Next Generation of MyCare Ohio Information for Trading Partners

The Ohio Department of Medicaid (ODM) has shared the below communication with trading partners. Providers are encouraged to share this information with their clearinghouses.

The Ohio Department of Medicaid (ODM) is bringing MyCare Ohio into the Next Generation program starting on January 1, 2026. At that time, Next Generation MyCare will be available in the 29 counties where MyCare Ohio is available today, with statewide expansion following later in 2026. These changes are part of ODM’s commitment to improve care for our members, reduce the burden on providers, and create a more seamless Electronic Data Interchange (EDI) transaction process for the trading partners (TP) who support them.

There are four critical things TPs must prepare to do leading up to the implementation of the Next Generation MyCare program.

Current Claim Submission: Today through December 31, 2025 - Continue to submit MyCare Ohio claims directly to the five current MyCare Ohio plans (Aetna Better Health of Ohio, CareSource, Buckeye Health Plan, Molina HealthCare of Ohio, and United Health Care), or to the member’s primary payer (i.e. Medicare).

Programming Preparation: Today through December 31, 2025 - Providers must submit their Next Generation MyCare claims either to the member’s primary payer or through the ODM One Front Door (OFD). ODM selected four Next Generation MyCare plans. Three of the plans are available for members to select statewide. The plans include some current MyCare Ohio plans and a new plan to the program. All plans will cover a member’s Medicare and Medicaid benefits. The plans available statewide are: 

  • Anthem Blue Cross and Blue Shield
  • CareSource
  • Molina HealthCare of Ohio

Buckeye Health Plan won’t be an option for new members or for those currently receiving care through another MyCare Ohio plan starting in the 2026 plan year. Current members receiving care through Buckeye Health Plan can continue to receive care through Buckeye Health Plan in the 2026 plan year if they choose.

All necessary configuration changes needed to route claims to the front door and to the proper plan should be completed by December 31, 2025.

New Claim Submission: January 1, 2026 – December 31, 2026 - The claim submission process for the Next Generation MyCare program will work in the same way it does today for the Next Generation Managed Care program. All claims will be submitted through the OFD and be forwarded to the plan identified by the Receiver ID in the header of the EDI transaction and the Payer ID in the 2010BB loop NM109. New Receiver and Payer IDs will be published in the Companion Guides in the coming days to help you and your providers prepare for this change. The cut-over on January 1, 2026, is a hard cut-over. All EDI Next Generation MyCare claims regardless of date of service (DOS) must be submitted via the OFD beginning on that date.

Statewide Expansion - On January 1, 2026, the Next Generation MyCare program will be available in the 29 counties where the current MyCare Ohio program is available. Beginning in April 2026, the program will roll out across the remaining counties in Ohio monthly, reaching statewide in August 2026. View the roll out schedule to learn more. TPs and providers will need to pay close attention to a member’s enrollment as it will be shifting into a Next Generation MyCare plan throughout 2026. Please communicate this change with your internal staff. Additional communications will be forthcoming. To ensure the right members of your team receive these notices contact the Ohio Medicaid Enterprise System (OMES) EDI Support team at 1-800-686-1516 opt 4 for assistance in updating your contact information

DUPLICATE ENROLLMENT IN MEDICAID & MARKETPLACE – NEW FAST FACTS

CMS released new Fast Facts (PDF) about the ways they are making sure people aren’t enrolled in more than one state Medicaid program or enrolled in both Medicaid and a Marketplace plan. Duplicate enrollment wastes taxpayer dollars and puts added strain on an already burdened health care system. Individuals identified with potential duplicate enrollment may need to take action to ensure they’re enrolled only in the program they’re eligible for. CMS shared the below efforts to eliminate duplicate enrollment:

  • CMS is developing an enhanced fraud and waste prevention measures under HR1 to strengthen program integrity.
  • CMS is partnering with states to systematically identify and address duplicate enrollments across Medicaid and CHIP programs.
  • CMS is working with ACA Exchanges to refine their data matching efforts and conduct at least biannual review to reduce duplicate enrollments.