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Next Generation of Ohio Medicaid Managed Care

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The Ohio Department of Medicaid is introducing its Next Generation managed care plans to focus on the individual, honor members’ choice, and provide continuity in the provision of members’ care. These changes do not apply to MyCare.

The Next Generation of Ohio Medicaid program will be implemented in stages to avoid unnecessary disruption and confusion for members and to reduce burdens on our service providers. The Next Generation program will be implemented in the following stages: 

Stage 1: On July 1, 2022, OhioRISE started providing specialized services, which will help children and youth with behavioral health needs and help coordinate care for those who receive care across multiple systems.  

Stage 2: On October 1, 2022, Centralized Provider Credentialing will begin which will reduce administrative burden on providers. Also, the Single Pharmacy Benefit Manager (SPBM) will begin providing pharmacy services across all managed care plans and members. 

Stage 3: On December 1, 2022, the implementation of the Next Generation managed care plans will occur. Members will experience benefits that help address their individual health care needs such as increased access to care coordination and care management supports. Also in stage three, ODM will implement additional improvements to streamline the process of claims and prior authorization submission for providers.

Ohio Medicaid members currently receiving healthcare benefits through Paramount Advantage will continue to receive healthcare benefits through that plan until stage 3 of the implementation of Next Generation managed care plans. Unless a member chooses another plan by stage 2, they will be enrolled with Anthem Blue Cross and Blue Shield in stage 3 of the implementation process. Current Paramount members can select a different plan at any time during the member transition and enrollment period.

In stage 3, the members in this group who are eligible for a managed care plan will be assigned to a Next Generation plan by ODM and will begin receiving services from that plan. ODM will notify impacted members which plan they have been assigned to, and members can select a different plan at any time now through November 30, 2022

Framework of the Next Generation Program

In 2019, the 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 people and not just the business of managed care. This is the first structural change since Centers for Medicare & Medicaid Services' (CMS) approval of Ohio’s program in 2005.

The focus of the Next Generation Ohio Medicaid program is on the individual with strong cross-agency coordination and partnership among MCOs, vendors, sister state agencies & ODM to support specialization in addressing critical needs.

With the Next Generation managed care program, ODM will work in collaboration with the Ohio Department of Job and Family Services (ODJFS), County Departments of Job and Family Services (CDJFS), Mental Health Addiction Services (MHAS), Department of Developmental Disabilities (DODD), Ohio Department of Aging and other agencies to support a more seamless and individualized experience for individuals and providers.

Next Generation of Ohio's Medicaid Managed Care Program

Goals of the Next Generation of Ohio’s Medicaid Managed Care Program 

Through this effort, we are working to achieve the following goals:

Next Generation of Medicaid Managed Care Goals

Ohio’s Medicaid managed care program will advance many of these goals through ODM’s population health approach, which is designed to address health inequities and disparities and achieve optimal outcomes for the holistic well-being of individuals receiving Medicaid. 

ODM envisions a Medicaid managed care program where 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. In the future program, a single pharmacy benefit manager (SPBM) will be responsible for providing and managing pharmacy benefits for all individuals along with coordinating and collaborating to achieve health care 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 and prior authorization submissions and for credentialing and re-credentialing. 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 intends to formalize coordinated care partnerships between community-based organizations and managed care organizations that will reduce infant mortality and preterm births, increase healthy behaviors, promote tobacco cessation, and address health care 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.

In order to better support providers, ODM plans to employ best practices to reduce administrative burdens such as centralized credentialing, standardized authorizations, and simplified medication management.

Improve care for children and adults with complex needs.

To strengthen care for children and adults with complex medical and behavioral health needs, ODM plans to develop a formalized model of care coordination, to tailor behavioral health services to meet the unique needs of children served by multiple state systems and children with other complex behavioral health needs, and to create robust partnerships between community-based organizations and managed care organizations.

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 is planning to enhance data analytics and consumer health care dashboards, such as its newly introduced unified prescription drug list, to streamline support and drive accountability across the continuum of care.

Communicating with ODM

There are several ways you can learn more about the next generation of Ohio’s managed care program and contact ODM with questions.