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Schedules and Rates
Schedules and Rates

Ambulatory Surgical Centers

Reimbursement for ambulatory surgery center services are processed using 3M’s Enhanced Ambulatory Patient Groups (EAPG). Services provided on or after January 2, 2020 will be processed using EAPG Version 3.14. Services provided on or after August 1, 2017 and on or before January 1, 2020 will be processed using Version 3.9. Please refer to Ohio Administrative Code rule 5160-22-01 and the ambulatory surgery center billing guidelines for additional information about EAPG payment methodology.

EAPG Covered Codes (PDF) (XLSX)
Base Rate:

  • $74.83 (effective 8/1/2017-1/1/2020)
  • $83.34 (effective 1/2/2020-Present)

Cost-to-Charge Ratio:

  • 18% (effective 8/1/2017-1/1/2020)
  • 20% (effective 1/2/2020-Present)

EAPG Adjuster:

  • EAPGs 134 and 149 are paid at 110% of the EAPG calculated amount (base rate x relative weight)-(effective 8/1/2017-1/1/2020)
  • EAPG 233 is paid at 145% and EAPG 485 is paid at 233% of the EAPG calculated amount (base rate x relative weight) - (effective 1/2/2020-Present)

EAPG Relative Weight Table

EAPG Claim Examples

Effective for dates of service prior to 8/1/17.
ASC Rates – ASCs are paid a facility fee for certain procedure codes as noted in the 'Current Surgical Group' column in the ASC section of the 'Medicine, Surgery, Radiology and Imaging, and Additional Procedures (Non-Institutional Services)' schedule.

Anesthesia Services

This table (PDF) lists the current payment amounts for anesthesia administration. It reflects the policy set forth in Ohio Administrative Code rule 5160-4-21.

CPT And HCPCS Level II Procedure Code Changes

Dental Services

This table (PDF) (XLSX) lists the current fees for Current Dental Terminology (CDT) procedure codes. It reflects the policy set forth in Ohio Administrative Code rule 5160-5-01.

Dialysis Center Services

The following tables list the payment amounts for dialysis center services prior to and as of July 1, 2021.  The tables reflect the policy set forth in Ohio Administrative Code rule 5160-13-02.

Durable Medical Equipment, Prostheses, Orthoses, And Supplies (DMEPOS)

The main DMEPOS payment schedule lists the current maximum payment amounts for many durable medical equipment items, prostheses, orthoses, and medical supplies. It reflects the policy set forth in Ohio Administrative Code Chapter 5160-10. (XLSX)

The Oxygen payment schedule lists the current maximum payment amounts for oxygen. It reflects the policy set forth in Ohio Administrative Code rule 5160-10-13. (XLSX)

The Wheelchair payment schedule lists the current maximum payment amounts for wheelchairs, parts, accessories, and related services. It reflects the policy set forth in Ohio Administrative Code rule 5160-10-16. (XLSX)

Eye Care Services

This table (XLSX) lists the current amounts for eye care services.  It reflects the policy set forth in Ohio Administrative Code rule 5160-6-01.

Home and Community-Based Services Waiver Fee Schedule

The fee schedule for DODD Home and Community Based Services can be found at:
https://dodd.ohio.gov/wps/portal/gov/dodd/forms-and-rules/rules-in-effect


The current and previous fee schedule for Ohio Home Care Waiver Home and Community Based Services can be found at:
Rule 5160-46-06 Ohio home care waiver program: reimbursement rates and billing procedures
http://www.registerofohio.state.oh.us/rules/search/details/320555

Rule 5160-46-06.1 Ohio home care waiver program: home care attendant services reimbursement rates and billing procedures
http://www.registerofohio.state.oh.us/rules/search/details/320559

The current and previous fee schedule for Assisted Living Services can be found at:
Rule 5160-1-06.5 Home and community based services (HCBS) waivers: assisted living http://www.registerofohio.state.oh.us/rules/search/details/320558

The current and previous fee schedule for PASSPORT Services can be found at:
Rule 5160-1-06.1 Home and community-based service waivers: PASSPORT
http://www.registerofohio.state.oh.us/rules/search/details/320557

The MyCare Waiver rules are found here:
https://codes.ohio.gov/ohio-administrative-code/rule-5160-58-04

The MyCare Ohio Managed Care Plans are not bound to pay the same rates as the other FFS waivers. The rates are dependent upon the agreed upon contract between each plan and their providers. If that contract stipulates FFS rates, then refer to the other FFS waiver fee schedules in this section, as applicable.

Home Health Rates

The current and previous fee schedule for home health services can be found at:
Rule 5160-12-05 Reimbursement: home health services
http://www.registerofohio.state.oh.us/rules/search/details/320709

Hospice Rates

  • Hospice Rates FFY 2023 – October 1, 2022 - September 30, 2023 for Providers in Compliance with Hospice Quality Reporting Requirements
  • Hospice Rates FFY 2023 – October 1, 2022 - September 30, 2023 for Providers not in Compliance with Hospice Quality Reporting Requirements
  • Hospice Rates FFY 2022 – October 1, 2021 - September 30, 2022 for Providers in Compliance with Hospice Quality Reporting Requirements
  • Hospice Rates FFY 2022 – October 1, 2021 - September 30, 2022 for Providers not in Compliance with Hospice Quality Reporting Requirements
  • Hospice Rates FFY 2021 – October 1, 2020 - September 30, 2021 for Providers in Compliance with Hospice Quality Reporting Requirements
  • Hospice Rates FFY 2021 – October 1, 2020 - September 30, 2021 for Providers not in Compliance with Hospice Quality Reporting Requirements
  • Hospice Rates FFY 2020 – October 1, 2019 - September 30, 2020 for Providers in Compliance with Hospice Quality Reporting Requirements
  • Hospice Rates FFY 2020 – October 1, 2019 - September 30, 2020 for Providers not in Compliance with Hospice Quality Reporting Requirements
  • Hospice Rates FFY 2019 – October 1, 2018 – September 30, 2019 for Providers in Compliance with Hospice Quality Reporting Requirements
  • Hospice Rates FFY 2019 – October 1, 2018 – September 30, 2019 for Providers not in Compliance with Hospice Quality Reporting Requirements
  • Hospice Rates FFY 2018 – October 1, 2017 – September 30, 2018 for Providers in Compliance with Hospice Quality Reporting Requirements
  • Hospice Rates FFY 2018 – October 1, 2017 – September 30, 2018 for Providers not in Compliance with Hospice Quality Reporting Requirements
  • Hospice Rates FFY 2017 – October 1, 2016 – September 30, 2017 for Providers that Comply with Quality Data Reporting Requirements
  • Hospice Rates FFY 2017 – October 1, 2016 – September 30, 2017 for Providers that Failed to Comply with Quality Reporting Requirements
  • Hospice Rates FFY 2016 – October 1, 2015 – September 30, 2016 for Providers that Comply with Quality Data Reporting Requirements
  • Hospice Rates FFY 2016 – October 1, 2015 – September 30, 2016 for Providers that Failed to Comply with Quality Reporting Requirements

Inpatient Hospital Services

Laboratory Services

This table (PDF) (XLSX) lists the current coverage and maximum payment amounts for clinical diagnostic procedures, pathology procedures, and related services.  It reflects the policy set forth in Chapter 5160-11 of the Ohio Administrative Code.

Medicaid Fee Schedule for Community Behavioral Health Providers (OhioMHAS Administered)

Medicine, Surgery, Radiology and Imaging, and Additional Procedures (Non-Institutional Services)

This schedule (PDF) - (XLSX) applies to most non-institutional fee-for-service providers.  It is published as Appendix DD to rule 5160-1-60 of the Ohio Administrative Code.

Nursing Facility Rates

Nursing Facility Rates

Outpatient Hospital Services

Reimbursement for outpatient hospital services are processed using 3M’s Enhanced Ambulatory Patient Groups (EAPG). Services provided on or after January 2, 2020 will be processed using EAPG Version 3.14. Services provided on or after August 1, 2017 and on or before January 1, 2020 will be processed using Version 3.9. Please refer to Ohio Administrative Code rule 5160-2-75 and the hospital billing guidelines for additional information about EAPG payment methodology.

The Outpatient Fee Schedules are several Appendices of Ohio Administrative Code Rule 5160-2-21, effective through 7/31/17.

  • Addendum (PDF) - (XLS) CPT Code Changes Effective 1/1/2017. This Addendum should be used in tandem with the 10/1/2016 appendices to determine coverage of procedure codes for dates of service on or after 1/1/2017. 

The following fee schedules are applicable for dates of service on or after 10/1/2016:

  • Appendix A (PDF) - (XLS) Local Level Codes & Modifiers.
  • Appendix B (PDF) - (XLS) Revenue Center Codes Requiring CPT or HCPCS Coding.
  • Appendix C (PDF) - (XLS) Ambulatory Surgery Fee Schedule.
  • Appendix D (PDF) - (XLS) Clinic Facility Fee Schedule.
  • Appendix E (PDF) - (XLS) Emergency Room Fee Schedule.
  • Appendix F (PDF) - (XLS) Ancillary Fee Schedule.
  • Appendix G (PDF) - (XLS) Outpatient Hospital Radiology Fee Schedule.
  • Appendix H Outpatient Hospital Laboratory Fee Schedule has been rescinded. Please refer to the Laboratory Services Fee Schedule for coverage and reimbursement rates of laboratory codes. Please refer to Appendix DD for reimbursement rate of CPT code 36416 (capillary blood draw).
    • Appendix H (PDF) - (XLS) Outpatient Hospital Laboratory Fee Schedule (for dates of service on or before 12/31/2015).
  • Appendix I (PDF) - (XLS) HCPCS Q-Codes Covered in an Outpatient Hospital Setting.

The following fee schedules are applicable for dates of service on or after 1/1/2016:

  • Addendum (PDF) - (XLS) CPT Code Changes Effective January 1, 2016.
  • Appendix A (PDF) - (XLS) Local Level Codes & Modifiers.
  • Appendix B (PDF) - (XLS) Revenue Center Codes Requiring CPT or HCPCS Coding.
  • Appendix C (PDF) - (XLS) Ambulatory Surgery Fee Schedule.
  • Appendix D (PDF) - (XLS) Clinic Facility Fee Schedule.
  • Appendix E (PDF) - (XLS) Emergency Room Fee Schedule.
  • Appendix F (PDF) - (XLS) Ancillary Fee Schedule.
  • Appendix G (PDF) - (XLS) Outpatient Hospital Radiology Fee Schedule.
  • Appendix H Outpatient Hospital Laboratory Fee Schedule has been rescinded. Please refer to the Laboratory Services Fee Schedule for coverage and reimbursement rates of laboratory codes. Please refer to Appendix DD for reimbursement rate of CPT code 36416 (capillary blood draw).

The following fee schedules are applicable for dates of service on or after 4/30/2015 through 12/31/2015: 

  • Appendix A (XLS) Local Level Codes & Modifiers.
  • Appendix B (XLS) Revenue Center Codes Requiring CPT or HCPCS Coding.
  • Appendix C (XLS) Ambulatory Surgery Fee Schedule.
  • Appendix D (XLS) Clinic Facility Fee Schedule.
  • Appendix E (XLS) Emergency Room Fee Schedule.
  • Appendix F (XLS) Ancillary Fee Schedule.
  • Appendix G (XLS) Outpatient Hospital Radiology Fee Schedule
  • Appendix H (XLS) Outpatient Hospital Laboratory Fee Schedule (for services on or after Jan. 1, 2010)

Outpatient Hospital Behavioral Health Services

The following information pertains to Behavioral Health Services provided by an outpatient hospital for dates of service on or after August 1, 2017:

Pharmacy

Pharmacy providers are paid as described in OAC rules 5160-9-05 (drugs including influenza vaccine) and 5160-9-02 (supplies). Visit Ohio Medicaid Pharmacy website for a searchable database of pharmacy coverage and rates.

Primary Rate Increase

2014

2013

Private Duty Nursing Rates

The current and previous fee schedule for private duty nursing services can be found at:
Rule 5160-12-06 Reimbursement: private duty nursing services

http://www.registerofohio.state.oh.us/rules/search/details/320710

Provider-Administered Pharmaceuticals

This table (XLS) lists the current coverage and fees for vaccines, injectable medications, and other drugs administered by practitioners. It reflects the policy set forth in the Ohio Administrative Code in rule 5160-4-12.

RN Assessment and RN Consultation Services

The current and previous fee schedule for RN Assessment and RN Consultation services can be found at:
Rule 5160-12-08 Registered nurse assessment and registered nurse consultation services

http://www.registerofohio.state.oh.us/rules/search/details/320711

Targeted Case Management

The DODD rates for targeted case management can be found at: TCM

OhioRISE Care Coordination rates: OhioRISE CC Rates

Transportation

This table (PDF) lists the current payment amounts for transportation by ambulance or wheelchair van. It reflects the policy set forth in Ohio Administrative Code rule 5160-15-28.

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