Rhode Island 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 Rhode Island's plan contracts, statutes and notices. For 14 of 22 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 14of 22
- Plans on record
- 12
- Directed payments
- 11amounts in the workspace
- Capitation cells
- 1,603PMPM rates in the workspace
Who sets the rate, by service line
The main rule Rhode Island'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 | 49,582 | Plans must pay at least thisPaid by the state, outside plans |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 7,227 | |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 5,758 | |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,015 | |
| Nursing facility | Paid by the state, outside plansPaid directly by the state, outside managed care | 2,957 | State-directed paymentPlans negotiate; applies out of network |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,802 | Paid by the state, outside plans |
| Behavioral health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,321 | Paid by the state, outside plansPlans must pay at least this |
| Hospital inpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,299 | Plans must pay at least this |
| Personal care & attendant | Plans must pay at least thisPlans must pay at least the published rate | 546 | Paid by the state, outside plansState-directed payment |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 541 | Plans must pay at least this |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 443 | Plans must pay at least thisPlans negotiate; applies out of network |
| Dental | Paid by the state, outside plansPaid directly by the state, outside managed care | 327 | Plans negotiate; applies out of network |
| Therapy (PT/OT/speech) | Paid by the state, outside plansPaid directly by the state, outside managed care | 283 | 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 | 278 | Plans negotiate; applies out of network |
| Other | Plans must pay at least thisPlans must pay at least the published rate | 234 | Paid by the state, outside plansState-directed payment |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 131 | Plans must pay at least thisPaid by the state, outside plans |
| Private duty nursing | Paid by the state, outside plansPaid directly by the state, outside managed care | 125 | Plans negotiate; applies out of networkPlans must pay at least this |
| Transportation | Paid by the state, outside plansPaid directly by the state, outside managed care | 116 | Plans must pay at least this |
| ABA / autism services | Paid by the state, outside plansPaid directly by the state, outside managed care | 67 | Plans must pay at least thisPlans negotiate; applies out of network |
| Clinics (FQHC/RHC) | Plans must pay at least thisPlans must pay at least the published rate | 27 | Plans negotiate; applies out of network |
| Home health | Plans must pay at least thisPlans must pay at least the published rate | 20 | Plans negotiate; applies out of network |
| Hospice | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2 |
What each plan rule means for providers
4 rules apply somewhere in Rhode Island'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, Radiology, Equipment & supplies, Pharmacy, Behavioral health, Hospital inpatient, Hospital outpatient, Vision & hearing and Hospice. Also applies in Nursing facility, Other home & community services, Dental, Therapy (PT/OT/speech) and 5 more. 70,393 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, Other home & community services, Dental, Therapy (PT/OT/speech), IDD services, Private duty nursing, Transportation and ABA / autism services. Also applies in Physician & professional, Pharmacy, Behavioral health, Personal care & attendant and 2 more. 4,527 rates.Plans must pay at least the published rate
The plan contract, a statute or a state notice requires plans to pay network providers no less than the state's fee-for-service rate for the service.
For contracting: The published rate is your floor. Negotiate up from it, and if a plan pays less, the contract provision is the basis for a payment dispute.
Main rule for Personal care & attendant, Other, Clinics (FQHC/RHC) and Home health. Also applies in Physician & professional, Behavioral health, Hospital inpatient, Hospital outpatient and 6 more. 913 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.
Also applies in Nursing facility, Personal care & attendant and Other. 11 rates.Using Rhode Island's plan rules in a contract negotiation
- Find your service line in the table above. In Rhode Island, Personal care & attendant, Other, Clinics (FQHC/RHC) and Home health carry a floor as the main rule, so the published rate is the least a plan may pay.
- Pull the published rate for each code you bill from the Rhode Island 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 Rhode Island changes a published rate, plans bound by a floor or pass-through must follow. For lines where plans negotiate (Physician & professional, Lab & pathology, Radiology and others), a change only reaches you if your contract ties your rate to the schedule.
- Bill carved-out services to the state. In Rhode Island, Physician & professional, Nursing facility, Pharmacy, Behavioral health, Personal care & attendant, Other home & community services, Dental, Therapy (PT/OT/speech), IDD services, Other, Vision & hearing, Private duty nursing, Transportation and ABA / autism services are paid at least partly outside the plans, at the published rate.
Rhode Island Medicaid managed-care plans
12 plans on record across 6 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 1,603 published capitation cells.
Frequently asked questions
Do Rhode Island 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, Behavioral health, Hospital inpatient, Personal care & attendant, Hospital outpatient, Other home & community services, Therapy (PT/OT/speech), Other, Vision & hearing, Private duty nursing, Transportation, ABA / autism services, Clinics (FQHC/RHC), Home health. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Rhode Island'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 Rhode Island Medicaid have?
12 plans are on record across 6 programs: Blue Cross & Blue Shield of Rhode Island (H4152-021), Medical Transportation Management, Inc. (MTM), Neighborhood Health Plan of Rhode Island, Neighborhood Health Plan of Rhode Island (H2126-001), Oxford Health Plans (UnitedHealthcare) (H3113-010), PACE (Program of All-Inclusive Care for the Elderly), as printed, Tufts Health Public Plans (Tufts Health Plan), United Healthcare of New England (H0764-001) and others.
Which services are paid outside managed care in Rhode Island?
Physician & professional, Nursing facility, Pharmacy, Behavioral health, Personal care & attendant, Other home & community services, Dental, Therapy (PT/OT/speech), IDD services, Other, Vision & hearing, Private duty nursing, Transportation and ABA / autism services: for at least part of these lines, the state pays the service directly at the published rate, even for plan members.
Does Rhode Island use state-directed payments?
Yes. 11 directed payments are on record, including Rhode Island Medicaid managed care state directed payments. 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?
14 of 22 classified service lines carry a rule tied to the state's published rates.