As a part Ohio Medicaid's effort to launch the Next Generation of Medicaid, the Ohio Department of Medicaid (ODM) is implementing OhioRISE (Resilience through Integrated Systems and Excellence), a specialized managed care program for youth with complex behavioral health and multisystem needs
OhioRISE ODM resources
About OhioRISE and AmeriHealth Caritas Ohio's role
OhioRISE is a specialized Medicaid managed care program for children and youth with complex behavioral health needs (mental health/substance use disorder) and multisystem needs. Aetna Better Health of Ohio (Aetna) is the managed care partner for the program. Members enrolled in the OhioRISE program will also keep their managed care enrollment for the physical health benefit.
Children and youth with multisystem needs are often involved in multiple community systems such as education, developmental disabilities, child protection, juvenile justice, mental health and addiction, and others.
The OhioRISE Program uses a "system of care" approach and the guiding principles of a wraparound philosophy. These techniques focus on "wrapping around" a child or youth through care coordination to provide services and supports through a coordinated network in their community. This helps ensure the child or youth functions better at home, in school, in the community, and throughout life.
OhioRISE care coordination uses a Child and Family Team (CFT). Children or youth and their caregivers select members of their CFT. The CFT meets regularly to assist with care planning that focuses on the child or youth's and family's strengths, beliefs, culture, community/natural supports, and their voice and choice. OhioRISE care coordination is provided at three levels of intensity:
- Limited Care Coordination (Tier 1) — delivered by Aetna and is the least intensive level.
- Moderate Care Coordination (Tier 2) — delivered by Care Management Entities (CMEs) and uses wraparound-informed strategies.
- Intensive Care Coordination (Tier 3) — delivered by CMEs and adheres to the High-Fidelity Wraparound model.
Who may benefit from OhioRISE?
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.
Who qualifies for OhioRISE?
Children or youth who may be eligible for OhioRISE:
- Are eligible for Ohio Medicaid (either managed care or fee-for-service),
- Are age 0-20,
- Are not enrolled in a MyCare Ohio plan, 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 or is admitted into a Psychiatric Residential Treatment Facility (PRTF).
What does OhioRISE cover?
OhioRISE covers all medically necessary Medicaid-covered behavioral healthcare services for eligible children and youth, with a few exceptions. Children and youth enrolled in the program continue to receive their physical health benefits and behavioral health emergency department services through their managed care organization (MCO) or fee-for-service (FFS) Medicaid while their behavioral health services are covered by Aetna, the OhioRISE Plan. OhioRISE also covers medications a doctor gives to a member in the office to treat mental health and substance use disorders.
In addition to all the mental health and substance use disorder services currently covered by Ohio Medicaid, new and improved services under the OhioRISE plan include:
- Intensive and Moderate Care Coordination (ICC/MCC).
- Intensive Home-Based Treatment (IHBT).
- Psychiatric Residential Treatment Facility (PRTF) — Available January 2023.
- Mobile Response and Stabilization Service (MRSS) — Also covered by MCOs and FFS Medicaid.
- Behavioral Health Respite.
- Primary Flex Funds.
Visit the ODM OhioRISE web page to learn more about these services.
How does a child or youth enroll in OhioRISE?
Most children and youth will be enrolled in OhioRISE if they are found eligible through the completion of a Child and Adolescent Needs and Strengths (CANS) assessment. If a CANS assessment indicates a child or youth is eligible for OhioRISE, their enrollment in OhioRISE is mandatory.
The child or youth will be enrolled in OhioRISE effective the date the assessment is submitted into the state's CANS IT system. Children and youth enrolled in OhioRISE will receive new member materials from Aetna, and a new Medicaid ID card showing OhioRISE eligibility, and will be contacted by a care coordinator from Aetna or their local CME.
If the CANS assessment indicates the child or youth is not eligible for the program, a notice of denial and hearing rights will be issued to their mailing address.
If a child's parent/guardian or a youth does not want the child or youth to be enrolled in OhioRISE, a disenrollment for Just Cause can be requested. The Just Cause disenrollment request will be reviewed and determined by the Ohio Department of Medicaid. A child or youth who is disenrolled from OhioRISE will not have access to most of the new and enhanced services listed above because those services, except for MRSS, are available only through the OhioRISE plan.
How can a CANS assessment be scheduled?
Providers, managed care partners, community organizations, and youth, families, and caregivers can request to have a CANS assessment scheduled with a certified CANS assessor. Once the referral is completed, a CANS assessor in the child's or youth's community will reach out to schedule a CANS assessment. The CANS assessor will ensure the assessment is scheduled at a time and place that is convenient for the youth and their family/caregiver. The following organizations can be contacted for more information on scheduling a CANS assessment:
- Medicaid Consumer Hotline at 1-800-324-8680 (TTY: 711), Monday through Friday 7 a.m. to 8 p.m. and Saturday 8 a.m. to 5 p.m.
- Aetna Better Health of Ohio at 1-833-711-0773 (TTY: 711), Monday through Friday from 7 a.m.to 8 p.m.
- A child's or youth's managed care organization, if they are enrolled in managed care.
- A CME in the child's or youth's community.
- A behavioral health provider or Family and Children First Council that has a CANS assessor on site.