Massachusetts 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 Massachusetts's plan contracts, statutes and notices. For 7 of 21 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 7of 21
- Plans on record
- 37
- Directed payments
- 80
- Capitation cells
- 164$4.75–$10,923.43 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 | 13,575 | Plans must pay at least thisPaid by the state, outside plans |
| Nursing facility | Paid by the state, outside plansPaid directly by the state, outside managed care | 8,406 | |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,849 | |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,772 | |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,740 | |
| Other | State-directed paymentDirected payments add to plan rates | 771 | Plans must pay at least thisPlans negotiate; applies out of network |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 463 | Plans must pay at least this |
| Behavioral health | Plans must pay at least thisPlans must pay at least the published rate | 425 | Plans negotiate; applies out of network |
| Hospice | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 228 | |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 160 | |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 106 | |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 97 | |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 97 | |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 73 | Plans must pay at least thisPlans negotiate; applies out of network |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 63 | |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 62 | |
| Private duty nursing | Paid by the state, outside plansPaid directly by the state, outside managed care | 50 | |
| Dental | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 46 | |
| Transportation | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 27 | Paid by the state, outside plans |
| ABA / autism services | Plans must pay at least thisPlans must pay at least the published rate | 6 | |
| Clinics (FQHC/RHC) | Plans must pay at least thisPlans must pay at least the published rate | 5 |
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 Massachusetts 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, IDD services, Behavioral health, Other home & community services, ABA / autism services, Clinics (FQHC/RHC). For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Massachusetts'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 Massachusetts Medicaid rates