ODM Launches Next Generation of Ohio Medicaid Program

On October 1, 2022, the Ohio Department of Medicaid (ODM) launched Stage 2 of the Next Generation of Ohio Medicaid program. This launch included the implementation of the Single Pharmacy Benefit Manager (SPBM) and Centralized Credentialing in the Provider Network Management (PNM) module, offering major positive changes for both members and providers.
What Medicaid managed care members need to know
As of October 1, Ohio Medicaid managed care members will experience the following exciting benefits:
  • The SPBM, operated by Gainwell Technologies, is partnering with members’ managed care organizations to improve member health.
  • The launch of the SPBM means individuals are not tied to an MCO solely for its pharmacy program, therefore they can select a health plan based on its ability to address their unique healthcare needs.
  • With more than 2600 pharmacy locations, the SPBM has the largest pharmacy network that has ever served Ohio Medicaid managed care.
  • Previously, members were juggling several ID cards, which can be difficult. The Next Generation member ID cards allow Ohio Medicaid and OhioRISE members to have one ID card that includes all member information, including pharmacy benefit information. Members finally have everything in one place!  
  • The SPBM does not apply to MyCare Ohio plans, which will continue to provide benefits to Ohioans who receive both Medicaid and Medicare benefits, with enhanced coordination of medical, behavioral, and long-term care services.
Are you a member or authorized representative with questions or need assistance?
  • Questions related to pharmacy benefits and prescriptions should be directed to Gainwell, Ohio Medicaid’s SPBM, by calling the Gainwell SPBM Help Desk at (833) 491-0344 or by visiting https://spbm.medicaid.ohio.gov.
  • All other member questions, including those related to Medicaid managed care eligibility, coverage, benefits, or managed care plan selection should be directed to the Medicaid Consumer Hotline at (800) 324-8680 or by visiting ohiomh.com.  
What Medicaid managed care providers need to know
With the launch, Ohio Medicaid providers will experience improvements from both the SPBM and Centralized Credentialing, including the following:
  • Pharmacists and prescribers will have greater ability to monitor quality, transparency, and accountability in the pharmacy program.   
  • The SPBM will implement a single set of clinical/prior authorization policies and claims process, and serve as a single point of contact, reducing the administrative burden on providers.
  • Providers subject to credentialing only undergo one credentialing and recredentialing process at the state level versus a separate credentialing process for each Ohio Medicaid managed care plan.  
  • There is no longer a need for paper agreements at long-term care facilities – all agreements are available online and do not require mailing back and forth for signatures.  
  • Providers can now view specialties and effective dates.
Are you a provider with questions or need assistance?
  • Questions related to pharmacy claims, prior authorizations, and other administrative tasks should be directed to the Gainwell SPBM Help Desk at (833) 491-0344 or by visiting https://spbm.medicaid.ohio.gov.
  • Questions related to Centralizing Credentialing and the PNM module, OH|ID, and portal password support should be directed to the ODM Integrated Help Desk at (800) 686-1516 or visit the PNM and Centralized Credentialing webpage on managedcare.medicaid.ohio.gov
To learn more about Ohio Medicaid’s Next Generation program and mission, visit the Ohio Medicaid Next Generation website, managedcare.medicaid.ohio.gov