Ohio Medicaid Fee Schedule 2026

Ohio Medicaid does not publish one single fee schedule. Instead, the Ohio Department of Medicaid (ODM) sets separate rates for each provider type. Several of these rates changed on January 1, 2026.

This update affects doctors, hospitals, dentists, nursing facilities, and pharmacies. It also affects how providers bill for patients who have both Medicare and Medicaid.

Below, you’ll find the confirmed 2026 rate changes, where to look up your specific fee schedule, and what’s different from last year. Information here reflects ODM data and provider guidance current as of June 2026.

Article Summary

• CPT and HCPCS billing codes updated statewide on January 1, 2026 (MAL 688)
• Nursing facility ventilator rates: $1,304.63/day (dependent) and $1,565.56/day (weaning)
• Next Generation MyCare Ohio launched January 1, 2026, for dual-eligible members in 29 counties, expanding statewide by August 2026
• Outpatient hospital payments still use the EAPG formula, updated with 2026 relative weights
• No single “master” fee schedule exists — rates are split by provider type on the ODM website
• Managed care plans like CareSource, Molina, and Buckeye may use different rates than ODM’s base fee-for-service schedule

What Is the Ohio Medicaid Fee Schedule?

The fee schedule is a list of prices. It shows how much ODM pays a provider for each covered service. Doctors, dentists, hospitals, and pharmacies all use it to bill correctly.

Ohio splits this into many smaller schedules. Each one covers a specific provider type, like dental, vision, or home health. ODM updates these on its own timelines, not all at once.

Why There’s No Single 2026 Document

Some providers search for one combined PDF with every 2026 rate. That document does not exist. ODM instead posts rates by category on its fee schedule and rates page.

This matters for billing accuracy. A rate change for nursing facilities does not mean dental rates changed too. Always check the specific category you bill under.

2026 CPT and HCPCS Code Updates (MAL 688)

Ohio Medicaid updated its procedure codes effective January 1, 2026. This change came through Medicaid Advisory Letter (MAL) 688. It keeps Ohio’s billing codes aligned with federal CPT and HCPCS standards used nationwide.

The update added, removed, and modified codes across several service types. Providers must use the new codes for any service performed on or after January 1, 2026.

What Changed in the Code Update

The full list of added, discontinued, and modified codes is posted on ODM’s fee schedule portal. Providers should check codes tied to their specialty before submitting claims for 2026 dates of service.

Update Area	What Changed
Effective date	January 1, 2026
Source document	Medicaid Advisory Letter (MAL) 688
Applies to	All providers billing CPT/HCPCS codes
Where to verify	ODM Fee Schedule & Rates portal

Nursing Facility Ventilator Rates for 2026

Nursing facilities that care for ventilator-dependent residents have set daily rates for 2026. These rates are higher than standard nursing facility per diem rates because ventilator care requires more staff and equipment.

Resident Type	2026 Daily Rate
Ventilator-dependent	$1,304.63 per day
Ventilator-weaning	$1,565.56 per day

The weaning rate is higher because it includes more intensive therapy aimed at helping the resident breathe without a ventilator over time.

Outpatient Hospital Reimbursement: The EAPG Formula

Ohio Medicaid pays outpatient hospital claims using a method called Enhanced Ambulatory Patient Groups, or EAPG. This groups similar outpatient services together and assigns each group a relative weight.

For 2026, ODM updated these relative weights. A higher weight means a higher payment for that specific service group. The base rate is multiplied by the weight to calculate the final payment.

Hospitals should confirm they’re using the current 2026 weight tables, since billing with outdated weights can cause claim denials or incorrect payments.

Next Generation MyCare Ohio: What Changed in 2026

MyCare Ohio is the program that coordinates care for people who qualify for both Medicare and Medicaid. These are called “dual-eligible” members. On January 1, 2026, this program shifted to a new model called Next Generation MyCare.

Four managed care organizations now run Next Generation MyCare: Anthem Blue Cross and Blue Shield, Buckeye Health Plan, CareSource, and Molina Healthcare of Ohio. The program launched in the 29 counties that previously had MyCare Ohio and is expanding statewide in phases through 2026.

How This Affects Provider Billing

Providers serving dual-eligible patients in MyCare counties must now bill through one of the four selected managed care plans. This replaces the older fee-for-service approach for many of these claims.

Each managed care plan may set its own payment rates within ODM guidelines. Providers should confirm which plan a dual-eligible patient is enrolled in before submitting a claim, since rates can differ between plans.

The age of eligibility for MyCare also changed. Members must now be 21 or older, up from 18. This reduces overlap with OhioRISE, a separate program for younger Ohioans with complex behavioral health needs.

Telehealth Reimbursement Rules for 2026

Ohio Medicaid sets its own telehealth rules. These are separate from Medicare’s telehealth policy. For 2026, audio-only telehealth coverage still depends on the specific service and where the patient is located.

There is no blanket rule that covers every audio-only visit the same way. Providers should check the service-specific guidance before billing audio-only telehealth claims, since payment can be denied if the service doesn’t qualify.

How to Find Your Specific 2026 Fee Schedule

Because Ohio splits its rates by category, finding the right number takes a few steps. Follow this process to locate accurate, current rates for your provider type.

1. Go to the ODM Fee Schedule & Rates page.
2. Select your provider category, such as dental, vision, home health, or DMEPOS.
3. Confirm the effective date shown matches your date of service.
4. Cross-check any code-specific questions against the relevant Medicaid Advisory Letter (MAL).
5. If your patient is in managed care, contact that plan directly for their specific rate, since it may differ from the ODM base rate.

Managed Care vs. Fee-for-Service Rates

If a patient is enrolled in a managed care plan like CareSource, Molina, or Buckeye, the ODM base fee schedule may not apply. Each managed care organization negotiates its own rates with providers, within state requirements.

Always confirm which plan covers the patient first. Billing the wrong rate can lead to claim delays or denials, even if the service itself was covered correctly.

Federal Influence: The Medicare Physician Fee Schedule

Ohio sets its own Medicaid rates, but many caps are shaped by federal numbers. The Centers for Medicare & Medicaid Services (CMS) finalized its Calendar Year 2026 Medicare Physician Fee Schedule, including updated relative value units (RVUs), in March 2026.

Ohio’s payment caps for certain services reference this federal data. This doesn’t mean Ohio Medicaid pays Medicare rates. It means some Ohio formulas use Medicare’s RVU file as part of the calculation.

If you’re checking eligibility for coverage rather than billing, it helps to understand income rules too. See our guide to Medicaid income limits by state in 2026 for a full state-by-state breakdown.

Frequently Asked Questions

What to Do Next

If you’re a provider, bookmark the ODM Fee Schedule & Rates page and check it before billing any 2026 service. If you’re a patient wondering whether you qualify for Medicaid coverage, review current income limits before you apply.