Ohio Medicaid managed care: what plans must pay
Managed-care plans don't publish their provider fee schedules. What is public is the rule each plan must follow, set in Ohio's plan contracts, statutes and notices. For 6 of 19 service lines, plans must follow a rule tied to the state's published rates.
- Lines with a binding rule
- 6of 19
- Plans on record
- 21
- Directed payments
- 34
- Capitation cells
- 1,739$130.16–$6,796.48 PMPM
Who sets the rate, by service line
| Service line | Main rule for plans | Rates | Also applies |
|---|---|---|---|
| Nursing facility | Plans must pay at least thisPlans must pay at least the published rate | 13,776 | |
| Physician & professional | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 9,605 | Plans expected to pay at least thisPaid by the state, outside plans |
| Hospital inpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 3,945 | Suggested schedule for plans |
| IDD services | Paid by the state, outside plansPaid directly by the state, outside managed care | 3,384 | |
| Hospital outpatient | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,572 | |
| Equipment & supplies | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 2,463 | |
| Lab & pathology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,882 | |
| Behavioral health | Plans expected to pay at least thisPlans are expected to pay at least the published rate | 1,266 | Plans must pay at least thisState sets the plan rate |
| Pharmacy | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 1,195 | Plans expected to pay at least this |
| Personal care & attendant | Paid by the state, outside plansPaid directly by the state, outside managed care | 908 | Plans negotiate; applies out of network |
| Radiology | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 634 | |
| Other home & community services | Paid by the state, outside plansPaid directly by the state, outside managed care | 572 | Plans negotiate; applies out of networkState sets the plan rate |
| Transportation | Paid by the state, outside plansPaid directly by the state, outside managed care | 364 | Plans negotiate; applies out of network |
| Dental | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 208 | |
| Vision & hearing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 202 | |
| Therapy (PT/OT/speech) | Paid by the state, outside plansPaid directly by the state, outside managed care | 134 | Plans negotiate; applies out of networkPlans must pay at least this |
| Private duty nursing | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 46 | Paid by the state, outside plans |
| Other | State-directed paymentDirected payments add to plan rates | 42 | Plans negotiate; applies out of network |
| Home health | Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network | 19 |
State-directed payments
Payments CMS approved under 42 CFR 438.6(c) that plans must make on top of, or as a minimum for, their negotiated rates.
Frequently asked questions
Do Ohio Medicaid plans have to pay the state fee schedule?
For some services. Plans must follow a rule tied to the state's rates for: Nursing facility, Physician & professional, Behavioral health, Pharmacy, Other home & community services, Therapy (PT/OT/speech). For other lines, plans negotiate rates with providers.
Where do these rules come from?
From Ohio's managed-care plan contracts, state statutes and regulations, provider notices and CMS-approved directed-payment filings. Each rate in the workspace carries its citation.
Can I see what each plan actually pays?
No plan publishes its provider fee schedule. The closest public signals are the binding rules above, state-set rates, directed payments and the state's own payment-level estimates in its directed-payment filings.