Texas 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 Texas's plan contracts, statutes and notices. For 12 of 22 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 12of 22
- Plans on record
- 19
- Directed payments
- 4
- Capitation cells
- —not published
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 | 52,449 | Plans must pay at least this |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 26,864 | Plans must pay at least this |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 15,429 | Plans must pay at least this |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 12,988 | Plans must pay at least this |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 7,589 | Plans must pay at least this |
| Dental | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 5,357 | |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 4,858 | Plans must pay at least this |
| Hospice | Paid by the state, outside plansPaid directly by the state, outside managed care | 3,215 | |
| Hospital inpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,569 | Plans must pay at least this |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,056 | Paid by the state, outside plansSuggested schedule for plans |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,701 | |
| Clinics (FQHC/RHC) | State wraparound guaranteeThe state guarantees the encounter rate on top of plan payment | 1,253 | Plans must pay at least thisPlans negotiate; applies out of network |
| Behavioral health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,008 | Paid by the state, outside plansPlans must pay at least this |
| Other home & community services | Suggested schedule for plansThe state publishes a suggested schedule for plans | 748 | Paid by the state, outside plansPlans negotiate; applies out of network |
| Other | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 665 | State-directed payment |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 213 | Suggested schedule for plans |
| Personal care & attendant | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 183 | Suggested schedule for plansPaid by the state, outside plans |
| Private duty nursing | Paid by the state, outside plansPaid directly by the state, outside managed care | 167 | Plans negotiate; applies out of networkSuggested schedule for plans |
| Nursing facility | Plans must pay at least thisPlans must pay at least the published rate | 93 | Paid by the state, outside plans |
| Transportation | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 60 | Paid by the state, outside plansSuggested schedule for plans |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 40 | Suggested schedule for plans |
| ABA / autism services | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 20 | Plans must pass increases through |
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.
| Program | Amount | Effective |
|---|---|---|
| Texas physician directed payment program (TIPPS) | 108.69% | 2026-09-01 |
| Texas physician directed payment program (TIPPS) | 108.33% | 2026-09-01 |
| Texas physician directed payment program (TIPPS) | 48.9% | 2026-09-01 |
| Texas behavioral health directed payment program (CMHCs/LBHAs) | $32.80 | 2026-09-01 |
Frequently asked questions
Do Texas 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, Radiology, Pharmacy, Equipment & supplies, Hospital outpatient, Hospital inpatient, Therapy (PT/OT/speech), Clinics (FQHC/RHC), Behavioral health, Nursing facility, ABA / autism services. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Texas'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.