Choosing a Medicaid Managed Care Plan

Health care is changing for many Ohio Medicaid consumers.

This means if you and/or members of your family receive health care benefits through the Covered Families and Children program or the Healthy Start program, you will be required to join a Managed Care Plan (MCP). This information will help you learn about Medicaid managed care and what it means to be a member of a managed care plan.

You will learn about:

• What a managed care plan is,

• How to choose the best plan and doctors for your family,

• How to find out more about the MCPs in your area,

• How and when you have to join an MCP,

• What your MCP must do for you and what you must do as an MCP member, and

• What special benefits and what rights you have as an MCP member.
  

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What is a Managed Care Plan?

A Managed Care Plan or “MCP” is a private health insurance company that is licensed through the Ohio Department of Insurance and has a provider agreement with the Ohio Department of Job and Family Services to provide health care to your family and others that are on Medicaid.

An MCP must provide or arrange for all the services you now get with the monthly Medicaid card. They do this through contracts with doctors, ssspecialists, hospitals, pharmacies and other health care professionals in your area. You will work with a primary care physician or “PCP” that will provide health care or refer you to a specialist in your MCP.

• Your MCP will also provide special services and extras, such as:

• A toll-free member services telephone number, with staff to help you get the care and services you need,

• A 24-hour (every day of the year) toll-free hotline with staff who can provide medical advice or direction on how to access health services,

• Help coordinating care for children with special health care needs, and

• Annual physical exams for adults.

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What should I consider when choosing a Managed Care Plan?

Because health care for you and your family is so important, choosing the best Managed Care Plan (MCP) is also important. Here are some questions to ask yourself before choosing your MCP:

• Which MCP offers all or most of the doctors I go to, or want to go to?

• Which MCP offers the hospitals I like to use?

• Which MCP offers extra services that I want or like? (such as gift certificates for members who get prenatal care and immunizations on time, or who keep HealthChek appointments).

You may have other concerns or questions that are important to you. Once we send you the information about the MCPs that are in your area, you can call the MCPs to ask your questions.

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What is a Primary Care Physician (PCP)?

After you choose an MCP, you will choose a doctor for each family member. This doctor is called a Primary Care Physician or “PCP”. Your PCP will work with you to coordinate your health care, such as giving you check-ups and shots, treating you for most of your health care needs, sending you to ssspecialists if needed, or admitting you to the hospital.

When choosing a PCP, keep the following in mind:

• Each MCP works with specific doctors. Make sure the PCP you want is on the MCP’s panel (list of the MCP’s health care providers).

• You can find out which doctors you can choose from in your area by calling the MCP’s toll-free member services telephone number or by calling the Managed Care Enrollment Center (see How do I select a Managed Care Plan?)

• You can choose a different PCP for each member of your family that enrolls in the MCP.
  

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My current providers of health care services

Use the space below to record the names of the doctors and other health care providers you and your family currently use or would like to use. Refer to this list when choosing an MCP and PCP for you and your family.

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Does everyone have to join a Managed Care Plan?

Children under nineteen (19) years of age 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 an out of home placement, or

• Receiving services through the Ohio Department of Health’s Bureau for Children with Medical Handicaps (BCMH).

At the time you receive a notice to choose an MCP, or at any time after your child is a member of an MCP, you can call 1-800-605-3040 (TTY 1-800-292-3572) 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. If we determine that your child meets the above criteria, your child’s MCP membership will end.

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How do I select a Managed Care Plan?

It is easy to join an MCP—you can select right over the telephone. You will receive a notice in the mail that tells you when it is time to choose an MCP for you and/or your family. The notice will tell you:

• You can call the toll-free telephone number that is on the notice (1-800-605-3040) any time Monday-Friday, 8 AM to 8 PM.

• If you are hearing impaired, you may call TDD/TYY 1-800-292-3572.

• You can have your questions answered about the MCPs in your service area to help you choose the MCP that is best for you.

• You will be asked questions about your family members’ health care needs so that your MCP will have the information to begin helping you.

You can learn more about Medicaid managed care before you choose a plan at www.jfs.ohio.gov/ohp/bmhc/con-man-care.stm or www.ohiossc.com on the internet. You will also receive information in the mail about the managed care plans in your area and how to contact them about their services and providers.

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What can I expect from my Managed Care Plan?

Your Managed Care Plan must:

• Provide you with all the same medically necessary services that are covered by Medicaid.

• Give you a member handbook that explains how to get health care through the MCP, and the rules you must follow when getting health care.

• Give you a member identification card to use every time you get health care. You will no longer get the monthly Medicaid card once you are an MCP member.

• Give you a directory of all doctors, ssspecialists, hospitals, pharmacies and other health care professionals who are in the MCP, that lists their addresses and telephone numbers. You can also see this information on your MCP’s member website.

• Offer a toll-free member services telephone number to help you and answer your questions.

• Offer a 24-hour, 7 days a week, toll-free medical advice hotline.

• Arrange translation services when needed if you or your family do not speak English.

• Allow you to change your primary care physician (PCP) at least monthly by calling the MCP.
  

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What if I already have services scheduled?

If you are changing from Medicaid fee-for-service to an MCP, and have any of the following services scheduled, it is important that you call the member services telephone number of the MCP that you select as soon as possible. For these services only, if your provider is not contracted with the MCP that you select, but you call before the date that the service is scheduled, you may be able to continue care with your current provider.

• Organ transplant or tissue replacement,

• Prenatal (pregnancy) care in your third trimester if you have already been seeing a doctor and/or have your delivery hospital arranged,

• Inpatient/outpatient surgery,

• Appointment with a specialist in the first month of MCP membership, or

• Chemotherapy or radiation treatment.

Your MCP must offer to pay your provider the same amount he/she would have received from Medicaid fee-for-service to provide these services. If your provider agrees to this payment, he/she can provide the service. If your provider does not agree to this payment, your MCP will help you find a contracted provider you can go to for the service.

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What are my responsibilities and rights when I belong to a Managed Care Plan?

As an MCP member you must:

• Choose one of your MCP’s doctors as your primary care physician (PCP) and agree to see your PCP or the providers to whom your PCP refers you.

• Follow all the rules in your MCP member handbook.

• Get your health care through the doctors, ssspecialists, hospitals, pharmacies and other health care professionals that are in your MCP’s provider directory, except under certain circumstances (see options below).

• Tell your MCP and your county caseworker right away if your address changes so they can send you important information about your health care and your benefits.

As an MCP member you have the option to:

• Go to certain doctors without being sent by, or getting a referral from, your PCP, as explained in your member handbook.

• Ask the MCP for help in getting services, such as help in finding a doctor, making an appointment, or getting a referral.

• Go to non-MCP providers for emergency care, or for services provided by certain other providers (federally qualified health centers/rural health clinics, family planning providers listed in your MCP’s provider directory, community mental health centers, and Ohio Department of Alcohol and Drug Addiction Services facilities that are Medicaid providers).

• Change MCPs during the first three months you are a member and annually during your area’s open selection month, or at any other times for good cause by calling (toll-free) 1-800-605-3040.
  

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Quick Facts about Medicaid Managed Care

Did you know?

• Medicaid Managed Care Plans (MCPs) cover the same medically-necessary services that regular Medicaid offers.

• Every MCP has a toll-free member services line to provide information about covered services and access to care.

• Every MCP has a 24-hour, toll-free nurse hotline to provide medical advice or direction.

• MCP members receive a membership identification card from the MCP instead of getting a monthly fee-for-service Medicaid card.
  

If you have any questions about Medicaid-covered services or choosing an MCP, please call the Managed Care Enrollment Center at (800) 605-3040. For those with hearing problems, please call TTY (800) 292-3572.

The information on this site is subject to change.

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Ohio Managed Care Enrollment Center

Call to speak with an Enrollment Counselor
Monday - Friday
8:00 a.m. to 8:00 p.m.
(800) 605-3040

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