Pennsylvania 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 Pennsylvania's plan contracts, statutes and notices. For 3 of 20 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 3of 20
- Plans on record
- 18
- Directed payments
- 34
- Capitation cells
- —not published
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 | 24,955 | Plans must pay at least this |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 11,572 | |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,788 | |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,756 | |
| Nursing facility | State-directed paymentDirected payments add to plan rates | 2,367 | |
| Hospital inpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,340 | |
| IDD services | Not classified yet | 954 | |
| Other home & community services | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 619 | |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 573 | |
| Behavioral health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 464 | State-directed payment |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 454 | |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 173 | |
| Dental | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 135 | |
| ABA / autism services | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 128 | |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 128 | |
| Transportation | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 110 | Plans must pay at least this |
| Personal care & attendant | Plans must pay at least thisPlans must pay at least the published rate | 98 | Plans negotiate; applies out of network |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 95 | |
| Private duty nursing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 37 | State-directed payment |
| Other | State-directed paymentDirected payments add to plan rates | 34 | |
| Clinics (FQHC/RHC) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 24 |
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 Pennsylvania 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, Transportation, Personal care & attendant. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Pennsylvania'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.
← All Pennsylvania Medicaid rates