Ohio Medicaid Guide: Eligibility, Waivers & Next Gen MyCare (2026)

Ohio Medicaid covers millions of Ohioans, from children and pregnant women to seniors in nursing homes and adults with disabilities. It runs through the Ohio Department of Medicaid (ODM), the joint federal-state health insurance program for people with limited income. For long-term care applicants, Ohio is an income-cap state: the 2026 Special Income Level (SIL) is $2,982 per month, 300% of the SSI Federal Benefit Rate. Ohio's rule says an applicant over that limit may establish a Qualified Income Trust (a Miller trust) to bring countable income down to the SIL. "May," not "must": nothing we could source establishes the trust as the only route for an over-cap Ohioan, so ask your county office what applies to you before assuming it is.1

For families navigating Ohio Medicaid in 2026, a major change is the transition from the MyCare Ohio Medicare-Medicaid Plan (MMP) demonstration to Next Generation MyCare, Ohio's Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP) for people age 21 and older who have both Medicare and Medicaid. It launched January 1, 2026 in 29 counties and rolls out statewide through August 2026.2

If you're a family caregiver, an aging Ohioan, a person with a disability, or a guardian working through Ohio Medicaid for the first time, this guide is your starting point. We cover what Medicaid does in Ohio, how it works for elderly and disabled adults (including long-term services and supports through PASSPORT, Assisted Living, Ohio Home Care, the new MyCare Ohio Waiver, and the DODD waivers), how to apply, financial eligibility for 2026, the Next Gen MyCare transition, Ohio's unusually broad estate recovery (and the pending HB 318 reform), and where to turn for free counseling and legal help.

For a deep dive on the dual-eligible architecture, see our Next Generation MyCare Ohio guide. For the federal context on FIDE-SNPs, see our federal FIDE-SNP hub.

60-Second Version

Coverage: Ohio Medicaid is delivered through ODM. Mainstream Medicaid Managed Care for non-dual populations is delivered by 7 plans (AmeriHealth Caritas, Anthem, Buckeye, CareSource, Humana Healthy Horizons, Molina, UHC Community Plan). Dual-eligibles age 21+ in Next Gen-launched counties enroll in Next Generation MyCare (4 plans: Anthem, Buckeye, CareSource, Molina, with Buckeye closed to new enrollees in PY2026). OhioRISE (Aetna Better Health) covers complex BH youth.

Three Ohio Medicaid eligibility pathways for adults:

1. Modified Adjusted Gross Income (MAGI): ages 19-64, expansion population, parents/caretakers, pregnant women, income test only, no asset test.
2. Aged, Blind, Disabled (ABD): 65+ or disabled, income $994/month (single, equal to the SSI Federal Benefit Rate) and asset limit $2,000 (single).
3. Long-Term Care/HCBS Special Income Limit: $2,982/month single (300% of the SSI Federal Benefit Rate); above this, Ohio's rule says you may use a Qualified Income (Miller) Trust to reduce countable income to the limit.1

1634 state: SSI receipt means automatic Medicaid (no separate application). Ohio became an income-cap (1634) state in 2014, converted from prior 209(b) status.1

1915(c) HCBS waivers: PASSPORT (age 60+), Assisted Living Waiver (21+), Ohio Home Care Waiver (birth through age 59, nursing-facility level of care), MyCare Ohio Waiver (capitated under Next Gen MyCare for duals), and the DODD Individual Options/Level One/SELF waivers (intellectual and developmental disabilities).3,7

Look-back: 60 months for institutional/HCBS only. No community Medicaid look-back in Ohio.1

Estate recovery: Ohio elects expanded recovery, reaching non-probate assets, transfer-on-death accounts, joint property, payable-on-death accounts, and living/revocable trusts under ORC 5162.21. HB 318 proposes narrowing recovery toward probate-only with low-value waivers, but was not enacted as of May 2026.5

How to apply: Online at benefits.ohio.gov, by mailing the signed paper application (form ODM 07216, Application for Health Coverage and Help Paying Costs) to your County Department of Job and Family Services (CDJFS), by phone (800-324-8680), or in person at your CDJFS. Long-term care applications use ODM 07400 plus the LTC supplement and go through the same CDJFS, and add the Adult Comprehensive Assessment Tool (ACAT) administered by your local Area Agency on Aging.1,6

Costs for context: a semi-private nursing home room in Ohio runs about $110,230 per year (roughly $9,186 per month) for 365 days of care, per the CareScout 2025 Cost of Care Survey released March 2, 2026; Medicaid covers the full cost once you meet financial and clinical eligibility.8

The 2026 Story: MyCare MMP to Next Gen MyCare

The federal CY2023 Medicare Advantage and Part D Final Rule (87 FR 27704, May 9, 2022) terminated all Financial Alignment Initiative (FAI) Medicare-Medicaid Plan demonstrations effective December 31, 2025. CMS transitioned the MMPs in the seven Financial Alignment Initiative states to integrated dual eligible special needs plans effective January 1, 2026. Ohio's MyCare Ohio MMP operated from May 2014 through 12/31/2025 in 29 counties grouped into 7 AAA regions.2

Ohio's response: Next Generation MyCare, a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP) under 42 CFR 422.2. Key changes from MMP:

• Four awarded carriers, three of them open statewide to new members: Anthem Blue Cross and Blue Shield, CareSource, and Molina Healthcare of Ohio. Buckeye Health Plan "will not be an option for new members or for those currently receiving care through another MyCare Ohio plan starting in the 2026 plan year." That is not an eviction: ODM says that if a member gets care through Buckeye today and wants to keep their plan, no action is required.
• Aetna Better Health of Ohio and UnitedHealthcare Community Plan EXITED Next Gen entirely. Aetna continues OhioRISE only; UHC continues mainstream Medicaid managed care only.
• Statewide expansion: 29 counties on 1/1/2026 to 88 counties by 8/1/2026 through six monthly tranches.
• Eligibility minimum age raised from 18 (MMP) to 21 (Next Gen).
• MyCare Ohio Waiver consolidates PASSPORT, Assisted Living, and Ohio Home Care waivers for dual-eligible MyCare members under OAC 5160-58.
• CO-D-SNPs (Coordination-Only D-SNPs) are no longer permitted for this population in Ohio, full integration is required.
• Exclusively Aligned Enrollment (EAE) under 42 CFR 422.514(h) is federally mandatory for FIDE-SNPs since 1/1/2025.
• You do not apply to Next Gen MyCare. ODM's wording is that individuals are in the program, once it is available in their county, if they meet the criteria. But meeting them is not always enough: ODM's own footnote excludes people who are on PACE or a Developmental Disabilities waiver (Individual Options, SELF, or Level One), or who have health insurance covering both inpatient hospital stays and doctor visits.2

The phased rollout schedule:2

• January 1, 2026, 29 counties (legacy MMP regions across 7 AAAs).
• April 1, 2026, 10 additional counties (parts of AAA4, AAA6, AAA11/Ashtabula).
• May 1, 2026, AAA2, AAA3, AAA5 county additions.
• June 1, 2026, AAA7 counties.
• July 1, 2026, AAA9 counties.
• August 1, 2026, AAA8 counties (statewide complete).

For full operational detail on the carriers, eligibility, MyCare Ohio Waiver, and pitfalls, see Next Generation MyCare Ohio.

Who Ohio Medicaid Covers

Ohio Medicaid covers these groups, at the 2026 income limits shown:1

• Children (Healthy Start CHIP-style): CHIP1 to 156% FPL (no premium) and CHIP2 from 156% to 206% FPL (premium tier).1
• Parents and caretaker relatives in households with children (under MAGI rules) up to 90% FPL.
• The adult MAGI group (named in Ohio Revised Code Chapter 5163 as Group VIII, and commonly called the expansion group) up to 138% FPL. That 138 is arithmetic, not a published number: ODM's own 2026 standards sheet carries the adult MAGI column at 133%, and federal rule 42 CFR 435.603(d)(4) adds a 5-percentage-point disregard when comparing income to the highest MAGI standard for a family size. Our source establishes the 133% and the deduction; it does not itself carry the Group VIII label or an age range, so confirm which category you fall in with your county office.1
• Pregnant women up to 200% FPL.
• Aged, Blind, Disabled (ABD) adults (65+, blind, or disabled per SSA standards), typically through SSI receipt or affirmative eligibility application.
• Persons receiving long-term services and supports (LTSS), including nursing facility residents, HCBS waiver participants, and Next Gen MyCare enrollees.
• Children with disabilities including those served by OhioRISE (BH-complex youth) and DODD waivers (I/DD).
• Working persons with disabilities through Medicaid Buy-In for Workers with Disabilities (MBIWD) under ORC § 5163.094.

CHIP for children above 138% FPL up to 206% FPL is delivered through the same Medicaid managed care infrastructure (Healthy Start Buckeye, etc.).1

The Three Ohio Medicaid Eligibility Pathways for Adults

For full operational detail on each pathway, 2026 income/resource thresholds, Group VIII / parents / pregnant women / children / MBIWD / family planning under MAGI; SSI Categorical / Categorically Needy / three Track C spend-down options under ABD; Special Income Limit, Miller Trust, spousal impoverishment, and home-equity exclusion under LTC, see Ohio Medicaid Eligibility & Income Limits.

Pathway 1, MAGI (Modified Adjusted Gross Income)

For adults 19-64, parents/caretakers, pregnant women, and most family Medicaid: applies the federal MAGI methodology under 42 CFR 435.603. Income only, no asset/resource test. Income limits (2026):1

• The adult MAGI group (ORC Chapter 5163's Group VIII): up to 138% FPL, which is ODM's published 133% standard plus the federal 5-percentage-point disregard. MAGI groups take no asset test, also federal: where financial eligibility is determined under 42 CFR 435.603, the agency "must not apply any assets or resources test."1
• Parents/Caretakers: up to 90% FPL.
• Pregnant women: up to 200% FPL.
• Children 0-18: up to 156% FPL (CHIP1, no premium) or 206% FPL (CHIP2, premium tier).

Ohio Group VIII Work and Community Engagement 1115: Federally approved February 2025; implementation 1/1/2026; estimated 62,000 disenrollments. Does NOT affect: dual-eligibles, NH residents, persons on disability, parents/caretakers of dependent children, pregnant women, persons in active SUD treatment, primary caregivers, full-time students.

Pathway 2, ABD (Aged, Blind, Disabled)

For adults 65+ or disabled per SSA standards (regardless of age): traditional non-MAGI methodology.1

• Income: $994/month single (equal to the 2026 SSI Federal Benefit Rate); $1,491/month couple.
• Resources: $2,000 single; $3,000 couple (both applying).

No income spend-down: Ohio ended its aged, blind, or disabled income spend-down on August 1, 2016, when it became a Section 1634 state. The Ohio Department of Medicaid states that from that date "individuals will no longer be able to spenddown to become eligible for Medicaid." A community-based ABD adult whose income exceeds the applicable limit therefore cannot buy in month by month. There is no monthly pay-in and no medical-bill spend-down to fall back on; the Qualified Income Trust is a long-term-care route, not a community one, and cannot substitute for the pathway that ended. No source we hold establishes any ABD spend-down or pay-in still in effect after that date, but an absence is not something a page can prove, so confirm current policy with ODM or your County Department of Job and Family Services (CDJFS).9

Reducing countable assets to the resource limit is a separate and still-valid step, unaffected by any of the above.9

And "no spend-down" is not the same as "no route," which matters most to a working Ohioan with a disability. Ohio runs the Medicaid Buy-In for Workers with Disabilities (MBIWD, also called Ohio WorkAbility), which ODM's own 2026 standards carry at 250% FPL with a resource limit of $15,668 for 2026, far above the SSI income standard and far above the $2,000 asset limit. We cannot source MBIWD's full eligibility conditions, so take this as a door to ask your CDJFS about rather than a test to apply to yourself.1 For the full breakdown of the ABD pathway, see Ohio Medicaid Eligibility & Income Limits.

1634 status (Ohio is 1634, NOT 209(b)): SSI recipients are automatically enrolled in Medicaid via SSA data exchange. Ohio became income-cap in 2014 (prior 209(b) status converted). The 209(b) states are CT/HI/IL/MN/MO/NH/ND/VA only.1

Pickle Amendment: Ohio applies federal Pickle protections to former SSI recipients who lost SSI due to Title II COLAs.

DAC (Disabled Adult Children) and Disabled Widow(er): Section 1634(c) and 1634(b) protections apply.

Section 1619(b): Working SSI recipients retain Medicaid above the SSI cash threshold (2026 OH threshold tracks federal calculation).

Pathway 3, LTC / HCBS Special Income Limit

For applicants needing nursing facility or HCBS waiver coverage:1

• Income: $2,982/month single (300% of the SSI Federal Benefit Rate in 2026); $5,964/month couple both applying.
• Resources: $2,000 single; $3,000 couple both applying. The community spouse is protected by the Community Spouse Resource Allowance (CSRA) of up to $162,660, with a floor of $32,532.10
• Home equity: Ohio applies the federal home-equity exclusion limit of $752,000 for 2026, the federal minimum tier (states may substitute an amount up to $1,130,000).1,11

The home-equity test can switch off entirely, and families miss this. Under 42 U.S.C. 1396p(f)(2) the limit "shall not apply" at all where the applicant's spouse, or a child under 21, or a blind or permanently and totally disabled child of any age, is lawfully residing in the home. That is a complete disapplication rather than a higher number, so home equity of any amount does not by itself disqualify such an applicant. Two more releases sit in the same statute: 1396p(f)(3) says nothing prevents using a reverse mortgage or a home equity loan to reduce equity below the limit, so being over it is not a permanent bar, and 1396p(f)(4) requires a hardship waiver process.11

Above the $2,982 income limit: OAC 5160:1-6-03.1(G) says an individual whose countable income exceeds the SIL may establish a Qualified Income Trust (QIT), also called a Miller trust, under 42 USC 1396p(d)(4)(B) to reduce countable income to or below the SIL. Read the word "may" carefully. No source we hold establishes the trust as the only route for an over-cap Ohioan, and this article previously said it was; ask your CDJFS what your alternatives are before you pay for a trust.1 The trust itself has strict terms: it must be irrevocable, only the individual's income may go into it, and the document must name the Ohio Department of Medicaid to receive the remaining trust property at the beneficiary's death up to the total medical assistance paid, ahead of any other creditor. Permissible disbursements are made in a set order: a monthly personal or maintenance needs allowance for the beneficiary, a maintenance allowance for the spouse and any dependents, health care costs, and up to fifteen dollars a month for the bank, attorney and other fees of setting up and running the trust, with ODM approval needed for more.11 It can only be used by someone whose income is above the SIL, who is eligible for Ohio Medicaid long-term care services, and who is subject to a patient-liability calculation, so it is not a substitute for the community spend-down Ohio ended in 2016.9 The trust pays out the $75 Personal Needs Allowance, health insurance premiums, the community spouse income allowance, and the remainder to the provider as patient liability. Being under the SIL is not the finish line either: you must still meet the resource rules, and you still owe a calculated patient liability.1,4

2026 Ohio Medicaid Financial Eligibility Limits

The figures below are the 2026 Ohio Medicaid financial thresholds for aged, blind, and disabled and long-term care applicants.1,10,11,4

Note: CSRA and MMMNA figures shown above are effective through 6/30/2026 and are federally re-indexed annually; verify the post-7/1/2026 figures before relying on them.

Two things the $75 line hides, and one of them is money a veteran keeps. Ohio's patient-liability rule runs in a set order, and at step (I)(2), before the $75 is subtracted at step (I)(3), it excludes up to $90 a month of Veterans Administration pension, including aid and attendance, paid to a veteran or a surviving spouse who is in a nursing facility or receiving HCBS waiver services (for a veteran with no spouse or dependent minor or disabled child, and for a surviving spouse with no such child). Because the pension comes out first, the $75 is taken from the resident's other income, so a qualifying veteran keeps the $90 on top of the $75, a total of $165 where there is at least $75 of other income. And $165 is not a ceiling: later steps subtract a community spouse's monthly income allowance, a family allowance, health insurance premiums and coinsurance, deductibles and copayments, the cost of medically necessary care Ohio recognizes that Medicaid does not cover, and up to $15 a month to administer a qualified income trust. Two of those have a route past their cap: a hearing decision can set a minimum monthly maintenance needs allowance above the cap, and court-ordered support that exceeds the calculated monthly income allowance is used instead.4

The $75 is a nursing-facility figure set inside a patient-liability sequence for institutionalized individuals. No source we hold settles what maintenance allowance an HCBS waiver participant receives in its place, so ask your case manager rather than assuming the same number.4

Ohio's 1915(c) HCBS Waivers

The waiver programs below are the ones Ohio's own rules establish for the populations this guide serves; we cannot source a definitive count of every 1915(c) waiver the state operates, so treat this as the set that matters here rather than the whole list. An HCBS-waiver applicant whose income exceeds base eligibility uses the Special Income Limit ($2,982/month single in 2026), which reaches waiver applicants because Ohio defines a continuous period of institutionalization to include thirty consecutive days of receiving, or being found eligible for and needing, HCBS waiver services. The resource limit is $2,000 for an individual and $3,000 for a married couple, and those are limits on countable resources, meaning what is left after exclusions, so the bare number is not a test a homeowner or car owner should apply to themselves.3,12,7

1. PASSPORT, Pre-Admission Screening System Providing Options and Resources Today

• Population: age 60+ via ODA/AAA
• Functional eligibility: nursing facility level of care (NF LOC) per ACAT
• Administration: Ohio Department of Aging (ODA) via the 12 Area Agencies on Aging (AAAs)
• Services: personal care, homemaker, adult day, home-delivered meals, PERS, transportation, skilled nursing, respite, home modification (limited), specialized equipment, IL assistance
• Financial eligibility: Special Income Limit ($2,982/month single)
• Cost limit and slots: the initial plan may not exceed $14,700 per month in waiver services, and there must be an available PASSPORT slot within the CMS-authorized limit for the program year. The cost limit is not a hard ceiling once you are enrolled; ODA can approve an ongoing plan above it
• One waiver service a month: you must need, and agree to receive, at least one waiver service monthly that is not available from another source, or else need continuous nursing longer than four hours plus at least one waiver service a year and monthly monitoring
• No double enrollment: you cannot be in PASSPORT and, at the same time, PACE, the state-funded PASSPORT or assisted living components, another Medicaid HCBS program, or the Residential State Supplement program
• A denial is appealable: fail any criterion and you are denied or disenrolled, but Ohio must notify you of your hearing rights under OAC division 5101:6
• Status: continues for non-dual or non-MyCare populations; for dual-eligibles in Next Gen MyCare counties, members are auto-converted to MyCare Ohio Waiver
• Full guide: The Ohio PASSPORT Waiver3

2. Assisted Living Waiver

• Population: age 21+
• Functional eligibility: NF LOC
• Setting: licensed Residential Care Facility (RCF / assisted living)
• Slots: a defined enrollment cap, NOT an entitlement (waitlist possible); confirm current slot count and waitlist status with ODA
• Administration: ODA via AAAs
• Services: personal care, medication administration, support coordination, dining, social activities. Medicaid never pays room and board here; the resident pays it from income
• Room and board is capped, and the number is knowable: OAC 5160-33-03 sets it at the SSI federal benefit rate minus fifty dollars, and providers may not charge more. With the 2026 SSI rate at $994, the ceiling is $944 a month, leaving $50 as the resident's monthly personal cushion. That is lower than the $75 nursing-facility personal needs allowance, which surprises families comparing the two
• Too little income is not automatically disqualifying: the same rule lets informal supports make a supplemental payment to the provider, capped at the gap between the resident's income and the maximum, and that payment is not counted in the resident's patient liability. A provider may also elect to accept a reduced room and board rate
• Full guide: Ohio Assisted Living Waiver12

3. Ohio Home Care Waiver

• Population: Ohioans from birth through age 59 with a nursing-facility-based level of care, intermediate or skilled, who would otherwise need hospitalization or nursing-facility care
• Setting: you must be able to live in a home and community-based setting, so someone currently in a nursing facility, residential care facility or adult foster home has to be able to move out to qualify
• Administration: ODM directly (not ODA), with case management through an ODM-designated contractor, a MyCare Ohio plan, or ODM itself
• Services: a fifteen-service package including personal care aide, home care attendant, waiver nursing, home-delivered meals, home modification, structured family caregiving, adult day health, and vehicle modification
• Cost limit: $14,700 per month for waiver services, tested at enrollment and ongoing, with ODM able to approve above it on the ongoing side
• The slot catch: meeting every clinical and financial test does not get you in. There must be an available program slot within the CMS-authorized limit for the waiver year
• Aging out: enrollees are disenrolled no later than 120 calendar days after their 60th birthday, and are offered the chance to move to PASSPORT if they meet its criteria
• Full guide: The Ohio Home Care Waiver7

4. MyCare Ohio Waiver (OAC 5160-58)

• Population: dual-eligibles (Medicare + Medicaid) age 21+ enrolled in Next Gen MyCare in launched counties
• Function: capitated 1915(c) waiver bundled into Next Gen MyCare FIDE-SNP
• Services: equivalent or expanded vs. PASSPORT/AL/OHC; ALSO includes Structured Family Caregiving (SFC), C-HCAS, CD-PCS
• Administration: ODM via Next Gen MyCare carriers (Anthem, Buckeye, CareSource, Molina), carriers contract care coordinators; some contract with AAAs for case management
• Full guide: The MyCare Ohio Waiver

5. DODD Waivers (Individual Options, Level One, SELF)

• Population: persons with intellectual or developmental disabilities (I/DD)
• Administration: Ohio Department of Developmental Disabilities (DODD), covering the Individual Options, Level One, and SELF waivers
• Eligibility: requires DODD level-of-care determination (different from NF LOC); Ohio County Boards of Developmental Disabilities are the local administrators
• Services: vary by waiver (Individual Options is most flexible/comprehensive; Level One has lower budget cap; SELF is participant-directed)
• Status: NOT part of MyCare; DODD-waiver beneficiaries are excluded from Next Gen MyCare

Mainstream Ohio Medicaid Managed Care (Non-Dual)

For non-dual Ohio Medicaid recipients, multiple plans operate the mainstream Medicaid Managed Care program under Ohio's Next Generation managed care procurement. The current carrier roster (commonly including AmeriHealth Caritas, Anthem, Buckeye, CareSource, Humana Healthy Horizons, Molina, and UnitedHealthcare Community Plan) shifts with state contracting cycles, so consult the Ohio Medicaid Managed Care plan directory for the current list.

These plans cover MAGI populations (Group VIII, parents/caretakers, pregnant women, children) and ABD members not in Next Gen MyCare. UHC and Aetna remain in the Ohio Medicaid landscape via mainstream MMC and OhioRISE respectively, even though both exited Next Gen MyCare.

Plan changes: Ohio members can change mainstream MMC plans during open enrollment (90 days from initial enrollment, then annually) or with just-cause changes year-round.

OhioRISE: BH for Children and Youth

OhioRISE (Resilience through Integrated Systems and Excellence) is Ohio's specialty Medicaid managed care plan for children and youth (ages 0-20) with the most complex behavioral health needs.

• Carrier: Aetna Better Health of Ohio (continuing 2026) operates OhioRISE under contract with ODM
• Target enrollment: tens of thousands of children and youth statewide; consult ODM for the current enrollment count
• Eligibility: Ohio Medicaid child/youth + meets functional criteria (assessed by CANS, Child and Adolescent Needs and Strengths tool)2
• Services: care coordination, intensive home-based treatment, mobile response and stabilization, psychiatric residential treatment, family peer support, transition to adult services
• Bridge to adult services: at age 21, OhioRISE youth who are dual-eligible should plan Next Gen MyCare enrollment proactively; non-dual continue under mainstream MMC

The Single Pharmacy Benefit Manager (SPBM)

Ohio runs a unified pharmacy benefit across all Medicaid managed care plans (mainstream managed care, Next Gen MyCare, and OhioRISE) through a single pharmacy benefit manager under contract with ODM, with a public portal at spbm.medicaid.ohio.gov. Because the SPBM was transitioning prior-authorization portals during 2026, refill important prescriptions ahead of any announced changeover and confirm the current PA process and Help Desk number with ODM before submitting time-sensitive prior authorizations.

You can apply through any of four channels, and long-term care applicants complete an added clinical step.1

Know your rights at the counter, because the date is what is at stake. Ohio Administrative Code 5160:1-2-01 requires the agency to not deny or discourage anyone's right to apply, to fulfill a request for an application within one business day, to give or send you a receipt showing the date of application, and to accept and register a signed application within one business day of receiving it. It may not delay registration or processing because you have not signed an acknowledgment of rights and responsibilities. That matters because the beginning date of your benefits depends on the date the signed application is received. Federally, 42 CFR 435.907(a) requires the agency to accept an application from the applicant, an adult in the applicant's household or family, an authorized representative, or, for a minor or an incapacitated person, someone acting responsibly for them, so an adult child can file for a parent who cannot and the county must take it. One protection is narrower than it sounds: the ban on requiring an in-person interview covers applications determined on MAGI income only, and does not reach a long-term-care or aged, blind and disabled determination.6

SSI applicants: SSI receipt automatically triggers Medicaid enrollment in Ohio (a 1634 state). No separate Medicaid application is needed; ODM is notified by SSA's State Data Exchange (SDX).1

Retroactive coverage. Federal law requires every state to make eligibility effective no later than the third month before the month of application, for covered services received in that window when the person would have been eligible at the time (42 U.S.C. 1396a(a)(34); 42 CFR 435.915). Two things a family should not assume. The exact start date inside that window is a state-plan choice rather than a federal one: the regulation says the agency may make eligibility effective on the first day of a month in which the person was eligible at any time, and the state plan must specify the date, so confirm Ohio's with ODM rather than counting on the first of the third month. And a state's window can be shorter than the federal default where a section 1115 demonstration changes it, which no source we hold settles for Ohio. The coverage does reach a person who has died, where the application is made on their behalf. Looking ahead, section 71112 of Public Law 119-21 shortens the window for applications made on or after January 1, 2027, to two months for most enrollees and CHIP and one month for the ACA adult expansion group, with the deceased-applicant path preserved on the same shortened clocks.13

Estate Recovery: Ohio's Unusually Broad Reach

Ohio elects expanded estate recovery, well beyond the federal floor. Under ORC 5162.21 (renumbered from ORC 5111.11), Ohio's estate recovery reaches both probate AND non-probate assets, taking the state option that 42 U.S.C. 1396p(b)(4)(B) allows above the probate-estate minimum. Ohio also takes the broad age-based option: the Attorney General, acting for ODM, recovers from the estate of a permanently institutionalized person of any age and of a person age 55 or older who was not permanently institutionalized, "in the amount of all medicaid benefits correctly paid including managed care capitation payments." We can source that Ohio's scheme is broader than the federal minimum; we cannot source where it ranks against other states, so do not read a national ranking into it. Ohio's "estate" covers:5

• 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 decedent
• Any other interest the decedent had at the moment before death

Two limits ride with that breadth on the age-55 track. Recovery reaches only benefits paid after the person turned 55, and it excludes benefits paid on or after January 1, 2010 under the Medicare premium assistance programs, meaning QMB, SLMB and QI. If the only Medicaid a person ever had was a Medicare Savings Program, that assistance is carved out of recovery.5

TEFRA Lien Authority (ORC 5162.211): ORC 5162.211(A) starts from a general prohibition on pre-death liens and then permits one, under division (B), on the real property of a permanently institutionalized recipient and on the recipient's spouse's real property, including property the two hold jointly. Division (C) bars any such lien on the home while the recipient's spouse, a child under 21 or a blind or disabled child, or a sibling who has an equity interest in the home and lived there at least a year before admission, lawfully resides there. And a lien that is imposed "shall dissolve on the recipient's discharge from the institution and return home," which is a real extinguishment rather than a postponement.5

Procedure (ORC 2117.061): after the estate's representative submits the Medicaid estate recovery notice form, ODM (acting through the Attorney General's office) presents its claim no later than 90 days after receiving that form, or one year after the decedent's death, whichever is later. There is no hard 90-day cutoff; the one-year-from-death limb is a floor, so a personal representative cannot bar the claim by delaying the notice.5

The protections are mostly deferrals, not forgiveness. This is the part families most often misread. Under OAC 5160:1-2-07(D), Ohio may recover only after the death of the surviving spouse, and only when there is no surviving child who is under 21 or blind or permanently and totally disabled. A surviving spouse delays recovery for life; it does not extinguish the claim, and the under-21 protection ends when that child turns 21.5

Two home protections run alongside, and both are written for the permanently-institutionalized track rather than the age-55 track. Where recovery is sought against a permanently institutionalized person, no recovery may be made against the home while there lawfully resides either:5

• A sibling who lived in the home for at least one year immediately before the admission and has lived there continuously since. Note what Ohio's recovery bar does not require: an equity interest in the home. That condition appears only in the pre-death lien bar at ORC 5162.211(C)(3), not here, and an earlier version of this guide wrongly imported it.
• A son or daughter who provided care that delayed the institutionalization, lived in the home for at least two years immediately before the admission and continuously since, and documents it with a level-of-care assessment, the attending physician's statement, and supporting care records. The paperwork is part of the test, not an afterthought.

Hardship waiver, and three other reliefs. ORC 5162.21(E) directs ODM to waive recovery where the Medicaid director determines it would work an undue hardship; the rule makes that case-by-case at the director's discretion, and an heir, potential heir, or person with an interest in estate assets must request it within thirty calendar days after the Attorney General's office mailed notice of the claim. We cannot source a published list of hardship grounds, so treat the standard as discretionary rather than checklist-based, and file inside the thirty days. Three more reliefs sit beside it: a Qualified Long-Term Care Partnership disregard given at eligibility is disregarded again at recovery; where an asset is not liquid, the Attorney General's office may set up a payment schedule, promissory note, or lien rather than force a sale; and a separate thirty-day window, running from the same mailing date, lets someone with an interest in the estate claim that assets are exempt under two named categories, government reparation payments to special populations and certain American Indian and Alaska Native income and resources.5

HB 318 (136th General Assembly, 2025-2026), a pending bipartisan reform sponsored by Reps. Stephens and Brennan, would narrow Ohio's recovery toward probate-only (eliminating the expanded non-probate reach) and add low-value estate waivers. It has not advanced beyond its initial Medicaid-committee referral (latest action June 4, 2025).5

Status as of May 2026: under House Medicaid Committee consideration; not enacted. Pro Seniors and Disability Rights Ohio leading advocacy.

Practical advice: For Ohio Medicaid LTSS applicants, estate recovery planning is more important than in most states. Strategies that protect from recovery in other states (TOD accounts, joint titling, revocable trusts) DO NOT protect from Ohio's expanded recovery. Consult an Ohio elder law attorney experienced in expanded recovery before estate-planning decisions.

For deeper context, see our Ohio Estate Recovery deep article and the Medicaid Estate Recovery Explained federal hub, which walks through 42 USC § 1396p(b), the 51-jurisdiction matrix, hardship-waiver standards, and the cross-state planning toolkit.

Paid Family Caregiving in Ohio

Ohio waivers do pay family caregivers, but the terms turn on which route you use, and the rules are narrower than families are often told.

Participant direction is available under the Ohio Home Care Waiver: personal care aide service may be delivered by a non-agency personal care aide rather than an agency employee, through Choices Home Care Attendant Service (C-HCAS) or Consumer-Directed Personal Care Service (CD-PCS), where the participant directs hiring, scheduling and training.7

Read the family-hire limit carefully, because this guide previously overstated it. Ohio's restriction is written for the agency route: under OAC 5160-46-04(G)(4), a criterion applying to agencies that employ personal care aides, parents of minor children, spouses, and relatives holding appointed legal decision-making authority for the individual may serve as a direct care worker only in accordance with OAC 5160-44-32, whose scope is agency-provided personal care aide and agency-provided waiver nursing. Whether, and on what terms, a spouse or parent may be paid outside the agency route is not settled by those rules. Do not commit to a caregiving arrangement, or leave a job for one, until ODM or your case manager confirms it in writing for your specific waiver.7

Structured Family Caregiving (SFC) is a separate daily-payment model for a live-in family caregiver, and it is one of the covered services in both the PASSPORT and Ohio Home Care benefit packages.3,7 Rates vary; confirm the current one, and who may be paid, with your AAA or waiver case manager.

All paid caregivers must:

• Pass Ohio BCI/FBI fingerprint background check
• Complete training (varies by waiver)
• Enroll as a Medicaid provider with ODM (typically 4-8 weeks)

For more on this, see Ohio Paid Family Caregiver Programs.

PACE in Ohio

McGregor PACE is the only operational PACE program in Ohio in 2026. PACE (Program of All-Inclusive Care for the Elderly) under 42 CFR Part 460 is a separate Medicare-Medicaid product with capitated payment to the PACE provider, mandatory day-center attendance, and an integrated provider team.

McGregor PACE service area: McGregor operates PACE sites across northeast Ohio (Cuyahoga and adjacent counties); consult the Medicaid.gov PACE locator for the current Ohio PACE roster and service area.

Eligibility: 42 CFR 460.150(b) sets four basic requirements, and (c)(1) adds a fifth condition at enrollment: age 55 or older; a state determination that you need the nursing-facility level of care Ohio's Medicaid plan covers; residence in the PACE organization's service area; any additional conditions in that organization's own PACE program agreement (which cannot modify the first three); and, at the time of enrollment, being able to live in a community setting without jeopardizing your health or safety. Eligibility to enroll is not limited to Medicare or Medicaid beneficiaries, and staying enrolled requires meeting the annual recertification requirements at 42 CFR 460.160.14

Cost, and leaving. A participant who is eligible for Medicaid may not be charged a monthly premium, and the organization must take the Medicaid capitation as payment in full, billing nothing further except any Medicaid spend-down liability and amounts due under post-eligibility treatment of income. A participant who is not Medicaid-eligible does pay a monthly premium. You can disenroll voluntarily at any time without cause, but it takes effect the first day of the month after the organization receives your notice, and PACE stays all-inclusive until then. Involuntary disenrollment is limited to enumerated grounds, and two protections matter for a family living with dementia: nonpayment is a ground only after a 30-day grace period and a failure to make satisfactory payment arrangements, and the organization may not disenroll someone for noncompliant behavior, defined to include repeated noncompliance with medical advice and repeated missed appointments, where that behavior stems from a mental or physical condition, unless it jeopardizes health or safety. An involuntary disenrollment takes effect on the first day of the next month beginning 30 days after notice, and the state agency must first review it and find the grounds adequately documented. None of the sections here give the participant a personal appeal right against involuntary disenrollment; that state review is the only safeguard they establish.14

PACE is mutually exclusive with Next Gen MyCare, a person enrolls in one or the other, and Ohio's PASSPORT rule likewise bars being in PASSPORT and PACE at the same time.3

PACE Association of Ohio is the state's PACE coordinating body. Ohio has statutory authority for PACE expansion to additional counties; consult the Association and ODM for the current operational footprint and timelines.

If Ohio Medicaid Denies or Cuts Your Coverage

Ohio's deadline is 90 days, and the clock starts the day after the notice is mailed rather than the day it reached you. ODJFS must receive your state-hearing request inside that window, and the date of the request is the date the state or local agency receives it. One condition rides with it: the ninety-day limit does not apply unless you were given notice of your hearing rights for the specific action being appealed. You can request a hearing orally, in writing, or electronically, by calling the ODJFS Bureau of State Hearings toll-free at 1-866-635-3748, by writing to PO Box 182825, Columbus, Ohio 43218-2825, or by faxing the request form to (614) 728-9574.15 That 90 is the ceiling 42 CFR 431.221(d) puts on what a state may allow, not a floor you are owed; Ohio uses it in full, and other states set shorter windows that bind just as firmly.16

Federal law gives applicants and beneficiaries a right to a fair hearing before the state agency, and 42 CFR 431.220(a) spells out six categories of person who hold it, not one. Two are easy to overlook: a nursing facility resident who believes the facility has wrongly decided they must be transferred or discharged, and a person challenging a preadmission or annual resident review determination. The list also expressly covers spend-down determinations, the amount of premiums and cost sharing, a change in the amount or type of services, and prior-authorization decisions. The right is not unconditional, though: under 431.220(b) the agency need not grant a hearing where the sole issue is a federal or state law requiring an automatic change that adversely affects some or all beneficiaries.13

The second clock is shorter, and it decides whether coverage keeps running. If you are already enrolled and the notice says your assistance or services will be reduced, stopped, or restricted, request the hearing within 15 days of receiving that notice to hold your benefits at the prior level. Continuation is conditional rather than automatic: Ohio's rule lists ten circumstances that end it, including a finding at the hearing that the sole issue is one of state or federal law rather than fact or judgment, and withdrawal or abandonment of the appeal. If you keep benefits and then lose, you may have to repay what you were not eligible to receive.15

Missing the fifteen days is not necessarily the end, and this is the part most people never learn. Under OAC 5101:6-4-01(C), if the agency receives your request within ten calendar days after the adverse action took effect and you show good cause for the delay, benefits are reinstated to the previous level retroactive to the date they were cut. Good cause means a death in the immediate family, sudden illness or injury to you or a close family member, or other circumstances that reasonably prevented a timely request. And under paragraph (D), where the action was taken without prior notice, a request received within fifteen calendar days from the mailing date of the notice restores benefits to the previous level.15 Federal law backs that second route: 42 CFR 431.231(c) says the agency must reinstate and continue services where the action was taken without the required advance notice, you request a hearing within 10 days of receiving the notice (receipt is presumed 5 days after the notice date unless you show otherwise), and the agency determines the action did not result from applying federal or state law or policy. That is a right to reinstatement, not a hope of one. Ask for continuation explicitly rather than assuming it happens on its own.17

If a Next Generation managed care plan issued the denial, appeal to the plan within 60 calendar days of the date its notice of action was issued, exhaust that appeal, then request a state hearing within 90 calendar days of the plan's adverse resolution. That 60-day clock is the plan track, not the eligibility-denial deadline. Two doors get you past the exhaustion requirement: if the plan fails to follow the notice and timing rules for appeals, you are deemed to have exhausted it and may go straight to a state hearing, and members proposed for or enrolled in the coordinated services program are exempt from appealing to the plan first. If the standard timeline could seriously jeopardize your life, health, or ability to regain maximum function, ask for an expedited appeal: the plan decides within one business day whether to expedite and must resolve within 72 hours, and if it refuses to expedite the appeal drops to the standard fifteen-day timeframe.18

The managed-care continuation trap. To keep benefits during a plan appeal, all four of these must hold: you request the appeal within fifteen days of the plan issuing its notice; the appeal is about terminating, suspending or reducing services you had not yet received; an authorized provider ordered them; and the authorization period has not expired. Then watch the end of it, because this is where coverage quietly stops: continued benefits run out if you fail to request the state hearing within fifteen days after the plan issues its adverse appeal resolution, which is not the 90 days you have to file the hearing request itself. File inside fifteen days if you need the services to keep flowing. If you lose, ODM may recover the cost of what was furnished while the appeal was pending, though in managed care that recovery is discretionary.18

Find every date on your own notice and file before the earliest one. See Ohio Medicaid Appeals and Fair Hearings for how to file, what the hearing itself involves, and what happens after a decision.

Keeping Ohio Medicaid Once You Have It

Eligibility is re-checked on a recurring cycle, and missing that step is one of the most common ways people lose coverage they still qualify for.

Ohio Medicaid must first try to renew your coverage automatically from information it already holds, and may only request documents if it cannot. When it does renew that way, it has to tell you the determination and its basis and that you must report anything inaccurate in the notice, but you are not required to sign and return that notice if everything on it is correct.19 If it does need paperwork, it must send a renewal form and give you at least 30 days from the date of the form, not from the date it was sent, to return it. It also may not make you sit for an in-person interview as part of a renewal, and it may not put you through renewal more often than once every 12 months. That duty, and the 90-day reconsideration window below, cover eligibility based on modified adjusted gross income (MAGI). If you qualify through age, disability, long-term care, a Medicare Savings Program, or the medically needy pathway, Ohio may offer the same windows but is not required to, so ask ODM what applies to you.19

If coverage does close because a form went unreturned, that is not the end of it. Federal rules require the agency to reconsider your eligibility without a new application if you return the renewal form within 90 days of the termination (required for MAGI-based coverage; a state option otherwise).19

Keep your address current, open anything from Ohio Medicaid, and return a renewal form the week it arrives. See Ohio Medicaid Recertification and Renewal for the full cycle and how to recover closed coverage.

Where to Get Help

Ohio has free counseling, ombudsman, and legal-aid resources for Medicaid and long-term care questions. Start with the state agencies below, then use your local Area Agency on Aging for in-person help.

Other support lines: Ohio Senior Medicare Patrol / Pro Seniors (800-488-6070, opt. 4); Ohio CareLine mental-health support (800-720-9616); and the 988 Suicide & Crisis Lifeline (call or text 988).

Area Agencies on Aging (12 statewide, call for in-person assessment, PASSPORT enrollment, MyCare transition help):

• 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 AAA (Marietta), 800-331-2644
• AAA9 Area Agency on Aging Region 9 (Cambridge), 800-945-4250
• AAA10A Western Reserve AAA (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 elderly legal services, 513-345-4160), Disability Rights Ohio (disabilityrightsohio.org), and your regional legal-aid office (Legal Aid of Western Ohio, Legal Aid Society of Cleveland, Southeastern Ohio Legal Services, or Community Legal Aid Services in Akron/Canton/Youngstown). For finding nursing-facility, assisted-living, and HCBS providers, LeadingAge Ohio and the Ohio Health Care Association keep member directories.

Federal: Medicare, 800-633-4227; national SHIP locator, shiphelp.org.21

Pending Ohio Policy

These items were pending as of May 2026; verify current status with ODM before relying on any of them in a single case.5,2

1. HB 318 (136th GA), estate recovery reform (narrow toward probate-only with low-value waivers); Pro Seniors and Disability Rights Ohio leading advocacy; in the House Medicaid Committee as of May 2026, not enacted.
2. SUD 1115 demonstration renewal, original demonstration extended through 12/31/2025 with renewal pending CMS approval as of May 2026; verify status against ODM and the CMS Section 1115 demonstrations page before relying on this in a single-case timeline.
3. Group VIII Work and Community Engagement 1115, federally approved February 2025; implementation 1/1/2026; estimated 62,000 disenrollments. Does NOT affect dual-eligibles, NH residents, persons on disability.
4. Phase 2 Next Gen MyCare statewide rollout, continues through August 2026; carrier provider networks in Phase 2 counties continue contracting through summer 2026.
5. PACE expansion, statutory authority for Franklin/Hamilton/Montgomery/Lucas/Trumbull/Ashtabula/Mahoning counties; no firm operational dates as of May 2026.
6. CY2027 federal D-SNP timing, a second integration trigger on 1/1/2027 (one D-SNP per state per parent organization for full-benefit dual-eligible-only plans), with the federal D-SNP look-alike threshold tightening further. Confirm the exact CMS parameters before relying on them.
7. H.R. 1 retroactive Medicaid coverage limits effective 1/1/2027, subject to CMS implementation guidance.

Learn More

Eligibility, applying, and financial planning

Long-term care and HCBS waivers

Managed care and statewide

Find personalized help navigating Ohio Medicaid 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.