Medicaid Managed Care Overview
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- Arron Edwards
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1 Medicaid Managed Care Overview
2 2011 Medicaid Reform Law In 2011, the General Assembly passed PA to address increasing budget pressures in the Medicaid program, requiring Illinois to enroll 50% of its Medicaid population in care coordination by January 1, 2015.
3 Medicaid MCO Characteristics Mandatory Enrollment Mandated Staff & Provider Trainings Auto-Assignments Required Member Materials IT Structure & Interface Stringent Marketing & Encounters Submission Outreach Regulations Capitated Rates based on FFS Defined Appeals & 85% MLR Grievances Procedures Defined Benefit Package Defined Population Defined Quality Measures & P4Ps Network Capacity Standards Defined Staffing Ratios Mandated Reporting Defined BEP Spend Robust Fraud, Waste & Abuse Standards State & Federal Policy Changes
4 Medicaid Programs & Populations Medicare-Medicaid Alignment Initiative (MMAI) Eligible for Medicare & Medicaid 100% Federal Poverty Level (FPL) years of age on Social Security Disability Income (SSDI) 65+ receiving Social Security Retirement Income Medicaid Long Term Supports & Services (MLTSS) Eligible for Medicare & Medicaid Opt Out of MMAI (Medicaid Coverage Only) 100% Federal Poverty Level (FPL) years of age on Social Security Disability Income (SSDI) 65+ receiving Social Security Retirement Income Integrated Care Program (ICP) Eligible for Medicaid 100% Federal Poverty Level (FPL) years of age (65+ that don t qualify for Medicare) Disabled receiving Supplemental Security Income (SSI) Family Health Program (FHP) Eligible for Medicaid All Kids, 0-18 years of age, 300% FPL Family Care, Parents/Guardians with Living with Children 0-18 years of age, 138% FPL Affordable Care Act Adults (ACA) Eligible for Medicaid under the ACA Adults without Children 0-18 years of age 138% Federal Poverty Level (FPL) years of age
5 Illinois Association of Medicaid Health Plans IAMHP Medicaid Health Plans Enrollment 1. MeridianHealth 389, BlueCross BlueShield of Illinois 382, IlliniCare Health (Centene) 217, Molina Healthcare 163, CountyCare 140, Harmony WellCare 138, NextLevel 56, Humana (MMAI Only 1/1/08) 12, Aetna Better Health (MMAI Only 1/1/18) 238, FHN/CCAI (Term. 12/31/17) 217, Cigna-HealthSpring (Term. 12/31/17) 4, Health Alliance (Term. 12/31/16) 0 September 2017
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7 Health and Human Services Transformation The Rauner Administration is committed to an ambitious Health and Human Services (HHS) Transformation initiative that is grounded in five themes: Prevention and population health; Paying for value, quality, and outcomes; Rebalancing from institutional to community care; Data Integration and Predictive Analytics; and Education and Self-Sufficiency. The issuance of a Purchase of Care Request for Proposals aimed at transforming the Medicaid managed care system is key element of the Health and Human Services Transformation initiative.
8 February 27, 2017 Medicaid Managed Care RFP is Issued The RFP indicated significant forthcoming changes to the Medicaid managed care system, including: Expanding managed care to the entire state Reducing the number of health plans 3-5 statewide plans 1-2 plans covering just Cook County Issuing one contract to a statewide plan to care for children who are or have previously been under the care of the Department of Children and Family Services
9 Illinois Association of Medicaid Health Plans Nine MCO Members (2018): CountyCare HealthChoice Illinois, Cook County Only NextLevel Health HealthChoice Illinois, Cook County Only Harmony WellCare HealthChoice Illinois BCBSIL HealthChoice Illinois, MMAI Molina Healthcare HealthChoice Illinois, MMAI Meridian Health HealthChoice Illinois, MMAI IlliniCare HealthChoice Illinois, DCFS, MMAI Aetna Better Health MMAI Humana MMAI
10 Illinois Department of Healthcare and Family Services Medicaid Managed Care Program Map January 1, 2018 All Statewide HealthChoice Illinois Plans serve Cook County. Two Cook County HealthChoice Illinois Plans serve only Cook County. ( ) Statewide HealthChoice Illinois Plans Blue Cross Community Health Plan Harmony Health Plan, Inc. IlliniCare Health Meridian Health Plan Molina Healthcare Cook County HealthChoice Illinois Plans CountyCare Health Plan NextLevel Health Partners Medicare Medicaid Alignment Initiative (MMAI) Aetna Better Health Premier Plan Cook, DuPage, Kane, Kankakee, Will Blue Cross Community Cook, DuPage, Kane, Kankakee, Lake, Will Humana Health Plan, Inc Cook, DuPage, Kane, Kankakee, Lake, Will IlliniCare Health Cook, DuPage, Kane, Kankakee, Lake, Will Meridian Complete Cook, DuPage, Kane, Will Molina Healthcare of Illinois Voluntary Enrollment only: Champaign, DeWitt, Ford, Knox, McLean, Peoria, Stark, Tazewell, Vermilion
11 HealthChoice Illinois Enrollment Process: Phase I Transition Assignment in Current MCO Regions Letters mailed October & November 2017 with effective date of January 1, 2018 Clients assigned to current MCO with 90-day option to change to another MCO Locked in for 12 months
12 HealthChoice Illinois Enrollment Process: Phase II Full Enrollment Packet in Expansion Regions Enrollment Packets mailed beginning January 2018 with effective date beginning April 1, 2018 Clients given 30-day option to voluntarily enroll with one of five statewide MCOs by calling Client Enrollment Broker (Maximus) If no choice is made, client will be auto assigned to an MCO based on an algorithm 90-day option period to change to another MCO Locked in for 12 months
13 HealthChoice Illinois Enrollment Process: Phase III Enrollment of Special Needs Children Enrollment Packets mailed beginning May 2018 with effective date beginning July 1, 2018 (TENTATIVE)
14 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, 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, 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
15 HFS Series: Succeeding in the New Managed Care #1. What is my relationship with plans that weren t awarded a contract for the new program? #2. Five key ways the new managed care will mean less work for providers #3. Simplified credentialing: Cutting back on provider overhead costs #4. How HFS and the health plans will communicate transition details to clients #5. How you can help your patients understand what they need to know about this transition
16 Simplified Credentialing From HFS: Under the new program, registering with the Department s online provider enrollment program will become the only requirement to begin developing relationships with every Medicaid managed care health plan Medicaid providers will need to only register with HFS IMPACT website Once an application is approved by HFS, the provider is considered credentialed with the Health Plan. Please be aware of two important features of this upgrade. First, the change applies only to Medicaid, not Medicare or other products. Second, although providers will be credentialed through IMPACT, they should continue to provide specific information requested by MCOs that is not included in the credentialing process but is needed for MCO Operations, such as provider office hours. Credentialing on it s own does not mean a provider and a health plan will be doing business together. Provider and plans must still enter into contractual relationships and satisfy all necessary operational requirements.
17 Illinois Department of Healthcare and Family Services Care Coordination Homepage Transition Letters and Client Communications Program Descriptions Enrollment Information Care Coordination Quality Metrics HealthChoice Illinois 2018 Model Contract
18 IAMHP Key Contacts
19 IAMHP Billing Guides
20 IAMHP Website Info for Providers In addition to the Key Contacts and Billing Guides, the Info for Providers section also includes links to Provider Manuals and Prior Authorization links 1/1/18 these sections will be updated as needed to reflect any URL changes, document updates, etc. IAMHP always welcomes suggestions, so please don t hesitate to share what additional information we can collect from the health plans and post to our site.
21 IAMHP Contact Information Samantha Olds Frey, Executive Director Cyrus Winnett, Associate Director
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