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Ohio’s Managed Care Overhaul Delayed – New Implementation Timeline

Client Alert

At the direction of Governor Mike DeWine, the Ohio Department of Medicaid (ODM) launched the Medicaid Managed Care Procurement process in 2019. ODM’s stated vision for the procurement was to focus on people and not just the business of managed care. This is the first structural change to Ohio’s managed care system since the Centers for Medicare & Medicaid Services' (CMS) approval of Ohio’s Medicaid program in 2005. Initially, all of the new managed care programs were supposed to be implemented starting on July 1, 2022. However, ODM Director Maureen Corcoran recently confirmed that this date will be pushed back for several managed care-related programs.

What Caused the Delay?

Like many plans over the past two years, ODM’s rollout of the Next Generation of Managed Care was delayed partially as a result of COVID-19. The federal government is not expected to renew the public health emergency status beyond mid-July, which will trigger the required eligibility redetermination of millions of Medicaid beneficiaries. Until then, Medicaid is barred from removing anyone from the program while receiving enhanced federal matching funds provided in response to the pandemic. In order to minimize disruption for all Medicaid beneficiaries, the phased approach to introducing the new managed care system will allow time for the public health emergency to end and the new managed care plan coverage to begin. Additionally, ODM states that the staggered start will also promote continuity of care, limit confusion, and provide adequate time for provider testing and training.

The New Plan

Originally, ODM was supposed to roll out seven new managed care plans, centralized credentialing, a single pharmacy benefit manager, and a new managed care plan for multi-system youth called OhioRISE on July 1, 2022. For the reasons named above, ODM is now instituting a staggered start. Here is the new implementation schedule:

  • Stage 1, July 1, 2022 – OhioRISE: OhioRISE will provide care coordination and specialized services to help children and youth with behavioral health needs who receive care across multiple systems. The program builds on the launch of a statewide network of community-based care management entities; the design and implementation of the Child and Adolescent Needs and Strengths assessment tool; and the completion of extensive community and provider training sessions for more than 1,650 participants.
  • Stage 2, October 2022 – Centralized Provider Credentialing & Single Pharmacy Benefit Manager: Centralized Provider Credentialing (CPC) will provide a single place for provider credentialing rather than forcing providers to be credentialed with each individual managed care plan. Medicaid will implement CPC through the Ohio Medicaid Enterprise System (OMES) Provider Network Management (PNM) module, which aims to reduce administrative burdens on providers and will largely replace the current MITS system. Additionally, in Stage 2, the Single Pharmacy Benefit Manager (SPBM) will begin providing pharmacy services across all managed care plans and members.
  • Stage 3, 4th quarter of 2022 – Next Generation Managed Care Plans: ODM will finish the three-phase implementation with the opening of all seven Next Generation Managed Care Plans to provide healthcare coverage under the new program. ODM will also complete the OMES implementation by launching the Fiscal Intermediary (FI), which seeks to simplify and streamline the provider process for submitting claims and prior authorizations.

Incumbent plans will still continue to operate as usual, including UnitedHealthcare Community Plan of Ohio, Molina Healthcare of Ohio, CareSource Ohio and Buckeye Community Health Plan. New plans include Humana Health Plan of Ohio, AmeriHealth Caritas of Ohio and Anthem Blue Cross and Blue Shield. Patients will have the opportunity to stay with their current plan or switch to a new one.

If you have any questions about any of the new Medicaid programs and how they may impact your practice, please reach out to your local BMD Healthcare Attorney or Ashley Watson at abwatson@bmdllc.com.


Supreme Court Issues Major False Claims Act Decision

Telehealth Flexibility Updates: HIPAA, DEA, and CMS

The Covid-19 Public Health Emergency (PHE) officially ended on May 11, 2023. But what does that mean for telehealth, a field that expanded exponentially during the PHE? Fortunately, many of the flexibilities will remain intact, at least temporarily. This client alert presents a brief overview of the timelines that providers need to follow, but for a more comprehensive review of telehealth flexibilities and when they will end

WEBINAR SERIES RECAP | Ending the Public Health Emergency + Post-Pandemic Check-Up

Some may take the position that the rest of the country already returned to a new “normal” following the COVID-19 pandemic.  But healthcare providers continue to implement COVID protocols and navigate the ever-changing healthcare regulations at both the federal and state levels.  It is important for healthcare providers to take time for a “Healthcare Check-Up” with the start of 2023 and the ending of the Public Health Emergency (“PHE”).

Sharp Rise in False Claims Act Cases - Navigating the FCA Waters

Recently, on April 18, 2023, the United States Supreme Court heard arguments regarding the FCA’s scienter, or mental state, requirement. To prove violation of the FCA, the statute requires that a defendant “knowingly” file false claims for payment. The term “knowingly” is defined within the statute to mean a person that acts with actual knowledge, deliberate ignorance, or reckless disregard. Circuit courts are split on how to interpret and apply the knowledge element of the FCA, and based on the Supreme Court’s decision, there will be a large impact on healthcare defendants and their businesses as well as anyone who contracts with, or receives money from, a federal program. A broader interpretation of the FCA would unnecessarily target and stifle healthcare, and other businesses, for simple errors in daily operations. This goes against the intended application of the FCA, which was to prevent fraudulent activity.

Areas of Opportunity in Columbus: Highlights from the Columbus Opportunity Summit

On April 27, 2023 Columbus Business First held its annual Columbus Opportunity Summit, bringing together business and economic development leaders to provide an update on how Central Ohio is preparing for expected growth in the coming years, an issue heightened by the arrival of Intel at its 1,000 acre site in Licking County, just outside of Columbus. The site will be home to two new chip factories with room to grow to a total of eight factories and is a $20 Billion investment.