Illinois Medicaid is Changing - What Case Managers & HIV Providers Need to Know

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Jennifer Simpson
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1 Illinois Medicaid is Changing - What Case Managers & HIV Providers Need to Know March 29, 2013 Ann Fisher, AIDS Legal Council of Chicago John Peller, AIDS Foundation of Chicago Download the slides & materials at

2 Webinar Instructions All attendees are in listen-only mode. Everyone can ask questions at any time using the chat feature, or questions to During Q & A segment the moderators will unmute everyone and take questions. If you have hold music on your phone, don t put us on hold! Download the slides:

3 Raise your Hand or Use the Question Feature to Ask Questions Download the slides:

4 Medicaid overview Medicaid covers about 13,000 people with HIV in Illinois May increase to 25,000 in a few years after ACA is implemented $17.2 billion program ($6.6 billion state, rest federal) Current Medical Programs Enrollment (11/30/12): 2.75 million (nearly 1 in 4 Illinoisans) Children: 1.67 million Seniors: 179,000 Adults with Disabilities: 263,000 Other Adults: 636,000

5 Medicaid is changing Care coordination Four prescription policy Redetermination project Monthly Medicaid card CountyCare Handouts & links:

6 New Medicaid State Law requires 50% of beneficiaries be enrolled in some form of Care Coordination by Payment for services will based on meeting defined quality measures rather than Fee for Service. Beneficiaries will be aggressively enrolled into risked based, care coordination programs: Integrated care management Care Coordination Entities and Managed Care Community Networks (MCCN) Medicare-Medicaid Alignment Initiative (MMAI) 3/29/2013 Prepared by Largent Government Solutions, LLC for the AIDS Foundation of Chicago 6

7 Old Medicaid vs. New Medicaid Major Characteristics of the Old Medicaid: Fragmented healthcare delivery system Services lack continuity of care for clients, with few linkages among providers or care transitions provided Most expensive Senior & Persons with Disabilities clients with complex health/behavioral health needs have to navigate healthcare system alone Medicaid is fee-for-service: pays for quantity, not quality of care or efficiency; does not reward collaboration; does not provide incentives for serving Senior and People with Disabilities clients in least restrictive environment Payment methodologies for hospitals, nursing homes and provider system in general are outdated -- don t reflect today s goals for quality of care and health outcomes 3/29/2013 Prepared by Largent Government Solutions, LLC for the AIDS Foundation of Chicago 7

8 What is care coordination? Care coordination is a multifaceted process wherein a team takes responsibility for the care of an individual, coordinating medical and social support services across different providers and organizations Care coordination involves communicating, networking, educating, and advocating for resources and facilitating access to those resources, resulting in improved health and quality of life Source: Nadeen Israel, Heartland Alliance

9 Type 1: Integrated Care Management HMOs: IlliniCare & Aetna Better Health Geographic Area: Cook County suburbs and collar counties Who is enrolled: Seniors and people with disabilities on Medicaid only (no dual eligibles) 40,000 people

10 Integrated Care Management Expansion April: Rockford area Aetna, Illinicare and CCAI) July: Central Illinois, Quad Cities and Metro East Chicago in January 2014

11 Type 2: Care Coordination Entities (CCE) Managed Care Community Networks (MCCN) Provider driven project to develop alternative models of care for seniors and adults with disabilities. Small plans 500 to start, max 5,000 in a few years Care Coordination Entity A CCE is a collaboration of providers and community agencies, governed by a lead entity, which receives a care coordination payment with a portion of the payment at risk for meeting quality outcome targets, in order to provide care coordination services for its Enrollees. Chicago area: Be Well Partners in Health, Healthcare Consortium of Illinois, Together4Health Downstate: Macon County Care Coordination, Precedence Care Coordination 3/29/2013 Prepared by Largent Government Solutions, LLC for the AIDS Foundation of Chicago 11

12 Type 2: Managed Care Community Networks (MCCN) A MCCN is an entity, other than a Health Maintenance Organization, that is owned, operated, or governed by providers of health care services within Illinois and that provides or arranges primary, secondary and tertiary managed health care services under contract with the Department [Illinois Department of Healthcare and Family Services] exclusively to persons participating in programs administered by the Department. Example: Community Care Alliance of Illinois

13 Type 3: Medicaid Medicare Alignment Initiative HMOs for dual eligibles enrolled in BOTH Medicare and Medicaid Integrate Medicare and Medicaid benefits and services to create a unified delivery system that is easier for beneficiaries to navigate. Integrated financing streams will help to improve care delivery and coordination by eliminating conflicting incentives between Medicare and Medicaid that encourage cost shifting, reduce beneficiary access to high-quality care and community-based services, and result in a lack of care management for chronic conditions. Similar to Medicare Advantage plans 3/29/2013 Prepared by Largent Government Solutions, LLC for the AIDS Foundation of Chicago 13

14 Type 3. Medicare Medicaid Alignment Roll out October 2013 Initiative (continued) Chicago area: Aetna Better Health, Illinicare, Meridian, HealthSpring, Humana, Blue Cross/Blue Shield Central IL: Molina, Health Alliance Program will be OPTIONAL for Medicare beneficiaries but if they opt out, they will be enrolled in managed care for Medicaid portion Clients will be able to select a plan, but will be autoenrolled if they do not choose one (or actively opt out) 3/29/2013 Prepared by Largent Government Solutions, LLC for the AIDS Foundation of Chicago 14

16 Care Coordination tips Watch for notices to clients explaining options CHOOSE A PLAN that includes your providers and covers your meds don t let HFS choose for you! Learn how to use the plan do you need a referral for an HIV doctor? Know your rights! Tell us about problems Download chart and MMW Care Coordination cheat sheet from

17 Questions?

18 What else is happening to Medicaid?

19 Continued implementation of the SMART Act = 62 spending reductions, utilization controls and provider rate cuts to save 1.6 billion dollars, including: 50% in managed care already discussed Four prescription limit Redetermination project CountyCare

20 Four prescription limit Now being rebranded as Four drug review policy Some honesty from the Department: The purpose of the four prescription policy is to have providers review their patients entire medication regimen and where possible and clinically appropriate, reduce duplication, unnecessary medications, polypharmacy, etc. The four prescription policy was developed as a result of budget negotiations, but best-practices call for an annual review of the full regimen of prescriptions for any patient. We must insist on this: The four prescription policy is not a hard limit. Medicaid patients can and should have access to medications that are medically necessary, even if they exceed four prescriptions per 30 days. The policy simply requires prior approval for prescriptions above the limit, for the purpose set forth above. Just now (March 12 th ) being fully implemented Does NOT include HIV drugs

21 Four prescription limit problems Providers sending people to Walmart instead of working through the pre-approval process Cumbersome pre-approval process HFS is working to simplify the process helps a lot if providers use the MEDI system Department has taken a lot of heat for this and is responding. But only because advocates have vigorously reported problems. So keep it up.

22 Redetermination Project Goal is to find people who are not eligible for Medicaid and get them off the rolls, mostly by doing computer matching Alleged to be up to $350 million in savings Always unlikely most fraud is by providers, not by recipients HFS getting a lot of heat for not moving more quickly on this SMART Act required state to hire a private company to do this. Hired Maximus in September, who have hired 500(!) workers Redeterminations began in January 2013

23 How the redetermination project works 1. On-line comparison between what data the recipient has submitted and what s in databases living in another state? Different income? Died? (probably not spending a lot of money on their health care in that situation) 2. If all okay, then Maximus will recommend continued eligibility without any contact with recipient. 3. If a conflict, or missing info, then a 10 day letter goes out to recipient.

24 Redetermination project, cont d 4. If within 10 days, send info back to Maximus 5. If 10 days missed, or info doesn t satisfy, then the whole case goes back to the local office with a recommendation to change (e.g. take an ineligible child off the case, or put on spenddown) or deny benefits 6. HFS making a big deal that it s up to the local office to make the final decision. MOST IMPORTANT: Watch for letters! Huge issue for our clients.

25 A minor related note new medical cards DHS is no longer sending out medical cards every month

26 New medical cards, cont d If a recipient is in managed care, they will have this card plus a card from the managed care plan plus their i.d. For a long time now the card has been a formality: providers really check eligibility at every visit. Having a card won t prove you are eligible (e.g. spenddown met), but it will make people nervous not to have it. Can get a replacement by calling DHS or HFS

27 CountyCare CountyCare (1115 waiver) Enrolling now Eligibility up to 138% FPL ($15,282) No categorical eligibility requirements, but must live in Cook County and meet citizenship requirements (same as Medicaid and SSI) and be age Restricted network includes county providers and participating federally qualified health centers, including Howard Brown. This is health insurance can save someone from bankruptcy Application info at

28 CountyCare, cont d Lots of things they re just now starting to try to figure out Care coordinators? Persuading people not to use the E.R? Are they getting enough money from the feds to actually do it?

29 CountyCare and Ryan White services Ryan White is payer of last resort So if eligible for CountyCare, then not eligible for Ryan White services that could be covered under County Care Primary care, pharmacy, long-term care services, behavioral and mental health services all covered under CountyCare Dental, emergency assistance, case management and other services still can get from Ryan White ADAP will probably start requiring clients to enroll in CountyCare at their next ADAP redetermination (not yet announced) Clients will get HIV meds from CountyCare once enrolled

30 CountyCare & Ryan White: Enrolled HIV Providers These facilities should help enroll clients in County Care at next ADAP determination (or sooner) Access Community Health Network (enrollment of city sites in process as of 3/7/13) Austin Health Center - CBC Initiative CORE Center Provident Hospital SSHARC Christian Community Health Center Erie Family Health Center Heartland Health Outreach Howard Brown Health Center Lawndale Christian Community Health Center Near North Health Center

31 PROCEED WITH CAUTION These facilities are NOT enrolled in CountyCare, and they should proceed with enrollment with caution. Chicago Department of Public Health Children's Memorial Hospital Loyola University Michael Reese (Mercy) Open Door Clinic (Elgin) Roseland Christian Health Ministries Sinai Health Systems South Shore Hospital University of Chicago University of Illinois at Chicago

32 All that, and more to come! Affordable Care Act, a/k/a Obamacare, starts enrolling people October 1, 2013 and starts coverage January 1, 2014 Except for people who do not meet the citizenship requirements, virtually all Ryan White clients will be eligible for health care coverage Medicaid if under 138% fpl Private insurance (with subsidies for most of our clients) above 139% fpl.

33 Support SB 26! Implements ACA provisions allowing the state to expand Medicaid to 138% of FPL Passed the Senate Needs to pass the House Lobby day: April 10, May 8, May 22. Contact to register

How to keep up? Keep your dial pointed right here! www.hivhealthreform.

34 How to keep up? Keep your dial pointed right here! and Arrange a training or call for help: AIDS Legal Council of Chicago, Ann Fisher: ann@aidslegal.com John Peller: jpeller@aidschicago.org,

Medicare Medicaid Alignment Initiative (MMAI) November 14, 2014

Medicare Medicaid Alignment Initiative (MMAI) November 14, 2014 MMW work is supported by grants from: The Chicago Community Trust Michael Reese Health Trust The Retirement Research Foundation Who We Are: