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

The phased rollout of the Next Generation MyCare Ohio Program—which integrates Medicare and Medicaid for dual-eligible individuals under a single coordinated system—reaches full statewide expansion:

• Statewide Footprint: Following its initial launch in 29 counties, the program expands monthly across the remaining 59 counties to achieve complete statewide coverage.
• Enhanced Authorization Turnarounds: MyCare plans are bound by stricter, accelerated turnaround times for prior authorizations and offer independent, binding External Medical Reviews.

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

The program requires adjustments to provider network agreements and managed care plan alignment:

• Participating Payers: The four approved Next Generation MyCare plans are Anthem Blue Cross and Blue Shield, Buckeye Health Plan, CareSource, and Molina Healthcare of Ohio. 
• Exiting Payers: Former MyCare payers Aetna Better Health of Ohio and UnitedHealthcare Community Plan are no longer part of the program. 
• Centralized Credentialing: The Ohio Department of Medicaid (ODM) is the sole credentialing source. Individual managed care plans cannot credential providers independently. You must complete and maintain your active enrollment via the state's central provider portal to treat and bill for MyCare or FFS patients. 

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.