For adults enrolled in Ohio’s MAGI Medicaid, coverage runs across the full range of medical care most people need: primary care and specialist visits, hospital stays and emergency room care, prescription drugs, mental health and substance use treatment, pregnancy and postpartum care, dental and vision, and rides to appointments when you have no other way to get there. Most services carry no copayment, and nearly every adult member receives care through a private managed care plan that contracts with the state.
Doctor Visits, Hospital Care, and Preventive Services
The core medical benefit covers primary care and specialist visits, with up to 24 visits every 12 months and additional visits allowed for specified conditions. Inpatient hospital stays, outpatient procedures, and emergency room care are all covered. Lab work, X-rays, and mammograms are included at no copay when medically necessary.1Ohio Department of Medicaid. Professional Medical Services
Family planning is covered separately with no copayment. That includes contraceptive management, pregnancy prevention counseling, and screening for genetic disorders.2Ohio Department of Medicaid. Family Planning
Prescription Drugs
Medications are covered through a statewide Unified Preferred Drug List that applies to every Ohio Medicaid member, regardless of which managed care plan you’re in. The list replaced six separate formularies when it launched in 2020, so every enrollee now works from the same formulary.3Ohio Department of Medicaid. Ohio Unified Preferred Drug List
You fill prescriptions at network pharmacies. Some drugs require prior authorization, meaning your prescriber has to confirm medical necessity before the pharmacy can dispense. Gainwell Technologies runs the pharmacy benefit as Ohio Medicaid’s Single Pharmacy Benefit Manager and handles prior authorizations and claims for both managed care and fee-for-service members. Mail-order and delivery options are available through the SPBM portal for maintenance medications. The Gainwell Customer Support Center takes pharmacy questions around the clock at 833-491-0344.4OH MCD SPBM.Web. Ohio Medicaid Pharmacy Services
Mental Health and Substance Use Treatment
MAGI Medicaid pays for individual, family, and group counseling and psychotherapy, along with psychiatric medications for mental illness or addiction. For adults with severe and persistent mental illness, the program covers high-intensity services and supports beyond standard outpatient therapy.5Ohio Department of Medicaid. Behavioral Health
Substance use disorder treatment includes intensive outpatient programs, residential treatment, and withdrawal management. Ohio Medicaid also covers mobile crisis team services, which send behavioral health professionals to you during a mental health emergency instead of requiring an ER trip.6ASPE. Crisis Services Billed to Medicaid – Lessons Learned from Eight States The 988 Suicide and Crisis Lifeline connects callers with local resources, and a Medicaid-covered mobile team can often respond on-site.
Pregnancy and Postpartum
Pregnancy coverage is comprehensive and carries no copayments. Covered services include prenatal care, prenatal risk assessments, ultrasounds, high-risk monitoring, nurse midwife services, labor and delivery, care coordination, counseling, education, and transportation to appointments. There is no visit limit for pregnancy-related care.7Ohio Department of Medicaid. Pregnancy
Postpartum Medicaid now runs for a full 12 months after delivery rather than the earlier 60-day window.8Ohio Department of Medicaid. Maternal and Infant Support Doula birth worker services became a covered benefit in October 2024. A Medicaid-enrolled, Board of Nursing-certified doula can provide non-clinical emotional, physical, and educational support during pregnancy, childbirth, and the postpartum period.9Ohio Department of Medicaid. Doulas
Dental, Vision, and Transportation
Adults 21 and older get a dental checkup and cleaning once every 12 months. Fillings, extractions, and other necessary dental work are covered, with a $3 copay per dental visit for adults.10Ohio Department of Medicaid. Dental
Vision coverage includes a routine eye exam and eyeglasses every 24 months for adults between 21 and 59, and every 12 months once you turn 60. Contact lenses are covered with prior authorization, and glaucoma screenings are included.11Ohio Department of Medicaid. Vision
If you have no way to get to a medical appointment, non-emergency medical transportation covers rides to and from any Medicaid-covered service. There is no copay, and the benefit is coordinated through your county Department of Job and Family Services.12Ohio Department of Medicaid. Transportation
Telehealth
You can see a doctor or therapist by video call, and Ohio also covers audio-only phone visits for situations where video isn’t practical. Remote patient monitoring, secure messaging through a patient portal, and store-and-forward image reviews are covered as well.13Ohio.gov. Telehealth Billing Guidelines Covered telehealth spans medical visits, behavioral health counseling, dental evaluations, physical and occupational therapy, nutrition counseling, and lactation consulting. Billing codes for audio-only visits took effect in January 2025, making phone-based care a permanent option.
What You’ll Pay
Most services carry no premium and no copayment. Where copays do apply for adults, they’re small:
- Non-emergency ER or hospital visit: $3
- Dental visit (age 21+): $3
- Eye exam: $2
- Eyeglasses fitting: $1
- Brand-name medication: $2
- Medication requiring prior authorization: $3
Several groups of adults are fully exempt from copays: pregnant members (up to 90 days postpartum, though routine eye exam and eyeglasses fitting copays still apply), nursing home residents, people receiving emergency services, anyone using family planning services, hospice patients, and members enrolled in a managed care plan that doesn’t charge copays.14Ohio Department of Medicaid. Medicaid Copays
A provider cannot refuse to treat you because you can’t pay a copay at the time of service. You still owe the amount afterward, and a provider may decline future non-emergency visits if you have accumulated unpaid copays, but they must apply that policy equally to all patients and tell you about it in advance.14Ohio Department of Medicaid. Medicaid Copays Federal rules cap total Medicaid cost-sharing for your household at 5% of family income, measured quarterly or monthly.15eCFR. Medicaid Premiums and Cost Sharing
How Managed Care Delivers These Benefits
Nearly all MAGI Medicaid adults receive care through a managed care organization. Seven private health plans currently participate: AmeriHealth Caritas Ohio, Anthem Blue Cross and Blue Shield, Buckeye Community Health Plan, CareSource Ohio, Humana Healthy Horizons in Ohio, Molina Healthcare of Ohio, and UnitedHealthcare Community Plan of Ohio. When you first enroll you’ll receive a letter asking you to pick one; if you don’t choose, the state assigns one. All seven plans must cover the same core Medicaid benefits, though their provider networks and extra wellness programs vary.16Ohio Department of Medicaid. Ohio Medicaid Managed Care Once you’re enrolled with a plan, you generally need to use its in-network providers for your care to be covered. If your current doctor isn’t in the plan’s network, you can switch plans.
Who Qualifies as an Adult
Ohio uses Modified Adjusted Gross Income rules to decide eligibility. For adults, the income ceiling depends on whether you have dependent children at home:
- Parents and caretaker relatives: household income up to 90% of the Federal Poverty Level
- Adults without dependent children, ages 19 to 64: household income up to 133% of the FPL
In 2026, the FPL is $15,960 for a single person and $33,000 for a family of four.17ASPE. 2026 Poverty Guidelines – 48 Contiguous States A single childless adult qualifies with annual income up to roughly $21,227, and a parent in a household of three qualifies at up to about $24,588.18Ohio.gov. Medicaid – 2026 Federal Poverty Level Income Guidelines You must also be an Ohio resident and either a U.S. citizen or in a qualifying immigration status.19Cornell Law School. Ohio Admin Code 5160-1-2-12 – Medicaid Non-Citizens MAGI Medicaid is the pathway for adults under 65 who are not qualifying on the basis of disability; the aged, blind, and disabled Medicaid categories use different rules and aren’t covered here.