Hawaii 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 Hawaii's plan contracts, statutes and notices. For 8 of 22 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 8of 22
- Plans on record
- 9
- Directed payments
- 15
- Capitation cells
- —not published
Who sets the rate, by service line
| Service line | Main rule for plans | Rates | Also applies |
|---|---|---|---|
| Physician & professional | Plans must pay at least thisPlans must pay at least the published rate | 7,468 | Plans negotiate; applies out of network |
| Hospital inpatient | State sets the plan rateThe state sets the rate plans pay | 3,542 | Plans negotiate; applies out of networkPlans must pay at least this |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,904 | |
| Dental | Paid by the state, outside plansPaid directly by the state, outside managed care | 1,760 | |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,495 | |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 630 | |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 112 | |
| Other home & community services | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 71 | Paid by the state, outside plans |
| Nursing facility | State sets the plan rateThe state sets the rate plans pay | 61 | Plans negotiate; applies out of networkPlans must pay at least this |
| Clinics (FQHC/RHC) | State sets the plan rateThe state sets the rate plans pay | 60 | Paid by the state, outside plansPlans negotiate; applies out of network |
| Hospice | State sets the plan rateThe state sets the rate plans pay | 47 | |
| ABA / autism services | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 43 | |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 32 | Plans must pay at least this |
| Transportation | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 31 | |
| Behavioral health | Plans must pay at least thisPlans must pay at least the published rate | 27 | State sets the plan ratePlans negotiate; applies out of network |
| Other | State-directed paymentDirected payments add to plan rates | 27 | Plans must pay at least this |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 22 | Plans negotiate; applies out of network |
| Personal care & attendant | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 18 | Paid by the state, outside plans |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 15 | |
| Private duty nursing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 11 | |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 4 | |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3 |
State-directed payments
Payments CMS approved under 42 CFR 438.6(c) that plans must make on top of, or as a minimum for, their negotiated rates.
Frequently asked questions
Do Hawaii 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, Hospital inpatient, Nursing facility, Clinics (FQHC/RHC), Hospice, Therapy (PT/OT/speech), Behavioral health, Other. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Hawaii'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.