On Wednesday, September 30, 2020, the Ohio Department of Medicaid (ODM) released a Request for Applications (RFA) for its managed care program. 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.
This RFA is for those interested in becoming managed care plans for children and adults within the Ohio Medicaid program. The selected plans will be an essential piece in improving the health and lives of millions of Ohioans. Any changes to Ohio's managed care plans will NOT disrupt member coverage or access to care.
The RFA and additional details about ODM’s Managed Care Procurement process can be found on the Request for Proposal page of ODM’s website.
ODM has designed its future Medicaid managed care program to achieve the following goals:
Improve wellness and health outcomes
Emphasize a personalized care experience
Support providers in better patient care
Improve care for children and adults with complex needs
Increase program transparency and accountability
Many of these goals will be advanced 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 next-generation Medicaid managed care program where ODM, the MCOs, PBM and OhioRISE work together to provide the best possible care for each individual. OhioRISE (Resilience through Integrated Systems and Excellence) - a single, statewide prepaid inpatient health plan - is 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 system 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.
For additional details about the future Ohio Medicaid managed care program and procurement, visit managedcare.medicaid.ohio.gov.