Download the PDF version of this page: Frequently Asked Questions about Medicaid: Managed Care
- What is managed care?
- Do I have to enroll in managed care?
- When can I change managed care plans?
- Will I still get the same services?
- Will I still go to the same doctors?
- What if I disagree with a decision by my managed care organization?
Managed care organizations are private companies that are paid a certain amount of money by Ohio Medicaid to provide the medical services that their members receive.
Do I have to enroll in managed care?
In the past, some people with disabilities were not required to receive services through managed care. However, the law recently changed, and now Medicaid can require people with disabilities to enroll in a managed care plan.
You may receive a written notice requiring you to choose a managed care plan. You may also receive information from the different managed care plans about the services they offer. If you are required to enroll in a managed care plan, and you do not select a plan during the enrollment period, you will automatically be enrolled in one of the plans.
If you want to choose a different managed care plan, you can do so within the first three months that you are enrolled in a plan. There is also an open enrollment period each year, when you can choose a different plan.
You can also choose a different managed care plan at any time if you have “just cause.” You must make a request to the Ohio Department of Job and Family Services to change plans for “just cause.” If your request is denied, you have the right to appeal. Examples of “just cause” include the following:
- You move out of the plan’s service area
- You need services that the plan does not cover for moral or religious reasons
- You need related services at the same time, but all of the services are not available through the plan
- You receive poor quality of care and cannot get appropriate care within the plan
- You don’t have access to medically necessary services
- You don’t have access to providers who are experienced in dealing with your health care needs
- The only primary care provider (PCP) who speaks your primary language leaves the plan, and there is another plan with a PCP who speaks your primary language
Managed care organizations are required to provide the same services as the general Medicaid (fee-for-service) plan. However, your managed care organization may have limits on the amount of a certain service that you can receive, different criteria for deciding whether you can receive a service, or a prior authorization process that you must go through to receive a service. When you enroll in a managed care plan, you will receive a member booklet with information about the benefits. Your doctor or other medical provider should also be able to assist you in finding out these limits or how to request authorization for your medical services.
It is important to remember that managed care organizations must provide Early Periodic Screening, Diagnosis, and Treatment (EPSDT or Healthchek) services for children under age 22. EPSDT includes services that are not provided for adults, or that do not have the same limits as services for adults. However, you may still have to request prior authorization for an EPSDT service.
Not necessarily. Each managed care organization has its own panel of medical providers that are covered by the plan. Before you choose a managed care plan, you should find out if your doctors are covered by that plan.
After you are enrolled in a managed care plan, you will receive a directory of all of the providers in that plan. You can also access the list of providers on the managed care organization’s website.
In limited situations, you may be able to receive services from a provider that is not covered by the plan. You must discuss the situation with your managed care plan in order to determine whether you can receive the services outside of the plan. These situations can include:
- If the plan does not have a provider for your medically necessary services
- If you have already scheduled services with a provider before you enroll in the plan
Each managed care organization has its own appeal process, but the general Medicaid appeal process is also available to you. You do not have to go through the managed care organization’s appeal process before using the general Medicaid appeal process.
Your member handbook provides information about the managed care organization’s appeal process, and who you can contact to appeal a decision. In addition, when you receive a written notice that your services are being reduced or denied, the notice will include information about the appeal process.
It is very important to follow the deadlines for the appeal process. In general, you should have 90 days from the date of the notice to request an appeal through your managed care organization or the general Medicaid appeal process. But read carefully, because in certain cases, it benefits you to request your appeal within 15 days of the notice.