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Medicaid redetermination

If any of your patients are covered by Medicaid, they are likely to be affected by the upcoming period of “redetermination.”

Every person covered by Medicaid must have their eligibility determined annually, but that process has been suspended during the federal public health emergency of COVID-19. The public health emergency will end May 11, 2023, and the redetermination process will resume.

Providers have a role to play in ensuring your patients stay covered. Learn more in the frequently asked questions below.

how will redetermination work in Ohio?

The Ohio Department of Medicaid has indicated that the redetermination period will last for 12 months, so approximately 8% of Ohioans covered by Medicaid will go through the process each month.

ODM estimates that about 70% of those people will be recertified as eligible for Medicaid automatically. The other 30% will need to take some action to keep their coverage – that includes approximately 38,000 children in central, south central and west central Ohio.

But many of those who need to take action will need to take it in the first few months after the end of the public health emergency.

why will some people be recertified automatically?

ODM can use documentation recently provided for benefit programs, like SNAP, to prove eligibility for Medicaid coverage. Because many people on Medicaid are also enrolled in these programs, their eligibility can be confirmed without any additional action. This is called “ex-parte redetermination.”

what happens when people now covered by Medicaid are not recertified automatically?

These people will receive mail at their last documented address from the Ohio Department of Medicaid or their county office of Job and Family Services in the coming months. Some are starting to receive that mail now. They must complete the forms and return them to retain coverage.

what if the Medicaid members have recently moved or do not have a stable address?

This is a big concern. Ohio’s contracted managed care plans (Buckeye Health Plan, CareSource, Molina Healthcare, Anthem Blue Cross and Blue Shield, Humana Health Horizons, AmeriHealth Caritas and United Healthcare Community) are receiving lists of their members whose coverage is not able to be renewed automatically. The plans, in turn, are trying to reach out to their members.

Hospitals and organizations across Ohio, including Nationwide Children’s Hospital, Dayton Children’s Hospital and Partners For Kids, also have comprehensive public outreach plans.

But there is no guarantee that everyone who should receive redetermination mail actually will receive it.

does redetermination have an impact on Next Generation Medicaid or newly added managed care plans?

Redetermination is a separate process, focused on determining individual eligibility for coverage. Next Generation Medicaid is focused on plans and the way coverage is provided. Even if a Medicaid member has chosen to enroll in a new plan because as a result of Next Generation Medicaid, they must still go through the redetermination process.

how does redetermination impact young people who are enrolled in OhioRISE?

Medicaid enrollment is one of the requirements of OhioRISE, and so those young people must also go through the redetermination process. In theory, most OhioRISE participants can be recertified automatically because of their connection to other benefit programs. But some caregivers may have to take additional action.

will I be able to see a patient’s Medicaid enrollment status in the new Medicaid Provider Network Management (PNM) system?

The PNM system is available to check current and past eligibility status. It is unclear if the system will be updated to include future renewal dates.

what can my practice do to help?

In short, use your position as a trusted family resource to educate your patients about redetermination.

  1. Encourage your patients to update their addresses and contact information through Ohio’s Benefits Self-Service Portal, by contacting the state at a toll-free number, or by contacting their county’s Job and Family Services office. Cards, fliers and posters are available to order from the brand resource center to help facilitate this process. Search "redetermination" to find them.
  2. Encourage your patients to look for mail from the Ohio Department of Medicaid or their county’s Job and Family Services Office. This mail may appear to be a routine notice and seem unimportant, and it may also appear to be a bill. It’s actually crucial to ensure they retain health care and prescription medication coverage.

if I have a patient who needs to re-enroll or enroll in Medicaid, who do I contact?

Place a referral order to financial advocates.

  • Search “REF550” or “Medicaid” wherever you search for Orders.
  • Select “Redetermination” under “Type”
  • Click “Accept”

Financial advocates can assist patients with both initial enrollment applications and applications to re-enroll in Medicaid.

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Dayton Children's is available to assist referring providers and their patients with an array of services.

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To consult with a pediatric specialist, contact the communication center: 937-641-4385 Monday-Friday | 7:30 am to 5:00 pm.

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