 Today, Governor Mike DeWine announced the Ohio Department of Medicaid’s (ODM) launch of OhioRISE (Resilience through Integrated Systems and Excellence), Ohio’s first-ever highly specialized behavioral health program for children and youth with the most complex behavioral health needs who are served by Medicaid. With leadership from the Governor’s Children's Initiative and the entire Family and Children First Cabinet Council, the OhioRISE program takes a huge step forward in achieving the governor’s vision of ensuring every child has the chance at a bright future.
Since taking office, Governor DeWine has been intentional in his administration’s efforts to better serve the needs of Ohio’s youth with complex behavioral health and multisystem needs. This collaborative, years long work has resulted in a program that:
- Puts young people and their caregivers in the driver’s seat, honoring family voice and choice through the services and systems being introduced through OhioRISE.
- Provides new and improved behavioral health services and supports to give more children and youth the opportunities they deserve to grow into healthy adults at home, in school, and in their communities.
- Uses evidence-based care coordination approaches that help children, youth and families navigate across multiple systems using care coordination.
- Helps to prevent custody relinquishment by better serving youth and families who need additional services because of their complex needs.
OhioRISE’s Day 1 Goals
Today, around 5,500 of Ohio’s youth and children with complex behavioral health challenges, also known as “Day 1 enrollees,” are being proactively enrolled into the OhioRISE program so we can begin assessing and meeting their needs. Over the last few months, ODM worked to identify eligible Medicaid children and youth with the most immediate needs. Children in custody receiving residential treatment, children living in out-of-state residential treatment facilities, and those who have recently been hospitalized for behavioral health conditions have been identified as those who will greatly benefit from increased care coordination through enrollment into the program.
Children and youth who may be eligible for OhioRISE:
- Are eligible for Ohio Medicaid (either managed care or fee for service)
- Are age 0-20, and
- Require significant behavioral health treatment, measured using the Ohio Children’s Initiative Child and Adolescent Needs and Strengths (CANS) assessment or a recent inpatient behavioral health/psychiatric residential treatment facility (PRTF).
Care coordination is being delivered to OhioRISE-enrolled children and youth by Aetna, the OhioRISE plan, and in their local communities by new centralized hubs called OhioRISE care management entities (CMEs). Care coordinators working at Aetna and the CMEs have been working since February to prepare for the launch, and many of them have already started assessing and providing early care coordination services to the first OhioRISE enrollees. Click here for guidance on who to contact for initiating a referral to the OhioRISE program.
What’s Next?
Our continued collaboration and hard work to reach our OhioRISE vision for children and youth does not stop here— OhioRISE is a long-term commitment to building capacity for community-based care that will keep children and youth close to their homes and families. In the coming months and years, we will continue to develop OhioRISE services, care coordination, and the system of care in local communities across our state. In 2023, OhioRISE will implement the new psychiatric residential treatment facility (PRTF) benefit, and by the end of July 2023, OhioRISE is expected to serve 50,000 - 60,000 children and youth. One year from today, the systems we know will be vastly different and will continue to grow.
Our collective work is already improving the lives of Ohio’s children, youth, and their families. Thank you for your support of OhioRISE and the Next Generation of Ohio Medicaid!
Find an overview of this announcement here. More information about the OhioRISE program can be found on the OhioRISE webpage. The OhioRISE Launch Information page of the OhioRISE webpage will provide regular updates regarding the OhioRISE launch and implementation. If you have any questions, please attend OhioRISE implementation open office hours, available every Tuesday from 2-3 p.m. starting July 5 to August 30. Click here to join the office hours.
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We want to make today’s launch and the continued implementation of the OhioRISE program as smooth as possible for you! Representatives on ODM’s, Aetna’s, and the Ohio Medicaid’s managed care organizations’ help desk hotlines are prepared to assist providers with all OhioRISE-related questions.
For Ohio Medicaid-related questions, please contact ODM’s Integrated Help Desk (IHD) at 800-686-1516, which is available Monday through Friday 8 a.m.-4:30 p.m. IHD’s Interactive Voice Response System (IVR) provides 24/7/365 access to information regarding client eligibility, claim and payment status, and provider information. Agents on the IHD hotline will be able to assist with issues and questions related to:
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- Using the Child and Adolescent Needs and Strengths (CANS) assessment tool and CANS IT system.
- Medicaid Information Technology System (MITS).
- General Medicaid member eligibility questions.
- General Medicaid payment/billing questions and issues.
- Enrolling as an Ohio Medicaid provider.
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For OhioRISE specific-questions, please contact Aetna’s OhioRISE Provider Experience Help Line at 833-711-0773 (option 2), which is available Monday through Friday 7 a.m.-8 p.m. OhioRISE Provider Experience Help Line representatives are available to assist you with issues and questions related to:
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- Contracting with Aetna/as an OhioRISE Plan provider.
- OhioRISE member claims, payment/billing questions and issues.
- OhioRISE member prior authorization.
- Verifying a member’s OhioRISE eligibility.
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Each of ODM’s managed care organizations (MCOs) have provider hotlines that are available to assist you. Contact information and hours vary by plan and according to the information available at medicaid.ohio.gov/resources-for-providers/managed-care/provider-mcp-resources. MCO provider hotline representatives are able to assist with issues and questions related to:
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- MCO member claims, payment/billing questions and issues.
- MCO prior authorization for a member with the MCO.
- Verifying a member’s MCO eligibility.
- Contracting with the MCO.
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Please find more information and regular updates about the OhioRISE launch on the OhioRISE Launch Information page of the OhioRISE webpage. Additional resources for OhioRISE community partners and providers can be found on the Resources for Community Partners and Providers page of the OhioRISE webpage.
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The OhioRISE program launched today! Below are six ways that you can help to support the OhioRISE program today and beyond.
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1. Talk to families, youth, and other community partners about OhioRISE.
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Click here to view the OhioRISE brochure. We encourage you to distribute to youth and their families who you think may benefit from the program. The brochure provides high-level information regarding OhioRISE to help youth and their families understand the program and its major components. Youth and their families will find information about eligibility, covered services, Child and Adolescent Needs and Strengths (CANS) assessments, how to get more information on OhioRISE, contact information for questions, and more.
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Click here to view the OhioRISE flyer, which provides comprehensive information on OhioRISE so that community partners have the knowledge necessary to talk to youth and their families regarding the program. The OhioRISE flyer provides supplemental information that is more in-depth than the OhioRISE brochure, including information about the basics of OhioRISE, eligibility, covered services, enrollment, and scheduling a CANS assessment.
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2. Facilitate the CANS assessment by referring or providing CANS assessments for children/youth who may need to be assessed for eligibility.
- If you’re a certified Ohio Children’s Initiative CANS assessor, you can conduct CANS assessments that are used to determine OhioRISE eligibility. Please remember to put the assessment in the CANS IT system, where eligibility will be assessed. If determined eligible, a child/youth’s OhioRISE enrollment will be effective on the day their assessment is put into the IT system. Resources for CANS assessors, including information on billing Medicaid for CANS assessments, a flyer for CANS assessors, and a flyer for young people and families about the CANS and OhioRISE, can be found here.
- If you encounter a child/youth who might benefit from OhioRISE services and supports, you can suggest that they obtain a CANS assessment to assess their eligibility for the program. They can contact their managed care plan’s member services line to be referred to a CANS assessor if they have Medicaid managed care, or they can contact the Medicaid Consumer Hotline at 800-324-8680 (TTY: 800-292-3572) to be provided with a list of local CANS assessors.
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3. Participate in a Child and Family Team when requested by a child/youth and family.
- If you provide services to or work with a child/youth enrolled in OhioRISE, you may be asked to be part of their Child and Family Team (CFT). Outreach will come from care coordinators at the OhioRISE CMEs or the OhioRISE plan. Click here to learn more about a CFT in the OhioRISE CME manual.
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4. Leverage the CFT process and child- and family-centered care plan (CFCP) when serving and working with children and youth enrolled in OhioRISE.
- You can coordinate and align your services and work with an OhioRISE enrollee through the CFT process. For example, your treatment plan can inform the CFCP, and the CFCP can help you do your work too.
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Click here to learn more about the CFT process and CFCP in the recorded Module 2 OhioRISE community and provider training or click here to access the training deck.
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Click here to learn more about a CFT in the OhioRISE CME manual.
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5. Provide treatment services and natural supports to OhioRISE-enrolled children and youth.
- We’re all working together to build a strong network of behavioral health service providers and natural supporting partners who can help young people enrolled in OhioRISE.
- If you’d like to provide Medicaid-billable behavioral health services to children and youth enrolled in OhioRISE, click here to access OhioRISE provider enrollment and billing guidance.
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6. Build relationships with Aetna, the OhioRISE Plan, and your local OhioRISE Care Management Entities (CMEs) – you’ll be working together to serve young people enrolled in OhioRISE.
- In addition to establishing key points and methods of contact, you can help Aetna and the CMEs understand current and desired community capacity for services and supports to help children and youth in OhioRISE.
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Click here to view the OhioRISE CMEs page of the OhioRISE webpage. You will find the contact information of the OhioRISE CME serving your geographic area under the “CME Contact Information” tab.
- You can contact Aetna’s OhioRISE Provider Experience Help Line at 833-711-0773.
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As a reminder, ODM and Aetna Better Health of Ohio have agreed to align OhioRISE practitioner modifier requirements for outpatient and professional claims with those used in ODM’s fee-for-service program. In accordance with this set of changes, the OhioRISE Provider Enrollment and Billing Guidance and the OhioRISE Care Management Entity (CME) Manual, both available on the OhioRISE Resources for Community Partners and Providers page, were updated on June 21. Both documents now describe Aetna’s practitioner modifier requirements for community behavioral health services as aligning with those in ODM’s fee-for-service program.
With the implementation of this update in Aetna’s billing requirements, Aetna will NOT REQUIRE practitioner modifiers on the following types of claims, unless the rendering practitioner holds multiple licenses or credentials with differing scope of practice.
- Community mental health agency claims (provider type 84).
- Community substance use disorder treatment provider claims (provider type 95).
- OhioRISE CME claims.
- Other professional and behavioral health services reimbursed in accordance with Appendix DD of Ohio Administrative Code (OAC) rule 5160-1-60 (this includes BH services rendered by providers other than community MH/SUD agencies).
- Outpatient hospital claims submitted for Enhanced Ambulatory Patient Groups (EAPG) reimbursement.
In alignment with ODM fee-for-service policy, Aetna will require practitioner modifiers on outpatient hospital claims submitted for Outpatient Hospital Behavioral Health (OPHBH) reimbursement. Aetna’s OPHBH practitioner modifier requirements will mirror ODM’s fee-for-service requirements.
Practitioners with multiple licenses or credentials
Aetna will require rendering practitioners holding multiple licenses or credentials with differing scopes of practice to use ODM’s requirements for enrollment and claims submission, including:
- Provider enrollment with a multi-license specialty.
- Rendering provider reporting their additional licensure/credentials on claims.
- Use of modifiers identified on ODM’s dual licensure grid, which can be found on https://bh.medicaid.ohio.gov/manuals.
Aetna will be reconfiguring its claims engine to incorporate the requirements outlined above. Until this reconfiguration is complete, Aetna will need to process some claims manually. Providers will not be required to resubmit or adjust claims at a later date if their claims are processed manually because of Aetna’s reconfiguration timeline.
Other changes were made to the OhioRISE Provider Enrollment and Billing Guidance and the OhioRISE Care Management Entity Manual on June 14, 2022, including some clarifying language and corrections made based on stakeholder feedback. Those changes are noted in the version logs at the beginning of each document.
The Medicaid Behavioral Health Provider Manual was also updated on June 14, 2022, to clarify that CANS assessments must be entered in Ohio’s CANS IT system only to establish and maintain OhioRISE eligibility.
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