With the implementation of the Next Generation MyCare program on January 1, 2026, there are several program improvements and changes for providers. We encourage you to help us spread the word as you interact with providers.

What are the benefits of the Next Generation MyCare program?

The Next Generation MyCare program has several improvements for providers, including:  

• Streamlined credentialing processes with ODM to become an Ohio Medicaid provider. Providers still need to contract with each of the Next Generation MyCare plans separately.   
• Better integration with the Next Generation MyCare plans, leading to shorter turnaround times for prior authorizations.   
• New External Medical Review (EMR) process.    
• Enhanced clinical coverage policies for Medicaid primary services, requiring more services to be covered.  Changes to the services provided will be dependent on the provider’s contract with each plan.   
• Reduced burden for prior authorizations on waiver services in a member’s person-centered care plan (same for private duty nursing).    
• Potential for more waiver providers due to increased network requirements.   
• Additional transportation requirements for the plans to support members in getting to their medical visits and services.      

How to become a Next Generation MyCare provider? 

To become a provider in the Next Generation MyCare program: 

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 the providers 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 

Refer to the Credentialing Guide and Requirements Document for more information. 

Which ID number should be used when submitting a dual benefit claim or a Medicaid-only claim where Medicaid is the primary payer?    

Providers must use the member’s Medicaid ID (MMIS number) when submitting claims through the Ohio Medicaid Enterprise System (OMES) one front door. Medicare ID numbers will not be accepted.   

Read the Next Generation MyCare ID Card One Pager to see the card template.   

How do providers submit claims? 

The process for submitting Electronic Data Interchange (EDI) claims in the Next Generation MyCare program is changing.   

• If providers are submitting their claims to the plans portal using direct data entry (DDE) claim, they will submit a single claim to the Next Generation MyCare plan via their existing process. Not all plans accept paper claims. Submit claims using the plans existing process.  
• If providers 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), they will submit the claim through the one front door, to the Ohio Medicaid Enterprise System (OMES). Providers 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 (found within the Companion Guides) in the 2010BB loop for claims to be directed to the correct plan for processing.  
• If providers are submitting an EDI claim for a Medicaid-only member, they 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 their 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 their 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. 

What if providers need to submit a claim for a member who was enrolled in a plan that will not be a part of the Next Generation MyCare program? 

Aetna Better Health of Ohio and United Healthcare Community Plan will no longer be MyCare plans as of December 31, 2025. Aetna and United will continue to pay claims for up to 365 days from the end of the year and are responsible for any claims that have dates of service through December 31, 2025. Any claims should be submitted to Aetna or United using existing processes. 

What are the changes for pharmacy providers?

In the Next Generation MyCare program, pharmacy providers will work with the Next Generation MyCare plan’s Pharmacy Benefit Manager to administer pharmacy benefits for MyCare members. Refer to the MyCare Ohio Pharmacy Billing Reference Guide for more information. 

 Where can providers learn more about the Next Generation MyCare Program?

• The MyCare Ohio webpage on ohio.gov shares information about the Next Generation program and houses all resources. 
• The Next Generation MyCare Provider Help Desk One-Pager shares contact information by topic in one place, so providers know who to contact when they have questions or need help.  
• The Next Generation MyCare Provider Frequently Asked Questions (FAQ) answers providers most common questions about the current and Next Generation MyCare program.  
• The Next Generation MyCare Member ID Card One Pager provides an overview of the card template. All MyCare Ohio members will receive a new Next Generation member identification (ID) card that will be used at their appointments. The Next Generation member ID cards include important information about a member’s plan, doctors, and who to contact for help all in one place. Providers must use the member’s Medicaid ID (MMIS number) when submitting claims through the Ohio Medicaid Enterprise System (OMES) one front door.