TOS
code TOS description IP LT OT RX
001 Inpatient hospital services, other than services in an institution for mental diseases X
002 Outpatient hospital services X
003 Rural health clinic services X
004 Other ambulatory services furnished by a rural health clinic X
005 Professional laboratory services, technical laboratory services X
006 Technical laboratory services X
007 Professional radiological services X
008 Technical radiological services X
009 Nursing facility services for individuals age 21 or older (other than services in an
institution for mental disease) X
010 Early and periodic screening and diagnosis and treatment (EPSDT) services X
011 Family planning services and supplies for individuals of child-bearing age X X
012 Physicians' services X
013 Medical and surgical services of a dentist X
014 Outpatient substance abuse treatment services X
015 Medical or otherremedial careorservices, otherthan physicians'services, provided
by licensed practitioners within the scope of practice as defined under State law X
016 Home health services — Nursing services X
017 Home health services — Home health aide services X
018 Home health services — Medical supplies, equipment, and appliances suitable for use in the home X X
019 Home health services — Physical therapy provided by a home health agency or by a
facility licensed by the State to provide medical rehabilitation services X
020 Home health services — Occupational therapy provided by a home health agency or
by a facility licensed by the State to provide medical rehabilitation services X
021 Home health services — Speech pathology and audiology services provided by a
home health agency or by a facility licensed by the State to provide medical
rehabilitation services X
022 Private duty nursing services X
023 Advanced practice nurse services X
024 Pediatric nurse X
025 Nurse-midwife service X
026 Nurse practitioner services X
027 Respiratory care for ventilator-dependent individuals X
028 Clinic services X
029 Dental services X
030 Physical therapy services (when not provided under home health services) X
031 Occupational therapy services (when not provided under home health services) X
032 Speech, hearing, and language disordersservices(when not provided under home
health services) X
033 Prescribed drugs X
034 Over-the-counter medications X
035 Dentures X
036 Medical equipment/prosthetic devices X X
037 Eyeglasses X
038 Hearing Aids X
039 Diagnostic services X
040 Screening services X
041 Preventive services X
042 Well-baby and well-childcare services as defined by the State. X
043 Rehabilitative services X
044 Inpatient hospital services for individuals age 65 or older in institutions for mental
diseases X
045 Nursing facility services for individuals age 65 or older in institutions for mental
diseases X
046 Intermediate care facility (ICF)/Intermediate Care Facilities for individuals with
Intellectual Disabilities (IIDICF)/Individuals with Intellectual Disabilities (IID)
services X
047 Nursing facility services, other than in institutions for mental diseases X
048 Inpatient psychiatric services for individuals under age 21 X
049 Outpatient mental health services, other than Outpatient substance abuse
treatment services. This TOS includes services furnished in a State-operated mental
hospital and including community-based services. X
050 Inpatient substance abuse treatment services and residential substance abuse
treatment services. X X
051 Personal care services X
052 Primary care case management services X
053 Targeted case management services X
054 Case Management services other than those that meett he definition of primary care
case management services ortargeted case management services X
055 Care coordination services X
056 Transportation services X
057 Enabling services X
058 Services furnished in a religious nonmedical health care institution X
059 Skilled nursing facility services for individuals under age 21 X
060 Emergency hospital services X X
061 Critical access hospital services — OT X
062 HCBS — Case management services X
063 HCBS — Homemaker services X
064 HCBS — Home health aide services X
065 HCBS — Personal care services X
066 HCBS — Adult day health services X
067 HCBS — Habilitation services X
068 HCBS — Respite care services X
069 HCBS — Day treatment or other partial hospitalization services, psychosocial
rehabilitation services and clinic services (whether or not furnished in a facility) for
individuals with chronic mental illness X
070 HCBS — Day Care X
071 HCBS — Training for family members X
072 HCBS — Minor modification to the home X
073 HCBS — Other services requested by the agency and approved by CMS as cost
effective and necessary to avoid institutionalization X
074 HCBS — Expanded habilitation services — Prevocational services X
075 HCBS — Expanded habilitation services — Educational services X
076 HCBS — Expanded habilitation services — Supported employment services, which
facilitate paid employment X
077 HCBS65-plus — Case management services X
078 HCBS-65-plus — Homemaker services X
079 HCBS-65-plus — Home health aide services X
080 HCBS-65-plus — Personal care services X
081 HCBS-65-plus — Adult day health services X
082 HCBS-65-plus — Respite care services X
083 HCBS-65-plus — Other medical and social services X
084 Sterilizations X X
085 Prenatal care and pre-pregnancy family planning services and supplies X X
086 Other Pregnancy-related Procedures X X
087 Hospice services X
088 Any other health care services or items specified by the Secretary and not excluded
under regulations X
089 Disposable medical supplies X X
090 Critical access hospital services — IP X
091 Skilled care — hospital residing X
092 Exceptional care — hospital residing X
093 Non-acute care — hospital residing X
115 Residential care X
119 Capitated payments to HMOs, HIOs, or PACE plans X
120 Capitated payments for primary care case management (PCCM) X
121 Premium payments for private health insurance X
122 Capitated payments to prepaid health plans (PHPs) X
123 Disproportionate share hospital (DSH) payments X X
127 Indian Health Service (IHS) — Family Plan X X
131 Drug Rebates X X
132 Supplemental payment — inpatient X
133 Supplemental payment — nursing X
134 Supplemental payment — outpatient X
135 Electronic health record (EHR) payments to provider X X
136 In vitro diagnostic products administered during any portion of the emergency
period for the detection of SARS–CoV–2 or the diagnosis of the virus that causes
COVID–19, and the administration of such in vitro diagnostic products X X X X
137 COVID–19 testing-related services X X X X
138 Per member per month (PMPM) payments for health home services X
139 Per member per month (PMPM) payments for Medicare Part A premiums X
140 Per member per month (PMPM) payments for Medicare Part B premiums X
141 Per member per month (PMPM) payments for Medicare Advantage Dual Special
Needs Plans (D-SNP) – Medicare Part C X
142 Per member per month (PMPM) payments for Medicare Part D premiums X
143 Per member per month (PMPM) payments for other payments X
144 Payments to individuals for personal assistance services under 1915(j) X
145 Medication Assisted Treatment (MAT) services and drugs for evidenced-based
treatment of Opioid Use Disorder (OUD) in accordance with section 1905(a)(29) of
the Social Security Act X X X X
146 Inpatient Psychiatric Services for beneficiaries between the ages of 22 and 64 who
receive services in an institution for mental disease (IMD) X X X X
147 Residential Pediatric Recovery Center (RPRC): A center or facility that furnishes
items and services for which medical assistance is available under the State plan to
infants with the diagnosis of neonatal abstinence syndrome without any other
significant medical risk factors. X X X X