Reprinted from the winter 2021 Issue of The Ohio Family Physician.
By: Mark Rastetter, MD, Chief Medical Officer, Humana Ohio Healthy Horizons Medicaid
As some of you may know by now, the Ohio Medicaid program is undergoing some significant changes. Over two years ago, a process was initiated by the state to explore and understand the challenges and improvements needed for Ohio Medicaid. I am mindful that some of you may have provided feedback in that process. The result of that work is what the Ohio Department of Medicaid (ODM) is calling The Next Generation of Ohio Medicaid and it will go into effect on July 1, 2022. There is a lot in this transition that will affect family physicians and the tens of thousands of patients we serve throughout Ohio. For the winter issue of The Ohio Family Physician, I wanted to discuss at a high level some of the changes taking place, and come spring, hopefully share more granular details that will impact family physicians. The full details of The Next Generation of Ohio Medicaid is public and available online.
The impetus for the significant programmatic changes taking place is rooted in the idea that Ohio can do better to care for its communities made most vulnerable by social and structural determinants of health. By aligning the inputs and incentives of all of the entities working within Ohio Medicaid towards health equity, we will all be able to collaborate and partner more effectively to improve health outcomes, eliminate health disparities, and improve value for the whole person and their families. There is also a recognition that if physicians and other health care professionals serving patients with Medicaid are overburdened with administrative tasks, not only are patients affected, but it also leads to further burnout, especially in primary care. Therefore, The Next Generation of Ohio Medicaid is designed to address multiple fronts. I will discuss the five largest changes, including:
Managed Care Procurement
A new request for application (RFA) was issued for Ohio Medicaid managed care contracts. There were 11 companies that applied and ultimately seven were chosen based on an extensive selection process. While some of the companies selected have been serving Ohio Medicaid previously and some are new, all have signed new provider agreements. All seven entities will serve Ohioans across the state— there are no regional contracts. The major changes in the new agreements are around eight categories: increased transparency and accountability, care management and coordination, claims adjudication, transportation coverage, telehealth coverage, prompt pay, health equity, and a focus on local presence and communication.
Ohio Single Pharmacy Benefit Manager
In the past, each managed care entity used their own pharmacy benefit manager to manage pharmacy benefits. In the next generation program, a single pharmacy benefit manager has been chosen through an RFA process. ODM sees a greater opportunity for oversight and transparency with this process, and prescribers will see more streamlined functionality. There will continue to be a unified preferred drug list managed by ODM with input from the participating health plans.
Fiscal Intermediary
In response to reducing the administrative burden to physicians and other health care professionals and healthcare facilities, a fiscal intermediary was selected through a separate RFA process. Claims and prior authorization requests will have a more streamlined, efficient, and transparent process through a single point of submission.
Centralized Credentialing
There will be a single entry point for credentialing and provider applications. Physicians and other health care professionals will no longer have to credential with each managed care entity, but just once at the state level. Although, credentialing by ODM does not guarantee your participation in a health plan’s network of providers. You and the health plan(s) must still choose to participate or not participate with one another via a contract. As a health care professional, you have the right to choose to participate with, or not participate with, any of the seven health plans. Your credentialing by ODM does not guarantee a contract with a health plan(s).
OhioRISE
Focusing on the unique challenges faced by children with complex behavioral health needs, a new program was designed called the Ohio Resilience through Integrated Systems and Excellence (OhioRISE). This program will serve roughly 60,000 Ohio children who not only require coordination across medical locations of care, but also often the juvenile justice system, child protection, the school system, and others. Each of the seven managed care entities will work closely with the OhioRISE program to assure efficient and effective transitions of members in and out of the program.
There is a lot of excitement on the horizon with this next generation program as it seeks to focus on the person and their health journey. As time moves forward and July 1, 2022, arrives, there is great hope that the five goals of ODM’s next generation plan will be fully realized. Those goals—to improve wellness and health outcomes, emphasize a personalized care experience, support professionals in better patient care, improve care for children and adults with complex needs, and increase program transparency and accountability— will bring improved health and well-being to millions of our fellow Ohioans, who today too often find themselves on the outside looking in when it comes to access to integrated and equitable health services.
References available on the Ohio Academy of Family Physicians website.