Nebraska 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 Nebraska's plan contracts, statutes and notices. For 9 of 22 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 9of 22
- Plans on record
- 5
- Directed payments
- 9amounts in the workspace
- Capitation cells
- 911PMPM rates in the workspace
Who sets the rate, by service line
The main rule Nebraska's managed-care plans follow for each service line, in plain language.
| 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 | 18,360 | State sets the plan rate |
| Nursing facility | Paid by the state, outside plansPaid directly by the state, outside managed care | 4,548 | Plans negotiate; applies out of network |
| Hospice | Paid by the state, outside plansPaid directly by the state, outside managed care | 4,524 | |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,777 | State sets the plan rate |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,755 | |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,795 | State sets the plan rate |
| Hospital inpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,680 | Plans expected to pay at least thisState sets the plan rate |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,019 | |
| Behavioral health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 866 | State sets the plan ratePlans expected to pay at least this |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 794 | Plans expected to pay at least this |
| Dental | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 200 | State sets the plan rate |
| Clinics (FQHC/RHC) | State sets the plan rateThe state sets the rate plans pay | 173 | |
| Other | State-directed paymentDirected payments add to plan rates | 165 | |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 125 | |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 103 | Plans negotiate; applies out of network |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 76 | |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 73 | |
| ABA / autism services | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 49 | State sets the plan rate |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 49 | Plans negotiate; applies out of network |
| Transportation | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 40 | Paid by the state, outside plans |
| Private duty nursing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 11 | |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 10 |
What each plan rule means for providers
5 rules apply somewhere in Nebraska's managed-care program. Here is what each one says and what it means when you contract with a plan.
Plans negotiate; the published rate applies out of network
Plans negotiate rates with their network providers. The published rate applies when a provider has no contract with the plan, as the default payment for out-of-network or non-contracted care.
For contracting: In-network rates can be above or below the published rate. The published rate is the benchmark both sides know, and the fallback if no contract is signed.
Main rule for Physician & professional, Lab & pathology, Equipment & supplies, Radiology, Hospital inpatient, Pharmacy, Behavioral health, Hospital outpatient, Dental, Vision & hearing, Therapy (PT/OT/speech), ABA / autism services, Transportation, Private duty nursing and Home health. Also applies in Nursing facility, Other home & community services and Personal care & attendant. 30,062 rates.Paid by the state, outside the plans
The service is carved out of managed care: the state pays it directly at its own rate, even for members enrolled in a plan.
For contracting: Bill the state's Medicaid program, not the plan, at the published rate. There is no plan contract to negotiate for this service.
Main rule for Nursing facility, Hospice, Other home & community services, IDD services and Personal care & attendant. Also applies in Transportation. 9,310 rates.The state sets the plan rate
The state sets the rate plans pay for the service, usually through a uniform schedule plans must use.
For contracting: There is little to negotiate on price. Contracting is about network participation, authorization and billing terms.
Main rule for Clinics (FQHC/RHC). Also applies in Physician & professional, Lab & pathology, Radiology, Hospital inpatient and 3 more. 464 rates.State-directed payment
Under a federal rule (42 CFR 438.6(c)), the state directs plans to pay a minimum fee schedule, a uniform increase or another payment arrangement for a class of providers, with CMS approval.
For contracting: Eligible providers receive the directed amount on top of, or as a floor under, negotiated rates. Check whether your provider class qualifies.
Main rule for Other. 9 rates.Plans are expected to pay at least the published rate
State guidance points plans to the fee-for-service rate as the minimum, but the language is less explicit than a contract requirement or applies only in some circumstances.
For contracting: Treat the published rate as a strong anchor, and confirm the minimum is written into your own plan agreement.
Also applies in Hospital inpatient, Behavioral health and Hospital outpatient. 191 rates.Using Nebraska's plan rules in a contract negotiation
- Find your service line in the table above. Check whether your line carries a floor, a state-set rate or a negotiated rate.
- Pull the published rate for each code you bill from the Nebraska fee schedule. Under a floor it is your minimum; under a negotiated rule it is the benchmark both sides know.
- Read the contract language yourself. The rule here is the state's requirement on the plan. Your own provider agreement can add terms, such as a percentage of the published rate, that the state rule doesn't forbid.
- Watch for state rate changes. When Nebraska changes a published rate, plans bound by a floor or pass-through must follow. For lines where plans negotiate (Physician & professional, Lab & pathology, Equipment & supplies and others), a change only reaches you if your contract ties your rate to the schedule.
- Bill carved-out services to the state. In Nebraska, Nursing facility, Hospice, Other home & community services, IDD services, Personal care & attendant and Transportation are paid at least partly outside the plans, at the published rate.
Nebraska Medicaid managed-care plans
5 plans on record across 2 programs.
State-directed payments and capitation
Payments CMS approved under 42 CFR 438.6(c) that plans must make on top of, or as a minimum for, their negotiated rates, and 911 published capitation cells.
Frequently asked questions
Do Nebraska 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, Hospital inpatient, Behavioral health, Hospital outpatient, Dental, Clinics (FQHC/RHC), ABA / autism services. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Nebraska'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.
How many managed-care plans does Nebraska Medicaid have?
5 plans are on record across 2 programs: Healthy Blue Nebraska (Community Care Health Plan of Nebraska), Managed Care of North America (MCNA) Dental, Molina Healthcare of Nebraska, Nebraska Total Care, UnitedHealthcare Community Plan of Nebraska (UnitedHealthcare of the Midlands).
Which services are paid outside managed care in Nebraska?
Nursing facility, Hospice, Other home & community services, IDD services, Personal care & attendant and Transportation: for at least part of these lines, the state pays the service directly at the published rate, even for plan members.
Does Nebraska use state-directed payments?
Yes. 9 directed payments are on record, including Nebraska Heritage Health state directed payment: non-state-owned hospital inpatient/outpatient uniform increase (LB1087 hospital assessment), Nebraska Heritage Health state directed payment: UNMC (public academic medical institution) practitioner uniform increase and Nebraska Medicaid managed care state directed payment: UNMC College of Dentistry uniform increase (dental PAHP 2023, Heritage Health from 2024). These are CMS-approved arrangements that make plans pay a minimum or an add-on for a class of providers.
How many service lines have a binding rule?
9 of 22 classified service lines carry a rule tied to the state's published rates.