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Managed Care Procurement

Managed Care Procurement

About the Medicaid Managed Care Procurement

In early 2019, Ohio Governor Mike DeWine called on ODM to ensure Ohioans get the best value in providing quality care. In response, we developed a bold, new vision for Ohio’s Medicaid program – one that focuses on people and not just the business of managed care. The new Medicaid program will be the first structural change since CMS’ approval of Ohio’s program in 2005.

Managed Care Procurement Summary

2021 Medicaid Managed Care Annual Open Enrollment

Beginning September 17, 2021, Ohio Medicaid managed care members will be able to change their plan by calling the Ohio Medicaid Consumer Hotline at 1-800-324-8680 or utilizing the Ohio Medicaid Consumer Hotline Member Portal at https://members.ohiomh.com/Login.aspx. Visit the Ohio Medicaid Consumer Hotline website at www.ohiomh.com for information. You do not have to do anything if you want to keep your current Medicadi managed care plan.

Medicaid Managed Care Procurement Award

On April 9, 2021, ODM announced the selection of six managed care plans to lead the department’s evolution of managed care services for its more than 3 million members and thousands of medical providers. Additional information about the announcement can be found in the press release and supplemental briefing document

Current Phase of the Ohio Medicaid Managed Care Request for Applications (RFA)

The selection reflects the results of intensive stakeholder engagement efforts to define opportunities to strengthen the structure of Ohio’s $20 billion managed care program. It addresses Governor Mike DeWine’s direction at the beginning of his term to re-evaluate Ohio’s managed care system with the goal of making the system more focused on individuals.  

The seven MCOs selected for the next generation managed care program are: 

ODM is projecting that beginning July 1, 2022, Ohio Medicaid managed care members will begin receiving services from one of the seven next generation managed care plans. This timeline allows ODM to go-live with a next generation program that is focused on the individual and provides members increased choice and ability to select a plan that fits their individual needs. This also takes the complexity of the systems and operational changes being made into consideration to provide ODM with time to conduct significant training to support providers in utilizing new systems. View the press release here.

Members will continue to receive services with their current managed care plans until the transition in 2022 and will not lose coverage. In fall 2021, managed care members will receive annual open enrollment notices as usual and will select from ODM's current managed care plans  these plans can be compared by viewing this document. In spring 022, managed care members will have the opportunity to select from ODM's next generation managed care plans. Additional details and communications about this process will be provided in the coming months. 

Providers are now able to begin contacting with the selected MCOs. Refer to the Resources
for Providers page to find MCO contact information for contracting.

New Managed Care Provider Agreements

ODM analyzed the information gathered via two requests for information (RFIs) and listening sessions to develop a framework to create the next generation of Ohio Medicaid’s managed care program. The framework for the program includes:

  • Identification of first-generation program gaps: Feedback highlighted challenges with the current program – many of which the state is constrained in addressing under the current Medicaid Provider Agreement.
  • Creation of a new contract: ODM developed a new Managed Care Organization (MCO) Provider Agreement aimed at addressing current program constraints and member and provider suggestions.
  • Changes to the status quo: The new MCO Provider Agreement creates more opportunities to position ODM to better adapt and respond to the constantly changing health care needs of Ohioans.
  • Implementation of the procurement process: ODM released a request for applications to solicit responses from MCOs; this will ultimately result in the issuance of the new MCO Provider Agreement to partners who will work with us to realize our mission.

Utilizing this framework, many new requirements have been added to the provider agreements. These new requirements can be found in the drop-downs below.

Increased Program Transparency and Enhanced Accountability

  • Increase transparency and ODM access to data from MCOs, subcontractors, and other entities doing business with the MCOs.
  • Strengthen language regarding accountability for, and the importance of, quality improvement projects.
  • Continue provisions that require MCOs to obtain approval from ODM for all downstream subcontracts associated with MCO duties and responsibilities. The new provisions create transparency into these downstream relationships and require subcontractors to mirror the protections and requirements set forth in the MCO provider agreements with ODM.
  • Clarify ODM’s role to ensure compliance with federal and state requirements.

Care Management and Coordination

  • Update the health risk assessment requirement for all members and require it for all new members within 90 calendar days of enrollment.
  • Strengthen collaboration requirements related to care coordination for children in custody, per the Ohio Department of Medicaid’s (ODM) guidance for children in custody.
  • Update quality improvement program language to emphasize disparity reduction and health equity efforts, with an emphasis on health equity as the utmost goal of the quality strategy.
  • Add coordination language for medication-assisted treatment and pre-release enrollment program participants through collaboration and communication with the Ohio Department of Rehabilitation and Corrections, Ohio Department of Mental Health and Addiction Services, and community providers.
  • Add responsibilities related to addiction treatment program drug courts.
  • Add requirements for MCOs to use level of care (LOC) and ODM’s prior authorization form for nursing facility stays. MCOs are required to accept the form if properly submitted by a nursing facility.
  • Clarify and strengthen language regarding inpatient hospital readmissions.
  • Revise third party payer requirements.

Claims Adjudication

  • Revise notification requirements for denied, pended, and/or suspended claims.
  • Update Claims Payment Systemic Errors (CPSE) requirements.
  • Reframe claims adjudication and communication with providers. For example, upon request of the provider, the MCO or MyCare Ohio Plans (MCOP) will be required to utilize a HIPAA-compliant electronic data interchange transaction (e.g. the 276/277) to provide information to the provider regarding all denied, paid, or pended claims status.
  • Update time frames for MCOs to load rates into systems and, if necessary, backdate and re-process claims.
  • Change provider notification requirements to ensure providers receive timely and accurate notification from MCOs when claims are being adjusted.
  • Clarify processes for billing inpatient hospital services.
  • Ease the administrative burden on nursing facilities and change of operator/provider (CHOP) regarding prior authorizations.
  • Add payment methodology for federally qualified health centers (FQHCs).
  • Add a 30-day notification requirement for providers and provider associations regarding pending policy changes.
  • Add sole-source language requirements to provider directories to inform members of any services that must be obtained from a specific provider.
  • Clarify online provider directory requirements, including a requirement to support online provider searches by specialty.

Transportation 

  • The member call center must have a selection for transportation services and the member services representatives must be trained to respond to transportation requests;
  • MCOs must not require more than 48 hours of advance notice for transportation needs and must provide exceptions for advance notice requirements for urgent member needs (e.g., for same or next day urgent appointments) and hospital discharges;
  • MCOs may not restrict the number of transports in a single day; and
  • MCOs must arrange and provide transportation for members who are enrolled with the OhioRISE program in a manner that ensures children, youth, and their families served by OhioRISE do not face transportation barriers to receive services.
  • MCOs are responsible for arranging for transportation for OhioRISE members regardless of whether the transportation is covered by the county or the MCO.
  • MCOs are responsible for arranging transportation in cases where transportation of families, caregivers, and siblings (other minor residents of the home) is needed to facilitate the treatment needs of the member and their family.
  • MCOs must provide additional transportation benefits for members under the age of 21. This medically necessary service cannot be a value-added service or have annual limitations.
  • MCOs must ensure specialized transportation for members who have cognitive or behavioral challenges that require different transportation providers or supports than available from counties or standard Medicaid provider network.

Telehealth 

  • MCOs must offer, promote, support, and expand the appropriate and effective use of telehealth.
  • MCOs must educate members and providers about the availability of telehealth, considerations for using telehealth versus in‐person visits, applicable requirements, and how to access telehealth options.
  • MCOs must support providers in offering telehealth, including providing "how to" guides on the technical requirements, workflows, coding, and billing.
  • MCOs must submit an annual telehealth report to ODM that includes but is not limited to: MCO's goals for telehealth and progress on meeting those goals, including performance measures; barriers to increased use of telehealth and MCO's strategies to overcome those barriers; telehealth utilization, including any changes from the previous year; MCO's activities to support increased use of telehealth, including any provider partnerships; and information regarding whether telehealth is improving access to needed services and/or helping make access more equitable.
  • Provider directories must indicate whether or not a provider offers telehealth, and if so, when telehealth is available.
  • MCOs population health approach must include strategies aimed at keeping individuals and their families at the center of all efforts to identify and meet population needs including removing barriers to care through supporting alternative sites and providers of care (e.g. telehealth).

Prompt Pay 

Unless the MCO and a network provider have established an alternative payment schedule, the MCO must:

  • Pay or deny 90% of all submitted clean claims within 21 calendar days of the date of receipt;
  • Pay or deny 99% of clean claims within 60 calendar days of the date of receipt; and
  • Pay or deny 100% of all claims within 90 calendar days of receipt.

These requirements are more stringent than what are required under federal regulations and will help address providers’ concerns regarding not knowing the status of their claims.

Health Equity

  • Address health care disparities by employing a deliberate and defined approach that is responsive to member and provider needs.
  • Provide health equity training for MCO staff.
  • Ensure equitable access to and the delivery of services to all members, including those with limited English proficiency, diverse cultural and ethnic backgrounds, or disabilities; and regardless of gender, sexual orientation, or gender identity.

Local Presence and Communication

MCOs must respond to requests for information within the following timeframes:

  • Within 24 hours for requests regarding member health, safety, and welfare.
  • Within two (2) business days for requests regarding member access to services.
  • Within five (5) business days for requests received through HealthTrack, for member inquiries.
  • Within five (5) business days for constituent inquiries received through external business relations.
  • Ten (10) business days for requests regarding policy research queries, coding, rate change inquiries, and all other requests for information.

Previous Procurement Phases: Request for Applications (RFA)

In Fall 2020, Ohio Medicaid released its RFA for the Managed Care Procurement for those interested in becoming managed care plans for children and adults within the Ohio Medicaid program. After the RFA response period closed, ODM evaluated the responses to the RFA, and the applicants were required to conduct oral presentations.

The following organizations submitted applications in response to ODM’s managed care solicitation:

  • Aetna Better Health® of Ohio
  • AmeriHealth Caritas Ohio, Inc.
  • Anthem Blue Cross and Blue Shield
  • Buckeye Community Health Plan
  • CareSource Ohio, Inc.
  • Humana Health Plan of Ohio, Inc.
  • Medical Mutual of Ohio
  • Molina Healthcare of Ohio, Inc.
  • OEHP Health Plan
  • Paramount Advantage
  • UnitedHealthcare Community Plan of Ohio, Inc.

The presentation from the Pre-Application Conference is also available.

Additional details and a link to the RFA can be found on the Ohio eProcurement website

Previous Procurement Phases: Requests for Information (RFIs)

Beginning in June 2019, the procurement process focused on collecting feedback and suggestions for improving the program from individuals who receive services through managed care, providers, advocacy groups and community-based organizations through two RFIs. Through this effort, Ohio Medicaid received more than 1,000 suggestions and pieces of feedback, which informed the development of RFAs, Requests for Proposals (RFPs) and provider agreements to support the next generation of Ohio’s Medicaid managed care program.

Additional details on these RFIs can be found in the drop-downs below.

Request for Information #1 

In early 2019, Ohio Governor Mike DeWine called on the Ohio Department of Medicaid (ODM) to ensure Ohioans get the best value in providing quality care. To inform the process, we launched our first RFI to collect feedback and suggestions from individuals who receive services through managed care, providers, advocacy groups, and community-based organizations.

“Our mission in this process is to focus on the individual rather than on the business of managed care,” said Governor DeWine. “The request for feedback released today seeks information specifically from individuals receiving Medicaid services, providers and advocates. Their voices are vital to a just and fair managed care program.”

ODM received nearly 1,000 responses during the RFI #1 response period, which closed on March 3, 2020. Visit the What We’ve Heard From the Individuals We Serve and What We’ve Heard From Providers pages for additional details on the themes of these responses.

The public (redacted) responses to RFI #1 are available on the RFI #1 Responses page at medicaid.ohio.gov

Request for Information #2 

The feedback gathered through RFI #1 informed development of RFI #2, which outlined our vision for the next generation of Ohio’s managed care program. This second RFI sought input from providers, associations, advocacy groups, data and information technology vendors, and managed care organizations. ODM received nearly 100 responses to RFI #2. The RFI #2 response period closed on March 3, 2020.

RFI #2 was a continuation of the process initiated by Governor DeWine to implement some of the most innovative health care reforms in the country. It examined the current health care experience of nearly 3 million Ohio Medicaid consumers and offered ideas to reduce barriers, streamline access, and enhance health care delivery. 
The public (redacted) responses to RFI #2 are available on the RFI #2 Responses page at medicaid.ohio.gov.

Communicating with ODM About the Managed Care Procurement

Throughout future phases of the procurement process, the Next Generation mailbox will remain open as a way for providers, advocates and individuals to communicate with ODM about the current managed care program. Additional resources are also available, as described in the video below.