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What is OhioRISE?

In an effort to improve care for youth with complex needs, the Ohio Department of Medicaid (ODM) is implementing a new program called Medicaid’s Next Generation Program, which includes OhioRISE (Resilience through Integrated Systems and Excellence). OhioRISE is a specialized managed care program that aims to provide comprehensive and highly coordinated behavioral health services for youth, ages 0-20, with complex behavioral health and multi-system needs.

According to ODM, OhioRISE seeks to: “Reduce unnecessary hospitalizations and emergency room visits, decrease involvement with the juvenile justice and corrections systems, reduce out-of-home and out-of-state placements (residential care and foster care), increase school attendance and performance; and reduce custody relinquishment for children, youth and families.” The Office of Governor Mike DeWine estimates that nearly 5,500 children and youth will be able to access OhioRISE services immediately and expects that ODM will enroll up to 50,000 children and youth by the end of 2022. 

Who is eligible?

Twenty Care Management Entities (CMEs) were chosen from across the state to serve as the singular point of contact for families in times of crisis and to manage the day-to-day needs of OhioRISE enrollees. ODM and the CMEs have started to reach out to families and programs that work with youth who may be immediately eligible for OhioRISE services. In order to qualify for services and be paired with a CME, a youth must:

• Be under the age of 21;
• Be determined eligible for Medicaid services;
• Not be enrolled in a MyCare Ohio plan; and
• Have one of the following:
  • Certain needs for behavioral health care, identified by a Child and Adolescent Needs and Strengths (CANS) assessment, or
  • Have a recent inpatient hospital stay for mental illness or substance use disorder, or 
  • Have a recent inpatient stay in a Psychiatric Residential Treatment Facility (PRTF).

Additional services for youth who have a higher level of behavioral health needs will be offered through a 1915(c) waiver to youth who meet the following criteria:

• Under the age of 21;
• Determined eligible for Ohio Medicaid;
• Not enrolled in a MyCare Ohio plan; and
• Determined to meet the following level of care criteria for inpatient psychiatric services:
  • Have certain needs for behavioral health care, identified by a CANS assessment,
  • Have a diagnosis of serious emotional disturbance (SED), and
  • Have documented functional impairment and behaviors. 

What services are available?

OhioRISE will provide the following services to eligible youth and their families, as facilitated by the CMEs:

• Care Coordination
  • Tier 3 – Intensive Care Coordination using a High-Fidelity Wraparound approach for members with high behavioral health needs
  • Tier 2 – Moderate Care Coordination using a Wraparound informed model for members with more moderate behavioral health needs
  • Tier 1 – Limited Care Coordination for members who may refuse care coordination or may need lower intensity care coordination
• Intensive Home-Based Treatment (IHBT):OhioRISE will make enhancements to existing IHBT services to recognize multiple service delivery models and align with the Family First Prevention Services Act.
• Psychiatric Residential Treatment Facility (PRTF): PRTF services are being developed to keep youth with the most intensive behavioral health needs in-state and closer to their families; these services will be launched in 2023.

• Mobile Response and Stabilization Service (MRSS): MRSS is a structured intervention and support service provided by a mobile service team and is designed to provide youth in crisis with immediate behavioral health services.
• Behavioral Health Respite: Behavioral health respite care provides short-term, temporary, community-based relief to the primary caregiver(s) of an OhioRISE-enrolled youth to support the caregiving relationship.
• Primary Flex Funds: Funds may be used for services not otherwise provided through Medicaid that address an identified need in the service plan.
• 1915(c) Waiver Services: Waiver Services are additional services  meant to support the most vulnerable youth and to keep families together and may include out-of-home respite care, transitional services and supports, therapeutic mentoring, and secondary flex funds for additional needed services not paid for under Medicaid. 

How can providers get involved?

ODM selected Aetna Better Health of Ohio as the OhioRISE plan administrator. Aetna will contract with the CMEs to connect OhioRISE members and families with the resources they need. Providers interested in contracting with Aetna for OhioRISE are encouraged to contact Aetna Better Health of Ohio at the following link: https://www.aetnabetterhealth.com/ohiorise/providers/index.html. 

ODM also launched the OhioRISE community and provider training series to help orient providers to the new programming offered through OhioRISE as well as billing and claims procedures. Recordings of these trainings can be found at: https://managedcare.medicaid.ohio.gov/managed-care/ohiorise/2-OhioRISE-Comunity-And-Provider-Trainings. 

For any questions on OhioRISE and how you may be able to participate as a provider, please reach out to Ashley Watson at abwatson@bmdllc.com.