FINANCE NEWS - MEDICAID Connect here to view Medicaid-specific Finance News prepared by OHA's Health Economics & Policy team.
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MEDICAID AND OHIO HOSPITALS Medicaid was the payer in 23% of Ohio hospital encounters in 2020. Enrollment in Medicaid jumped to 27% of the state's population during the COVID-19 pandemic as many lost employer-sponsored coverage.
MEDICAID EXPANSION Ohio expanded Medicaid program eligibility in 2014 to include additional uninsured adults with incomes up to 138% of the federal poverty level. To be eligible for Medicaid coverage, individuals must: Be a United States citizen or meet Medicaid citizenship requirements Have or get a Social Security number Be an Ohio resident Meet financial requirements according to Modified Adjusted Gross Income
WHO IS COVERED The Ohio Department of Medicaid reports beneficiaries and expenses by four eligibility categories. Each group has its own income requirements: Covered Families and Children, or CFC—Pregnant women, infants and children Group VIII, expansion population—Individuals at or below 138 percent of the federal poverty level, including childless adults Aged, Blind and Disabled, or ABD—Individuals with disabilities Other—Including elderly In response to the COVID-19 pandemic, federal legislation required state Medicaid agencies to maintain eligibility for individuals covered by Medicaid throughout the public health emergency. In return, states were provided with an enhanced FMAP of an additional 6.2%-point increase. In December 2022, Congress enacted the Consolidated Appropriations Act, 2023, officially delinking the continuous coverage provision from the public health emergency and phasing out the eFMAP throughout the remainder of 2023. Starting in February 2023, the Ohio Department of Medicaid has retuned to routine eligibility operations. With the reinstatement of routine eligibility operations, individuals can be terminated beginning on April 1, 2023. It is critical that Medicaid members take the necessary steps to update their contact information, respond to requests for information (including renewal packets), or transition to other coverage if they are no longer eligible for Medicaid. Providers can assist by reminding patients that Medicaid eligibility redeterminations have restarted. More information can be accessed here.
WHAT MEDICAID COVERS Medicaid assists in paying for: Inpatient and outpatient hospital care Physician, midwife and specific nurse practitioner care Laboratory and x-ray services Nursing home and home health care Early and periodic screening, diagnosis and treatment for children under age 19 Family planning Rural health clinics/federal qualified health centers Prescription drugs
NEXT GENERATION MANAGED CARE PROGRAM The Ohio Department of Medicaid has implemented several strategic initiatives to support their Next Generation Managed Care program. This new program represents the first structural change to the program in 15 years, and were implemented in phases starting on October 1, 2022. These initiatives include: Seven Next Generation managed care organizations responsible for managing benefits that help address members’ healthcare needs, such as increased access to care coordination and care management supports OhioRISE, which is a specialized managed care program for youth with complex behavioral health and multisystem needs Single Pharmacy Benefit Manager, or SPBM, which provides pharmacy services across all Medicaid managed care plans and members Fiscal Intermediary, or FI, which processes claims submitted via the Electronic Data Interchange Centralized credentialing, which is a single, centralized provider credentialing process at the state level Supporting these strategic initiatives includes the go-live of the new Provider Network Management, or PNM, module which serves as the single-entry point for secure portal functions such as claims submissions, prior authorizations, and member eligibility verification. Click here for more information.