Virginia 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 Virginia's plan contracts, statutes and notices. For 20 of 22 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 20of 22
- Plans on record
- 123
- Directed payments
- 56amounts in the workspace
- Capitation cells
- 10,369PMPM rates in the workspace
Who sets the rate, by service line
The main rule Virginia's managed-care plans follow for each service line, in plain language.
| Service line | Main rule for plans | Rates | Also applies |
|---|---|---|---|
| Nursing facility | Plans must pay at least thisPlans must pay at least the published rate | 28,801 | |
| Physician & professional | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 15,777 | 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 | 4,937 | |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 4,348 | State wraparound guarantee |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,213 | Plans must pay at least this |
| Dental | Paid by the state, outside plansPaid directly by the state, outside managed care | 2,859 | State sets the plan rate |
| Equipment & supplies | Plans must pay at least thisPlans must pay at least the published rate | 2,133 | Plans negotiate; applies out of networkPaid by the state, outside plans |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,935 | |
| Other | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,720 | State-directed paymentPlans must pay at least this |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,028 | Plans must pay at least thisPaid by the state, outside plans |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 420 | Plans must pay at least thisPlans negotiate; applies out of network |
| Behavioral health | Plans must pay at least thisPlans must pay at least the published rate | 419 | Paid by the state, outside plansPlans negotiate; applies out of network |
| Hospice | Plans must pay at least thisPlans must pay at least the published rate | 198 | Plans negotiate; applies out of network |
| Other home & community services | Plans must pay at least thisPlans must pay at least the published rate | 174 | Paid by the state, outside plansPlans negotiate; applies out of network |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 124 | Plans must pay at least thisPaid by the state, outside plans |
| Private duty nursing | Plans must pay at least thisPlans must pay at least the published rate | 100 | Paid by the state, outside plansPlans negotiate; applies out of network |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 99 | Plans must pay at least this |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 96 | Plans must pay at least this |
| Transportation | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 80 | Paid by the state, outside plansPlans must pay at least this |
| ABA / autism services | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 71 | Plans must pay at least this |
| Personal care & attendant | Plans must pay at least thisPlans must pay at least the published rate | 57 | Paid by the state, outside plansPlans negotiate; applies out of network |
| Clinics (FQHC/RHC) | Plans must pay at least thisPlans must pay at least the published rate | 2 | Paid by the state, outside plans |
What each plan rule means for providers
8 rules apply somewhere in Virginia'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, Hospital inpatient, Hospital outpatient, Lab & pathology, Radiology, Other, Pharmacy, Home health, Vision & hearing, Therapy (PT/OT/speech), Transportation and ABA / autism services. Also applies in Equipment & supplies, IDD services, Behavioral health, Hospice and 3 more. 32,273 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 Nursing facility, Equipment & supplies, Behavioral health, Hospice, Other home & community services, Private duty nursing, Personal care & attendant and Clinics (FQHC/RHC). Also applies in Physician & professional, Lab & pathology, Other, Pharmacy and 6 more. 30,972 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 Dental and IDD services. Also applies in Physician & professional, Equipment & supplies, Other, Pharmacy and 7 more. 2,586 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.
Also applies in Dental. 818 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 Other. 56 rates.Plans must pass rate increases through
When the state raises its fee-for-service rate for the service, plans are required to raise what they pay providers by the same amount or percentage.
For contracting: Watch the state's rate notices, and check that plan payments change on the same effective date. The base rate itself may still be negotiated.
Also applies in Physician & professional. 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 Behavioral health. 2 rates.State wraparound guarantee
For health centers, the state pays the difference between what the plan paid and the clinic's prospective payment rate.
For contracting: The clinic is made whole to its own rate whatever the plan pays, so the plan rate mostly affects cash flow and reconciliation timing.
Also applies in Hospital outpatient. 1 rates.Using Virginia's plan rules in a contract negotiation
- Find your service line in the table above. In Virginia, Nursing facility, Equipment & supplies, Behavioral health, Hospice, Other home & community services, Private duty nursing, Personal care & attendant and Clinics (FQHC/RHC) 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 Virginia 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 Virginia changes a published rate, plans bound by a floor or pass-through must follow. For lines where plans negotiate (Physician & professional, Hospital inpatient, Hospital outpatient and others), a change only reaches you if your contract ties your rate to the schedule.
- Bill carved-out services to the state. In Virginia, Physician & professional, Dental, Equipment & supplies, Other, Pharmacy, IDD services, Behavioral health, Other home & community services, Home health, Private duty nursing, Transportation, Personal care & attendant and Clinics (FQHC/RHC) are paid at least partly outside the plans, at the published rate.
Virginia Medicaid managed-care plans
60 plans on record across 9 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 10,369 published capitation cells.
Frequently asked questions
Do Virginia Medicaid plans have to pay the state fee schedule?
For some services. Plans must follow a rule tied to the state's rates for: Nursing facility, Physician & professional, Hospital outpatient, Lab & pathology, Dental, Equipment & supplies, Other, Pharmacy, IDD services, Behavioral health, Hospice, Other home & community services, Home health, Private duty nursing, Vision & hearing, Therapy (PT/OT/speech), Transportation, ABA / autism services, Personal care & attendant, Clinics (FQHC/RHC). For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Virginia'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 Virginia Medicaid have?
60 plans are on record across 9 programs: AETNA, Aetna, Aetna Better Health, Aetna Better Health for Virginia, Aetna Better Health of Virginia, All Cardinal Care Managed Care MCOs (not by plan), All Care for Seniors, AllCare and others.
Which services are paid outside managed care in Virginia?
Physician & professional, Dental, Equipment & supplies, Other, Pharmacy, IDD services, Behavioral health, Other home & community services, Home health, Private duty nursing, Transportation, Personal care & attendant and Clinics (FQHC/RHC): for at least part of these lines, the state pays the service directly at the published rate, even for plan members.
Does Virginia use state-directed payments?
Yes. 56 directed payments are on record, including Virginia Cardinal Care managed care state directed payments (42 CFR 438.6(c)). 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?
20 of 22 classified service lines carry a rule tied to the state's published rates.