Written & Reviewed by Akash Biswas, MSW | Former Medicaid Caseworker Trainer | Verified against official Medicaid.gov and Ohio Administrative Code | Last Updated: August 2026
Ohio does not have one single Medicaid fee schedule that covers every service. Instead, payment rules come from a main rule plus several service-specific rules.
This guide breaks down what is confirmed for 2026, and what is still unknown for 2027.
Quick Summary:
- Ohio’s main payment rule is OAC 5160-1-60, effective January 1, 2026
- Medicaid pays the lesser of the provider’s charge or the Medicaid maximum rate
- Different programs (behavioral health, PASSPORT, assisted living) use their own rate appendices
- No official statewide 2027 fee schedule has been published yet
- Not sure if you qualify for coverage? Try our Medicaid eligibility calculator in 2026 to check your status
What Is the Ohio Medicaid Fee Schedule?
A fee schedule is a list of prices. It shows how much Medicaid will pay a doctor or provider for a service. Ohio does not use one list for everything.
How It Works
Ohio’s core rule sets the general payment method. Then, specific services — like behavioral health or home care — follow their own rate appendices. This keeps rates fair across very different types of care.
Why It Matters for You
If you have Ohio Medicaid, this affects what your provider gets paid. It does not usually change what you owe. Under Ohio’s rule, providers cannot bill you for the unpaid difference on a covered service.
Statewide Payment Framework (OAC 5160-1-60)
Ohio’s core payment rule is OAC 5160-1-60. The current version took effect January 1, 2026. It sets the baseline rules that most other Medicaid payment rules point back to.
Effective Date and Purpose
This rule says Medicaid payment is payment in full for a covered service. Providers generally cannot ask you to pay the leftover balance. This protects patients from surprise bills for covered care.
Maximum Payment Rule
Medicaid pays whichever is lower: the provider’s submitted charge, or the state’s set maximum rate. This is a ceiling, not a guarantee of full payment. It keeps costs predictable for the state.
Usual-and-Customary Charge Limit
If a provider normally charges other patients less for the same service, Medicaid will not pay more than that lower amount. This stops providers from charging Medicaid a higher price than everyone else.
Different Rates for Different Programs
Some programs use their own appendix instead of the general rule. For example, PASSPORT home and community-based services use rates from OAC 5160-1-06.1. That version became effective April 17, 2026.
2026 Service-Specific Fee Rules
Several service types have their own confirmed 2026 rates. Here is what applies right now.
Behavioral Health Payment Rates
For most non-community behavioral health providers, payment is a percentage of the standard rate:
| Service Type | Payment Percentage |
|---|---|
| Testing | 100% |
| Services by a physician, APRN, physician assistant, or licensed psychologist | 100% |
| Services by a licensed practitioner or supervised practitioner | 85% |
| Supervised trainee or assistant | 85% of supervisor’s rate |
Community behavioral health centers follow a separate rule (OAC 5160-27-03) instead.
PASSPORT Home and Community-Based Waiver
PASSPORT helps older adults stay in their homes instead of a nursing facility. The Ohio Department of Aging runs this program with the Ohio Department of Medicaid. Its maximum payment rates are listed in the appendix to OAC 5160-1-06.1, effective April 17, 2026.
Assisted Living Waiver Rates
Assisted living waiver rates are listed in Appendix A to OAC 5160-1-06.5. The version currently in effect started July 1, 2024. It has not been confirmed as updated for 2026 or 2027.
Medicare Cost-Sharing Payment Rules
Many Ohio Medicaid members also have Medicare. These rules decide how Ohio Medicaid pays the leftover Medicare costs. This is not a general fee schedule, but it matters for dual-eligible members.
| Claim Type | Ohio Medicaid Payment Method |
|---|---|
| Medicare Part B (non-hospital) | Pays the least of: owed deductible/coinsurance, the gap between Medicare-approved and Medicare-paid amounts, or the gap to Medicaid’s own maximum rate |
| Medicare Advantage (Part C) | Pays the least of: billed charges, Part C cost-sharing owed, the plan-to-Medicaid rate gap, or Medicaid’s Part A/B liability formula |
| Hospital inpatient, outpatient, or ER crossover claims | Governed by OAC 5160-2-25 |
| Nursing-facility crossover claims (per diem) | Governed by OAC Chapter 5160-3 |
Part B Services
Ohio pays the smallest of several possible amounts. This keeps the state from overpaying when Medicare has already covered most of the cost.
Medicare Advantage / Part C
The same “pay the least amount” approach applies here. The exact math depends on what the Medicare Advantage plan already paid.
Hospital and Nursing-Facility Crossover Claims
These claim types use their own separate rules instead of the Part B formula. Hospital claims follow OAC 5160-2-25. Nursing facility per diem claims follow OAC Chapter 5160-3.
2026 Managed-Care Hospital Payment Arrangement
CMS approved a special payment deal for a narrow group of Ohio hospitals in 2026. This is not the general Medicaid fee schedule. It only applies to one class of hospitals.
Who Is Covered
This applies to academic medical centers with more than 200 beds that are also Charter County Hospitals under Ohio law. It runs from January 1 through December 31, 2026.
Payment Levels
Eligible hospitals can get up to about 210% of Medicaid for inpatient claims. Outpatient claims can reach about 245% of Medicaid. The total estimated payment is $171,549,902, split between federal and state funds.
Quality Holdback
Ohio holds back 0.2% of this total amount. Hospitals only get that portion if they meet quality targets. In 2026, a hospital picks two of four measures and must hit both targets.
Ohio Medicaid Fee Schedule 2027: What We Know So Far
As of August 20, 2026, there is no confirmed statewide Medicaid Fee Schedule FY 2027 published yet. This section covers what is and is not confirmed.
No Confirmed Statewide 2027 Update
No official Ohio or CMS document shows a full, code-level 2027 fee schedule. There are no confirmed 2027 dollar amounts or percentage changes for the general provider rate structure right now.
What the 2026 Hospital Arrangement Says About 2027
The 2026 hospital payment deal is part of a longer multi-year plan. But CMS has not approved a 2027 payment amount or renewal yet. The document only mentions future quality-measure goals, not new rates.
What This Means for You
If you are a provider, watch for updates later in 2026. If you are a patient, this mostly affects provider payment, not your out-of-pocket costs. You can check your Medicaid eligibility in 2026 to confirm your coverage status stays the same.
Frequently Asked Questions
Q: Does Ohio have one Medicaid fee schedule for all services?
A: No. Ohio uses a core payment rule (OAC 5160-1-60) plus separate rate appendices for specific programs like behavioral health, PASSPORT, and assisted living waivers. Each service type may follow its own maximum payment method.
Q: When did Ohio’s current Medicaid payment rule take effect?
A: The current version of OAC 5160-1-60 took effect January 1, 2026. This rule sets the general framework most other Ohio Medicaid payment rules refer back to for maximum allowable amounts.
Q: Is there a 2027 Ohio Medicaid fee schedule yet?
A: No confirmed statewide 2027 fee schedule has been published as of August 2026. Only a 2026 managed-care hospital payment arrangement mentions future quality-program plans, not new 2027 rates.
Q: Can my provider bill me for the difference Medicaid does not pay?
A: Generally, no. Under Ohio’s rule, Medicaid payment is considered payment in full for covered services. Providers usually cannot bill you the unpaid balance on a Medicaid-covered service.
Q: How does Medicaid pay for behavioral health services in Ohio?
A: Payment depends on who provides the service. Physicians, APRNs, and licensed psychologists are paid 100% of the rate. Supervised practitioners and trainees are typically paid 85% of that same rate.
Q: Does this fee schedule affect my Medicaid eligibility?
A: No. Fee schedules control provider payment, not who qualifies for coverage. To check your own status, see our Medicaid income limits by state in 2026 guide.
Sources & Disclaimer
Sources:
- Ohio Administrative Code, Chapter 5160-1
- Ohio Administrative Code, Chapter 5160-8
- CMS/Ohio Medicaid State-Directed Payment Approval
- Medicaid.gov
- Healthcare.gov — Medicaid & CHIP
Last Updated: August 2026
CheckMedicaid.com is not affiliated with any government agency. This content is for educational purposes only. For official eligibility or payment questions, contact the Ohio Department of Medicaid or visit Medicaid.gov.
