Maryland 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 Maryland's plan contracts, statutes and notices. For 3 of 14 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 3of 14
- Plans on record
- 10
- Directed payments
- 22
- Capitation cells
- 342$72.97–$93,700.08 PMPM
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 | 12,805 | Paid by the state, outside plansPlans must pass increases through |
| Lab & pathology | Paid by the state, outside plansPaid directly by the state, outside managed care | 3,310 | |
| Nursing facility | Paid by the state, outside plansPaid directly by the state, outside managed care | 2,646 | |
| Equipment & supplies | Not classified yet | 2,472 | |
| Radiology | Not classified yet | 2,373 | |
| Pharmacy | Paid by the state, outside plansPaid directly by the state, outside managed care | 2,124 | |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 684 | |
| Behavioral health | Paid by the state, outside plansPaid directly by the state, outside managed care | 508 | |
| Dental | Paid by the state, outside plansPaid directly by the state, outside managed care | 231 | |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 215 | |
| Home health | Not classified yet | 125 | |
| Therapy (PT/OT/speech) | Paid by the state, outside plansPaid directly by the state, outside managed care | 104 | |
| Other | State-directed paymentDirected payments add to plan rates | 47 | Plans must pay at least this |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 20 | |
| ABA / autism services | Paid by the state, outside plansPaid directly by the state, outside managed care | 17 | |
| Vision & hearing | Not classified yet | 7 | |
| Private duty nursing | Not classified yet | 6 | |
| Hospital outpatient | Not classified yet | 5 | |
| Hospital inpatient | State sets the plan rateThe state sets the rate plans pay | 3 | |
| Clinics (FQHC/RHC) | Not classified yet | 2 | |
| Transportation | Paid by the state, outside plansPaid directly by the state, outside managed care | 2 |
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 Maryland 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, Other, Hospital inpatient. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Maryland'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.