Washington 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 Washington'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
- 51
- Directed payments
- 53
- 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 | 16,421 | Plans must pay at least thisPlans must pass increases through |
| Lab & pathology | Plans may pay no morePlans may pay no more than the published rate | 4,130 | Plans negotiate; applies out of networkPlans must pass increases through |
| Nursing facility | Paid by the state, outside plansPaid directly by the state, outside managed care | 4,111 | |
| Hospital inpatient | Plans must pay at least thisPlans must pay at least the published rate | 3,721 | |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,516 | Plans must pass increases through |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,519 | Paid by the state, outside plans |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 1,523 | Plans must pay at least thisPlans negotiate; applies out of network |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 1,462 | Plans negotiate; applies out of network |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,180 | |
| Hospital outpatient | Plans must pay at least thisPlans must pay at least the published rate | 1,116 | Plans negotiate; applies out of networkState sets the plan rate |
| Clinics (FQHC/RHC) | State wraparound guaranteeThe state guarantees the encounter rate on top of plan payment | 902 | State sets the plan rate |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 393 | 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 | 378 | Plans negotiate; applies out of network |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 311 | Paid by the state, outside plansPlans must pay at least this |
| Behavioral health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 225 | Paid by the state, outside plansState sets the plan rate |
| Home health | Plans must pay at least thisPlans must pay at least the published rate | 159 | Paid by the state, outside plans |
| Hospice | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 109 | |
| Other | State-directed paymentDirected payments add to plan rates | 65 | Plans negotiate; applies out of networkPlans must pay at least this |
| Private duty nursing | Paid by the state, outside plansPaid directly by the state, outside managed care | 62 | Plans must pay at least this |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 39 | |
| ABA / autism services | Plans must pay at least thisPlans must pay at least the published rate | 36 | |
| Transportation | Paid by the state, outside plansPaid directly by the state, outside managed care | 30 |
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 Washington 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, Lab & pathology, Hospital inpatient, Radiology, Other home & community services, Hospital outpatient, Clinics (FQHC/RHC), Personal care & attendant, Therapy (PT/OT/speech), Behavioral health, Home health, Other, Private duty nursing, ABA / autism services. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Washington'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 Washington Medicaid rates