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 plan members' prescription drug coverage through one statewide benefit manager, and carves high-need youth behavioral health into a separate plan called OhioRISE.

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, including 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.
  • 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.
  • 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 one of the rule's need criteria. A child in OhioRISE still gets regular health care coverage from their managed care plan or directly from Medicaid.
  • One pharmacy benefit manager covers every plan. Since October 2022, Gainwell Technologies has run Ohio Medicaid's Single Pharmacy Benefit Manager, so plan members' prescriptions follow one preferred drug list whichever plan they are in. Dual eligibles and MyCare Ohio members are not in it.
  • 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. Federal rule sets the floor underneath that: 90 days after initial enrollment, then at least once every 12 months.
  • Appeals run plan first, State Hearing second. File a plan appeal within 60 days of the date on the plan's notice. If the plan upholds it, Ohio gives you 90 days from the mail date of the plan's appeal decision to request a State Hearing. To keep a reduced or stopped service running, ask for continued benefits within 10 calendar days after the plan sends its notice.

Why Most Ohio Medicaid Members Are in a Managed Care Plan

Ohio delivers Medicaid to most members through managed care: ODM signs a provider agreement with each licensed managed care organization (MCO), and each member has chosen or been assigned to one. The current lineup took effect when ODM launched the Next Generation program on February 1, 2023. OhioRISE, whose enrollment rule dates to July 1, 2022, and the statewide pharmacy manager, which took over plan members' prescriptions on October 1, 2022, came first.

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 rules in OAC Chapter 5160-58 (see the MyCare Ohio guide).

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 other groups the rule specifies by paragraph, 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, people enrolled in PACE, and several other groups.

The Seven Ohio Medicaid Managed Care Plans

ODM contracts with each plan through a managed care provider agreement. The differences you will feel are in provider network, extras, and member service. Each plan's Member Services number is on your member ID card and its website. The second column matters if someone in your household is about to have both Medicaid and Medicare.

Plan (name on ODM's contract list) Also a Next Generation MyCare plan for new members?
Anthem Blue Cross and Blue Shield Yes
AmeriHealth Caritas Ohio No
Buckeye Community Health Plan (Buckeye Health Plan) No; current MyCare members may stay
CareSource Ohio Yes
Humana Healthy Horizons in Ohio No
Molina Healthcare of Ohio Yes
UnitedHealthcare Community Plan of Ohio No

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, gets OhioRISE's behavioral health services through Aetna, and still gets regular health care coverage from their managed care plan or directly from Medicaid.

Who Qualifies for OhioRISE

To be eligible under OAC 5160-59-02, a youth must be 20 or younger at enrollment, eligible for Ohio Medicaid, and not in a MyCare Ohio plan, and must also qualify in one of these ways: a Child and Adolescent Needs and Strengths (CANS) assessment by a certified Ohio assessor, within 90 days before the determination, showing the required level of need; meeting the criteria for moderate care coordination or intensive home-based treatment (IHBT); or an inpatient hospital admission for mental illness or substance use disorder. Enrollment is mandatory and starts the first day of the month the criteria are met.

Enrollment ends at the earliest of several triggers, including the month after the youth turns 21 (later for some inpatient psychiatric stays), MyCare Ohio enrollment, and loss of Medicaid. There is also a two-year mark: with no qualifying CANS in two years and no IHBT or qualifying inpatient stay in the past 365 days, the youth is disenrolled, so a family that stops using services can lose the program. Denials and disenrollments carry state hearing rights. OhioRISE member services is 1-833-711-0773.

What OhioRISE Covers

ODM describes the split simply: OhioRISE's behavioral health services come through Aetna, and the child's regular health care coverage stays with their managed care plan or Medicaid. For a specific service, ask OhioRISE member services which side covers it.

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

Since October 1, 2022, prescription drug coverage for members of Ohio Medicaid managed care plans has been the responsibility of one Single Pharmacy Benefit Manager, Gainwell Technologies, rather than of 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 administers the pharmacy benefit across both managed care and fee-for-service.

The same preferred drug list governs every plan, because the SPBM, not your plan, is making the pharmacy coverage decision. The practical takeaways:

  • A prescription denial for a plan member comes from the SPBM, not your plan. Call Gainwell SPBM member and provider support at 1-833-491-0344.
  • Dual eligibles, MyCare Ohio members, most nursing-facility residents, and most waiver participants are not in the SPBM, so don't start with Gainwell for them.
  • Since April 27, 2026, prescribers file prior authorizations through the Agadia PromptPA portal, not the SPBM secure portal.

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.

1
Step 1

Get approved for Medicaid

Apply online at Ohio Benefits, by phone at 1-800-324-8680, in person at your County Department of Job and Family Services (CDJFS), or by mail. Once you are approved, you are enrolled in managed care unless OAC 5160-26-02 excludes you. Its exclusions cover, among others, people with both Medicaid and Medicare, people in PACE, and most nursing-facility residents and waiver participants.

2
Step 2

Choose a plan, or be assigned one

A member is a Medicaid recipient who has either selected or been assigned to a managed care entity, so if you do not pick, one is picked for you. Compare networks first, since that is the difference you will live with.

3
Step 3

Ask questions at the Ohio Medicaid Consumer Hotline

The hotline, 1-800-324-8680, is ODM's member contact point for questions and for help completing an application.

4
Step 4

Change plans in your first three months

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. Federal rule 42 CFR 438.56 sets the floor: for cause at any time, and without cause during the 90 days after initial enrollment (or after the state's notice of it, if later), then at least once every 12 months.,

5
Step 5

After that, use open enrollment or just cause

OAC 5160-26-02.1 also lets you request a different plan during an open enrollment month for your service area, or at any time when your request meets one of the rule's just cause reasons. The federal cause list at 42 CFR 438.56(d)(2) includes moving out of the plan's service area, poor quality of care, lack of access to covered services, and lack of access to providers experienced with your care needs.

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.
  • Dual eligibility: people enrolled in both Medicaid and Medicare are excluded from Next Gen plan enrollment and are served through MyCare Ohio instead.
  • High-need youth behavioral health: OhioRISE, operated by Aetna Better Health of Ohio.
  • Prescription drugs: the Gainwell Single Pharmacy Benefit Manager, not your plan.
  • 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 prescription 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.

Ohio's managed care program runs in accordance with the federal Medicaid managed-care rules at 42 CFR part 438, layered on top of ODM's own provider agreement with each plan. 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 owed, 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 appeal to the plan, by phone or in writing. Under 42 CFR 438.408, the state must set a resolution timeframe no longer than 30 calendar days for a standard appeal and 72 hours for an expedited one. Those are ceilings: the plan must decide as fast as your health requires. Know the exception before you count on the date: either clock can be extended by up to 14 calendar days if you request it, or if the plan shows the state, to its satisfaction, that it needs more information and the delay is in your interest.

A previously authorized service keeps running during the plan appeal only if you ask: file on time and request continuation by the later of 10 calendar days after the plan sends its notice or the change's effective date, for a service an authorized provider ordered whose authorization hasn't expired. If the plan wins in the end, it may recover the cost of the continued services.

Stage 2: State Hearing

You can request a State Hearing once the plan upholds its decision, or right away if the plan misses its federal notice and timing deadlines (42 CFR 438.408(f)). The Ohio Department of Job and Family Services (ODJFS) Bureau of State Hearings must receive your request within 90 calendar days of the mail date of the plan's appeal decision.

To keep the service running, don't wait: federal rule ends continued benefits unless you request the hearing and continuation within 10 calendar days after the plan sends its appeal decision. Missed it? Ask anyway: federal rule lets the agency reinstate services when the hearing request comes no more than 10 days after the date of action, and requires it when there was no advance notice and you ask within 10 days of receiving the notice. If you lose the hearing, you may have to repay continued benefits.

Ask by calling or writing your local county agency, writing to the Bureau at PO Box 182825, Columbus, Ohio 43218-2825, or mailing or faxing the request form to (614) 728-9574. The Bureau's toll-free line, 1-866-635-3748, is for taking part by telephone and for asking about continuing benefits when services changed without written notice.

The plan itself is a party to the hearing. Free legal help comes from Ohio's legal-aid network, Pro Seniors, and Disability Rights Ohio.

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. 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 21 or older and not already in PACE, a Developmental Disabilities waiver, an intermediate care facility, or other hospital-and-doctor coverage. It launched January 1, 2026 in the 29 counties where MyCare Ohio began and rolled out to the rest of Ohio from April 1 to August 1, 2026, with Anthem, CareSource, and Molina available statewide to new members.

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 Next Generation MyCare is the integrated pathway for most full-duals age 21 and older.
  • 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. The adult extension (expansion) category is the exception: those members stay in managed care.

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 cost sharing 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 increased each year (the indexing began October 1, 2015) 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.

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.

Frequently Asked Questions

Which of the seven plans can I actually pick where I live?

ODM contracts with all seven for the Next Generation program, and Ohio's plan-change rule is written around "an open enrollment month for the member's service area," so confirm the plans serving your county with ODM before you decide. The comparison that matters more is which of them has your doctors, your child's pediatrician, and your hospital under contract.

Is OhioRISE a plan I have to pick separately?

No. Eligibility turns on the rule's need criteria, most often a CANS assessment, and enrollment is mandatory for a youth who meets them. OhioRISE adds behavioral health services; regular coverage still comes from the child's managed care plan or Medicaid.

Why is my prescription denial coming from Gainwell and not my plan?

For Next Gen plan members, prescription coverage is the Gainwell Single Pharmacy Benefit Manager's responsibility, not the plan's. Call Gainwell SPBM support at 1-833-491-0344, or have your prescriber file a prior authorization. Dual eligibles and MyCare Ohio members are not in the SPBM.

Can I switch plans more than once a year?

Sometimes, but not on demand. Ohio's rule gives most members in a mandatory managed care population three openings: the initial three months of plan enrollment, an open enrollment month for their service area, and any time the request meets one of the rule's just cause reasons. A child in foster care has a fourth, any-time route, started by the children's services agency or court. Federal causes include poor quality of care and lack of access to covered services. Outside those openings, a change is not automatic.

Can family members be in different plans?

Yes. Under Ohio's rule, each Medicaid recipient selects or is assigned a plan individually. Many families pick the same plan for simplicity.

Do I lose managed care if I move into a nursing facility?

Usually, but not always, and the exception matters. OAC 5160-26-02 excludes nursing-facility residents from plan enrollment, so most members leave their plan. The rule carves out people covered in the adult extension (Medicaid expansion) category and two other groups it specifies, who stay in managed care. If you are an expansion-category adult, ask your county worker to confirm which side of that line you are on before you assume your plan is ending.

If I am a full-dual eligible, should I be in Next Gen or MyCare?

The choice is not yours to make in the way the question implies: OAC 5160-26-02 excludes people enrolled in both Medicaid and Medicare from Next Gen plan enrollment. Next Generation MyCare, Ohio's integrated program for most full-duals 21 and older, launched January 1, 2026, and ODM says it is now implemented across Ohio. See the MyCare Ohio guide for the county list and carriers.

Ohio Medicaid Consumer Hotline ODM's member contact point: questions about your coverage and help completing an application. A voluntary-enrollment member who requests disenrollment is disenrolled after notifying this hotline. 1-800-324-8680https://www.ecfr.gov/current/title-42/section-435.907 benefits.ohio.gov
OhioRISE (Aetna Better Health of Ohio) Behavioral health plan for youth with complex needs; member services (TTY: 711). 1-833-711-0773https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-A/section-438.56
Gainwell Single Pharmacy Benefit Manager Pharmacy claims and prescription-denial questions for Next Gen plan members. Since April 27, 2026, prescribers file prior authorizations through the Agadia PromptPA portal instead of the SPBM secure portal. 1-833-491-0344https://www.medicaid.gov/medicaid/spa/downloads/OH-26-0003.pdf spbm.medicaid.ohio.gov
ODJFS Bureau of State Hearings Receives and hears State Hearing requests for denied, reduced, or terminated services. Send the request form to PO Box 182825, Columbus, Ohio 43218-2825, or fax (614) 728-9574. Call the toll-free line if you need to take part in the hearing by telephone, or if your services changed without written notice and you want to ask whether you should be getting continuing benefits. 1-866-635-3748https://www.ecfr.gov/current/title-42/section-431.221
Free Legal Help Ohio's legal-aid network, Pro Seniors, and Disability Rights Ohio represent low-income Ohioans on Medicaid appeals. www.ohiolegalhelp.org

Learn More

MedicaidOhio Next Gen MyCareMyCare Ohio changed in 2026. Here is how Next Generation MyCare works: the four carriers, the phased statewide rollout, who can enroll, and how to act. MedicaidOhio MyCare Ohio WaiverHow the MyCare Ohio Waiver works in 2026: OAC 5160-58 authority, the four FIDE-SNP carriers, passive enrollment, integrated HCBS, and two-stage appeals. MedicaidOhio Medicaid Eligibility & Income LimitsOhio Medicaid 2026 income and asset limits across the MAGI, ABD, and long-term-care pathways: the $2,982 income cap, the $2,000 asset limit, and Miller Trusts. MedicaidHow to Apply for Ohio MedicaidHow to apply for Ohio Medicaid: the application channels, form ODM 07216, the 60-month look-back, processing timelines, retroactive coverage, and how to appeal. MedicaidOhio HCBS WaiversEvery Ohio Medicaid HCBS waiver: PASSPORT, the Assisted Living Waiver, the Ohio Home Care Waiver, MyCare Ohio, and the DODD waivers (IO, Level One, SELF). MedicaidOhio Medicaid Programs OverviewOhio Medicaid in 2026: eligibility pathways and income limits, HCBS waivers, the Next Gen MyCare transition, estate recovery, and how to apply, explained.

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.

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