Virginia 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 Virginia's plan contracts, statutes and notices. For 20 of 22 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 20of 22
- Plans on record
- 123
- Directed payments
- 56
- Capitation cells
- 10,369$65.06–$32,013.46 PMPM
Who sets the rate, by service line
| Service line | Main rule for plans | Rates | Also applies |
|---|---|---|---|
| Nursing facility | Plans must pay at least thisPlans must pay at least the published rate | 28,801 | |
| Physician & professional | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 15,777 | 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 | 4,937 | |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 4,348 | State wraparound guarantee |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,213 | Plans must pay at least this |
| Dental | Paid by the state, outside plansPaid directly by the state, outside managed care | 2,859 | State sets the plan rate |
| Equipment & supplies | Plans must pay at least thisPlans must pay at least the published rate | 2,133 | Plans negotiate; applies out of networkPaid by the state, outside plans |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,935 | |
| Other | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,720 | State-directed paymentPlans must pay at least this |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,028 | Plans must pay at least thisPaid by the state, outside plans |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 420 | Plans must pay at least thisPlans negotiate; applies out of network |
| Behavioral health | Plans must pay at least thisPlans must pay at least the published rate | 419 | Paid by the state, outside plansPlans negotiate; applies out of network |
| Hospice | Plans must pay at least thisPlans must pay at least the published rate | 198 | Plans negotiate; applies out of network |
| Other home & community services | Plans must pay at least thisPlans must pay at least the published rate | 174 | Paid by the state, outside plansPlans negotiate; applies out of network |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 124 | Plans must pay at least thisPaid by the state, outside plans |
| Private duty nursing | Plans must pay at least thisPlans must pay at least the published rate | 100 | Paid by the state, outside plansPlans negotiate; applies out of network |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 99 | Plans must pay at least this |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 96 | Plans must pay at least this |
| Transportation | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 80 | Paid by the state, outside plansPlans must pay at least this |
| ABA / autism services | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 71 | Plans must pay at least this |
| Personal care & attendant | Plans must pay at least thisPlans must pay at least the published rate | 57 | Paid by the state, outside plansPlans negotiate; applies out of network |
| Clinics (FQHC/RHC) | Plans must pay at least thisPlans must pay at least the published rate | 2 | Paid by the state, outside plans |
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.
Frequently asked questions
Do Virginia Medicaid plans have to pay the state fee schedule?
For some services. Plans must follow a rule tied to the state's rates for: Nursing facility, Physician & professional, Hospital outpatient, Lab & pathology, Dental, Equipment & supplies, Other, Pharmacy, IDD services, Behavioral health, Hospice, Other home & community services, Home health, Private duty nursing, Vision & hearing, Therapy (PT/OT/speech), Transportation, ABA / autism services, Personal care & attendant, Clinics (FQHC/RHC). For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Virginia'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.