Ohio Medicaid Fee Schedule 2026: Rates, Updates & Provider Guide

Written & Reviewed by Akash Biswas, MSW | Former Medicaid Caseworker Trainer | Verified against official Medicaid.gov and Ohio Department of Medicaid (ODM) guidelines | Last Updated: March 2026

The Ohio Medicaid fee schedule for 2026 includes updated reimbursement rates, new CPT/HCPCS codes, and major billing changes tied to the Next Generation MyCare Ohio program.

Ohio does not publish a single master fee schedule. Instead, rates are split by provider type and updated through Medicaid Advisory Letters (MALs).

This guide covers all key 2026 fee schedule changes. You will learn about new reimbursement rates, billing requirements, and how to look up specific codes.

Quick Summary

• Ohio Medicaid updated CPT and HCPCS codes effective January 1, 2026 (MAL 688)
• Nursing facility ventilator rates are $1,304.63/day (dependent) and $1,565.56/day (weaning)
• The Next Generation MyCare Ohio program launched January 1, 2026, changing how providers bill for dual-eligible members
• Outpatient hospital payments use the EAPG formula with 2026 relative weights
• No single master fee schedule exists — rates are organized by provider type on the ODM website
• To check if you or a family member qualifies for coverage, visit the Medicaid eligibility calculator for 2026

What Is the Ohio Medicaid Fee Schedule?

The Ohio Medicaid fee schedule is a list of payment rates. It shows how much the Ohio Department of Medicaid (ODM) pays providers for covered services.

These rates apply to doctors, hospitals, dentists, pharmacies, and other providers who serve Medicaid members.

Ohio does not release one large document with every rate. Instead, ODM publishes separate fee schedules for each provider type.

These include medical, dental, vision, pharmacy, and durable medical equipment (DMEPOS).

Rates are updated through Medicaid Advisory Letters and posted on the ODM website.

How Fee Schedules Work in Ohio

ODM sets a maximum payment for each service code. Providers bill their usual charge. Medicaid pays the lesser of the provider’s charge or the Medicaid maximum.

For most non-institutional services, Ohio’s fee schedule is set at 80% of the Medicare allowed amount. Some services need manual review. These are called “by-report” services.

Fee-for-Service vs. Managed Care Rates

Not all Ohio Medicaid members are in fee-for-service. Most are enrolled in managed care plans. Each managed care plan negotiates its own rates with providers. The ODM fee schedule applies directly to fee-for-service claims.

Managed care plans may pay different amounts, but the ODM schedule serves as a baseline.

For a broader look at how Medicaid rates work across states, see our guide to the Medicaid fee schedule in 2026.

What Changed in the Ohio Medicaid Fee Schedule for 2026?

Several important updates took effect on January 1, 2026. Providers must know these changes to bill correctly and receive proper payment.

2026 CPT and HCPCS Code Updates (MAL 688)

Medicaid Advisory Letter (MAL) 688 updated the Ohio fee schedule. It aligns with the January 1, 2026, CPT and HCPCS Level II code sets released by the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS).

Providers must use the new 2026 codes for all dates of service on or after January 1, 2026.

Prior Authorization Changes

New CMS-aligned interoperability rules took effect January 1, 2026. These rules set faster response times for prior authorization decisions.

They also require more transparency in the approval process. This applies across all Ohio Medicaid programs.

Rate Increases from HB 33

Ohio House Bill 33 authorized significant rate increases starting January 1, 2024. Those increases — about 5% across most codes — remain in effect for 2026 dates of service.

Notable increases included a 93% boost for dental providers and a 79% increase for transportation providers.

Next Generation MyCare Ohio: Major Billing Changes for 2026

The biggest change for Ohio Medicaid providers in 2026 is the launch of Next Generation MyCare Ohio.

This program changes how providers bill for dual-eligible members (people who have both Medicare and Medicaid).

What Is Next Generation MyCare Ohio?

Next Generation MyCare Ohio is a managed care program. It combines Medicare and Medicaid benefits into one plan for dual-eligible members.

The Ohio Department of Medicaid launched it on January 1, 2026, in the 29 counties where MyCare Ohio was already available.

Statewide expansion began April 1, 2026, and will continue through the rest of the year.

Selected Next Generation MyCare Plans

Providers must contract with one of the four selected plans to get paid for serving these members:

Buckeye Health Plan is not accepting new members in the Next Generation program. Current Buckeye members can stay if they choose.

The “One Front Door” Billing System

All claims for dual-eligible members with dates of service on or after January 1, 2026, must go through the Ohio Medicaid Enterprise System (OMES) “One Front Door” portal. Medicare remains the primary payer. Medicaid is the secondary payer. If you submit claims correctly, they will automatically cross over from Medicare to the Next Generation MyCare plan.

Pharmacy Benefits Under Next Gen MyCare

Pharmacy benefits for Next Generation members are handled differently. Each plan uses its own Pharmacy Benefit Manager (PBM). This is not the same fee-for-service Single PBM used for other Medicaid populations. Providers must check with the member’s specific plan for formulary and billing details.

2026 Nursing Facility Fee Schedule & Ventilator Rates

Ohio released specific reimbursement rates for nursing facilities providing ventilator care. These enhanced rates apply to fee-for-service, MyCare Ohio, and managed care populations for State Fiscal Year 2026 (July 1, 2025 – June 30, 2026).

Ventilator Program Daily Rates

Ventilator Billing Rules

• ICD-10 Requirement: You must use diagnosis code Z99.11 (Dependence on respirator status) for both categories
• Weaning Limit: The weaning rate is limited to 90 days per calendar year per individual
• Prior Approval: You need prior approval through ODM form 10227 and must have the correct specialty code assigned
• Bed-Hold Days: Do not use the enhanced ventilator codes for bed-hold days — bill using standard leave day codes at the facility’s regular Medicaid per diem rate

Section GG and Case-Mix Scoring

Functional status scoring updates (known as “Section GG”) were implemented in late 2025. These continue to affect case-mix scores and reimbursement rates for nursing facilities into 2026. Your facility’s per diem rate depends in part on these assessments.

Outpatient Hospital EAPG Reimbursement in 2026

Ohio Medicaid pays outpatient hospital claims using the Enhanced Ambulatory Patient Group (EAPG) system. There is no downloadable app or simple rate lookup. You must calculate payment using the official EAPG formula and the 2026 relative weights table.

Step 1: Get Your Data

First, download the 2026 EAPG relative weights. Go to medicaid.ohio.gov, then navigate to “Provider Billing” > “Fee Schedule and Rates” > “Outpatient Hospital.” Look for the file called “EAPG Relative Weights – Effective 1/1/2026.” Ohio typically uses EAPG Version 3.17 or newer.

Next, find your hospital’s base rate. This rate is specific to your hospital’s peer group (Critical Access, Teaching, Children’s, etc.). It is listed on your facility’s rate letter or the “Hospital Rates” CSV file on the same ODM page.

Step 2: The EAPG Calculation Formula

For each line item on your claim, multiply three numbers:

Payment = Base Rate × Relative Weight × Discount Factor

The discount factor works like this:

Step 3: Example Calculation

If your base rate is $140 and you perform a procedure with a 2026 relative weight of 2.5 (no discounting):

$140 × 2.5 × 1.0 = $350.00

That $350 would be the Medicaid payment for that single procedure. Secondary procedures on the same visit would be discounted at 50%.

2026 Income and Asset Limits That Affect Eligibility

Reimbursement only matters if the patient is eligible. Ohio Medicaid income limits changed in 2026 due to federal cost-of-living adjustments (COLA).

Understanding these limits helps providers confirm a patient’s coverage status.

For full details on income thresholds by household size, read our complete guide to Ohio Medicaid income limits in 2026.

Long-Term Care and Waiver Eligibility

The $2,982 monthly income limit equals 300% of the 2026 SSI Federal Benefit Rate. This is about a 2.8% increase from 2025.

Spousal Impoverishment Protections

These protections keep a healthy spouse from losing all income and assets when their partner enters a nursing facility.

Aged, Blind, and Disabled (ABD) Medicaid

The income limit for regular ABD Medicaid is $994 per month. This is linked to the 2026 SSI Federal Benefit Rate. For a detailed breakdown of who qualifies, visit our page on Ohio Medicaid eligibility in 2026.

How to Look Up a Specific Fee Schedule Rate

Ohio does not have one searchable database for every Medicaid rate. Here is how to find the rate for a specific CPT code.

Option 1: ODM Fee Schedule Search Tool

Visit medicaid.ohio.gov. Navigate to “Resources for Providers” > “Billing” > “Fee Schedule and Rates.” Use the fee schedule search tool. Enter the CPT or HCPCS code. Make sure the effective date is set to January 1, 2026, or later.

Option 2: Download the CSV Files

On the same ODM page, you can download CSV files organized by provider type. Available files include medical/surgical, dental, vision, DME, and more. Select the file effective 1/1/2026 for the correct rates.

Option 3: Contact the ODM Helpdesk

Call the Ohio Medicaid Integrated Helpdesk at 800-686-1516. Representatives are available Monday through Friday, 8:00 AM to 4:30 PM Eastern. You can also email IHD@medicaid.ohio.gov.

To compare how Ohio’s rates fit within the national picture, see our guide to Medicaid income limits by state in 2026.

FAQ

Sources & Disclaimer

Sources:

• Medicaid.gov — Official Federal Medicaid Information
• Healthcare.gov — Medicaid & CHIP Overview
• Ohio Department of Medicaid (ODM) — Provider Resources

Last Updated: March 2026

Disclaimer: CheckMedicaid.com is not affiliated with any government agency. This content is for educational purposes only. For official eligibility determination or provider billing guidance, contact your state Medicaid office or visit Medicaid.gov.