New York 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 New York's plan contracts, statutes and notices. For 6 of 21 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 6of 21
- Plans on record
- 122
- Directed payments
- 0
- Capitation cells
- —not published
Who sets the rate, by service line
| Service line | Main rule for plans | Rates | Also applies |
|---|---|---|---|
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 152,526 | Paid by the state, outside plansSuggested schedule for plans |
| Behavioral health | Plans must pay at least thisPlans must pay at least the published rate | 67,495 | Plans negotiate; applies out of networkPaid by the state, outside plans |
| Clinics (FQHC/RHC) | State wraparound guaranteeThe state guarantees the encounter rate on top of plan payment | 28,086 | Paid by the state, outside plans |
| Physician & professional | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 14,034 | |
| Nursing facility | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 9,436 | |
| Hospital inpatient | Suggested schedule for plansThe state publishes a suggested schedule for plans | 8,636 | Plans negotiate; applies out of network |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 5,240 | Plans negotiate; applies out of networkPlans must pay at least this |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 3,871 | Plans must pay at least this |
| Hospice | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,726 | |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,306 | |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,692 | |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,056 | |
| Transportation | Paid by the state, outside plansPaid directly by the state, outside managed care | 598 | Plans must pay at least this |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 484 | |
| Personal care & attendant | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 382 | Paid by the state, outside plans |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 357 | |
| Other | Plans must pay at least thisPlans must pay at least the published rate | 252 | |
| Dental | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 246 | |
| Private duty nursing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 18 | |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 16 | Paid by the state, outside plans |
| Pharmacy | Paid by the state, outside plansPaid directly by the state, outside managed care | 13 | |
| ABA / autism services | Not classified yet | 8 |
Frequently asked questions
Do New York Medicaid plans have to pay the state fee schedule?
For some services. Plans must follow a rule tied to the state's rates for: Behavioral health, Clinics (FQHC/RHC), Other home & community services, IDD services, Transportation, Other. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From New York'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.