Rhode Island 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 Rhode Island's plan contracts, statutes and notices. For 14 of 22 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 14of 22
- Plans on record
- 12
- Directed payments
- 11amounts in the workspace
- Capitation cells
- 1,603PMPM rates in the workspace
Who sets the rate, by service line
The main rule Rhode Island's managed-care plans follow for each service line, in plain language.
| 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 | 49,582 | Plans must pay at least thisPaid by the state, outside plans |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 7,227 | |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 5,758 | |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,015 | |
| Nursing facility | Paid by the state, outside plansPaid directly by the state, outside managed care | 2,957 | State-directed paymentPlans negotiate; applies out of network |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,802 | Paid by the state, outside plans |
| Behavioral health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,321 | Paid by the state, outside plansPlans must pay at least this |
| Hospital inpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,299 | Plans must pay at least this |
| Personal care & attendant | Plans must pay at least thisPlans must pay at least the published rate | 546 | Paid by the state, outside plansState-directed payment |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 541 | Plans must pay at least this |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 443 | Plans must pay at least thisPlans negotiate; applies out of network |
| Dental | Paid by the state, outside plansPaid directly by the state, outside managed care | 327 | Plans negotiate; applies out of network |
| Therapy (PT/OT/speech) | Paid by the state, outside plansPaid directly by the state, outside managed care | 283 | Plans negotiate; applies out of networkPlans must pay at least this |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 278 | Plans negotiate; applies out of network |
| Other | Plans must pay at least thisPlans must pay at least the published rate | 234 | Paid by the state, outside plansState-directed payment |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 131 | Plans must pay at least thisPaid by the state, outside plans |
| Private duty nursing | Paid by the state, outside plansPaid directly by the state, outside managed care | 125 | Plans negotiate; applies out of networkPlans must pay at least this |
| Transportation | Paid by the state, outside plansPaid directly by the state, outside managed care | 116 | Plans must pay at least this |
| ABA / autism services | Paid by the state, outside plansPaid directly by the state, outside managed care | 67 | Plans must pay at least thisPlans negotiate; applies out of network |
| Clinics (FQHC/RHC) | Plans must pay at least thisPlans must pay at least the published rate | 27 | Plans negotiate; applies out of network |
| Home health | Plans must pay at least thisPlans must pay at least the published rate | 20 | Plans negotiate; applies out of network |
| Hospice | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2 |
Rhode Island Medicaid managed-care plans
12 plans on record across 6 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 1,603 published capitation cells.
Frequently asked questions
Do Rhode Island 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, Behavioral health, Hospital inpatient, Personal care & attendant, Hospital outpatient, Other home & community services, Therapy (PT/OT/speech), Other, Vision & hearing, Private duty nursing, Transportation, ABA / autism services, Clinics (FQHC/RHC), Home health. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Rhode Island'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.