Next Generation MyCare Ohio 2026: FIDE-SNP Guide for Duals

If you or a family member in Ohio has both Medicare and Medicaid, the way those two programs work together changed dramatically on January 1, 2026. The federal MyCare Ohio Medicare-Medicaid Plan (MMP) demonstration that operated from May 2014 through December 31, 2025 ended along with the rest of the CMS Financial Alignment Initiative (FAI), terminated nationally by the CY2023 MA/Part D Final Rule (87 FR 27704, May 9, 2022). In its place, Ohio launched Next Generation MyCare, a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP) architecture under 42 CFR 422.2 with full Medicaid LTSS capitation, Exclusively Aligned Enrollment (EAE) per 42 CFR 422.514(h), and a phased statewide rollout running from January through August 2026.

Two facts that national coverage routinely misses about Ohio's transition: only four carriers were awarded Next Gen MyCare contracts (Anthem, Buckeye, CareSource, Molina), meaning the prior MMP carriers Aetna Better Health of Ohio and UnitedHealthcare Community Plan exited the program; and Buckeye Health Plan is closed to new enrollees in plan year 2026, so the practical choice for new applicants narrows to three plans (Anthem, CareSource, Molina). Ohio is also expanding the program from the 29 counties served under MMP to all 88 counties through six monthly tranches, making this the single largest state geographic expansion of dual-eligible integrated coverage in 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, what's pending in Ohio policy (HB 318 estate recovery reform), and what to watch for over the next four years.

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 & TennCare CHOICES, New York Medicaid Advantage Plus, and Massachusetts SCO & 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 Exited)
• Phased Geographic Rollout: 29 Counties on 1/1/2026 → 88 Counties by 8/1/2026
• Eligibility for Next Gen MyCare
• The MyCare Ohio Waiver: How It Replaces PASSPORT, Assisted Living, and Ohio Home Care for Dual-Eligibles
• Ohio Medicaid Financial Eligibility for LTSS (2026)
• The Special Income Limit ($2,982) and Qualified Income (Miller) Trusts
• Pay-In Spend-Down for ABD Adults
• Care Coordination in Next Gen MyCare
• Behavioral Health Integration: Ohio's Carve-In Model
• Paid Family Caregiving: C-HCAS, CD-PCS, and Structured Family Caregiving
• PACE in Ohio: McGregor Only (For Now)
• Three Worked Examples
• Provider Network Considerations (Phase 1 vs Phase 2 Counties)
• 14 Common Ohio-Specific Pitfalls
• Estate Recovery: Ohio's Unusually Broad Reach (and HB 318 Reform Watch)
• 2026 → 2027 → 2030 Timing Waterfall (Ohio-Specific)
• Where to Get Help in Ohio
• Pending Ohio Policy
• Related Reading

60-Second Version

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

Four awarded carriers in 2026:

1. Anthem Blue Cross and Blue Shield Ohio, new entrant; statewide for new enrollees; 833-727-2169.
2. CareSource MyCare Ohio, continuing carrier; statewide for new enrollees; 855-475-3163.
3. Molina HealthCare of Ohio MyCare, continuing carrier; statewide for new enrollees; 866-856-8295.
4. Wellcare Buckeye MyCare Ohio Dual Align (HMO D-SNP), closed to new enrollees in PY2026; current MMP members auto-transitioned; not available in Belmont or Ashtabula counties; 855-445-3562.

Exited as of 12/31/2025: Aetna Better Health of Ohio (still operates OhioRISE) and UnitedHealthcare Community Plan of Ohio (still operates mainstream Medicaid managed care).

Phased rollout:

• January 1, 2026, 29 counties (the original MMP regions across AAA1, AAA2, AAA4, AAA6, AAA10A, AAA10B, AAA11).
• April 1, 2026, 10 additional counties.
• May 1, 2026, additional AAA2, AAA3, AAA5 counties.
• June 1, 2026, AAA7 counties.
• July 1, 2026, AAA9 counties.
• August 1, 2026, AAA8 counties (statewide complete).

Default-enrollment for current dual-eligibles is auto-assignment with a 90-day "freedom of choice" window for the Medicaid side; aligned Medicare-Medicaid enrollment requires affirmative action via the Ohio Medicaid Consumer Hotline (800-324-8680) or Medicare (800-633-4227).

Key 2026 numbers: ABD income $994/month (= 2026 SSI FBR); special income limit $2,982/month (300% SSI); resource limit $2,000 (single)/$3,000 (couple, both applying); CSRA up to $162,660; MMMNA up to $4,066.50; PNA $75/month (raised 10/1/2025 from $50, ALW remains $50); home equity exclusion $752,000; 60-month institutional/HCBS look-back; no community Medicaid look-back.

Ohio is a 1634 state, NOT a 209(b) state, SSI receipt = automatic Medicaid (per SSA POMS SI 01715.020). The 209(b) states are CT, HI, IL, MN, MO, NH, ND, VA only.

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 11 capitated MMP states (with California, Illinois, Massachusetts, Michigan, Minnesota, New York–FIDA-only, Rhode Island, South Carolina, Texas, plus Washington's Managed FFS 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 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.

MMP enrollment grew substantially over the demonstration's eleven-year run; consult the ODM Annual Report for current historical figures. The CY2023 MA/Part D Final Rule ended this demonstration nationwide effective December 31, 2025, closing the FAI capitated MMP model in favor of integrated D-SNPs (FIDE-SNP, HIDE-SNP, or applicable integrated plan structures).

Ohio's response was to design Next Generation MyCare as a FIDE-SNP under 42 CFR 422.2, retain the integrated benefits package and care-coordinator model, capitate the MyCare Ohio Waiver into the FIDE-SNP, and use the transition as the occasion to expand the program statewide rather than remain in the original 29 counties. ODM issued the Next Gen MyCare procurement in 2024 and announced contract awards on October 31, 2024.

Next Gen vs MMP, what's different:

• New entrant Anthem; departures of Aetna and UHC.
• Phase 2 expansion to all 88 counties through monthly tranches running January–August 2026.
• FIDE-SNP architecture replaces three-way MMP contract; Medicaid managed by ODM contract, Medicare managed by CMS contract, Exclusively Aligned Enrollment (EAE) ties the two.
• Eligibility minimum age increased from 18 to 21.
• MyCare Ohio Waiver continues as the single capitated waiver replacing PASSPORT, Assisted Living, and Ohio Home Care for MyCare members.
• CO-D-SNPs (Coordination-Only 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. Anthem joined as a new entrant. Aetna Better Health of Ohio and UnitedHealthcare Community Plan exited the program entirely. Aetna continues to operate OhioRISE (the children/youth specialty BH plan) and UHC continues to operate mainstream Medicaid managed care for non-MyCare populations, but neither is a Next Gen MyCare option.

Aetna Better Health of Ohio (exited Next Gen MyCare; continues OhioRISE): Members who were Aetna MMP enrollees as of 12/31/2025 were sent ODM notices to choose a new Next Gen plan; if no selection by the deadline, ODM auto-assigned. Aetna continues to honor MMP-period claims for 365 days post-termination.

UnitedHealthcare Community Plan of Ohio (exited Next Gen MyCare; continues mainstream MMC): Same auto-assignment mechanism. UHC continues mainstream Medicaid managed care for non-MyCare populations and 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 has three plans to choose from in most counties, Anthem, CareSource, Molina, and four in counties where Buckeye remains for current members. ODM's own auto-assignment algorithm uses provider continuity, prior carrier relationship, and geography to default-assign.

Phased Geographic Rollout: 29 Counties on 1/1/2026 → 88 Counties by 8/1/2026

This is the single largest dual-eligible integrated-coverage geographic expansion in any state in 2026. ODM's published rollout schedule:

Phase 1, January 1, 2026, 29 counties (the legacy MMP regions):

• 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

A member must:

1. Be age 21 or older (raised from MMP's 18+).
2. Be full-benefit dual-eligible, Medicare Parts A and B + full Ohio Medicaid (not QMB-only or SLMB-only or QI-1 partial duals).
3. Reside in a county where Next Gen MyCare has launched.
4. Meet one of:
   • Nursing facility level of care (per ACAT assessment),
   • Eligibility for the MyCare Ohio Waiver (or PASSPORT, Assisted Living, Ohio Home Care for those transitioning),
   • Aged, Blind, or Disabled (ABD) status without LTSS need but qualifying for full Medicaid.
5. Not be enrolled in PACE (which is mutually exclusive with Next Gen MyCare).
6. Not be on a DODD waiver (Individual Options, Level One, SELF), DODD-waiver beneficiaries are excluded from MyCare.
7. Not be in OhioRISE (children/youth BH plan, age 0-20, no overlap).
8. Not be incarcerated or institutionalized in IMD-equivalent settings.

Who's NOT eligible: Partial duals (QMB-only, SLMB-only, QI-1), Medicare-only persons not on Medicaid, Medicaid-only persons not on Medicare, persons under 21, residents of counties not yet rolled in, PACE enrollees, DODD-waiver beneficiaries, and persons on the I/DD level-of-care pathway. These populations remain on their existing plan structures (Original Medicare or non-MyCare Medicare Advantage + mainstream Medicaid managed care or PASSPORT/Assisted Living/Ohio Home Care waivers).

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

Ohio operates five 1915(c) HCBS waivers in 2026:

1. PASSPORT, administered by the Ohio Department of Aging (ODA) via the 12 AAAs; serves age 60+ (or 60-64 with physical disability); requires NF level of care; non-dual or duals not in MyCare counties or duals choosing not to enroll in MyCare.
2. Assisted Living Waiver, administered by ODA via AAAs; serves 21+; requires NF level of care; pays for services in licensed Residential Care Facilities (assisted living); approximately 6,000 enrollment slots; not an entitlement (waitlist possible).
3. Ohio Home Care Waiver, administered by ODM directly; serves 18-59 (or younger); physical disability; NF level of care.
4. MyCare Ohio Waiver (OAC 5160-58), capitated under Next Gen MyCare plans; consolidates the three above for dual-eligible MyCare members; provides equivalent or expanded services.
5. DODD Waivers (Individual Options, Level One, SELF), for the I/DD population, administered by the Ohio Department of Developmental Disabilities; not part of MyCare.

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

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

MyCare Ohio Waiver service categories (per OAC 5160-58):

• Personal care
• Homemaker services
• Adult day services
• Home-delivered meals
• Personal Emergency Response System (PERS)
• Transportation (non-emergency medical and supportive)
• Skilled nursing services in the home
• Respite care
• Home modification (limited)
• Specialized medical equipment and supplies
• Out-of-home respite (including in licensed AL facilities)
• Pest control
• Independent Living Assistance
• Choices Home Care Attendant Service (C-HCAS), participant-directed
• Consumer-Directed Personal Care Service (CD-PCS), participant-directed
• Structured Family Caregiving (SFC), daily-care payment for live-in family caregiver

Waiver functional eligibility (NF Level of Care): assessed through the Adult Comprehensive Assessment Tool (ACAT) administered by the AAA on behalf of ODA. ACAT scores ADL/IADL deficits, cognitive function, behavioral health, and medical complexity. The threshold for NF level of care is a documented need for ongoing assistance with multiple ADLs or significant cognitive impairment.

Ohio Medicaid Financial Eligibility for LTSS (2026)

Ohio is a 1634 state. SSI receipt = automatic Medicaid enrollment with no separate application. The 209(b) states are CT, HI, IL, MN, MO, NH, ND, VA only, Ohio is NOT among them.

For the full eligibility framework, MAGI vs. ABD vs. LTC pathways, the three Track C spend-down options, application via CDJFS / ODM 07400 / 07408 / OBLTSS, retroactive coverage, recertification, and the 60-month transfer-penalty / APPR mechanics, see Ohio Medicaid Eligibility & Income Limits.

Pickle Amendment: Ohio applies federal Pickle protections to former SSI recipients who lost SSI due solely to Title II COLAs. Disabled Adult Children (DAC): Section 1634(c) protections apply (DACs who lose SSI due to parent's death/disability/retirement remain Medicaid-eligible). Disabled Widow(er) (DW): 1634(b) protections apply. Section 1619(b): allows working SSI recipients to retain Medicaid above the SSI cash threshold; 2026 Ohio threshold tracks the federal calculation (verify current number on SSA.gov).

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

Ohio uses the Special Income Limit pathway at 300% of SSI ($2,982/month single in 2026) for institutional and HCBS-waiver Medicaid. Applicants whose monthly income does not exceed $2,982 qualify financially for institutional or waiver Medicaid (subject to resource and other tests).

When monthly income exceeds $2,982, Ohio law requires a Qualified Income Trust (QIT), also called a Miller Trust, to redirect the excess into a trust account. The mechanics:

1. Applicant establishes the QIT, a written, irrevocable trust naming the State of Ohio as remainder beneficiary up to the total medical assistance paid.
2. Applicant deposits all of their monthly income into the trust account.
3. Each month, the trust pays out:
   • The Personal Needs Allowance ($75/month for NF residents),
   • Health insurance premiums (Medicare Part B, Medigap if any, Part D plan if not auto-paid by LIS),
   • The MMMNA to a community spouse (if applicable),
   • The remainder to the nursing facility or HCBS provider as patient liability/share-of-cost.

The QIT mechanism is a federal device authorized by 42 USC § 1396p(d)(4)(B) and is required in income-cap states. Ohio has been an income-cap state since 2014, prior to that, Ohio was a 209(b) state with a different methodology, but the conversion to 1634/income-cap status simplified eligibility for SSI populations while requiring QITs for higher-income LTSS applicants.

Common QIT pitfalls:

• Failing to deposit ALL income into the trust each month, partial deposits will not satisfy the income-cap rule and Medicaid will be denied.
• Establishing the trust mid-month and missing the first month's full deposit, creates an eligibility gap.
• Naming someone other than the state as remainder beneficiary, invalidates the trust under 42 USC § 1396p(d)(4)(B).
• Using a generic SNT or pooled trust template instead of a Miller Trust template, different statutes (d)(4)(A), (d)(4)(B), (d)(4)(C); Miller is (d)(4)(B).

Pay-In Spend-Down for ABD Adults

Ohio operates a Pay-In Spend-Down option for ABD adults (Aged, Blind, Disabled) whose income exceeds the $994 ABD limit but who do NOT need institutional or HCBS-waiver coverage. The mechanism:

• Applicant calculates the difference between their countable income and $994.
• Each month, applicant pays the difference directly to ODM as a premium-like payment (this is the "pay-in").
• Once the spend-down is paid, Medicaid coverage activates for that month.
• Alternative: applicant accumulates medical bills equal to the difference each month, once the bills equal the spend-down amount, Medicaid covers from that point forward in the month.

Why this matters for dual-eligibles: Many MyCare-eligible duals have income above $994 but below $2,982. They qualify for full ABD Medicaid via pay-in spend-down (or via one of the Medicare Savings Programs, QMB/SLMB/QI-1, which doesn't require pay-in but provides only premium and cost-sharing assistance, not full Medicaid). The MyCare Ohio Waiver requires full Medicaid, so the QMB-only path doesn't get a member into MyCare; pay-in spend-down or the special income limit pathway is required.

For nursing facility/HCBS Medicaid, pay-in spend-down doesn't apply, the $2,982 special income limit (with Miller Trust if exceeded) is the operative rule.

Care Coordination in Next Gen MyCare

Each Next Gen MyCare enrollee receives:

1. One Care Coordinator (typically RN, social worker, or LSW), the single point of contact across Medicare and Medicaid, including LTSS, BH, primary care, specialist coordination, transitions of care, and crisis response.
2. Comprehensive Health Assessment within 30 days of enrollment, repeated at least annually and at significant changes in condition.
3. Person-Centered Service Plan (PCSP) developed by the Interdisciplinary Care Team (ICT), includes the member, primary care provider, BH provider, LTSS coordinator, informal caregiver, and any other relevant professionals (pharmacist, specialist, AAA case manager retained as ICT consultant).
4. Integrated Health Risk Assessment combining Medicare and Medicaid risk factors for stratification.
5. 24/7 nurse advice line (plan-specific phone numbers).
6. Transitions of Care (TOC) protocol, each plan must have a documented protocol for hospital discharge, SNF discharge, home health initiation, and crisis stabilization transitions.

Care Coordinator caseload ratios (per ODM contract): For LTSS-using members, 1 care coordinator per ≤ 60 members; for non-LTSS dual members, ratios are higher but typically 1:120 or better. The ODM contract specifies caseload limits in the MCOP Provider Agreement.

ICT meeting frequency: at least quarterly for LTSS users; more frequent at care transitions or crisis events.

Continuity with AAAs: Three of the four Next Gen plans (Anthem, CareSource, Molina) have publicly committed to subcontracting some PASSPORT-track case management functions to AAAs. Buckeye's prior MMP arrangement included AAA partnerships; continuation under Next Gen is plan-specific. For families who valued an AAA case manager relationship, request explicitly that the plan retain the AAA as a service-delivery partner, not all plans do this automatically.

Behavioral Health Integration: Ohio's Carve-In Model

Effective July 1, 2018, Ohio carved behavioral health services into Medicaid managed care for fee-for-service populations; the carve-in expanded fully into managed care by 2020. Adult behavioral health is not carved out to a Behavioral Health Organization (BHO) or Pre-Paid Inpatient Health Plan (PIHP), Ohio operates a fully integrated model where the MCO (or, for Next Gen, the FIDE-SNP) covers physical, behavioral, and SUD services under one capitation.

Implications for Next Gen MyCare members:

• One care coordinator handles physical, behavioral, and LTSS, no need to navigate a separate BH plan.
• Plans contract with OhioMHAS-licensed providers under Ohio Department of Mental Health and Addiction Services standards.
• 988 Suicide & Crisis Lifeline routes Ohio callers to in-state crisis lines; mobile crisis teams contracted through the local Alcohol, Drug Addiction, and Mental Health Services (ADAMHS) Boards.
• Inpatient psychiatric services covered through the FIDE-SNP (Medicare 190-day lifetime limit applies to freestanding psychiatric hospitals; Medicaid covers state-operated psychiatric hospital stays under 1915(b) authority).

OhioRISE bridge at age 21: Youth aging out of OhioRISE who become dual-eligible at 21 should plan their MyCare enrollment proactively. The OhioRISE care coordinator and the new MyCare care coordinator should overlap during the transition; ODM's OhioRISE-to-Adult-Service-Transition protocol governs.

SUD 1115 demonstration: Ohio operates an active 1115 SUD demonstration providing federal financial participation for IMD residential SUD treatment (otherwise blocked by the 30-day IMD exclusion). The original demonstration was extended through 12/31/2025; ODM submitted a renewal in April 2024. Renewal status as of May 2026 was still pending at CMS and may be confirmed via the Medicaid.gov 1115 Waiver Tracker.

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

Ohio expanded paid family caregiver options materially in late 2024:

• Effective October 1, 2024: Self-direction expanded under the Ohio Home Care Waiver.
• Effective November 15, 2024: Self-direction expanded under the MyCare Ohio Waiver.

Two participant-direction options apply across MyCare and Ohio Home Care waivers:

1. Choices Home Care Attendant Service (C-HCAS): Participant directs hiring, scheduling, training, and termination of attendants. Rate flexibility within the participant's individual budget (rates set within state-defined ranges; participant negotiates within budget). Participant can hire family members (including spouses, adult children, grandchildren, nieces, nephews, in-laws).
2. Consumer-Directed Personal Care Service (CD-PCS): Similar participant-direction but with state-set rates (not budget-flexible). Participant can hire family members under the same scope as C-HCAS.

Structured Family Caregiving (SFC): A separate daily-care model under PASSPORT, MyCare Ohio, and Ohio Home Care waivers. SFC pays a live-in family caregiver a tiered daily rate; consult the AAA case manager or the MyCare care coordinator for the current SFC tier rates. The caregiver must live in the same residence as the participant, provide the bulk of personal care, and meet documentation/training requirements. SFC tiers reflect the participant's care needs, tier 1 light care, tier 2 moderate, tier 3 heavy (supports persons close to NF level of care).

Excluded relationships: Spouses cannot be paid under SFC (federal SFC rules prohibit spouses; some Ohio waivers allow spouses under C-HCAS, consult with the AAA case manager). Legally responsible relatives for minor children are also excluded.

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: McGregor Only (For Now)

Ohio has one operational PACE program in 2026:

• McGregor PACE, five sites:
  • Warrensville Heights (Cuyahoga County, main site)
  • Forest Hill (Cleveland Heights, Cuyahoga County)
  • Brooklyn (Cuyahoga County)
  • Ohio Living Rockynol (Akron, Summit County)
  • Elyria (Lorain County)

PACE is a Program of All-Inclusive Care for the Elderly under 42 CFR Part 460, a separate Medicare-Medicaid product with capitated payment to the PACE provider, mandatory day-center attendance, integrated medical/social/LTSS services, and a unique provider-team model. PACE is mutually exclusive with Next Gen MyCare, a person enrolls in one or the other.

PACE eligibility: Age 55+, NF level of care, residence in a PACE service area, and ability to live safely in the community. (Note: PACE's age 55 minimum is lower than Next Gen MyCare's 21, but PACE's NF-level-of-care requirement is stricter than Next Gen's various eligibility pathways.)

Expansion in development: Ohio statutory authority exists for PACE expansion to Franklin, Hamilton, Montgomery, Lucas, Trumbull, Ashtabula, and Mahoning counties. As of May 2026, no firm operational dates have been announced. The PACE Association of Ohio (paceoh.org, 614-481-5444) is the state-level coordinating organization.

Common confusion: Concordia Lutheran PACE Toledo does NOT operate, Concordia transferred operations to McGregor in 2010. Direction Home Akron PACE does NOT operate as a separate PACE program, the Rockynol site is McGregor's Akron presence. Older directories sometimes list these as separate; they are not.

Three Worked Examples

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

Doris lives alone in Cleveland Heights. She has Medicare Parts A/B and Ohio Medicaid (qualified via SSI, then aged into Medicare). Income: $1,420/month Social Security, no other income. Resources: $1,800. She has been on the PASSPORT Waiver for three years getting 25 hours/week of home care, adult day services twice weekly, and PERS. Her AAA case manager is from Western Reserve Area Agency on Aging.

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:

• Income $1,420/month is below the Special Income Limit ($2,982), so no Miller Trust required.
• Resources $1,800 below the $2,000 limit, eligible.
• No patient liability for HCBS waiver in Ohio (different from NF); home care services covered by Medicaid via MyCare capitation.
• Personal Needs Allowance not applicable (she's community-dwelling, not in NF).
• Medicare premiums (Part B at the current-year amount on medicare.gov) paid by Medicaid as QMB/full dual.

Key questions to verify:

• Are her current home care aides on the C-HCAS/CD-PCS roster, or do they need to enroll as Medicaid providers?
• Does Anthem's transitions-of-care protocol cover her existing prior authorizations?
• What's the PCP appointment continuity if Cleveland Clinic ever drops Anthem?

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

Kenneth lived independently until a stroke in October 2025 that required nursing facility admission. He's at a NF in Canton. His income: $2,650/month (combination of Social Security and a small pension). Spouse Eileen (age 67) lives in their owned home (equity $180,000); she has $48,000 in retirement savings and $720/month Social Security.

1/1/2026 transition:

• Stark is in AAA10B, Phase 1 county, Next Gen MyCare available from day one.
• Kenneth was admitted under MMP coverage (he was a CareSource MMP member). He auto-transitioned to CareSource MyCare on 1/1/2026, same plan, same NF, same care coordinator (CareSource committed to keeping continuity for current MMP NF members).
• His patient liability is calculated each month: $2,650 income minus $75 PNA minus Eileen's MMMNA up to $4,066.50 (Eileen's $720 income is below the MMMNA, so Kenneth contributes the difference from his income to Eileen up to MMMNA, practically, $2,650 - $75 - (Eileen's MMMNA gap of up to $3,346.50) = potentially zero patient liability if all eligible).

Key calculation, Community Spouse Monthly Income Allowance (CSMIA):

• Eileen's gross income: $720/month
• MMMNA (Ohio uses the federal formula; Eileen receives up to $4,066.50 if needed)
• CSMIA = MMMNA – Eileen's income = up to $3,346.50 transferred from Kenneth
• After CSMIA + Kenneth's $75 PNA, remaining income from Kenneth's $2,650 = $0–$50/month patient liability to NF
• The NF receives Medicaid + the small patient liability + Medicare Part A daily benefit

Resources:

• Eileen's $48,000 + Kenneth's accounts: assessed at the snapshot date (date of NF admission). CSRA up to $162,660 protects Eileen. Kenneth's countable resources must be ≤ $2,000 for him to qualify.
• Home equity $180,000 is below $752,000 home equity exclusion (Ohio applies federal floor); home is exempt while Eileen lives there.

Key questions to verify:

• Has the resource snapshot been performed with proper documentation?
• Has Eileen completed the Spousal Resource Assessment with the ODM Long-Term Care eligibility worker?
• Is the NF an in-network provider for CareSource MyCare?

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

Marcia has multiple sclerosis. She lives alone in a small home in Athens. Income $1,180/month SSDI; resources $850. She's been on the Ohio Home Care Waiver since 2018 receiving 18 hours/week of personal care plus skilled nursing. She has Medicare (qualified via 24-month SSDI Medicare entitlement) and full Ohio Medicaid (qualified via SSI then aged-into-Medicare workflow).

Phase 2E rollout, August 1, 2026:

• Athens is in AAA8, Phase 2E county, Next Gen MyCare launches 8/1/2026.
• Until 8/1/2026, Marcia continues on Ohio Home Care Waiver with ODM as the direct administrator. Her Medicare Advantage is currently a UnitedHealthcare D-SNP (non-aligned), and her Medicaid is FFS.
• In June 2026, she'll receive an ODM enrollment notice giving her options: Anthem, CareSource, or Molina (Buckeye is closed to new enrollees).
• Marcia chooses Molina HealthCare of Ohio MyCare based on a friend's positive experience and Molina's Athens-area provider network depth.
• On 8/1/2026, Marcia auto-transitions: Ohio Home Care Waiver → MyCare Ohio Waiver; UHC D-SNP → Molina MyCare (she affirmatively switched).

Care coordination handoff:

• Her ODM Ohio Home Care Waiver case manager prepares a transition packet with current PCSP, services, providers, and authorizations.
• Molina's care coordinator schedules a Comprehensive Health Assessment in the first 30 days post-transition.
• The Interdisciplinary Care Team includes Marcia, her neurologist (in Athens), her PCP, the home care agency, and a peer support counselor (Marcia has a co-occurring depression diagnosis that benefits from peer support, covered under Ohio's BH carve-in).

Key questions to verify:

• What's Molina's transition-of-care protocol for prior authorizations from her ODM-direct waiver period?
• Does Molina's neurologist network in Athens include her current neurologist?
• Is her preferred home care agency in Molina's network?

Provider Network Considerations (Phase 1 vs Phase 2 Counties)

Phase 1 counties (1/1/2026 launch) had three months of pre-launch provider contracting following the October 2024 contract awards. Networks are deepest in Cuyahoga, Franklin, Hamilton, Montgomery, and Lucas, the major urban anchors. Buckeye's MMP networks transferred largely intact for current members. Anthem entered fresh and built networks from existing Anthem mainstream MMC and Anthem Medicare Advantage relationships.

Phase 2 counties (April–August 2026 launches) have shorter provider-contracting windows. Some specialty providers (rural neurologists, endocrinologists, behavioral health prescribers) are not yet in-network for all four MyCare plans. Members in Phase 2 counties who depend on a specific specialist should call the carrier's member services line BEFORE enrollment to verify network status.

Hospital network coverage by major system in 2026 (general guidance, verify with carrier before relying):

• Cleveland Clinic (Cuyahoga, Lake, Lorain, Medina, Summit, Stark, Trumbull, Mahoning, Tuscarawas, etc.), Anthem in-network strong; CareSource in-network; Molina in-network in NE Ohio; Buckeye in-network in NE Ohio.
• University Hospitals (Cuyahoga, Lake, Geauga, Portage, Summit, Stark), broadly in-network across all four plans.
• OhioHealth (Franklin, Delaware, Madison, Pickaway, Marion, etc.), broadly in-network.
• Mount Carmel Health (Franklin), broadly in-network.
• Mercy Health (Cincinnati, Toledo, NW Ohio), in-network across plans; CareSource and Anthem strongest.
• TriHealth (Hamilton, Butler, Warren), broadly in-network.
• University of Cincinnati Medical Center (Hamilton), broadly in-network.
• ProMedica (Toledo, NW Ohio), broadly in-network.
• Premier Health (Montgomery, Greene, Clark), broadly in-network.

SNF/NF network coverage: Most major Ohio nursing facility chains (HCR ManorCare/Heartland, Communicare, Ciena, ProMedica Senior Care, Genesis HealthCare, Trilogy) contract with multiple Next Gen plans. For the current count of Medicare/Medicaid-certified Ohio nursing facilities, consult the Ohio Long-Term Care Consumer Guide. Members already in a NF as of 1/1/2026 retain their facility under transition-of-care provisions; new admissions should verify network status.

Home care agency network: Network coverage of Ohio Medicaid-certified home care agencies varies materially by carrier and by region. Members should ask the AAA case manager (for those in Phase 2 counties) or the new MyCare care coordinator (for those already enrolled) for in-network agency lists in their county.

14 Common Ohio-Specific Pitfalls

1. Forgetting that Aetna and UnitedHealthcare exited MyCare. Members who don't act may have been auto-assigned to a plan they would not have chosen. Verify your assignment via Ohio Medicaid Consumer Hotline (800-324-8680).
2. Buckeye Health Plan is closed to new MyCare enrollees in 2026. New applicants should not select Buckeye. Existing Buckeye members moving to Belmont or Ashtabula counties will be reassigned.
3. Medicaid-only auto-assignment vs full Medicare-Medicaid alignment. If you don't proactively select an aligned Medicare plan, ODM auto-assigns Medicaid only, you keep your existing Medicare Advantage or Original Medicare and miss the integration benefits. Call Medicare or 800-324-8680 to align.
4. PACE incompatibility with MyCare. McGregor PACE participants should NOT enroll in Next Gen MyCare. The two are mutually exclusive.
5. PASSPORT/Assisted Living/Ohio Home Care members in Phase 1 counties auto-converted to MyCare Ohio Waiver on 1/1/2026. AAA case manager relationships may not carry over automatically, request continuity explicitly.
6. Estate Recovery exposure is unusually broad in Ohio. Living trusts, joint ownership, transfer-on-death accounts are NOT safe-harbor in Ohio (unlike most states). HB 318 reform is pending but not enacted as of May 2026. Plan estate recovery carefully with a qualified Ohio elder law attorney.
7. Pharmacy filled at non-Gainwell network pharmacy. SPBM transition to Agadia PromptPA Portal (4/27/2026) may create temporary PA hiccups. Refill important prescriptions before the changeover.
8. Phase 2 county members who don't pre-select. Auto-assignment defaults to Medicaid-only enrollment (not aligned). To get full integrated benefits, members must affirmatively call before their county's launch date.
9. DODD waiver beneficiaries are excluded from MyCare. Adults on Individual Options, Level One, or SELF waivers are not eligible.
10. Ohio's 1634-state status, but income above SSI FBR ($994 in 2026) requires either Special Income Limit pathway, Miller Trust, or pay-in spend-down. Many families miss this distinction and incorrectly assume "SSI ≠ automatic full Medicaid for higher-income duals."
11. Look-back is institutional/HCBS only. No community Medicaid look-back in Ohio. Asset transfers reviewed only when seeking institutional or HCBS waiver coverage.
12. Out-of-county move complications. Member moves to a county where MyCare not yet available, reverts to Medicaid FFS for Medicaid; keeps Medicare. Re-enrolled when phase rolls in.
13. OhioRISE-to-MyCare bridge at age 21. Youth aging out of OhioRISE who are dual-eligible at 21 should plan MyCare enrollment proactively.
14. Misunderstanding the Special Income Limit / Miller Trust requirement. $2,982 is the income cap; above it, a Qualified Income (Miller) Trust is required and must capture ALL monthly income, partial deposits fail the test.

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

Ohio is one of the most aggressive estate recovery states in the country. Under ORC 5162.21 (renumbered from ORC 5111.11), Ohio's expanded estate recovery includes both probate AND non-probate assets:

• Transfer-on-death (TOD) accounts
• Jointly-owned property (with right of survivorship)
• Payable-on-death accounts
• Assets in living/revocable trusts
• Life estates created by the deceased Medicaid recipient
• Any other interest the decedent had at the moment before death

This expanded estate recovery is materially broader than the federal floor (which requires only probate-asset recovery). Ohio is among approximately 8 states with expanded recovery; most states limit recovery to probate-only assets.

TEFRA Lien Authority (ORC 5162.211): Ohio has authority to place liens on property of permanently institutionalized Medicaid recipients before death, including in some circumstances on a community spouse's property. Federal hardship and exemption protections apply.

Hardship Waiver: Available; petition must be filed within 30 days of estate recovery notice. Grounds include:

• Income-producing property (e.g., family farm) where recovery would impoverish surviving relatives.
• Substantial care provided by relatives that allowed the decedent to remain at home.
• Modest estate value (currently no statutory floor; HB 318 would set $10,000 floor).
• Other equitable circumstances.

Federal exemptions still apply:

• No recovery while a surviving spouse is alive.
• No recovery while a minor child or disabled child of the decedent survives.
• No recovery if a sibling with equity interest who lived in the home for at least 1 year before institutionalization survives.
• No recovery if a "caretaker child" (adult child who lived in the home and provided care for at least 2 years before institutionalization) survives.

HB 318 (136th General Assembly, 2025–2026): Pending reform legislation, sponsored by Reps. Stephens and Brennan (bipartisan). Would:

1. Limit estate recovery to probate-only (eliminating expanded non-probate reach).
2. Waive recovery under $10,000 (currently no statutory floor).
3. Cap home-equity liens at 75% of value for homes ≤$150,000.

Status as of May 2026: under House Medicaid Committee consideration; not enacted. Pro Seniors (Cincinnati) and Disability Rights Ohio are leading advocates. If enacted, HB 318 would substantially reduce estate recovery exposure for middle-income Ohio families.

Procedure (ORC 2117.061): ODM (acting through the Attorney General's office) files a creditor's claim against the estate within 90 days of receiving notice of the decedent's death. Failure to file within 90 days bars the claim. Estate fiduciaries must notify ODM of death.

Practical advice: For dual-eligibles in Ohio, estate recovery planning is more important than in most states. Consult with an Ohio elder law attorney experienced in expanded recovery before titling assets jointly, establishing transfer-on-death accounts, or creating revocable trusts as estate planning vehicles, these strategies that work in other states may NOT protect from Ohio's recovery reach.

2026 → 2027 → 2030 Timing Waterfall (Ohio-Specific)

Where to Get Help in Ohio

State counseling:

• Ohio Senior Health Insurance Information Program (OSHIIP), 1-800-686-1578; oshiipmail@insurance.ohio.gov; free 1-on-1 Medicare counseling, Part D plan finder, MSP/LIS, dual-eligible plan comparison.
• Ohio Medicaid Consumer Hotline, 800-324-8680; Mon-Fri 7am-8pm ET, Sat 8am-5pm ET; ohiomh.com; for plan changes, eligibility questions, complaints.
• PASSPORT statewide warm-transfer line, 1-866-243-5678 (auto-routes by ZIP to local AAA).

Area Agencies on Aging (12 statewide):

• AAA1 Council on Aging of Southwestern Ohio, Cincinnati, 800-252-0155.
• AAA2 Area Agency on Aging, PSA 2, Dayton, 800-258-7277.
• AAA3 Area Agency on Aging 3, Lima, 800-653-7277.
• AAA4 Area Office on Aging of Northwestern Ohio, Toledo, 800-472-7277.
• AAA5 Ohio District 5 AAA, Ontario (Mansfield), 800-860-5799.
• AAA6 Central Ohio Area Agency on Aging (COAAA), Columbus, 800-589-7277.
• AAA7 Area Agency on Aging 7, Rio Grande, 800-582-7277.
• AAA8 Buckeye Hills Area Agency on Aging, Marietta, 800-331-2644.
• AAA9 Area Agency on Aging Region 9, Cambridge, 800-945-4250.
• AAA10A Western Reserve Area Agency on Aging, Cleveland, 800-626-7277.
• AAA10B Direction Home Akron Canton, Uniontown, 800-421-7277.
• AAA11 Direction Home Eastern Ohio, Youngstown, 800-686-7367.

Legal aid and advocacy:

• Pro Seniors Inc. (Cincinnati, statewide), 800-488-6070 (Senior Medicare Patrol opt. 4); 513-345-4160 (Legal Helpline for Ohioans 60+); proseniors.org.
• Legal Aid of Western Ohio (Toledo, NW Ohio), lawolaw.org.
• Legal Aid Society of Cleveland, lasclev.org.
• Southeastern Ohio Legal Services, seols.org.
• Community Legal Aid Services (Akron/Canton/Youngstown), communitylegalaid.org.
• Disability Rights Ohio, disabilityrightsohio.org.
• Justice in Aging (national), justiceinaging.org.

Long-term care and provider associations:

• Ohio Long-Term Care Ombudsman, 800-282-1206 (statewide).
• LeadingAge Ohio, leadingageohio.org.
• Ohio Health Care Association (OHCA), ohca.org.
• PACE Association of Ohio, paceoh.org; 614-481-5444.

Federal:

• Medicare, 800-633-4227.
• SHIP Locator (national), shiphelp.org.

Plan member services (Next Gen MyCare):

• Anthem, 833-727-2169.
• Buckeye, 855-445-3562.
• CareSource, 855-475-3163.
• Molina, 866-856-8295.

SPBM: Gainwell Technologies Help Desk, 833-491-0344.

Crisis: 988 Suicide & Crisis Lifeline (call or text 988); Ohio CareLine, 800-720-9616.

Pending Ohio Policy

1. HB 318 (136th General Assembly), estate recovery reform; Pro Seniors and Disability Rights Ohio leading advocacy; House Medicaid Committee consideration as of May 2026; not yet enacted.
2. SUD 1115 demonstration renewal, original demonstration extended through 12/31/2025; ODM submitted renewal April 2024; CMS granted temporary extension; final renewal status pending as of May 2026 (verify on Medicaid.gov 1115 Waiver Tracker).
3. Group VIII Work and Community Engagement 1115, Ohio submitted February 2025; targets Medicaid expansion population (ages 19-55); planned 1/1/2026 implementation. ODM's coverage-loss projections appear in the §1115 demonstration application; check the current CMS-approved version for active estimates. Does NOT affect dual-eligibles (work requirements exclude duals, NH residents, and persons on disability).
4. PACE expansion, statutory authority exists for expansion to Franklin, Hamilton, Montgomery, Lucas, Trumbull, Ashtabula, Mahoning counties; no firm operational dates announced.
5. Phase 2 carrier networks, provider contracting in Phase 2 counties continues through summer 2026; specialty network adequacy will be a focus area for OSHIIP and Pro Seniors counseling in mid-to-late 2026.
6. CY2027 MA/Part D Proposed Rule (FR 2025-21456, 11/28/2025), declined EHO4All Health Equity Index; final rule expected mid-2026.
7. CY2027 federal D-SNP timing, second waterfall trigger 1/1/2027 (one D-SNP per state per parent for FBDE-only); Anthem, CareSource, Molina, Buckeye each have to consolidate any FBDE-only D-SNPs.
8. Cross-state concerns: Ohio's estate recovery reach may attract scrutiny if HB 318 stalls; LeadingAge Ohio has signaled concern about CMS Medicaid managed care rate adequacy for the new FIDE-SNP capitation methodology.

Learn More

• Ohio Medicaid Programs Overview
• Ohio Medicaid Eligibility & Income Limits
• Ohio MyCare Ohio Waiver
• Ohio Medicaid Managed Care Plans
• Ohio Estate Recovery
• Ohio Personal Needs Allowance

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.