Colorado Medicaid managed care: what plans must pay
Managed-care plans don't publish their provider fee schedules. What is public is the rule each plan must follow, set in Colorado's plan contracts, statutes and notices. For 5 of 20 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 5of 20
- Plans on record
- 24
- Directed payments
- 0
- Capitation cells
- 372$18.94–$8,681.48 PMPM
Who sets the rate, by service line
| Service line | Main rule for plans | Rates | Also applies |
|---|---|---|---|
| Physician & professional | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 22,749 | Paid by the state, outside plansPlans must pay at least this |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 9,737 | Paid by the state, outside plans |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 5,200 | |
| Dental | Paid by the state, outside plansPaid directly by the state, outside managed care | 2,177 | Plans negotiate; applies out of network |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,166 | |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,174 | |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 445 | |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 436 | |
| Hospice | Paid by the state, outside plansPaid directly by the state, outside managed care | 358 | |
| Nursing facility | Paid by the state, outside plansPaid directly by the state, outside managed care | 335 | |
| Behavioral health | Plans must pay at least thisPlans must pay at least the published rate | 308 | Paid by the state, outside plansPlans negotiate; applies out of network |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 265 | Plans must pay at least thisPlans negotiate; applies out of network |
| Transportation | Paid by the state, outside plansPaid directly by the state, outside managed care | 234 | |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 170 | |
| Other | Paid by the state, outside plansPaid directly by the state, outside managed care | 149 | |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 99 | Paid by the state, outside plansPlans must pay at least this |
| Home health | Paid by the state, outside plansPaid directly by the state, outside managed care | 42 | |
| Clinics (FQHC/RHC) | Plans must pay at least thisPlans must pay at least the published rate | 20 | |
| Hospital outpatient | Not classified yet | 11 | |
| ABA / autism services | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 8 | |
| Private duty nursing | Paid by the state, outside plansPaid directly by the state, outside managed care | 7 |
Frequently asked questions
Do Colorado Medicaid plans have to pay the state fee schedule?
For some services. Plans must follow a rule tied to the state's rates for: Physician & professional, Behavioral health, Other home & community services, Therapy (PT/OT/speech), Clinics (FQHC/RHC). For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Colorado's managed-care plan contracts, state statutes and regulations, provider notices and CMS-approved directed-payment filings. Each rate in the workspace carries its citation.
Can I see what each plan actually pays?
No plan publishes its provider fee schedule. The closest public signals are the binding rules above, state-set rates, directed payments and the state's own payment-level estimates in its directed-payment filings.