Idaho 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 Idaho's plan contracts, statutes and notices. For 3 of 8 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 3of 8
- Plans on record
- 7
- Directed payments
- 0amounts in the workspace
- Capitation cells
- 19PMPM rates in the workspace
Who sets the rate, by service line
The main rule Idaho's managed-care plans follow for each service line, in plain language.
| Service line | Main rule for plans | Rates | Also applies |
|---|---|---|---|
| Physician & professional | Not classified yet | 8,314 | |
| Hospital outpatient | State sets the plan rateThe state sets the rate plans pay | 5,086 | |
| Equipment & supplies | Not classified yet | 2,067 | |
| Radiology | Not classified yet | 1,707 | |
| Lab & pathology | Not classified yet | 1,634 | |
| Hospital inpatient | Not classified yet | 1,518 | |
| Behavioral health | Not classified yet | 1,200 | |
| Pharmacy | Not classified yet | 940 | |
| Dental | State sets the plan rateThe state sets the rate plans pay | 230 | |
| Nursing facility | Not classified yet | 159 | |
| Clinics (FQHC/RHC) | State sets the plan rateThe state sets the rate plans pay | 144 | |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 131 | |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 125 | |
| Vision & hearing | Not classified yet | 121 | |
| Other | Not classified yet | 104 | |
| Hospice | Not classified yet | 97 | |
| ABA / autism services | Not classified yet | 37 | |
| Transportation | Paid by the state, outside plansPaid directly by the state, outside managed care | 28 | |
| Therapy (PT/OT/speech) | Not classified yet | 28 | |
| Home health | Not classified yet | 19 | |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 15 | |
| Private duty nursing | Paid by the state, outside plansPaid directly by the state, outside managed care | 12 |
Idaho Medicaid managed-care plans
7 plans on record across 4 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, and 19 published capitation cells.
Frequently asked questions
Do Idaho 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, Dental, Clinics (FQHC/RHC). For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Idaho'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.