MedicaidReimbursementMedium impact
IL 2713-MC-D: Commercial Lesser of Logic - AMENDED
Iowa Medicaid·IA · Psychiatry·Informational Letter
Effective date
Dec 1, 2025
We identified it
Jun 21, 2026
Summary
Iowa Medicaid has amended its Commercial Lesser of Logic policy to exclude Certified Community Behavioral Health Clinics (CCBHCs) from the requirement that limits Medicaid payments to the lesser of cost-sharing or the difference between primary insurance payments and Medicaid fees. CCBHCs will now receive full enhanced rate reimbursement regardless of commercial insurance payments.
Action Required
By December 1, 2025: Billing teams at CCBHCs must verify their clinic's certification status and update billing procedures to ensure they are not subject to Lesser of Logic calculations. Contact Iowa Medicaid MCOs to confirm proper claim processing for enhanced rate reimbursement. Non-CCBHC providers must ensure secondary Medicaid billing follows Lesser of Logic rules where Medicaid payment cannot exceed cost-sharing amounts or allowable differences.