Health Care Delivery System

Ohio Medicaid

Medicaid is Ohio’s largest health payer.  Over 90,000 hospitals, nursing homes and other providers deliver services for individuals insured by Medicaid. Over 2.6 million Medicaid enrollees are served by the five statewide managed care plans (MCPs). As of March 2019, enrollment was 2,651,279 – a net increase since the first Marketplace Open Enrollment period. 

Most Medicaid beneficiaries now receive Medicaid health care benefits through one of five private managed care plans. Ohio Department of Medicaid (ODM) pays the health plans monthly, per person, using capitation rates.  In 2017, Ohio extended managed care enrollment to additional populations that had previously been excluded from care coordination, including children in Ohio’s foster care and children in custody system and individuals enrolled in the Ohio Department of Health (ODH) Children with Medical Handicaps and Breast and Cervical Cancer Programs. The state also offered optional managed care for individuals with developmental disabilities enrolled on a HCBS Waiver administered by the Ohio Department of Developmental Disabilities.

In the 2018-19 fiscal year budget, Ohio implemented a rule that the state should seek federal approval for a work requirement that would apply to the Medicaid expansion population. Of the more than 700,000 people enrolled in Medicaid expansion, it is estimated that 36,000 will need to start working or enroll in job training, education, or certain volunteer activities, for at least 20 hours per week, in order to avoid being disenrolled. The rest of the Medicaid expansion population is either already working or would be exempt from the work requirement.

This requirement would not apply to enrollees age 50 or older, children, pregnant women, caretakers caring for minor children or a disabled person, people receiving unemployment or Supplemental Security Income, people in drug or alcohol treatment programs, or anyone deemed physically or mentally unable to work.

Partnership

During the past three years, the ODH and the ODM have transformed their relationship towards joint decision-making and trusted advisors for both agencies.  In strategic planning to improve health outcomes for Ohio’s most vulnerable populations, the agencies have developed and defined common metrics, created dual data reports, and developed processes for bi-directional data exchange.  To stay abreast of needs and relationship development, the agencies meet bi-weekly to support data sharing and advise policy implementation and planning processes.

In March 2019, the cooperative agreement between ODH and ODM was updated in regard to:

• Coordination of health services, conducting outreach, program eligibility, payment for services for Ohio citizens;
• Performing environmental lead risk assessments for Medicaid eligible children identified as having elevated blood lead levels;
• Performing lead hazard abatement activities in the homes of low-income children and pregnant women;
• Reimbursement of ODH bureaus and/or local public health departments for Medicaid administrative activities provided by them;
• Maintaining and enhancing the statewide automated Immunization Information System (Impact/SIIS) including the Vaccines For Children Program (VFC) through a collaborative exchange of electronic data from ODM to ODH;
• Reimbursing ODH the cost of operating the Ohio Tobacco Quit Line to the extent it complies with the State Medicaid Letter (SMDL #11-007) dated June 24, 2011;
• Defining the relationships and responsibilities between the parties for the conduct of desk reviews, interim settlements, field audits, and final settlements for ODH's Bureau for Children with Medical Handicaps (BCMH).

Examples of joint initiatives include:

In FY 2018, ODM required managed care agencies to provide enhanced prenatal and maternal care through infant vitality efforts.  In determining and informing implementation of the strategies for ODM’s infant vitality funding, ODH was an equal partner in identifying evidence-based strategies, scoring and common metrics. This collaboration continues to be an important way for ODH and ODM to coordinate infant vitality efforts at the local level.

The Ohio Medicaid Technical Assistance and Policy Program (MEDTAPP) enables the use of federal Medicaid administrative funds to identify barriers and improvements in accessing healthcare services and improving health care workforce in high need areas. The following agencies serve on the MEDTAPP advisory committee: ODM, ODH, Ohio Department of Department of Developmental Disabilities (DODD), Ohio Department of Mental Health and Addiction Services (OMHAS), and the Ohio Department of Higher Education (ODHE). Specific projects include:

• Workforce Development
  • MEDTAPP Healthcare Access Initiative
  • MEDTAPP Health Professions Data Warehouse
• Maternal and Infant Health
  • Care Models Directed at Reducing Ohio’s Infant Mortality Rate
  • MEDTAPP Maternal and Child Health (MCH) Outcomes
  • Best Evidence for Advancing Child Health in Ohio NOW! (BEACON)
• Health Services Research and Data
  • Ohio Medicaid Assessment Survey (OMAS)
• Integrated Physical & Behavioral Health

The MEDTAPP MCH projects are implemented by the Ohio State University Government Resource Center and include:

• Smoke Free Families quality improvement projects in collaboration with the Ohio Chapter of the America Academy of Pediatrics and the Ohio Perinatal Quality Collaborative (OPQC). The goals for these projects, respectively, are to implement the 5As of smoking cessation in pediatric and in obstetric practices in order to improve screening and referral for smoking cessation services.
• The Ohio Progesterone Promotion Project engages maternity care providers to increase screening for the need for progesterone, as well as utilization of progesterone when indicated. This project is in collaboration with OPQC.
• The Pregnancy Risk Assessment Form (PRAF) started as a paper form completed by Medicaid obstetric providers at the first prenatal care visit to identify risks for intervention/referral needed to improve birth outcomes. The PRAF 2.0 is an electronic version of the same form, and projects are underway to improve use of the PRAF 2.0 among all Medicaid obstetric providers.  This project is in collaboration with OPQC.
• The Ohio Type 2 Diabetes Learning Collaborative which seeks to identify women of reproductive age at high risk for developing type 2 diabetes (e.g., women with a history of gestational diabetes mellitus (GDM), women who are overweight/obese, of a high risk racial/ethnic group, have a family history of type 2 diabetes). After working with obstetric providers to increase postpartum visit rates and postpartum glucose screening rates, and saturating the number of Medicaid providers, the project moved to working with primary care providers to better identify high risk women to ensure recommended glucose screenings are conducted. In FY 2018, a dyad program was implemented at one Family Medicine clinic to jointly see the mother for postpartum care combined with well child visits.
• The Ohio Pregnancy Assessment Survey (OPAS) is Ohio’s PRAMS-like survey. OPAS began in 2016 after Ohio had participated in PRAMS from 1999-2015. By implementing our own survey, and leveraging MEDTAPP funding, OPAS, unlike PRAMS, provided county-level estimates for Ohio’s 3 largest counties for the first time. Furthermore, OPAS sample sizes have continued to increase to around 4000-5000 respondents, compared with ~600 respondents in PRAMS.

The Infant Mortality Research Partnership (IMRP), a collaboration between state agencies, researchers, and subject matter experts, and uses big data to gain a better understanding of how to lower infant mortality in Ohio. The IMRP team includes the ODH, ODM, ODHE, and university researchers across multiple disciplines such as biostatistics, pediatrics, and geography. ODH continues to be an active partner in IMRP, which is currently in Phase II which is working to improve upon and expand previous models that focus on factors that increase risk, such as those related to social and behavioral health or structural and institutional factors.  These models will be used to predict preterm birth risk, for example, during prenatal care by integrating a risk calculator within the electronic health record in obstetric clinics. The risk calculator is currently being piloted in a large, academic hospital system.

ODH conducts a bi-weekly case conference with ODM to review individual cases where CSHCN families are experiencing challenges with coverages through managed care plans.  This process has proven beneficial not only in remediating challenges for individual families, but also in driving policy change and clarification between ODM and the plans.