New Mexico 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 Mexico's plan contracts, statutes and notices. For 22 of 22 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 22of 22
- Plans on record
- 5
- Directed payments
- 53amounts in the workspace
- Capitation cells
- —not published
Who sets the rate, by service line
The main rule New Mexico's managed-care plans follow for each service line, in plain language.
| Service line | Main rule for plans | Rates | Also applies |
|---|---|---|---|
| Hospital outpatient | Plans must pay at least thisPlans must pay at least the published rate | 12,932 | |
| Physician & professional | Plans must pay at least thisPlans must pay at least the published rate | 7,877 | |
| Equipment & supplies | Plans must pay at least thisPlans must pay at least the published rate | 3,489 | |
| Lab & pathology | Plans must pay at least thisPlans must pay at least the published rate | 1,902 | |
| Radiology | Plans must pay at least thisPlans must pay at least the published rate | 1,719 | |
| Pharmacy | Plans must pay at least thisPlans must pay at least the published rate | 1,077 | |
| Hospital inpatient | Plans must pay at least thisPlans must pay at least the published rate | 851 | |
| Hospice | Plans must pay at least thisPlans must pay at least the published rate | 531 | |
| Other | State-directed paymentDirected payments add to plan rates | 278 | Plans must pay at least thisState sets the plan rate |
| Dental | Plans must pay at least thisPlans must pay at least the published rate | 249 | |
| Behavioral health | Plans must pay at least thisPlans must pay at least the published rate | 185 | Plans expected to pay at least thisState sets the plan rate |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 177 | State sets the plan rate |
| Nursing facility | Plans must pay at least thisPlans must pay at least the published rate | 141 | State-directed payment |
| Therapy (PT/OT/speech) | Paid by the state, outside plansPaid directly by the state, outside managed care | 88 | Plans must pay at least thisState sets the plan rate |
| Transportation | Plans must pay at least thisPlans must pay at least the published rate | 55 | Paid by the state, outside plans |
| Vision & hearing | Plans must pay at least thisPlans must pay at least the published rate | 49 | |
| ABA / autism services | Plans must pay at least thisPlans must pay at least the published rate | 48 | |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 43 | State sets the plan ratePlans must pay at least this |
| Personal care & attendant | Plans expected to pay at least thisPlans are expected to pay at least the published rate | 14 | Paid by the state, outside plansState sets the plan rate |
| Private duty nursing | Paid by the state, outside plansPaid directly by the state, outside managed care | 12 | Plans expected to pay at least thisState sets the plan rate |
| Home health | State sets the plan rateThe state sets the rate plans pay | 9 | Plans expected to pay at least this |
| Clinics (FQHC/RHC) | Plans must pay at least thisPlans must pay at least the published rate | 1 |
New Mexico Medicaid managed-care plans
5 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.
Frequently asked questions
Do New Mexico 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, Physician & professional, Equipment & supplies, Lab & pathology, Radiology, Pharmacy, Hospital inpatient, Hospice, Other, Dental, Behavioral health, IDD services, Nursing facility, Therapy (PT/OT/speech), Transportation, Vision & hearing, ABA / autism services, Other home & community services, Personal care & attendant, Private duty nursing, Home health, Clinics (FQHC/RHC). For other lines, plans negotiate rates with providers.
Where do these rules come from?
From New Mexico'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.