John Esker

An Ohio Medicaid insurer implemented several reimbursement and coverage updates recently, centered on specialty medication administration sites, pharmacy billing rules, and duplicate-claims payment integrity.
A new site-of-care policy now governs specialty medication administration for Ohio Medicaid members, adding a clear reimbursement consideration when scheduling where those treatments are delivered.
Ohio's update also added new clinical coverage criteria for one gene therapy, meaning providers may need to verify eligibility requirements before submitting related claims.
Revised buy-and-bill pharmacy policies now cover several drugs and biosimilars, so Ohio practices may want to recheck reimbursement workflows tied to medication purchasing and billing.
The insurer also revised its duplicate-claims payment integrity policy, giving Ohio Medicaid providers another operational update to review as current reimbursement rules take hold.

Ohio Payer Reimbursement Changes

Private Medicare plans covered ~54% of eligible US beneficiaries, offering drug coverage, spending caps, dental, and vision, but also tighter networks and prior authorization.
In a ~1M beneficiary study, ~200K developed medical conditions while ~800K did not, and sicker patients became more likely to leave their existing plans.
As health needs grew, beneficiaries increasingly traded extra benefits for broader access, a pattern the analysis described as dynamic adverse selection behavior.
Dementia had the biggest disenrollment effect, and supplemental coverage protections helped beneficiaries exit private plans for traditional coverage, especially when medical complexity was highest.
The broader takeaway: Medicare for All would not erase healthcare trade-offs, because access, utilization controls, spending decisions, and who can say no still matter.