West 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 West Virginia's plan contracts, statutes and notices. For 10 of 21 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 10of 21
- Plans on record
- 5
- Directed payments
- 0
- Capitation cells
- —not published
Who sets the rate, by service line
| Service line | Main rule for plans | Rates | Also applies |
|---|---|---|---|
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 57,450 | Plans must pay at least this |
| Physician & professional | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 14,053 | Plans must pay at least this |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,442 | |
| Equipment & supplies | Plans must pay at least thisPlans must pay at least the published rate | 3,281 | |
| Nursing facility | Paid by the state, outside plansPaid directly by the state, outside managed care | 3,111 | |
| Hospital inpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,950 | |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,902 | |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 920 | Plans must pay at least this |
| Dental | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 301 | |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 300 | |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 300 | |
| Hospice | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 276 | |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 111 | Plans must pay at least this |
| Therapy (PT/OT/speech) | Paid by the state, outside plansPaid directly by the state, outside managed care | 106 | Plans negotiate; applies out of networkPlans must pay at least this |
| Behavioral health | Plans must pay at least thisPlans must pay at least the published rate | 98 | Plans negotiate; applies out of networkPaid by the state, outside plans |
| Transportation | Paid by the state, outside plansPaid directly by the state, outside managed care | 37 | Plans must pay at least this |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 28 | Plans must pay at least thisPlans negotiate; applies out of network |
| ABA / autism services | Not classified yet | 14 | |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 10 | |
| Clinics (FQHC/RHC) | State sets the plan rateThe state sets the rate plans pay | 8 | |
| Private duty nursing | Paid by the state, outside plansPaid directly by the state, outside managed care | 5 | Plans negotiate; applies out of network |
| Other | Paid by the state, outside plansPaid directly by the state, outside managed care | 4 | Plans negotiate; applies out of network |
Frequently asked questions
Do West 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: Hospital outpatient, Physician & professional, Equipment & supplies, Pharmacy, Vision & hearing, Therapy (PT/OT/speech), Behavioral health, Transportation, Other home & community services, Clinics (FQHC/RHC). For other lines, plans negotiate rates with providers.
Where do these rules come from?
From West 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.
← All West Virginia Medicaid rates