Documents and forms for Humana Healthy Horizons in Ohio members

Welcome Kit

All new members get a Quick Start Guide in the mail. You also can view it below. Your Quick Start Guide includes the information you need at the start of your enrollment in Humana Healthy Horizons^® in Ohio.

Quick Start Guide – English

Quick Start Guide – Spanish

Welcome letter from Gainwell

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Health Risk Assessment (HRA)

The HRA is a set of health questions for you to answer. Your answers will help us make sure you get the care you need. Your Quick Start Guide includes an HRA and a postage-paid envelope in which to return it. You also can download an HRA below.

Health Risk Assessment – English

Health Risk Assessment – Spanish

Earn $30 in rewards through Go365 for Humana Healthy Horizons^® if you complete your HRA during the first 90 days of enrollment in Humana Healthy Horizons in Ohio. This reward is available to all members.

Learn more about Go365 for Humana Healthy Horizons

Member Handbook

Have questions about your plan, benefits, and covered services? Check out your Member Handbook. Your handbook also has information about our medical necessity criteria. To request we send you a handbook or a copy of this criteria, call 877-856-5702 (TTY: 711), Monday – Friday, from 7 a.m. – 8 p.m., Eastern time.

Member Handbook – English

Member Handbook – Spanish

Healthcare power of attorney and living will (advance directive)

If you need to change your address

To make sure you don’t lose your Medicaid coverage, be sure to keep your information current with the Ohio Department of Medicaid (ODM). If you need to change your address:

• Call the Ohio Medicaid Consumer Hotline at 800-324-8680, Monday – Friday, 7 a.m. – 8 p.m., and Saturday, 8 a.m. – 5 p.m.
• Contact a case worker through your local department of job and family services
• Use your Ohio Benefits Self-Service account, if you have one, to report the change through the online portal

Learn more about updating your information when needed

Provider directories

Refer to the provider directory in the region where you live to find information about in-network providers, specialists, healthcare facilities, and more. You also can use our Find a Doctor service.

Ohio Counties

Adams, Brown, Clinton, and Highland

• All Provider Types

Allen and Crawford

• All Provider Types

Auglaize, Fulton, Henry, Mercer, Ottowa, Paulding, Sandusky, Van Wert,  and Williams

• All Provider Types – Part 1 of 2
• All Provider Types – Part 2 of 2

Butler and Warren

• Hospitals, Urgent Care Centers, Primary Care Providers, Other Health Care Providers, Durable Medical Equipment, Lab Services, Dental Services, Vision Providers
• Behavioral Health – Part 1 of 2
• Behavioral Health – Part 2 of 2
• Specialists

Champaign, Darke, Logan, Miami, Preble, and Shelby

• All Provider Types

Clark

• All Provider Types

Clermont

• All Provider Types

Defiance, Seneca, and Wood

• All Provider Types

Greene

• All Provider Types

Hamilton

• Hospitals, Urgent Care Centers, Primary Care Providers,Durable Medical Equipment, Lab Services, Dental Services, Vision Providers
• Behavioral Health - Part 1 of 4
• Behavioral Health - Part 2 of 4
• Behavioral Health – Part 3 of 4
• Behavioral Health – Part 4 of 4
• Other Health Care Providers
• Specialists - Part 1 of 2
• Specialists - Part 2 of 2

Hancock, Hardin, Marion, Putnam, and Wyandot

• All Provider Types

Lucas

• Hospitals, Urgent Care Centers, Primary Care Providers, Other Health Care Providers, Durable Medical Equipment, Lab Services, Dental Services, Vision Providers
• Behavioral Health - Part 1 of 3
• Behavioral Health - Part 2 of 3
• Behavioral Health - Part 3 of 3
• Specialists

Montgomery

• Hospitals, Urgent Care Centers, Primary Care Providers, Other Health Care Providers, Durable Medical Equipment, Lab Services, Dental Services, Vision Providers
• Behavioral Health - Part 1 of 3
• Behavioral Health - Part 2 of 3
• Behavioral Health - Part 3 of 3
• Specialists - Part 1 of 2
• Specialists - Part 2 of 2

Indiana, Kentucky, and Michigan border counties

IN counties: Delaware, Fayette, Henry, Randolph, Union, and Wayne

• All Provider Types

IN counties: Adams, Allen, Blackford, De Kalb, Jay, Lagrange, Noble, Steuben, Wells and Whitley. MI counties: Hillsdale, Jackson, Lenawee, Monroe, Washtenaw, and Wayne

• All Provider Types

IN counties: Dearborn, Franklin, and Ohio. KY counties: Boone, Bracken, Campbell, Kenton, Lewis, Mason, and Pendleton

• All Provider Types

Ohio Counties

Ashland, Coshocton, Erie, Holmes, Huron, Knox, Richland, and Wayne

• Hospitals, Urgent Care Centers, Primary Care Providers, Durable Medical Equipment, Lab Services, Dental Services, Vision Providers
• Behavioral Health – Part 1 of 2
• Behavioral Health – Part 2 of 2
• Specialists and Other Health Care Providers

Ashtabula, Columbiana, Harrison, and Jefferson

• All Provider Types

Carrol

• Behavioral Health
• All Provider Types except Behavioral Health

Cuyahoga

• Hospitals, Urgent Care Centers, Primary Care Providers, Durable Medical Equipment, Lab Services, Dental Services, Vision Providers
• Behavioral Health – Part 1 of 7
• Behavioral Health – Part 2 of 7
• Behavioral Health – Part 3 of 7
• Behavioral Health – Part 4 of 7
• Behavioral Health – Part 5 of 7
• Behavioral Health – Part 6 of 7
• Behavioral Health – Part 7 of 7
• Other Health Care Providers – Part 1 of 2
• Other Health Care Providers – Part 2 of 2
• Specialists – Part 1 of 3
• Specialists – Part 2 of 3
• Specialists – Part 3 of 3

Geauga and Lorain

• All Provider Types except Behavioral Health
• Behavioral Health

Lake

• All Provider Types

Mahoning

• All Provider Types except Behavioral Health
• Behavioral Health

Medina and Portage

• All Provider Types – Part 1 of 2
• All Provider Types – Part 2 of 2

Stark and Tuscarawas

• All Provider Types except Behavioral Health
• Behavioral Health

Summit

• Hospitals, Urgent Care Centers, Primary Care Providers, Other Health Care Providers, Durable Medical Equipment, Dental Services, Vision Providers
• Behavioral Health - Part 1 of 2
• Behavioral Health - Part 2 of 2
• Specialists

Trumbull

• All Provider Types except Behavioral Health
• Behavioral Health

Pennsylvania and W. Virginia border counties

PA county: Allegheny. WV counties: Brooke and Hancock

• All Provider Types

PA counties: Beaver, Butler, Crawford, Erie, Lawrence, Mercer, Venango, and Washington

• All Provider Types

Ohio Counties

Athens, Belmont, Guernsey, Meigs, Monroe, Morgan, Muskingum, Noble, and Washington

• All Provider Types except Behavioral Health
• Behavioral Health – Part 1 of 2
• Behavioral Health – Part 2 of 2

Delaware, Fairfield, and Union

• All Provider Types – Part 1 of 2
• All Provider Types – Part 2 of 2

Fayette, Hocking, Licking, Madison, Morrow, Perry, and Pickaway

• All Provider Types – Part 1 of 2
• All Provider Types – Part 2 of 2

Franklin

• Hospitals, Urgent Care Centers, Primary Care Providers, Durable Medical Equipment, Lab Services, Dental Services, Vision Providers
• Behavioral Health – Part 1 of 5
• Behavioral Health – Part 2 of 5
• Behavioral Health – Part 3 of 5
• Behavioral Health – Part 4 of 5
• Behavioral Health – Part 5 of 5
• Other Health Care Providers
• Specialists – Part 1 of 4
• Specialists – Part 2 of 4
• Specialists – Part 3 of 4
• Specialists – Part 4 of 4

Gallia, Pike, Scioto, and Vinton

• All Provider Types – Part 1 of 2
• All Provider Types – Part 2 of 2

Jackson, Lawrence, and Ross

• All Provider Types – Part 1 of 2
• All Provider Types – Part 2 of 2

Kentucky and W. Virginia border counties

KY counties: Boyd, Carter, Greenup, Lewis. WV counties: Cabell, Jackson, Lincoln, Marshall, Mason, Ohio, Pleasants, Putnam, Ritchie, Tyler, Wayne, Wetzel, Wirt, Wood

• All Provider Types

ODM online provider directory

View the Gainwell member handbook

Get answers to frequently asked questions about Gainwell and your pharmacy coverage

Preferred Drug List

The Ohio Department of Medicaid (ODM) Unified Preferred Drug List (PDL) is a list of drugs and medicines covered for Ohio residents who receive Medicaid benefits. Gainwell Technologies administers pharmacy benefits for all Ohio Medicaid recipients. Your provider can prescribe you drugs and medicines on this list if needed. If your provider wants to prescribe you medicine that requires prior authorization, he or she will send Gainwell Technologies a prior authorization request.

Review the ODM Unified PDL

We want you to be happy with the care you get. We hope you get the best care possible.

If you are not happy with any part of your healthcare plan, Member Services, your provider, or a facility, you can send in a grievance.

You also can appeal a claim or a denied service using the grievances and appeals forms.

If you are sending an appeal or grievance for another covered member, be sure to fill out an Appointment of Representative Form.

ODM Appeals

Learn more about grievances and appeals

Your doctor can use the Change PCP form to let us know that they will be your primary care physician (PCP).

Change PCP form

The legal and privacy notices below provide information about:

• How Humana uses, and when we might share, your personal information
• Your privacy rights

Individual privacy rights – English

Individual privacy rights – Spanish

Rights and responsibilities – English

Rights and responsibilities – Spanish

Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Notice – English

Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Notice – Spanish

To give us permission to share your medical information with someone, you must complete and send back to us a Consent for Release of Medical Information and a Consent for Release of Protected Health Information.

Consent for Release of Medical Information – English

Consent for Release of Medical Information – Spanish

Consent for Release of Protected Health Information – English

Consent for Release of Protected Health Information – Spanish

Notice of Non-Discrimination

Humana Inc. and its subsidiaries comply with applicable Federal civil rights laws and do not discriminate or exclude people because of their race, color, religion, gender, gender identity, sex, sexual orientation, age, disability, national origin, military status, veteran status, genetic information, ancestry, ethnicity, marital status, language, health status, or need for health services.

Notice of Non-Discrimination – English   

Notice of Non-Discrimination – Spanish  

Notice of Availability of Language Assistance Services and Auxiliary Aids and Services

Humana Inc. and its subsidiaries comply with Section 1557 by providing free auxiliary aids and services to people with disabilities when auxiliary aids and services are necessary to ensure an equal opportunity to participate.

Multi-Language Interpreter Services and formats – English  

Multi-Language Interpreter Services and formats – Spanish  

As part of our efforts to improve the healthcare system, we are committed to:

• Detecting, correcting, and preventing healthcare fraud
• Educating our members about how to detect and/or prevent fraud

Learn more about detecting, preventing, and reporting healthcare fraud and how you can help

Refer to the below information to see how we’re measured as a health plan and also how we’re doing.

Guide to Healthcare Effectiveness Data and Information Set (HEDIS^®) measurements

State of Health Care Quality Report (NCQA)

Expanded Benefits Reimbursement Form

We hope you don’t have to pay out of pocket for the benefits you get as a Humana Healthy Horizons in Ohio member. If you do, let us know by filling out an Expanded Benefits Reimbursement claim form, and you may get a refund.

Fill out the form below to send a reimbursement claim.

Expanded Benefits Reimbursement Form – English

Expanded Benefits Reimbursement Form – Spanish