OhioRISE aims to shift the system of care and keep more kids and families together by creating new access to in-home and community-based services for children with the most complex behavioral health challenges. The OhioRISE program’s child and family-centric delivery system recognizes the need to specialize services and support for this unique group of children and families. Aetna Better Health of Ohio (the OhioRISE plan) is partnering with ODM, sister state agencies, providers, families, and other stakeholders to develop and implement new and enhanced services, including those listed under the "OhioRISE services" tab on this page. You can learn more about the OhioRISE program's services and delivery system by watching the video below.
OhioRISE features a new 1915(c) Medicaid waiver that drives toward improving cross-system outcomes for its enrollees. The new home and community based OhioRISE waiver features access to all of the services in the OhioRISE program and its own unique waiver services targeted toward this population. The waiver is intended to keep families supported in the community with a goal to prevent institutionalization. Click on the "OhioRISE 1915(c) Waiver" tab below for more information on the waiver's services and eligibility requirements.
Next Generation of Ohio Medicaid Implementation
The Next Generation of Ohio Medicaid is being implemented in stages. The first stage – the launch of OhioRISE – started on July 1, 2022. Staggering the start and beginning with OhioRISE helps us meet the immediate behavioral health needs of children and youth served by multiple systems and their families while avoiding unnecessary disruption and confusion for members reducing burdens on our service providers. Additionally, the staggered approach remains true to our Next Generation vision – to ensure that we keep our focus on the individual, honor members' choice, and provide continuity in the provision of members’ care.
To learn more about the Next Generation of Ohio Medicaid and the staggered implementation, check out the OhioRISE Factsheet.
Children and youth who may be eligible for OhioRISE:
- Are eligible for Ohio Medicaid (either managed care or fee-for-service),
- Are age 0-20, and
- Require significant behavioral health treatment needs, measured using the Ohio Child and Adolescent Needs and Strengths (CANS) assessment.
Children and youth may also be eligible for OhioRISE due to certain urgent conditions. For example, if a child or youth is in a hospital for behavioral health reasons.
New and enhanced services available through OhioRISE include:
- Intensive and Moderate Care Coordination: two levels of this service (intensive and moderate) will be consistent with principles of High-Fidelity Wraparound and be delivered by a Care Management Entity-qualified agency.
- Intensive Home-Based Treatment (IHBT): OhioRISE will make changes to existing IHBT services and align with the Family First Prevention Services Act (FFPSA).
- Psychiatric Residential Treatment Facility (PRTF): this service is aimed at keeping youth with the most intensive behavioral health needs in-state and closer to their families and support systems.
- Mobile Response and Stabilization Service (MRSS): provide youth in crisis and their families with immediate behavioral health services to ensure they are safe and receive necessary supports and services (this new service will also be available to children who are not enrolled in OhioRISE).
- Behavioral Health Respite: provide short-term, temporary relief to the primary caregiver(s) of an OhioRISE plan enrolled youth, in order to support and preserve the primary caregiving relationship.
- Primary Flex Funds: services, equipment, or supplies not otherwise provided through the Medicaid state plan that address an identified need in the service plan, including improving and maintaining the individual’s opportunities for full participation in the community.
OhioRISE 1915(c) Waiver
OhioRISE features a new 1915(c) Medicaid waiver that drives toward improving cross-system outcomes for its enrollees. The new home and community based OhioRISE waiver features access to all of the services in the OhioRISE program and its own unique waiver services targeted toward this population. The waiver is intended to keep families supported in the community with a goal to prevent institutionalization. Learn more about the waiver by watching the video below:
What are the services children and youth will have access to through the OhioRISE Waiver?
- Out-of-Home Respite: A service provided to individuals unable to care for themselves that is furnished on a short-term basis because of the absence or need for relief of those persons who normally provide care for the individual.
- Transitional Services and Supports (TSS): Shorter-term supports for individuals and their families to help them understand, mitigate, and provide connections to long-term solutions that address behavior challenges.
- Secondary Flex Funds: Services, equipment, or supplies not otherwise provided through the waiver or through Medicaid that address an identified need in the service plan, including improving and maintaining the individual’s opportunities for full participation in the community.
How can children and youth access the OhioRISE Waiver?
A child or youth can be referred for the waiver through their local care management entity (CME). Youth and families interested in receiving a waiver referral for the OhioRISE Waiver can do so through a number of different “access points.” It is anticipated that behavioral health providers that a youth is connected with can help make the appropriate referral for a CANS assessment to determine waiver eligibility to a CME in the child’s or youth’s local area.
It is important to remember that a waiver referral is the first step in accessing the OhioRISE Waiver. In addition to meeting Medicaid and OhioRISE program eligibility, a child or youth must also meet the following requirements to be eligible for the waiver:
- Have an Inpatient Psychiatric Level of Care.
- Have a diagnosis of a Serious Emotional Disturbance (also known as SED).
- Have documented functional limitations.
- Need at least one of the OhioRISE Waiver services.
- Have waiver needs that are less than or equal to the waiver service cost limit of $15,000.
OhioRISE Delivery System
OhioRISE services will be provided through a collaborative delivery system, as illustrated in the image below.
OhioRISE Delivery System
For Ohio Medicaid managed care youth members who are not enrolled in the OhioRISE plan, Ohio Medicaid MCOs and the fee for service program will continue coverage for the Medicaid’s existing behavioral health services and MRSS. MCOs will manage also administrative care coordination, utilization management, and quality improvement efforts. The Ohio Medicaid MCOs also will be responsible for assuring access to the Child and Adolescent Needs and Strengths (CANS) assessment to determine when a child needs the enhanced services of the OhioRISE plan.
ODM presented highlights of the OhioRISE program to stakeholders via webinar:
OhioRISE is governed by ODM, the Governor DeWine's Children’s Initiatives, and Ohio’s Family and Children First Cabinet Council. Council members include:
- Ohio Department of Mental Health and Addiction Services (MHAS)
- Ohio Department of Job and Family Services (ODJFS)
- Department of Youth Services (DYS)
- Ohio Department of Rehabilitation and Correction (DRC)
- Ohio Department of Health (ODH)
- Ohio Department of Developmental Disabilities (DODD)
- Ohio Department of Education (ODE)
- Office of Family & Children First
Member Care FAQs
To learn about the OhioRISE program, please click here to view the OhioRISE Member Care FAQs. You will find answers to common questions including:
- How is OhioRISE different from Ohio Medicaid’s typical coverage for behavioral health?
- Who may benefit from OhioRISE?
- Who is eligible for OhioRISE?
- When can a child or youth start receiving OhioRISE services?
Please send your additional questions to the OhioRISE mailbox.
The OhioRISE Plan
On April 1, 2021, ODM selected Aetna Better Health of Ohio to serve as the new OhioRISE prepaid inpatient health plan (PIHP) for the state’s children with the most complex behavioral health and multi-system needs. Click here to read the full press release.
OhioRISE services through Aetna Better Health of Ohio began on July 1, 2022.
On October 28, 2020, ODM released a request for applications (RFA) to solicit responses from managed care organizations (MCOs) interested in serving an estimated 60,000 Ohio children as the program’s MCO. After the close of the December 16, 2020 response period, Ohio Medicaid evaluated responses from four bidders and conducted oral presentations with each.
This announcement is the culmination of years of work to create a stronger, family-focused system of care for children dealing with intense behavioral health needs.
As the OhioRISE plan, Aetna will partners the state, providers, and community organizations to expand access to in-home and community-based services. Aetna contracts with regional care management entities to ensure OhioRISE members and families have the resources they need to navigate their interactions with multiple systems such as juvenile justice and corrections, child protection, developmental disabilities, mental health and addiction, education, and others.
A link to the OhioRISE RFA can be found on the Ohio e-Procurement website.
ODM Policy Guidance for the OhioRISE Plan
Contracting with the OhioRISE Plan
Providers interested in contracting with Aetna to provide behavioral health services to children and youth enrolled in the OhioRISE program are encouraged to contact Aetna Better Health of Ohio. Providers can contact Aetna via the provider relations contact information listed below.