- Medicaid Managed Care FAQ
Medicaid Managed Care FAQ
Medicaid Managed Care Frequently Asked Questions
1. What is a Medicaid Managed Care Plan (MCP)?
In Ohio, most individuals who have Medicaid must join a managed care plan (MCP) to receive their health care. An MCP is a private health-care insurance company that provides medically necessary health care. The Ohio Department of Medicaid contracts with plans that provide medically necessary services as determined by the Ohio benefit package. Additionally, plans provide:
- A toll-free medical advice phone line that is open 24 hours a day every day
- Help coordinating care for individuals with special health care needs
- Annual physical exams for adults
Some MCPs may also choose to provide other services and benefits, such as:
- Transportation to medical appointments and Medicaid redetermination appointments
No or lower co-payments (Individuals who use an Ohio Medicaid card may have co-payments for dental services, routine eye examinations,
eye glasses, and non-emergency services provided in a hospital emergency room.)
2. How do I enroll in a managed care plan?
Shortly after you are approved for Medicaid you will get a letter asking you to pick a plan. Individuals who do not choose a managed care plan will be automatically enrolled in one to receive coverage. The individual will be notified of their assigned plan and how they can choose and enroll in a different plan.
3. How do I change my managed care plan?
Once an individual has been assigned to a managed care plan they will have 90 days to choose a new plan. After that, individuals may change their plan every year during the open enrollment period or if they can show just cause for the change.
4. What Should I expect as a member of a MCP?
Managed care acts just like regular private health insurance. Once you are enrolled in a managed care plan, you will get a new card in the mail. Keep this card for as long as you are on the plan. Your plan will also send information about the doctors, providers, health services and benefits that are available to you. The member handbook will explain covered services, grievance and appeal processes, your rights as a member of the plan, and much more.
You will receive reminders from your managed care plan about preventative medical services, such as screenings, tests, and immunizations to keep you healthy.
Each plan also has an online member portal. You can create an account to access additional information and reprint your identification card.
You may request the services of a care manager from the managed care plan to help you coordinate your medical care, help you navigate the managed care system, and help you with accessing community resources, as needed.
5. How often will I get a new Medicaid Managed Care Plan card?
MCPs send one permanent card when an individual enrolls with the plan.
6. Can my parent/spouse or anyone else speak to the managed care plan on my behalf?
The Health Information Portability and Accountability Act of 1996 (HIPAA) protects confidential health information. If you are 18 years or older, HIPAA prohibits the plans from discussing your information with anyone. You may grant permission to the plan to speak to another person. There are two different types of designations:
- Authorized Representative - someone who can call the plan and hear information about you.
- Personal Representative - someone who can contact the plan, hear information about you, and make medical decisions on your behalf.
If you would like to appoint a personal or authorized representative, complete this form
and send it to your managed care plan.
7. What happens when I enroll with a managed care plan but I am already approved or scheduled to get health care from a doctor or hospital that does not work with my new MCP?
Managed care plans are required to work with you during your transition of care. Call the MCP’s member services team before you receive any services and they can provide you with information on what steps you must take for the care to be covered by your new plan.
8. How do I obtain health care through my MCP?
Your MCP’s member handbook provides information about how you get health care through your MCP. You will get health care from doctors and hospitals who work with your MCP. You should choose an MCP that has most of the doctors and hospitals you want to use. If the doctors or hospitals you have been using do not work with your MCP, you will have to change doctors or hospitals.
9. Managed care plan responsibilities
Your MCP must:
- Provide you with all medically necessary health care.
- Give you a member handbook that explains how to access health care through the MCP including the rules you must follow. Read the handbook as soon as you get it.
- Give you a member identification card. You will not get an Ohio Medicaid card after you are enrolled in a managed care plan.
- Provide a directory of all doctors, specialists, hospitals, and other health care professionals who are in the MCP, that lists their addresses and telephone numbers, and whether they will see you as a new patient. You can also see this information on your MCP’s member website.
- Have a toll-free member services line to help you and answer your questions.
- Have a toll-free medical advice phone line that is open 24 hours a day every day.
- Provide translation services.
- Allow you to change your Primary Care Provider.
- Help you file a complaint or request a state hearing if you are unhappy with your health care services.
- Help coordinate care for individuals with special health care needs.
- Provide annual physical exams for adults.
- Provide medically necessary emergency or non-emergency ambulette transportation .
- Provider non-emergency transportation if you must travel 30 miles or more to see MCP-authorized providers and you ask the MCP to provide transportation.
10. How can I arrange transportation?
If you have full Medicaid eligibility and you are having difficulty in getting to a medically necessary service, then you may request transportation assistance. The type of assistance available may depend on whether you are a member of a Medicaid managed care or MyCare Ohio plan, in which county you live, and whether you are bringing along a non-folding wheelchair or power scooter that doesn't fit easily in a standard vehicle.
Medicaid managed care and MyCare Ohio plans can offer free transportation to their members as an additional benefit above and beyond what the state requires. This "value-added" benefit can be limited to a specific number of trips a year. Members may take these trips to get to healthcare appointments and other services as well, but no one is required to use them up or even to use them at all. Any Medicaid-eligible individual may contact the local CDJFS to request transportation assistance.
If you are a member of a Medicaid managed care or MyCare Ohio plan, then contact your plan in any of the following circumstances:
- You use a non-folding wheelchair or power scooter that doesn't fit easily in a standard vehicle or you need to sit in your folding wheelchair during transport.
- You must travel 30 miles or more (one way) because the medically necessary treatment covered under your plan is not available at a closer location.
- You have a value-added ride available that you want to use.
More information on Transportation Assistance
11. What should I expect to receive from my MCP as a new member?
Once you are enrolled in a MCP, you will get a welcome letter and your member identification (ID) card in the mail. MCPs send one permanent card when you enroll, instead of the monthly paper card that is sent by Medicaid FFS. Keep this card while you are on the plan. The MCP will also send you information about your doctors, health services, and scope of coverage. As an MCP member, you can also request a member handbook. You will also receive other communications from your MCP, including newsletters, health care reminders, opportunities to earn wellness incentives, and more.
If you need to replace your ID card, you can get a new card by either calling your MCP Member Services Department or by signing up with your MCP in their Member Services Portal. You can print a copy of your ID card immediately from the MCP portal. If you order a card via telephone, it should arrive in the mail in 7-10 business days from the date of your request.
12. What services are covered by my MCP?
MCPs cover all the same services that are covered by Medicaid FFS, but they may require prior approval for services. Your plan’s member handbook will tell you what services require prior approval. Your provider requests prior approval from the MCP. If the request is denied, you can ask your MCP for an appeal by calling Member Services Department or writing to your MCP. You must request your appeal within 60 days following the denial. If your appeal is denied, you can ask for a State Hearing.
If you need help to get to a medical appointment, your MCP may be able to help you. If your medical appointment is 30 or more miles away from your home, and there aren’t any closer participating network providers, your MCP is required to assist you with getting to and from your appointment, if you need help. MCPs also offer enhanced transportation benefits, which vary by region, to help you with transportation to medical appointments, WIC appointments, and visiting your local Department of Job and Family Services.
13. How can I file a complaint against my MCP?
If you are not satisfied with your MCP, you can make a complaint. You can contact your MCP’s Member Services Department or write to your MCP to file a grievance. Your MCP must research and respond to your grievance in accordance with Ohio Administrative Code Rule 5160-26-08.4.
You can also make a complaint by calling the Medicaid Consumer Hotline at 1-800-324-8680.
Interested in more information on Medicaid’s Coordinated Services program (CSP)? Click the link to see the CSP FAQ.
Coordinated Services Program FAQ