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 statewide, routes every prescription through one pharmacy 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. The long-term-care population (nursing facility, Home and Community-Based Services waivers, and MyCare Ohio duals) is served through different programs, not standard managed care.1
• Seven plans serve the general Medicaid population statewide. 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. Every plan operates statewide, and you can choose any plan in any county.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 stays in a Next Gen plan for physical health.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
• Enrollment is mostly passive, but you have choice. After Medicaid approval, the Ohio Medicaid Consumer Hotline at 1-800-324-8680 assigns you a plan if you do not pick one. You can switch for any reason within your first 90 days and again 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

The long-term-care population sits outside standard managed care. Nursing-facility long-stay care, PASSPORT, the Assisted Living Waiver, the Ohio Home Care Waiver, and developmental-disability waivers run through separate pathways, and full-dual eligibles in the MyCare demonstration counties get their long-term services through MyCare Ohio plans instead.

The Seven Ohio Medicaid Managed Care Plans

All seven Next Gen plans operate statewide, and you can pick any plan in any county. Every plan covers the same core Medicaid benefit package for non-long-term-care members; the real differences are in provider network, supplemental benefits, and member service. The table below lists each plan's parent company and published Member Services line so you can compare side by side. Confirm the current number on your member ID card or through the Ohio Medicaid Consumer Hotline, since plan phone lines change.1

Because Ohio uses centralized provider credentialing, most providers are credentialed once for all seven plans at the same time. What still differs plan to plan is contracting, that is, whether a given plan has signed that provider to its network. So the practical question when you choose is not "is my doctor credentialed" 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 have Ohio Medicaid, and stays enrolled in one of the seven Next Gen plans for physical health 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 Next Gen plan. Before OhioRISE, a child with complex needs could bounce between the managed care plan, county children's services, juvenile justice, and developmental-disability providers with no single accountable plan; OhioRISE consolidates that into one plan with one set of care coordinators.

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

Since October 2022, every Ohio Medicaid retail prescription has flowed through one Single Pharmacy Benefit Manager, Gainwell Technologies, rather than through each managed care plan. Gainwell processes all managed-care pharmacy claims through a single statewide portal using one Unified Preferred Drug List (UPDL), the formulary maintained by ODM's Pharmacy and Therapeutics (P&T) Committee. Gainwell also became the pharmacy benefit manager for Ohio Medicaid fee-for-service in July 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 one formulary applies to every plan, prior authorizations follow you if you change plans, and you can use any in-network pharmacy regardless of plan. 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.
• MyCare Ohio long-term care: full-dual eligibles in the MyCare demonstration counties get long-term services through MyCare plans.
• 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 directory, and the Consumer Hotline can check on a call.
2. Supplemental benefits. Plans compete on extras not required by the state contract, such as an over-the-counter allowance, added adult dental or vision, and healthy-rewards programs. These vary year to year, so pick the ones that match your household.
3. Care management. If you or a family member has complex needs, ask each plan how often a care manager checks in and how to reach one.
4. Confirm with the Hotline. Call 1-800-324-8680 to make your choice once you have compared.5

Each plan must also meet ODM's network-adequacy standards under OAC Chapter 5160-26, including time-and-distance limits and appointment-availability standards. If a plan cannot meet those standards in your county, it must arrange out-of-network care or transportation; you can request that by calling Member Services.

Continuity of Care When You Switch Plans

When you change plans or are newly enrolled, continuity-of-care protections keep care from stopping abruptly. Existing prior authorizations, ongoing pregnancy care, active cancer or transplant treatment, and residential behavioral-health placements can continue with your current providers for a transition period. To activate these protections, call your new plan's Member Services soon after enrollment and give the names of your providers and the services you are receiving; ask the plan for the exact length of each continuity window, since it depends on the 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 The plan must resolve a standard appeal within 30 calendar days, or a 72-hour expedited appeal when a delay would jeopardize your health, under 42 CFR 438.408.7

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

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).9 You request it through the Ohio Department of Job and Family Services (ODJFS) Bureau of State Hearings, which must receive your request within 90 days of the plan's resolution notice; to keep a reduced or terminated service running during the hearing, file within 15 days. You can call the Bureau of State Hearings at 1-866-635-3748, mail the request form that came with your notice, or file through the Ohio Benefits portal.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

Most Ohio Medicaid members in Next Gen managed care are not eligible for MyCare Ohio. 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 29 counties and is expanding statewide through August 1, 2026, with Anthem, CareSource, and Molina available statewide to new members.10

A few common transitions:

• Aging into Medicare on Next Gen: you keep Next Gen for Medicaid and add a separate Medicare plan; in MyCare counties you may also be offered MyCare enrollment.
• Needing long-term care: when a Next Gen member needs nursing-facility care or a major waiver, they leave Next Gen for the long-term-care pathway, often coordinated with a PASSPORT or Ohio Home Care Waiver case manager.
• Outside MyCare counties: full-dual eligibles usually stay in Next Gen for Medicaid and use Original Medicare or a Medicare Advantage plan for the Medicare side, coordinating the two themselves.

Cost-Sharing in Ohio Medicaid Managed Care

Ohio Medicaid charges minimal cost-sharing. Standard Medicaid has no monthly premium and no deductible, and any copays are nominal and capped by federal rule under 42 CFR part 447. Emergency, family-planning, pregnancy-related, and preventive services have no copay, and there is no copay for children, pregnant members, or members in nursing facilities or waivers. If a plan or provider bills you more than the allowed copay, decline the charge and call Member Services.11

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.