Rule 5160-58-02 | MyCare Ohio plans: eligibility, ineligibility, and optional enrollment.
(A) Eligibility.
(1) An individual is enrolled in a MyCare Ohio plan (MCOP) if he or she meets all of the following criteria:
(a) Age twenty-one or older at the time of enrollment in the MCOP;
(b) Eligible for medicare parts A, B, and D, and full benefits under the medicaid program.
(2) The following individuals are not eligible for enrollment in an MCOP:
(a) Individuals enrolled in the program of all-inclusive care for the elderly (PACE);
(b) Individuals who have other verified third-party creditable health care coverage, except medicare coverage as authorized by 42 U.S.C. 1395 (January 1, 2026);
(c) Individuals who are inmates of public institutions as defined in 42 CFR 435.1010 (October 1, 2025);
(d) Individuals with intellectual disabilities who have a level of care that meets the criteria specified in rule 5123-8-01 of the Administrative Code and receive services through a home and community-based services (HCBS) waiver administered by the Ohio department of developmental disabilities (DODD); and
(e) Individuals with intellectual disabilities who receive services through an intermediate care facility for individuals with intellectual disabilities (ICF-IID).
(3) Indians, who are members of federally recognized tribes, may voluntarily choose to enroll in an MCOP, and may choose not to enroll. Verification of membership in a federally recognized tribe is needed for request of enrollment exclusion.
(4) If an individual meets eligibility requirements in paragraph (A)(1) of this rule and does not meet an exclusion in paragraph (A)(2) of this rule or an optional enrollment in paragraph (A)(3) of this rule, then the individual is enrolled into an MCOP for medicaid benefits.
(5) Nothing in this rule should be construed to limit or in any way jeopardize an eligible individual's basic medicaid eligibility or eligibility for medicare or other non-medicaid benefits to which he or she may be entitled.
(B) MyCare Ohio plan enrollment.
(1) The following applies when the MyCare Ohio service area expands beginning January 1, 2026:
(a) When a service area is designated, in accordance with paragraphs (B)(1)(c) to (B)(1)(i) of this rule, by the Ohio department of medicaid (ODM) as mandatory for eligible individuals, ODM confirms the eligibility of each individual. Upon the confirmation of eligibility:
(i) Eligible individuals residing in the service area who are currently MCOP members are deemed participants in the mandatory program; and
(ii) All other eligible individuals residing in the mandatory service area may request MCOP membership at any time but must select a MCOP following receipt of a notification of mandatory enrollment (NME) issued by the Ohio department of medicaid (ODM).
(b) MyCare Ohio plan membership selection procedures for the mandatory program:
(i) A newly eligible individual who does not make a choice following issuance of a NME by ODM and one additional notice, is assigned to a MCOP by ODM, the medicaid consumer hotline, or other ODM-approved entity.
(ii) ODM or the medicaid consumer hotline assigns the individual to a MCOP based on prior medicaid fee-for-service, managed care organization, or MCOP membership history, whenever available, or at the discretion of ODM.
(c) Effective January 1, 2026, the mandatory service area includes the following twenty-nine counties: Butler, Clark, Clermont, Clinton, Columbiana, Cuyahoga, Delaware, Geauga, Greene, Franklin, Fulton, Hamilton, Lake, Lorain, Lucas, Madison, Mahoning, Medina, Montgomery, Portage, Pickaway, Ottawa, Stark, Summit, Trumbull, Union, Wayne, Warren, and Wood.
(d) Effective April 1, 2026, the following counties are added to the mandatory service area: Ashtabula, Defiance, Erie, Fairfield, Fayette, Henry, Licking, Paulding, Sandusky, and Williams.
(e) Effective May 1, 2026, the following counties are added to the mandatory service area: Allen, Ashland, Auglaize, Champaign, Crawford, Darke, Hancock, Hardin, Huron, Knox, Logan, Marion, Mercer, Miami, Morrow, Preble, Putnam, Richland, Seneca, Shelby, VanWert, and Wyandot.
(f) Effective June 1, 2026, the following counties are added to the mandatory service area: Adams, Brown, Gallia, Highland, Lawrence, Jackson, Pike, Ross, Scioto, and Vinton.
(g) Effective July 1, 2026, the following counties are added to the mandatory service area: Belmont, Carroll, Coshocton, Guernsey, Harrison, Holmes, Jefferson, Muskingum, and Tuscarawas.
(h) Effective August 1, 2026, the following counties are added to the mandatory service area: Athens, Hocking, Meigs, Monroe, Morgan, Noble, Perry, and Washington.
(i) The mandatory services area includes previously named counties from paragraph (B)(1)(c) of this rule, adding counties named in paragraphs (B)(1)(c) to (B)(1)(h) of this rule, until all eighty-eight counties are included.
(C) Commencement of coverage. Coverage of MCOP members is effective on the first day of the calendar month specified on the ODM-produced HIPAA compliant 834 daily or monthly enrollment file to the MCOP.
(D) All of the following apply to dual-benefits members in the MyCare Ohio program:
(1) Unless CMS implements a passive enrollment under 42 CFR 422.60 (October 1, 2025), an eligible individual's decision to enroll in the MCOP for medicare benefits is choice-based and ODM does not auto-assign MyCare Ohio members in an MCOP for medicare benefits.
(2) Any individual enrolled in MyCare Ohio may exercise the choice of MCOP for their medicare benefits during their initial medicare enrollment. medicare open enrollment, or subject to 42 CFR 422.62 (October 1, 2025), 42 CFR 423.38 (October 1, 2025) or other enrollment period allowable under federal rules.
(3) In accordance with 42 CFR 422.66(c)(2) (October 1, 2025), individuals who are enrolled in an MCOP or ODM-contracted MCO with an affiliated MCOP, who become eligible for the MyCare Ohio program, and do not choose to receive their medicare benefits through another medicare payer, are deemed to have elected the MCOP for both their medicare and medicaid benefits.
Last updated January 5, 2026 at 8:51 AM
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