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Today, the Ohio Department of Medicaid (ODM) has begun its Phase 2 Rollout of the Next Generation MyCare program. In addition to the 29 counties that went live on January 1, the program is now available in Sandusky, Erie, Henry, Williams, Defiance, Paulding, Fayette, Fairfield, Licking, and Ashtabula counties. From now until August 1, the program will continue to roll out across the state. The program provides enhanced healthcare benefits to Ohioans who have both Medicaid and Medicare and helps you better serve members through streamlined processes, better integration with the plans, and enhanced clinical coverage policies.
In the program, you must enroll with ODM and contract with the Next Generation MyCare plans to provide services to members. Ohio Department of Aging (AGE) enrolled providers can continue to provide services and submit claims but must contract with the plans if you have not already.
If you serve members who are changing plans or newly enrolled in the program, you can continue to provide services for a certain amount of time without having a contract with the MyCare plans. If you want to continue to serve members past the transition period, you need to follow the steps to become a provider.
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Claims for Next Generation MyCare members can be submitted to the plan’s portal using Direct Data Entry (DDE) or via Electronic Data Interchange (EDI). View the Provider Claims Submission One-Pager to learn more.
What if I am new to billing in the Next Generation MyCare Program?
Billing services in the Next Generation MyCare program is generally the same as the Managed Care program. If you submit claims for Managed Care members today, consider using the same process for MyCare members. If you use a trading partner, contact them before the program starts to check if you need to take any extra steps for your claim to be accepted by ODM.
If you do not have an existing process for submitting claims for MyCare members today, consider which option is best for you.
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Providers with a smaller volume of claims typically utilize the DDE process. Visit the MyCare plans' DDE portals to learn how to enroll and submit claims.
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Providers with a large volume of claims typically contract with a trading partner to support in billing and reconciliation of what has been submitted and processed. View ODM’s Electronic Data Interchange (EDI) Authorized Trading Partners list to see the trading partners currently authorized to work with ODM and providers. If you want to use a trading partner, you are encouraged to contact a few to find the one that best fits their needs.
Note: To submit claims for MyCare members, you must use the correct plan Receiver ID and payer ID for the program. Additionally, you must use the member’s Medicaid ID even if they have other ID numbers.
Refer to the Companion Guides for more information.
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Helping members receive care is ODM’s priority. To verify if an individual is enrolled in a MyCare plan, you can take the following actions:
- Check the member ID card. If the ID card has a Next Generation MyCare program logo, it is indicative that the member is a MyCare member.
- Check member eligibility via Provider Network Management (PNM) or the EDI 270/271 process.
If after completing these steps you encounter issues verifying a member’s enrollment, we encourage you to contact Member Services and follow existing billing guidance.
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If you have questions about claims, prior authorizations, contracting, member eligibility or other provider-specific functions, we are here to help. Contact ODM Integrated Helpdesk at 800-686-1516 or IHD@medicaid.ohio.gov from Monday through Friday, 8 a.m. – 4:30 p.m. Eastern Time. If you have questions about a MyCare member’s Long Term Care Services or waiver service status, call the member’s plan or the ODM Integrated Helpdesk. You can also view the Provider Help Desk One-Pager to learn more about the additional help desks available to you.
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Eligible individuals living in Sandusky, Erie, Henry, Williams, Defiance, Paulding, Fayette, Fairfield, Licking, and Ashtabula counties may start receiving their benefits through a Next Generation MyCare plan right now. When their benefits begin depends on whether – and when – they select a plan or are automatically assigned one.
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Members who selected a plan before April 1 are now receiving care through their selected plan.
- Members who did not select a plan before April 1 will be automatically enrolled in a plan for their Medicaid benefits. Members will receive a letter from ODM with more information about their plan and its start date.
- If a member wants to get their benefits through a MyCare plan sooner or change their plan, they should contact the Ohio Medicaid Consumer Hotline at 800-324-8680. Members cannot begin receiving care through a MyCare plan ahead of the date the program becomes available in their county.
- Members who are eligible for the MyCare Ohio Waiver will start receiving services through the waiver once their plan starts.
Once a member is enrolled with their plan, they should receive a new member ID card and other materials explaining their benefits.
Members can keep seeing their current doctors for a limited time after they start receiving care through the program. After that transition period ends, members will need to make sure their doctor is in their plan’s network.
How can you support members?
If a member has questions about their plan or benefits, direct them to contact the Ohio Medicaid Consumer Hotline at 800-324-8680 Monday through Friday 7 a.m. – 8 p.m. and Saturdays 8 a.m. – 5 p.m. Eastern time or visit www.ohiomh.com.
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On May 1, the Ohio Department of Medicaid (ODM) is expanding its rollout of the Next Generation MyCare program in Preble, Darke, Miami, Shelby, Champaign, Logan, Van Wert, Putnam, Hancock, Allen, Mercer, Auglaize, Hardin, Seneca, Huron, Wyandot, Crawford, Richland, Ashland, Marion, Morrow, and Knox counties! Join us for a webinar to learn about the program, what it means for you, and what steps you may need to take ahead of the program rollout.
Webinars are held on the third Wednesday of each month through August, alternating between a session specific to the Ohio Department of Aging (AGE) providers and all other provider types. View the schedule on the Resources for Providers webpage to pick the session that best fits your needs. Presentations for each session type will be available online after the first session.
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Sandata/HHAeXchange, the Ohio Department of Medicaid’s (ODM) Electronic Visit Verification (EVV) system partner, is making support and learning faster, better, and easier for providers. Three new portals are going live April 20.
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Sandata’s Customer Support Portal is getting a fresh new look! Improved functionality, easier navigation, and a modern design. Providers will be able to submit tickets quickly and follow a streamlined tracking process for faster resolutions from Sandata’s Technical Customer Care (TCC) team. See how it works.
- Sandata’s TCC team can still be reached by using the phone numbers and emails providers know.
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Sandata Learn will be moving to HHAeXchange University. The upgraded version will feature a modern interface, enhanced functionality, and more intuitive navigation to make finding support videos and materials easier. The content providers rely on today will migrate to the new site. It will also house new resources as they become available. Take a look at what's in store.
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Sandata on Demand is getting a new home and a new name. It will become Sandata Knowledge Base offering richer functionality, intuitive navigation, and Caree, a virtual assistant for instant answers and training resources. Learn more and take a look here!
ODM and Sandata/HHAeXchange are committed to making this a smooth transition. We’ll be sharing more information about these new upgrades in the days ahead, offering more insight on how to prepare for the transitions ahead.
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ODM is revamping the ways we connect with providers and all our members. Follow us for updates on healthcare coverage, wellness tips, and important information for Ohioans. Stay connected and informed about the latest initiatives and resources available.
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