Ohio Medicaid Managed Health Care Program

MCP Enrollment

Current enrollment information is reported in the Medicaid Managed Care Monthly Enrollment Report.

Enrollment in the counties in which Ohio's Medicaid managed care program operates is classified as mandatory, voluntary, or preferred option. In voluntary enrollment counties consumers have a choice between enrolling in an MCP or utilizing the traditional fee-for-service program. In mandatory enrollment counties, all eligible consumers must enroll in one of the participating MCPs in order to receive health services. Enrollees are "locked-in" the selected MCP for up to a year in voluntary and mandatory enrollment counties. Disenrollment during this period is permitted within the first three months of their initial enrollment or if there is a justifiable reason or "just cause" as determined by BMHC.

Currently, in six counties, a preferred option enrollment program is in place. In these counties, a consumer is automatically enrolled in an MCP if the consumer fails to select Medicaid fee-for-service. Enrollees are not "locked-in" to an MCP for any specific period of time and may choose fee-for-service Medicaid at any time.

From a consumer perspective, several options are offered to provide information needed to choose an MCP. MCP information sources include:

• Unbiased enrollment information and assistance by telephone and local outreach;
• General managed care information brochures, videos and comparison charts;
• A centralized toll-free number (1-800-324-8680 or TDD 1-800-292-3572) to respond to consumer questions, provide information and offer a referral mechanism to facilitate the resolution of complaints.

Quality of Care / Access to Care

BMHC has measures in place to assure that the quality of care and access to care received through MCPs meets or exceeds set standards. Access and quality of care measures include:

• A review of health services utilization data;
• A federally-required annual quality improvement (QI) survey performed by an external quality review organization that includes a medical record audit, a corporate MCP review, which includes a grievance audit, and quality of care studies of clinical processes and outcomes;
• Encounter data-based performance measures for prenatal care, preventive care for children and adolescents which includes HEALTHCHEK and immunizations, and pediatric asthma;
• Monitoring of provider panels;
• Primary care physician capacity and geographical location in relation to Medicaid consumers;
• Grievance/Complaint monitoring.

Aggregate utilization data is submitted annually based on paid claims. Utilization is not only reviewed for quality measures, but also as a measure of access to health services. Grievances and complaints are also monitored for both quality and access issues. All quality-related grievances and complaints are checked and response times to access-related grievances are closely monitored. Other access measures include minimum provider panel requirements. ODJFS started collecting individual encounter data from the MCPs in July 1996. This data set is used as a data source for the Performance Measures and, in the future, for program monitoring including rate setting.

MCP Performance

To assure the effectiveness of MCP activities in providing access to quality care, MCP performance is monitored through:

• The use of continuing quality improvement approaches to encourage ongoing MCP performance above basic program requirements;
• The use of independent enrollee satisfaction surveys;
• A review of enrollee complaints and grievances, state hearings, and voluntary disenrollments;
• The ongoing monitoring of reports identifying provider turnover;
• A review of cost reports and annual reviews of audited financial reports and disclosure statements;
• The submission of MCP-developed marketing and member materials;
• The development and monitoring of corrective action plans for certain program problems or deficiencies.

Whenever possible, ODJFS conducts comparable surveys and data collection among Medicaid consumers served by the fee-for-service (FFS) delivery system (i.e., satisfaction surveys and utilization reviews). Information obtained on both FFS and MCP-enrolled groups is provided to participating plans and to consumers as a part of a coordinated strategy to assure access to medically necessary quality care.

For additional information about Ohio's Medicaid managed care program, please contact:

Bureau of Managed Health Care
30 East Broad Street
Columbus, OH 43215
(614) 466-4693
(614) 728-4516 fax