Ohio Medicaid Managed Care Plans (2026): Next Gen Plans, OhioRISE, Gainwell SPBM, Enrollment Rules

If you or your child have Ohio Medicaid and you are not in a Long-Term Care setting, you almost certainly belong to a managed care plan. The large majority of Ohio Medicaid members get their care through one of the Next Gen managed care plans rather than through fee-for-service Medicaid. Yet most members never learn how the system was rebuilt under the Next Generation Ohio Medicaid program, why one company handles every prescription regardless of plan, why behavioral-health crises get routed to a separate plan called OhioRISE, or what you can actually do if a plan denies care.

This guide walks through every operational piece of Ohio's Next Gen Medicaid managed care landscape: the contracted plans, the dedicated behavioral-health plan for kids and youth with high needs, the statewide Single Pharmacy Benefit Manager, the Centralized Credentialing System for providers, how enrollment actually happens for new Medicaid members, what is covered through the plan versus carved out to fee-for-service, and the appeals path that runs from the plan to the Bureau of State Hearings.

By Brevy Care Team · Last verified May 11, 2026

Why Ohio Uses Managed Care

Ohio's heavy reliance on managed care is a deliberate policy choice that took its current form when the Ohio Department of Medicaid (ODM) launched the Next Generation Ohio Medicaid program. Three goals drive it:

1. Cost predictability. ODM pays plans a per-member-per-month (PMPM) capitated rate, which protects the General Revenue Fund from utilization spikes and shifts most insurance risk to plans.
2. Care coordination at scale. A managed care plan is a single accountable entity for HEDIS quality measures, care management, behavioral-health integration with OhioRISE, and member-experience metrics tied to autoassignment.
3. Provider experience. Next Gen consolidated credentialing, claims processing standards, and a single pharmacy benefit so that a provider does not have to learn separate sets of plan rules.

The federal authorities underlying the program are layered: the federal Medicaid managed-care statute, Ohio's managed-care OAC chapter on codes.ohio.gov, and the contracts ODM holds with each plan. The OhioRISE behavioral-health plan operates under a separate combination waiver authority. The MyCare Ohio program for full-dual eligibles operates under yet another set of waivers (see the MyCare Ohio guide).

ODM describes its Next Gen strategy as "moving from a transactional Medicaid program to a personalized care experience that focuses on the individual," a phrase that essentially means more wraparound services, more provider integration, and more accountability for plan quality.

The Next Gen Background

Ohio Medicaid managed care has been in place for many years, and the modern Next Gen program is the result of a multi-year rebuild. ODM ran a procurement, selected Next Gen plans and a separate OhioRISE carrier, brought up the statewide pharmacy benefit and OhioRISE, and went live with Next Gen managed care for the broader Medicaid population. ODM later added another Next Gen carrier to expand member choice. The Next Gen plan menu, OhioRISE for high-acuity youth behavioral health, and MyCare for full-dual eligibles in the demonstration counties together make up the current managed-care landscape. Verify the current plan list and any recent additions/exits with ODM.

The Next Gen launch was a substantial reshaping of Ohio Medicaid. A large share of members were transitioned from the prior carrier landscape to the new architecture; members were moved to their existing plan whenever possible, with ODM and the Consumer Hotline managing the rest.

The Next Gen Managed Care Plans

The Next Gen plans operate statewide. You can pick any plan in any county. Each plan covers the full Medicaid benefit package for non-LTC members, with the same core services across plans; differences are in provider network composition, supplemental benefits, care management programs, and customer service experience.

Anthem Blue Cross and Blue Shield (Elevance)

Statewide. Member Services 1-844-912-1226. Anthem operates one of the broadest physical-health provider networks in Ohio, with strong tie-ins to OhioHealth, Premier Health, and Mercy Health. Anthem also operates a MyCare Ohio carrier under a separate contract (see the MyCare carrier list). Parent company is Elevance Health.

AmeriHealth Caritas Ohio

Statewide. Member Services 1-833-764-7700. AmeriHealth Caritas is one of the Next Gen entrants that had not previously operated in Ohio Medicaid. Parent company runs Medicaid plans in many states. AmeriHealth has invested heavily in maternal-health programs and community-health-worker integration.

Buckeye Health Plan (Centene)

Statewide. Member Services 1-866-246-4358. Buckeye has long been one of the larger Ohio Medicaid plans by membership. Parent company Centene also operates Wellcare for Medicare Advantage. Buckeye exited the MyCare market but remains a major Next Gen plan; verify current MyCare carrier participation with ODM.

CareSource

Statewide. Member Services 1-800-488-0134. CareSource is one of the largest Ohio Medicaid plans by membership and is an Ohio-headquartered nonprofit plan in the Next Gen lineup. It is based in Dayton and operates Medicaid plans in several other states. CareSource also continues as a MyCare Ohio carrier; verify current status with ODM.

Humana Healthy Horizons in Ohio

Statewide. Member Services 1-877-856-5707. Humana is the most recent Next Gen plan addition. It was added by ODM to expand member choice and to introduce a national plan with strong Medicare Advantage operations into the Medicaid market. Humana is one of the largest D-SNP operators nationally, which positions it well for members who age into Medicare.

Molina HealthCare of Ohio

Statewide. Member Services 1-800-642-4168. Molina has been in Ohio Medicaid for many years and continues to operate both Next Gen managed care and MyCare Ohio; verify current participation with ODM. Molina has a strong dual-eligible specialty focus and operates D-SNPs in multiple Ohio counties.

UnitedHealthcare Community Plan of Ohio

Statewide. Member Services 1-800-895-2017. UnitedHealthcare Community Plan continues as a Next Gen plan even after UnitedHealthcare exited the MyCare Ohio market. Parent company UnitedHealth Group is one of the largest Medicare Advantage operators nationally, which means a UnitedHealthcare Community Plan member often has a smooth path into a UnitedHealthcare D-SNP if they become full-dual eligible.

OhioRISE: The Separate Behavioral-Health Plan for Youth With High Needs

Ohio's most distinctive Next Gen design choice was carving out high-acuity youth behavioral health into a separate plan, OhioRISE, operated by Aetna Better Health of Ohio.

What OhioRISE Is

OhioRISE (Resilience through Integrated Systems and Excellence) is a managed care plan dedicated to children, youth, and young adults up to the program's age threshold who have complex behavioral-health needs. It is not a stand-alone Medicaid program; OhioRISE members must also be enrolled in Ohio Medicaid. A child in OhioRISE remains in one of the Next Gen plans for physical health.

Who Qualifies for OhioRISE

A youth qualifies if they meet the OhioRISE eligibility criteria, which include:

• Currently receiving intensive behavioral-health services (residential treatment, partial hospitalization, intensive home-based treatment, or multi-system involvement)
• Recently used inpatient or residential psychiatric care
• Have a CANS (Child and Adolescent Needs and Strengths) assessment score indicating intensive services are needed
• Are at risk of out-of-home placement due to behavioral-health needs

The CANS assessment is administered by Care Management Entities (CMEs) under contract with Aetna Better Health of Ohio. A primary care provider, school counselor, or family can request an OhioRISE eligibility assessment through 1-833-711-0773.

What OhioRISE Covers

OhioRISE covers the full continuum of intensive behavioral-health services, including:

• Intensive Home-Based Treatment (IHBT)
• Multi-Systemic Therapy (MST) and Functional Family Therapy (FFT)
• Behavioral Health Respite
• Psychiatric Residential Treatment Facility (PRTF) services
• Mobile Response and Stabilization Services (MRSS) for crisis
• Care coordination through Care Management Entities

Routine outpatient behavioral health (regular therapy and medication management for moderate needs) remains with the Next Gen plans. OhioRISE is the high-acuity plan.

Why the Carve-Out Matters

Before OhioRISE, kids with complex needs cycled between Medicaid managed care plans, county children's services boards, juvenile justice systems, and Department of Developmental Disabilities providers without any single accountable plan. OhioRISE consolidates that complexity into one plan with one set of care coordinators, so a family is not negotiating across five different systems for the same child.

For physical health and routine care, a youth in OhioRISE continues to use their Next Gen plan as usual; OhioRISE pays for the intensive behavioral-health services on top.

The Single Pharmacy Benefit Manager (SPBM)

Ohio's Single Pharmacy Benefit Manager is one of Next Gen's most consequential structural choices: every Ohio Medicaid prescription flows through one statewide formulary and one pharmacy benefit administrator, regardless of which managed care plan the member is in.

Why Ohio Created a Single PBM

Before the SPBM launched, each Medicaid managed care plan ran its own pharmacy benefit, which meant multiple formularies, multiple sets of prior-authorization rules, multiple preferred-drug lists, and multiple pharmacy reimbursement methods. Pharmacists could not predict which plan would approve which medication. Members switching plans often had to switch medications.

Ohio created the SPBM to solve those problems. The state contracted with Gainwell Technologies to operate one statewide pharmacy benefit, with one Unified Preferred Drug List (PDL), one set of clinical edits, and one set of prior-authorization procedures.

How the SPBM Works

• Administrator: Gainwell Technologies operates pharmacy claims processing.
• Prior authorization: Agadia PromptPA operates the statewide prior-authorization platform.
• Formulary: ODM maintains the Unified Preferred Drug List, updated quarterly by the Pharmacy and Therapeutics Committee.
• Pharmacy network: Most Ohio retail pharmacies participate. Member Services 1-833-491-0344.
• Member experience: A member can use any in-network pharmacy regardless of plan; prior authorizations follow the member if they change plans; medication continuity is preserved.

What Is Carved In vs Carved Out

The SPBM covers retail pharmacy (prescriptions filled at a pharmacy). Specialty drugs administered in a physician office or infusion center (J-code drugs billed under medical benefit) are still administered through the managed care plan, not the SPBM. Medicare Part D continues to be primary for dual eligibles, with Medicaid pharmacy wrap-around for non-Part-D-covered medications.

Centralized Credentialing

The Ohio Medicaid Enterprise System operates a Centralized Credentialing System, meaning a provider credentials once with Ohio Medicaid and is then credentialed for all Next Gen plans, OhioRISE, and the SPBM at the same time. Before Next Gen, each plan required its own credentialing paperwork.

For members, Centralized Credentialing has a practical effect: when a provider joins Ohio Medicaid, the provider is generally available for every Next Gen plan. Plan-network differences are mostly contracting differences (whether a plan has accepted the provider's contract terms), not credentialing differences.

Enrollment: How You End Up in a Plan

Ohio Medicaid managed care enrollment is mostly passive, but you have meaningful choice. Here is how it works in practice for a new Medicaid member.

Step 1: Get Approved for Medicaid

You apply through Ohio Benefits, by phone at 1-800-324-8680, or in person at your county Department of Job and Family Services (CDJFS). Once your application is approved and your Medicaid eligibility category is determined, you are mandatory for managed care unless you fall into an excluded population (LTC, MyCare-eligible duals in demonstration counties, dual-eligible in non-demonstration counties who decline managed care, or members in restricted eligibility categories).

Step 2: The Ohio Medicaid Consumer Hotline Assigns or Chooses

The Ohio Medicaid Consumer Hotline (1-800-324-8680) is the centralized choice-counseling vendor for Next Gen. The Hotline does three things at enrollment:

1. Sends a Choice Packet soon after Medicaid approval. The packet lists the Next Gen plans, basic differences, and instructions for choosing.
2. Gives the member a window to choose. If the member chooses, they are enrolled in the chosen plan.
3. Auto-assigns if the member does not choose. Auto-assignment uses an algorithm that considers prior plan history, family members' current plans, and a fair-share distribution rule across the Next Gen plans.

You can call the Hotline directly at 1-800-324-8680 to make a choice rather than waiting for the packet. The Hotline is the same entity for Next Gen plan choices, MyCare Ohio plan choices, and OhioRISE eligibility questions.

Step 3: Free Switching at Enrollment

After enrollment, you have a published free-switch window to switch plans for any reason. Call the Hotline; the switch takes effect the first of the following month.

Step 4: Annual Open Change Period

After the free-switch window closes, you can change plans during your annual Open Change Period (a published window around your enrollment anniversary), or for "just cause" reasons such as a provider leaving the network, a plan denying needed services, or quality-of-care concerns. The Hotline tells you whether your reason qualifies.

Coverage Effective Date

A plan change processed by the Hotline takes effect the first of the next month. If you call mid-month, your new plan starts the following month; you remain in your old plan for the rest of the current month.

What Is Covered Through the Plan vs Carved Out

Ohio Medicaid managed care covers a comprehensive benefit package, but several services are "carved out" to fee-for-service Medicaid or to other programs.

What Your Next Gen Plan Covers

• Primary and specialty physician services
• Hospital inpatient and outpatient care
• Emergency department visits
• Behavioral health (outpatient therapy, medication management, SUD treatment for routine needs)
• Maternity care
• EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) for kids
• Lab and imaging
• Durable medical equipment
• Medicaid home health under Ohio's home-health OAC chapter (skilled nursing, home health aide, therapy on a short-term/acute basis)
• Dental and vision (within Medicaid scope)
• Non-emergency medical transportation (NEMT) coordination
• Care management

What Is Carved Out to Fee-for-Service or Other Programs

• Long-Term Services and Supports (LTSS): Nursing facility long-stay care, PASSPORT, Assisted Living Waiver, Ohio Home Care Waiver, DODD waivers (IO, Level One, SELF) all run through fee-for-service Medicaid or through different programs.
• MyCare Ohio LTSS: Full-dual eligibles in the MyCare demonstration counties get LTSS through MyCare carriers, not through standard Next Gen plans.
• High-acuity youth behavioral health: OhioRISE (Aetna Better Health of Ohio).
• Retail pharmacy: Gainwell SPBM (not the Next Gen plan).
• County-administered services: Children's services, child welfare placement, and certain juvenile-justice involvement remain with county boards.

This means the Next Gen plan is your primary coordinator for acute and routine care, but it is not the right place to call for LTC placement, HCBS waiver enrollment, or DODD services.

How Plans Differ (And How to Choose)

All Next Gen plans cover the same core Medicaid benefit package. Real differences are in provider network composition, supplemental benefits, care management programs, and customer service.

Provider Network Match

The single most important factor for most members. Before choosing a plan, check whether your primary care provider, your child's pediatrician, your behavioral-health provider, and your hospital of choice are all in the plan's network. Each plan publishes a provider directory online; the Hotline can also check on a call.

Supplemental Benefits

Plans compete on supplemental benefits not required by the state contract. These vary year to year and may include:

• Over-the-counter (OTC) benefit allowance
• Dental services beyond the Medicaid scope (some plans add adult dental beyond what ODM requires)
• Vision allowance for frames
• Healthy-rewards programs for preventive screenings, vaccines, prenatal care
• Telehealth-first specialty consultations
• Member-services concierge for complex cases

Care Management Programs

Each plan operates care management for members with complex needs. Plan-level care management is automatic for members with high utilization, multiple chronic conditions, or high-risk pregnancy. If you have complex needs, ask the plan how often a care manager will check in and how to reach them.

Customer Service Experience

The Hotline publishes annual member-experience scores for each plan. ODM also uses CAHPS member-experience surveys. Plans that score poorly on member experience face autoassignment penalties; ODM autoassigns fewer new members to plans with low scores.

A Practical Decision Rubric

1. Pull the provider directory for each plan; check whether your providers are in network.
2. Look at supplemental benefits; pick the ones that match your household's needs (kids → check dental and vision; adult → check OTC and behavioral-health network).
3. Call Member Services for the top two plans and ask a real question (a prior-authorization question, a member-card question, a specialty-referral question). The plan with the better answer is usually the right plan.
4. Confirm with the Hotline at 1-800-324-8680 before choosing.

Provider Network Adequacy Rules

ODM requires each Next Gen plan to meet network-adequacy standards under Ohio's managed-care OAC chapter on codes.ohio.gov. The core standards include:

• Time and distance: Primary care within published travel-time and travel-distance limits, with separate standards for specialty care, behavioral health, hospitals, and pharmacies, and looser limits for rural counties.
• Provider-to-member ratios: Minimum ratios for primary care, behavioral health, and specialty care.
• Appointment availability: Published standards for urgent care, routine care, and preventive care.

If a plan does not meet network-adequacy standards in your county, the plan must arrange single-case agreements with out-of-network providers, pay out-of-network rates, or provide transportation to a network provider. You can request out-of-network coverage by calling Member Services.

Continuity of Care

When you change plans (or are newly enrolled), you have continuity-of-care protections so that care does not abruptly stop.

What Continuity of Care Covers

• Existing prior authorizations for the same services continue for the published continuity window with the new plan
• Existing pregnancy care continues with the existing OB provider through the postpartum period
• Existing transplant evaluations, oncology treatment, and serious-illness care continue with the existing providers for an extended continuity window
• Existing residential behavioral-health placements continue with the existing facility for the published continuity window

To activate continuity-of-care protections, call your new plan's Member Services soon after enrollment and provide the names of your providers and the services you are receiving.

Appeals: Plan-Level 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 pathway.

Stage 1: Plan-Level Appeal

• Deadline: the published plan-appeal filing window from the Adverse Benefit Determination notice.
• How to file: Call the plan's Member Services and ask for an appeal. The plan must accept the appeal verbally; written confirmation usually follows.
• Resolution timeline: Standard appeals within the published resolution window; expedited appeals (when delay would jeopardize health) within the published expedited window.
• Aid pending: If you file within the published aid-pending window and the service was previously authorized, the service continues during the appeal.

Stage 2: State Hearing

If the plan upholds its denial, you can request a State Hearing under Ohio's state-hearings OAC rule on codes.ohio.gov.

• Deadline: the published State Hearing filing window from the plan's resolution notice.
• How to file: Call the Bureau of State Hearings at 1-866-635-3748, mail a request, file through the Ohio Benefits portal, or visit your county CDJFS.
• Aid pending: within the published aid-pending window from the plan's resolution notice for terminations and reductions of previously authorized services.
• Hearing: Conducted by a State Hearing Officer at the Ohio Department of Job and Family Services. Free legal representation is available through Pro Seniors (Cincinnati), Ohio Legal Aid (statewide network), and Disability Rights Ohio.
• Decision: Binding on both the plan and ODM. Either party can request administrative review within the published filing window.

Federal Appeal (Last Resort)

If the State Hearing decision is adverse, you can request federal review through CMS. This is rare and typically used by advocacy attorneys.

How Managed Care Relates to MyCare Ohio

Most Ohio Medicaid members in Next Gen managed care are not eligible for MyCare Ohio. MyCare is specifically for full-dual eligibles (Medicare + Medicaid) in the MyCare demonstration counties.

When Members Move Between Programs

• Aging into Medicare while on Next Gen: When a member with Medicaid becomes Medicare-eligible (by age or on disability), they keep Next Gen for Medicaid and add a separate Medicare plan. In MyCare counties, they may also be offered MyCare enrollment.
• MyCare disenrollment: A member who leaves MyCare (by opting out of the Medicaid side or by moving out of a MyCare county) returns to Next Gen for the Medicaid portion of their coverage.
• LTSS need: When a Next Gen member needs nursing facility care or a major HCBS waiver, they transition out of Next Gen and into fee-for-service Medicaid for LTSS, often coordinated with a PASSPORT or OHCW case manager.

Why Most Full Duals Outside MyCare Counties Stay in Next Gen

Outside the MyCare demonstration counties, full-dual eligibles do not have access to integrated MyCare plans. They typically keep Next Gen for the Medicaid side and use a Medicare Advantage D-SNP or Original Medicare for the Medicare side. Coverage coordination is the member's responsibility.

Common Operational Mistakes

1. Assuming managed care covers LTSS. Nursing facility long-stay, PASSPORT, AL Waiver, OHCW, and DODD waivers are not managed care benefits.
2. Choosing a plan without checking provider networks. Plans differ in network composition; the wrong choice can force a member to switch providers.
3. Missing the free-switch window. After the published free-switch window closes, you need just-cause or the annual Open Change Period.
4. Calling the plan for OhioRISE-eligible behavioral-health needs. High-acuity youth behavioral health goes through OhioRISE, not the Next Gen plan.
5. Calling the plan for a prescription denial. Prescription denials go through the SPBM (Gainwell), not the Next Gen plan.
6. Skipping the continuity-of-care call. New plan members who do not call to activate continuity protections often see prior authorizations lapse.
7. Letting the plan-appeal window pass. The State Hearing window starts after the plan's resolution notice, but the plan-level appeal must come first.
8. Confusing Next Gen with MyCare Ohio. Different programs, different eligibility populations, different carriers.
9. Confusing plan network adequacy with credentialing. Centralized Credentialing means most providers are credentialed for all plans, but plans still differ in which providers they have contracted with.

Cost-Sharing in Ohio Medicaid Managed Care

Ohio Medicaid charges minimal cost-sharing for managed care members. Most members have:

• No premium. Standard Medicaid has no monthly premium (the Medicaid Buy-In for Workers with Disabilities (MBIWD) is a separate program and is not standard Medicaid managed care).
• No deductible.
• Nominal copays. Some services may have a small published copay; emergency services, family planning, pregnancy-related care, and preventive care have no copay. Total cost-sharing is capped by federal rule.
• No copay for children, pregnant women, or members in nursing facilities or HCBS waivers.

If a plan or provider asks you to pay more than the allowed copay, refuse the charge and call Member Services. Cost-sharing rules are enforced by the plan and ODM.

How to Read a Plan's Member Materials

When you get a Plan Member Handbook (every plan must send one promptly after enrollment), look for:

• PCP assignment. The handbook lists your assigned PCP; you can change to any in-network PCP at any time.
• Prior authorization rules. Lists services that require prior auth.
• Pharmacy benefit. Should direct you to the SPBM (Gainwell) for pharmacy.
• Member ID card. Lists Member ID, plan name, RxBIN/RxPCN for pharmacy (these are SPBM identifiers, the same across plans).
• Appeals and grievances. Plan-level appeal procedures.
• Continuity of care. How to request continuity protections.
• Care management. How to request a care manager.

A few more common questions families ask:

Can I have different Next Gen plans for different family members? Yes. Each Medicaid-eligible family member chooses individually. Many families choose the same plan for simplicity, but it is not required.

Do I lose managed care if I move into a nursing facility? Yes. Long-stay nursing facility care is fee-for-service Medicaid and is not paid through Next Gen plans. Your CDJFS coordinates the transition with the facility.

What is the difference between a plan denial and an SPBM denial? A plan denial is for a service the Next Gen plan administers (physician services, hospital care, durable medical equipment, plan-administered behavioral health). An SPBM denial is for a retail prescription. Different appeal pathways.

Who handles non-emergency medical transportation (NEMT)? Each Next Gen plan administers NEMT for its members. Call your plan's Member Services to schedule. Counties also administer some NEMT services for non-managed-care members.

Can I see an out-of-network provider? For emergency services, yes, with no penalty. For routine care, generally no unless the plan does not have an adequate network and you request out-of-network coverage. The plan must arrange a single-case agreement or transportation to a network provider if it cannot meet network adequacy.

Last verified May 2026. Ohio's Next Gen Medicaid managed care program, OhioRISE behavioral-health plan, the Gainwell Single Pharmacy Benefit Manager, and the MyCare Ohio demonstration are administered by the Ohio Department of Medicaid (ODM). Plan offerings, network composition, and supplemental benefits change at least annually. Verify with the Ohio Medicaid Consumer Hotline at 1-800-324-8680 before making coverage decisions. This article is for general information and does not constitute legal, financial, or medical advice.

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