CFC Consumer Guide - East Central Region

In Ohio, most individuals who receive Medicaid through the Covered Families and Children (CFC) program must be enrolled in a Managed Care Plan.

Managed Care Plans (MCPs)

A managed care plan is a private health insurance company that is licensed through the Ohio Department of Insurance (ODI) and has a provider agreement with the Ohio Department of Job and Family Services (ODJFS) to provide health care to you. They do this through contracts with doctors, specialists, hospitals and other health care providers in your region.

Plans Available to You

Because you live in the East Central Region, which includes Ashland, Carrol, Holmes, Portage, Richland, Stark, Summit, Tuscarawas and Wayne counties, the MCP's that are available to you are:

• Buckeye Community Health Plan
• CareSource
• United Healthcare Community Plan of Ohio

Exclusions

Consumers who are dually eligible under both Medicaid and Medicare; and Consumers enrolled in a waiver program are excluded from enrollment in a Medicaid Managed Care Plan.

Optional Enrollment

Children younger than age nineteen (19) years of age eligible for the CFC Healthy Start, Healthy Families programs have the option of being an MCP member if they are:

• Eligible for Supplemental Security Income (SSI) under Title XVI;
• Receiving foster care or adoption assistance under Title IV-E;
• In foster care or out-of-home placement; or
• Receiving services through the Ohio Department of Health’s Bureau for Children with Medical Handicaps (BCMH).

If you believe that your child meets any of the above criteria and you do not want your child to be a member of an MCP, you must call the ODJFS Managed Care Enrollment Center toll-free at:

1-800-605-3040
(TTY) 1-800-292-3572
En Espanol 1-800-605-3040
Monday-Friday 8:00 am to 8:00 pm.

If we determine that your child meets the above criteria, your child will not have to join an MCP.

Choosing an MCP

Because your health care is so important, choosing the MCP that best suits your needs is also important. Here are some questions to ask yourself before choosing or changing your MCP:

• Which MCP has all or most of the doctors I go to, or want to go to, on its list of providers?
• Which MCP has the hospitals I like to use on its list of providers?
• Which MCP offers the extra services that I need or want?
• Which MCP requires a co-payment?

You may have other concerns or questions that are important to you and your health that you need to consider when choosing an MCP. You can call the MCPs in your region to ask your questions.

If you are not already enrolled in an MCP, you will receive a notice that tells you when it is time for you to choose an MCP. The notice tells you about managed health care and how you can enroll.

Choosing an MCP is Easy! To choose your MCP, you can call the ODJFS Managed Care Enrollment Center toll-free at 1-800-605-3040, 1-800-292-3572 (TTY), 1-800-605-3040 (en Espanol), Monday through Friday, 8 a.m. to 8 p.m. An enrollment counselor will tell you about managed care, answer your questions and help you choose an MCP. Or, you may enroll online through this website!

If you do not choose an MCP by the deadline, one will be chosen for you! The notice you receive will contain a date by which you must choose an MCP. If you do not choose an MCP by this date, you will receive a letter telling you which MCP has been chosen for you. The letter will tell you how to make sure this is the MCP you want by calling the toll-free number above. If, for whatever reason, you do not get the MCP you want, you can change your MCP under certain circumstances.

Changing Your MCP

If you are already enrolled in an MCP, but you think you may want a different MCP, you can change at certain times. Those times are:

• If you have been an MCP member for less than three months;
• During your annual open enrollment month (November is the open enrollment month for CFC individuals in the East Central Region); and
• For just cause (for an explanation of just cause, please refer to your member handbook).

Just call the Managed Care Enrollment Center toll-free at 1-800-605-3040, 1-800-292-3572 (TTY) or 1-800-605-3040 (en Espanol) or go online and visit www.ohiomcec.com. An enrollment counselor will answer your questions and help you change from one MCP to another if you meet one of the reasons above.

Your Rights

If you are unhappy with your MCP or its providers, you have the right to file an appeal, a grievance/complaint and/or a state hearing. You should call your MCP at its toll-free number, and staff members will provide you with the following information:

• The requirements and time frames for filing an appeal, grievance/complaint or state hearing;
• The rules about state hearings and how to ask for a state hearing; and
• An explanation of how you may be able to have your services continue if you file an appeal or request a state hearing, and when you might have to pay for those services.

Your MCP Must Provide You With:

• All the same medically necessary services that are covered by the traditional Medicaid fee-for-service plan;
• A member handbook that explains how to receive health care through the MCP, and the rules you must follow when getting health care services;
• A member identification card, which you must show every time you receive health care services;
• A directory of all doctors, specialists, hospitals and other health care professionals who are with the MCP. This directory lists their addresses and telephone numbers. You can also see this information on your MCP’s member Web site. Most providers are also listed at www.ohiomcec.com;
• Information on how to get benefits such as family planning services from out-of-panel providers.

As an MCP Member You Must:

• Choose a primary care provider (PCP) from the MCP’s network and agree to see your PCP or the providers whom you are referred to;
• Follow all the rules in your MCP member handbook;
• Get your health care through the doctors, specialists, hospitals and other health care professionals that are in your MCP’s provider directory, except under the special circumstances listed in your member handbook; and
• Tell your MCP and your county caseworker right away if your address changes, so they can send you important information about your health care benefits.

Special Services

Each MCP must offer special services to members in addition to all medically necessary Medicaid-covered services, such as:

• A primary care provider or “PCP,” who will work with you to provide your health care or refer you to a specialist in your MCP;
• A toll-free member services telephone center with staff to help you get the care and service you need;
• A 24-hour (every day of the week) toll-free medical advice line with staff who can provide medical advice or direction on how to access health services;
• Information for members with special needs in other formats, such as large print, or materials that can be explained by the MCP orally;
• Interpreter services for any language, including assistance with written materials; and
• Annual physical exams for adults.

Additional Services

MCPs often provide more services and benefits than the traditional Medicaid fee-for-service program. For a complete list of additional services and benefits offered by an MCP, please call the MCP’s toll-free number.

Obtaining Services

Your MCP member handbook has information about getting health care. You can also call your MCP to ask questions. Make sure you know the following:

• What services are available;
• How to obtain health care services, including prior authorization requirements;
• How after-hours and emergency coverage are provided;
• Information on how to get benefits such as family planning services from out-of-panel providers;
• The MCP’s policy on referrals for specialty care and for other services not provided by your primary care provider (PCP);
• Information on post-stabilization care services (certain services received in the emergency room after your emergency has been stabilized);
• Information on advance directives;
• Information about your rights and responsibilities.

Monthly Outreach Calendar

Have questions? Need help? Want to talk in person? We have staff in your community. Come and meet with us. The calendar below lists events where you can find us. We will be happy to answer your questions. We can also enroll you in a health plan and PCP if you are ready to do so. You know your family’s health needs best. It is important for you to choose the health plan and PCP that is best for you.

View Calendar

Transitioning from Regular Medicaid to an MCP

Already have services scheduled?

If you are changing from regular Medicaid to an MCP, and have health care services already approved and/or scheduled, it is important that you call your MCP’s member services telephone number. In certain situations, for a brief time after you enroll, your MCP may allow you to receive care from a provider that is not contracted with the MCP. However, you must call your MCP before you receive the care. It is especially important to call your MCP to let them know if you have the following services already approved and/or scheduled:

• Organ, bone marrow or hematopoietic stem cell transplant;
• Inpatient/outpatient surgery;
• Appointment with a primary care or specialty provider;
• Chemotherapy or radiation treatments;
• Third trimester prenatal (pregnancy) care, including delivery;
• Services you receive at home, including home health care, therapies and nursing;
• Non-routine dental or vision services (for example, braces or surgery); and
• Medical equipment.

Transportation

When you are an MCP member, you still have access to transportation for medical appointments. You will be able to receive certain transportation services through your MCP, and you will be able to receive certain transportation services through your local CDJFS.

Note: Emergency Ambulance Services are always covered by calling 911.

MCPs must provide non-emergency transportation for their members if:

1. It is medically necessary for a member to use an ambulance or ambulette (wheelchair van) for transportation to an MCP-covered service; and/or;
2. The transportation is requested by a member who must travel 30 miles or more from his/her home to reach an MCP-authorized provider.

MCPs may provide additional transportation services as an extra benefit to members. The extra transportation assistance is in addition to the transportation MCPs must provide to their members as listed above. For more information on how to arrange non-emergency transportation, contact the MCP’s member services line.

The County Department of Job and Family Services will provide transportation through the Non-Emergency Transportation (NET) program whenever the MCP does not offer extra transportation services.

Note: Additional transportation benefits offered by your MCP do not have to be used prior to getting NET services.

Contact Information

You may have questions about certain doctors, hospitals or other questions about an MCP before you choose or change plans. Here are important toll-free member services telephone numbers and web sites for the MCPs in your region:

Please keep in mind...

This Consumer Guide contains important information about how to get health care through an MCP, but it does not contain all the information you need to know about your MCP.

Keep your MCP identification card in a safe place. Do not throw it away. Make sure you have your identification card with you when you need health care services.

Remember that answers to your questions or help in getting health care are just a phone call away. Call your MCP’s member service toll-free number; the MCP is there to help you.

You can also call the ODJFS Managed Care Enrollment Center toll-free at 1-800-605-3040, 1-800-292-3572 (TTY) or 1-800-605-3040 (en Espanol) Monday through Friday, 8 a.m. to 8 p.m. An enrollment counselor will tell you about managed care, answer your questions and help you choose an MCP. Remember, you can look at information and enroll online through this website.