North Dakota 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 North Dakota's plan contracts, statutes and notices. For 2 of 2 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 2of 2
- Plans on record
- 5
- Directed payments
- 0amounts in the workspace
- Capitation cells
- 20PMPM rates in the workspace
Who sets the rate, by service line
The main rule North Dakota'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 | 7,162 | |
| Hospital outpatient | State sets the plan rateThe state sets the rate plans pay | 4,059 | |
| Nursing facility | Not classified yet | 1,880 | |
| Equipment & supplies | Not classified yet | 1,816 | |
| Radiology | Not classified yet | 1,722 | |
| Lab & pathology | Not classified yet | 1,640 | |
| Dental | Not classified yet | 552 | |
| Other home & community services | Not classified yet | 388 | |
| Clinics (FQHC/RHC) | Not classified yet | 95 | |
| Pharmacy | Not classified yet | 73 | |
| Hospital inpatient | State sets the plan rateThe state sets the rate plans pay | 51 | |
| IDD services | Not classified yet | 45 | |
| Vision & hearing | Not classified yet | 44 | |
| Behavioral health | Not classified yet | 43 | |
| Transportation | Not classified yet | 35 | |
| Personal care & attendant | Not classified yet | 27 | |
| Therapy (PT/OT/speech) | Not classified yet | 27 | |
| Home health | Not classified yet | 22 | |
| Other | Not classified yet | 22 | |
| ABA / autism services | Not classified yet | 7 | |
| Private duty nursing | Not classified yet | 5 |
What each plan rule means for providers
1 rule applies somewhere in North Dakota's managed-care program. Here is what each one says and what it means when you contract with a plan.
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 outpatient and Hospital inpatient. 2 rates.Using North Dakota's plan rules in a contract negotiation
- Find your service line in the table above. Check whether your line carries a floor, a state-set rate or a negotiated rate.
- Pull the published rate for each code you bill from the North Dakota 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 North Dakota changes a published rate, plans bound by a floor or pass-through must follow.
19 lines (Physician & professional, Nursing facility, Equipment & supplies, Radiology and others) are not classified yet; for them, assume the plan negotiates until a rule is published.
North Dakota Medicaid managed-care plans
5 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 20 published capitation cells.
Frequently asked questions
Do North Dakota 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, Hospital inpatient. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From North Dakota'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 North Dakota Medicaid have?
5 plans are on record across 4 programs: Blue Cross Blue Shield of North Dakota, Health Management, Northland PACE, Primary Care Case Management (PCCM), Sanford Health Plan.
Which services are paid outside managed care in North Dakota?
None of the classified service lines in North Dakota is recorded as carved out of managed care.
Does North Dakota use state-directed payments?
No state-directed payment for North Dakota is on record.
How many service lines have a binding rule?
2 of 2 classified service lines carry a rule tied to the state's published rates.