MyCare Ohio Waiver (2026): FIDE-SNP Carriers, Enrollment, and Appeals

If you have both Medicare and Medicaid in Ohio and live in a MyCare county, the MyCare Ohio Waiver folds both coverages into one managed care plan with a single care coordinator. That plan includes long-term services and supports, and it absorbs the PASSPORT Waiver and the Ohio Home Care Waiver for full-dual eligibles enrolled in MyCare. This guide explains how the waiver works in 2026: who is eligible, how to choose a plan during enrollment, and how to appeal a denial, all under the Next Generation MyCare expansion that reaches all 88 Ohio counties by August 1, 2026.

Key Takeaways

• The MyCare Ohio Waiver operates under OAC Chapter 5160-58 and is a §1915(b)(c) combination waiver authorized by 42 USC 1396n(b) (managed care) and 42 USC 1396n(c) (home and community-based services). It blends federal authority for both managed-care delivery and HCBS into a single integrated program.
• MyCare requires full-dual eligibility, which means simultaneous enrollment in Medicare (Part A and Part B at minimum, often plus Part D) and Ohio Medicaid. Medicaid-only beneficiaries do not enroll in MyCare; they remain in standard Ohio Medicaid managed care or fee-for-service depending on their service needs.
• Four carriers contract with the Ohio Department of Medicaid to operate Next Generation MyCare Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs) for Plan Year 2026: Anthem Blue Cross and Blue Shield (a new entrant, statewide for new enrollees), CareSource, Molina Healthcare of Ohio, and Buckeye Health Plan (now Wellcare Buckeye MyCare Ohio Dual Align HMO D-SNP, which is closed to new enrollees for PY2026 and not available in Belmont or Ashtabula counties). Aetna Better Health of Ohio and UnitedHealthcare Community Plan of Ohio exited Next Generation MyCare effective December 31, 2025 and no longer offer a MyCare plan. Each carrier has its own provider network, drug formulary, and care coordination model.1
• MyCare absorbs PASSPORT and the Ohio Home Care Waiver services for dual eligibles under OAC 5160-58-04. HCBS services continue, but service delivery moves from the Area Agency on Aging or ODM waiver structure to the carrier's care coordination structure.
• Enrollment can be passive (auto-enrollment) or voluntary. Eligible dual eligibles who do not actively choose a MyCare plan are auto-assigned to a carrier and have an opt-out window. The opt-out rules differ for the Medicare side and the Medicaid side, and getting them right is one of the most consequential decisions a dual-eligible family makes.
• The MyCare county footprint is expanding through Next Generation MyCare, Ohio's transition from the original CMS Medicare-Medicaid Plan demonstration (May 2014 through December 31, 2025) to a FIDE-SNP architecture that launched January 1, 2026 (Phase 1, 29 counties) and rolls out statewide in phases reaching all 88 counties by August 1, 2026. See /medicaid/ohio/next-gen-mycare for the program-level rollout detail.
• Care coordination is the defining feature of MyCare. Every enrollee has a designated care coordinator employed by the carrier, who builds the person-centered service plan, authorizes HCBS services, coordinates Medicare-side benefits, manages transitions of care, and serves as the day-to-day point of contact across both coverages.
• Appeals are integrated, then run in two stages. Because Next Generation MyCare uses Exclusively Aligned Enrollment, the carrier runs one integrated plan-level appeal for overlapping Medicare and Medicaid benefits under the Applicable Integrated Plan rules (42 CFR 422.629 through 422.634). If the plan upholds a denial of a Medicaid-funded benefit, the enrollee can request a State Hearing through the Ohio Department of Job and Family Services Bureau of State Hearings at 1-866-635-3748, and can keep services in place during the hearing by filing in time.

Why does the MyCare Ohio Waiver exist?

Before MyCare launched in May 2014, dual eligibles in Ohio navigated two completely separate programs that did not coordinate with each other. Medicare covered acute and post-acute medical care, hospital stays, physician visits, durable medical equipment, and short-term skilled-nursing or home health for medically eligible recoveries. Medicaid covered long-term services and supports (LTSS), waiver-based home and community-based services, nursing facility care for long-stay residents, Medicaid drug coverage, and the wraparound benefits that fill Medicare's coverage gaps. The two systems used different providers, different prior authorization rules, different formularies, different appeal pipelines, and different case management. A dual-eligible person with a complex chronic condition might have a Medicare Part D plan, a Medicaid waiver case manager at the Area Agency on Aging, a Medicare Advantage primary care provider, a Medicaid home health agency, and a Medicare home health agency, with none of them talking to each other.

The result was fragmentation. Care fell through the cracks at every transition. Medicare-paid hospital stays would end without a smooth handoff to Medicaid-paid HCBS. Medicare home health (under 42 CFR Part 484) would terminate and the Medicaid PASSPORT case manager would scramble to authorize personal care. Drug coverage disputes between Medicare Part D and Medicaid wraparound left families paying out of pocket. Care plans were duplicated, contradictory, or absent. For a population that disproportionately uses both acute and long-term services, the fragmentation drove avoidable hospitalizations, premature institutionalization, and poor quality of life.

MyCare Ohio was designed to fix that fragmentation by putting the entire Medicare-plus-Medicaid benefit package into a single carrier and giving every enrollee a single care coordinator with authority across both programs. The state secured a §1915(b)(c) combination waiver from CMS in 2013, ran the program from May 2014 through December 2025 as a federal Medicare-Medicaid Plan demonstration under the Financial Alignment Initiative, and on January 1, 2026 transitioned to a Fully Integrated Dual Eligible Special Needs Plan architecture under 42 CFR 422.2 (FIDE-SNP definition) and 42 CFR 422.514(h) (Exclusively Aligned Enrollment). The state authority for the Medicaid side is OAC Chapter 5160-58, and that is the waiver this article walks through.

For the program-rollout history and the transition mechanics of moving from the MMP demonstration to FIDE-SNP, see the companion piece at /medicaid/ohio/next-gen-mycare. This article focuses on how the MyCare Waiver itself operates: eligibility, enrollment, services, care coordination, prior authorization, appeals, and the relationships to the underlying waivers it absorbs.

Who is eligible for MyCare

MyCare eligibility requires three things, all of which must be true at the same time. Under Next Generation MyCare, an enrollee must also be age 21 or older, a threshold raised from the original MMP demonstration's 18-and-over rule.1

First, full-dual eligibility. An enrollee must be simultaneously enrolled in Medicare and Ohio Medicaid. Medicare enrollment includes Part A (hospital), Part B (medical), and, in the FIDE-SNP architecture, the MyCare plan provides Part D (prescription drug) coverage as well. Ohio Medicaid enrollment must be in a category that qualifies for MyCare, which generally means full-benefit Medicaid (not partial-benefit categories like Qualified Medicare Beneficiary-only). Partial duals who only qualify for Medicare Savings Programs without full Medicaid do not enroll in MyCare; they remain in fee-for-service Medicare with Medicaid paying their premiums and cost-sharing per 42 USC 1396a(a)(10)(E).

Second, residence in a MyCare county. MyCare does not operate statewide. The original 2014 footprint covered 29 counties organized into seven regions: the Northeast Region around Cleveland, the Northeast Central Region around Akron and Canton, the Northwest Region around Toledo, the West Central Region around Dayton, the Central Region around Columbus, the East Central Region around Mansfield, and the Southwest Region around Cincinnati. The Next Generation MyCare expansion adds counties in phases across 2026, reaching statewide coverage of all 88 counties by August 1, 2026. Whether a particular county is in MyCare in 2026 depends on the rollout phase; the Ohio Department of Medicaid maintains the authoritative current county list. Dual eligibles who live outside MyCare counties get their Medicare and Medicaid through separate plans and remain eligible for PASSPORT or the Ohio Home Care Waiver on the standard non-MyCare track.

Third, the underlying Medicaid eligibility that qualifies someone for full Medicaid in the first place. This typically means meeting Ohio's Medicaid financial eligibility. For the institutional and HCBS-waiver categories that align with MyCare's HCBS-eligible enrollees, Ohio uses the Special Income Level set at 300% of the Supplemental Security Income (SSI) Federal Benefit Rate, which is $2,982 per month for a single applicant in 2026; other dual eligibles qualify through one of the categorical pathways for the broader dual-eligible population. Clinical eligibility applies on top of the financial test if the enrollee is receiving home and community-based services through the MyCare absorption of PASSPORT or the Ohio Home Care Waiver.2 That clinical eligibility for HCBS continues to flow through the same Adult Comprehensive Assessment Tool (ACAT) process administered by Area Agencies on Aging that operates outside MyCare; the carrier's care coordinator then takes over service plan execution.

There are several populations who are technically dual-eligible but specifically excluded from MyCare or treated under special rules. People enrolled in a Program of All-Inclusive Care for the Elderly (PACE) program do not enroll in MyCare because PACE itself is a fully-integrated managed care model that already coordinates Medicare and Medicaid. People with end-stage renal disease (ESRD) who became Medicare-eligible specifically through ESRD have historically had limited MyCare enrollment, though FIDE-SNP rules under 42 CFR 422.514 have evolved on this point; check with the Ohio Medicaid Consumer Hotline at 1-800-324-8680 for current rules. People in nursing facility long-stay status who entered before MyCare county phase-in can sometimes be carved into MyCare and sometimes continue under FFS Medicaid plus a Medicare Advantage or Original Medicare arrangement; the rules depend on rollout phase and individual circumstances.

The combination of Medicare + Medicaid + MyCare county residence is what triggers MyCare enrollment. Drop any of the three and the person is in a different program structure entirely.

How enrollment actually happens

MyCare uses a hybrid enrollment model that includes both passive enrollment and active enrollment. Under Next Generation MyCare, current Medicare-Medicaid Plan members were moved into the FIDE-SNP plans as the program rolled out across Ohio from January 1 through August 1, 2026, while newly eligible duals are auto-assigned to one of the participating carriers. The mechanics are different on the Medicare side and the Medicaid side, and the most common family confusion is misunderstanding which side they have actually enrolled in or opted out of.1

Passive (auto) enrollment. When someone in a MyCare county becomes newly dual-eligible, ODM identifies them and assigns them to a MyCare carrier through an auto-assignment algorithm. The assignment is based on factors like which carrier the person has a prior relationship with, geographic provider network match, family member alignment with the same carrier, and load balancing across carriers. The state sends written notice with the assigned carrier, the effective date (typically the first of the month following the assignment), and instructions for changing plans or opting out. For the Medicaid side, passive enrollment becomes effective on the date stated in the notice unless the person actively opts out within the opt-out window. For the Medicare side, passive enrollment into the Medicare-Medicaid Plan or FIDE-SNP is also possible, but federal Medicare rules require additional notice and a longer opt-out window.

Active (voluntary) enrollment. A dual eligible can also actively choose their MyCare plan. They can call the Ohio Medicaid Consumer Hotline at 1-800-324-8680, work with their AAA case manager, contact the carrier directly, or use Medicare's online plan selection at medicare.gov. Active enrollment lets the family compare carriers based on provider networks, formularies, care coordination quality, supplemental benefits, and reputation. Active enrollment is almost always better than passive enrollment because the family makes a deliberate choice instead of accepting an auto-assignment that may not match their actual provider relationships.

Plan switching. Once enrolled, an enrollee can switch MyCare carriers. The Medicaid side allows switching monthly (effective the first of the following month). The Medicare side under FIDE-SNP follows special enrollment period rules under 42 CFR 422.62, which generally allow dual eligibles to switch monthly as well, though specific election periods apply. The Medicare-side rules for FIDE-SNP are more flexible than standard Medicare Advantage enrollment, reflecting the recognition that dual eligibles need stability options.

Opt-out. A dual eligible can decline MyCare entirely and remain in fee-for-service Medicare (or a non-MyCare Medicare Advantage plan) plus fee-for-service Medicaid (or standard Ohio Medicaid managed care for the non-LTSS portions of Medicaid). The Medicaid opt-out is generally not available for the LTSS portion if the person is receiving PASSPORT or OHCW services in a MyCare county; the Medicaid waiver delivery becomes the MyCare plan rather than the AAA, even if the Medicare side is opted out. This asymmetry confuses families: opting out of MyCare on the Medicare side does not opt them out of the Medicaid-side waiver absorption. The Medicaid opt-out for the entire MyCare structure is available in narrower circumstances, typically when MyCare is not appropriate (such as PACE enrollment) or when the person is choosing to receive their Medicaid through FFS rather than managed care under exception criteria.

Practical implication. Families navigating MyCare enrollment for a newly-eligible dual should treat the auto-assignment letter as a starting point, not a final decision. Reach out to the AAA case manager (if PASSPORT or OHCW is in play), call the Ohio Medicaid Consumer Hotline at 1-800-324-8680 for plan comparison, check each carrier's provider directory for the primary care provider and specialists the person already sees, compare drug formularies for Medicare Part D coverage, and then make an active choice within the opt-out window. The default assignment is rarely the best fit.

Which carriers offer MyCare in 2026?

Four carriers contract with ODM to operate MyCare FIDE-SNP plans for Plan Year 2026. Three of them (Anthem Blue Cross and Blue Shield, CareSource, and Molina Healthcare of Ohio) are available statewide to new members, subject to network adequacy in expansion counties. The fourth, Buckeye Health Plan, is not an option for new members in plan year 2026. Aetna Better Health of Ohio and UnitedHealthcare Community Plan are no longer MyCare Ohio plans as of December 31, 2025.1

Each carrier sets its own provider network, drug formulary, and care coordination model, and all four must meet federal FIDE-SNP standards and Ohio's MyCare contract requirements, so baseline quality is regulated even though operational reality varies. To reach a carrier, use the member-services number printed on your plan ID card or the plan-finder on each carrier's website above; the Ohio Medicaid Consumer Hotline at 1-800-324-8680 can confirm which plans are open in your county. Choose the carrier whose network includes your current providers, whose formulary covers your prescriptions on preferred tiers, that operates well in your county, and that is strong in the service line you need most, whether that is skilled nursing facility transitions, behavioral health, complex disability, dementia care, or end-stage organ disease.

What does MyCare cover?

The defining feature of the MyCare benefit package is that it integrates everything an enrollee gets from Medicare and Medicaid into a single plan. As a Fully Integrated Dual Eligible Special Needs Plan under 42 CFR 422.2, each carrier holds both a Medicare Advantage contract with CMS and a Medicaid managed-care contract with the state, so one plan delivers both programs' benefits. That includes:1

Medicare-side benefits. Hospital inpatient care (Part A), skilled nursing facility short stays (Part A covers up to 100 days per benefit period when the skilled-care criteria are met, under 42 CFR 409.61), home health services for qualifying recoveries (Part A and Part B, under 42 CFR Part 484), hospice (Part A), physician and outpatient services (Part B), durable medical equipment (Part B), preventive services (Part B), mental and behavioral health (Part B), and prescription drugs (Part D, embedded in the FIDE-SNP).

Medicaid wraparound. Cost-sharing assistance (Medicaid pays Medicare premiums, copays, and coinsurance per 42 USC 1396a(a)(10)(E)), dental, vision, hearing, transportation to medical appointments (Non-Emergency Medical Transportation), and Medicaid-only drug coverage for any medications that Medicare Part D excludes.

Long-term services and supports. For enrollees who meet the nursing facility level of care, MyCare delivers home and community-based services that absorb the PASSPORT Waiver benefit package (for enrollees age 60+) or the Ohio Home Care Waiver benefit package (for enrollees age 18-59 with disability). This is the OAC 5160-58-04 service continuation. For enrollees in long-stay nursing facility status, MyCare covers the institutional Medicaid benefit (NF custodial care after the Medicare 100-day SNF benefit exhausts). For enrollees in licensed Residential Care Facilities under the Assisted Living Waiver, the integration with MyCare follows specific rules that the carrier and AAA coordinate.

Behavioral health. Inpatient psychiatric, outpatient mental health, substance use disorder treatment, community-based behavioral health services, and crisis services are all integrated into the MyCare benefit. This is a major operational improvement over the pre-MyCare structure, where behavioral health was often carved out into separate managed care arrangements that did not coordinate with physical health.

Supplemental benefits. FIDE-SNPs can offer supplemental benefits beyond what standard Medicare provides. These vary by carrier and may include over-the-counter health products, fitness programs, meal delivery for post-hospital transitions, transportation beyond NEMT, and chronic condition support services. The supplemental benefits are one of the few areas where carriers compete on value beyond core compliance.

What MyCare does not cover is generally limited to room and board in non-Medicaid settings (the same federal HCBS rule that excludes room and board from PASSPORT and OHCW), purely cosmetic procedures, services from providers who are not in the plan network without prior authorization or emergency justification, and services that exceed federal or state coverage limits. The plan operates as the single payer for everything that is covered.

How PASSPORT and OHCW services continue inside MyCare

This is the operational mechanic that families most commonly misunderstand. When a PASSPORT or OHCW participant moves into MyCare (either by becoming dual-eligible while already on PASSPORT or OHCW, or by entering MyCare and then qualifying for HCBS), their HCBS services continue under OAC 5160-58-04. The service authorization, service plan, and benefit package are preserved. What changes is who delivers and coordinates the services.

Before MyCare, a PASSPORT participant's services were coordinated by an Area Agency on Aging case manager who was employed by the regional AAA. The AAA case manager authorized services, monitored provider performance, conducted reassessments, and responded to changes in condition. Services were billed to ODM through fee-for-service Medicaid using the PASSPORT waiver claim codes.

Inside MyCare, the same person has a MyCare care coordinator employed by the carrier (Anthem, Buckeye, CareSource, or Molina). The care coordinator authorizes services, monitors providers, conducts reassessments per the carrier's care management protocols, and responds to changes in condition. Services are no longer billed through FFS Medicaid; they are billed through the carrier's claims system as part of the MyCare capitation. The PASSPORT or OHCW provider relationships continue if the provider is in the carrier's network; if not, the care coordinator works with the family to either transition to an in-network provider or pursue a single-case agreement for the existing provider.

The AAA does not entirely disappear from the picture. The AAA still conducts the ACAT-based nursing facility level of care assessment that establishes clinical eligibility for HCBS. Some AAAs also subcontract with MyCare carriers to provide care coordination services using AAA staff. The arrangements vary by carrier and by AAA region; some carriers run care coordination entirely with their own staff, others contract substantially with AAAs, and many do a mix.

Service plan continuity. Federal rules and ODM contract requirements oblige the carrier to honor the existing PASSPORT or OHCW service plan during a continuity-of-care period after the enrollee transitions into MyCare. The carrier cannot abruptly reduce or terminate authorized services without proper notice and appeal rights. During that transition window, the carrier evaluates the service plan, conducts its own reassessment, and either continues, modifies, or proposes changes to the service array. Ask your carrier in writing how long your continuity-of-care protection runs and what happens at the reassessment. Any reduction or termination is subject to the same appeal rights as in standalone PASSPORT or OHCW.

Provider network considerations. Losing a trusted home health aide or a familiar agency right when a parent's care is already in flux is one of the most stressful parts of this transition, and families are right to push back on it. The biggest practical disruption families experience when transitioning into MyCare is provider network changes. A long-standing home health agency, personal care provider, adult day program, or DME supplier may not be in the new carrier's network. The carrier is required to work with the enrollee to either bring the provider into the network (often through a single-case agreement), transition to an in-network provider with similar capabilities, or document an exception. Families should raise provider network concerns directly with the care coordinator early in the transition and escalate to the carrier's member services line and ODM's MyCare oversight team if continuity is compromised.

The care coordinator role

The single most important relationship a MyCare enrollee has is with their care coordinator, employed by the carrier and assigned to the enrollee within days of enrollment. The care coordinator is the integration point across Medicare and Medicaid, across acute care and HCBS, across the physical health benefit and the behavioral health benefit, and across primary care and specialist care.

Core care coordinator responsibilities include conducting an initial health risk assessment soon after enrollment within the timeline the carrier's FIDE-SNP contract sets, developing and updating the person-centered service plan, authorizing HCBS services and Medicare-side services where prior authorization is required, monitoring service delivery and quality, managing transitions of care (hospital admission, hospital discharge, SNF admission, SNF discharge, ED visits), responding to changes in clinical condition, addressing social determinants of health, connecting the enrollee with community resources, and serving as the day-to-day point of contact for the enrollee and family.

Caseload structure. Carriers operate different care coordination models. Some carriers assign every enrollee to a single care coordinator who handles all aspects of the case. Others use a team model where a registered nurse care manager handles clinical issues, a social worker handles social determinants and HCBS, and a member services representative handles administrative issues. Caseloads vary by carrier and by enrollee acuity; an enrollee in long-stay nursing facility status with stable conditions may share a coordinator with many other enrollees, while an enrollee with complex behavioral health and HCBS needs may have intensive contact with a dedicated coordinator.

In-home assessments. Most carriers conduct in-home assessments for HCBS-receiving enrollees at the start of enrollment and at periodic intervals. The in-home assessment confirms the service plan, identifies unmet needs, documents the home environment, and builds the care coordinator's understanding of the enrollee's actual life situation rather than the clinical picture alone.

Escalation paths. When a care coordinator is unresponsive, inaccessible, or making decisions the family disagrees with, the family can escalate to the carrier's care management supervisor, to the carrier's member services line, to the carrier's grievance department, to ODM's MyCare oversight team via the Ohio Medicaid Consumer Hotline at 1-800-324-8680, to the Ohio Long-Term Care Ombudsman at 1-800-282-1206 (for HCBS and facility issues), and ultimately to a State Hearing.

Prior authorization and service approval

MyCare uses prior authorization for a defined set of services and procedures. The exact list varies by carrier but generally includes:

• Non-emergent hospital admissions beyond a defined acuity threshold
• Skilled nursing facility admissions (both Medicare-paid short-stay SNF and Medicaid-paid long-stay NF)
• HCBS service initiation and increases above pre-authorized levels
• Specialty pharmacy and high-cost medications
• Out-of-network services including providers and DME suppliers
• Certain advanced imaging (MRI, CT, PET) per Medicare Advantage utilization management rules
• Certain DME above standard categories (custom power chairs, specialized beds, environmental control)
• Behavioral health residential treatment and inpatient psychiatric admissions for non-emergent cases
• Home health services that exceed Medicare home health criteria and must be authorized as Medicaid HCBS
• Out-of-state services for non-emergency care

The carrier must respond to prior authorization requests within federally defined timelines. Under the Medicare Advantage organization-determination rules at 42 CFR 422.568 and 422.572, a standard pre-service request is generally decided within 14 calendar days, and an expedited request (used when waiting the standard time could seriously jeopardize the enrollee's health) within 72 hours. Prescription drug prior authorizations follow the shorter Part D coverage-determination timeframes. Ask the carrier to confirm the exact deadline for your specific request and to flag it as expedited if your health is at risk.

When prior authorization is denied, the enrollee receives a written notice that includes the reason for denial, the specific clinical criteria not met, the appeal rights, and the deadline for appeal. The denial notice must comply with federal Medicare and Medicaid notice rules and Ohio's MyCare contract requirements. A denial of HCBS service authorization is also subject to State Hearing rights under OAC 5101:6-7-01.

A cut to a parent's authorized home health hours can feel like the plan is overriding what you and the doctor already know your family needs, and that fear is legitimate, but these decisions are appealable, and many are reversed. The most common prior authorization disputes in MyCare involve home health service hour reductions when the carrier transitions an enrollee from PASSPORT or OHCW into MyCare, DME requests that the carrier characterizes as not medically necessary, skilled nursing facility level of care determinations when the carrier wants to transition an enrollee from SNF rehabilitation to HCBS or assisted living, and out-of-network single-case agreement disputes when a long-standing provider is not in the carrier's network. Families navigating these disputes should document the clinical justification carefully, work with the treating provider to submit supporting documentation, and escalate aggressively when continuity of care is at risk.

How appeals work in MyCare

Next Generation MyCare plans operate under Exclusively Aligned Enrollment, which means the same carrier holds both your Medicare and your Medicaid coverage. Federal rules require these aligned plans to run an integrated appeals process for the benefits where Medicare and Medicaid overlap, under the Applicable Integrated Plan rules at 42 CFR 422.629 through 422.634. Instead of forcing a family to figure out whether a denied service is a "Medicare problem" or a "Medicaid problem," the carrier issues a single integrated notice and runs one integrated plan-level appeal for the overlapping benefits. This is a real improvement over the pre-2026 model, where Medicare and Medicaid appeals ran on entirely separate tracks.

Stage one: the integrated plan-level appeal. When the carrier issues an adverse decision (denial, reduction, suspension, or termination of services), you have the right to file an appeal with the plan. The carrier must send a written notice that explains the reason for the decision, your appeal rights, and the filing deadline. A reviewer who was not involved in the original decision then reviews the appeal and can overturn, modify, or uphold it. The carrier must decide within the timeframes set by 42 CFR 422 Subpart M and the matching Medicaid managed-care rules: generally a faster, expedited path when a delay would seriously jeopardize the enrollee's health, and a longer standard path otherwise. Ask the carrier in writing for the exact deadline that applies to your specific denial and request the expedited path if your health is at risk.

Stage two: the State Hearing for Medicaid benefits. If the plan upholds a denial that involves a Medicaid-funded benefit (HCBS authorization, Medicaid wraparound coverage, dental, vision, non-emergency transportation, long-stay nursing facility, or any other Medicaid-funded service), you can request a State Hearing through the Ohio Department of Job and Family Services Bureau of State Hearings. The State Hearing is an independent administrative hearing under OAC 5101:6-7-01, conducted by an ODJFS hearing officer who is not employed by the Ohio Department of Medicaid or the carrier. File by phone at 1-866-635-3748, by mail, in person at a county Department of Job and Family Services office, or online through the Ohio Benefits self-service portal; the adverse notice states your filing deadline.

Continuing your benefits during a Medicaid appeal. When the appeal concerns a termination or reduction of services you are already receiving, Ohio's State Hearing rules let you keep those services in place while the hearing is pending if you file in time, usually before the proposed change takes effect. This protection prevents the carrier from cutting off authorized services during the months-long hearing process, so file fast and ask the Bureau of State Hearings to continue your benefits.

Medicare-only benefits. For the small set of denials that involve a Medicare benefit with no Medicaid overlap, the standard Medicare Advantage appeal pipeline under 42 CFR 422 Subpart M still applies after the plan-level appeal: an Independent Review Entity (IRE), then an Administrative Law Judge, then the Medicare Appeals Council, then federal district court. For most everyday MyCare disputes, though, the integrated plan appeal plus the Medicaid State Hearing is the path that matters.

Legal representation. Free legal help is available from Ohio Legal Aid, Pro Seniors Cincinnati at 1-800-488-6070, Disability Rights Ohio at 1-800-282-9181 (especially for disability-related MyCare appeals on the Medicare or Medicaid side), and county legal aid offices. The Long-Term Care Ombudsman at 1-800-282-1206 advocates for HCBS recipients and facility residents and can support appeals related to service continuity.

How does the MyCare Ohio Waiver fit with the rest of Ohio Medicaid?

The MyCare Waiver sits at a specific intersection of Ohio's Medicaid landscape. It is not a substitute for PASSPORT or the Ohio Home Care Waiver; rather, it absorbs the service delivery of those waivers for the subset of waiver participants who are also Medicare-eligible and live in MyCare counties. The federal cost-neutrality requirements of §1915(c) HCBS waivers continue to apply to the absorbed services, which is why the underlying service packages of PASSPORT and OHCW are preserved inside MyCare under OAC 5160-58-04. The Assisted Living Waiver, while integrated with MyCare for dual eligibles in MyCare counties, follows specific rules about how AL Waiver services are coordinated with MyCare carrier benefits.

For Medicaid-only members who are not dual eligibles, MyCare does not apply. They receive their Medicaid through standard Ohio Medicaid managed care (operated by the same carriers but under different contracts) or fee-for-service Medicaid for the population segments still in FFS. HCBS services for Medicaid-only members continue to flow through PASSPORT, OHCW, the AL Waiver, or the DODD waivers depending on eligibility, with case management handled by AAAs or County Boards of DD.

For dual eligibles outside MyCare counties, MyCare also does not apply. These individuals have separate Medicare coverage (fee-for-service Medicare or a non-MyCare Medicare Advantage plan) and separate Ohio Medicaid coverage (fee-for-service or standard Medicaid managed care). HCBS services flow through PASSPORT or OHCW on the standard non-MyCare track. The expansion of MyCare through Next Gen is gradually narrowing this population by adding counties to the MyCare footprint.

For DODD waiver participants (Individual Options, Level One, SELF), MyCare interacts differently. DODD waiver services are administered by County Boards of DD under OAC Chapter 5123, not by ODM or ODA. Dual-eligible DODD waiver participants may be enrolled in MyCare for their Medicare and acute-care Medicaid benefits while their DODD waiver services continue to be administered through the County Board structure. The integration mechanics are different from PASSPORT/OHCW absorption and depend on the specific waiver and the county.

For nursing facility long-stay residents who are dual-eligible in MyCare counties, MyCare typically covers the Medicaid NF benefit (room and board paid from income, with the resident keeping a Personal Needs Allowance of $75 per month in 2026 under Ohio Administrative Code 5160:1-6-07; Medicaid pays the gap to the facility per institutional Medicaid rules) along with Medicare for any acute episodes.3 The MyCare carrier coordinates the long-stay placement, monitors quality, and manages any transitions back to community settings.

Practical guidance for families approaching MyCare

If you are newly approaching MyCare, here is the operational sequence that produces the best outcomes:

Key statutes, rules, and authorities

• 42 USC 1396n(b) (federal §1915(b) managed care waiver authority)
• 42 USC 1396n(c) (federal §1915(c) HCBS waiver authority)
• 42 USC 1396a(a)(10)(E) (Medicare Savings Programs and dual eligibility)
• 42 CFR 422.2 (FIDE-SNP definition under Medicare Advantage rules)
• 42 CFR 422.514(h) (Exclusively Aligned Enrollment for FIDE-SNPs)
• 42 CFR 422 Subpart M (Medicare Advantage appeals process)
• 42 CFR Part 484 (Medicare home health conditions of participation)
• Ohio Administrative Code Chapter 5160-58 (MyCare Ohio Waiver)
• OAC 5160-58-04 (continuation of PASSPORT and OHCW services within MyCare)
• OAC Chapter 5160-31 (PASSPORT Waiver, for service package incorporation)
• OAC Chapter 5160-46 (Ohio Home Care Waiver, for service package incorporation)
• OAC Chapter 5160-33 (Assisted Living Waiver)
• OAC Chapter 5160-3 (Medicaid financial eligibility for long-term care)
• OAC 5101:6-7-01 (State Hearings procedures)

Key phone numbers and contacts

Learn More

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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.