Home » Blog Articles » Ohio Medicaid » Next Generation of Ohio Medicaid: What Providers Need to Know

The state of Ohio is continuing to update their Medicaid managed care program. This transition known as Ohio Next Generation of Managed Care has been an ongoing process over the previous years. In early 2023, Ohio Medicaid will require some updates as to how medical providers are reimbursed for their services.

Advanced Billing & Consulting Services (ABCS) provides medical billing services for a variety of healthcare specialties. However, revenue cycle management for psychiatry and community behavioral health are one of the company’s primary specializations.

Next Generation, MyCare & OhioRise:

The newly redesigned updates to the Next Generation managed care plans does not include MyCare Ohio plans. MyCare Ohio will continue to utilize benefits from both Medicaid and Medicare. Individuals enrolled in the OhioRISE program will use Aetna for behavioral health benefits and their managed care organization or fee-for-service Medicaid for other health care services.

As a reminder, OhioRISE or Resilience through Integrated Systems and Excellence, is another newly created managed care program. The goal of the program is to improve the state of Ohio’s ability to provide supports and services for children with complex behavioral health needs. These supports and services include children in Ohio’s foster care system.

Ohio Next Generation:

The Ohio Department of Medicaid (ODM) has developed what they call Provider Network Management and the Ohio Medicaid Enterprise System. These are essential pieces of their Next Generation managed care program. As they implement these changes, their goal is to avoid or minimize any unnecessary disruptions in the delivery of healthcare services.

The orderly and secure rollout of these new online portals and databases is particularly important. For Example, in 2021, Ohio Medicaid experienced a data breach which exposed roughly 334,000 healthcare provider’s data. In this instance, a third-party data manager company (Maximus Corp) was the target of the attack.

However, it was reported that the information of individuals who receive Medicaid services were not part of the data breach. Naturally, Ohio Medicaid does not want a repeat of this incident or similar negative experiences.

Managed care plan members have access to seven different Next Generation Managed Care plans. They will need to analyze and compare the plans, and then select the one that is best for them.

The seven managed care plan insurance providers include:

  • AmeriHealth Caritas Ohio, Inc.
  • Anthem Blue Cross and Blue Shield.
  • Buckeye Health Plan.
  • CareSource Ohio, Inc.
  • Humana Healthy Horizons in Ohio.
  • Molina HealthCare of Ohio, Inc.
  • UnitedHealthcare Community Plan of Ohio, Inc.

For additional questions about the specific details of these plans, people can visit the the Ohio Medicaid Managed Care Member FAQ page.

As of February 1, 2023, the seven Next Generation of managed care plans become available to serve members. Simultaneously, the Ohio Department of Medicaid will make available the newly designed Electronic Data Interchange (EDI) and the Fiscal Intermediary (FI) systems.

What can Providers Expect?

The Ohio Department of Medicaid has stated that the newly designed Electronic Data Interchange and the Fiscal Intermediary systems will require providers to learn some new processes.

A few of the processes that will not change:

  • Managed care organization portals are used to access plan eligibility information.
  • Providers will continue to use managed care plan portals to direct data enter claims and prior authorizations.
  • The new Electronic Data Interchange system will not process prior authorizations.

ODM has advised Ohio healthcare providers to not interrupt their delivery of crucial services. They should continue to submit claims and prior authorizations as well as other administrative functions.

As ODM launches their Next Generation of managed care plans and program requirements, they will also implement their newly created Electronic Data Interchange or EDI. The interchange is designed to increase overall system transparency and visibility of member’s care and quality of medical services.

However, there are some administrative changes in the reimbursement process. Please contact the Ohio Department of Medicaid for more specific details.

For additional information on other procedures that are changing, as well as the ones that are not, for healthcare providers — please contact ABCS RCM.

About Us

Advanced Billing & Consulting Services provides billing and patient statement solutions for a variety of healthcare practitioners. Their services include medical billing, insurance enrollment/credentialing monitoring services as well as web design for healthcare practices and agencies.

As an Ohio-based company, they also provide software tools, EVV and billing services for agencies that provide supports for the Ohio I-DD community.

To learn more, email or call them at 614-890-9822.

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