Florida 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 Florida's plan contracts, statutes and notices. For 6 of 22 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 6of 22
- Plans on record
- 46
- Directed payments
- 0
- Capitation cells
- 5,071$2.16–$44,315.86 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 | 9,874 | State sets the plan ratePaid by the state, outside plans |
| Nursing facility | State sets the plan rateThe state sets the rate plans pay | 9,555 | |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 6,255 | |
| Hospital inpatient | Plans expected to pay at least thisPlans are expected to pay at least the published rate | 6,178 | |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,143 | Paid by the state, outside plans |
| Hospital outpatient | Plans expected to pay at least thisPlans are expected to pay at least the published rate | 1,821 | |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,723 | |
| Clinics (FQHC/RHC) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 935 | |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 886 | |
| Hospice | State sets the plan rateThe state sets the rate plans pay | 775 | |
| Dental | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 233 | Paid by the state, outside plans |
| Therapy (PT/OT/speech) | Paid by the state, outside plansPaid directly by the state, outside managed care | 174 | Plans negotiate; applies out of network |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 124 | |
| Behavioral health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 112 | Paid by the state, outside plansPlans expected to pay at least this |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 111 | Plans negotiate; applies out of network |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 78 | |
| Private duty nursing | Paid by the state, outside plansPaid directly by the state, outside managed care | 71 | Plans negotiate; applies out of network |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 57 | Plans negotiate; applies out of network |
| ABA / autism services | Paid by the state, outside plansPaid directly by the state, outside managed care | 47 | Plans negotiate; applies out of network |
| Other | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 25 | |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 15 | |
| Transportation | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 10 |
Frequently asked questions
Do Florida 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, Nursing facility, Hospital inpatient, Hospital outpatient, Hospice, Behavioral health. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Florida'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.