Oregon 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 Oregon's plan contracts, statutes and notices. For 5 of 22 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 5of 22
- Plans on record
- 17
- Directed payments
- 39
- Capitation cells
- 34,644$0.01–$23,855.05 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 | 38,299 | Paid by the state, outside plansPlans expected to pay at least this |
| Other | State-directed paymentDirected payments add to plan rates | 10,937 | Paid by the state, outside plans |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,258 | |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,164 | |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,763 | |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,235 | |
| Hospital inpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 951 | |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 443 | Plans must pay at least this |
| Behavioral health | Paid by the state, outside plansPaid directly by the state, outside managed care | 358 | Plans negotiate; applies out of networkPlans expected to pay at least this |
| Dental | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 274 | |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 134 | Plans negotiate; applies out of networkPlans expected to pay at least this |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 129 | |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 117 | Plans negotiate; applies out of network |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 60 | |
| Hospice | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 59 | |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 49 | |
| Transportation | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 27 | Paid by the state, outside plans |
| Private duty nursing | Paid by the state, outside plansPaid directly by the state, outside managed care | 14 | Plans negotiate; applies out of network |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 11 | |
| ABA / autism services | Plans expected to pay at least thisPlans are expected to pay at least the published rate | 7 | |
| Nursing facility | Paid by the state, outside plansPaid directly by the state, outside managed care | 6 | |
| Clinics (FQHC/RHC) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 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 Oregon 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, Hospital outpatient, Behavioral health, Other home & community services, ABA / autism services. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Oregon'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.