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Next Generation of Ohio Medicaid Managed Care
Ohio Department of Medicaid Managed Care Mission

Next Generation of Ohio Medicaid Managed Care

Learn about the future Ohio Medicaid Managed Care program.

On February 1, 2023, Ohio Medicaid implemented the Next Generation managed care plans, the new Electronic Data Interchange, and Fiscal Intermediary. These changes are providing Ohio Medicaid managed care members enhanced healthcare services that best fit their individual healthcare needs and improve the provider experience by increasing transparency and visibility of care and services

In 2019, Ohio Department of Medicaid (ODM) launched the Medicaid Managed Care Procurement process with a bold, new vision for Ohio’s Medicaid program – one that focuses on the individual and not just the business of managed care. This is the first structural change since Centers for Medicare and Medicaid Services' (CMS) approval of Ohio’s program in 2005.

 The Next Generation managed care plan changes do not apply to the MyCare Ohio program, which will continue to provide benefits to Ohioans who receive both Medicaid and Medicare benefits, with enhanced coordination of medical, behavioral, and long-term care services.

The Next Generation Ohio Medicaid program emphasizes strong cross-agency coordination and partnership among MCOs, vendors, sister state agencies, and ODM to support specialization in addressing critical needs.

Implementation of the Next Generation Program

The Next Generation of Ohio Medicaid program is being implemented in stages to avoid unnecessary disruption and confusion for members and to reduce burdens on our service providers.

  • On July 1, 2022, OhioRISE began providing specialized services which help children and youth with behavioral health needs and coordinate care for those who receive services across multiple systems. 
  • On October 1, 2022, the Centralized Provider Credentialing initiative began, reducing administrative burden on providers. Also, the Single Pharmacy Benefit Manager (SPBM) began providing pharmacy services across all managed care plans and members.
  • On February 1, 2023, the implementation of the Next Generation managed care plans occurred, allowing members to experience benefits that address their individual healthcare needs, such as increased access to care coordination and care management supports. Additionally, the Electronic Data Interchange (EDI) is the new exchange point for trading partners on all claims-related activities, providing transparency and visibility regarding care and services. The Fiscal Intermediary (FI) assists in routing managed care claims submitted to EDI and adjudicate and pay fee-for-service claims submitted to EDI.

Our focus has been and continues to be on implementing new components and improvements as they are fully ready to support achieving our mission. ODM remains committed to listening to members, providers, and managed care plan partners, and we have taken a hands-on approach to resolving implementation issues that have been experienced by providers. ​Leading up to our next implementation, we have been actively seeking input from stakeholders and conducting testing of all systems.

Ohio Medicaid members receiving healthcare benefits through Paramount Advantage before February 1, 2023, who did not select a different Next Generation plan during open enrollment in 2022, have been enrolled with Anthem Blue Cross and Blue Shield. If a member chose a different Next Generation plan during open enrollment in 2022, they are now enrolled in the plan they selected and began receiving healthcare benefits through the selected plan on February 1, 2023.

Members who were newly eligible for a managed care plan since March 1, 2022, have been assigned to a Next Generation plan by ODM and began receiving services from that plan on February 1, 2023. ODM has notified impacted members which plan they have been assigned to. Learn more about the Next Generation plans at https://ohiomh.com/.

Goals of the Next Generation of Ohio's Medicaid managed care program

Ohio Medicaid’s Next Generation managed care program advances many of our goals through ODM’s population health approach. This approach is designed to address health inequities and disparities and achieve optimal outcomes for the holistic well-being of individuals receiving Medicaid.

In the Next Generation program, ODM, the MCOs, and OhioRISE (Resilience through Integrated Systems and Excellence), a specialized managed care organization, are responsible for providing behavioral health services to children involved in multiple state systems and/or with complex behavioral health needs. 

Additionally, a single pharmacy benefit manager (SPBM) is responsible for providing and managing pharmacy benefits for all individuals.  The SPBM is also responsible for coordinating and collaborating to achieve healthcare excellence through a seamless service delivery system for individuals, providers, and systems partners. 

To reduce provider burden and promote consistency across the Medicaid managed care program,  
ODM has retained the administrative responsibilities for centralized claims submissions, prior authorization submissions, and for credentialing and re-credentialing providers. ODM’s fiscal intermediary (FI) will serve as a single clearinghouse for all medical (non-pharmacy) claims. ODM’s FI will also serve as the single, centralized location for provider submission of prior authorization requests. Under ODM’s centralized credentialing process providers will submit an application for Medicaid enrollment and credentialing to ODM and will not need to submit credentialing and re-credentialing materials to MCOs. 

To learn more about the goals of Ohio’s Next Generation managed care program, view the drop-down sections below.

Improve wellness and health outcomes

To improve health outcomes and support individual wellness, ODM formalized coordinated care partnerships between community-based organizations and MCOs to reduce infant mortality and preterm births, increase healthy behaviors, promote tobacco cessation, and address healthcare inequities.

Emphasize a personalized care experience

The Request for Information (RFI)  invited ideas that strengthen the managed care organization and provider capabilities to deliver more personalized care. ODM looks to improve member-provider communications, employ technologies to increase consumer engagement, and support programs to enhance wellness behaviors and outcomes for individuals and their families as they access a continuum of care tailored to their unique needs. 

Support providers in better patient care

To better support providers, ODM employed best practices such as centralized credentialing, standardized authorizations, and simplified medication management to reduce administrative burdens.

Improve care for children and adults with complex needs

To strengthen care for children and adults with complex medical and behavioral health needs, ODM has:

  • Developed a formalized model of care coordination.
  • Tailored behavioral health services to meet the unique needs of children served by multiple state systems and children with other complex behavioral health needs.
  • Created robust partnerships between community-based organizations and MCOs.

Increase program transparency and accountability

Program transparency through the use and analysis of real-time, reliable data can dramatically strengthen care oversight and outcomes. ODM has enhanced data analytics and consumer healthcare dashboards, such as its newly introduced unified prescription drug list (UPDL), to streamline support and drive accountability across the continuum of care.

Communicating with ODM

There are several ways you can learn more about Ohio’s Next Generation managed care program and contact ODM with questions.

What is Medicaid Managed Care?

Medicaid managed care provides healthcare benefits for individuals enrolled in the Ohio Medicaid program. In Ohio, most people approved for Medicaid are automatically eligible for Medicaid managed care coverage. Shortly after enrolling in Medicaid, individuals get a letter asking them to choose a Medicaid managed care plan. Once enrolled with a managed care plan, the plan sends a permanent card for use when seeking services from providers, as well as information about coverage details.

Medicaid managed care differs from the Medicare program. Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with end-stage renal disease. Visit medicare.gov for more information about the Medicare program.