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MedicaidManagedCareOverview
2011Medicaid
ReformLaw
In2011,theGeneralAssemblypassedPA96-1501toaddressincreasingbudgetpressuresintheMedicaidprogram,requiringIllinoistoenroll50%ofitsMedicaidpopulationin“carecoordination”byJanuary1,2015.
MedicaidMCO
Characteristics
• MandatoryEnrollment• Auto-Assignments
• ITStructure&Interface• EncountersSubmission
• CapitatedRatesbasedonFFS• 85%MLR
• DefinedBenefitPackage• DefinedPopulation
• DefinedQualityMeasures&P4Ps
• NetworkCapacityStandards
• DefinedStaffingRatios
• MandatedStaff&ProviderTrainings
• RequiredMemberMaterials• StringentMarketing&OutreachRegulations
• DefinedAppeals&GrievancesProcedures
• MandatedReporting
• DefinedBEPSpend
• RobustFraud,Waste&AbuseStandards
• State&FederalPolicyChanges
MedicaidPrograms&Populations
Medicare-MedicaidAlignmentInitiative(MMAI)• EligibleforMedicare&Medicaid• 100%FederalPovertyLevel(FPL)• 19-64yearsofageonSocialSecurity
DisabilityIncome(SSDI)• 65+receivingSocialSecurity
RetirementIncome
MedicaidLongTermSupports&Services(MLTSS)• EligibleforMedicare&Medicaid• OptOutofMMAI(MedicaidCoverage
Only)• 100%FederalPovertyLevel(FPL)• 19-64yearsofageonSocialSecurity
DisabilityIncome(SSDI)• 65+receivingSocialSecurity
RetirementIncome
IntegratedCareProgram(ICP)• EligibleforMedicaid• 100%FederalPovertyLevel(FPL)• 19-64yearsofage(65+thatdon’t
qualifyforMedicare)• DisabledreceivingSupplemental
SecurityIncome(SSI)
FamilyHealthProgram(FHP)• EligibleforMedicaid• AllKids,0-18yearsofage,300%FPL• FamilyCare,Parents/Guardianswith
LivingwithChildren0-18yearsofage,138%FPL
AffordableCareActAdults(ACA)• EligibleforMedicaidundertheACA• AdultswithoutChildren0-18yearsof
age• 138%FederalPovertyLevel(FPL)• 19-64yearsofage
IllinoisAssociationofMedicaidHealthPlans
IAMHPMedicaidHealthPlans Enrollment1. MeridianHealth 389,0002. BlueCrossBlueShieldofIllinois 382,0003. IlliniCare Health(Centene) 217,0004. MolinaHealthcare 163,0005. CountyCare 140,0006. HarmonyWellCare 138,0007. NextLevel 56,0008. Humana(MMAIOnly1/1/08) 12,0009. AetnaBetterHealth(MMAIOnly1/1/18) 238,00010. FHN/CCAI(Term.12/31/17) 217,00011. Cigna-HealthSpring (Term.12/31/17) 4,00012. HealthAlliance(Term.12/31/16) 0
September2017
HealthandHumanServices
Transformation
TheRaunerAdministrationiscommittedtoanambitiousHealthandHumanServices(HHS)Transformationinitiativethatisgroundedinfivethemes:
• Preventionandpopulationhealth;• Payingforvalue,quality,andoutcomes;• Rebalancingfrominstitutionaltocommunitycare;• DataIntegrationandPredictiveAnalytics;and• EducationandSelf-Sufficiency.
TheissuanceofaPurchaseofCareRequestforProposalsaimedattransformingtheMedicaidmanagedcaresystemiskeyelementoftheHealthandHumanServicesTransformationinitiative.
February27,2017–
MedicaidManagedCareRFPisIssued
TheRFPindicatedsignificantforthcomingchangestotheMedicaidmanagedcaresystem,including:• Expandingmanagedcaretotheentirestate• Reducingthenumberofhealthplans• 3-5statewideplans• 1-2planscoveringjustCookCounty• IssuingonecontracttoastatewideplantocareforchildrenwhoareorhavepreviouslybeenunderthecareoftheDepartmentofChildrenandFamilyServices
IllinoisAssociationofMedicaidHealthPlansNineMCOMembers(2018):
• CountyCare– HealthChoiceIllinois,CookCountyOnly
• NextLevelHealth– HealthChoiceIllinois,CookCountyOnly
• HarmonyWellCare– HealthChoiceIllinois
• BCBSIL– HealthChoiceIllinois,MMAI
• MolinaHealthcare– HealthChoiceIllinois,MMAI
• MeridianHealth– HealthChoiceIllinois,MMAI
• IlliniCare– HealthChoiceIllinois,DCFS,MMAI
• AetnaBetterHealth–MMAI
• Humana–MMAI
Illinois Department of Healthcare and Family ServicesMedicaid Managed Care Program Map
January 1, 2018
Blue Cross Community Health Plan
Harmony Health Plan, Inc.
IlliniCare Health
Meridian Health Plan
Molina Healthcare
Statewide HealthChoice Illinois Plans
CountyCare Health Plan
NextLevel Health Partners
Cook County HealthChoice Illinois Plans
All Statewide HealthChoice Illinois Plans serve Cook County.
Two Cook County HealthChoice Illinois
Plans serve only Cook County. ( )
Medicare Medicaid Alignment Initiative (MMAI)
Aetna Better Health Premier PlanCook, DuPage, Kane, Kankakee, Will
Blue Cross CommunityCook, DuPage, Kane, Kankakee, Lake, Will
Humana Health Plan, IncCook, DuPage, Kane, Kankakee, Lake, Will
IlliniCare HealthCook, DuPage, Kane, Kankakee, Lake, Will
Meridian CompleteCook, DuPage, Kane, Will
Molina Healthcare of IllinoisVoluntary Enrollment only: Champaign, DeWitt, Ford,
Knox, McLean, Peoria, Stark, Tazewell, Vermilion
HealthChoice Illinois
• EnrollmentProcess:PhaseITransitionAssignmentinCurrentMCORegions
• LettersmailedOctober&November2017witheffectivedateofJanuary1,2018
• ClientsassignedtocurrentMCOwith90-dayoptiontochangetoanotherMCO
• Lockedinfor12months
HealthChoice Illinois
• EnrollmentProcess:PhaseIIFullEnrollmentPacketinExpansionRegions
• EnrollmentPacketsmailedbeginningJanuary2018witheffectivedatebeginningApril1,2018
• Clientsgiven30-dayoptiontovoluntarilyenrollwithoneoffivestatewideMCOsbycallingClientEnrollmentBroker(Maximus)
• Ifnochoiceismade,clientwillbeautoassignedtoanMCObasedonanalgorithm
• 90-dayoptionperiodtochangetoanotherMCO
• Lockedinfor12months
HealthChoice Illinois
• EnrollmentProcess:PhaseIIIEnrollmentofSpecialNeedsChildren
• EnrollmentPacketsmailedbeginningMay2018witheffectivedatebeginningJuly1,2018(TENTATIVE)
HealthChoice Illinois Transition and Expansion Mail Schedule October 16, 2017
Description Mail Start Week Mail End Week Effective Enrollment Date*
Auto-Assignment Date* Counties included in mailing
Transition of members currently enrolled with a managed care health plan that was awarded a new contract for January 1, 2018. Members will stay enrolled with their current health plan. Each member will be mailed a HealthChoice Illinois transition notice.
October 30, 2017 November 30, 2017 January 1, 2018 N/A Current Mandatory and Voluntary (VMC) Counties. Only MCO members will be included in the daily transition notice mailings.
Transition of members currently enrolled with a managed care health plan that was not awarded a new contract for January 1, 2018. Members will be transitioned to a new health plan. Each member will be mailed a HealthChoice Illinois transition notice.
November 6, 2017
November 30, 2017
January 1, 2018
N/A
Current Mandatory and Voluntary (VMC) Counties. Only MCO members will be included in the daily transition notice mailings.
Enrollment of newly eligible potential enrollees, previous Illinois Health Connect members, and no-longer excluded populations (does not include Special Needs Children or DCFS Youth in Care). Each individual will be mailed a HealthChoice Illinois enrollment packet. Each individual will have a 30-day enrollment choice period to select a health plan and Primary Care Provider.
January 8, 2018 February 16, 2018 Earliest effective Choice enrollment date is April 1, 2018
Earliest Auto-Assignment date is April 1, 2018
All counties statewide will be included in the daily enrollment packet mailings.
Enrollment of Special Needs Children. Each individual will be mailed a HealthChoice Illinois enrollment packet. Each individual will have a 30-day enrollment choice period to select a health plan and Primary Care Provider.
May 7, 2018 May 16, 2018 TENTATIVE Earliest effective Choice enrollment date is July 1, 2018
TENTATIVE Earliest Auto-Assignment date is July 1, 2018
All counties statewide will be included in the daily enrollment packet mailings.
Enrollment of DCFS Youth in Care into a HealthChoice Illinois plan.
TENTATIVE Earliest effective enrollment date is July 1, 2018
All counties statewide will be included in the assignment process.
*All individuals will have a 90-day switch period to select a different plan. Sample transition and enrollment packet materials are available on the Illinois Client Enrollment Broker Program web site at www.enrollhfs.illinois.gov/
HFSSeries:Succeedingin
theNewManagedCare
• #1.Whatismyrelationshipwithplansthatweren’tawardedacontractforthenewprogram?• #2.Fivekeywaysthenewmanagedcarewillmeanlessworkforproviders• #3.Simplifiedcredentialing:Cuttingbackonprovideroverheadcosts• #4.HowHFSandthehealthplanswillcommunicatetransitiondetailstoclients• #5.Howyoucanhelpyourpatientsunderstandwhattheyneedtoknowaboutthistransition
SimplifiedCredentialing
FromHFS:• Underthenewprogram,registeringwiththeDepartment’sonlineproviderenrollmentprogramwillbecome
theonlyrequirementtobegindevelopingrelationshipswitheveryMedicaidmanagedcarehealthplan…Medicaidproviderswillneedtoonlyregisterwith HFSIMPACTwebsite…
• OnceanapplicationisapprovedbyHFS,theproviderisconsideredcredentialedwiththeHealthPlan.• Pleasebeawareoftwoimportantfeaturesofthisupgrade.First,thechangeappliesonlytoMedicaid,not
Medicareorotherproducts. Second,althoughproviderswillbecredentialedthroughIMPACT,theyshouldcontinuetoprovidespecificinformationrequestedbyMCOsthatisnotincludedinthecredentialingprocessbutisneededforMCOOperations,suchasproviderofficehours.
• Credentialingonit’sowndoesnotmeanaproviderandahealthplanwillbedoingbusinesstogether.Providerandplansmuststillenterintocontractualrelationshipsandsatisfyallnecessaryoperationalrequirements.
IllinoisDepartmentofHealthcareandFamilyServices– CareCoordinationHomepage• TransitionLettersandClientCommunications• ProgramDescriptions• EnrollmentInformation• CareCoordinationQualityMetrics• HealthChoiceIllinois2018ModelContract
IAMHPKeyContacts
IAMHPBillingGuides
IAMHPWebsite– InfoforProviders
• InadditiontotheKeyContactsandBillingGuides,theInfoforProviderssectionalsoincludeslinkstoProviderManualsandPriorAuthorizationlinks• 1/1/18thesesectionswillbeupdatedasneededtoreflectanyURLchanges,documentupdates,etc.• IAMHPalwayswelcomessuggestions,sopleasedon’thesitatetosharewhatadditionalinformationwecancollectfromthehealthplansandposttooursite.
