District of Columbia 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 District of Columbia's plan contracts, statutes and notices. For 4 of 8 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 4of 8
- Plans on record
- 6
- Directed payments
- 0amounts in the workspace
- Capitation cells
- —not published
Who sets the rate, by service line
The main rule District of Columbia's managed-care plans follow for each service line, in plain language.
| Service line | Main rule for plans | Rates | Also applies |
|---|---|---|---|
| Physician & professional | Paid by the state, outside plansPaid directly by the state, outside managed care | 73,073 | |
| Behavioral health | Paid by the state, outside plansPaid directly by the state, outside managed care | 2,874 | |
| Hospital inpatient | Plans must pay at least thisPlans must pay at least the published rate | 2,745 | Plans negotiate; applies out of network |
| Equipment & supplies | Not classified yet | 1,945 | |
| Lab & pathology | Plans must pay at least thisPlans must pay at least the published rate | 1,496 | |
| Radiology | Not classified yet | 1,367 | |
| Pharmacy | Not classified yet | 1,122 | |
| Dental | Not classified yet | 700 | |
| Hospital outpatient | Plans must pay at least thisPlans must pay at least the published rate | 616 | |
| IDD services | Not classified yet | 347 | |
| Vision & hearing | Not classified yet | 306 | |
| Clinics (FQHC/RHC) | Plans must pay at least thisPlans must pay at least the published rate | 303 | |
| Therapy (PT/OT/speech) | Not classified yet | 289 | |
| Other home & community services | Not classified yet | 216 | |
| Transportation | Paid by the state, outside plansPaid directly by the state, outside managed care | 93 | |
| Personal care & attendant | Not classified yet | 59 | |
| Home health | Not classified yet | 38 | |
| Private duty nursing | Not classified yet | 34 | |
| ABA / autism services | Not classified yet | 16 | |
| Nursing facility | Paid by the state, outside plansPaid directly by the state, outside managed care | 13 | |
| Other | Not classified yet | 1 | |
| Hospice | Not classified yet | 1 |
District of Columbia Medicaid managed-care plans
6 plans on record across 4 programs.
Frequently asked questions
Do District of Columbia Medicaid plans have to pay the state fee schedule?
For some services. Plans must follow a rule tied to the state's rates for: Hospital inpatient, Lab & pathology, Hospital outpatient, Clinics (FQHC/RHC). For other lines, plans negotiate rates with providers.
Where do these rules come from?
From District of Columbia'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.