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.

September 24, 2026

Overview

Due to new federal laws, Medicaid eligibility requirements will be changing for individuals eligible for and enrolled in Group VIII coverage (also known as MAGI Adult or Ribicoff coverage). The new rules will introduce a Work and Community Engagement Requirement for certain non-exempt individuals to demonstrate ongoing participation in work or community activities for a minimum of 80 hours per month as a condition of coverage.

What is changing?

• To maintain Medicaid eligibility, some individuals in Group VIII must demonstrate that they meet new qualifying activities such as work, education, job training or community service, unless they meet an exemption.
• Beginning January 1, 2027, federal law will require renewals to take place every six months. This is more frequent than the current 12-month renewal requirement. To renew Medicaid coverage, individuals will need to show they met the Work and Community Engagement Requirement for at least one month since their last application or renewal. Example: If an individual’s last renewal was in January and they renew again in July, they must show that they were exempt or met the work requirement for at least one month between January and July.
• When impacted individuals come up for renewal, the Ohio Department of Medicaid (ODM) will first try to use data already available to electronically verify that the individual is excluded from or meeting the requirement. If ODM is unable to verify using this data, then individuals will receive a request for more information.

When will these changes take effect?

The Work and Community Engagement Requirement will take effect on January 1, 2027.

How do members know if the requirement applies to them?

• The new requirement only applies to individuals eligible for and enrolled in Group VIII coverage, which refers to adults aged 19 through 64 who have Medicaid because their income is at or below 138% of the Federal Poverty Level.
• These changes do not affect individuals who have Medicaid for reasons other than income, or those who have certain health conditions or meet other exemptions.
• To find out if they are part of Group VIII, individuals can log in to their Self-Service Portal (SSP) account and look on the “View My Benefits” page. They also can look at a recent notice from ODM if they do not use the Self-Service Portal

Thank you to everyone who provided feedback in our 3 Question Survey last month. If you did not have an opportunity to share your needs, please complete the quick survey at the link below. In October, we will begin sharing more specific details in answer to your questions. 

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August 28, 2026

HR1 requires states to implement new Medicaid Work Requirements starting with Redetermination Renewals on January 1, 2027. Certain Medicaid members ages 19–64 may need to complete at least 80 hours each month of approved activities—such as employment, job training, education or volunteer service—unless they qualify for an exemption. 

What providers should know

• Some members may qualify for exemptions. Helping members understand and access available exemptions early may reduce avoidable coverage disruptions.
• Providers and community partners will play an important role in helping members navigate these changes and maintain access to care.
• Buckeye Health Plan and Centene will continue working with state partners and network providers to support a smooth, efficient implementation.

Additional details and provider resources will be shared as implementation guidance becomes available. Please watch for future updates and help members respond promptly to Medicaid eligibility communications.

We’re here to make sure you have everything you need to keep your patients from losing coverage unnecessarily. To ensure we capture and address your needs, please respond to a 3-question survey.

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