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What the Next Generation of Ohio Medicaid Managed Care Means for Vendors
What the Next Generation of Ohio Medicaid Managed Care Means for Vendors
What the Next Generation of Ohio Medicaid Managed Care Means for Vendors

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 time Ohio has made changes to the structure of its Medicaid program since CMS’ approval of Ohio’s program in 2005.

We began by conducting a review of the structure that is in place today. We first considered feedback and suggestions from individuals and providers when making decisions about how to evolve the Medicaid Managed Care program in Ohio through our first Request for Information (RFI).

In early 2020, we released a second RFI seeking input from providers, associations, advocacy groups, data and information technology vendors, and managed care organizations. After receiving nearly 100 responses, RFI #2 closed on Tuesday, March 3, 2020. The Managed Care Procurement page of this website contains additional information about the goals of the second RFI and a summary of the input we received from respondents.

As a result of the feedback received, ODM is implementing its vision for a future program that is based on addressing the needs of its more than 3 million members and thousands of providers. The result is a comprehensive and coordinated set of services and supports focused on members, their families, and providers.

Medicaid Managed Care

ODM announced the selection of six health care organizations to lead the department’s evolution of managed care services. Ohio Medicaid’s managed care procurement was a rigorous, competitive process focused on quality, innovation, and value. ODM’s next generation program emphasizes plan coordination with OhioRISE – which addresses care for children with complex behavioral needs – and the single pharmacy benefit manager (SPBM) -- designed to ensure more accountability and transparency in Medicaid’s pharmacy program. Initiatives such as centralized credentialing and fiscal intermediary streamline administrative functions and reduce duplicative processes for providers. Visit the Managed Care Procurement page of this website to learn more.

OhioRISE

ODM selected Aetna to serve as the specialized managed care organization (MCO) for the state’s children with the most complex behavioral health needs under the new OhioRISE (Ohio Resilience through Integrated Systems and Excellence) program. Aetna will work with ODM and Governor DeWine’s Family and Children First Cabinet Council to implement a child and family-centric model featuring new targeted services and intensive care coordination delivered by community partners. Aetna also will coordinate with the state’s Medicaid MCOs and the new SPBM to ensure medical and pharmaceutical services and supports are integrated in the child’s comprehensive health plan. Visit the OhioRISE page of this website to learn more.

Single Pharmacy Benefit Manager (SPBM)

ODM selected Gainwell Technologies to be the agency’s SPBM. The award moves Ohio closer to realizing greater transparency and accountability in Medicaid’s $3 billion pharmacy program. The SPBM is part of a larger overhaul of the Medicaid program designed to put the needs of Medicaid members first and bring visibility to the use of state dollars. Doing so meant structuring the program as a specialized managed care health plan that rewards the SPBM for patient wellness and health outcomes.

ODM announced Myers and Stauffer as its Pharmacy Pricing and Audit Consultant (PPAC - formerly known as pharmacy operational support vendor). In this capacity, the firm will serve a critical role in bringing greater transparency and accountability to the state’s Medicaid prescription drug benefit. The PPAC will work with ODM to establish pharmacy prices and conduct fiscal oversight of the SPBM. PPAC oversight is designed to eliminate potential SPBM conflicts of interest, prevent prescription drug steerage, and identify other potential financial mechanisms that could obscure visibility, reduce public confidence, and increase taxpayer expenses.

Visit the SPBM page of this website to learn more.

Provider Network Management (PNM) Module & Centralized Credentialing

ODM is in the process of modernizing its management information systems. This modernization roadmap, developed in accordance with Centers for Medicare and Medicaid Services (CMS) guidance, includes a transition to a modular system called the Ohio Medicaid Enterprise System (OMES) that will support ODM in meeting several modernization goals.

As a part of this roadmap, updated and new functionality is being built into OMES rather than MITS. The Provider Network Management (PNM) module is a new modular component of OMES that will replace the current MITS provider enrollment subsystem and the current MITS provider portal. Through the PNM, ODM is implementing a single, centralized provider credentialing process at the state level. Visit the PNM & Centralized Credentialing page of this website to learn more.

Fiscal Intermediary (FI)

ODM awarded its FI service contract to Gainwell Technologies, taking another important step forward in delivering a person-centric next generation managed care program to Ohio. The FI is a part of a larger effort to modernize ODM’s management information systems, developed in accordance with CMS guidance. Adopting CMS’ modernization guidance saves the state 90% of the design and build costs, and 75% of the maintenance expenses.

The module will serve as a single clearinghouse for all provider claims and prior authorization requests, validating transactions and routing requests to the appropriate MCO for resolution and reimbursement. In addition to streamlining the claims process, the FI will strengthen ODM’s ability to assess compliance with Medicaid managed care regulations, review encounter data, and track performance measures. Visit the Fiscal Intermediary page of this website to learn more.