Ohio Medicaid Managed Care Plans 2026: Next Gen & OhioRISE

Most Ohio Medicaid members get their care through one of seven Ohio Medicaid managed care plans, and if you or your child are enrolled and not in long-term care, you almost certainly belong to one. Under the Next Generation of Ohio Medicaid program, the Ohio Department of Medicaid (ODM) contracts with seven managed care organizations, routes retail pharmacy through one statewide benefit manager, and carves high-need youth behavioral health into a separate plan called OhioRISE.

This guide walks through how that system actually works: the seven contracted plans and how to compare them, the separate behavioral-health plan for children and youth with complex needs, the statewide Single Pharmacy Benefit Manager, how you get enrolled and how to switch plans, what the plan covers versus what is carved out, and the two-stage appeals path with the real filing deadlines in days.

The 60-Second Version

• Ohio Medicaid is mostly managed care. Most Ohio Medicaid members belong to one of seven Next Generation managed care plans. Ohio Administrative Code 5160-26-02 excludes several groups from plan enrollment: people enrolled in both Medicaid and Medicare, people in PACE, and, subject to exceptions that include the adult extension (expansion) category, people who live in a nursing facility or who receive services through a Medicaid waiver.1
• Seven plans serve the Medicaid managed care population. AmeriHealth Caritas Ohio, Anthem Blue Cross and Blue Shield, Buckeye Health Plan, CareSource, Humana Healthy Horizons in Ohio, Molina Healthcare of Ohio, and UnitedHealthcare Community Plan of Ohio. What differs most plan to plan is which providers each one has under contract, so compare networks before you choose.1
• OhioRISE is a separate plan for youth with complex behavioral-health needs. Aetna Better Health of Ohio operates OhioRISE for members age 20 or younger who meet the assessment criteria. A child in OhioRISE receives physical health services through a separate managed care organization or through fee-for-service Medicaid.2
• One pharmacy benefit manager covers every plan. Since October 2022, Gainwell Technologies has run Ohio Medicaid's Single Pharmacy Benefit Manager, so every retail prescription uses one statewide formulary no matter which plan you are in.1
• You get defined windows to change plans. Under OAC 5160-26-02.1, a member in a mandatory managed care population may request a different plan from the date of enrollment through the initial three months of plan enrollment, during an open enrollment month for the member's service area, and at any time when the request meets a just cause reason.1 Federal rule sets the floor underneath that: 90 days after initial enrollment, then at least once every 12 months.3
• Appeals run plan first, State Hearing second. File a plan appeal within 60 days of a denial; if the plan upholds it, request a State Hearing within 90 days of the plan's resolution notice. File within 15 days to keep a reduced or terminated service running during the appeal.4

Why Most Ohio Medicaid Members Are in a Managed Care Plan

Ohio delivers Medicaid to most members through managed care: ODM pays private managed care organizations (MCOs) a set monthly rate per member, and each MCO becomes the single accountable entity for that member's covered care. The current lineup took shape when ODM launched the Next Generation of Ohio Medicaid program on February 1, 2023, rebuilding the plan menu, adding OhioRISE for youth behavioral health, and moving every plan's pharmacy benefit to one statewide manager.1

The legal framework is layered. Ohio's managed-care program runs under Ohio Administrative Code Chapter 5160-26 and the federal Medicaid managed-care rules at 42 CFR part 438, on top of the individual contracts ODM holds with each plan. OhioRISE operates under a separate behavioral-health authority in OAC Chapter 5160-59, and MyCare Ohio for full-dual eligibles runs under its own MyCare Ohio Waiver authority (see the MyCare Ohio guide).1

Most of the long-term-care population sits outside standard managed care, but the line is not a clean one. OAC 5160-26-02 excludes from plan enrollment anyone who resides in a nursing facility or who receives Medicaid services through a waiver component, except for people covered in the adult extension (Medicaid expansion) category and two named waiver groups, who stay in managed care. So PASSPORT, the Assisted Living Waiver, the Ohio Home Care Waiver, and developmental-disability waivers generally run through separate pathways, while an expansion-category adult can be in a nursing facility and still be enrolled in a plan. The same rule excludes people enrolled in both Medicaid and Medicare, who are served through MyCare Ohio instead, and people enrolled in PACE.1

The Seven Ohio Medicaid Managed Care Plans

ODM contracts with all seven plans under the same Next Generation provider agreements, which ODM updated at launch to minimize the differences between how providers interact with each plan. The real differences you will feel are in provider network, supplemental benefits, and member service. The table below lists each plan's published Member Services line so you can start comparing. Confirm the current number, and confirm that the plan serves your county, on your member ID card or with ODM, since plan phone lines and service areas change.1

Credentialing and contracting are two different things. A provider can be credentialed to bill Ohio Medicaid and still not be in a particular plan's network, because contracting is what puts that provider under a specific plan. So the practical question when you choose is not "does my doctor take Ohio Medicaid" but "is my doctor in this plan's network."

OhioRISE: Behavioral Health Coverage for Youth With Complex Needs

OhioRISE (Resilience through Integrated Systems and Excellence) is a separate Medicaid managed care plan for children and youth with complex behavioral-health needs, operated by Aetna Better Health of Ohio. It is not a stand-alone program: an OhioRISE member must also be determined eligible for Ohio Medicaid, and receives physical health services through a separate managed care organization or through fee-for-service Medicaid while OhioRISE covers the intensive behavioral-health services.2

Who Qualifies for OhioRISE

To be eligible under OAC 5160-59-02, a youth must be 20 years of age or younger, be enrolled in Ohio Medicaid, and not be in a MyCare Ohio plan. Youth ages 6 to 20 must have a submitted Child and Adolescent Needs and Strengths (CANS) assessment, completed by a certified Ohio assessor within 90 days before the eligibility determination, showing the required level of need. Enrollment starts the first day of the month the criteria are met, and a youth disenrolls after reaching age 21 (with a limited extension to age 22 for certain inpatient psychiatric stays).2

A primary care provider, school counselor, or family can request an OhioRISE eligibility assessment by calling Aetna Better Health of Ohio at 1-833-711-0773. The CANS assessment is administered through the regional Care Management Entities (CMEs) that coordinate care for OhioRISE members.2

What OhioRISE Covers

OhioRISE covers the intensive end of behavioral health: Intensive Home-Based Treatment, Multi-Systemic Therapy and Functional Family Therapy, behavioral-health respite, Psychiatric Residential Treatment Facility services, Mobile Response and Stabilization Services for crisis, and care coordination through a Care Management Entity. Routine outpatient behavioral health, such as regular therapy and medication management for moderate needs, stays with the physical-health plan. The point of the carve-out is a single accountable plan and one set of care coordinators for a child whose needs would otherwise be split across the managed care plan, county children's services, juvenile justice, and developmental-disability providers.

The Single Pharmacy Benefit Manager (SPBM): One Formulary for Every Plan

Since October 1, 2022, outpatient (retail) pharmacy for Ohio Medicaid managed care members has been administered by one Single Pharmacy Benefit Manager, Gainwell Technologies, rather than by each managed care plan. All managed-care pharmacy claims go through the single statewide SPBM portal, and coverage decisions apply the Ohio Medicaid Unified Preferred Drug List (UPDL), the preferred drug list ODM implemented and that ODM's Pharmacy and Therapeutics (P&T) Committee reviews and recommends drugs for. Gainwell also became the Single Pharmacy Benefit Manager for Ohio Medicaid fee-for-service on July 1, 2023, so one entity now runs retail pharmacy across the whole program.1

Before the SPBM, each plan ran its own formulary, prior-authorization rules, and preferred-drug list, so members who switched plans often had to switch medications. Now the same preferred drug list governs every plan, because the SPBM, not your plan, is making the pharmacy coverage decision. The practical takeaways:

• A retail prescription denial comes from the SPBM, not your plan. Call Gainwell SPBM member and provider support at 1-833-491-0344.1
• Specialty drugs given in a physician office or infusion center (billed under the medical benefit) are still handled by your managed care plan, not the SPBM.
• For dual eligibles, Medicare Part D stays primary; Medicaid pharmacy covers only drugs Part D does not.

How You Get Enrolled in a Plan

Ohio Medicaid managed care enrollment is mostly passive, but you have a real choice at each step. Here is how it works for a new member.

What Managed Care Covers, and What Is Carved Out

Your Next Gen plan is your primary coordinator for acute and routine care. It covers primary and specialty physician services, hospital inpatient and outpatient care, emergency care, routine behavioral health, maternity care, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services for children, lab and imaging, durable medical equipment, short-term home health, dental and vision within Medicaid scope, non-emergency medical transportation (NEMT), and care management.

Several services are carved out of the plan and handled elsewhere:

• Long-term services and supports: nursing-facility long-stay care, PASSPORT, the Assisted Living Waiver, the Ohio Home Care Waiver, and developmental-disability waivers run through fee-for-service Medicaid or separate programs for the members OAC 5160-26-02 excludes from plan enrollment. Adult extension (expansion) enrollees are one of the exceptions and stay in managed care.1
• Dual eligibility: people enrolled in both Medicaid and Medicare are excluded from Next Gen plan enrollment and are served through MyCare Ohio instead.1
• High-need youth behavioral health: OhioRISE, operated by Aetna Better Health of Ohio.2
• Retail pharmacy: the Gainwell Single Pharmacy Benefit Manager, not your plan.1
• County-administered services: children's services, child-welfare placement, and certain juvenile-justice involvement stay with county boards.

The practical rule: your plan is the right call for acute and routine care, but not for long-term-care placement, waiver enrollment, or a retail-pharmacy denial.

How to Choose the Right Plan

Because all seven plans cover the same core benefits, the choice comes down to a few practical checks:

1. Provider network match. The most important factor. Before choosing, confirm your primary care provider, your child's pediatrician, any behavioral-health provider, and your preferred hospital are all in the plan's network. Each plan publishes an online provider directory.
2. Extras and care management. Plans compete on benefits the state contract does not require, and those change year to year. If someone in your household has complex needs, ask each plan how often a care manager checks in and how to reach one.
3. Ask what you still cannot tell from the directory. The Ohio Medicaid Consumer Hotline, 1-800-324-8680, is ODM's member line for questions about your coverage.5

Ohio's managed care program runs in accordance with the federal Medicaid managed-care rules at 42 CFR part 438, which is where network-adequacy obligations sit, layered on top of ODM's own contract with each plan.1 If you cannot get to an in-network provider for a covered service, call Member Services and ask, in writing if you can, how the plan intends to cover it.

Continuity of Care When You Switch Plans

Ohio's managed care contracts include continuity-of-care protections so that an in-progress course of treatment does not stop the day your plan changes. Do not assume they apply automatically. Call your new plan's Member Services as soon as you are enrolled, name your current providers and the services you are receiving, and ask for the exact length of the continuity window for each one, since it varies by service.

How to Appeal a Denial: Plan Appeal First, State Hearing Second

When a Next Gen plan denies, reduces, or terminates a service you believe you are entitled to, you have a two-stage appeal path with firm deadlines.

Stage 1: Plan Appeal

Under federal rule 42 CFR 438.402, you have 60 calendar days from the date on the plan's adverse benefit determination notice to file an appeal with the plan, either by phone or in writing.6 Under 42 CFR 438.408, the state must set a resolution timeframe no longer than 30 calendar days for a standard appeal and no longer than 72 hours for an expedited one. Know the exception before you count on the date: either clock can be extended by up to 14 calendar days if you request the extension, or if the plan shows the state agency that more information is needed and the delay is in your interest.7

Federal aid-paid-pending rules continue a previously authorized service during an appeal only when you request it in time. If you file within 15 days and the service was already authorized, it keeps running while the appeal is decided.4,8 One caution: if your assistance continues and you then lose, you may have to pay back benefits you were not eligible to receive.4

Stage 2: State Hearing

If the plan upholds its denial, you can request a State Hearing, but only after the plan's one internal appeal is exhausted, under 42 CFR 438.408(f).7 The Ohio Department of Job and Family Services (ODJFS) Bureau of State Hearings must receive your request within 90 days of the mailing date on the notice; to keep a reduced or terminated service running during the hearing, request it within 15 days of receiving that notice. You ask for a hearing by calling or writing your local county agency, or by filling out the state hearing request form that came with your notice and mailing it to the ODJFS Bureau of State Hearings, PO Box 182825, Columbus, Ohio 43218-2825, or faxing it to (614) 728-9574. The Bureau's toll-free line, 1-866-635-3748, is the number to call to ask to take part in the hearing by telephone and to ask whether your benefits should be continuing.4

A State Hearing decision binds both the plan and ODM. Free legal help is available from Ohio's legal-aid network, Pro Seniors, and Disability Rights Ohio. If the State Hearing decision is adverse, an administrative appeal to ODM is the next step, which is why filing the plan appeal first, and on time, matters.4

How Managed Care Relates to MyCare Ohio

The two programs do not overlap: OAC 5160-26-02 excludes people enrolled in both Medicaid and Medicare from Next Gen plan enrollment.1 Next Generation MyCare is Ohio's integrated program for full-dual eligibles (people with both full Medicaid and Medicare Parts A, B, and D) who are age 21 or older. It launched January 1, 2026 in the 29 former demonstration counties, with expansion to the rest of Ohio scheduled from April 1 through August 1, 2026, and Anthem, CareSource, and Molina available statewide to new members.9

A few common transitions:

• Becoming dually eligible: once you have both Medicaid and Medicare, you are outside the Next Gen exclusion rule's managed care population, and MyCare Ohio is the integrated pathway for full-duals age 21 and older.1
• Needing long-term care: a Next Gen member who enters a nursing facility or a waiver generally leaves Next Gen for the long-term-care pathway, often coordinated with a PASSPORT or Ohio Home Care Waiver case manager. The adult extension (expansion) category is the exception: those members stay in managed care.1

Cost-Sharing in Ohio Medicaid Managed Care

Medicaid cost-sharing is nominal by design, because federal rule caps what any state Medicaid program may charge. Under 42 CFR part 447, the maximum allowable copayment slides with family income against the Federal Poverty Level, with separate ceilings for outpatient services, inpatient stays, preferred and non-preferred drugs, and non-emergency use of the emergency department. Those dollar ceilings are re-indexed every October 1 by the medical care component of the CPI-U, so the operative maximum is higher than the base figure printed in the regulation, and in no case may cost sharing equal or exceed what the agency pays for the service.10

Your own copay amounts and exemptions come from your plan's member handbook, not from the federal ceilings. If a provider bills you more than the copay your handbook lists, do not pay it on the spot; call Member Services and ask them to reprocess the claim.

Learn More

Find personalized help choosing your Ohio Medicaid managed-care plan at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.