California 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 California's plan contracts, statutes and notices. For 3 of 21 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 3of 21
- Plans on record
- 231
- Directed payments
- 0
- Capitation cells
- 45,656$0.00–$22,362.09 PMPM
Who sets the rate, by service line
| Service line | Main rule for plans | Rates | Also applies |
|---|---|---|---|
| Behavioral health | Paid by the state, outside plansPaid directly by the state, outside managed care | 96,817 | Plans negotiate; applies out of networkState-directed payment |
| Physician & professional | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 22,338 | Paid by the state, outside plansState-directed payment |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 21,168 | State-directed paymentPlans negotiate; applies out of network |
| Other | Paid by the state, outside plansPaid directly by the state, outside managed care | 18,976 | Plans negotiate; applies out of networkState-directed payment |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 16,397 | |
| Transportation | Paid by the state, outside plansPaid directly by the state, outside managed care | 12,488 | Plans negotiate; applies out of networkPlans must pay at least this |
| Therapy (PT/OT/speech) | Paid by the state, outside plansPaid directly by the state, outside managed care | 11,727 | Plans negotiate; applies out of networkState-directed payment |
| Clinics (FQHC/RHC) | State wraparound guaranteeThe state guarantees the encounter rate on top of plan payment | 6,151 | Plans negotiate; applies out of network |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 4,216 | Plans negotiate; applies out of networkState-directed payment |
| Hospital inpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,588 | Paid by the state, outside plans |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,089 | State-directed payment |
| Nursing facility | State-directed paymentDirected payments add to plan rates | 2,941 | |
| ABA / autism services | Paid by the state, outside plansPaid directly by the state, outside managed care | 1,764 | |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 1,706 | Plans negotiate; applies out of network |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,678 | State-directed payment |
| Dental | Paid by the state, outside plansPaid directly by the state, outside managed care | 877 | |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 659 | State-directed payment |
| Hospice | Plans must pay at least thisPlans must pay at least the published rate | 234 | |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 221 | Paid by the state, outside plans |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 13 | |
| Private duty nursing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 8 | Paid by the state, outside plans |
Frequently asked questions
Do California Medicaid plans have to pay the state fee schedule?
For some services. Plans must follow a rule tied to the state's rates for: Transportation, Clinics (FQHC/RHC), Hospice. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From California'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 California Medicaid rates