Medicaid Managed Care is Coming to Illinois WHAT YOU NEED TO KNOW. February Case Manager Webinar Series

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Mae Webb
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1 Medicaid Managed Care is Coming to Illinois WHAT YOU NEED TO KNOW February Case Manager Webinar Series

2 Welcome! Welcome to our webinar series on Medicaid managed care for people with HIV in Illinois. Today Overview of managed care with a focus on the Integrated Care Program (ICP) March Managed care for dual eligibles people on Medicare & Medicaid (dates to be announced)

3 Use the question feature to ask questions. Or you can questions Everyone can ask questions at any time using the questions feature You can also questions to

4 Today s Presenters John Peller, AIDS Foundation of Chicago, moderator Stephanie Altman, Shriver Center Jessie Beebe, AIDS Foundation of Chicago Justin Hayford, AIDS Legal Council of Chicago

5 Four main ways people with HIV can get on Medicaid in IL Seniors & People with a Disability Low-income adults who are totally disabled with no work history Dual Eligibles Low-income adults who are totally disabled who have a work history New eligibles, ACA eligibles Low-income adults age who are not disabled and do not have children in the home (CountyCare) Parents/Caretakers Low-income parents or caretakers who have children in their home

6 Managed Care and Care Coordination in Illinois Stephanie Altman Assistant Director of Health Care Justice Shriver Center

7 Illinois Coordinated Care Vehicles Illinois Medicaid Care Coordination & Managed Care Initiatives a. Care Coordination Entity (CCE) b. Managed Care Community Network (MCCN) c. Accountable Care Entity (ACE) d. Managed Care Organization (MCO)/Health Maintenance Organization (HMO)

8 Legislative Mandate to Implement Coordinated Care Initiatives Put at least 50% of Illinois Medicaid recipients in a Care Coordination/Managed Care program by January 2015 ICP Integrated Care Program (Older Adults and Disabled AABD only) MMAI Medicare Medicaid Alignment Initiative (Dual Eligibles) MCE Managed Care Entity (Umbrella Term for CCE, MCCN, MCO/HMO, ACE) CCE Care Coordination Entity (Target Populations) MCCN Managed Care Community Network MCO/HMO Managed Care Organization/Health Maintenance Organization ACE Accountable Care Entity (called Accountable Care Organization (ACO) in other states) CCMN - Children with Complex Medical Needs

9 Illinois Transition to Managed Care Illinois moving at least 50% of all Medicaid recipients into a Care Coordination Program by January This shift is because of a 2011 Illinois Medicaid Reform Law. Illinois has been traditionally a primarily fee for service system. Illinois Medicaid Program moving from fee-for-service to capitated, risk-based payments.

10 Measures of Success in Coordinated Care Care Coordination & Integration Successful if: Funded at needed levels Services that impact a person s health within and outside the care coordination entity are fully funded (e.g. services covered in Medicaid program; case management; and support services in Supportive Housing) Adequate and accessible network of providers Person-centered engagement If we figure out how to do all of the above well, we will: Improve our healthcare delivery system Improve Population Health Reduce Costs

11 Improving Health and Reducing Cost of Care for High-Utilizers Will impact most people receiving Medicaid benefits in Illinois. According to HFS, 16% of Medicaid recipients who are Seniors and Persons with Disabilities (SPD) cost 55% of the Medicaid budget (for all agencies). HFS stated goal is to create integrated delivery systems that provide quality care and result in better health outcomes for Illinois Medicaid recipients at reduced costs.

12 CCE, ACE and ACOs: Provider-Led Options What are Provider-Led Networks of Care? A network of doctors, hospitals, mental health and substance use treatment providers that shares responsibility for providing care to a specific group of patients. Pay providers for the quality of services they provide, rather than the volume in other words, veer away from the fee-for-service system. The entity is offered a bonus for giving patients high quality care at a reduced cost. But, if they fail to hit certain quality targets or do not manage to reduce the cost of care, they will be paid less.

13 Managed Care Structures in Illinois Illinois Medicaid will have a unique structure: Four different models of Managed Care Entities Health Maintenance Organizations (HMO) (sometimes called Managed Care Organization (MCO) - traditional insurancebased, with full-risk capitated payments. Aetna Better Health, BlueCross, IlliniCare, Meridian, HealthSpring, Humana (others outside Chicago) Managed Care Community Network (MCCN) - new providerorganized entity, with full-risk capitated payments. Community Care Alliance of IL CountyCare (will become an MCCN)

14 Managed Care Structures in Illinois Illinois Medicaid will have a unique structure: Four different models of Managed Care Entities Care Coordination Entity (CCE) new providerorganized network, care coordination fee, medical/other services paid fee-for-service Together4Health, Be Well, EntireCare (others outside Chicago) Accountable Care Entity (ACE) new providerorganized entity, initially paid through fee-forservice structure, transition to partial risk at month 19 and full-risk capitated payments after 3 years Not established yet Illinois Medicaid will use a common set of quality measures to evaluate the performance of all managed care entities (HMOs, MCCNS, CCEs, and ACEs)

15 Illinois Care Coordination Plan Care Coordination Summary Care Coordination Expansion Map Care Coordination Roll-Out by Health Plan

16 Initial Target Populations Initial focus of these entities will be on specific populations within the Illinois Medicaid Program: For example, initial focus for the 5 CCEs and 1 MCCN operating in Illinois will be SPDs (Seniors and Persons with Disabilities). Initial focus of ACEs will be parents and caretaker relatives, children, and the newly eligible / Medicaid Expansion population.

17 What about CountyCare? Started as an 1115 waiver special Medicaid program that was an early expansion of Medicaid to low-income adults without children CountyCare will continue! Anyone enrolled now can stay enrolled in CountyCare In July, Medicaid expansion population will be able to choose CountyCare or another plan

18 Questions?

19 Enrollment Information For Recipients Medicaid recipients will receive information in the mail about the Managed Care Entity options (e.g. HMO, MCCN, ACE, CCE) available to them and have a certain window of time to pick one. Once an entity is picked, the Medicaid recipient is locked into that entity for one year (exceptions for some groups of Medicaid recipients.)

20 What Information do Clients Receive from HFS for the ICP Program? An initial client enrollment packet is mailed to households with potential enrollees. The packet includes: An enrollment letter An Integrated Care Plan Information Guide Enrollment Tips for picking a health plan and PCP A comparison chart listing the extra benefits, network hospitals, and other information for each of the two health plans A reminder notice is mailed to clients two weeks after the initial enrollment packet is mailed A second client enrollment packet is mailed to clients who have not responded to the initial client enrollment packet within 30 days. The packet includes a cover letter with the name of the health plan and PCP to whom the client will be assigned if they don t make a choice within the next 30 days. Enrollees will receive a welcome packet from their chosen or assigned health plan to confirm their enrollment. Enrollees may change their PCP by calling their health plan. Once each year, during their open enrollment period, enrollees will have a 60-day period to change their health plan. This will be the only time each year they are allowed to switch health plans. A letter will be sent notifying them of their open enrollment period.

21 Sample HFS Introduction Letter You must enroll in the Integrated Care Program. To enroll (become a member), you must choose a health plan and a primary care provider (PCP). Your PCP is the doctor or clinic you go to when you are sick or need a checkup. Your health plan is the group of doctors, hospitals, and other providers who work together to give you the healthcare you need. Please read everything that came with this letter to make the best choice for you. Your new health plan will cover all the medical and waiver services you get now. Your plan will cover the waiver services you get at home, such as a personal assistant or homemaker, adult day care, or a home emergency response system. You must choose by [DATE]. Please choose a health plan and PCP for the person listed here: [HOC_NAME] Date of birth: [HOC_DOB] ID #: [HOC_RIN] Now you have more health plans to choose from. The plans are: [planname] [planname] [planname] Questions? Visit or call (TTY: ). The call is free! You can get this information in other languages or formats, such as large print or audio. Tenemos informacio n en espan ol. Servicio de inte rpretes gratis! Llame al If you do not choose by [DATE], we will choose for you. It is better if you choose a health plan and PCP, because you know you healthcare needs best. For help choosing, read Tips to Help You Choose and Your Health Plan Choices that came with this letter. There are two ways to enroll: Call us at (TTY: ). The call is free. Go to and click Enroll. After you enroll, your health plan will send you a Welcome Packet in the mail. Thank you, Illinois Client Enrollment Services

22 How to Enroll Medicaid recipients can enroll in a CCE, MCCN, ACE, or MCO through: phone the HFS Client Enrollment Broker (CEB) (MAXIMUS) at (TTY: ), OR online

23 Exceptions, Single Case Agreements, and Appeals Exceptions and Appeals can be filed if past 90 day window to switch plans or if already switched plans once or neither plan included necessary provider and patient needs to continue to see an out of network provider. Toolkit developed in 2011 by the Family Resource Center and posted on DCFS and HFS Website for ICP Program has helpful tips on exceptions and single case agreements to use out of network provider: ed_care_toolkit.pdf

24 Talking with Consumers about Care Coordination Jessie Beebe, AIDS Foundation of Chicago

25 Care coordination/managed care education Concrete, specific examples about how care coordination/managed care will impact and improve their care Opportunity to talk about how the health care system is changing for the better what steps the client can take to improve their health and take advantage of system changes Questions from clients will I have to switch doctors? do I have to leave any of my programs? General concerns about change. Try to focus on positive aspects of change, emphasis the support that will be available to help adjust to changes

26 Care Coordination/Managed Care Education

27 Care Coordination/Managed Care Education

28 My Health Care Team I currently get my medications from pharmacy or clinic. I usually pick up my medications every weeks/months. My medications are: My primary care doctor is: I see him/her at clinic or hospital. I usually see my doctor every weeks/months. The specialist I see for my major heath condition is: I see him/her at clinic or hospital. I usually see my specialist every weeks/months. Other specialists I see are: I see him/her at clinic or hospital. I usually see my specialist every weeks/months. I went to clinic/hospital the last time I was very sick. I get my mental health care at hospital or clinic. I usually see mental health specialists every weeks/months. My psychiatrist is My therapist is My Primary Care Doctor is affiliated with the following health plans. Circle the plan that best fits your health care needs:

29 Care Coordination/Managed Care Education Opportunity to talk with clients about: How they receive care now and their level of satisfaction with their provider(s) What is important to them in a primary care provider (relationship, convenience, etc.) Barriers and challenges to access and engagement in health care If low engagement, motivational interviewing exploring how increased engagement will directly impact their lives, improve their health, contribute to other goals that are important to them (especially if health is not a priority)

30 Care Coordination/Managed Care Education More opportunities: Health care system moving towards increased community-based, preventive and wellness care. How and why to utilize preventive, wellness and primary care versus emergency room and hospital care How to navigate a clinic setting make appointments, follow up on referrals, etc. How to develop positive relationships with clinic staff, including providers How to problem- solve if they have a negative experience with clinic and/or providers How to address challenges and barriers that may prevent them from accessing care

31 How can case managers/providers help clients Encourage clients to open all of their mail. Clients should save letters/mail for the case manager or someone they trust to review with them. Assist with calling the enrollment broker with the client or make sure client has phone number and knows when to call broker and which plan to request. Remind clients that if they do not choose a plan they will be assigned to one. Clients may need to be reminded about deadlines. Help clients switch plans if there are any problems or issues with the plan they chose or were assigned to. Assess problems and come up with solutions to work on together.

32 The Role of Case Managers in Health Care Engagement Case managers may help by encouraging participants to take advantage of new health care opportunities in the following ways: Encourage clients to schedule regular appointments with primary care providers Prompt clients to follow-through with follow-up appointments suggested by medical professionals Assist with locating a convenient pharmacy and setting a schedule for medication pick-up to avoid missed re-fills Include discussions about health care in routine case management services

33 Resources List and short description of 5 CCEs and 1 MCCN ubjectid=2&recnum=10634 ACE Background and Overview Integrated Care Project (ICP) Medicare-Medicaid Alignment Initiative (e.g. Duals Project) Children With Complex Health Needs

34 Contact us! Stephanie Altman, John Peller, Jessie Beebe, Justin Hayford,

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: