New Jersey 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 New Jersey's plan contracts, statutes and notices. For 11 of 15 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 11of 15
- Plans on record
- 62
- Directed payments
- 17
- Capitation cells
- —not published
Who sets the rate, by service line
| Service line | Main rule for plans | Rates | Also applies |
|---|---|---|---|
| Physician & professional | Plans must pay at least thisPlans must pay at least the published rate | 67,045 | Plans expected to pay at least this |
| Lab & pathology | Plans must pay at least thisPlans must pay at least the published rate | 9,385 | |
| Radiology | Not classified yet | 7,473 | |
| Equipment & supplies | Not classified yet | 6,152 | |
| Pharmacy | Not classified yet | 3,841 | |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,689 | |
| Hospital inpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,838 | |
| Behavioral health | Plans must pay at least thisPlans must pay at least the published rate | 1,806 | Paid by the state, outside plansPlans negotiate; applies out of network |
| Dental | Plans must pay at least thisPlans must pay at least the published rate | 1,623 | |
| Other home & community services | State sets the plan rateThe state sets the rate plans pay | 642 | Paid by the state, outside plansPlans must pay at least this |
| Vision & hearing | Not classified yet | 450 | |
| Home health | Not classified yet | 258 | |
| Therapy (PT/OT/speech) | Paid by the state, outside plansPaid directly by the state, outside managed care | 253 | |
| Nursing facility | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 231 | Plans must pay at least this |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 221 | |
| Hospice | Not classified yet | 132 | |
| Private duty nursing | Plans must pay at least thisPlans must pay at least the published rate | 76 | |
| Personal care & attendant | State sets the plan rateThe state sets the rate plans pay | 71 | |
| Transportation | Paid by the state, outside plansPaid directly by the state, outside managed care | 71 | Plans must pay at least this |
| Clinics (FQHC/RHC) | State wraparound guaranteeThe state guarantees the encounter rate on top of plan payment | 41 | |
| ABA / autism services | Not classified yet | 30 | |
| Other | State-directed paymentDirected payments add to plan rates | 22 | State sets the plan rate |
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 New Jersey 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, Lab & pathology, Behavioral health, Dental, Other home & community services, Nursing facility, Private duty nursing, Personal care & attendant, Transportation, Clinics (FQHC/RHC), Other. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From New Jersey'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 New Jersey Medicaid rates