Maryland 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 Maryland's plan contracts, statutes and notices. For 3 of 14 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 3of 14
- Plans on record
- 10
- Directed payments
- 22amounts in the workspace
- Capitation cells
- 342PMPM rates in the workspace
Who sets the rate, by service line
The main rule Maryland's managed-care plans follow for each service line, in plain language.
| Service line | Main rule for plans | Rates | Also applies |
|---|---|---|---|
| Physician & professional | Plans must pay at least thisPlans must pay at least the published rate | 12,805 | Paid by the state, outside plansPlans must pass increases through |
| Lab & pathology | Paid by the state, outside plansPaid directly by the state, outside managed care | 3,310 | |
| Nursing facility | Paid by the state, outside plansPaid directly by the state, outside managed care | 2,646 | |
| Equipment & supplies | Not classified yet | 2,472 | |
| Radiology | Not classified yet | 2,373 | |
| Pharmacy | Paid by the state, outside plansPaid directly by the state, outside managed care | 2,124 | |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 684 | |
| Behavioral health | Paid by the state, outside plansPaid directly by the state, outside managed care | 508 | |
| Dental | Paid by the state, outside plansPaid directly by the state, outside managed care | 231 | |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 215 | |
| Home health | Not classified yet | 125 | |
| Therapy (PT/OT/speech) | Paid by the state, outside plansPaid directly by the state, outside managed care | 104 | |
| Other | State-directed paymentDirected payments add to plan rates | 47 | Plans must pay at least this |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 20 | |
| ABA / autism services | Paid by the state, outside plansPaid directly by the state, outside managed care | 17 | |
| Vision & hearing | Not classified yet | 7 | |
| Private duty nursing | Not classified yet | 6 | |
| Hospital outpatient | Not classified yet | 5 | |
| Hospital inpatient | State sets the plan rateThe state sets the rate plans pay | 3 | |
| Clinics (FQHC/RHC) | Not classified yet | 2 | |
| Transportation | Paid by the state, outside plansPaid directly by the state, outside managed care | 2 |
What each plan rule means for providers
5 rules apply somewhere in Maryland's managed-care program. Here is what each one says and what it means when you contract with a plan.
Paid by the state, outside the plans
The service is carved out of managed care: the state pays it directly at its own rate, even for members enrolled in a plan.
For contracting: Bill the state's Medicaid program, not the plan, at the published rate. There is no plan contract to negotiate for this service.
Main rule for Lab & pathology, Nursing facility, Pharmacy, IDD services, Behavioral health, Dental, Other home & community services, Therapy (PT/OT/speech), Personal care & attendant, ABA / autism services and Transportation. Also applies in Physician & professional. 3,840 rates.Plans must pay at least the published rate
The plan contract, a statute or a state notice requires plans to pay network providers no less than the state's fee-for-service rate for the service.
For contracting: The published rate is your floor. Negotiate up from it, and if a plan pays less, the contract provision is the basis for a payment dispute.
Main rule for Physician & professional. Also applies in Other. 565 rates.State-directed payment
Under a federal rule (42 CFR 438.6(c)), the state directs plans to pay a minimum fee schedule, a uniform increase or another payment arrangement for a class of providers, with CMS approval.
For contracting: Eligible providers receive the directed amount on top of, or as a floor under, negotiated rates. Check whether your provider class qualifies.
Main rule for Other. 22 rates.The state sets the plan rate
The state sets the rate plans pay for the service, usually through a uniform schedule plans must use.
For contracting: There is little to negotiate on price. Contracting is about network participation, authorization and billing terms.
Main rule for Hospital inpatient. 3 rates.Plans must pass rate increases through
When the state raises its fee-for-service rate for the service, plans are required to raise what they pay providers by the same amount or percentage.
For contracting: Watch the state's rate notices, and check that plan payments change on the same effective date. The base rate itself may still be negotiated.
Also applies in Physician & professional. 10 rates.Using Maryland's plan rules in a contract negotiation
- Find your service line in the table above. In Maryland, Physician & professional carries a floor as the main rule, so the published rate is the least a plan may pay.
- Pull the published rate for each code you bill from the Maryland fee schedule. Under a floor it is your minimum; under a negotiated rule it is the benchmark both sides know.
- Read the contract language yourself. The rule here is the state's requirement on the plan. Your own provider agreement can add terms, such as a percentage of the published rate, that the state rule doesn't forbid.
- Watch for state rate changes. When Maryland changes a published rate, plans bound by a floor or pass-through must follow.
- Bill carved-out services to the state. In Maryland, Physician & professional, Lab & pathology, Nursing facility, Pharmacy, IDD services, Behavioral health, Dental, Other home & community services, Therapy (PT/OT/speech), Personal care & attendant, ABA / autism services and Transportation are paid at least partly outside the plans, at the published rate.
7 lines (Equipment & supplies, Radiology, Home health, Vision & hearing and others) are not classified yet; for them, assume the plan negotiates until a rule is published.
Maryland Medicaid managed-care plans
10 plans on record across 2 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 342 published capitation cells.
Frequently asked questions
Do Maryland Medicaid plans have to pay the state fee schedule?
For some services. Plans must follow a rule tied to the state's rates for: Physician & professional, Other, Hospital inpatient. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Maryland'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.
How many managed-care plans does Maryland Medicaid have?
10 plans are on record across 2 programs: Aetna Better Health of Maryland (ABH), CareFirst BlueCross BlueShield Community Health Plan (CFCHP), Jai Medical Systems, Inc. (JMS), Kaiser Permanente of the Mid-Atlantic States, Inc. (KPMAS), Maryland Physicians Care (MPC), MedStar Family Choice, Inc. (MSFC), PACE (MDH-contracted PACE organizations), Priority Partners (PPMCO) and others.
Which services are paid outside managed care in Maryland?
Physician & professional, Lab & pathology, Nursing facility, Pharmacy, IDD services, Behavioral health, Dental, Other home & community services, Therapy (PT/OT/speech), Personal care & attendant, ABA / autism services and Transportation: for at least part of these lines, the state pays the service directly at the published rate, even for plan members.
Does Maryland use state-directed payments?
Yes. 22 directed payments are on record, including Maryland HealthChoice (1115 Medicaid managed care, 9 MCOs). These are CMS-approved arrangements that make plans pay a minimum or an add-on for a class of providers.
How many service lines have a binding rule?
3 of 14 classified service lines carry a rule tied to the state's published rates.