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This week’s In Focus section delves into the Next Generation MyCare Ohio managed care program, spotlighting the request for applications (RFA) that the Ohio Department of Medicaid (ODM) released on May 31, 2024. The MyCare Ohio Program, which serves people who are dually eligible for both Medicaid and Medicare, is undergoing a substantial transformation. Transitioning from the financial alignment initiative (FAI) demonstration model used in 29 counties, it is evolving into a statewide, fully integrated dual eligible special needs plan (FIDE-SNP) model. This shift is more than procedural; it signifies a pivotal moment of transition to new federal D-SNP requirements.  

Background 

The MyCare Ohio Program launched in May 2014 as a Centers for Medicare & Medicaid Services (CMS) FAI demonstration. MyCare Ohio integrates Medicare and Medicaid benefits for dually eligible members enrolled in competitively selected MyCare Ohio managed care plans, providing one care coordinator and streamlined communication and services. It serves 150,000 individuals in 29 counties.  

CMS is sunsetting all FAI demonstration programs on December 31, 2025, prompting ODM to convert to the FIDE-SNP model.  

Next Generation RFA 

The MyCare Ohio Program will convert to the Next Generation MyCare Ohio Program in January 2026. ODM is modeling portions of the program after the state’s Next Generation Medicaid managed care program. The Next Generation MyCare Ohio Program initially will be implemented in the 29 currently participating counties and then expand statewide, covering a total of 250,000 eligible individuals. Medicaid managed care organizations (MCOs) that serve the program will need to become CMS-approved FIDE-SNPs. MCOs awarded a Next Generation MyCare Ohio contract will need to notify CMS of their intent to establish a statewide FIDE-SNP in Ohio by fall 2024 to begin operations in January 2026. 

ODM anticipates selecting up to four Next Generation MyCare Ohio MCOs to serve enrollees statewide, though a decision on the number of plans will be finalized as awards are made and based on what is most advantageous to the state.   

MCOs will need to develop a member-focused strategy with care coordination as a priority. MCOs will also increase focus on behavioral health coordination. According to ODM, goals for the Next Generation program include: 

• Focusing on the individual 
• Improving individual and population wellness and health outcomes 
• Creating a personalized care experience 
• Supporting providers in continuously improving care 
• Improving care for people with complex needs to promote independence in the community 
• Increasing program transparency and accountability 

Next Generation MyCare will advance these goals through a population health approach, designed to address inequities and disparities in care.  

The program will enroll dually eligible individuals ages 21 and older. This is a change from the current program, which enrolls dual eligibles who are 18 years old and older. The eligible age increase is being made to align with the Medicaid early and periodic screening, diagnostic, and treatment (EPSDT) benefit.  

The new program also will continue to offer all the same services available through Ohio’s home care, PASSPORT (long-term services and supports), and assisted living waivers. 

Evaluation 

Applications initially will be reviewed to confirm the applicant meets the mandatory requirements. Applicants who meet the mandatory requirements will proceed to review and evaluation of responses to application questions that fall into seven topic areas, with a total of 1,000 available points (see Table 1).  Of note, if an applicant is not currently serving as either a Next Generation MCO or a MyCare Ohio MCO, the applicant will receive zero points for qualifications and experience. Organizations that have yet to participate in at least one of these programs should consider the effect on their total score.  

Table 1 

Current Market 

Five MCOs—CVS/Aetna, CareSource, Centene/Buckeye, Molina, and United—participate in the current MCOP, with two or three of them participating in each of the seven regions. 

Timeline 

MCOs should submit a notice of intent to apply by June 21. Proposals are due August 2, and awards will be issued October 8. Implementation is scheduled for January 1, 2026.  

Connect With Us  

Ohio is one of several states transitioning from a FAI demonstration at the end of December 2025. Additionally, the 2025 Medicare Advantage Final Rule includes new policies affecting D-SNPs that could reshape the integrated care plan landscape in many states.  

°ÄÃÅÁùºÏ²Ê (°ÄÃÅÁùºÏ²Ê) will host a webinar June 20, 2024, to review the current landscape and federal changes that will affect D-SNPs in 2025 and beyond. The session will feature an analysis of the new regulations and a discussion of the critical strategic and product impacts on Medicare organizations that offer D-SNPs or are considering offering D-SNPs. Attendees also will have the opportunity to engage with the panelists during a Q&A session.  

More information on the webinar is available here. Contact °ÄÃÅÁùºÏ²Ê expert Sukey Barnum to learn more about the Ohio RFA and Holly Michaels Fischer, Greg Gierer, Dara Smith, and Tim Murray for details about the nationwide D-SNP rules and landscape.