Utah 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 Utah's plan contracts, statutes and notices. For 5 of 21 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 5of 21
- Plans on record
- 27
- Directed payments
- 0amounts in the workspace
- Capitation cells
- 1,235PMPM rates in the workspace
Who sets the rate, by service line
The main rule Utah'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 | 25,973 | Paid by the state, outside plansState wraparound guarantee |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 5,171 | |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 4,580 | |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,847 | |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,903 | Paid by the state, outside plans |
| Hospital inpatient | Plans must pay at least thisPlans must pay at least the published rate | 1,642 | |
| Dental | Plans must pay at least thisPlans must pay at least the published rate | 816 | |
| Nursing facility | Paid by the state, outside plansPaid directly by the state, outside managed care | 373 | Plans negotiate; applies out of network |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 328 | Plans negotiate; applies out of network |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 307 | |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 201 | Paid by the state, outside plans |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 170 | Plans must pay at least this |
| Behavioral health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 119 | Paid by the state, outside plansState wraparound guarantee |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 103 | Plans negotiate; applies out of network |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 79 | |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 74 | Plans negotiate; applies out of network |
| Transportation | Paid by the state, outside plansPaid directly by the state, outside managed care | 72 | Plans negotiate; applies out of network |
| Private duty nursing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 63 | Paid by the state, outside plans |
| Hospice | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 42 | |
| ABA / autism services | Paid by the state, outside plansPaid directly by the state, outside managed care | 24 | Plans negotiate; applies out of network |
| Clinics (FQHC/RHC) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1 |
Utah Medicaid managed-care plans
27 plans on record across 7 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 1,235 published capitation cells.
Frequently asked questions
Do Utah 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, Hospital inpatient, Dental, Hospital outpatient, Behavioral health. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Utah'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.