Documents and forms
Find the documents and forms you need to get the most from your health plan.
Humana Healthy Horizons in Ohio
Change of 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
Change PCP form
Your doctor can use the Change PCP form to let us know that they will be your primary care physician (PCP).
Detecting, correcting and preventing healthcare fraud
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
Expanded benefits reimbursement
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
Childcare Assistance Reimbursement form – English
Childcare Assistance Reimbursement form – Spanish
Youth Development and Recreation Reimbursement form – English
Youth Development and Recreation Reimbursement form – Spanish
Grievances and appeals forms
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.
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.
Legal and privacy notices
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
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
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.
Performance measurement
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)
Pharmacy resources
View the Gainwell member handbook
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.
Power of Attorney (POA) / Living will
Provider directories
You can search for a provider near you using our Find care tool
You can also find the ODM online provider directory here
For printable PDFs, please visit our provider directories webpage .
Quick Start Guide
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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Humana Healthy Horizons in Ohio
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Find Care
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Value-added benefits
Learn about the extra benefits and services available to Humana Healthy Horizons in Ohio members.
Documents & forms
Find the documents and forms you need, including your Member Handbook.