Arizona 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 Arizona's plan contracts, statutes and notices. For 8 of 22 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 8of 22
- Plans on record
- 19
- Directed payments
- 25
- Capitation cells
- 1,217$0.71–$11,910.37 PMPM
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 | 108,338 | |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 18,013 | Paid by the state, outside plans |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 10,075 | |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 9,047 | |
| Hospital inpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 8,214 | Paid by the state, outside plans |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 5,902 | |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,403 | |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,925 | |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,219 | Plans expected to pay at least this |
| IDD services | State sets the plan rateThe state sets the rate plans pay | 1,146 | Plans expected to pay at least this |
| Behavioral health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 868 | Suggested schedule for plans |
| Dental | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 851 | |
| Transportation | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 588 | Suggested schedule for plansState sets the plan rate |
| Other home & community services | Plans expected to pay at least thisPlans are expected to pay at least the published rate | 463 | Plans negotiate; applies out of networkSuggested schedule for plans |
| Home health | Plans expected to pay at least thisPlans are expected to pay at least the published rate | 153 | Plans must pass increases through |
| Other | State-directed paymentDirected payments add to plan rates | 152 | Plans negotiate; applies out of network |
| Personal care & attendant | Plans expected to pay at least thisPlans are expected to pay at least the published rate | 145 | Plans negotiate; applies out of networkSuggested schedule for plans |
| Nursing facility | Plans must pass increases throughPlans must pass through state rate increases | 130 | |
| Private duty nursing | Plans expected to pay at least thisPlans are expected to pay at least the published rate | 78 | Plans negotiate; applies out of networkSuggested schedule for plans |
| ABA / autism services | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 71 | |
| Clinics (FQHC/RHC) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 54 | |
| Hospice | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 36 |
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 Arizona Medicaid plans have to pay the state fee schedule?
For some services. Plans must follow a rule tied to the state's rates for: Therapy (PT/OT/speech), IDD services, Transportation, Other home & community services, Home health, Personal care & attendant, Nursing facility, Private duty nursing. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Arizona'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.