San Clemente Medicaid providers billed $4,054,831 for services within the Evaluation and Management category in 2024, according to information from the U.S. Department of Health and Human Services Medicaid Provider Spending database. This amount reflected a 64.4% rise from 2023, when $2,466,636 was billed for the same category.
Medicaid operates as a public insurance initiative managed at the state level and financed collaboratively by federal and state governments. The program provides coverage to low-income Americans, seniors, children, and individuals with disabilities, representing a significant segment of the U.S. health care system.
As Medicaid funding is taxpayer-sourced, shifts in billing levels indicate how community resources for public health care are distributed.
The “Evaluation and Management” classification identifies a set of Medicaid-billed services distinguished by the nature of care, organized using standardized HCPCS and CPT code sets. In this analysis, each code was sorted into a single service grouping using specific code prefixes and numeric ranges, ensuring accurate summations over time without duplication.
Though Medicaid spending increased in several service categories, Evaluation and Management saw the largest total Medicaid payments in San Clemente during 2024.
Statewide in California, Evaluation and Management stood as the second-highest category by aggregate payments in 2024.
Comparing the five-year period before 2024, Medicaid payments in San Clemente for the Evaluation and Management category rose by $3,009,651, a 288% increase. Periods of heightened growth appeared in 2021 and 2022, when notable year-over-year increases occurred.
Spending tied to Evaluation and Management was distributed citywide, mostly concentrated in specific ZIP codes. In 2024, the 92672 ZIP code made up $3,793,151 in Medicaid payments for Evaluation and Management, while 92673 accounted for $261,679. Collectively, these two areas comprised 100% of such Medicaid payments in San Clemente that year.
Within the Evaluation and Management category, Medicaid spending focused on a handful of individual billing codes.
From 2023 to 2024, San Clemente’s Medicaid Evaluation and Management billing surged by 64.4%, while overall Medicaid claims in the city rose by 42.2% across all categories in that same timeframe.
According to the Centers for Medicare & Medicaid Services, federal and state Medicaid spending reached approximately $871.7 billion during the 2023 fiscal year. This represented around 18% of nationwide health expenditures and showed a sharp rise from the pre-pandemic level of $613.5 billion in 2019.
This growth equates to an increase of about 40% in a matter of years, mostly driven by higher enrollment and greater utilization during and following the pandemic.
In recent years, federal budget measures under the Trump administration have featured proposals aiming to reduce national Medicaid funding and alter program structure. Notably, the “One Big Beautiful Bill Act,” enacted in 2025, is expected to decrease federal Medicaid outlays by more than $1 trillion over the following decade, introducing work requirements and increased cost-sharing that could reduce benefits and coverage for some recipients. As a result, additional costs may shift to states, and the pace of federal Medicaid funding growth could be capped, though millions of Americans will continue to use the program.
| Year | Total Medicaid Payments | % Change From Previous Year |
|---|---|---|
| 2020 | $1,045,180 | 6.7% |
| 2021 | $1,607,694 | 53.8% |
| 2022 | $2,083,807 | 29.6% |
| 2023 | $2,466,636 | 18.4% |
| 2024 | $4,054,830 | 64.4% |
| Rank | Category | Medicaid Payments | Share of City Total |
|---|---|---|---|
| 1 | Evaluation and Management | $4,054,830 | 59.4% |
| 2 | Surgery | $1,489,458 | 21.8% |
| 3 | Alcohol and Drug Abuse Treatment | $381,184 | 5.6% |
| 4 | National Codes Established for State Medicaid Agencies | $292,125 | 4.3% |
| 5 | Dental Services | $202,245 | 3% |
| 6 | Pathology and Laboratory Procedures | $135,685 | 2% |
| 7 | Radiology Procedures | $95,478 | 1.4% |
| 8 | Ambulance and Other Transport Services and Supplies | $87,181 | 1.3% |
| 9 | Medicine Services and Procedures | $41,091 | 0.6% |
| 10 | Procedures / Professional Services | $38,539 | 0.6% |
| 11 | Drugs Administered Other than Oral Method | $6,941 | 0.1% |
| 12 | Durable Medical Equipment | $4,178 | 0.1% |
| 13 | Durable medical equipment (DME) Medicare administrative contractors (MACs) | $229 | <0.1% |
| 14 | Temporary National Codes (Non-Medicare) | $0 | <0.1% |
| HCPCS Code | Description | Medicaid Payments | Claims |
|---|---|---|---|
| 99213 | Office o/p est low 20 min | $1,711,220 | 449 |
| 99214 | Office o/p est mod 30 min | $1,072,243 | 361 |
| 99203 | Office o/p new low 30 min | $730,898 | 283 |
| 99204 | Office o/p new mod 45 min | $361,707 | 142 |
| 99212 | Office o/p est sf 10 min | $64,122 | 75 |
| 99243 | Off/op cnsltj new/est low 30 | $45,494 | 23 |
| 99215 | Office o/p est hi 40 min | $32,517 | 16 |
| 99202 | Office o/p new sf 15 min | $21,907 | 19 |
| 99391 | Per pm reeval est pat infant | $4,801 | 11 |
| 99223 | 1st hosp ip/obs high 75 | $3,018 | 3 |
| 99394 | Prev visit est age 12-17 | $2,519 | 14 |
| 99392 | Prev visit est age 1-4 | $1,732 | 7 |
| 99393 | Prev visit est age 5-11 | $1,625 | 12 |
| 99222 | 1st hosp ip/obs moderate 55 | $863 | 1 |
| 99188 | App topical fluoride varnish | $157 | 8 |
| 98940 | Chiropract manj 1-2 regions | $0 | 12 |
Note: HCPCS codes are shown for context within the category. Category totals and rankings in this article are based on standardized service groupings rather than individual billing codes.
Information in this article was obtained from the U.S. Department of Health and Human Services Medicaid Provider Spending database. The source data can be found here.
