1. What the OPS plan does to the structure of Medicaid

Baseline:

• Recent Ohio Medicaid budget: $34B (even higher now)

• Under the 55% plan: 

  • $18.7B goes into the Provider Supplement Pool

  • $15.3B remains in traditional Medicaid

But here’s the key: Once prices drop across the board, Medicaid doesn’t need to be this big anymore.

Because:

• Every visit, test, and surgery is 60–80% cheaper (projected)

• Doctors and hospitals are still fully paid because of the supplement

• Insurance premiums drop, so fewer people need Medicaid just to survive

So the same amount of care can be delivered with far less total spending.

2. How the 55% plan lowers actual spending needs

Right now-Medicaid does not pay the inflated “chargemaster” prices that providers list on their bills. Those high numbers are simply the provider’s internal pricing system, not the amount Medicaid actually reimburses. Instead, Medicaid uses its own fixed fee schedule and pays only the approved amount for each service, which is often a small fraction of the billed charge. Providers must accept this payment as payment in full and cannot bill the patient for the difference. This means that while medical bills may appear high on paper, Medicaid consistently pays only its standardized, much lower rates. This is a problem!

 

• Right now, Medicaid pays its own fixed rates, not the provider's inflated charges listed below.

  • $120–160 primary visits

  • $250–350 specialist visits

  • $1,200–2,400 MRIs

  • $8,000–22,000 surgeries

Under the 55% plan:

• Those same services are very reasonable and that is what they pay! 

  • $35 primary

  • $75 specialist

  • $250 MRI

  • $2,000 surgery

Even with the supplement, the total system cost per patient is much lower than today’s Medicaid structure, because:

• There’s less bureaucracy

• Less fraud and waste

• Less administrative overhead

• More direct, transparent pricing

So, over a few years, Ohio could say:

“We don’t need $34B for Medicaid anymore. We can safely run this system on, say, $26B.”

That’s an $8B reduction in the overall Medicaid budget, not just a reshuffle.

 

OPS Medicaid Co‑Pay Structure

OPS keeps Medicaid premiums at $0/month, but adds small co‑pays so everyone contributes a little and the system stays strong.

Doctor Visits

• Primary care: $5

• Specialist: $10

Imaging

• MRI: $20

• CT: $10

Medications

• Generic: $4

• Brand‑name: $8

Emergency Room

• ER visit: $25 (waived if admitted)

Hospital Stay

• $50 per admission

Outpatient Surgery

• $100 co‑pay

Mental Health

• Counseling: $5

• Psychiatrist: $10

Labs

• $3–$5

These co‑pays are small, predictable, and designed to preserve dignity while keeping Medicaid simple and affordable.

PART 3 — Legislative Clause 

Section X — Medicaid Co‑Pay Requirements Under OPS

1. Premiums Medicaid premiums shall remain $0/month for all eligible individuals and families.

2. Co‑Pay Structure Medicaid beneficiaries shall contribute small co‑pays for covered services as follows:

   • Primary care: $5

   • Specialist care: $10

   • Generic medications: $4

   • Brand‑name medications: $8

   • MRI: $20

   • CT: $10

   • ER visit: $25 (waived if admitted)

   • Hospital admission: $50

   • Outpatient surgery: $100

   • Mental health counseling: $5

   • Psychiatrist: $10

   • Labs: $3–$5

3. Purpose Co‑pays shall be used to:

   • reduce unnecessary utilization

   • promote responsible use of medical services

   • stabilize the OPS supplement pool

   • preserve dignity through shared contribution

4. Prohibition on Additional Fees No deductibles, premiums, or additional cost‑sharing may be added to Medicaid under OPS.

5. Hardship Waivers Providers may waive co‑pays for individuals experiencing financial hardship.

 

Effects on Medicaid

Right now, this system leaves no one happy. Patients see huge bills they never actually owe. Doctors see tiny reimbursements that barely cover their costs. Medicaid sees inflated charges it never pays and a system that looks more expensive than it really is.

The OPS plan improves this situation by removing the inflated numbers entirely. When providers bill through OPS, the prices shown are the real prices—transparent, honest, and aligned with what Medicaid already pays. Medicaid continues paying its standard low rates, but providers gain a clearer, more predictable structure that reflects actual costs instead of artificial chargemaster prices. This reduces confusion, lowers administrative friction, and helps stabilize relationships between Medicaid and providers.

In short, Medicaid keeps paying its affordable rates, patients see realistic prices, and providers finally work within a system that doesn’t force them to pretend their services cost five times more than Medicaid will ever reimburse.

✔ “Medicaid pays standardized rates, not the inflated prices listed on medical bills.”

 

3. What happens to the “extra” money we don’t use

Once the system proves it can run on less:

• The Medicaid appropriation itself can be cut

• That freed-up money can be used to:

  • Reduce state taxes

  • Fund debt reduction

  • Support other critical areas (schools, roads, mental health, and other areas of healthcare etc.)

  • Or even direct relief (rebates, credits) to families

In other words:

The 55% OPS plan doesn’t just “spend Medicaid differently”—

it makes Medicaid smaller and returns some of the tax burden back to the people.

4. How this eases financial strain “all around”

For families

• Lower premiums

• Lower out-of-pocket costs

• Less need to rely on Medicaid just to survive

• Potential tax relief or state credits from reduced Medicaid spending

For doctors and hospitals

• Higher income

• Less paperwork

• More stable revenue

• Less dependence on complex Medicaid billing

For the state

• Lower long-term obligations

• Less pressure on future budgets

• More room to respond to crises without raising taxes

For those at the very bottom of the financial bracket

• The remaining $15.3B (and later, a smaller but still significant amount) is focused on:

  • Truly struggling families

  • Creating small co-pays (a few dollars)

  • Creating access to the same low prices and high-quality providers

5. The narrative we are building

We are not just saying:

“Let’s redirect Medicaid money.”

We are saying: 

“Let’s cut the cost of care, pay doctors well, protect medical freedom, and then shrink Medicaid itself so we can give some of that money back to the people who earned it.”

How OPS Improves Doctor–Insurance Relations

The OPS plan strengthens relationships between doctors and insurance companies by removing the inflated chargemaster prices that create tension on both sides. Today, providers submit extremely high bills, insurers reject those numbers, and both parties end up frustrated doctors feel underpaid, and insurers feel overcharged. OPS replaces this system with clear, honest pricing that reflects the real cost of care. When providers bill realistic amounts, insurers can process claims more quickly, reimburse more predictably, and negotiate more fairly. This transparency reduces conflict, lowers administrative burden, and helps rebuild trust between doctors and insurers who have long been stuck in a cycle of inflated charges and low reimbursements.