MyCare Ohio Prior Authorization and Managed Care Appeals

How MyCare Ohio Changes the Approval Process

If your parent is dually eligible for both Medicare and Medicaid, they're enrolled in one of Ohio's three Next Generation MyCare Ohio managed care plans — Anthem Blue Cross and Blue Shield, CareSource, or Molina Healthcare. Since the statewide expansion completed in August 2026, all 88 Ohio counties are covered.

Under MyCare, a single managed care plan controls all Medicare and Medicaid benefits: hospital coverage, prescription drugs, skilled nursing, home care waiver services, and long-term supports. This means the plan — not traditional fee-for-service Medicare — approves or denies post-acute care. For families, the practical impact is that the hospital or SNF must get prior authorization from the MyCare plan before admitting your parent for rehabilitation or continuing a skilled nursing stay.

What Requires Prior Authorization

Not every service needs advance approval, but the high-cost ones almost always do:

• SNF admission and continued stay. The MyCare plan must authorize the initial post-hospital SNF admission and may review continued need under the plan's utilization-review schedule.
• Home health services beyond routine visits. Extended therapy, home modifications, and specialized equipment usually require PA.
• Durable medical equipment. Power wheelchairs, hospital beds, and complex rehab equipment need plan approval before the supplier delivers.
• Transfers between facilities. Moving from one SNF to another or from an SNF to an inpatient rehab facility requires plan authorization.

The MyCare care coordinator assigned to your parent is the starting point for all authorization requests. The hospital discharge planner or SNF case manager works with the care coordinator to submit the clinical documentation — but the family should know who that coordinator is and have their direct phone number.

When a Prior Authorization Is Denied

If the MyCare plan denies a prior authorization — refuses to approve a SNF stay, cuts short a rehabilitation extension, or rejects a DME order — the family has two escalation paths:

Step 1: Plan-Level Internal Appeal. File with the MyCare plan directly. The plan must provide a written notice explaining the denial reason and your right to appeal. For urgent situations (the patient is in the hospital and needs immediate SNF placement), request an expedited review and follow the deadline and response timing stated in the plan's notice.

Step 2: State Fair Hearing. If the internal appeal fails, the family can request a state hearing through the Ohio Department of Job and Family Services. This is an independent review by a state hearing officer who evaluates whether the plan's denial was consistent with coverage rules and medical necessity criteria.

For Medicare-specific denials (not Medicaid-side), the appeal process goes through the standard Medicare appeals chain — including a potential review by Commence Health if the denial involves a hospital discharge or service termination.

The Care Coordinator's Role

Every MyCare enrollee is assigned a care coordinator who is supposed to function as a single point of contact — scheduling services, coordinating between providers, and helping the family navigate the system. In theory, this simplifies care management. In practice, the quality of coordination varies significantly by plan and by region.

If the assigned care coordinator isn't responsive or isn't helping with discharge coordination, escalate to the plan's member services line and request a supervisor or ask what process applies to a coordinator reassignment.

The care coordinator should be involved in the hospital discharge planning conference — not brought in after the discharge plan is already finalized. If the hospital social worker hasn't contacted the MyCare plan as part of discharge planning, flag this to the patient advocate.

Keeping the System Accountable

The Hospital-to-Home in Ohio guide includes a Next Generation MyCare Ohio Navigator that walks through the prior authorization process, the appeal timelines, and the care coordinator escalation path — so families know exactly what to ask for and when to push back.

See more Ohio guides →