on payment rates

Essential Payment Info Resources

Center for Medicare and Medicaid Services (CMS)

This is the homepage of the federal government's Medicare reimbursement system resources.  It contains information on reimbursement laws and regulations, studies on health care delivery, datasets of Medicare claims data for research, fee schedules and explanations, etc.  Click on the "Medicare" tab to find what you're looking for.

Medicare Learning Network

Provides articles and brochures explaining many aspects of the Medicare program in a fair amount of detail.

Medicare Coverage Database

Use this resource if you want to know whether a procedure or service is covered. Follow this link to search the database by keyword, procedure, and/or date.

Medicare Physician Fee Schedule Lookup

Enter one or more HCPCS procedure codes plus other parameters and find out what Medicare reimburses for physician services, facility/technical component, and global payments for non-hospital settings.

Ambulatory Surgical Center (ASC) Fee Schedule Explained

Medicare Advantage (Medicare's HMO)

This link leads you to information explaining the ins and outs of the Medicare Advantage HMO plan, which may involve different reimbursement mechanisms than the "traditional" Medicare plan.

Medicare Drug Coverage and Pricing

This is the homepage of Medicare's website area relating to Medicare Part D drug coverage.

  • For an Excel spreadsheet listing each drug plan by state and by insurance company--including premium amounts and key plan coverage details, go to the Medicare Prescription Drug Coverage General Information homepage. Under the "Downloads" section, click on the current "Plan and Premium Information for Medicare Plans Offering Part D Coverage (ZIP)."
  • The Medicare Part B drug pricing guidelines and "average sales price" can be found on this page of the Medicare & Medicaid website.  The tables are organized by drug HCPCS number, with common naming included.  For a downloadable list of all HCPCS codes including drug codes (and the associated "official" drug names), visit this page.
  • Medicaid also has a drug pricing survey that is more up-to-date than Medicare's--called the National Average Drug Acquisition Cost (NADAC) survey.  It's updated weekly.
  • For annual sales totals of the top 100 drugs by year and by quarter, visit the website's sales statistics page.

Medicare Managed Care Plans Including Medicare Advantage (MA)

Medicare DRG "Find-A-Code"

This is a private website on which one can look up DRGs to determine average payment amounts.

Medicare Waivers

A small number of states and participating provider categories (e.g., physician-hospital partnerships) have received waivers from the Medicare program that allows them to create and manage a different method of providing and paying for care to Medicare beneficiaries. Maryland, for example, has an all-payer system within which all payers (Medicare, Medicaid, commercial insurers, etc.) pay the same hospital inpatient rates established using a formula administered by state government.  In the Maryland case, the waiver remains in effect only so long as the amount paid for services by Medicare does not exceed the amount the program would have paid under the standard program.

In other situations, Medicare develops an interest in testing certain alternative care delivery and payment systems, then solicits bids from providers the U.S. or target region to provide services under the alternative approach.

Maryland--Health Services Cost Review Commission

Medicare Demonstration Projects & Evaluation Reports