The OhioRISE program's child and family-centric delivery system recognizes the need to specialize services and support for this unique group of children and families.
Enrollment Process
The first step to enrolling in OhioRise is to determine eligibility. This is done through the completion of a CANS assessment. A CANS assessment gathers the young person and family’s story to understand their needs and strengths, and to help determine the best ways to provide help. The CANS assessment is updated regularly to aid with ongoing care planning.
Following a CANS assessment, children and youth found to be eligible are enrolled in OhioRISE effective the date their CANS assessment is submitted.
The Next Generation of Ohio Medicaid is being implemented in stages. The first stage – the launch of OhioRISE – started on July 1, 2022. Staggering the start and beginning with OhioRISE helps us meet the immediate behavioral health needs of children and youth served by multiple systems and their families while avoiding unnecessary disruption and confusion for members reducing burdens on our service providers. Additionally, the staggered approach remains true to our Next Generation vision – to ensure that we keep our focus on the individual, honor members’ choice, and provide continuity in the provision of members’ care.
To learn more about the Next Generation of Ohio Medicaid and the staggered implementation, check out the OhioRISE Factsheet.
Children and youth who may be eligible for OhioRISE:
- Are eligible for Ohio Medicaid (either managed care or fee-for-service),
- Are age 0-20, and
- Require significant behavioral health treatment needs, measured using the Ohio Child and Adolescent Needs and Strengths (CANS) assessment.
Children and youth may also be eligible for OhioRISE due to certain urgent conditions. For example, if a child or youth is in a hospital for behavioral health reasons.
New and enhanced services available through OhioRISE include:
- Intensive and Moderate Care Coordination: two levels of this service (intensive and moderate) will be consistent with principles of High-Fidelity Wraparound and be delivered by a Care Management Entity-qualified agency.
- Intensive Home-Based Treatment (IHBT): OhioRISE will make changes to existing IHBT services and align with the Family First Prevention Services Act (FFPSA).
- Psychiatric Residential Treatment Facility (PRTF): this service is aimed at keeping youth with the most intensive behavioral health needs in-state and closer to their families and support systems.
- Mobile Response and Stabilization Service (MRSS): provide youth in crisis and their families with immediate behavioral health services to ensure they are safe and receive necessary supports and services (this new service will also be available to children who are not enrolled in OhioRISE).
- Behavioral Health Respite: provide short-term, temporary relief to the primary caregiver(s) of an OhioRISE plan enrolled youth, in order to support and preserve the primary caregiving relationship.
- Primary Flex Funds: services, equipment, or supplies not otherwise provided through the Medicaid state plan that address an identified need in the service plan, including improving and maintaining the individual’s opportunities for full participation in the community.
OhioRISE features a new 1915(c) Medicaid waiver that drives toward improving cross-system outcomes for its enrollees. The new home and community based OhioRISE waiver features access to all of the services in the OhioRISE program and its own unique waiver services targeted toward this population. The waiver is intended to keep families supported in the community with a goal to prevent institutionalization.
What are the services children and youth will have access to through the OhioRISE Waiver?
- Out-of-Home Respite: A service provided to individuals unable to care for themselves that is furnished on a short-term basis because of the absence or need for relief of those persons who normally provide care for the individual.
- Transitional Services and Supports (TSS): Shorter-term supports for individuals and their families to help them understand, mitigate, and provide connections to long-term solutions that address behavior challenges.
- Secondary Flex Funds: Services, equipment, or supplies not otherwise provided through the waiver or through Medicaid that address an identified need in the service plan, including improving and maintaining the individual’s opportunities for full participation in the community.
How can children and youth access the OhioRISE Waiver?
A child or youth can be referred for the waiver through their local care management entity (CME). Youth and families interested in receiving a waiver referral for the OhioRISE Waiver can do so through a number of different “access points.” It is anticipated that behavioral health providers that a youth is connected with can help make the appropriate referral for a CANS assessment to determine waiver eligibility to a CME in the child’s or youth’s local area.
- Have an Inpatient Psychiatric Level of Care.
- Have a diagnosis of a Serious Emotional Disturbance (also known as SED).
- Have documented functional limitations.
- Need at least one of the OhioRISE Waiver services.
- Have waiver needs that are less than or equal to the waiver service cost limit of $15,000.
For Ohio Medicaid managed care youth members who are not enrolled in the OhioRISE plan, Ohio Medicaid MCOs and the fee for service program will continue coverage for the Medicaid’s existing behavioral health services and MRSS. MCOs will manage also administrative care coordination, utilization management, and quality improvement efforts. The Ohio Medicaid MCOs also will be responsible for assuring access to the Child and Adolescent Needs and Strengths (CANS) assessment to determine when a child needs the enhanced services of the OhioRISE plan.
OhioRISE Governance
- Ohio Department of Mental Health and Addiction Services (MHAS)
- Ohio Department of Job and Family Services (ODJFS)
- Department of Youth Services (DYS)
- Ohio Department of Rehabilitation and Correction (DRC)
- Ohio Department of Health (ODH)
- Ohio Department of Developmental Disabilities (DODD)
- Ohio Department of Education (ODE)
- Office of Family & Children First
On April 1, 2021, ODM selected Aetna Better Health of Ohio to serve as the new OhioRISE prepaid inpatient health plan (PIHP) for the state’s children with the most complex behavioral health and multi-system needs. Click here to read the full press release. OhioRISE services through Aetna Better Health of Ohio began on July 1, 2022.
On October 28, 2020, ODM released a request for applications (RFA) to solicit responses from managed care organizations (MCOs) interested in serving an estimated 60,000 Ohio children as the program’s MCO. After the close of the December 16, 2020 response period, Ohio Medicaid evaluated responses from four bidders and conducted oral presentations with each.
This announcement is the culmination of years of work to create a stronger, family-focused system of care for children dealing with intense behavioral health needs.
As the OhioRISE plan, Aetna will partners the state, providers, and community organizations to expand access to in-home and community-based services. Aetna contracts with regional care management entities to ensure OhioRISE members and families have the resources they need to navigate their interactions with multiple systems such as juvenile justice and corrections, child protection, developmental disabilities, mental health and addiction, education, and others.
A link to the OhioRISE RFA can be found on the Ohio e-Procurement website.
As part of OhioRISE, ODM also created a new 1915(c) Home and Community Based Services (HCBS) Medicaid waiver to offer additional services for qualifying children and youth who have some of the greatest needs within the program. Learn more about the OhioRISE Waiver by watching the below video:
Our CME Values
Care Management Entities (CMEs) serve as “locus of accountability” for children and youth with complex challenges and their families. They offer two tiers of care coordination: intensive care coordination and moderate care coordination.
Roles of CMEs
CMEs are the OhioRISE plan’s collaborative partner. The “go-to” place to help families/caregivers, providers and other community partners navigate a complex and often confusing multi-system environment.
In addition to individual work with youth and caregivers, the CMEs will work with community partners (service providers, public child-serving agencies and other stakeholders) to develop the local system of care.
CMEs are culturally and linguistically competent, with agencies, programs and care coordination services that reflect the cultural, racial, ethnic, and linguistic differences of the populations they serve to facilitate access to and utilization of appropriate services and supports and to eliminate disparities in care.
Dedicated CME Supports
- Transition of Care Coordinator: Primary point of contact for planning, managing, and troubleshooting transition issues as members transition from MCOs into the OhioRISE Plan or back to the MCOs.
- System of Care Accelerator: Asists with coordination amongst systems to drive health and wellness and address the social determinants of health.
- Population Health Specialist: Responsible for identifying and implementing strategies to improve health outcomes through collaboration, data analysis, and stakeholder engagement.
FAQs
OhioRISE provides the following new and improved behavioral health services:
- Intensive and Moderate Care Coordination
- Improved Intensive Home-Based Treatment (IHBT)
- In-state Psychiatric Residential Treatment Facilities (PRTFs)
- Behavioral Health Respite
- Primary Flex Funds
- Mobile Response and Stabilization Services (MRSS)
A child or youth can be referred for the waiver through their local care management entity (CME). Youth and families interested in receiving a waiver referral for the OhioRISE Waiver can do so through a number of different “access points.” It is anticipated that behavioral health providers that a youth is connected with can help make the appropriate referral for a CANS assessment to determine waiver eligibility to a CME in the child’s or youth’s local area.
It is important to remember that a waiver referral is the first step in accessing the OhioRISE Waiver. In addition to meeting Medicaid and OhioRISE program eligibility, a child or youth must also meet the following requirements to be eligible for the waiver:
- Have an Inpatient Psychiatric Level of Care.
- Have a diagnosis of a Serious Emotional Disturbance (also known as SED).
- Have documented functional limitations.
- Need at least one of the OhioRISE Waiver services.
- Have waiver needs that are less than or equal to the waiver service cost limit of $15,000.
Children and youth who may benefit from OhioRISE:
- Have multiple needs that result from behavioral health challenges,
- Have multisystem needs or are at risk for deeper system involvement, and/or
- Are at risk of out-of-home placement or are returning to their families from out-of-home placement.
Young people with multisystem needs often require help and services from community systems which may include juvenile justice, child protection, developmental disabilities, schools, mental health and addiction, and others.
Children and youth who may be eligible for OhioRISE:
- Are eligible for Ohio Medicaid (either managed care or fee-for-service),
- Are age 0-20, and
- Require significant behavioral health treatment needs, measured using the Ohio Child and Adolescent Needs and Strengths (CANS) assessment.
Children and youth may also be eligible for OhioRISE due to certain urgent conditions. For example, if a child or youth is in a hospital for behavioral health reasons.
A CANS assessment is a tool used to determine eligibility for OhioRISE. It gathers the young person and family’s story to understand their needs and strengths, and to help determine the best ways to provide help. The CANS assessment is updated regularly to aid with ongoing care planning.
To ask for a CANS assessment, contact:
- A child or youth’s managed care organization,
- Aetna Better Health of Ohio,
- A local care management entity,
- The Medicaid Consumer Hotline, or
- Behavioral health providers or Family and Children First Councils, which may have a CANS assessor onsite or be able to link to one.
Click here for more information about how to obtain a referral for a CANS assessment.
Following a CANS assessment, children and youth found to be eligible are enrolled in OhioRISE effective the date their CANS assessment is submitted. In urgent cases, enrollment into OhioRISE will be:
- The date of admission for an inpatient hospital stay for mental illness or substance use disorder or
- The date of admission into a Psychiatric Residential Treatment Facility (PRTF).
Yes. If a child or youth is eligible for OhioRISE, enrollment into OhioRISE is mandatory. If a child or youth is not eligible, a notice of denial and hearing rights will be mailed to them. If a child or youth or their parent/guardian does not want them to be enrolled in OhioRISE, they can ask to be disenrolled. ODM will review the request and decide if disenrollment is appropriate. A child or youth who is disenrolled from OhioRISE will not be able to get the new and improved services because these services are only available through OhioRISE.