What You Need To Know As Ohio Overhauls Medicaid

Nov. 15--The overhaul of Ohio's Medicaid program has farther reaching consequences than CareSource.

The health insurance program for 3 million Ohioans with low incomes and disabilities is a major policy tool. It's a key source of health care for the Dayton region, which is older and less affluent than the state as a whole, and also a source of funding for hospitals, doctors and other providers.

The change is designed to improve the care of the 2.7 million Ohioans who get their care get their Medicaid benefits through a system called Medicaid managed care where an insurance company that manages the plan and pays out the claims. Five insurance plans manage these policies in Ohio.

"We're in a fairly unique group of states who have made a pretty near comprehensive commitment to manage care. So we want to keep pushing the envelope in terms of getting the best outcomes for people that we support," State Medicaid Director Maureen Corcoran, in an interview after the procurement was publicly posted in October.

Some of the outcomes that the overhaul aims to improve have been documented in state and federal reports.

Loren Anthes, Medicaid researcher with Cleveland-based Center for Community Solutions, reported that the state had a "secret shopper" program that found trying to learn more about Medicaid member consumer experiences, the ability to schedule an appointment for routine care was less than 70%; the ability to schedule an appointment as a new patient was around 75%; on average, patients had to wait 27 days for an appointment; and only 7 in 10 contracted physicians accepted new patients.

When looking at the Healthcare Effectiveness Data and Information Set, which is a widely used set of performance measures in the Medicaid managed care industry, only 52% of Ohio children get their health checks completed, fewer than 2 in 3 children get regular vaccinations, and fewer than half of children have annual dental appointments.

Ohio is trying to create a new set of rules that gets better results. Gov. Mike DeWine's office announced the request for proposals as part of a new vision for Ohio's Medicaid program that focuses on people -- not just the business of managed care.

"Since coming into office in January of 2019, my administration has been evaluating our Medicaid program to develop a vision of a better, healthier, and more productive state," DeWine had said. "With input from Ohioans covered by Medicaid, physicians, hospitals, health care providers, and managed care plans, this will be the first major overhaul of Medicaid in 15 years."

The overhaul has so far been a massive effort.

For the past 18 months, the DeWine administration has been doing the leg work leading up to this bid. This includes getting feedback from 1,100 different people and organizations.

Ohio Medicaid will let the winning bids know with award letters Jan. 25, 2021. The goal is for the newly rebid system to go live Jan. 5, 2022.

Some of the new conditions that Ohio Medicaid wants for insurance companies it contracts with include making the system easier to use, adding population health measures to keep people healthy, and the new conditions also add new accountability measures.

The method that will be used to score applicants like CareSource includes different points for different categories, with a total 1,000 points as the highest possible score.

The scoring method puts the highest emphasis on population health measures, where companies can earn up to 395 points. Qualifications and experience is the lowest weighted category, worth up to 85 points.

Some of the aspects of the bid includes that insurance companies are asked to describe how they will identify and address the need for reliable transportation to services, and they must submit a plan for how they will invest a portion of profits back into the community. The system also comes with a range of penalties for non-compliance, such as an insurance company getting an enrollment freeze until they fix the particular issue.

The new system is also supposed to make it easier for doctors and other providers to work with the system, such as having a single point for filing claims instead of the current system of working with up to five different plans.

"The thing I noticed in particular is there's a big shift away from the interests of the managed care companies to the interests of patients and providers," Anthes said.

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