- 2,129,706 beneficiaries were enrolled in Medicaid as of July 1, 2011. Of these, 1,605,821 were enrolled in managed care through seven Medicaid-only managed care organizations (MCOs). The state has a full-risk managed care program operated under a 1932(a) State Plan Amendment.
- Physical and oral health services (including the EPSDT benefit) are delivered through managed care. Children are mandatorily enrolled in MCOs. Behavioral health benefits delivered through the state’s community behavioral health system (primarily state-certified community mental health centers) are paid for on a fee-for-service basis; services not obtained through this system are covered by managed care plans.
According to regulations (Ohio Administrative Code 5160-1-01) in Ohio:
"’Medical necessity’ is a fundamental concept underlying the medicaid program. Physicians, dentists, and limited practitioners render, authorize, or prescribe medical services within the scope of their licensure and based on their professional judgment regarding medical services needed by an individual. Unless a more specific definition regarding medical necessity for a particular category of service is included within division-level 5101:3 of the Administrative Code, ‘medically necessary services’ are defined as services that are necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. A medically necessary service must:
|Initiatives to Improve Access
Managed care contracts in Ohio require health plans to have on staff an “EPSDT/Maternal Child Health Manager” to help Medicaid-enrolled families navigate the health care system and access EPSDT benefits.
These managers also help to coordinate services specific to the maternal and child health needs of enrollees and link members to community-based resources.
|Reporting & Data Collection||
Appendix M of Ohio’s managed care contracts specify minimum performance standards on select quality measures. Several child-specific measures specified in the contracts are NCQA Healthcare Effectiveness Data and Information Set (HEDIS) metrics, including measures of child and adolescent access to primary care and number of child and adolescent well-care visits. The contracts also gauge performance based on children’s rating of a health plan (in a CAHPS survey) and use a CHIPRA core set measure of asthma-related emergency room visits.
Community mental health centers can apply to become Medicaid Health Home providers, offering services to individuals with serious and persistent mental illness. Services offered through Medicaid Health Homes include: “comprehensive care management, care coordination, health promotion, comprehensive transitional care, individual and family support services, referrals to community and social support services, and the use of health information technology to link health home activities.”
|Support to Providers and Families||
Ohio’s Department of Jobs and Family Services (which houses Medicaid) has produced EPSDT services brochures for families. In addition, managed care contracts require that managed care organizations provide families with member handbooks that at least include: descriptions of screening and treatment services under the EPSDT benefit; the state’s periodicity schedule; clarification that EPSDT services are provided to children with no cost-sharing; and information on prior authorization requirements.
Managed care organizations must also annually educate providers on the EPSDT benefit, including: components of a screen; the state’s periodicity schedule; and common billing codes and procedures related to services under the EPSDT benefit.
Managed care organizations (MCOs) in Ohio are required to engage in a number of care coordination activities, including:
The MCO must employ a Care Management Director, a nurse responsible for operating a Care Management Program and ensuring Medicaid beneficiaries’ services are coordinated. Plans are also responsible for coordinating behavioral health services with physical health services, including services obtained through the community behavioral health system (behavioral health services for which the MCO is not financially responsible).