Managed care for Ohio Medicare/Medicaid “Dual Eligibles”

Ohio will soon launch My Care Ohio, a 3-year pilot program instituting managed care for people who have health care coverage through both Medicare and Medicaid, the so-called “dual eligible” people.  The pilot program focuses on the state’s population centers.  (Several other states are implementing similar programs.)

Who’s in?  People on both Medicare and Medicaid who are
in nursing homes;
on the Passport waiver;
on the Choices waiver;
on the Assisted Living waiver;
on the Ohio Home Care waiver; or
on the Transitions Carve Out waiver.

Who’s out?
People with ICF-MR level of care served in an ICF/IID facility;
People on a waiver from Department of Developmental Disabilities;
People on monthly spend-down that isn’t met every month; and
People on third-party health insurance (usually through a retirement plan.)

People on a Medicaid “Period of Restricted Coverage” (i.e., they gave away assets so Medicaid won’t cover all of their costs) will be IN the managed care program for the costs that Medicaid will cover during that restricted period.  After the Period of Restricted Coverage ends (assuming that the managed care program is still going,) these people will be on the managed care program for their full Medicaid coverage.  (This news arrived in an email from the Ohio Department of Medicaid the afternoon after the original version of this post was published.)

The following counties (sorted by district) are included:

Northeast district
Cuyahoga, Geauga, Lake, Lorain, and Medina counties
Buckeye, CareSource and United are available Managed Care Organizations (MCOs)
Enrollment starts May 2014

Northeast Central district
Columbiana, Mahoning, and Trumbull counties
CareSource and United are available MCOs
Enrollment starts June 2014

Northwest district
Fulton, Lucas, Ottowa, and Wood counties
Aetna and Buckeye are available  MCOs
Enrollment starts June 2014

Southwest district
Butler, Clermont, Clinton, Hamilton, and Warren counties
Aetna and Molina are available MCOs
Enrollment starts June 2014

Central district
Delaware, Franklin, Madison, Pickaway and Union counties
Aetna and Molina are available MCOs
Enrollment starts July 2014

East Central district
Portage, Stark, Summit, and Wayne counties
CareSource and United are available MCOs
Enrollment starts July 2014

West Central district
Clark, Green, and Montgomery counties
Buckeye and Molina are available MCOs
Enrollment starts Juny 2014

The Ohio Department of Medicaid expects 100,000 people to be in the program, with 37,000 of them on one of the waivers.

People on both Medicare and Medicaid in the regions listed above will receive a “friendly letter” approximately 60 days before their district’s enrollment start.  That first letter will allow them 30 days to choose an MCO.  (Making a choice of plans is called “active enrollment.”)  The person can actively enroll in an MCO for both Medicare and Medicaid or can enroll in an MCO for Medicaid only.  (Those that enroll in both have the ability to switch plans monthly.)

For people who do not choose a plan in the 30 days after the friendly letter, a second letter will come explaining that the person has been assigned to one of the plans in his or her district.  (This is called “passive enrollment.”)  According to the Department of Medicaid, the assignment of an MCO via passive enrollment will be performed by a complicated algorithm that considers past usage of medical providers.  Even after this passive enrollment, a person can change plans in the first 90 days after the start date.  During 2014, passive enrollment will be used only for Medicaid. (During the enrollment period for 2015, passive enrollment will be used for both Medicare and Medicaid.)

For a limited period of time during the transition to managed care, people will keep their same services at the same rates.  The period of time during which no change will occur varies among the different services, especially waiver services.

After this transition period, MCOs may drop providers.  This is the big point that will impact the covered people.  When a trusted provider is no longer available, people’s care and their confidence in their care will be impacted.

Editorial note:  I realize this is about as readable as the stock listings.  Sorry.  My Care Ohio is a potential sea change in how long term care is administered, so I wanted to lay out my understanding of the program.  I hope to offer more analysis in the future.

Second editorial note:  I changed this post slightly a day after it was originally published.  I wanted to get this information posted at my usual Friday morning time, but my midnight proofreading wasn’t very good.  I did my proofreading when I had the chance.  Sorry.

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Jim Koewler’s mission is
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