Missouri 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 Missouri's plan contracts, statutes and notices. For 17 of 22 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 17of 22
- Plans on record
- 4
- Directed payments
- 25
- 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 | 52,675 | Plans negotiate; applies out of networkPaid by the state, outside plans |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,924 | Plans must pay at least this |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,915 | Plans must pay at least this |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,720 | Plans must pay at least thisPaid by the state, outside plans |
| Hospital outpatient | Plans must pay at least thisPlans must pay at least the published rate | 1,013 | Plans negotiate; applies out of network |
| Dental | Plans must pay at least thisPlans must pay at least the published rate | 931 | Plans negotiate; applies out of network |
| Behavioral health | Plans must pay at least thisPlans must pay at least the published rate | 552 | Paid by the state, outside plansState sets the plan rate |
| Nursing facility | Paid by the state, outside plansPaid directly by the state, outside managed care | 535 | |
| Vision & hearing | Plans must pay at least thisPlans must pay at least the published rate | 514 | Plans negotiate; applies out of networkPaid by the state, outside plans |
| Hospital inpatient | Plans must pay at least thisPlans must pay at least the published rate | 509 | |
| Therapy (PT/OT/speech) | Plans must pay at least thisPlans must pay at least the published rate | 308 | Paid by the state, outside plansPlans negotiate; applies out of network |
| ABA / autism services | Paid by the state, outside plansPaid directly by the state, outside managed care | 180 | Plans must pay at least this |
| Clinics (FQHC/RHC) | State sets the plan rateThe state sets the rate plans pay | 126 | Plans must pay at least this |
| Pharmacy | Plans must pay at least thisPlans must pay at least the published rate | 107 | |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 79 | Plans negotiate; applies out of networkPlans must pay at least this |
| Transportation | Plans must pay at least thisPlans must pay at least the published rate | 75 | Paid by the state, outside plans |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 63 | |
| Hospice | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 54 | |
| Other | State-directed paymentDirected payments add to plan rates | 41 | Paid by the state, outside plansPlans negotiate; applies out of network |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 37 | Plans must pay at least this |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 35 | Plans negotiate; applies out of network |
| Private duty nursing | Paid by the state, outside plansPaid directly by the state, outside managed care | 23 | Plans negotiate; applies out of networkPlans must pay at least this |
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 Missouri 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, Lab & pathology, Radiology, Equipment & supplies, Hospital outpatient, Dental, Behavioral health, Vision & hearing, Hospital inpatient, Therapy (PT/OT/speech), ABA / autism services, Clinics (FQHC/RHC), Pharmacy, Other home & community services, Transportation, IDD services, Private duty nursing. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Missouri'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.