Illinois 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 Illinois's plan contracts, statutes and notices. For 11 of 21 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 11of 21
- Plans on record
- 71
- Directed payments
- 96
- Capitation cells
- 40$88.04–$921.10 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 | 15,448 | |
| Transportation | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 4,230 | Plans must pay at least thisPaid by the state, outside plans |
| Nursing facility | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,930 | Plans must pay at least this |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,577 | |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,269 | State-directed paymentPlans must pay at least this |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,078 | |
| Hospital inpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,424 | State-directed paymentPlans must pay at least this |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,895 | |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,343 | |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 1,169 | Plans must pay at least this |
| Clinics (FQHC/RHC) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,113 | |
| Dental | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 480 | |
| Behavioral health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 464 | Paid by the state, outside plansPlans must pay at least this |
| Other home & community services | Plans must pay at least thisPlans must pay at least the published rate | 387 | Plans negotiate; applies out of networkPaid by the state, outside plans |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 184 | |
| Other | State-directed paymentDirected payments add to plan rates | 100 | Plans negotiate; applies out of network |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 74 | Paid by the state, outside plansPlans must pay at least this |
| Home health | Plans must pay at least thisPlans must pay at least the published rate | 62 | Plans negotiate; applies out of network |
| Private duty nursing | Plans must pay at least thisPlans must pay at least the published rate | 50 | Paid by the state, outside plansPlans negotiate; applies out of network |
| Personal care & attendant | Plans must pay at least thisPlans must pay at least the published rate | 46 | Plans negotiate; applies out of network |
| ABA / autism services | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 10 |
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 Illinois Medicaid plans have to pay the state fee schedule?
For some services. Plans must follow a rule tied to the state's rates for: Transportation, Nursing facility, Hospital outpatient, Hospital inpatient, IDD services, Behavioral health, Other home & community services, Therapy (PT/OT/speech), Home health, Private duty nursing, Personal care & attendant. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Illinois'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.