Medicaid requirements

 

Ohio Medicaid program

In Ohio, the Medicaid program is a jointly administered federal/state program that provides payment for necessary medical services to eligible persons who are unable to pay for such services.

As a Medicaid provider in Ohio, you could see members enrolled in any of the following programs:

• Healthy Families offers health care to families with household incomes up to 90% of the federal poverty level and a child (or children) younger than age 18 in the home.
• Healthy Start provides health care coverage for children younger than age 19 and pregnant women who qualify based on income.
• Medicaid Buy-In for Workers with Disabilities (MBIWD) provides health care coverage to working Ohioans with disabilities.
• Medicaid Managed Care. Most Medicaid beneficiaries are eligible for membership in an Ohio Medicaid managed care plan (MCP). EyeMed provides the vision network for some of these Medicaid MCPs.

Refer to the EyeMed Ohio Medicaid Provider Manual (requires inFocus login to access) for additional details.

 

Managed care plans

As an Ohio provider, you are an in-network provider for members enrolled in the following managed care plans:

• Anthem
• CareSource
• Humana Healthy Horizons

 

Medicaid enrollment

To provide routine vision care services to Ohio Medicaid members, you must enroll with both programs:

1. Ohio Medicaid. You can enroll and check your application status via the OH|ID portal. You must ensure your Medicaid registration (type 1 NPI, type 2 NPI, location affiliations) matches how you plan to submit claims to EyeMed.
2. EyeMed Vision Care^®. You can enroll with us by completing a New Provider Application, and entering “Ohio Medicaid” in the notes section. Typical turnaround time is 10 business days.

 

Provider requirements

In-network Medicaid providers must:

• Review and meet all requirements outlined in the EyeMed Ohio Medicaid Provider Manual (requires inFocus login to access), including some that are unique to this plan.
• Provide both exams and materials to Medicaid members.

 

Medicaid lab

You have the option to use the EyeMed lab network or a lab of your choice for Ohio Medicaid members. If you use EyeMed’s lab network, you must use Classic Optical.

Medicaid frame selection

If you don’t use the EyeMed lab network, Medicaid members may choose from a selection of frames you offer instead of the Medicaid-approved frame collection. You must be able to dispense standard size frames at no cost to the member.

Eyeglass frames should be durable ZYL frames (plastic), such as Opti-Colors. You must offer a frame selection of at least 36 ANSI-approved frames that meet the following criteria:

• 12 girl frames, varied materials
• 12 boy frames, varied materials
• 6 women frames, varied materials
• 6 men frames, varied materials
• Eye size assortment between 42 and 57

You should also have available, or be able to order, frames for infants or those with allergies to frame materials and other special needs.

If you use EyeMed’s lab network, you must register in EyeMed’s online claims system with Classic Optical. Once registered, you’ll receive a frame kit with a selection of frames available to members. NOTE: You will only receive a frame kit if you don’t already have one in your dispensary.

• The collection is for display and try-on use only.
• Do not send frames from the kit to the lab.
• If a frame manufacturer discontinues production of a frame that is listed as a benefit, you may use the discontinued frame from your sample kit.

You should also have available, or be able to order, frames for infants or those with allergies to frame materials and other special needs.

Submitting claims and ordering glasses

If you use the EyeMed lab network:

• Register for Classic Optical in our online claims system and search for labs listed as Medicaid in the “services provided” field. Refer to the Registering for a Medicaid lab job aid for step-by-step instructions.
• Follow our normal lab ordering process using our online claims system.
  • You must select the correct job type and indicate the reason for any medically necessary lenses.
  • Refer to the Filing claims for Medicaid job aid for step-by-step instructions.

Refer to the Claims codes section in the EyeMed Ohio Medicaid Provider Manual (requires inFocus login to access) for detailed instructions.

 

Coordination of Benefits (COB)

Details for how the COB process is administered in the state of Ohio can be found in the EyeMed Ohio Medicaid Provider Manual. You must be logged into your account on inFocus to access the manual.

Medicaid coordination of benefits

• Primary payer. Medicaid is considered the payer of last resort.
  • Federal regulations require you to bill all identifiable financial resources available for payment, including Medicare, prior to billing Medicaid.
• Submitting COB claims. File COB claims in hard copy using a CMS 1500 form. You must attach a copy of the primary plan’s explanation of benefits/remittance advice.
  • Refer to the hard copy claims process in the EyeMed Ohio Medicaid Provider Manual for further instructions.
  • If you do not follow this process, your claim will be denied and you may be responsible for returning money to the member.

TPL guidance

If you find:	Then a case member may be eligible for:
A case member is over 65 or blind or disabled	Medicare and Medicare supplemental policies
A case member, absent parent, stepparent, dependent child, new spouse of an absent parent, or anyone else who is legally or voluntarily responsible for a case member is EMPLOYED or UNION MEMBER	Employment-related health insurance
A case member, spouse of a case member, absent parent or stepparent is ACTIVE-DUTY MILITARY or a VETERAN	Military health insurance for active duty, retired military and their dependents coverage
A case member has been in an accident or otherwise accidentally injured: INJURY/TRAUMA/ACCIDENT	Workman’s compensation Homeowner’s insurance Automobile insurance Liability insurance

 

Related provider resources Provider Manual – Ohio Medicaid Registering for Medicaid network labs Filing claims for Medicaid Medically Necessary Contact Lens Form – Ohio Medicaid