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Health & Science

Ohio Plans First Major Overhaul to Medicaid in 15 Years

Banner of Andrew Butler
Mark Butler
The Ohio Medicaid overhaul could help people like Mark Butler. His son Andrew has developmental disabilities and needs specialized care. Andrew is pictured here on a banner when he graduated from high school.

Last week, Ohio Gov. Mike DeWine proposed changes to the state’s Medicaid program, the first major overhaul in 15 years.

The changes, which will have to be approved by the federal government, will help improve health outcomes of Ohioans covered by the program, specifically children and those who need specialized care, DeWine said.

Medicaid covers low-income residents, long-term care in nursing homes, pregnant women, and children. It is managed differently by each state. 

Currently, Ohio’s program is one big, complex system. The proposed changes to Medicaid will break it into five pieces, one of which is called Ohio Rise. That program will provide services for children with developmental disabilities who need specialized care, as a way to make sure parents aren’t forced to give up custody just to get their kids the resources they need.

Kids are the largest group covered under Medicaid. Some of them are part of the state’s foster care system. There are nearly 150 kids who have to get specialized services out of state because there aren’t doctors within their Medicaid plan in Ohio who will provide the intensive services they need. The changes should fix that, said Maureen Corcoran, director of Ohio's Medicaid program.

“I think this whole effort is really changing the status quo of how we provide services to individuals on Medicaid. And probably most exciting to me is the work around Ohio Rise and supporting the governor’s initiative around an opportunity for every Ohio child,” Corcoran said.

Separating the pieces out is a way to make the system more efficient, she said.

For example, right now, a doctor might prescribe a certain medication to a person on Medicaid, but if the doctor doesn’t look up the patient's specific Medicaid insurance plan, it can cause confusion at the pharmacy. The patient might show up to the pharmacy and realize the doctor prescribed them a brand of drug that isn’t covered by their plan.

Medicaid provides insurance for many low-income residents in Ohio. Having to return to the pharmacy multiple times is a barrier for patients getting the medicine they need. It can cause even more issues if the person doesn’t have easy access to transportation.

The changes will streamline the prescription drug process under the Medicaid program and eliminate some hurdles for doctors to prescribe medicine that’s covered by all Medicaid plans, Corcoran said.

Another piece of the new Medicaid plan will cut out a lot of the red tape for doctors in other areas as well.

There are five different insurance companies or five different Medicaid managed care plans that Ohioans can choose from to cover their care. If a doctor wants to offer their services to people on Medicaid, they have to go through a complicated process to be considered in-network.

Right now, doctors have to go to all the different companies, each one separately reviews the request, and it could take 6-8 months. With the changes, there will be a centralized process, and doctors will only have to go through it once.  This will speed the process up to only take a week or two, which is a huge difference from the current process taking half a year or more, Corcoran said.

The hope for the new system is that it will more directly improve the health of people on Medicaid, she said.

John Corlett, executive director of the Cleveland-based policy think tank Center for Community Solutions, said the Medicaid changes will help Ohio low-income residents with housing, food insecurity, and transportation issues. A person’s health is influenced by everything around them, not just their health care, and by improving some of these other factors, you can actually improve a person’s health outcomes, Corlett said.

So if a doctor tells a patient to go to the food bank and get healthy food, the changes in the system will close the loop and make sure the hospital and insurance company know the patient may need help getting groceries, he said.

The changes are expected to be implemented by January 2022.

There’s a competitive bidding process for insurance companies over the next couple of months, Corcoran said. Once the state picks which companies will offer the best deals for Ohioans on Medicaid, the plan will have to be approved by the federal government.
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