Workers’ Compensation Fee Schedules by State: 2026 Rules Explained

Table of Contents#

What Is a Workers’ Compensation Fee Schedule?
Core Factors That Shape State-Specific Fee Schedules
Workers’ Compensation Fee Schedule Rules by State
Common Exceptions to State Fee Schedules
How to Ensure Compliance With Your State’s Fee Schedule
Frequently Asked Questions
References

What Is a Workers’ Compensation Fee Schedule?#

A workers’ comp fee schedule is a regulatory tool designed to:

Control costs for employers and workers’ comp insurers by preventing overbilling
Guarantee fair, consistent reimbursement for medical providers treating work-related injuries
Protect injured workers from unexpected balance billing (charges above the approved reimbursement rate)

Most states base their fee schedules on the Medicare Resource-Based Relative Value Scale (RBRVS), a national system that assigns relative values to each medical service based on the time, skill, and overhead required to deliver it. States then apply a custom multiplier to these baseline Medicare rates to match local cost of living and care costs.

Core Factors That Shape State-Specific Fee Schedules#

While Medicare’s RBRVS is the most common baseline, states adjust their schedules based on the following key variables:

Cost of living adjustments (COLA): States with higher average living costs (e.g., New York, California) apply higher multipliers to Medicare rates.
Pharmacy carve-outs: 38 states maintain separate fee schedules for prescription drugs, usually based on the national Average Wholesale Price (AWP) minus a state-specific discount plus a flat dispensing fee.
Care type limits: Many states cap the number of covered visits for low-acuity care (e.g., chiropractic, physical therapy) per claim to avoid unnecessary treatment costs.
Balance billing rules: Most states prohibit providers from charging injured workers the difference between their standard rate and the fee schedule’s maximum reimbursement rate.
Dispute resolution processes: Each state has its own process for resolving billing disagreements between providers, insurers, and injured workers.

Workers’ Compensation Fee Schedule Rules by State#

Below is a breakdown of rules for the 10 most populous U.S. states, plus a regional overview for all other states:

Top 10 Most Populous States#

State	Core Fee Schedule Rules
California	Uses an annual Official Medical Fee Schedule (OMFS) that reimburses at approximately 154.51% of Medicare RBRVS rates for physician services (effective March 1, 2026). Chiropractic and physical therapy visits are capped at 24 per claim unless pre-authorized. Prescription drugs are reimbursed at AWP minus 17% plus a $5 dispensing fee.
Texas	Regulated by the Texas Department of Insurance (TDI), with a 125% Medicare RBRVS multiplier for in-network providers. No mandatory fee schedule applies to non-network providers that share written cost estimates with patients prior to treatment. Prescription drugs are reimbursed at AWP minus 15% plus a $4 dispensing fee.
Florida	Updated periodically, with a 175% Medicare RBRVS multiplier for physician services and 210% for surgical procedures (effective January 2025). Initial chiropractic care is capped at 12 visits per claim. Prescription drugs use the state Medicaid pharmaceutical fee schedule as a baseline, and telehealth services are reimbursed at the same rate as in-person care.
New York	Run by the New York State Workers’ Compensation Board, with a 140% Medicare RBRVS multiplier (one of the highest in the U.S.) to account for high local care costs. Balance billing is prohibited for all work comp claims, regardless of provider network status. Prescription drugs are reimbursed at AWP minus 12% plus a $5.25 dispensing fee.
Pennsylvania	Updated annually, with a 110% Medicare RBRVS multiplier for physician services and 110% of Medicare DME rates for medical equipment. Telehealth services are reimbursed at 90% of the in-person rate. Prescription drugs are reimbursed at AWP minus 17% plus a $4.50 dispensing fee.
Illinois	Updated every 3 years by the Illinois Workers’ Compensation Commission, with a 130% Medicare RBRVS multiplier for physician services and 120% of Medicare rates for hospital outpatient care. Chiropractic visits are capped at 52 per claim unless extended by the commission.
Ohio	One of four U.S. monopolistic workers’ comp states (all insurance is provided through the state Bureau of Workers’ Compensation). Fee schedule uses a 122% Medicare RBRVS multiplier, with a closed formulary for prescription drugs. Balance billing is prohibited for all work comp claims.
Georgia	Uses a 120% Medicare RBRVS multiplier for physician services, and 110% of Medicare DME rates for equipment. Out-of-network providers cannot balance bill unless they notify the insurer of planned costs prior to treatment. Prescription drugs are reimbursed at AWP minus 15% plus a $4 dispensing fee.
North Carolina	Updated every 2 years, with a 118% Medicare RBRVS multiplier for physician services. Physical therapy visits are capped at 30 per claim unless pre-authorized. Prescription drugs are reimbursed at AWP minus 16% plus a $3.50 dispensing fee.
Michigan	Updated annually, with a 125% Medicare RBRVS multiplier for physician services and 115% of Medicare diagnosis-related group (DRG) rates for inpatient hospital care. Prescription drugs are reimbursed at Average Acquisition Cost (AAC) plus 10% plus a $4 dispensing fee.

Regional & Special Case Overview#

Monopolistic states (North Dakota, Washington, Wyoming, Ohio): All workers’ comp coverage is provided through state-run funds, so fee schedules are uniform across all claims with no adjustments from private insurers.
Northeast states (Massachusetts, Connecticut): Average 130-140% Medicare RBRVS multipliers due to high local cost of living.
Southern/Midwest states: Average 110-125% Medicare RBRVS multipliers, with lower average prescription drug dispensing fees.
West states (Oregon, Washington, Nevada): Average 120-130% Medicare RBRVS multipliers, with strict limits on balance billing.
States with no mandatory fee schedule for professional services (as of 2025): Indiana, Iowa, Missouri, New Hampshire, New Jersey, and Wisconsin. These states use “usual and customary” local care rates to determine reimbursement, which WCRI research shows results in prices 41% to 188% higher than the median of fee schedule states.

Common Exceptions to State Fee Schedules#

Most states allow exceptions to standard fee schedule rules in the following scenarios:

Catastrophic injuries: Traumatic brain injuries, spinal cord injuries, and amputations often qualify for higher reimbursement limits to cover long-term care and support services.
Out-of-state treatment: If an injured worker receives care outside the state where their injury occurred, most states apply the fee schedule of the injury state, though some allow use of the treatment state’s schedule for emergency care.
Rural provider exemptions: 19 states waive standard fee schedule limits for providers in medically underserved rural areas to guarantee access to care for workers in remote industries (e.g., agriculture, mining).
Pre-authorized experimental treatments: Fee schedule limits do not apply to experimental or emerging treatments that are pre-approved by the insurer and state workers’ comp board.

How to Ensure Compliance With Your State’s Fee Schedule#

For Employers#

Review your state workers’ comp board website annually to check for fee schedule updates, which often take effect January 1 of each year.
Partner with a workers’ comp insurance provider that automatically applies your state’s fee schedule to all claims to avoid overpayment.
Train HR teams to share in-network provider lists with injured workers to reduce the risk of billing disputes and balance billing.

For Medical Providers#

Confirm applicable fee schedule rates prior to submitting work comp claims to reduce the risk of rejected or underpaid claims.
Follow state-specific prior authorization requirements for high-cost services, physical therapy, and chiropractic care.

For Injured Workers#

Notify all care providers that your treatment is for a work-related injury to ensure they bill the workers’ comp insurer directly rather than sending you a bill.
Contact your state workers’ comp board immediately if you receive a balance bill for care related to your work injury.

Frequently Asked Questions#

Q: Can providers charge more than the fee schedule maximum?#

A: In all states with mandatory fee schedules, providers are prohibited from balance billing injured workers for the difference between their standard rate and the fee schedule reimbursement rate. Insurers are only required to pay the maximum scheduled rate.

Q: How often are fee schedules updated?#

A: Most states update their core medical fee schedules annually or every 2-3 years. Prescription drug fee schedules are usually updated quarterly to reflect changes in national drug pricing.

Q: Do independent contractors have access to fee schedule protections?#

A: No, workers’ comp insurance only covers full-time and part-time employees. Independent contractors are responsible for their own medical costs for work-related injuries, and fee schedule rules do not apply to their care.

References#

U.S. Bureau of Labor Statistics. (2025). 2024 Workplace Injury and Illness Summary Report.
National Council on Compensation Insurance (NCCI). (2026). State Workers’ Compensation Fee Schedule Annual Overview.
Workers Compensation Research Institute (WCRI). (2026). Medical Price Index for Workers’ Compensation, 36-State Study.
State Workers’ Compensation Regulatory Agency Websites: California Department of Industrial Relations, Texas Department of Insurance, New York State Workers’ Compensation Board, Ohio Bureau of Workers’ Compensation.
California Division of Workers’ Compensation. (2026). Official Medical Fee Schedule (OMFS) Update Order, Effective March 1, 2026.
Florida Department of Financial Services. (2025). Workers’ Compensation Health Care Provider Reimbursement Manual, 2025 Edition.