The Idaho Medicaid Fee Schedule 2026 shows how much providers get paid. New rates started January 1, 2026, with major changes.
Idaho also ended two programs and moved to managed care.
Quick Summary:
- New fee schedule rates took effect January 1, 2026
- Healthy Connections program ended December 31, 2025
- Therapy services need approval after 20 visits per year
- Most providers get paid 85% of the maximum rates
- Idaho may cut Medicaid budgets by 1-2% more
- Income limits: $1,047/month (singles) for regular Medicaid
Last Updated: February, 2026
What Is the Idaho Medicaid Fee Schedule?
The fee schedule lists maximum payment amounts. It shows what Idaho Medicaid pays providers for services. This includes doctor visits, therapy, and hospital care.
Providers must bill their usual charge. They cannot charge Medicaid patients less than other patients. The fee schedule sets the payment ceiling, not the floor.
Who Uses the Fee Schedule?
Doctors, hospitals, and therapists use it daily. Billing specialists check it before submitting claims. Understanding Idaho Medicaid eligibility 2026 helps providers know who qualifies.
State officials also review it regularly. They ensure payments stay within budget limits.
How Rates Are Set
Idaho bases rates on Medicare benchmarks. Most services pay at 90% of Medicare rates. Primary care codes pay up to 100% of Medicare.
The state reviews rates annually. Federal approval is required for major changes.
2026 Fee Schedule Updates
Idaho made big changes starting January 1, 2026. The Department of Health and Welfare released new schedules. Providers saw rate adjustments across all service types.
New State-Developed Rates
All fee-for-service rates were updated January 1, 2026. The 304-page numerical fee schedule covers January through March. Private and governmental providers get the same rates.
You can view official rates at the Idaho Department of Health and Welfare provider portal.
Managed Care Transition
Idaho shifted from fee-for-service to managed care. House Bill 345 authorized this major change. Two programs ended completely on December 31, 2025.
Programs That Ended:
- Healthy Connections Value Care (HCVC)
- Healthy Connections Primary Care Case Management
These programs paid extra for care coordination. Providers lost these enhanced payments in 2026.
Behavioral Health Plan Changes
The Idaho Behavioral Health Plan (IBHP) got new rates. Federally Qualified Health Centers (FQHCs) saw updates on January 1, 2026. Rural Health Clinics (RHCs) received revised rates on January 9, 2026.
Behavioral health services now use separate fee schedules. Check the Magellan provider portal for specific rates.
Provider Payment Rates
Understanding how much you’ll get paid is crucial. Rates vary by provider type and service category. Most advanced practice nurses get 85% of the maximum allowed.
Standard Reimbursement Percentages
Nurse practitioners receive 85% of the allowed maximum. Physician assistants also get 85% of standard rates. Clinical nurse specialists and certified nurse midwives follow the same rule.
Physicians typically receive 100% of allowed amounts. However, the allowed amount may differ from billed charges.
Specialty Rate Exceptions
Some services have individually negotiated rates. Psychiatric residential treatment facilities (PRTF) negotiate directly with the state. Residential treatment centers (RTC) also have custom agreements.
These rates are not published in standard schedules. Contact the Office of Reimbursement for specific information.
Prior Authorization Requirements
Physical therapy now requires approval after 20 visits. Occupational therapy follows the same 20-visit limit. Speech-language pathology also needs authorization after 20 yearly visits.
This rule started January 1, 2026. It applies per calendar year per discipline. Providers must track visits carefully to avoid claim denials.
2026 Income and Asset Limits
Eligibility depends on income and resources. Limits changed slightly for 2026. Understanding Idaho Medicaid income limits in 2026 helps determine who qualifies.
Regular Medicaid Limits
Single adults can earn up to $1,047 monthly. Married couples have a $1,511 monthly limit. Asset limits stay at $2,000 for singles and $3,000 for couples.
These apply to aged, blind, and disabled categories. Other categories may have different thresholds.
Common Income Limits (Single Person)
- Expansion Adults (Ages 19-64): $1,835 / month (138% of the Federal Poverty Level).
- Long-Term Care (Nursing Home / Waivers): $3,002 / month.
- Aged, Blind, or Disabled (AABD): $1,047 / month.
- Medicare Savings Programs:
- QMB: Up to $1,338 / month.
- SLMB: $1,338 to $1,601 / month.
- QI: $1,601 to $1,799 / month.
Nursing Home and Long-Term Care
Nursing home residents can earn $3,002 monthly (single). Married couples applying together have a $5,984 limit. Assets must stay under $2,000 (single) or $3,000 (couple).
Medicaid waivers use the same limits. Home and community-based services (HCBS) follow identical rules. Compare these to the broader Medicaid income limits by state in 2026 to see how Idaho ranks.
Spousal Protections
A community spouse can keep assets up to $162,660. This is 50% of the couple’s total assets. The Minimum Monthly Maintenance Needs Allowance (MMMNA) is $2,643.75.
These protections run through June 30, 2026. They help prevent spousal impoverishment.
Budget Cuts and Future Changes
Idaho faces significant budget pressures in 2026. The state legislature is considering additional cuts. These could affect provider payments and beneficiary services.
Current and Proposed Reductions
A 4% provider rate cut already happened in 2025. It affected 88 service codes used by schools. Now legislators discuss 1-2% additional cuts for 2026-2027.
Idaho must close a $555 million budget shortfall. Medicaid represents a large portion of state spending. Cuts may target various service categories.
Impact on Services
Adult dental coverage may be eliminated. Home and community-based services could see reductions. Nursing facilities face potential rate freezes or cuts.
Providers worry about network adequacy. Some may stop accepting Medicaid patients. Access to care could decline, especially rurally. The national Medicaid fee schedule 2026 trends show similar pressures nationwide.
Federal Transparency Rules
New 2026 federal rules require clearer rate publishing. States must compare payments to Medicare rates. This ensures adequate access and payment fairness.
Idaho must show rates support patient access. Federal oversight has increased monitoring efforts.
How to Access Fee Schedules
Finding current rates is essential for accurate billing. Idaho provides multiple online resources. All schedules are publicly available.
Official State Resources
Visit the Idaho Department of Health and Welfare website for complete schedules. Search “Fee Schedules 2026” in the public documents portal. Download the numerical fee schedule PDF (304 pages).
The provider portal offers searchable rate tools. You can look up specific procedure codes. Updates appear monthly in MedicAide newsletters.
Provider Support Contacts
Call Gainwell Technology at (866) 686-4272 for claims questions. Email pricing questions to MedicaidReimTeam@dhw.idaho.gov. The Office of Reimbursement phone number is (208) 287-1180.
Response times vary by inquiry type. Complex questions may take several business days.
Important Compliance Dates
Several key deadlines affect providers in 2026. Missing these can result in payment delays. Mark your calendar for these critical dates.
Ongoing Requirements
Laboratories must pay CLIA fees online starting March 1, 2026. Use pay.gov for certification and survey fees. Paper payments are no longer accepted.
Prior authorization requests need timely submission. Submit therapy PA requests before the 20th visit. Late requests may cause claim denials.
Billing Best Practices
Always bill your usual and customary charge. Do not reduce fees just for Medicaid patients. Medicaid pays the lesser of billed charge or fee schedule.
Verify patient eligibility before each visit. Check for active managed care enrollment. Confirm coverage for planned services.
Frequently Asked Questions (FAQs)
What are the 2026 Idaho Medicaid fee schedule rates?
The 2026 Idaho Medicaid fee schedule began January 1, 2026, with state-developed rates. Most services pay at 90% of Medicare rates, while primary care pays up to 100%. Nurse practitioners and physician assistants receive 85% of the allowed maximums. Download the complete 304-page schedule from the Idaho DHW website.
How much can a single person earn for Idaho Medicaid in 2026?
Single adults can earn up to $1,047 monthly for regular Medicaid (aged, blind, disabled). Nursing home residents can earn $3,002 monthly. Asset limits are $2,000 for singles. Income limits vary by program category, so check specific eligibility requirements for your situation.
When did Idaho end Healthy Connections Medicaid?
Idaho ended Healthy Connections on December 31, 2025. The Healthy Connections Value Care (HCVC) program also terminated the same date. These primary care case management programs provided care coordination and 24/7 nurse lines. The state transitioned to managed care models starting January 1, 2026.
Do therapists need prior authorization for Idaho Medicaid in 2026?
Yes, physical therapy, occupational therapy, and speech-language pathology require prior authorization after 20 visits per calendar year per discipline. This rule started January 1, 2026. Each therapy type counts separately, so a patient could receive 20 PT, 20 OT, and 20 SLP visits before needing authorization.
Where can I find the current Idaho Medicaid fee schedule online?
Access the official Idaho Medicaid fee schedule at healthandwelfare.idaho.gov/providers or publicdocuments.dhw.idaho.gov/WebLink. Search “Fee Schedules 2026” for the numerical schedule and specialty schedules. The provider portal includes searchable rate tools. Contact Gainwell Technology at (866) 686-4272 for claims support.
Will Idaho cut Medicaid rates more in 2026?
Idaho already implemented a 4% rate cut in 2025 for certain services. Legislators are considering additional 1-2% cuts for 2026-2027 to address a $555 million budget shortfall. Proposed cuts may affect adult dental coverage, home services, and provider reimbursements. Final decisions depend on legislative action.
Key Takeaways
The 2026 Idaho Medicaid fee schedule reflects significant changes. New rates took effect January 1, 2026. Two major programs ended, and therapy services need prior authorization.
Providers should monitor the DHW website regularly. Budget pressures may bring additional rate changes. Stay informed to ensure accurate billing and reimbursement.
Income limits remain modest for regular Medicaid beneficiaries. Asset limits protect individuals while controlling program costs. Spousal protections continue through mid-2026.
Disclaimer: This article provides general information only. It does not constitute legal, medical, or financial advice. For specific questions about your Medicaid coverage or provider reimbursement, contact the Idaho Department of Health and Welfare directly or consult a qualified professional.
