Ohio Dual Eligible Medicare-Medicaid Benefits: MyCare, Costs, Rights

If you have both Medicare and Medicaid in Ohio, the two programs work together to cover almost everything: Medicare pays first for hospital stays, doctor visits, and prescriptions, and Ohio Medicaid picks up the premiums, deductibles, and copayments Medicare leaves behind, plus services Medicare does not cover at all. Ohio dual eligible Medicare and Medicaid benefits are being reorganized in 2026 under the Next Generation MyCare program, which coordinates both sets of benefits through a single managed care plan and is rolling out statewide through August 1, 2026.¹

Who Qualifies as Dual Eligible in Ohio

You have to qualify for each program on its own. On the Medicare side, that usually means turning 65, receiving Social Security disability for 24 months, or having end-stage renal disease.² On the Ohio Medicaid side, you have to fit within the state’s income and asset limits, and how much help you get depends on which category you fall into.

People who qualify for full Ohio Medicaid receive the broadest coverage. If your income is too high for full Medicaid, you may still qualify for a Medicare Savings Program, which pays some or all of your Medicare costs.

Medicare Savings Programs and 2026 Income Limits

All four Medicare Savings Programs use the same resource limits in 2026: $9,950 for an individual and $14,910 for a couple. QDWI is the exception, with lower limits of $4,000 and $6,000.³

Qualified Medicare Beneficiary (QMB): Pays Part A and Part B premiums, deductibles, coinsurance, and copayments. Monthly income limit: $1,350 for an individual, $1,824 for a couple. Combined with full Medicaid, this is the most protective tier and leaves you paying essentially nothing.⁴
Specified Low-Income Medicare Beneficiary (SLMB): Pays your Part B premium only. Monthly income limit: $1,616 for an individual, $2,184 for a couple.⁴
Qualifying Individual (QI): Also covers the Part B premium. Monthly income limit: $1,816 for an individual, $2,455 for a couple. Funding is limited each year and applications are taken first-come, first-served.⁴
Qualified Disabled and Working Individual (QDWI): Pays the Part A premium for people who lost premium-free Part A because they returned to work. Monthly income limit: $5,405 for an individual, $7,299 for a couple.⁴

The savings are not small. The standard Part B premium is $202.90 per month in 2026, and the Part A hospital deductible is $1,736 per admission.⁵ Even the most limited program saves over $2,400 a year on the Part B premium alone.

What’s Covered When You Have Both

Medicare always pays first for services it covers. Your provider bills Medicare, Medicare pays its share, and then Medicaid pays the rest up to the state’s payment rate.⁶ For full-benefit dual eligibles, that means the $1,736 hospital deductible, the 20% coinsurance on outpatient services, and the monthly Part B premium are all absorbed.

Ohio Medicaid also covers services Medicare largely ignores. Adult dental care includes checkups and cleanings once every 12 months, fillings, extractions, crowns, root canals, and dentures, with a $3 copay per visit for adults 21 and older.⁷ Routine vision care, eyeglasses, non-emergency medical transportation, and long-term nursing facility care are covered as well. Many Next Generation MyCare plans layer on extras like over-the-counter product allowances or additional rides to appointments.

Prescription drugs work a little differently depending on where you live. If you live in a nursing home with full Medicaid, you pay nothing for covered drugs. In an assisted living facility or at home, you pay a small copay per drug.⁶

The Next Generation MyCare Program in 2026

Ohio replaced the original MyCare Ohio program on January 1, 2026, with Next Generation MyCare. Instead of dealing with a separate Medicare insurer and a separate Medicaid insurer, you get both benefits through a single plan, and that plan covers your entire healthcare benefit.¹

Who Gets Enrolled Automatically

Once the program reaches your county, you are enrolled automatically if you have full Medicaid, have Medicare Parts A, B, and D, and are 21 or older. The age threshold rose from 18 under the old program. You are excluded if you participate in PACE, are on a Developmental Disabilities waiver, or have other qualifying health coverage that includes both hospital and doctor services.¹

Three plans are available statewide: Anthem Blue Cross and Blue Shield, CareSource, and Molina Healthcare of Ohio. Buckeye Health Plan is available only to members who were already in it under the old MyCare Ohio program.¹

Rollout Schedule

The program launched in 29 counties on January 1, 2026, covering the counties in the old MyCare Ohio footprint. Additional northwest and central Ohio counties phase in during April, and southeast Ohio comes online by August 1, 2026.¹

Your Choices Within the Program

You have flexibility on the Medicare side. You can take only your Medicaid benefits through the plan and keep Original Medicare or a different Medicare Advantage plan. You can also align both your Medicare and Medicaid benefits through the same Next Generation MyCare plan at any time by enrolling through Medicare, with coverage starting the first day of the following month. If you receive only Medicaid through the plan and want to switch plans, you have 90 days from enrollment to change.¹

Prescription Drug Costs Through Extra Help

If you are dual eligible, you qualify automatically for Extra Help, the federal program that cuts Part D costs. No separate application is needed. Full Medicaid, a Medicare Savings Program paying your Part B premium, or SSI payments all trigger automatic enrollment.⁸

Under Extra Help in 2026, you pay no plan premium and no deductible. Copayments cap at $5.10 for generic drugs and $12.65 for brand-name drugs. Once your total drug costs hit $2,100 for the year, you pay nothing for covered drugs the rest of the year. With QMB status on top of full Medicaid, your copay never exceeds $4.90 per drug.⁸ If you do not pick a Part D plan, Medicare will enroll you in one so you are not left without drug coverage.

Balance Billing Protection for QMBs

This is a right that a lot of QMB beneficiaries do not know they have. Federal law prohibits every Medicare provider and supplier from billing QMB beneficiaries for Part A or Part B cost-sharing, including deductibles, coinsurance, and copayments. The ban applies to all providers who accept Medicare, not just those who also accept Medicaid.⁹ If a bill for Medicare cost-sharing arrives and you have QMB status, the bill is illegal. Contact your plan or the Ohio Medicaid Consumer Hotline at 800-324-8680 to report it.

Estate Recovery and the Look-Back Rule

Two rules matter most if long-term care is part of the picture, either for you or a spouse.

The first is estate recovery. After a Medicaid recipient dies, the Ohio Attorney General, acting for the Ohio Department of Medicaid, can seek to recover what Medicaid paid. Recovery applies to permanently institutionalized individuals of any age for all Medicaid benefits paid, and to individuals 55 or older who were not permanently institutionalized for benefits paid after they turned 55. Ohio does not recover payments made under the Medicare Savings Programs for benefits paid on or after January 1, 2010. Ohio defines “estate” broadly, reaching beyond probate assets to property held through joint tenancy, survivorship, living trusts, or life estates.¹⁰

Recovery is blocked while a surviving spouse, a child under 21, or a child of any age who is blind or permanently disabled is living.¹¹ A home is also protected when certain family members still live there: a sibling who lived in the home for at least a year before the individual entered a nursing facility and has stayed since, or a son or daughter who lived in the home for at least two years before institutionalization and provided care that delayed the need for a facility. Ohio must waive recovery when it would cause undue hardship.¹⁰

The second rule is the 60-month look-back. If you transfer assets for less than fair market value before applying for Medicaid long-term care, the state looks back five years from your application date to find those transfers. Gifts, below-market sales, or transfers to family members inside that window can trigger a penalty period during which Medicaid will not pay for nursing facility care. The penalty is calculated by dividing the value transferred by the average daily cost of nursing home care in your area at the time of application. Transfers to a spouse, to a trust for a blind or disabled child, or of a home to certain qualifying family members are exempt.¹²

If Your Coverage Is Denied, Reduced, or Cut

You have the right to a fair hearing. The state must send you written notice at least 10 days before any action takes effect, explaining what is planned, why, and how to request a hearing. You can represent yourself, or bring a lawyer, relative, or friend.¹³

The deadline matters more than most people realize. If you request a hearing before the date the action is supposed to take effect, the state generally must continue your benefits at the current level until a decision is reached.¹³ File the request as soon as the notice arrives.

Next Generation MyCare plans are classified as Applicable Integrated Plans, which means they are required to offer unified appeals and grievance processes covering both Medicare and Medicaid disputes through a single procedure where feasible.¹⁴ The plan’s denial letter explains how to appeal and the timelines that apply.

How to Apply

Medicare entitlement is usually automatic through age or disability. The action step on your end is applying for Ohio Medicaid, which you can do in three ways:

Online at the Ohio Benefits Self-Service Portal, ssp.benefits.ohio.gov.¹⁵
In person or by mail at your local county Job and Family Services office.¹⁵
By phone through the Ohio Medicaid Consumer Hotline at 800-324-8680.¹⁶

Once Medicaid approves you and identifies you as dual eligible, the state will auto-enroll you in a Next Generation MyCare plan if the program is live in your county and you meet the criteria. You will get a notice explaining your plan assignment and how to switch plans. The Consumer Hotline is also the number to call for help choosing between Anthem, CareSource, and Molina, or with questions about how your existing Medicare coverage fits with the new plan.

1
Ohio Department of Medicaid. Next Generation MyCare Program
2
Centers for Medicare & Medicaid Services. Original Medicare (Part A and B) Eligibility and Enrollment
3
Medicare.gov. Medicare Savings Programs
4
Social Security Administration. Medicare Savings Programs Income and Resource Limits
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Centers for Medicare & Medicaid Services. 2026 Medicare Parts A and B Premiums and Deductibles
6
Medicare.gov. Who Pays First
7
Ohio Department of Medicaid. Dental
8
Medicare.gov. Help With Drug Costs
9
Centers for Medicare & Medicaid Services. Prohibition on Billing Qualified Medicare Beneficiaries
10
Ohio Legislative Service Commission. Ohio Administrative Code 5160:1-2-07 – Medicaid: Estate Recovery
11
Medicaid.gov. Estate Recovery
12
Office of the Law Revision Counsel. 42 USC 1396p – Liens, Adjustments and Recoveries, and Transfers of Assets
13
eCFR. 42 CFR Part 431 Subpart E – Fair Hearings for Applicants and Beneficiaries
14
Centers for Medicare & Medicaid Services. D-SNPs: Integration and Unified Appeals and Grievance Requirements
15
Ohio Department of Medicaid. How to Apply or Renew for Medicaid
16
Ohio Department of Medicaid. Contact Us