Certain Aged, Blind or Disabled individuals are not permitted to join the Medicaid managed care program if they are:

• Children under twenty-one years of age;
• Individuals who are dually eligible under both the Medicaid and Medicare programs;
• Institutionalized individuals; (e.g. individuals living in long term care facilities)
• Individuals eligible for Medicaid by spending down their income or resources to meet Medicaid eligibility requirements; or
• Individuals receiving Medicaid Waiver services. (e.g. Passport, Individual Options, Home Care etc.)

If you receive a notice to choose an MCP, but you fit one of the categories listed above, call the ODJFS Managed Care Enrollment Center (MCEC) toll-free at 1-800-605-3040 (TTY 1-800-292-3572) Monday through Friday, 8:00 a.m. to 8:00 p.m. The MCEC Enrollment Counselor will verify that the consumer meets one of the above categories and will return the consumer to the Medicaid fee-for-service program.

Because your health care is so important, choosing the MCP that best suits your needs is also important. Here are some questions to ask yourself before choosing your MCP:

• Which MCP has all or most of the doctors I go to, or want to go to, on its list of providers?
• Which MCP has the hospitals and pharmacies I like to use on its list of providers?
• Which MCP offers the extra services that I need or want?

You may have other concerns or questions that are important to you and your health that you need to consider when choosing an MCP. You can call the MCPs in your region to ask your questions. The MCPs’ toll-free telephone numbers are in this guide.

Each MCP must offer special services to members in addition to all medically-necessary Medicaid covered services, such as:

• A primary care provider or “PCP”, who will work with you to provide your health care or refer you to a specialist in your MCP;
• A toll-free member services telephone center with staff to help you get the care and service you need;
• A 24 hour (seven days a week) toll-free medical advice line with staff who can provide medical advice or direction on how to access health services;
• Information for members with special needs in other formats, such as large print, or materials can be explained by the MCP orally;
• Interpreter services for any language including assistance with written materials; and
• Annual physical exams for adults.

If you have serious health problems, your Managed Care Plan (MCP) may offer you extra help to manage your health. This is called Case Management.

If you have one or more of the serious health conditions listed below, you will receive special help from a case manager who will:

• Serve as your point of contact if you have questions about your health, and to check how you are feeling;
• Work with you and your primary care provider or specialist to create a treatment plan to meet your health care needs;
• Assist you in scheduling appointments with physicians or specialists;
• Help you get the care you need, such as receiving necessary medications or assistance in arranging transportation to get to appointments.

• Asthma
• Chronic Obstructive Pulmonary Disease
• Congestive Heart Failure
• Coronary Artery Disease
• Diabetes
• Non-Mild Hypertension
• Severe Mental Illness
• High Risk or High Cost Substance Abuse Disorders
• Severe Cognitive and/or Developmental Disabilities

Contact your MCP if you think you may need case management services or to learn more about additional services offered by your plan. The MCPs’ toll-free telephone numbers are in this guide.

When you are an MCP member you still have access to transportation for medical appointments. You will be able to receive certain transportation help through your MCP and you will be able to receive certain transportation services through your local CDJFS.

Note: Emergency Ambulance Services are always covered by calling 911.

MCPs must provide non-emergency transportation for their members if:

1. It is medically necessary for a member to use an ambulance or ambulette (wheel chair van) for transportation to an MCP-covered service; and/or;
2. Requested by a member who must travel 30 miles or more from his/her home to reach an MCP-authorized provider.

MCPs may provide additional transportation services as an extra benefit to members. The extra transportation assistance listed below is in addition to the transportation MCPs must provide to their members listed above. For more information on how to arrange non-emergency transportation, contact the MCP’s member services line.

The county department of job and family services will provide transportation through the Non-Emergency Transportation (NET) program whenever the transportation shown below is not provided by the MCP.

Note: Additional transportation benefits offered by your MCP do not have to be used prior to getting NET services.

MCP	Additional Transportation Benefits	Must Call MCP in Advance
CareSource	30 one-way trips permember per 12-month period to any covered medical care, WIC or CDJFS re-determination appointment when each one-way trip is less than 50 miles	48 hours (2 business days) or up to 30 days in advance notice requirement
Molina Health Care of Ohio	30 one-way trips per member per 12-month period to any covered medical care, WIC, or CDJFS redetermination appointment	48 hours (2 business days) notice requirement
Unison Health Plan of Ohio Inc.	30 one-way trips per member per 12-month period to any covered medical care, WIC, participating pharmacy or CDJFS re-determination appointments.	48 hours (2 business days) notice requirement

Some MCPs provide more services and benefits than the regular Medicaid fee-for-service (FFS) program. For a complete list of additional services and benefits offered by an MCP, please call the MCP’s toll-free number.

Following are examples for each MCP:

MCP	Additional Services
CareSource	No co-pays Preventive dental exam every 6 months More eyeglass frame choices
Molina Health Care of Ohio, Inc.	No co-pays $230 in gift cards for Motherhood Matters Program $10 gift card for annual dental exam Choice between glasses or soft contacts every 12 months
Unison Health Plan of Ohio Inc.	No co-pays Personal member service representative $80 gift card for keeping pregnancy-related appointments Choice between soft contacts or glasses

You may have questions about certain doctors, hospitals or other questions about an MCP before you choose or change plans. Here are important toll-free member services telephone numbers and websites for the MCPs in your region:

CareSource	Molina Healthcare of Ohio, Inc.	Unison Health Plan of Ohio Inc.
1-800-993-0780	1-866-408-9501	1-800-895-2017
(TTY) 1-800-750-0750	(TTY) 1-800-750-0750	(TTY) 1-888-616-0021
www.caresource-ohio.com	www.unisonhealthplan.com	www.molinahealthcare.com
Monday - Friday 7:00 am - 7:00 pm	Monday - Friday 7:00 am - 7:00 pm	Monday - Friday 7:00 am - 7:00 pm

Your MCP must provide you the following:

• All the same medically necessary services that are covered by Medicaid fee-for-service.
• A member handbook that explains how to receive health care through the MCP, and the rules you must follow when getting health care services.
• A member identification card you must show every time you receive health care services.
• A directory of all doctors, specialists, hospitals, pharmacies and other health care professionals who are with the MCP. This directory lists their addresses and telephone numbers. You can also see this information on your MCP’s member website. Most providers are also listed at www.ohiomcec.com.
• Information on how to get benefits such as family planning services from out-of-panel providers.

As an MCP member you must:

• Choose one of your MCP’s doctors as your primary care provider (PCP) and agree to see your PCP or the providers to whom your PCP refers you.
• Follow all the rules in your MCP member handbook.
• Get your health care through the doctors, specialists, hospitals, pharmacies, and other health care professionals that are in your MCP’s provider directory, except under the special circumstances listed in your member handbook.
• Tell your MCP and your county caseworker right away if your address changes, so they can send you important information about your health care benefits.

How you get health care services as a managed care plan (MCP) member may be different from fee-for-service Medicaid and your MCP may also have policies you must follow for certain services. It is important to read your member handbook and call your MCP if you have questions such as:

• How to get health care services and medications including whether you must get approval from your MCP before you can get the service/medications?
• How to get health care services not provided by your primary care provider (PCP) including whether you must have a referral from your PCP before you can get the service?
• How after-hours and emergency coverage are provided?
• What are the MCP’s policies for post-stabilization care services (certain services received in the emergency room after your emergency has been stabilized)?
• What are the MCP’s policies on advance directives (for example a living will or a durable power of attorney)?
• What are your rights and responsibilities as an MCP member?

What if I already have services scheduled?

If you are changing from Medicaid fee-for-service to an MCP, and have health care services already approved and/or scheduled, it is important that you call the member services telephone number of your MCP as soon as possible. In certain situations, for a brief time after you enroll, your MCP may allow you to receive care from a provider that is not contracted with the MCP. However, you must call your MCP before you receive the care. It is especially important to call your MCP to let them know if you have the following services already approved and/or scheduled:

• Organ, bone marrow, or hematapoietic stem cell transplant,
• Inpatient/outpatient surgery,
• Appointment with a primary care or specialty provider;
• Chemotherapy or radiation treatments,
• Third trimester prenatal (pregnancy) care, including delivery.
• Services you receive at home, including home health, therapies, and nursing;
• Non-routine dental or vision services (for example braces or surgery); and
• Medical equipment.

If you are not already enrolled in an MCP, you will receive a notice that tells you when it is time for you to choose an MCP. The notice tells you about managed health care and how you can enroll.

Choosing an MCP is Easy! To choose your MCP, you can call the ODJFS Managed Care Enrollment Center toll-free at 1-800-605-3040 (TTY 1-800-292-3572) Monday through Friday, 8:00 a.m. to 8:00 p.m. An Enrollment Counselor will tell you about managed care, answer your questions, and help you choose an MCP. If you use the web, you can look at information and enroll on the internet

If you do not choose an MCP by the deadline, one will be chosen for you! The notice you receive will contain a date by which you have to choose an MCP. If you do not choose an MCP by this date, you will receive a letter telling you which MCP has been chosen for you. The letter will tell you how to make sure this is the MCP you want by calling the toll-free number above. If, for whatever reason, you do not get the MCP you want, you can change your MCP under certain circumstances.

If you are already enrolled in an MCP, but you think you may want a different MCP, you can change at certain times.

• If you have been an MCP member for less than three months;
• During your Open Enrollment month; and (You should have received a notice that tells you December is the open enrollment month for your region).
• You can change at other times for special reasons. (In Ohio, this is called “Just Cause”).

If you have a problem with your MCP that makes you want to change to a new MCP, first you must call your MCP to see if they can help you. There is also information in your member handbook about the reasons for Just Cause. Your reason(s) will be reviewed by ODJFS. You may be contacted by a worker to discuss your issues or to ask for information. ODJFS may also contact your MCP, and in some cases the doctors or other medical providers you use will also be contacted. Once all of the information is reviewed, you will receive a letter that tells you if your request has been approved. If it is denied, you may have the right to a state hearing.

To change your MCP, call the ODJFS Managed Care Enrollment Center toll-free at 1-800-605-3040 or (TTY) 1-800-292-3572 and explain your reason(s). You can also change your MCP online.

If you are unhappy with your MCP or its providers, you have the right to file an appeal, a grievance/complaint, and/or a state hearing. You should contact the MCP at their toll-free number and they can provide you with the following information:

• The requirements and timeframes for filing an appeal, grievance, or state hearing,
• The rules about state hearings and how to ask for a state hearing; and
• An explanation of how you may be able to have your services continue if you file an appeal or request a state hearing, and when you might have to pay for these services.

This Consumer Guide contains important information about how to get health care through an MCP, but it does not contain all the information you need to know about your MCP. Please be sure to keep this Consumer Guide along with your MCP Member Handbook and Provider Directory in a safe place.

Keep your MCP identification card in a safe place. Do not throw it away. Make sure you have your identification card with you when you need health care services.

Remember, as an MCP member, answers to your questions or help in getting health care are a phone call away. Call your MCP’s member service toll-free number; the MCP is there to help you.

You can also call the ODJFS Managed Care Enrollment Center toll-free at 1-800-605-3040, Monday through Friday, 8:00 a.m. to 8:00 p.m. (TTY) 1-800-292-3572, En Espanol 1-800-605-3040. An Enrollment Counselor will tell you about managed care, answer your questions and help you choose an MCP. If you use the web you can look at information and enroll on the internet at www.ohiomcec.com.

Please use the chart below to keep the names and telephone numbers of your MCP and the doctors and other providers you and your family members use.

MCP's Name	Member Services Telephone Number
24/7 Medical Advice Line
	Name	Phone Number
Family Doctors
Pediatricians
Dentists
Pharmacies
Hospitals

Call to speak with an Enrollment Counselor
Monday - Friday
8:00 a.m. to 8:00 p.m.
(800) 605-3040