June 30, 2026

• CMS Interoperability and Prior Authorization Rule: The second phase of the federal Interoperability and Prior Authorization final rule takes effect on January 1. This requires physician offices and practitioners to interface with modernized, streamlined electronic systems that enforce faster turnaround times for prior authorizations.
• Work and Community Engagement Requirements: Starting in 2027, certain able-bodied adult Medicaid recipients (ages 18-64) will be required to work, train, or volunteer at least 80 hours per month to maintain coverage. Individuals in substance use disorder treatment programs or with serious medical conditions/disabilities are exempt. Practices may see shifts in patient continuous enrollment as patients navigate these new reporting rules.
• Payment Suspensions and Program Integrity: The Ohio Department of Medicaid (ODM) and the Centers for Medicare & Medicaid Services (CMS) have rolled out continuous stricter audits and data analytics to suspend payments to high-risk providers showing billing anomalies.
• State Financial Headwinds: Ohio is navigating federal changes (like the federal HR 1 limits on provider taxes) that reduce the state's capacity to raise revenue and enhance provider payments, which may create downstream financial pressure on clinics, hospitals, and reimbursement rates.

For the latest localized policies and billing requirements, check updates regularly through the Ohio Department of Medicaid portal.

Ohio Fee-For-Service (FFS) claims and the Next Generation MyCare program operate under unified fiscal and EDI clearings, with full statewide managed care expansion actively altering billing operations. 

Jun 30, 2026

Statewide Next Gen MyCare 

Ohio’s Next Generation MyCare program, which brings Medicare and Medicaid benefits together under one coordinated system for dual-eligible individuals, will be statewide throughout 2027. Providers should be aware of the approved participating plans, the continued county-by-county rollout in 2026, and ODM’s centralized credentialing requirements.

• Participating plans: The approved Next Generation MyCare plans are Anthem Blue Cross and Blue Shield, Buckeye Health Plan, CareSource, and Molina Healthcare of Ohio.
• Statewide expansion: After launching in 29 counties, the program will continue expanding monthly throughout 2026 across the remaining 59 counties, reaching full statewide coverage throughout 2027.
• Centralized credentialing: The Ohio Department of Medicaid is the sole credentialing source for MyCare. Managed care plans cannot credential providers independently, so providers must complete and maintain active enrollment through the state’s central provider portal to treat and bill for MyCare or fee-for-service patients.

June 30, 2026

Both FFS and Next Generation MyCare utilize the electronic single-point-of-entry infrastructure:

• The "Front Door" Protocol: All EDI claims must pass through the Ohio Front Door (OFD) clearings.
• Routing Rules: Ensure your billing software or clearinghouse incorporates the updated Receiver and Payer IDs in the EDI transaction headers (specifically loop 2010BB) to direct MyCare dual-benefit claims vs. traditional state FFS claims properly.
• Credentialing Warning: The Ohio Department of Medicaid remains the sole credentialing body. Providers cannot bypass state enrollment to contract directly with individual MyCare MCO networks.

Ohio Fee-For-Service (FFS) and the Next Generation MyCare program operate under a unified framework within the Ohio Medicaid Enterprise System (OMES). The program manages the healthcare benefits of dual-eligible individuals (those with both Medicare and Medicaid), which will reach full statewide implementation across all 88 Ohio counties following phased regional rollouts.

June 30, 2026

Both FFS and Next Generation MyCare utilize identical single-point-of-entry architecture for Electronic Data Interchange (EDI):

• The Single Entryway: All 837 professional, institutional, and dental claims must go directly to the OMES EDI clearinghouse. Do not send claims directly to individual MyCare managed care plans.
• ID Mapping: Claims must be submitted using the member's 12-digit Medicaid Identification Number, regardless of whether the service is routed to FFS or a Next Generation MyCare plan.
• Pharmacy Routing: Traditional FFS pharmacy claims continue via the state's Single Pharmacy Benefit Manager (SPBM). For MyCare dual-eligible members, pharmacy billing is routed to the specific MyCare plan's PBM to coordinate Medicare Part D and Medicaid wrap-around drug benefits.

For complete operational rules, technical specifications, and companion guides, consult the Ohio Department of Medicaid Provider Portal.