Ohio Medicaid Announces New Utilization Management Requirements for Community Behavioral Health Services

The Ohio Department of Medicaid (ODM) has approved new utilization management requirements for select community behavioral health and substance use disorder services, effective July 1, 2026. These changes apply to Community Behavioral Health Centers and will introduce authorization thresholds for certain services once specified utilization limits are reached.

According to ODM, the changes were implemented in response to sustained growth in the utilization of select behavioral health services across Medicaid populations. The intent is to ensure members receive appropriate, coordinated care while establishing safeguards to address potential overutilization and service layering.

Importantly, providers will still be able to initiate services without prior authorization. Authorization will only be required once established service thresholds have been reached. ODM describes this as a "pass-through" approach designed to preserve access to care while ensuring ongoing medical necessity review.

What Providers Should Do Now

As the July 1 implementation date approaches, providers should:

• Review the affected service categories and authorization thresholds

• Assess current utilization monitoring processes

• Educate clinical, billing, and administrative staff on the new requirements

• Prepare workflows for authorization requests when utilization limits are reached

• Communicate operational impacts across your organization

Additional Resources

For complete details regarding affected services, authorization thresholds, exclusions, and submission requirements, please review the following resources:

• ODM/Humana Network Notification (PDF attached)

• Ohio Medicaid Behavioral Health Provider Resources

• Humana Healthy Horizons Prior Authorization Resources

OBHPN will continue to monitor implementation guidance and share updates as additional information becomes available.

Download: ODM/Humana Network Notification (PDF)

Learn More: [Humana link]