One of the requirements to receive a Medicaid Waiver is to have Medicaid coverage. Sometimes, the services covered by Medicaid are not understood or even overlooked by families. Because of this, services families have available to them are not used. This toolkit provides information about Medicaid and the services you have available to you. In addition, to help clarify what is available, a Medicaid State Plan Services online course is now available in DODD MyLearning. This online course requires an OH|ID account to access.
Choosing Managed Care
In many cases, as a Medicaid recipient, you’ll be required to select a Medicaid Managed Care Plan that coordinates your acute services and care. A Medicaid Managed Care plan does not substitute for the care coordination you may receive through your county board of developmental disabilities. You will receive a letter asking you to choose a plan within your area. Read about the plans available to you and find the plan that works best for you. You can compare plans and enroll in your chosen plan at https://www.ohiomh.com/. To enroll you can also call the Ohio Medicaid consumer hotline: (800-324-8680). It is important to keep in mind what services you may need, what insurance plans your doctor takes, and what additional benefits would be the best help to you. Learn more here. Of important note, if you receive this letter and do not select a manage care plan, one will be selected for you.
Medicaid covers many services for eligible Ohioans. These include inpatient hospital services; outpatient hospital services; Early, Periodic, Screening, Diagnostic, and Treatment Services (EPSDT); and home health services. A list of covered services can be found here. Some essential services are highlighted below:
Healthchek: This is Ohio’s Early and Periodic Screening Diagnosis and Treatment (EPSDT) program for anyone younger than the age 21 who is enrolled in Ohio Medicaid. This program provides lots of care for children by making sure they have preventative, dental, mental health, developmental, and specialty services. This program covers ten check-ups in the first two years of life, and annual check-ups, and offers a comprehensive physical examination that includes many screenings. Some of these covered services include, but are not limited, to the following:Inpatient/outpatient hospital services
- Lab and x-ray services
- Extended Home health and private duty nursing services
- Personal care services
- Physical therapy and related services
- Any medical care or other types of remedial care (for example, occupational therapy) recognized under state law
- Other diagnostic, screening, and rehabilitative services recommended by a licensed Medicaid provider
- Durable medical equipment
- Dental services
- Certified pediatric nurse practitioner services
- Nursing facilities, ICFs/IID, and inpatient psychiatric hospitals
- Respiratory care services
EPSDT is available to anyone under 21 years of age and enrolled in Medicaid. No additional application is needed for a person to receive EPSDT covered services. Learn more about Healthchek in the frequently asked questions here.
Home Health Services: These are services provided by home health nursing, home health aides, and therapies, such as physical therapy, occupational therapy, and speech therapy. To receive these in-home services, they must be certified by the person’s doctor. More information for Home Health Services can be found here.
Nursing Services: Registered Nurse Assessment and Consultation Services
A registered nurse (RN) assessment will be performed on a person participating in the Medicaid program before the person receiving the following services for the first time:
- State plan home health services;
- Private duty nursing services;
- Waiver nursing services;
- Personal care aide services furnished by a Medicare-certified home health agency or an otherwise accredited agency and/or
- HOME choice nursing services
Also, an assessment is completed before any change being made to a person’s current package of services, and any time the RN is informed that the person receiving services has experienced a significant change, including improvement or decline in condition.
Medical Supplies, Equipment, and Appliances
Medical supplies, equipment, and appliances (Durable Medical Equipment or DME) must be medically necessary and provided based on federal requirements.
Before these types of services are prescribed, a practitioner must document a face-to-face encounter with a person. Also, prior authorization (permission) from Medicaid must be obtained before payment is made for certain covered items or quantities of certain items beyond established limits.
Home Health: PT, OT, Speech Pathology and Audiology Services
Physical therapy, occupational therapy, speech-language pathology, and audiology services are available to anyone with a need for such services, in the person’s place of residence, or in any setting in which normal life activities take place.
These services may only be provided by a Medicare Certified Home Health Agency.
No more than a combined total of 8 hours per day of intermittent/part-time nursing services, home health aide services and PT, OT, speech pathology, and audiology services.
Visits shall not be more than 4 hours in length.
No weekly limits for PT, OT, speech pathology, or audiology services.
Private Duty Nursing (PDN)
People enrolled in Medicaid who meet program requirements are eligible to receive PDN services.
People could be eligible for between 4 and 12 hours of PDN services per day. In certain emergency circumstances, as outlined in the rule, a person could receive up to 16 hours per day.
People can also receive PDN after a hospital stay for up to 56 hours a week and up to 60 consecutive days.
PDN is not for the provision of maintenance care.
For more information visit https://medicaid.ohio.gov/FOR-OHIOANS/Covered-Services#1690645-private-duty-nursing-services
Ohio Medicaid program covers, with limitations, general dental services as well as medical and surgical services furnished by a dentist.
Some of the dental services covered by Ohio Medicaid include:
- Checkups and cleanings
- Fillings, extractions, and crowns
- Medical and surgical dental services
- Root canals
Dental Service Limitations
- Some dental services may have limitations. For example, braces are only covered only for people under 21 and only when medically necessary.
- If a person is subject to a copay amount, the copay for dental services is $3.
- Some dental services also require prior approval for consideration.
For further information, visit https://medicaid.ohio.gov/FOR-OHIOANS/Covered-Services#1683587-dental
All Medicaid beneficiaries are entitled to drug coverage, except for those beneficiaries eligible to enroll in Medicare Part D.
- A less than 34 day supply is dispensed at a time for drugs treating acute conditions.
- A less than a 120 day supply is dispensed at a time for drugs treating chronic conditions.
Prior authorization is required for name-brand prescription drugs when generics are available to the beneficiary.
For more information, visit https://medicaid.ohio.gov/FOR-OHIOANS/Covered-Services#1683595-prescriptions and https://pharmacy.medicaid.ohio.gov/
The following items are covered under the Ohio Medicaid State Plan, with prior authorization:
- Glass lenses;
- Tinted lenses;
- UV-protective lenses;
- Photochromatic lenses;
- Frames or lenses provided by a source other than an optical laboratory holding a current volume purchase contract
A comprehensive vision exam and a complete set of eyeglasses may be provided every 12 or 24 months without prior authorization and is based on the age of the person. (Medical necessity must be documented if a PA is needed or if eyeglasses are needed more frequently)
For more information, visit https://medicaid.ohio.gov/FOR-OHIOANS/Covered-Services#1683599-vision
Behavioral Health Services
Behavioral health is a term referring to the treatment of mental illness and/or substance use disorders.
The benefits under the behavioral health program are not those which a county board of developmental disabilities can provide, except for Clermont County.
People who need behavioral health services will receive services from a local community behavioral health agency.
It’s important to remember that there are many behavioral health services available to people enrolled in Medicaid. The following details just a few of the services available.
If you’re covered by Medicaid and you’re having trouble getting to health care services, transportation assistance may be available. Learn more about transportation assistance at https://medicaid.ohio.gov/Portals/0/For%20Ohioans/Programs/Transportation-Card.pdf
Ohio Medicaid offers its consumers four different options for getting health care services. Access to these services depends mainly on a consumer's Medicaid eligibility category and/or care needs https://medicaid.ohio.gov/FOR-OHIOANS/Already-Covered/Getting-Care
Keep in Mind
- Waiver services are not part of a state’s state plan, but those who are enrolled on waivers have access to state plan services.
- When you hear things like “card services” or “Medicaid card services” this is referring to services offered to anyone eligible for the Medicaid program statewide.
- There are limitations to certain services provided under Ohio’s State Plan.
Managed Care Plan Grievances
People enrolled in an MCP and who have concerns regarding service provisioning, etc. can contact their plan. A person can file a “grievance” with the plan.
If a person is unsatisfied with the MCP’s response to their grievance, a person can reach out to the Medicaid Hotline at 1800-324-8680 or submit a constituent inquiry with pertinent information here: https://medicaid.ohio.gov/CONTACT