MyCare Ohio: Home and Community Based Services via Ohio Medicaid’s Managed Care Program

Last updated: May 14, 2021

 

Overview of MyCare Ohio Home & Community Based Services

MyCare Ohio is a managed care program through which “dual eligible” elderly and disabled Ohioans can receive their Medicare and Medicaid benefits. The term “dual eligible” refers to persons who are Medicare and Medicaid eligible. In addition to medical, behavioral health, and nursing home care, this program also provides a variety of home and community-based services (HCBS) for those at risk of nursing home admittance. The long-term care benefits one receives is based on their needs and circumstances. Examples of potential services and supports include personal emergency response systems, adult day care, home modifications for safety and accessibility, assistance moving from a nursing home back into the community, and personal care assistance.

Beneficiaries of MyCare Ohio receive their benefits via a single Medicaid plan provided by a managed care organization (MCO). A MCO is essentially a private healthcare company. The MCO has a network of care providers and program participants receive services via these providers. There are several managed care plans from which to choose based on the county in which one lives. While persons enrolled in MyCare Ohio can receive their Medicare benefits via this program, it is not required. Instead, they can receive Medicare benefits in the same manner as before.

There is some flexibility of providers for persons receiving home and community based services, as some benefits, such as homemaker services and personal care assistance, may be consumer directed. This means that rather than receive services by the MCO’s network of licensed care providers, a program participant can hire their own caregiver. While this includes adult children, nieces / nephews, grandchildren, and siblings, spouses and legal guardians cannot be hired. A financial management services agency handles the financial aspects of employment responsibilities, such as withholding tax and issuing payments.

MyCare Ohio is not available statewide. In the 29 counties in which it is available, program enrollment is mandatory for eligible persons. This includes those on nursing home Medicaid or receive benefits through the Assisted Living Waiver or the PASSPORT Waiver. That said, these individuals will continue to receive the same benefits through MyCare Ohio. There is an exception for persons enrolled in the PACE Program. They do not have to enroll in MyCare Ohio.

MyCare Ohio is also known as the Integrated Care Delivery System (ICDS) Medicaid Waiver or the ICDS Demonstration. It is a 1915(b) Managed Care Delivery System Waiver that operates along with a 1915(c) Home and Community Based Services (HCBS) Waiver. With 1915(c) waivers, the federal government requires a state to limit the number of participant slots. This means, theoretically speaking, a waitlist forms for HCBS when all the “slots” have been filled. However, the state of Ohio does not “cap” the number of program participants, which means a waitlist for services does not form. If needed, the state will amend the number of available slots with the federal government to allow more people to access the program.

 What is Medicaid Managed Care?
Medicaid pays doctors, hospitals, and other providers in one of two ways, either “Fee-For Service” or “Managed Care”. Under Fee-For Service, Medicaid pays providers directly for each service they provide. Beneficiaries can receive services from any Medicaid-certified provider. Under Managed Care, Medicaid contracts with a Managed Care Organization (MCO). Medicaid pays the MCO a set amount for each beneficiary, rather than for each service provided. The MCO has a network of doctors, hospitals, and other providers and the MCO pays them. Beneficiaries must use providers within the network.

 

Benefits of MyCare Ohio Home & Community Based Services

In addition to medical benefits, such as physician appointments, laboratory work, x-rays, and hospitalization, and behavioral health benefits, a variety of long-term care services and supports are also available via MyCare Ohio. Though these may include the following, an individual care plan will determine which benefits a program participant will receive.

– Adult Day Care – also called adult day health services. Provides daytime supervision, personal care assistance, and nursing services in a community-based group setting.
– Alternative Meals Service – i.e., obtaining meals from restaurants / senior centers
– Assisted Living / Memory Care Services (for persons with dementia)
– Care Management
– Community Integration Service – assistance with tasks necessary for independent living (i.e., banking and escorting persons on errands) and information / training on independent living activities (i.e., money management and navigating public transportation)
– Community Transition Services – assistance with security deposit and utility set-up fees for persons moving from a nursing home to a private residence
– Enhanced Community Living Service – health monitoring, personal care assistance, homemaker services
– Home Care Attendant
– Home Maintenance / Chore
– Home Medical Equipment / Assistive Devices
– Home Modifications
– Homemaker Services – meal preparation, light housecleaning, laundry
– Meal Delivery
– Non-Emergency Transportation
– Nutritional Consultation
– Nursing Facility Care
– Nursing Services
– Personal Care Assistance – assistance with bathing, grooming, eating, transferring, and toileting
– Personal Emergency Response System
– Respite Care – out-of-home care to relieve a primary caregiver
– Social Work Counseling

Program participants can live in their own home, the home of a loved one, an assisted living residence, or an adult foster care home.

 

Eligibility Requirements for MyCare Ohio

 As an alternative to reading the criteria below, one can take a quick and easy Ohio Medicaid eligibility test for seniors here

The MyCare Ohio Program is a mandatory Medicaid program for OH residents who are 18+ years old, eligible for Medicaid and Medicare (Parts A, B and D), and live in one of the 29 counties in which the program is available. The counties include Butler, Clark, Clermont, Clinton, Columbiana, Cuyahoga, Delaware, Franklin, Fulton, Geauga, Greene, Hamilton, Lake, Lorain, Lucas, Madison, Mahoning, Medina, Montgomery, Ottawa, Pickaway, Portage, Stark, Summit, Trumbull, Union, Warren, Wayne, and Wood. Additional eligibility criteria follows and is relevant for persons who require home and community based services.

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR), which increases on an annual basis in January. In 2021, an applicant, regardless of marital status, can have a monthly income up to $2,382. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,382 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance. The maximum amount that can be transferred in 2021 is $3,259.50 and is intended to ensure the non-applicant spouse has a minimum monthly income of this amount. Non-applicant spouses who have their own income equal to or greater than this amount are not entitled to a spousal income allowance.

Assets
In 2021, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $3,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse can retain up to $2,000 in assets and the non-applicant spouse can keep up to $109,560. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a look back rule and violating it results in a penalty period of Medicaid ineligibility.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our spend down calculator.  

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, Ohio Medicaid considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $603,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– The applicant’s spouse lives in the home.
– The applicant has an adult child (over 21 years of age) who is blind or disabled and living in the home.
– The applicant has a child under 21 years old living in the home.

To learn more about the potential of Medicaid taking the home, click here.

 

Medical Criteria: Functional Need

An applicant must require a nursing facility level of care (NFLOC). The tool used to determine if this level of care need is met is the Adult Comprehensive Assessment Tool (ACAT). Generally, the necessity of supervision or assistance with completing the activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting, eating) and assistance with instrumental activities of daily living (i.e., preparing meals, grocery shopping, accessing transportation, etc.) indicates one requires this level of care. While persons with Alzheimer’s disease or a related dementia might meet the functional need for care, a diagnosis of dementia in and of itself does not mean one will meet a NFLOC.

 For more information about long-term care Medicaid in Ohio, click here

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Ohio Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

When persons have income over the limits, Miller Trusts, also called a qualified income trust can help. “Excess” income is deposited into the trust, no longer counting as income.

When persons have assets over the limits, there are many options. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Medicaid asset protection trusts are another option that protects assets from Medicaid’s asset limit. Still another option is to “spend down” countable assets, such as paying off debt, updating home plumbing and heating, and buying household furnishings.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid planners are educated in the planning strategies available in the state of Ohio to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, some planning strategies not only help one meet Medicaid’s financial criteria, but also protect assets from Medicaid’s estate recovery program. Unfortunately, they often violate Medicaid’s 60-month look back rule. Therefore, they should be implemented well in advance of the need for long-term care. However, there are some workarounds, and Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner

 

How to Apply for MyCare Ohio Home & Community Based Services

Before You Apply

Prior to applying for MyCare Ohio, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are delayed is required documentation is missing or not submitted in a timely manner.

 

Application Process

To apply for MyCare Ohio, an applicant must apply and be approved for Ohio Medicaid. Persons can apply online at Ohio Benefits or via their local County Department of Job and Family Services (CDJFS) Office. Persons can call the Consumer Helpline at 1-844-640-6446 (OHIO). Alternatively, persons can call 1-866-243-5678.

Eligible persons will need to choose a managed care health plan or one will automatically be assigned. To see plans by county, click here and scroll down to “select your county” under question 2.

For additional information about MyCare Ohio, click here. The Ohio Medicaid Consumer Hotline is also available at 1-800-324-8680. The Ohio Department of Medicaid’s Office of Managed Care administers the MyCare Ohio Program.

 

Approval Process & Timing

The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further. While the state does not use a waitlist for services for MyCare Ohio, there potentially could be a delay in the receipt of home and community based services if a care provider is not immediately available.

Determine Your Medicaid Eligibility

Get Help Qualifying for Medicaid