MyCare Ohio: Information for Providers

MyCare Ohio logo

MyCare Ohio represents a big change in the delivery of health care, long-term care and behavioral health services to people who are eligible for both Medicare AND Medicaid.

For providers who are accustomed to working with Council on Aging to enroll clients in waiver programs (PASSPORT, Assisted Living Waiver) or to request additional waiver services, MyCare Ohio means adjusting to new processes and time tables. 

The information on this webpage is intended to help providers better understand MyCare Ohio – particularly Council on Aging’s role. You may also want to visit our MyCare Ohio consumer page. 


About MyCare Ohio

MyCare Ohio is Ohio's Integrated Care Delivery System (ICDS) - a system of managed care plans designed to coordinate physical, behavioral, and long-term care services for individuals over the age of 18 who are eligible for both Medicaid and Medicare. This includes people with disabilities, older adults, and individuals who receive behavioral health services. The program is administered by the Ohio Department of Medicaid (ODM).

In general, those benefitting from MyCare Ohio have complex medical needs and significant social, residential and other barriers to meeting their daily living needs.
Key aspects of this system include:

  • A Team Approach to Care Coordination: MyCare Ohio focuses on individuals to effectively coordinate their care based on their specific needs. An individual’s care team may include: the individual, family/caregiver, the MyCare Ohio plan care manager, the waiver service coordinator (if appropriate), the primary care provider, specialists, and other providers as applicable.
  • MyCare Ohio Plans: Ohio selected five managed care plans to manage Medicare and Medicaid benefits for people enrolled in MyCare Ohio. Two plans serve Butler, Clermont, Clinton, Hamilton and Warren counties: Aetna Better Health of Ohio and Molina Healthcare
  • Combined Benefit Package: MyCare Ohio participants will have access to all standard Medicare and Medicaid benefits, including:
    • doctor and hospital visits, 
    • mental health services, 
    • and long-term care services (via nursing homes, assisted living facilities and in-home care), if applicable. In addition, MyCare Ohio plans may include additional services as part of their benefit package.

Hospice patients will continue to receive their Hospice benefits separately from MyCare Ohio.


MyCare Ohio Health Plans

In our region (Butler, Clermont, Clinton, Hamilton and Warren counties), consumers can choose between two MyCare Ohio health plans:

  1. Aetna Better Health of Ohio
  2. Molina Healthcare

These health plans have contracts with the Ohio Department of Medicaid to operate in our 5-county region as part of the new MyCare Ohio system.

The health plan is the consumer’s point of contact for all their Medicare and Medicaid services and questions. Consumers work with their health plan to make decisions about their care and services.

Under MyCare Ohio, consumers are required to enroll in one of the health plans for their Medicaid benefits, but have the option to keep their Medicare services separate. This option is called:

  1. Medicare Opt-in: the plan provides consumer’s Medicare benefits (either Aetna or Molina). This option leaves the consumer with a single point of contact for all their Medicare and Medicaid services. OR
  2. Medicare Opt-out: stay with consumer’s current Medicare Advantage plan or traditional Medicare. Consumer must still choose a MyCare Ohio managed care plan for their Medicaid benefits. This plan will provide and pay for all the consumer’s Medicaid services.

Eligibility and Enrollment

Enrollment in MyCare Ohio is mandatory for people who:

  1. are 18 or older; and 
  2. live in Butler, Clermont, Clinton, Hamilton or Warren counties; and 
  3. currently receive services from BOTH Medicaid and Medicare.

The following groups are not eligible for MyCare Ohio.

  • Individuals receiving services through a developmental disability waiver through their DD board 
  • Individuals who are eligible for Medicaid through a delayed spend-down (see FAQ)
  • Individuals who have third-party insurance (see FAQ)

Consumers who are eligible for MyCare Ohio will receive a letter from the Ohio Department of Medicaid explaining how to enroll in the program and choose a health plan. 

Providers with questions about enrollment and eligibility should contact Ohio Department of Medicaid Provider Hotline.

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Council on Aging's Role in MyCare Ohio

Council on Aging’s role in Ohio’s Medicaid waiver programs (PASSPORT, Assisted Living, and Ohio Home Care) has changed as a result of MyCare Ohio.

Like you, we now serve in a provider capacity. We have contracts with our region’s MyCare health plans – Aetna and Molina – to provide care management and/or wavier service coordinator services for MyCare Ohio consumers who are enrolled in a waiver program. (see related FAQ)

  • For Aetna, we are the care manager for plan members on waiver programs. 
  • For Molina, we are the waiver service coordinator for plan members age 60 and older only.
  • For waiver consumers who are NOT enrolled in MyCare Ohio, our role has NOT changed. We continue to administer PASSPORT and the Assisted Living Waiver and provide care management for the Ohio Home Care Waiver for individuals who are not Medicare/Medicare eligible.

In these roles, we assess people’s level-of-care for waiver programs and manage or coordinate their long-term care services. We also visit individuals in their homes to monitor how they are doing. But our contracts with Aetna and Molina are different.

For Aetna plan members, COA establishes the waiver care plan and services and authorizes services with Aetna’s approval. For Molina plan members, COA’s role is more limited. Molina develops the care plan. COA makes recommendations for the service plan and authorizations, but Molina must approve units over a certain level.

If a MyCare Ohio member is applying to a waiver program for the first time, the person must contact his or her health plan first. After a phone screening, the health plan may make a referral to Council on Aging, which handles assessments and determines level of care eligibility.

Management functions of MyCare Ohio belong to the two health plans.  Aetna and Molina manage their respective provider networks, operate their own IT systems which COA must use, and pay claims to providers for services that have been authorized. 

Click here to see a table that describes our different roles and responsibilities for the 1) Elderly Services Programs, 2) for traditional Medicaid waiver programs, and 3) for the Medicaid waiver services provided to MyCare Ohio members enrolled in Aetna or Molina. The following flow charts may also help in understanding COA's roles and responsibilties within MyCare Ohio. 

Process to request additional/new waiver services for a MyCare Ohio consumer who is already enrolled in a waiver program such as PASSPORT, the Assisted Living Waiver or Ohio Home Care Waiver
MyCare Ohio flow chart adding additional services

 

Process for MyCare Ohio consumers who are applying to a waiver program (PASSPORT, Assisted Living Waiver, Ohio Home Care Waiver) for the first time.
MyCare Ohio flow chart for new consumers to waiver programs

 

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MyCare Ohio Help

Council on Aging Contacts

Council on Aging's Aetna Team: (513) 827-3441

Council on Aging's Molina Team: (513) 827-3443

Health Plan Contacts

Aetna Better Health of Ohio
Aetna Provider Services Phone #: 1 (855) 364-0974 option #2
Aetna Provider Services Email: OH_ProviderServices@aetna.com 
Aetna Provider Resource Website

Southwest Region Provider Relations

Southwest Region Community Liaison

Molina Healthcare
Molina Provider Services Phone #: 1 (855) 322-4079
Molina Provider Email: ProviderServices@MolinaHealthcare.com 
Molina Provider Resources Website

Ohio Department of Medicaid

The Ohio Department of Medicaid (ODM) has compiled a special section on its website specifically for providers affected by MyCare Ohio.

ODM’s Provider Hotline, 1-800-686-1516, may also be able to provide assistance. The automated hotline is available 24/7 and representatives are available Monday – Friday, 8am – 4:30pm.

MyCare Ohio Ombudsman

With the launch of MyCare Ohio, Ohio's Long-term Care Ombudsmen are now available to help consumers with questions or concerns related to any of their MyCare-covered services (transportation, physician services, prescription issues, hospital issues, and more).

Additionally, the MyCare Ombudsman will work as the Long-term Care Ombudsman does, offering consultation to providers related to general issues, with a focus on benefit to the consumer.

To reach the MyCare Ohio Ombudsman for Butler, Clermont, Clinton, Hamilton and Warren counties:

Pro Seniors Inc.
Ms. LeVon Pressley
Lpressley@proseniors.org
Direct Dial: 513-458-5536
Toll Free: 800-488-6070

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MyCare Ohio Provider FAQs

The following FAQs have been compiled from questions we have received and researched answers to, as well as questions generated after the member and provider forums that were held across the state early in 2014.  

Answers to questions from the member/provider forums have been provided by the Ohio Department of Medicaid.  Click here for a complete list of these FAQs.  We are sharing the more relevant FAQs here for your convenience. 

FAQs from Ohio Department of Medicaid

I am a provider, will I be required to get a prior authorization for services. If so, how long will that take?

Each MyCare Ohio Plan (MCOP) will determine which services require prior authorization. All non-contracted provider services require authorization. The plans’ websites post information about authorization requirements. For standard authorization decisions, the MyCare Plan must provide notice to the requesting provider and member as expeditiously as the member's health condition requires but no later than fourteen calendar days following receipt of the request for service. If the standard authorization timeframe could seriously jeopardize the member's life or health or ability to attain, maintain, or regain maximum function, the MyCare Plan must make an expedited authorization decision and provide notice of the authorization decision as expeditiously as the member's health
condition requires but no later than three working days after receipt of the request for service (ref OAC 5160-3-26-03.1). Providers and members who believe an expedited decision is appropriate are encouraged to document this as part of the request.

What is the difference between the waiver service coordinator and the MyCare Ohio Plan care manager?

The Care Manager is the person ultimately accountable for the care of MyCare members. The Care Manager will lead and coordinate the member's trans-disciplinary care team and ensure overall coordination of services. The Waiver Service Coordinator is the MyCare waiver service expert who will ensure that all functions under the waiver occur including the monitoring of waiver service plans and health and welfare issues. They will address issues related specific to waiver services. This may or may not be someone different than the Care Manager.

FAQs from Council on Aging: 

Regarding scheduling transporation for Molina consumers:

Updated 1/13/2016: Effective Jan 1. 2016 Secure Transportation with be Molina’s transportation vendor for MyCare and Medicare. The new MyCare Ohio transportation number (Secure) is (844) 491-4761.  Members who call the Logisticare phone number to schedule transportation should be automatically redirected to Secure. 

Regarding continuation of services for providers who are not contracted with Aetna or Molina:

Click here for an e-mail explanation that was sent to service providers from COA's Provider Services Department on June 2, 2014.

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Ohio Consumer Voice for Integrated Care

According to the Memorandum of Understanding (MOU) between Ohio and the Centers for Medicare and Medicaid Services (CMS), each MyCare Ohio plan is required to obtain beneficiary and community input on issues of program management and enrollee care through a range of approaches. 

Each MyCare Ohio plan must establish at least one beneficiary advisory committee and a process for that committee to provide input to the governing board. The plan must also demonstrate that the advisory committee composition reflects the diversity of the MyCare Ohio enrollee population, and participation of individuals with disabilities, including enrollees, within the governance structure of the plan.

Additionally, Ohio must maintain additional processes for ongoing stakeholder participation and public comment.

As a provider, if you work with consumers  you feel would be a good fit for one of the advisory committees, please contact the Universal Health Care Action Network's (UHCAN) Ohio Consumer Voice for Integrated Care by e-mail or (614) 456-0060 x237. 

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