West 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 West Virginia's plan contracts, statutes and notices. For 10 of 21 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 10of 21
- Plans on record
- 5
- Directed payments
- 0amounts in the workspace
- Capitation cells
- —not published
Who sets the rate, by service line
The main rule West Virginia's managed-care plans follow for each service line, in plain language.
| Service line | Main rule for plans | Rates | Also applies |
|---|---|---|---|
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 57,450 | Plans must pay at least this |
| Physician & professional | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 14,053 | Plans must pay at least this |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,442 | |
| Equipment & supplies | Plans must pay at least thisPlans must pay at least the published rate | 3,281 | |
| Nursing facility | Paid by the state, outside plansPaid directly by the state, outside managed care | 3,111 | |
| Hospital inpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,950 | |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,902 | |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 920 | Plans must pay at least this |
| Dental | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 301 | |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 300 | |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 300 | |
| Hospice | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 276 | |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 111 | Plans must pay at least this |
| Therapy (PT/OT/speech) | Paid by the state, outside plansPaid directly by the state, outside managed care | 106 | Plans negotiate; applies out of networkPlans must pay at least this |
| Behavioral health | Plans must pay at least thisPlans must pay at least the published rate | 98 | Plans negotiate; applies out of networkPaid by the state, outside plans |
| Transportation | Paid by the state, outside plansPaid directly by the state, outside managed care | 37 | Plans must pay at least this |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 28 | Plans must pay at least thisPlans negotiate; applies out of network |
| ABA / autism services | Not classified yet | 14 | |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 10 | |
| Clinics (FQHC/RHC) | State sets the plan rateThe state sets the rate plans pay | 8 | |
| Private duty nursing | Paid by the state, outside plansPaid directly by the state, outside managed care | 5 | Plans negotiate; applies out of network |
| Other | Paid by the state, outside plansPaid directly by the state, outside managed care | 4 | Plans negotiate; applies out of network |
What each plan rule means for providers
4 rules apply somewhere in West Virginia's managed-care program. Here is what each one says and what it means when you contract with a plan.
Plans negotiate; the published rate applies out of network
Plans negotiate rates with their network providers. The published rate applies when a provider has no contract with the plan, as the default payment for out-of-network or non-contracted care.
For contracting: In-network rates can be above or below the published rate. The published rate is the benchmark both sides know, and the fallback if no contract is signed.
Main rule for Hospital outpatient, Physician & professional, Radiology, Hospital inpatient, Lab & pathology, Pharmacy, Dental, Home health, Hospice and Vision & hearing. Also applies in Therapy (PT/OT/speech), Behavioral health, Other home & community services, Private duty nursing and 1 more. 81,761 rates.Paid by the state, outside the plans
The service is carved out of managed care: the state pays it directly at its own rate, even for members enrolled in a plan.
For contracting: Bill the state's Medicaid program, not the plan, at the published rate. There is no plan contract to negotiate for this service.
Main rule for Nursing facility, IDD services, Therapy (PT/OT/speech), Transportation, Other home & community services, Personal care & attendant, Private duty nursing and Other. Also applies in Behavioral health. 3,533 rates.Plans must pay at least the published rate
The plan contract, a statute or a state notice requires plans to pay network providers no less than the state's fee-for-service rate for the service.
For contracting: The published rate is your floor. Negotiate up from it, and if a plan pays less, the contract provision is the basis for a payment dispute.
Main rule for Equipment & supplies and Behavioral health. Also applies in Hospital outpatient, Physician & professional, Pharmacy, Vision & hearing and 3 more. 3,367 rates.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 Clinics (FQHC/RHC). 8 rates.Using West Virginia's plan rules in a contract negotiation
- Find your service line in the table above. In West Virginia, Equipment & supplies and Behavioral health carry a floor as the main rule, so the published rate is the least a plan may pay.
- Pull the published rate for each code you bill from the West Virginia 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 West Virginia changes a published rate, plans bound by a floor or pass-through must follow. For lines where plans negotiate (Hospital outpatient, Physician & professional, Radiology and others), a change only reaches you if your contract ties your rate to the schedule.
- Bill carved-out services to the state. In West Virginia, Nursing facility, IDD services, Therapy (PT/OT/speech), Behavioral health, Transportation, Other home & community services, Personal care & attendant, Private duty nursing and Other are paid at least partly outside the plans, at the published rate.
1 line (ABA / autism services) is not classified yet; for it, assume the plan negotiates until a rule is published.
West Virginia Medicaid managed-care plans
5 plans on record.
Frequently asked questions
Do West 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: Hospital outpatient, Physician & professional, Equipment & supplies, Pharmacy, Vision & hearing, Therapy (PT/OT/speech), Behavioral health, Transportation, Other home & community services, Clinics (FQHC/RHC). For other lines, plans negotiate rates with providers.
Where do these rules come from?
From West 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.
How many managed-care plans does West Virginia Medicaid have?
5 plans are on record: Aetna Better Health of West Virginia, Highmark Health Options West Virginia, The Health Plan of West Virginia, UniCare Health Plan of West Virginia, Wellpoint West Virginia.
Which services are paid outside managed care in West Virginia?
Nursing facility, IDD services, Therapy (PT/OT/speech), Behavioral health, Transportation, Other home & community services, Personal care & attendant, Private duty nursing and Other: for at least part of these lines, the state pays the service directly at the published rate, even for plan members.
Does West Virginia use state-directed payments?
No state-directed payment for West Virginia is on record.
How many service lines have a binding rule?
10 of 21 classified service lines carry a rule tied to the state's published rates.