Next Generation MyCare Ohio

The Ohio Department of Medicaid (ODM) launched the Next Generation MyCare program effective January 1, 2026, to better serve Ohioans who are dually eligible for Medicaid and Medicare. The program and all four Next Generation MyCare plans are now live in the existing 29 MyCare counties, with statewide expansion planned later this year.

Claims Submission Overview

As a reminder, all Next Generation MyCare claims must now be submitted via EDI through the Ohio Medicaid Enterprise System (OMES), also referred to as the “one front door” (OFD).

 Effective 1/1/26, all MyCare claims must be submitted through the OFD, regardless of date of service. Claims will be routed to the appropriate plan based on the Receiver ID in the header of the EDI transaction, and the Payer ID in the 2010BB loop NM109. New Receiver and Payer IDs are published in the 837P companion guide. ODM sent trading partners an email with billing reminders on 1/7/26 outlining some common issues.

For Anthem, Buckeye, CareSource, and Molina, claims must be billed through the OFD effective 1/1/26 regardless of date of service. For claims submitted on or after 1/1/26, including claims with dates of service prior to 1/1/26, providers should submit claims through the OFD using the Next Generation MyCare Plan Payer IDs from the current companion guide, and the member’s MMIS (Medicaid ID) number. This applies even though the companion guide indicates the new payer IDs are for dates of service beginning 1/1/26.

Primary Payer Scenarios

The ODM MyCare FAQ (linked below) outlines claims submission requirements for various primary payer configurations.

Dual Benefit Members or Medicaid-Only Members (Medicaid is Primary):

  • Submit EDI claims through the OFD to OMES.
  • Use the member’s Medicaid ID (MMIS), even if other member IDs exist.
  • Use the Next Generation MyCare Plan Receiver ID and the appropriate Payer ID in the 2010BB loop to ensure correct routing.

Medicare-Covered Services for Medicaid-Only Members (Crossover Claims):

  • If Medicare is the primary payer, submit the claim to Medicare using your standard process. Claims for MyCare members will automatically cross over to the Next Generation MyCare plan.
  • If a Medicare Advantage (Part C) plan is the primary payer, submit the claim to that payer first. After adjudication, submit the claim through the OFD using the appropriate Receiver ID and Payer ID for the Next Generation MyCare plan.

Please refer to the companion guides and FAQ for additional details.

Aetna and United Claims Runout

Aetna Better Health of Ohio and UnitedHealthcare are no longer MyCare Ohio plans as of December 31, 2025. However, both plans will continue to process and pay claims for up to 365 days following the end of the year and remain responsible for claims with dates of service through December 31, 2025. These claims should continue to be submitted directly to Aetna or United using existing processes. As a reminder, the MyCare Ohio contract is separate from the Ohio Medicaid Managed Care contract and United remains a Medicaid managed care plan through the UHC community plan, while Aetna retains the OhioRISE contract.

Outbound Transactions and Eligibility Lookups

ODM has also shared that the Next Generation MyCare plans are currently experiencing issues with outbound transactions, including the delivery of 277 Claims Acknowledgements (277CA) and 835 Electronic Remittance Advice (ERA) files, as well as with member eligibility processing through the Next Generation MyCare managed care 270/271 process. In addition, CareSource is experiencing issues impacting its ability to deliver outbound managed care 835 ERA files. The plans are actively working to resolve these issues. Once resolved, providers should begin receiving 277CAs and 835 ERAs through normal processes, and member eligibility lookups may resume through the standard Next Generation MyCare MCO 270/271 process. In the interim, providers may contact the plans directly to obtain claim adjudication status and 835 ERA information. Member eligibility can also be verified through Provider Network Management (PNM) or by using the fee-for-service 270/271 eligibility process.

The below resources are also helpful for providers.