Wisconsin 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 Wisconsin's plan contracts, statutes and notices. For 7 of 21 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 7of 21
- Plans on record
- 35
- Directed payments
- 36
- Capitation cells
- 43,640$0.01–$10,947.74 PMPM
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 | 35,646 | Paid by the state, outside plansPlans may pay no more |
| Other | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 14,468 | Paid by the state, outside plansState-directed payment |
| Nursing facility | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 10,734 | State sets the plan ratePlans may pay no more |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 5,559 | Paid by the state, outside plans |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 4,432 | Paid by the state, outside plans |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 4,180 | State sets the plan ratePaid by the state, outside plans |
| Hospital inpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,323 | |
| Dental | Paid by the state, outside plansPaid directly by the state, outside managed care | 1,387 | Plans negotiate; applies out of network |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,089 | |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 855 | Plans must pay at least this |
| Therapy (PT/OT/speech) | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 744 | Paid by the state, outside plansPlans may pay no more |
| Behavioral health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 685 | Paid by the state, outside plans |
| IDD services | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 263 | State sets the plan ratePaid by the state, outside plans |
| Hospice | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 218 | |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 213 | Plans negotiate; applies out of networkPlans must pay at least this |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 151 | |
| Transportation | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 73 | Paid by the state, outside plansState sets the plan rate |
| ABA / autism services | Paid by the state, outside plansPaid directly by the state, outside managed care | 31 | Plans negotiate; applies out of network |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 28 | Plans must pay at least thisPlans may pay no more |
| Private duty nursing | Plans may pay no morePlans may pay no more than the published rate | 5 | Plans negotiate; applies out of network |
| Home health | Plans may pay no morePlans may pay no more than the published rate | 4 |
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 Wisconsin 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, Equipment & supplies, Hospital outpatient, IDD services, Other home & community services, Transportation, Personal care & attendant. For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Wisconsin'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.
← All Wisconsin Medicaid rates