Kentucky 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 Kentucky's plan contracts, statutes and notices. For 6 of 20 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 6of 20
- Plans on record
- 15
- Directed payments
- 23
- Capitation cells
- 234$4.00–$9,080.31 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 | 18,545 | State sets the plan rate |
| Behavioral health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 6,446 | Paid by the state, outside plans |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 5,179 | |
| Equipment & supplies | State sets the plan rateThe state sets the rate plans pay | 2,550 | Plans negotiate; applies out of network |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,473 | |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,428 | |
| Nursing facility | Paid by the state, outside plansPaid directly by the state, outside managed care | 597 | Plans negotiate; applies out of network |
| Dental | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 555 | |
| Hospital inpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 398 | Plans must pay at least this |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 216 | Paid by the state, outside plans |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 148 | State sets the plan ratePlans negotiate; applies out of network |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 131 | State sets the plan rate |
| ABA / autism services | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 72 | |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 58 | |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 42 | |
| Other | State-directed paymentDirected payments add to plan rates | 38 | Plans must pay at least this |
| Transportation | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 28 | Paid by the state, outside plans |
| Private duty nursing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 25 | Paid by the state, outside plans |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 24 | |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 18 |
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 Kentucky 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, Equipment & supplies, Hospital inpatient, Other home & community services, Vision & hearing, Other. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Kentucky'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.