Navigating the Next Generation MyCare Program - What Providers Need to Know

Mark your calendars - the Next Generation MyCare program starts on January 1, 2026. ODM hosted a Next Generation MyCare Program Overview for Providers webinar, the slides should be available on the MyCare Ohio website linked below soon.  

What is the Next Generation MyCare Program? 

The Next Generation MyCare program is designed to better serve Ohioans who are eligible for both Medicaid and Medicare by helping members get the care they need all in one plan. The program has key changes for both members and providers. 

Becoming a Next Generation MyCare Provider 

To become a provider in the Next Generation MyCare program you must: 

  1. Enroll with ODM by visiting the Medicaid Provider Portal and completing the online application (credentialing, if required, will occur automatically during application processing), and;
  2. Contract with the Next Generation MyCare plans by contacting each of the plans you wish to contract with.
    • Anthem Blue Cross and Blue Shield​: 833-727-2170
    • Buckeye Health Plan: 833-998-4892
    • CareSource: 800-488-0134
    • Molina HealthCare of Ohio: 855-322-4079 

Submitting Next Generation MyCare Claims: 

The process for submitting Electronic Data Interchange (EDI) claims in the Next Generation MyCare program is changing. If you are not an Ohio Medicaid provider, your claims will be rejected.   

  • If you are submitting your claims to the plans portal using Direct Data Entry (DDE), you will submit a single claim to the Next Generation MyCare plan via their existing process. The Next Generation MyCare plans will not accept paper claims. 
  • If you are submitting an EDI claim for a dual benefit member (a member who gets their Medicaid and Medicare benefits from one Next Generation MyCare plan) or for a Medicaid-only member (a member who gets only their Medicaid benefits from one Next Generation MyCare plan) where the Medicaid is the primary payer, you will submit the claim through the one front door, to the Ohio Medicaid Enterprise System (OMES). You must use the member’s Medicaid ID even if they have other ID numbers. The submitted file must use the Next Generation MyCare Plan Receiver ID and the appropriate Payer ID in the 2010BB loop for claims to be directed to the correct Next Generation MyCare plan for processing.  
  • If you are submitting an EDI claim for a Medicare covered service for a Medicaid-only member, you will submit the claim, also known as a crossover claim, to the primary payer.  
    • If Medicare is the primary payer, submit the claim to Medicare using your normal process. Claims for Ohio MyCare members will be automatically crossed over to the Next Generation MyCare plan.   
    • If the primary payer is a Medicare Advantage/Part C plan, submit the claim to that payer using your normal process. Once the primary payer has adjudicated the claim and returned the Remittance Advice, submit the claim through the OMES one front door using the Receiver ID and Payer ID as described for a dual benefit claim.

Refer to the Companion Guides for more information. Updated companion guides with new payer IDs have been posted.

How Can You Help the Members You Serve? 

As we approach the implementation of the Next Generation MyCare program, there are a couple key things you need to know about members. 

  • Each year Medicaid open enrollment is from November 1 to November 30 and Medicare open enrollment is from October 15 to December 7. During this time, members can select a plan. If members have questions, they can call the Ohio Medicaid Consumer Hotline at 800-324-8680. 
  • Once a member is enrolled in their MyCare plan, they will receive a MyCare member ID card in the mail from their plan before the program begins. Look for the MyCare logo on the card to confirm their enrollment. Check out our Next Generation MyCare Member ID Card One-Pager to learn more.   

Where Can You Learn More? 

Visit the MyCare Ohio webpage on medicaid.ohio.gov or view our Next Generation MyCare Program Provider Frequently Asked Questions (FAQ) document to learn more.  You can also view our Next Generation MyCare Provider Help Desk One-Pager to find who to call for help.

Next Generation MyCare Provider Resources:

In preparation for the Next Generation MyCare program on January 1, 2026, ODM created resources that you can use and share when interacting with other providers.