02/02/2023

New Changes in the Ohio Medicaid Next Generation Managed Care Program are Here

Yesterday, the Ohio Department of Medicaid (ODM) launched new initiatives as part of its Next Generation of Ohio Medicaid program. This included the launch of its seven Next Generation managed care plans, available for members to receive a more personalized care experience with services and supports to best fit their individual healthcare needs. Additionally, ODM launched the Electronic Data Interchange (EDI) and Fiscal Intermediary (FI) to improve the provider experience by increasing transparency and visibility of care and services.

The Next Generation managed care plan changes and EDI trading partner transactions do not apply to the MyCare Ohio program, which will continue to provide benefits to Ohioans who receive both Medicaid and Medicare, with enhanced coordination of medical, behavioral, and long-term care services.

What Medicaid managed care members need to know:

• Next Generation managed care plans began serving members February 1.
• All Ohio Medicaid managed care members should have received a new member ID card in the mail from their Next Generation plan. Members can still make and go to appointments and get prescriptions without their new ID card – just present an old ID card and let the provider or pharmacy know the individual is an Ohio Medicaid managed care member with an old ID card. 

Are you a member or authorized representative who needs assistance or questions answered?

Ohio Medicaid managed care members can utilize the resources below to learn more about the February 1 launch of the Next Generation program.

• The February 1 Launch Ohio Medicaid Member One-Pager serves as a quick reference guide for members to see key changes, benefits, and additional information.
• The Ohio Medicaid Managed Care Member Frequently Asked Questions (FAQ) document answers the most common questions members have about the February 1 launch.

In addition to the resources above, Ohio Medicaid managed care members can reach out to the help desks listed below or review the February 1 Launch Ohio Medicaid Member Help Desk One-Pager.

• Questions related to Medicaid managed care eligibility, coverage, benefits, plan selection, your Next Generation member ID card, or other Ohio Medicaid topics should be directed to the Ohio Medicaid Consumer Hotline at 800-324-8680 or by visiting https://ohiomh.com/.
• Questions related to value-added benefits provided by the plan, issues receiving services, assistance finding a provider, or non-emergency transportation should be directed to the member’s current managed care plan.

• Aetna Better Health of Ohio: 833-711-0773​
• AmeriHealth Caritas Ohio, Inc.: 833-764-7700​
• Anthem Blue Cross and Blue Shield: 844-912-0938​
• Buckeye Health Plan: 866-246-4358​
• CareSource: 800-488-0134​
• Humana Healthy Horizons in Ohio: 877-856-5702​
• Molina Healthcare of Ohio, Inc.: 800-642-4168​
• UnitedHealthcare Community Plan: 800-895-2017

What Medicaid managed care providers need to know:

• EDI and Trading Partners: ODM has implemented the new EDI to be the new exchange point for trading partners on all claims-related activities. The FI will assist in routing managed care claims submitted to the EDI and adjudicate and pay fee-for-service (FFS) claims. Providers who have a trading partner should confirm their trading partner is authorized to work with Deloitte, the new EDI vendor. EDI claims – FFS and managed care – can be submitted by trading partners to the new EDI vendor. This does not include MyCare.
• Direct data entry (DDE): DDE FFS prior authorizations and claims should continue to be submitted to the Provider Network Management (PNM) module. Managed Care prior authorizations and claims should be entered directly into that specific plan's managed care portal.
• Next Generation Program Changes: All FFS prior authorizations should continue to be submitted via direct data entry (DDE) to the Provider Network Management (PNM) module. All managed care prior authorizations should be entered directly into that specific plan's managed care portal. Providers who submit FFS claims by direct data entry should continue to submit to the PNM module. Providers who enter managed care claims by direct data entry should submit into that specific plan's managed care portal. All claim attachments for managed care, and FFS must be submitted via their respective portals. Trading partners will not submit attachments or prior authorizations on behalf of providers. Learn more about submitting claims and prior authorizations on the Next Generation website.

Are you a provider who needs assistance or questions answered?

Ohio Medicaid providers can utilize the resources below to learn more about the February 1 launch of the Next Generation program:

• The February 1 Launch Ohio Medicaid Provider One-Pager serves as a quick reference guide for providers to learn about key changes, benefits, and where to direct members who are looking for additional resources and information.
• The Next Generation Managed Care Plans Provider, Ohio Medicaid Enterprise System EDI, and FI FAQ documents answer the most common questions providers have about the February 1 launch.

In addition to the resources above, Ohio Medicaid providers can reach out to the help desks listed below or review the February 1 Launch Ohio Medicaid Provider Help Desk One-Pager.

• Questions related to Ohio Medicaid Enterprise System (OMES) submitted claims or prior authorizations or other administrative tasks should be directed to the ODM Integrated Help Desk (IHD) at 800-686-1516 or ihd@medicaid.ohio.gov.

To learn more about Ohio Medicaid’s Next Generation program and mission, visit the Next Generation website.