Delaware 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 Delaware's plan contracts, statutes and notices. For 2 of 18 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 2of 18
- Plans on record
- 5
- Directed payments
- 30amounts in the workspace
- Capitation cells
- —not published
Who sets the rate, by service line
The main rule Delaware's managed-care plans follow for each service line, in plain language.
| 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 | 21,669 | |
| Physician & professional | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 14,340 | Paid by the state, outside plans |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 4,827 | |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,292 | |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,584 | |
| Dental | Not classified yet | 216 | |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 192 | Paid by the state, outside plans |
| Behavioral health | Paid by the state, outside plansPaid directly by the state, outside managed care | 145 | Plans negotiate; applies out of network |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 83 | |
| Other | Paid by the state, outside plansPaid directly by the state, outside managed care | 76 | State-directed payment |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 73 | |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 67 | Paid by the state, outside plans |
| Hospital inpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 55 | |
| Transportation | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 23 | Paid by the state, outside plans |
| ABA / autism services | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 18 | |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 12 | Plans must pay at least this |
| Private duty nursing | Plans must pay at least thisPlans must pay at least the published rate | 8 | Plans negotiate; applies out of networkPaid by the state, outside plans |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 7 | |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 6 |
Delaware Medicaid managed-care plans
5 plans on record across 3 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.
Frequently asked questions
Do Delaware Medicaid plans have to pay the state fee schedule?
For some services. Plans must follow a rule tied to the state's rates for: Home health, Private duty nursing. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Delaware'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.