Next Generation MyCare Ohio 2026: A Dual-Eligible Guide

If you or a parent in Ohio has both Medicare and Medicaid, the way those two programs work together changed on January 1, 2026. A coverage letter about a "new plan" is unsettling, but the short version is reassuring: nobody loses benefits in this transition, and you have time and free help to choose. Here is what changed and what to do.

The old MyCare Ohio Medicare-Medicaid Plan (MMP) demonstration, which ran from May 2014 through December 31, 2025, ended along with the rest of the federal Financial Alignment Initiative (FAI). In its place, the Ohio Department of Medicaid (ODM) launched Next Generation MyCare, a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP). Under 42 CFR 422.2, a FIDE-SNP is a single plan that holds both a Medicare Advantage contract with CMS and a Medicaid managed-care contract with the state, so one carrier coordinates Medicare, Medicaid, and long-term care together.1

Two things about Ohio's transition that national coverage routinely misses: only four carriers were awarded Next Gen MyCare contracts (Anthem, Buckeye, CareSource, and Molina), so the prior MMP carriers Aetna Better Health of Ohio and UnitedHealthcare Community Plan are no longer MyCare Ohio plans; and Buckeye Health Plan is not an option for new members in plan year 2026, which narrows the practical choice for a new applicant to three plans (Anthem, CareSource, and Molina). Ohio is also expanding the program from the 29 counties served under MMP to the rest of the state through monthly waves running January through August 2026.

This guide explains how Ohio got here, who can enroll, what the Next Gen MyCare plans cover, how the MyCare Ohio Waiver replaces three legacy 1915(c) waivers for dual-eligibles, the 2026 financial-eligibility numbers, and what is pending in Ohio policy such as HB 318 estate-recovery reform.

For federal-level FIDE-SNP context, see our companion guide Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs). For state-cluster siblings, see Tennessee BlueCare Plus and TennCare CHOICES, New York Medicaid Advantage Plus, and Massachusetts SCO and One Care.

In This Guide

• 60-Second Version
• The MyCare Ohio MMP Story: Why Next Gen Exists
• The Four Next Gen MyCare Carriers (and the Two That Left)
• Phased Geographic Rollout
• Eligibility for Next Gen MyCare
• The MyCare Ohio Waiver and How It Replaces the Legacy Waivers
• Ohio Medicaid Financial Eligibility for LTSS (2026)
• The Special Income Level and Qualified Income (Miller) Trusts
• There Is No Income Spend-Down in Ohio
• Care Coordination in Next Gen MyCare
• Behavioral Health Integration
• Paid Family Caregiving
• PACE in Ohio
• Three Worked Examples
• Provider Network Considerations
• Common Ohio-Specific Pitfalls
• Estate Recovery and the HB 318 Reform Watch
• Timing Waterfall
• Where to Get Help in Ohio
• Pending Ohio Policy

60-Second Version

Next Generation MyCare is Ohio's post-MMP FIDE-SNP program for full-benefit dual-eligibles age 21 or older who live in a county where the program operates.1 It bundles Medicare Parts A, B, and D, Medicaid acute care, the MyCare Ohio 1915(c) Waiver for long-term services and supports (LTSS), and behavioral health under one contracted carrier, with a single care coordinator and one ID card.

The four awarded carriers in 2026:

1. Anthem Blue Cross and Blue Shield, available statewide for new members; 833-727-2169.
2. CareSource, available statewide for new members; 855-475-3163.
3. Molina Healthcare of Ohio, available statewide for new members; 866-856-8295.
4. Buckeye Health Plan, not an option for new members in plan year 2026; current Buckeye MMP members were moved to its Next Gen plan unless they chose another; 855-445-3562.

No longer MyCare Ohio plans as of December 31, 2025: Aetna Better Health of Ohio (still operates the OhioRISE specialty plan) and UnitedHealthcare Community Plan of Ohio (still operates mainstream Medicaid managed care).

Phased rollout, by Ohio Department of Medicaid schedule:

• January 1, 2026: the 29 counties where MyCare Ohio already operated (Area Agency on Aging regions AAA1, AAA2, AAA4, AAA6, AAA10A, AAA10B, and AAA11).
• April 1, 2026: additional counties.
• May 1, 2026: additional AAA2, AAA3, and AAA5 counties.
• June 1, 2026: AAA7 counties.
• July 1, 2026: AAA9 counties.
• August 1, 2026: AAA8 counties, completing the statewide rollout.

For a current dual-eligible, enrollment on the Medicaid side defaults to auto-assignment, but aligning your Medicare with your Medicaid carrier takes one call to the Ohio Medicaid Consumer Hotline (800-324-8680) or Medicare (800-633-4227).1,2,3

Key 2026 numbers. For aged, blind, or disabled (ABD) community Medicaid, the income standard equals the SSI Federal Benefit Rate of $994 a month for an individual and $1,491 for a couple. For institutional and waiver (LTSS) Medicaid, the Special Income Level is $2,982 a month for an individual, the countable-asset limit is $2,000 (single) or $3,000 (couple, both applying), the Community Spouse Resource Allowance runs up to $162,660, the Minimum Monthly Maintenance Needs Allowance runs up to $4,066.50, and the home-equity exclusion is $752,000.4 The nursing-facility Personal Needs Allowance is $75 a month, raised from $50 effective January 1, 2026.5 Ohio applies a 60-month look-back for institutional and HCBS-waiver transfers and has no community Medicaid look-back.6

Ohio is a 1634 state as of August 1, 2016, meaning SSI receipt brings automatic Medicaid with no separate application.4 It is not a 209(b) state; the eight states SSA identifies as having elected the more restrictive 209(b) option are Connecticut, Hawaii, Illinois, Minnesota, Missouri, New Hampshire, North Dakota, and Virginia.7

The MyCare Ohio MMP Story: Why Next Gen Exists

Ohio joined the federal Financial Alignment Initiative (FAI) Medicare-Medicaid Plan (MMP) demonstration in May 2014, becoming one of the capitated MMP states (alongside California, Illinois, Massachusetts, Michigan, Minnesota, New York, Rhode Island, South Carolina, Texas, and Washington's managed fee-for-service variant). The MyCare Ohio MMP demonstration operated under a three-way contract among CMS, the Ohio Department of Medicaid (ODM), and five plans: Aetna Better Health of Ohio, Buckeye Health Plan, CareSource, Molina Healthcare, and UnitedHealthcare Community Plan.

The MMP geographic footprint was 29 counties grouped into seven Area Agency on Aging (AAA) regions: Northeast (AAA10A and AAA10B), Northeast Central (AAA11), Central (AAA6), Southwest (AAA1), West Central (AAA2), and Northwest (AAA4). Coverage required a member to be:

• Age 18+ (now 21+ under Next Gen),
• Full-benefit dual-eligible (Medicare A/B and full Medicaid),
• Resident of one of the 29 MMP counties,
• And meeting at least one of: nursing facility level of care, eligibility for one of the legacy waivers (PASSPORT, Assisted Living, or Ohio Home Care), or qualifying chronic conditions.

CMS ended the FAI capitated MMP model nationwide effective December 31, 2025, transitioning the Medicare-Medicaid Plans in the Financial Alignment Initiative states to integrated dual eligible special needs plans (D-SNPs) effective January 1, 2026.1 Ohio's response was to design Next Generation MyCare as a FIDE-SNP, keep the integrated benefits package and care-coordinator model, fold the MyCare Ohio Waiver into the FIDE-SNP, and use the transition to expand the program statewide rather than stay in the original 29 counties. ODM ran the Next Gen procurement in 2024 and announced the contract awards on October 31, 2024.

Next Gen versus MMP, what changed:

• New entrant Anthem, and the departure of Aetna and UnitedHealthcare from MyCare.
• Expansion from the original 29 counties to the rest of Ohio through monthly waves running January to August 2026.
• The FIDE-SNP structure replaces the three-way MMP contract: Medicaid runs under an ODM contract, Medicare under a CMS contract, and Exclusively Aligned Enrollment (EAE) ties the two together.
• The minimum age rose from 18 to 21.
• The MyCare Ohio Waiver continues as the single capitated waiver that replaces PASSPORT, Assisted Living, and Ohio Home Care for MyCare members.
• Coordination-Only D-SNPs (CO-D-SNPs) are no longer permitted for this population in Ohio; full integration is required.

The Four Next Gen MyCare Carriers (and the Two That Exited)

Of the five MMP carriers, only Buckeye, CareSource, and Molina were awarded Next Gen contracts, and Anthem joined as a new entrant. Aetna Better Health of Ohio and UnitedHealthcare Community Plan are no longer MyCare Ohio plans as of December 31, 2025. Aetna still operates OhioRISE, the specialty behavioral-health plan for children and youth, and UnitedHealthcare still operates mainstream Medicaid managed care for non-MyCare populations, but neither is a Next Gen MyCare option.1

Aetna Better Health of Ohio (no longer a MyCare plan; continues OhioRISE): Members who were Aetna MMP enrollees as of December 31, 2025 received ODM notices to choose a new Next Gen plan, and ODM auto-assigned anyone who did not select one by the deadline. If you have an open claim or authorization from your Aetna MMP period, confirm the runout window directly with Aetna member services rather than assuming it carries over.

UnitedHealthcare Community Plan of Ohio (no longer a MyCare plan; continues mainstream managed care): The same auto-assignment mechanism applied. UnitedHealthcare continues mainstream Medicaid managed care for non-MyCare populations and offers Medicare Advantage D-SNP products outside MyCare in Ohio for non-aligned dual-eligibles.

The practical effect: a new dual-eligible applying for Next Gen MyCare in 2026 chooses among Anthem, CareSource, and Molina, plus Buckeye in counties where it still serves current members. ODM's auto-assignment process weighs provider continuity, any prior carrier relationship, and geography when it default-assigns a member.

Phased Geographic Rollout: 29 Counties on January 1, 2026, Then the Rest of Ohio by August 1, 2026

Ohio is rolling Next Gen MyCare out in waves, county by county. The Ohio Department of Medicaid launched it in 29 counties on January 1, 2026, and is expanding it to the rest of the state from April 1 through August 1, 2026. Here is the published schedule by AAA region.1

Phase 1, January 1, 2026, the 29 legacy MMP counties:

• AAA1 (Council on Aging of SW Ohio): Butler, Warren, Clinton, Hamilton, Clermont.
• AAA2 (Dayton, Catholic Social Services): Montgomery, Clark, Greene.
• AAA4 (NW Ohio/Toledo): Lucas, Fulton, Ottawa, Wood.
• AAA6 (Central Ohio Area Agency on Aging, COAAA): Franklin, Delaware, Union, Madison, Pickaway.
• AAA10A (Western Reserve, Cleveland): Lorain, Cuyahoga, Medina, Lake, Geauga.
• AAA10B (Direction Home Akron Canton): Summit, Portage, Stark, Wayne.
• AAA11 (Direction Home Eastern Ohio, Youngstown): Columbiana, Mahoning, Trumbull.

Phase 2A, April 1, 2026, 10 counties:

• AAA4: Sandusky, Erie, Henry, Williams, Defiance, Paulding.
• AAA6: Fayette, Fairfield, Licking.
• AAA11: Ashtabula.

Phase 2B, May 1, 2026:

• AAA2: Preble, Darke, Miami, Shelby, Champaign, Logan.
• AAA3: Van Wert, Putnam, Hancock, Allen, Mercer, Auglaize, Hardin.
• AAA5: Seneca, Huron, Wyandot, Crawford, Richland, Ashland, Marion, Morrow, Knox.

Phase 2C, June 1, 2026:

• AAA7: Ross, Vinton, Highland, Pike, Jackson, Gallia, Brown, Adams, Scioto, Lawrence.

Phase 2D, July 1, 2026:

• AAA9: Holmes, Tuscarawas, Carroll, Jefferson, Coshocton, Harrison, Belmont, Guernsey, Muskingum.

Phase 2E, August 1, 2026, statewide complete:

• AAA8: Hocking, Perry, Morgan, Noble, Monroe, Washington, Athens, Meigs.

Until a county's launch date, current dual-eligibles continue under whatever combination of Medicare Advantage / Original Medicare and Medicaid FFS / mainstream MMC they had before. PASSPORT, Assisted Living, and Ohio Home Care waivers continue uninterrupted for them. Once their county rolls in, they have an opportunity to enroll in Next Gen MyCare; if they do nothing, ODM auto-assigns to Medicaid-only Next Gen enrollment (not full Medicare-Medicaid alignment).

Why phased: ODM cited operational lift, provider contracting, IT system migration, AAA case management transition, member outreach in non-MMP counties, as the reason for the eight-month statewide rollout. The MMP veterans (Phase 1 counties) had the existing MMP infrastructure to convert.

Eligibility for Next Gen MyCare

To be enrolled when the program is available in your county, you must meet all of the core criteria the Ohio Department of Medicaid sets:1

1. Be age 21 or older (raised from the MMP demonstration's minimum of 18).
2. Be a full-benefit dual-eligible, meaning you have Medicare Parts A, B, and D plus full Ohio Medicaid (not a QMB-only, SLMB-only, or QI-1 partial dual).
3. Live in a county where Next Gen MyCare has launched.

Within that population, members fall into one of three care groups: those who meet a nursing-facility level of care, those eligible for the MyCare Ohio Waiver (or for PASSPORT, Assisted Living, or Ohio Home Care while transitioning), and aged, blind, or disabled (ABD) adults who qualify for full Medicaid without an LTSS need.

You are excluded from MyCare if you are enrolled in PACE (the Program of All-Inclusive Care for the Elderly, which is mutually exclusive with MyCare), on a Department of Developmental Disabilities (DODD) waiver such as Individual Options, Level One, or SELF, enrolled in OhioRISE, or incarcerated.

Who is not eligible at all: partial duals (QMB-only, SLMB-only, QI-1), people with Medicare but not Medicaid, people with Medicaid but not Medicare, anyone under 21, residents of counties not yet rolled in, PACE enrollees, and DODD-waiver beneficiaries. These groups stay on their existing arrangements, such as Original Medicare or a non-MyCare Medicare Advantage plan plus mainstream Medicaid managed care or a PASSPORT, Assisted Living, or Ohio Home Care waiver.

The MyCare Ohio Waiver: How It Replaces PASSPORT, Assisted Living, and Ohio Home Care for Dual-Eligibles

Five 1915(c) waiver tracks matter to a MyCare-eligible dual-eligible in 2026. (The fifth, DODD, is itself three separate waivers, so Ohio's total 1915(c) count is higher than five; these are the tracks that decide whether MyCare reaches you.)

1. PASSPORT, the Ohio Department of Aging (ODA) waiver operated through its designees (the area agencies on aging plus Catholic Social Services of the Miami Valley); serves people age 60 or older who meet an intermediate or skilled level of care; the individual plan-of-care cost limit is $14,700 a month.8
2. Assisted Living Waiver, an ODA waiver (Ohio Administrative Code Chapter 5160-33) that pays a licensed residential care facility for the assisted-living service package but never for room and board; the resident pays room and board from income, capped at the SSI Federal Benefit Rate minus $50, which is $944 a month in 2026.9
3. Ohio Home Care Waiver, run directly by ODM (OAC Chapters 5160-44 through 5160-46) for Ohioans from birth through age 59 who need a nursing-facility level of care.10
4. MyCare Ohio Waiver (OAC 5160-58), capitated under the Next Gen MyCare plans; it consolidates the three waivers above for dual-eligible MyCare members and provides equivalent or expanded services.
5. DODD Waivers (Individual Options, Level One, SELF), for the intellectual and developmental disabilities population, administered by the Ohio Department of Developmental Disabilities and not part of MyCare.

What conversion feels like. When a Next Gen MyCare enrollee is already on PASSPORT, Assisted Living, or Ohio Home Care at the time of enrollment, ODM converts them to the MyCare Ohio Waiver automatically. Services continue without a lapse, but the case-manager assignment changes: instead of an AAA case manager, the member gets a care coordinator assigned by the plan. Plans contract with AAAs for some case-management functions (continuity is plan-specific), so a member may still work with a familiar AAA staffer.1

If a member later disenrolls from MyCare (moves out of a MyCare county, opts out, or transfers to PACE), ODM moves them back to the appropriate legacy waiver, but only if they still meet that waiver's eligibility criteria. There is no guaranteed return slot in PASSPORT or Assisted Living if the program has reached capacity in the meantime.

MyCare Ohio Waiver services (under OAC 5160-58) include personal care, homemaker services, adult day services, home-delivered meals, a personal emergency response system, non-emergency transportation, in-home skilled nursing, respite care (including out-of-home respite), home modification, specialized medical equipment, and independent-living assistance. It also offers the participant-directed options described below: Choices Home Care Attendant Service, Consumer-Directed Personal Care Service, and Structured Family Caregiving.

Waiver functional eligibility (nursing-facility level of care): assessed through a comprehensive level-of-care assessment administered on behalf of the Ohio Department of Aging. The assessment weighs deficits in activities of daily living, cognitive function, behavioral health, and medical complexity. The threshold for a nursing-facility level of care is a documented need for ongoing help with multiple activities of daily living or significant cognitive impairment.

Ohio Medicaid Financial Eligibility for LTSS (2026)

These are the 2026 numbers the Ohio Department of Medicaid uses for long-term-care eligibility. The income-cap (Special Income Level) and asset rules below decide whether a dual-eligible can access the MyCare Ohio Waiver's long-term-care benefit.4

Ohio is a 1634 state, so SSI receipt brings automatic Medicaid with no separate application.4 The eight states SSA identifies as having elected 209(b) are Connecticut, Hawaii, Illinois, Minnesota, Missouri, New Hampshire, North Dakota, and Virginia; Ohio is not among them.7

For the full eligibility framework, including the MAGI, ABD, and long-term-care pathways, how to apply through a county agency or the Ohio Benefits portal, and the transfer-penalty mechanics, see Ohio Medicaid Eligibility and Income Limits.

Federal protections that still apply in Ohio. The Pickle Amendment protects former SSI recipients who lost SSI solely because of Social Security cost-of-living increases. Disabled Adult Children protections under Section 1634(c) keep DACs who lose SSI after a parent's death, disability, or retirement Medicaid-eligible. Disabled Widow(er) protections under 1634(b) work similarly. Section 1619(b) lets a working SSI recipient keep Medicaid above the SSI cash-benefit threshold; the current Ohio threshold tracks the federal calculation, which you can confirm on SSA.gov.

The Special Income Level ($2,982) and Qualified Income (Miller) Trusts

For institutional and HCBS-waiver Medicaid, Ohio uses a Special Income Level set at 300 percent of the SSI Federal Benefit Rate, which is $2,982 a month for a single applicant in 2026. An applicant whose countable income does not exceed $2,982 qualifies financially for institutional or waiver Medicaid, subject to the resource and other tests.11

When countable income exceeds $2,982, Ohio rule (OAC 5160:1-6-03.2) requires a Qualified Income Trust (QIT), also called a Miller Trust, under 42 U.S.C. 1396p(d)(4)(B). The mechanics are specific:11

1. The applicant establishes an irrevocable trust that names the Ohio Department of Medicaid as the remainder beneficiary up to the total medical assistance Medicaid paid.
2. Only the applicant's own income may go into the trust (interest earned on the trust corpus is the only exception).
3. Each month, the trust pays out a personal or maintenance needs allowance for the beneficiary, a maintenance allowance for a spouse and any family dependents, and health-care costs (including Medicare and other insurance premiums), with the remainder applied to the cost of care.

ODM provides Form ODM 10193 (the QIT verification form) and a QIT template for this purpose.

Common QIT mistakes that cause a denial:

• Not routing enough income through the trust each month so that countable income still exceeds the Special Income Level.
• Establishing the trust mid-month and missing the first month's required deposit, which creates an eligibility gap.
• Naming someone other than the state as the remainder beneficiary, which invalidates the trust.
• Using a generic special-needs or pooled-trust template instead of a Miller Trust; these are different statutory devices under 42 U.S.C. 1396p(d)(4), and a Miller Trust is the (d)(4)(B) form.

There Is No Income Spend-Down in Ohio

This is the point where Ohio differs from most states, and getting it wrong costs a family months. Ohio does not operate an aged, blind, or disabled (ABD) income spend-down. The pathway ended when Ohio became a Section 1634 state: the Ohio Department of Medicaid's Medicaid Eligibility Procedure Letter No. 115 states that under the prior Section 209(b) policy individuals could spend down, and that "when Ohio becomes a 1634 state on August 1, 2016, individuals will no longer be able to spenddown to become eligible for Medicaid." The rule that once carried the monthly "pay-in" process, OAC 5160:1-3-04.1, no longer exists, and OAC Chapter 5160:1-3 contains no spend-down rule at all.12

So an ABD adult in the community whose countable income is over the $994 individual standard ($1,491 for a couple) cannot use a monthly pay-in or a pile of medical bills to buy their way to eligibility. Older Ohio guidance, and some county fact sheets still posted online, describe a program that has not existed for a decade.12,4

What this means for a dual-eligible. For institutional and HCBS-waiver long-term care, the operative rule is not a spend-down but the Special Income Level: countable income at or below $2,982 a month qualifies, and above it a Qualified Income (Miller) Trust brings countable income back to or below the SIL.11 That SIL pathway is what reaches a MyCare member who needs waiver or nursing-facility services with income between $994 and $2,982. A pay-in does not. A Medicare Savings Program (QMB, SLMB, or QI-1) is a different thing again: it helps with Medicare premiums and cost-sharing but is not full Medicaid, so a QMB-only path does not get a member into MyCare, which requires full Medicaid.1

One thing that is not affected: asset spend-down. Reducing countable resources to the $2,000 individual limit (by paying down debt, prepaying a funeral, or making exempt purchases) remains a normal and valid way to qualify on the resource side. It is the income spend-down that Ohio eliminated.12

Care Coordination in Next Gen MyCare

Each Next Gen MyCare enrollee receives:

1. One care coordinator, the single point of contact across Medicare and Medicaid, covering long-term care, behavioral health, primary and specialist care, transitions of care, and crisis response.
2. A comprehensive health assessment within 30 days of enrollment, repeated at least annually and at significant changes in condition.
3. A person-centered service plan developed by an interdisciplinary care team that includes the member, the primary care provider, the behavioral-health and long-term-care providers, and an informal caregiver.
4. A 24/7 nurse advice line and a documented transitions-of-care protocol for hospital, nursing-facility, and home-health discharges and crisis stabilization.

Care-coordinator caseloads: the ODM provider agreement caps how many members each care coordinator may carry, with tighter limits for members who use long-term services and supports than for those who do not. Ask your plan how many members your assigned coordinator carries if you want a sense of how much individual attention to expect.

Care-team meeting frequency: the Interdisciplinary Care Team meets at least quarterly for LTSS users, and more often at care transitions or during a crisis.

Continuity with AAAs: the Next Gen plans subcontract some PASSPORT-track case-management functions to AAAs, though the arrangement is plan-specific. If you valued a relationship with an AAA case manager, ask your plan directly to keep the AAA involved as a service-delivery partner, because not every plan does this automatically.

Behavioral Health Integration

Ohio integrates adult behavioral health into Medicaid managed care, so a Next Gen MyCare plan covers physical health, behavioral health, and substance-use-disorder services under one capitation. The practical benefit for a member is that one care coordinator handles physical, behavioral, and long-term care, with no separate behavioral-health plan to navigate. Plans contract with providers licensed by the Ohio Department of Mental Health and Addiction Services, and the 988 Suicide and Crisis Lifeline routes Ohio callers to in-state crisis services.1

OhioRISE bridge at 21: a youth aging out of OhioRISE who becomes dual-eligible at 21 should plan their MyCare enrollment in advance, so the OhioRISE care coordinator and the new MyCare care coordinator can overlap during the transition.

SUD 1115 demonstration: Ohio operates an 1115 substance-use-disorder demonstration that provides federal funding for residential SUD treatment in an institution for mental diseases (otherwise blocked by the IMD exclusion). The original demonstration was extended through December 31, 2025, and ODM submitted a renewal. Because the renewal status is time-sensitive, verify it on the Medicaid.gov 1115 waiver tracker rather than relying on any status printed here.

Paid Family Caregiving: C-HCAS, CD-PCS, and Structured Family Caregiving

Ohio expanded participant-directed care under both the Ohio Home Care Waiver and the MyCare Ohio Waiver. Under the Ohio Home Care Waiver, personal-care services may be furnished by a non-agency direct-care worker, and a parent of a minor child, a spouse, or a relative with legal decision-making authority may serve as a paid worker only through the conditional pathway in OAC 5160-44-32. Two participant-direction options run across the MyCare and Ohio Home Care waivers:10

1. Choices Home Care Attendant Service (C-HCAS): the participant directs hiring, scheduling, training, and termination of attendants, with rate flexibility inside the participant's individual budget. The participant may hire family members.
2. Consumer-Directed Personal Care Service (CD-PCS): similar participant direction, but with state-set rates rather than budget flexibility. The participant may hire family members under the same scope.

Structured Family Caregiving (SFC): a separate daily-care model that pays a live-in family caregiver a tiered daily rate. The caregiver must live with the participant, provide the bulk of personal care, and meet documentation and training requirements. Ask your AAA case manager or MyCare care coordinator for the current SFC tier rates.

Who cannot be paid: federal SFC rules prohibit paying a spouse under SFC, and legally responsible relatives for minor children are excluded; some Ohio waivers allow a spouse under C-HCAS, so confirm with your case manager.

Background-check requirements: All paid caregivers must pass Ohio BCI/FBI fingerprint background check, complete Caregiver training (varies by waiver), and enroll as a Medicaid provider with Ohio Department of Medicaid. The Medicaid Provider Enrollment process for individual caregivers typically takes several weeks; check current timing with ODM Provider Enrollment.

PACE in Ohio

PACE, the Program of All-Inclusive Care for the Elderly under 42 CFR Part 460, is a separate Medicare-Medicaid product: the PACE provider receives a capitated payment and delivers integrated medical, social, and long-term-care services, usually anchored by a day center. PACE is mutually exclusive with PASSPORT: Ohio's PASSPORT rule makes eligibility conditional on the individual agreeing not to be simultaneously enrolled in PACE, in another Medicaid home and community-based program, or in the residential state supplement program.8 Ohio applies the same either-or logic to Next Gen MyCare, so a person enrolls in one program or the other, not both.

PACE eligibility: age 55 or older, a nursing-facility level of care, residence in a PACE service area, and the ability to live safely in the community. PACE's minimum age is lower than MyCare's 21, but its level-of-care requirement is stricter.

Availability and expansion: Ohio's main operating PACE program is McGregor PACE in the Cleveland and Akron area. Ohio has statutory authority to expand PACE to additional counties, including Franklin, Hamilton, Montgomery, Lucas, Trumbull, Ashtabula, and Mahoning. Firm dates for new sites were not announced at the time of writing; the PACE Association of Ohio (paceoh.org, 614-481-5444) is the best source for current site news.

Three Worked Examples

These three people are illustrative, not real. The dollar figures for each person are hypothetical, but they are measured against the real 2026 Ohio limits cited throughout this guide.

Example 1: Doris, Cuyahoga County, age 73, nursing-facility level of care, full dual-eligible

Doris lives alone in Cleveland Heights. She has Medicare Parts A and B and Ohio Medicaid (she qualified through SSI, then aged into Medicare). Her income is $1,420 a month in Social Security, with no other income, and her countable resources are $1,800, below the $2,000 limit. She has been on the PASSPORT Waiver for three years, getting about 25 hours a week of home care, adult day services twice weekly, and a personal emergency response system. Her AAA case manager is from the Western Reserve Area Agency on Aging.4

1/1/2026 transition:

• Cuyahoga is a Phase 1 county, so she's eligible for Next Gen MyCare on day one.
• Doris received an ODM enrollment notice in November 2025. She chose Anthem MediBlue MyCare Dual Advantage based on her PCP's network membership (her PCP at Cleveland Clinic is in-network with Anthem).
• ODM converted her PASSPORT Waiver to MyCare Ohio Waiver automatically. Same services, same hours, same provider, but a new care coordinator from Anthem replaces her AAA case manager (Anthem is subcontracting some case management to Western Reserve AAA, so she may continue working with the same AAA staffer in a partnership role).
• Anthem assigns a Comprehensive Health Assessment within 30 days, conducts an Interdisciplinary Care Team meeting with her PCP and home care agency, and develops a Person-Centered Service Plan.

Financial mechanics:

• Her $1,420 monthly income is below the $2,982 Special Income Level, so no Miller Trust is required.4
• Her $1,800 in resources is below the $2,000 limit, so she is eligible.
• Ohio charges no patient liability for an HCBS waiver (unlike a nursing facility), so her home-care services are covered by Medicaid through the MyCare capitation.
• A nursing-facility Personal Needs Allowance does not apply because she lives in the community.
• Her Medicare premiums are paid by Medicaid as a full dual-eligible.

What to verify: that her home-care aides are enrolled Medicaid providers, that Anthem's transitions-of-care protocol covers her existing prior authorizations, and that her PCP stays in-network.

Example 2: Kenneth, Stark County, age 65, nursing-facility resident, full dual-eligible

Kenneth lived independently until a stroke in October 2025 led to a nursing-facility admission in Canton. His income is $2,650 a month from Social Security and a small pension. His spouse Eileen (age 67) lives in their owned home (about $180,000 in equity) and has $48,000 in retirement savings and $720 a month in Social Security.4

Transition on January 1, 2026:

• Stark County is in AAA10B, a Phase 1 county, so Next Gen MyCare is available from day one.
• Kenneth was a CareSource MMP member, so he moved to CareSource Next Gen on January 1, 2026, keeping the same plan, the same nursing facility, and the same care coordinator.

Community Spouse Monthly Income Allowance (CSMIA) and patient liability. Because Eileen's own $720 a month falls short of the Minimum Monthly Maintenance Needs Allowance, Kenneth can divert some of his income to her to close the gap. Read the MMMNA numbers carefully: $4,066.50 is the maximum, not the amount every community spouse gets. The 2026 federal range runs from a $2,705.00 minimum to that $4,066.50 cap, and where a particular spouse lands inside it is set by the county eligibility worker, driven largely by shelter costs. That range is the difference between owing nothing and owing several hundred dollars a month, so it is worth working through:4

• Kenneth's $2,650 income less his $75 Personal Needs Allowance leaves $2,575.5
• At the $2,705.00 floor, Eileen's allowance is $2,705.00 less her own $720, or $1,985. Roughly $590 of Kenneth's income then remains as patient liability paid to the facility each month, before any deduction for his health-insurance premiums.
• At the $4,066.50 cap, her allowance would exceed everything Kenneth has left, and his patient liability would be $0.

Do not assume the cap. Ask the eligibility worker for the MMMNA figure they actually used and the shelter costs behind it; whatever is left after the PNA and the spousal allowance is what the family owes the facility, and Medicaid plus Kenneth's Medicare Part A benefit covers the rest.4

Resources. Eileen's $48,000 plus Kenneth's accounts are assessed at the snapshot date (his nursing-facility admission). The Community Spouse Resource Allowance of up to $162,660 protects Eileen's share, and Kenneth's countable resources must be at or below $2,000 for him to qualify. The home's $180,000 equity is below the $752,000 home-equity exclusion, and the home is exempt while Eileen lives there.4

What to verify: that the resource snapshot is documented, that Eileen has completed the spousal resource assessment with the ODM long-term-care eligibility worker, and that the nursing facility is in-network with CareSource.

Example 3: Marcia, Athens County, age 58, full dual-eligible, on the Ohio Home Care Waiver

Marcia has multiple sclerosis and lives alone in a small home in Athens. Her income is $1,180 a month in Social Security Disability Insurance, and her resources are $850, below the $2,000 limit. She has been on the Ohio Home Care Waiver since 2018, receiving about 18 hours a week of personal care plus skilled nursing. She has Medicare (through 24 months of SSDI entitlement) and full Ohio Medicaid.4

Phase 2E rollout, August 1, 2026:

• Athens County is in AAA8, a Phase 2E county, so Next Gen MyCare launches there on August 1, 2026.
• Until then, Marcia continues on the Ohio Home Care Waiver with ODM as the direct administrator. Her Medicare is currently a non-aligned UnitedHealthcare D-SNP, and her Medicaid is fee-for-service.
• In June 2026 she receives an ODM enrollment notice listing her options: Anthem, CareSource, or Molina (Buckeye is not open to new members).
• Marcia chooses Molina Healthcare of Ohio based on a friend's experience and Molina's Athens-area network.
• On August 1, 2026, her Ohio Home Care Waiver converts to the MyCare Ohio Waiver, and her Medicare moves to Molina (she chose to align).

Care-coordination handoff: her Ohio Home Care Waiver case manager prepares a transition packet with her current service plan, providers, and authorizations; Molina's care coordinator schedules a comprehensive health assessment in the first 30 days; and her care team includes her Athens neurologist, her PCP, and her home-care agency.

What to verify: Molina's transition-of-care protocol for her existing prior authorizations, and whether her neurologist and home-care agency are in Molina's network.

Provider Network Considerations (Phase 1 vs Phase 2 Counties)

Phase 1 counties (January 1, 2026 launch) had several months of provider contracting after the October 2024 contract awards, so networks are most developed in the major urban anchors such as Cuyahoga, Franklin, Hamilton, Montgomery, and Lucas. Phase 2 counties launching from April through August 2026 had shorter contracting windows, and some specialty providers (for example, rural neurologists, endocrinologists, or behavioral-health prescribers) may not yet be in-network with every MyCare plan.

The practical rule is the same in every county: before you enroll or switch, call the carrier's member-services line and confirm that your specific doctors, hospital, nursing facility, and home-care agency are in-network. Network status changes, and the only reliable answer is the plan's current directory.

Hospitals and major systems: the large Ohio health systems generally contract with multiple Next Gen plans, but coverage varies by plan and region, so verify with the carrier before relying on it.

Nursing facilities: most major Ohio nursing-facility chains contract with multiple Next Gen plans. A member already in a facility as of January 1, 2026 keeps that facility under transition-of-care provisions; a new admission should verify network status first. For Ohio's certified nursing facilities, see the Ohio Long-Term Care Consumer Guide.

Home-care agencies: in-network coverage of Ohio Medicaid-certified home-care agencies varies by carrier and region. Ask your AAA case manager (in a Phase 2 county) or your new MyCare care coordinator (if already enrolled) for the in-network agency list in your county.

Common Ohio-Specific Pitfalls

1. Forgetting that Aetna and UnitedHealthcare are no longer MyCare plans. A member who does not act may have been auto-assigned to a plan they would not have chosen. Verify your assignment with the Ohio Medicaid Consumer Hotline (800-324-8680).3
2. Buckeye is not an option for new members in 2026. A new applicant should not select Buckeye.
3. Medicaid-only auto-assignment is not the same as full Medicare-Medicaid alignment. If you do not proactively align your Medicare, ODM enrolls only the Medicaid side, you keep your existing Medicare, and you miss the integration benefits. Call Medicare or 800-324-8680 to align.3
4. PACE and MyCare are mutually exclusive. A McGregor PACE participant should not enroll in Next Gen MyCare.
5. A legacy waiver converts automatically, but the case manager may change. PASSPORT, Assisted Living, and Ohio Home Care members convert to the MyCare Ohio Waiver, and AAA case-manager relationships may not carry over unless you ask for continuity.
6. Estate recovery reaches further in Ohio than in most states. Living trusts, joint ownership, and transfer-on-death accounts are not a safe harbor here. HB 318 reform was pending and not enacted at the time of writing; confirm its current status on the Ohio House bill-status page for HB 318 and plan with a qualified Ohio elder-law attorney.
7. Watch for pharmacy prior-authorization hiccups during any single-pharmacy-benefit-manager transition. Refill important prescriptions ahead of an announced changeover.
8. Phase 2 members who do not pre-select default to Medicaid-only enrollment. To get the full integrated benefit, call before your county's launch date.
9. DODD-waiver beneficiaries are excluded. Adults on Individual Options, Level One, or SELF waivers are not eligible for MyCare.
10. SSI does not equal automatic full Medicaid for a higher-income dual, and there is no income spend-down to fall back on. Ohio eliminated the ABD income spend-down on August 1, 2016. Income above the $994 SSI Federal Benefit Rate reaches full Medicaid only through the Special Income Level pathway (with a Miller Trust above $2,982), which requires an institutional or HCBS-waiver level of care.12,4
11. The look-back applies only to institutional and HCBS-waiver Medicaid. Ohio has no community Medicaid look-back, so asset transfers are reviewed only when you seek institutional or waiver coverage.
12. Moving to a county where MyCare has not launched reverts the Medicaid side to fee-for-service while Medicare continues; you re-enroll when that county's wave begins.
13. Plan the OhioRISE-to-MyCare bridge at 21. A youth aging out of OhioRISE who is dual-eligible at 21 should plan MyCare enrollment in advance.
14. The Miller Trust must capture enough income. The Special Income Level is $2,982 a month; above it, a Qualified Income (Miller) Trust is required and must be funded each month, or eligibility fails.

Estate Recovery: Ohio's Unusually Broad Reach (and HB 318 Reform Watch)

Ohio is among the most aggressive estate-recovery states. Under ORC 5162.21, Ohio elects expanded estate recovery that reaches both probate and non-probate assets, including property conveyed to a survivor or heir through joint tenancy, tenancy in common, survivorship, a life estate, a living trust, or other arrangement. This is broader than the federal floor, which lets a state limit recovery to probate assets. Recovery applies to permanently institutionalized recipients of any age and to recipients age 55 or older.13

Pre-death liens (ORC 5162.211): Ohio may place a lien on the real property of a permanently institutionalized Medicaid recipient, and in some circumstances on the recipient's spouse's property. Federal hardship and exemption protections apply.13

Federal exemptions still apply. Recovery is deferred or barred while a surviving spouse is alive or a surviving child is under 21, blind, or permanently and totally disabled, with additional protections for a resident sibling who holds an equity interest and lived in the home for at least one year, and for a caretaker adult child who lived in the home and provided care for at least two years before institutionalization.

HB 318 (136th General Assembly): a pending bill, sponsored by Representatives Stephens and Brennan, would narrow Ohio's recovery toward probate-only with low-value waivers. As of the most recent action it had been referred to the House Medicaid Committee on June 4, 2025 and had not advanced. Because a bill's status changes, confirm it on the Ohio House HB 318 status page. Pro Seniors and Disability Rights Ohio are leading advocates; if enacted, the bill would substantially reduce estate-recovery exposure for middle-income Ohio families.13

Claim procedure (ORC 2117.061): the estate's representative files a Medicaid estate-recovery notice, and the Ohio Department of Medicaid presents its claim no later than 90 days after receiving that notice or one year after death, whichever is later. Estate fiduciaries must notify ODM of the death.

How much Ohio recovers: press reporting of Ohio Attorney General records has put annual collections at roughly $94 million in fiscal year 2024 (about $91.1 million in fiscal year 2023). These are press figures, not confirmed on a state agency page, so treat them as approximate.13

Practical advice: estate-recovery planning matters more in Ohio than in most states. Talk to an Ohio elder-law attorney experienced in expanded recovery before titling assets jointly, opening transfer-on-death accounts, or creating revocable trusts. Strategies that protect a family elsewhere may not protect against Ohio's reach.

Timing Waterfall (2024 to 2030)

Where to Get Help in Ohio

Pending Ohio Policy

These items were in motion at the time of writing. Each is time-sensitive, so verify the current status at the linked tracker rather than relying on the snapshot here.

1. HB 318 (estate-recovery reform). Referred to the House Medicaid Committee and not yet enacted; track it at the Ohio House HB 318 status page.
2. SUD 1115 demonstration renewal. The prior demonstration was extended through December 31, 2025, and ODM submitted a renewal; check the Medicaid.gov 1115 waiver tracker.
3. Group VIII work and community engagement 1115. Targets the Medicaid expansion population; work requirements exclude dual-eligibles, so this does not affect MyCare members. Check the CMS-approved version on the 1115 tracker for current terms.
4. PACE expansion. Statutory authority exists to add counties (including Franklin, Hamilton, Montgomery, Lucas, Trumbull, Ashtabula, and Mahoning); the PACE Association of Ohio has current site news.
5. Phase 2 carrier networks. Provider contracting in Phase 2 counties continued through summer 2026; specialty-network adequacy is a focus area for OSHIIP and Pro Seniors counseling.
6. Federal D-SNP timing. Under the federal CY2025 D-SNP Final Rule, plans continue consolidating dual-eligible products toward exclusively-aligned enrollment over the next several years.

Learn More

Find personalized help navigating Ohio's dual-eligible plans 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.