CareSource-Ohio Medicaid Managed Care Program

As of August 2019, the state of Ohio has enrolled 2,635,478 individuals in Medicaid and CHIP. Ohio adopted and implemented Medicaid expansion for low-income adults on 1/1/2014.

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Overview

In November 2011, Kentucky enrolled approximately ninety percent (90%) of the Medicaid population in managed care, through which Medicaid Managed Care Organizations (MCOs) are paid a fixed monthly capitated rate per enrollee and are at financial risk for recipient use and service expenditures. The MCOs are responsible for managing both physical and behavioral health services for their members.

The Kentucky Department for Medicaid Services (DMS) currently contracts with five (5) Managed Care Organizations (MCOs) to provide coverage for most of Kentucky’s Medicaid recipients. The Medicaid population in Kentucky is approximately 90% managed care with the remaining 10%, comprising mostly individuals in Long Term Care and Waiver programs.

There are five Managed Care companies supporting Kentucky managed care: Aetna, Anthem, Passport, WellCare, and Humana CareSource. As of the end of October 2019, enrollment in Kentucky’s five managed care plans is as follows:

There are five Managed Care companies supporting the Ohio MCP: CareSource, Buckeye Community Health Plan, Molina Healthcare of Ohio, Paramount Advantage, and United Healthcare Community Plan of Ohio. As of January 2019, enrollment in Ohio’s five managed care plans is as follows:

CareSource: 1,187,855

Buckeye Community Health Plan: 285,533

Molina Healthcare of Ohio: 265,196

Paramount Advantage: 228,443

United Healthcare Community Plan of Ohio: 270,070

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In addition to the MCP, Ohio also offers another managed care program, MyCare Ohio (MCOP), which is designated for Ohioans who receive BOTH Medicaid and Medicare benefits. MCOP is a demonstration project that integrates Medicare and Medicaid Services into one program, operated by a managed care plan. MyCare Ohio operates in seven geographic regional covering 29 counties and includes more than 100,000 beneficiaries. MyCare Ohio currently authorized by CMS through December 31, 2019. The state is seeking reauthorization.

MyCare Ohio includes all benefits available through traditional Medicare and Medicaid programs, including Long Term Services and Supports (LTSS) and Behavioral Health.

In addition, MyCare Ohio plans may include additional services to their members. There are two choices for receiving MyCare Ohio benefits:

Dual-Benefits: A MyCare Ohio plan provides both the Medicare and Medicaid benefits for members. Members are eligible to receive added benefits of the plan, such as $0 copayments for prescription drugs covered by Medicare, additional transportation services, etc.
Medicaid-Only Benefits: A MyCare Ohio plan only covers Medicaid-covered services. Members will continue to receive prescription drugs through their Part D plans and any associated co-payments. Medicare benefits would be provided through traditional Medicare or through a private insurance company, commonly referred to as a “Part C” plan.

MyCare Ohio managed care plans include:

CareSource: 28,013

Buckeye Health Plan, Inc.: 20,835

Aetna Better Health of Ohio, Inc.: 25,262

Molina Healthcare of Ohio, Inc.: 20,978

United Healthcare Community Plan of Ohio, Inc. 24,892

CareSource MyCare Ohio is available only to people who live in the service area. The service area includes the following twelve (12) counties in Ohio: Columbiana, Lorain, Stark, Cuyahoga, Mahoning, Summit, Geauga, Medina, Trumbull, Lake, Portage, Wayne. In addition, individuals with an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID) level of care served in an ICF-IID waiver, in the PACE (Program for All-Inclusive Care for the Elderly) program, or individuals who have third-party insurance including retirement benefits are not eligible for MyCare Ohio.

Ohio Medicaid has a network of providers statewide including (but not limited to hospitals, family practice doctors, pharmacies and durable medical equipment companies. These providers bill Medicaid directly for health care services they provide to Medicaid consumers. Medicaid consumers eligible for getting care through Traditional Medicaid may go to any Ohio Medicaid provider who accepts Medicaid patients.

The Traditional Medicaid FFS delivery system in Ohio is used as a transitional method for delivering care to the Childless Adult group until they are enrolled in one of the Ohio Medicaid managed care plans (MCPs). MCPs must provide Medicaid-covered behavioral health services for members. However, services provided through the publicly funded community behavioral health system are carved-out of the capitation rates. Behavioral health services provided in publicly funded community behavioral health centers are paid for on a fee for service basis and are not the responsibility of the MCPs. MCP members are allowed to directly access behavioral health services provided through the publicly funded community behavioral system or the MCPs. The initial fee-for-service period for beneficiaries to select or be assigned to an MCP will be the same timeframe outlined in Ohio’s federally approved managed care state plan amendment (SPA).

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Coverage

CareSource Ohio covered services include:

Acupuncture
Ambulance and Ambulette (Wheelchair Van) Transportation
Certified Nurse Practitioner Services (CNP)
Dental Services
Diagnostic Services
Federally Qualified Health Center or Rural Health Clinic services
Family Planning Services/ Supplies
Home Health Service
Hospice Care
Medical Supplies
Nursing Facility Services (CareSource will cover the stay for members unless the Ohio Department of Medicaid determines that the member will return to fee-for-services Medicaid)

Orthotics/Prosthetics
Over-the-Counter (OTC) Medications Covered with a prescription from a doctor
Physical and Occupational Therapy
Prescription drugs
Prostate screening Services
Psychiatry
Residential treatment
Addiction Services For inpatient services
Certified Nurse Midwife Services (CNM)
Chiropractic (back) Services
Developmental Therapy Services
Durable Medical Equipment
Free-Standing birth center services
Hearing exams and aids
Private Duty Nursing

Inpatient Hospital Services
Mental Health and Substance Use Disorder Treatment Services
Obstetric/Maternity Care Prenatal and postpartum care
Outpatient Hospital Services
Pain Management Services
Podiatry (foot) Services
Preventive mammogram (breast) and cervical cancer (Pap test) exams
Primary Care Provider Services
Renal dialysis (kidney disease)
Respite Services

Data Considerations

HMS receives all claims data from CareSource Ohio, with the exception of Dental, which has not been routinely received since 2014. It is important to note that since HMS receives claims data directly from CareSource Ohio, we are receiving actual claims data as opposed to encounter only data. However, providers for this claim population are not paid on a Fee-For-Service basis. Rather providers receive payment directly from CareSource, which may pay more or less than the Medicaid FFS rate.

HMS does not receive the FFS claims data for services covered by traditional Medicaid in Ohio under its contract with CareSource Ohio.