Managed Medicaid Rates

Managed Medicaid rates are included in the scope of MRFs when there are specific negotiated rates in contracts between the provider and the Medicaid Managed Care Organization (MCO). These rates may be based on state Medicaid reimbursement schedules, such as a percentage of the applicable fee schedule rate, or on other payment methodologies entirely unrelated to Medicaid as specified within contracts, including those based on Medicare.

Straight Medicaid rates are not included in MRFs, as stated by CMS. Our focus is on the negotiated rates specific to Managed Medicaid contracts to ensure transparency and compliance with CMS regulations.

Basis of Rates

State Medicaid Fee Schedules: Managed Medicaid rates often align with state-specific Medicaid fee schedules. These schedules may include patient-specific adjustments, such as different rates for pediatric versus adult patients.

Other Methodologies: In some cases, the rates are based on methodologies unrelated to Medicaid, potentially aligning with Medicare or other negotiated agreements.

Inclusions and Carve-outs

Detailed Benefits: The list of benefits under state Medicaid is typically extensive and detailed, making it challenging to calculate a standard rate for all services. There may be separate rates for services like mental health or other specialized care that are considered in scope or out of scope. Often the rules around Medicaid payment and eligibility are conditional and based on patient-specific info, Turquoise identifies as complete a list of payable services as is feasible and then utilizes algorithms communicate rate nuances.

Algorithms: When rates are based on complex adjustments or standard fee schedules, Turquoise includes these details in the algorithm field of the MRF. This field helps to capture the nuances of Medicaid reimbursement methodologies and ensures compliance with CMS requirements.

By accurately identifying and including the payable services and relevant details, Turquoise ensures that the MRFs reflect the negotiated managed Medicaid rates, promoting transparency and aiding in compliance with regulatory standards.