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

If you are 21 or older with full Ohio Medicaid and Medicare Parts A, B, and D, the MyCare Ohio Waiver can put both coverages in one managed care plan with a single care coordinator. That plan also covers long-term services and supports, and MyCare members who get PASSPORT Waiver or Ohio Home Care Waiver services are enrolled in the MyCare Ohio waiver instead. Next Generation MyCare, which replaced the original program on January 1, 2026, reached the rest of Ohio in phases between April 1 and August 1, 2026.

Key Takeaways

• MyCare Ohio plans are defined in OAC Chapter 5160-58: rule 5160-58-01 makes each one a health insuring corporation that is also a Fully Integrated Dual Eligible Special Needs Plan, holding both a Medicare Advantage contract with CMS and a Medicaid managed care contract with the state.1
• MyCare requires full-dual eligibility, which under Next Generation MyCare means full Ohio Medicaid plus Medicare Parts A, B, and D, held at the same time, and an enrollee must be age 21 or older.1 People with Medicaid but no Medicare 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. Three are available statewide to new members: Anthem Blue Cross and Blue Shield, CareSource, and Molina Healthcare of Ohio. The fourth, Buckeye Health Plan, is not an option for new members in plan year 2026. Aetna Better Health of Ohio and United Healthcare Community Plan are no longer MyCare Ohio plans as of December 31, 2025. Each carrier has its own provider network, drug formulary, and care coordination model.1
• PASSPORT and Ohio Home Care Waiver services move inside MyCare. ODM says a MyCare member who gets waiver services through the Ohio Home Care Waiver, PASSPORT, or the Assisted Living Waiver is enrolled in the MyCare Ohio waiver starting January 1, 2026, with the same benefits, or more, available.2 Day-to-day coordination moves from the Area Agency on Aging or ODM waiver structure to the plan.
• You don't apply for MyCare; you are placed in it. ODM says people who meet the criteria are in the program once it is available in their county, and anyone who did not pick a plan is automatically enrolled in one for their Medicaid benefits. Whether your Medicare also comes through that plan is a separate choice, and the rules for switching plans differ for the two kinds of member.1
• MyCare now reaches all of Ohio. Next Generation MyCare replaced the original Medicare-Medicaid Plan demonstration on January 1, 2026, starting in the 29 counties where MyCare Ohio already operated; Phase 2 rolled it out to the rest of the state from April 1 to August 1, 2026, and ODM's August 2026 member FAQ says it is now implemented across Ohio.1 See /medicaid/ohio/next-gen-mycare for the program-level rollout detail.
• Care coordination is the defining feature of MyCare. A member who gets both Medicare and Medicaid from one MyCare plan has one care coordinator for both sets of benefits and one organization responsible for all of their health care, including long-term care and behavioral health. A member on a waiver may also have a waiver service coordinator, and ODM says the two work together.2
• Appeals start with the plan, then can go to a State Hearing. For a Medicaid benefit, the State Hearing request is due within 90 days of the mail date of the plan's appeal resolution decision, sent to the Ohio Department of Job and Family Services Bureau of State Hearings or your county agency.3

Why does the MyCare Ohio Waiver exist?

Before MyCare launched, dual eligibles in Ohio dealt with 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 ran it as a Medicare-Medicaid Plan demonstration under CMS's Financial Alignment Initiative until CMS moved the Medicare-Medicaid Plans in all seven Financial Alignment Initiative states to integrated dual eligible special needs plans effective January 1, 2026. Ohio's successor is a Fully Integrated Dual Eligible Special Needs Plan, defined at 42 CFR 422.2 as a single entity holding both a Medicare Advantage contract with CMS and a Medicaid managed care contract with the state.1 The state rules for MyCare Ohio plans are in OAC Chapter 5160-58, and the MyCare Ohio waiver is what 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, plus a fourth condition about other coverage covered below. Under Next Generation MyCare, an enrollee must also be age 21 or older.1

First, full-dual eligibility. An enrollee must be simultaneously enrolled in Medicare and Ohio Medicaid. Under Next Generation MyCare, the Medicare side is not satisfied by Part A and Part B alone: ODM states the criteria as full Medicaid plus Medicare Parts A, B, and D.1 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 can still get help with Medicare costs such as monthly premiums through Ohio's Medicare premium assistance programs (QMB, SLMB, QI-1, and QDWI), using the same Ohio Medicaid application.4

Second, the program has to be available in your county. Next Generation MyCare started on January 1, 2026 in the 29 counties where the original MyCare Ohio demonstration already operated, and Phase 2 rolled it out to the rest of the state from April 1 to August 1, 2026. ODM's August 2026 member FAQ says the program is now implemented across Ohio, so this test no longer screens anyone out by county.1 If you have questions about your own enrollment, the Ohio Department of Medicaid is the agency that runs the program.

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 someone whose income is too high under the regular rules, Ohio has a Special Income Level set at 300% of the Supplemental Security Income (SSI) Federal Benefit Rate, which is $2,982 per month in 2026. Ohio's rule opens that route only to a person in a "continuous period of institutionalization" as its rules define it, the resource limit ($2,000 for a single long-term care applicant) still applies, and someone eligible this way still owes a monthly patient liability to the long-term care provider. A person whose income is above the Special Income Level may set up a qualified income trust (a Miller trust) to bring countable income down to it.5 Clinical eligibility applies on top of the financial test if the enrollee is receiving home and community-based services through PASSPORT or the Ohio Home Care Waiver. Ohio's nursing facility-based level of care determination is made by ODM or its designee, and the state's level of care form still reserves its recommendation section for PASSPORT Administrative Agency staff.6 The plan's care coordinator then takes over service plan execution.

Fourth, no coverage that keeps you out. Meeting the age and coverage tests is not enough on its own. ODM's member FAQ adds that a person must not already be enrolled in a Program of All-Inclusive Care for the Elderly (PACE), a Developmental Disabilities waiver (Individual Options, Self-Empowered Life Funding, or Level One), or an Intermediate Care Facility, and must not have other health insurance that covers both inpatient hospital stays and doctor visits.1

Meet all of those and you are in the program; there is no separate MyCare application. ODM's wording is that individuals "are in the program, when the program is available in their county, if they meet the following criteria."1

How enrollment actually happens

MyCare enrollment has an automatic part and a part you choose. The mechanics are different on the Medicare side and the Medicaid side, and the most common family confusion is misunderstanding which side a plan actually covers. ODM calls a member whose MyCare plan carries both Medicare and Medicaid a "dual benefit member," and one whose plan carries only Medicaid a "Medicaid-only member."1

Automatic enrollment for Medicaid benefits. A person who meets the criteria and did not select a plan before the program reached their county "will be automatically enrolled in a plan for your Medicaid benefits," in ODM's words. Members of Aetna Better Health of Ohio and United Healthcare Community Plan, which are no longer MyCare Ohio plans as of December 31, 2025, were moved the same way if they did not pick a new plan during open enrollment, and ODM says the plan they landed in will have as many of their current doctors as possible.2

Choosing your plan. A dual eligible can also pick a MyCare plan deliberately. ODM directs members to the Ohio Medicaid Consumer Hotline at 1-800-324-8680 to discuss their options for picking a new plan, and to the Ohio Senior Health Insurance Information Program (OSHIIP), Ohio's free Medicare counseling program, at 1-800-686-1578 for help comparing the plans available in their area, including the Next Generation MyCare plans.2 Choosing lets the family compare carriers on provider networks, formularies, care coordination, and supplemental benefits instead of accepting an automatic assignment that may not match the providers the person already sees.

Plan switching. The rules depend on which kind of member you are. A Medicaid-only member can pick a different plan for their Medicaid benefits for up to 90 days after joining the program, and after that can change plans during the year for just cause, which ODM defines as being concerned with, or having issues getting care because of, the plan they are on. A dual benefit member is not held to the 90-day window: they can change their Next Generation MyCare plan at any time through Medicare, and the new plan and benefits begin on the first day of the following month.1

Medicare is your choice; Medicaid is not. If you meet the criteria, there is no opt-out from MyCare for your Medicaid benefits: ODM places you in a plan. What you decide is whether your Medicare comes through the same plan. A Medicaid-only member keeps Medicare separately and can move it into their MyCare plan "at any time through Medicare," with the change taking effect on the first day of the following month. The real exits from MyCare are the exclusions above: PACE, a Developmental Disabilities waiver, an Intermediate Care Facility, or other insurance that covers both hospital stays and doctor visits.1

Practical implication. Families handling MyCare enrollment for a newly eligible dual should treat the assigned plan as a starting point, not a final decision. Reach out to the waiver case manager (if PASSPORT or OHCW is in play), check each carrier's provider directory for the primary care provider and specialists the person already sees, compare drug formularies, and, as a Medicaid-only member, make any change within the 90 days after joining.1 The default assignment may not be 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. The fourth, Buckeye Health Plan, is not an option for new members in plan year 2026, or for members currently receiving care through one of the other MyCare plans; a member who already has Buckeye and wants to keep it need take no action. Aetna Better Health of Ohio and United Healthcare 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 each one holds both a Medicare Advantage contract with CMS and a Medicaid managed care contract with the state. 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. ODM sends members to the Ohio Medicaid Consumer Hotline, at 1-800-324-8680, to talk through their options for picking a new plan.2 Choose the carrier whose network includes your current providers, whose formulary covers your prescriptions on preferred tiers, 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 after a qualifying hospital stay, and nothing after day 100),7 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. The Medicaid benefits that sit alongside Medicare, such as transportation to medical appointments (Non-Emergency Medical Transportation) and other Medicaid-covered services; your plan's member handbook lists exactly what it covers.

Long-term services and supports. ODM says a MyCare member who gets waiver services through the Ohio Home Care Waiver, PASSPORT, or the Assisted Living Waiver is enrolled in the MyCare Ohio waiver, with the same benefits, or more, available to them, and that a dual benefit member's one plan is responsible for long-term care services.2 For enrollees in long-stay nursing facility status, MyCare covers the institutional Medicaid benefit (custodial nursing facility care, which Medicare's skilled nursing benefit does not pay for after day 100).7 For enrollees in licensed Residential Care Facilities under the Assisted Living Waiver, the carrier coordinates those services within MyCare.

Behavioral health. ODM lists behavioral health services among the benefits one MyCare plan is responsible for, alongside physical health and long-term care, for a member who gets both Medicare and Medicaid from it.2 That typically spans inpatient psychiatric care, outpatient mental health, substance use disorder treatment, and crisis services.

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 community settings, 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: ODM says a MyCare member who gets Ohio Home Care Waiver, PASSPORT, or Assisted Living Waiver services is enrolled in the MyCare Ohio waiver, with the same benefits, or more, available to them.2 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. A member on a waiver may have both this care coordinator and a waiver service coordinator, and ODM says the two work together on the member's needs.2 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. ODM or its designee still makes the nursing facility-based level of care determination, and the state's level of care form reserves its recommendation section for PASSPORT Administrative Agency staff.6 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. ODM's commitment is that a waiver participant moving into the MyCare Ohio waiver keeps the same benefits, or more.2 After the move, the carrier reviews the service plan, does its own reassessment, and either continues, modifies, or proposes changes to the services. Ask your carrier in writing whether any transition protection applies to your existing services and what happens at the reassessment. A plan decision to reduce, stop, or limit a service can be appealed to the plan and then taken to a State Hearing, as described below.3

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. Ask the carrier whether it will bring the provider into the network (for example, through a single-case agreement) or help you move to an in-network provider with similar capabilities. Raise provider network concerns directly with the care coordinator early in the transition, and escalate to the carrier's member services line if continuity is at risk. If the plan itself is the problem, a Medicaid-only member can change plans for just cause, and a dual benefit member can change plans at any time through Medicare.1

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 after 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 the Ohio Medicaid Consumer Hotline at 1-800-324-8680, where ODM sends members to talk through their options for picking a new plan,2 to Ohio's State Long-Term Care Ombudsman hotline at 1-800-282-1206, which also connects to regional ombudsman programs,8 and, for a decision about a service, through the plan appeal 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, and a Medicaid managed care plan must post a list of all items and services that require prior authorization, so check your plan's list before you start.9 The list commonly 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 federal deadlines. Under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), Medicare Advantage and Medicaid managed care plans must generally send a decision within 7 calendar days for a standard request and 72 hours for an expedited (urgent) request starting in 2026, and the Medicaid managed care rule lets a plan extend those clocks only when the enrollee or provider asks or the plan justifies a need for more information. That rule does not cover drug prior authorizations, which run on their own notice and appeal rules.9 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 plan must give a specific reason for the denial, however the decision was sent.9 A denial of a Medicaid service, such as HCBS authorization, can go to a State Hearing once the plan has decided your appeal: under OAC 5101:6-3-02, you have 90 days from the mail date of the plan's appeal resolution decision to ask for one.3

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. Plans must publicly post the percentage of standard prior authorization requests approved after appeal, so you can see how often appeals succeed at your plan.9 Prior authorization disputes in MyCare often 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 in 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

When the same MyCare plan holds both your Medicare and your Medicaid, ODM lists "one organization to contact if they need to file an appeal" as a benefit of that alignment, against "multiple organizations to contact if they need to appeal a denial" for a member whose plan covers Medicaid only.2 Ohio is one of the states where CMS issues integrated materials for applicable integrated plans,10 the dual eligible special needs plans that must use the unified Medicare-Medicaid appeals process of 42 CFR 422.629 through 422.634. Under it, the plan sends written notice of every appeal decision, and one that is not fully in your favor must explain the next level of appeal under Medicare and Medicaid and your right to keep Medicaid-covered benefits while that next level is pending, if it applies.11

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, 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. For a MyCare appeal resolution decision, OAC 5101:6-3-02 gives you 90 calendar days from the date that decision was mailed, and the request counts as made on the date the state or local agency receives it. You can ask orally, in writing, or electronically: call or write your county agency, write to ODJFS Bureau of State Hearings, PO Box 182825, Columbus, Ohio 43218-2825, or fax the request form to (614) 728-9574. Only you can make a request by telephone, and a written request someone else makes for you must include your signed statement naming them as your representative. The Bureau's toll-free line, 1-866-635-3748, is for asking to take part in the hearing by phone or asking whether you should be receiving continuing benefits.3

Continuing your benefits during a Medicaid appeal. Keeping services at the prior level runs on a second, shorter clock. A recipient whose services will be reduced, stopped, or restricted is told to request the hearing within 15 days of receiving that notice. Continuation is conditional, not automatic: Ohio's rule lists circumstances that end it, including withdrawing the appeal and a MyCare member specifically waiving continued benefits. For a managed-care appeal resolution, the plan must continue or reinstate benefits only until the authorized services are received or the State Hearing decision is issued, whichever comes first, and if you lose the hearing you may have to repay benefits you were not eligible to receive.3 So file fast.

Medicare benefits. When the plan upholds its denial of a Medicare benefit, the disputed issues go to an independent review entity that contracts with CMS. The plan sends the case file itself, and CMS's guidance says you will not need to take any action. For a benefit that both Medicare and Medicaid may cover, the case goes to the independent review entity and you should also be told your Medicaid appeal rights; if you appeal in more than one place and get conflicting decisions, the plan is bound by the ones in your favor.11

Legal representation. Free legal help is available from Ohio Legal Aid, Pro Seniors Cincinnati, Disability Rights Ohio (especially for disability-related MyCare appeals), and county legal aid offices. Ohio's State Long-Term Care Ombudsman hotline, 1-800-282-1206, is another place to turn, and the Ohio Department of Aging publishes a regional contact map for the ombudsman serving your area.8

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 takes over the service delivery of those waivers for waiver participants who are MyCare members. ODM says a MyCare member who gets Ohio Home Care Waiver, PASSPORT, or Assisted Living Waiver services is enrolled in the MyCare Ohio waiver, with the same benefits, or more, available to them.2

For people with Medicaid but no Medicare, MyCare does not apply. They receive their Medicaid through standard Ohio Medicaid managed care (whose plans include some of the same companies, under different contracts) or fee-for-service Medicaid for the population segments still in FFS. HCBS services for them 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.

There is no longer a part of Ohio that MyCare does not reach: ODM's August 2026 member FAQ says Next Generation MyCare is implemented across the state. The dual eligibles who stay outside it are the ones its exclusions cover, such as people enrolled in PACE or an Intermediate Care Facility, or with other health insurance that covers both inpatient hospital stays and doctor visits.1

For Developmental Disabilities waiver participants (Individual Options, Self-Empowered Life Funding, or Level One), the answer is simpler: enrollment in one of those waivers is among the conditions ODM lists that keep a person out of Next Generation MyCare, so a dual-eligible DD waiver participant is not a MyCare member.1

For nursing facility long-stay residents who are MyCare members, MyCare typically covers the Medicaid nursing facility benefit along with Medicare for any acute episodes. The resident keeps a Personal Needs Allowance of $75 per month in 2026 under Ohio Administrative Code 5160:1-6-07, the rule's other deductions (such as an allowance for a community spouse and health insurance premiums) come off next, and what remains of their income is paid to the facility as patient liability, with Medicaid paying the rest.13 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 CFR 422.2 (FIDE-SNP definition: one entity holding a Medicare Advantage contract with CMS and a Medicaid managed care contract with the state)1
• 42 CFR 422.629 through 422.634 (unified Medicare-Medicaid appeals for applicable integrated plans)11
• 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 plans; rule 5160-58-01 defines a MyCare Ohio plan as a health insuring corporation that is also a FIDE SNP)1
• OAC 5160-26-02 (excludes people enrolled in both Medicaid and Medicare from standard Medicaid managed care enrollment)12
• OAC 5160:1-6-03.1 (the Special Income Level for long-term care, $2,982 a month in 2026)5
• OAC 5160:1-6-07 (the $75 Personal Needs Allowance and the patient liability calculation)13
• OAC 5160-3-14 (nursing facility-based level of care determinations)6
• OAC 5101:6-3-02 and OAC 5101:6-4-01 (State Hearing deadlines and continued benefits)3

Key phone numbers and contacts

Learn More

Find personalized help navigating MyCare Ohio 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.