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Majority of Medicaid to be Managed Care: Is Your Pharmacy Signed Up?

Also: Information for Pharmacists Calling Medicare

A major change is happening with Medicaid. By the end of 2006, most of your Medicaid patients will be in managed care provided by the companies listed below. BE SURE YOU HAVE SIGNED up as a provider, or those patients can no longer come to your pharmacy!

The Ohio Department of Job and Family Services (ODJFS) is expanding Medicaid managed care statewide for specific populations as a result of passage of Am. Sub. House Bill 66. The Covered Families and Children (CFC) procurement process is based on eight geographic regions.

Once Medicaid consumers become members of a Medicaid health plan, they receive the same health benefits as they did prior to membership, plus added benefits such as a medical home model focusing on prevention, care coordination, member services and a 24/7 nurse line. Healthcare providers must enter into a contract with the consumer's Medicaid health plan in order to receive reimbursement from the health plan for services rendered.

Interested health plans have already started contracting with health care providers. ODJFS will be working closely with provider associations to relay important information that affects providers during this time of change. If providers have questions about the expansion of the Medicaid managed care program and how providers are affected by this change, providers can refer to the Provider Questions and Answers document posted on ODJFS' website for providers at http://jfs.ohio.gov/ohp/bmhc/pro-man-care.stm . If you have additional questions, please submit them to bmhc@odjfs.state.oh.us.

ODJFS has established minimum provider panel requirements for each of the eight regions, however, health plans independently determine the specific providers with whom they contract. The health plans listed to the right are eligible to contract with providers in all eight regions, however, some health plans may only be pursuing provider contracts in specific regions and may not be contracting with providers outside those areas.

Medicaid Managed Care Regions
East Central: Ashland, Carroll, Holmes, Portage, Richland, Stark, Summit, Tuscarawas, Wayne
Central: Crawford, Delaware, Fairfield, Fayette, Franklin, Hocking, Knox, Licking, Logan, Madison, Marion, Morrow, Perry, Pickaway, Pike, Ross, Scioto,
Northeast Central: Columbiana, Mahoning, Trumbull
Northeast: Ashtabula, Cuyahoga, Erie, Geauga, Huron, Lake, Lorain, Medina
Northwest: Allen, Auglaize, Defiance, Fulton, Hancock, Harding, Henry, Lucas, Mercer, Ottawa, Paulding, Putnam, Sandusky, Seneca, Van Wert, Williams, Wood, Wyandot
Southeast: Athens, Belmont, Coshocton, Gallia, Guernsey, Harrison, Jackson, Jefferson, Lawrence, Meigs, Monroe, Morgan, Muskingum, Noble, Vinton, Washington
Southwest: Adams, Brown, Butler, Clermont, Clinton, Hamilton, Highland, Warren
West Central: Champaign, Clark, Darke, Greene, Miami, Montgomery, Preble, Shelby

Medicaid Managed Care Providers

 

AMERIGROUP Community Care
Ohio Network Development; 888.821.1108
Southwest and West Central Regions

Buckeye Community Health Plan, Inc.
Debra Collins, Vice President of Contracting
614.220.4900 Ext. 24114; dcollins@centene.com
East Central and Northwest Regions

CareSource
CareSource Provider Recruitment Connection
877.725.4577; Connect@care-source.com
Central, East Central, Northeast, Northeast Central, Southeast, Southwest, and West Central Regions

Molina Healthcare of Ohio, Inc.
Jim Hayden; 614.781.4304
Jim.hayden@molinahealthcare.com
Central, Southeast, Southwest, and West Central Regions

Paramount Advantage
Dale Ocheske; 419.887.2804
dale.ocheske@promedica.org
Northwest Region

QualChoice Select, Inc.
Rebecca N. Holland; 440.460.4045
rholland@qualchoice.com
Northeast Region

Unison Health Plan of Ohio, Inc.
Amanda Hewett; 614.890.6850
Amanda.Hewett@unisonhealthplan.com
Northeast Central, East Central, and Southeast Regions

WellPoint, Inc.
Randy S. Thomas; 805.384.3348
Randy.S.Thomas@wellpoint.com
Northeast, Northeast Central, and
Northwest


Information for Pharmacists Calling Medicare

The special CMS contact phone line for pharmacists (1.866.835.7595) was no longer available after June 23, 2006. CMS originally created the pharmacist contact line at the startup of the Medicare Prescription Drug Benefit...when data was less likely to reflect accurate beneficiary information and Plans were experiencing high call volumes. Since January, the average wait-time on Plan customer service numbers has decreased dramatically, and the number of daily calls to the CMS pharmacist contact line has decreased by more than 80 percent.

Beginning on June 24, pharmacists who call 1.866.835.7595 will be redirected to the 1.800 Medicare (1.800.633.4227) interactive voice response system...where they will have access to the same information and service as they do today. Callers to 1.800.Medicare reach a Call Service Representative (CSR) with little or no wait-times.
Medicare Part D Plans should continue to be the first pharmacy contact for nearly all questions... including formulary and cost sharing issues, payment inquiries, and other contracting questions. If the pharmacist does not receive appropriate information from the Plan, or would like to file a complaint, they should contact 1.800.Medicare or their CMS Regional Office. Additionally, pharmacists should continue to call 1.800.Medicare to determine Medicare eligibility or to obtain enrollment information if it cannot be obtained from the patient or through the E1 query.


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