Next Generation of Ohio Medicaid Managed Care

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.

 


With the projected implementation of Ohio Medicaid’s next generation of managed care on July 1, 2022, ODM intends to put the individual at the center of focus and improve the design, delivery, and timeliness of care coordination. This effort depends on the collective implementation of several strategic initiatives, including:


Learn more about the new next generation program timeline on the Managed Care Procurement.

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


View the brief video below for more details on how these efforts work together to build a future program that does better for the people we serve.


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.


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