Ohio Medicaid Fee Schedule
Ohio Medicaid pays $46.23 for an established-patient office visit (99213): 8th-lowest of 45 Medicaid programs, at 65% of the median. Its rates for the most-billed codes are below, ranked against every state.
- Schedule as of
- January 2026
- Codes priced
- 7,309
- 99213 vs. median
- 65% of median
Current Ohio Medicaid rates for common codes
Each amount is the unmodified non-facility rate in the January 2026 schedule. Where a code appears under more than one rate type, it is the state's ordinary statewide rate when its rules name one, and otherwise the median across rate types. Modifier-specific and facility-only rows are listed separately under the service.
| Code | Service | Non-facility rate |
|---|---|---|
| 99213 | Office visit, established patient (low complexity)1 rate type
| $46.23In effect since Jan 1, 20248th-lowest of 45 · 65% of median |
| 99214 | Office visit, established patient (moderate complexity) | $70.11In effect since Jan 1, 20246th-lowest of 45 · 69% of median |
| 99203 | Office visit, new patient (low complexity) | $61.22In effect since Jan 1, 20245th-lowest of 45 · 69% of median |
| 99204 | Office visit, new patient (moderate complexity) | $93.36In effect since Jan 1, 20245th-lowest of 45 · 70% of median |
| 99285 | Emergency department visit, high severity with threat to function | $94.23In effect since Jan 1, 20245th-lowest of 42 · 68% of median |
Dot: Ohio. Tick: median across state programs. Line: lowest to highest state. Base fee-for-service rates; supplemental payments some states add are not included.
Ohio is 8th-lowest of 45 for 99213. See where all 7,309 Ohio Medicaid codes rank.
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Compare any other code across state programs. The free view shows a few states per code; Ohio's full schedule is in the complete dataset.
What to know about the Ohio Medicaid fee schedule
- Ohio pays the lesser of the submitted charge or the Medicaid maximum, and prices newly covered codes at 80% of the Medicare allowed amount. OAC 5160-1-60 Appendix DD to OAC 5160-1-60 (Jan 2026)
- Nurse practitioners get 100% of the Medicaid maximum outside a hospital and 85% inside, and physician assistants get 85%. OAC 5160-4-04 OAC 5160-4-03
- Comprehensive Primary Care practices earn risk-adjusted per-member-per-month payments and shared savings on top of the fee schedule. OAC 5160-19-02
- Practitioners in public medical school health systems get a plan-paid directed increase of 137.15% on top of base Medicaid payments. CMS: Ohio state directed payment preprint, 2024
Ohio Medicaid fee schedule FAQ
Does a listed code mean the service is covered by Ohio Medicaid?
No. A listed Ohio Medicaid fee is not a coverage, authorization, or payment guarantee. Coverage, prior authorization and place-of-service limits are set in ODM's rules in the Ohio Administrative Code, chapter 5160-4 for physician services.
Does this Ohio rate apply to Medicaid managed-care plans?
Most Ohio Medicaid members are enrolled in ODM's Next Generation managed care program, whose plans launched February 1, 2023. Managed care plans pay providers under their own contracts, so those rates are not on this schedule. The fee-for-service rates apply when Ohio Medicaid pays a claim directly.
Why might my actual payment differ from the displayed rate?
These are the January 2026 Ohio Medicaid rates. A claim can pay a different amount because of the date of service, modifier, place of service, units billed, provider enrollment or taxonomy, bundling with another service, coverage policy, prior authorization, and claim edits.
Why is there no published rate for this code?
Ohio prints a pricing indicator instead of an amount for some codes, such as By Report, bundled with no separate payment, priced during prior authorization, or non-covered. A code may also be bundled into another service or priced on a different Ohio Medicaid schedule. A missing rate does not mean the service is noncovered or pays $0.
Where can I find other Ohio Medicaid fee schedules?
Ohio Medicaid publishes separate fee schedules by provider type alongside the Non-Institutional Fee Schedule (OAC 5160-1-60, Appendix DD), and its provider manual sets the coverage and billing rules.
How does Ohio Medicaid set the maximum payment for a new code?
Under rule 5160-1-60, when Ohio first covers a procedure code, 'the initial maximum payment amount is set at eighty per cent of the medicare allowed amount.' Payment on a claim is 'the lesser of the submitted charge or the established medicaid maximum', less any third-party payments and copayment. Facility and non-facility sites can carry different maximums.
How do Ohio Medicaid rates compare to Medicare?
Ohio is one of the lower-paying states. The KFF Medicaid-to-Medicare fee index for 2024 puts Ohio at 0.56 for primary care, 0.67 for obstetric care and 0.63 across all services, against national averages of 0.66, 0.88 and 0.75. Obstetric care is where Ohio trails the national average most.
How much does Ohio Medicaid pay nurse practitioners and physician assistants?
Under rule 5160-4-04, a service by a certified nurse practitioner, clinical nurse specialist or certified nurse midwife is paid at 85% of the Medicaid maximum in a hospital setting and 100% in a non-hospital setting. Under rule 5160-4-03, a physician assistant is paid the lesser of the submitted charge or 85% of the Medicaid maximum. Either provider acting as assistant at surgery gets 25% of the maximum for the primary surgical procedure.
Do Ohio Medicaid managed care plans have to pay the fee-for-service rate?
No general rule requires it. KFF counts about 90% of Ohio Medicaid enrollees in managed care plans (July 2024), and each plan negotiates rates with its network. For an authorized out-of-network service, rule 5160-26-05 requires the plan to set 'a mutually agreed upon compensation amount' with the provider rather than defaulting to the Appendix DD maximum.
What is Ohio's Comprehensive Primary Care (CPC) program?
CPC is Ohio Medicaid's primary care payment model. Enrolled practices receive a 'prospective risk-adjusted PMPM payment' for each attributed member, can earn an annual shared savings payment for savings on total cost of care, and pediatric practices in CPC for Kids receive an extra flat PMPM and can earn a bonus. Managed care plans attribute their own members, so the payments also flow through managed care.
Are some Ohio physicians paid far above the Medicaid fee schedule?
Yes, through a state directed payment. Ohio requires its managed care plans to pay practitioners in health systems affiliated with a state public medical school a uniform increase, which CMS's 2024 preprint put at 137.15% on top of base Medicaid payments, paid monthly by the plans to bring those practitioners up to a set share of the average commercial rate.
Neighboring and high-enrollment Medicaid fee schedules
States bordering Ohio first, then the largest programs.