Presentation on theme: "Illinois: care coordination and healthcare reform"— Presentation transcript:
1 Illinois: care coordination and healthcare reform Illinois Department of Healthcare and Family ServicesAugust 2014
2 Medicaid Reform LawThe Medicaid reform law [PA ], requires that by January 1, 2015, at least 50 percent of the individuals covered under Medicaid be enrolled in a care coordination program that organize care around their medical needs.
3 Care coordinationis the centerpiece of Illinois’ Medicaid reform. It’s aligned with Illinois’ Medicaid reform law and the federal Affordable Care Act
4 What HFS is doing to implement care coordination Initially focus on the most complex, expensive clientsTake an ‘integrated’ approach to careBringing together local primary care providers (PCPs), specialists, hospitals, nursing homes, behavioral health and other providers to organize care around a patient’s needs.Measure quality and health outcomesContinue to work closely with stakeholders and sister agencies on the most effective way to bring this new healthcare delivery system to Illinois
5 What EXISTS NOWCurrent HFS Managed Care Programs
6 Current Programs – Primary Care Case Management (PCCM) Called Illinois Health Connect (IHC)Became fully operational in November 2007A mandatory program; eligible enrollees may opt out of IHC if enrolling in a managed care planOperates statewide for most individuals covered by an HFS Medicaid Program1.7 million IHC clients have a medical home through a PCP. The PCP makes referrals to specialists for additional care or tests as needed* PCCM is NOT an MCO. It is a FFS model that includes care coordination
7 Current Programs – Integrated Care Program (ICP) HFS implemented the first Integrated Care Program (ICP) on May 1, 2011For seniors and persons with disabilities (SPD) who have Medicaid, but not Medicare (cannot be a ‘dual’)Mandatory program for SPD 19 and overEnrollment occurs through client enrollment brokerIndividuals have at least two plans to choose from
8 ICP is a mandatory program currently operating in: ICP –Geography and TimelineICP is a mandatory program currently operating in:Greater Chicago Region – began ,expanded to include City of ChicagoRockford Region – beganCentral Illinois Region – beganMetro East Region – beganQuad Cities Region – began
9 ICP Managed Care Organizations (MCOs) HFS contracts with several health plans to serve the ICP population. Different regions are served by different health plans1. Aetna Better Health2. IlliniCare Health Plan (Centene)3. Meridian Health Plan of Illinois4. Molina Healthcare5. Health Alliance Medical Plan6. Blue Cross Blue Shield7. Cigna-HealthSpring8. Humana Health PlanManaged Care Community Networks (MCCNs)1. Community Care Alliance of Illinois (CCAI)2. County Care
10 ICP –MCOs and MCCNs How are MCOs and MCCNs different? MCOs are licensed Health Maintenance Organizations (HMOs) by the Dept of InsuranceMCCNs are provider‐owned and governed entities that operate like MCOs, but are certified by HFS rather than Dept of InsuranceHow are MCOs and MCCNs the same?MCOs and MCCNs both operate on a full‐risk capitated basisHFS eligibility systems look identical for both MCOs and MCCNsTo the member, the enrollment process is the same and so is the level of benefits provided
11 ICP Care Coordination Entities (CCEs) Care Coordination Entities are provider based networks that offer care coordination to clientsClients remain Fee-For-ServiceHFS contracts with several of CCEs to serve the ICP population. Different regions are served by different CCEs.Be Well Partners in HealthHealthcare Consortium of Illinois (Entire Care)Macon County Care Coordination (My Health Care Consortium)Precedence Care CoordinationTogether4HealthNext Level
12 Current Programs – Medicare Medicaid Alignment Initiative (MMAI) 3-way contract between HFS, Federal CMS, and MCOImpacts those who are dually eligible for full Medicaid & Medicare benefitsClients will have access to all services under one MCO, another step away from fragmented careIncludes both community and LTSS clientsIndividuals are passively enrolled with option to opt out. If they are receiving Long Term Services and Supports (LTSS) however, they are required to select a health plan for those specific services.
13 MMAI – LTSS LTSS : Long Term Services and Supports Under MMAI, the LTSS population includes nursing home residents and those receiving Home and Community Based Services(HCBS) waivers:Elderly (Community Care Program participants)Traumatic Brain InjuryHIV/AIDSPhysically DisabledSupportive Living Facility
14 MMAI- flexibility for the Consumer All services currently received are covered plus care coordination under an integrated health care delivery system. Additionally, all of the MMP health plans offer added benefits at no cost to consumer.Ability to switch health plans under MMAI, though it may be best to stay with one health plan as that health plan’s care coordinator will get to know and understand their needs.To aid in transition to the MMP, Continuity of Care for the first 180 days is available. Existing care plans and providers are covered during this time period with hopes of a more permanent relationship between MMP and provider.
15 MMAI – Number Eligible Geographic Region Number of Dual Beneficiaries Eligible for MMAIGreater Chicago128,000Central Illinois20,000
16 MMAI – Geography and Timeline The MMAI demonstration operates in the Greater Chicago Region and the Central Illinois Region. The program is still rolling out as indicated in the timeline below:March 2014: Voluntary Enrollment for Community population beganJune 2014: Passive Enrollment for Community population beganJuly 2014: Voluntary Enrollment for LTSS population beganOctober 2014: Passive Enrollment for LTSS population Begins
17 MMAI - Managed Care Organizations Greater Chicago Area:Aetna Better HealthIlliniCare Health Plan (Centene)Meridian Health Plan of IllinoisCigna-HealthSpringHumana Health PlanBlueCross/Blue Shield of IllinoisCentral Illinois:Molina Healthcare of IllinoisHealth Alliance Medical Plans
18 Other managed care initiatives Brand New HFS Managed Care Programs
19 Brand New – Family Health Program (FHP) FHP is a mandatory program that began in Summer 2014For children and their families as well as the newly eligible Affordable Care Act (ACA) adultsEstimated 1.5 million potential enrolleesExcluded Populations:DCFS Foster childrenChildren whose case is coordinated by DSCCThose in spenddown, or in other partial benefit programs, such as the Illinois Breast and Cervical Cancer programThose who have comprehensive Third Party Insurance
20 FHP- Geography and Timeline In August 2014, FHP began enrollment in the Metro East Region (Clinton, Madison, and St Clair counties) first and is currently expanding to the other four mandatory regions including:Central IL Region- estimated September 2014Quad Cities Region- estimated October 2014Rockford Region- estimated October 2014Greater Chicago Region- estimated November 2014
21 FHP Managed Care Organizations (MCOs) HFS has contracted with several health plans to serve the FHP population. Different regions will be served by different health plans.1. Aetna Better Health2. Blue Cross Blue Shield3. Harmony Health Alliance Medical Plan4. IlliniCare Health Plan (Centene)5. Meridian Health Plan of Illinois6. Molina HealthcareManaged Care Community Networks (MCCNs)1. County Care2. Family Health Network (FHN)
22 FHP- Care Coordination Entities for Children with Special Needs (CSN CCEs) CSN CCEs are provider based organizations that offer care coordination to children with complex medical needs.All Medicaid covered services remain Fee-For-ServiceHFS will contract with three CSN CCEs to serve the FHP population. Different regions will be served by different CSN CCEs.La Rabida Coordinated Care Network for CCMNLurie Children’s Health Partners CCEOSF Healthcare System Children’s CCE
23 FHP Accountable Care Entities (ACEs) ACEs are provider based organizations that will offer care coordination to the FHP and ACA adult population.Must include, at a minimum, a hospital, PCP, specialist and BH providerBegin as a Fee-For-Service model, but are on a 3 year path to a full-risk capitated payment modelMinimum served: 40,000 clients in Cook County, 20,000 in collar counties, and 10,000 downstate
24 FHP Accountable Care Entities (ACEs) HFS will contract with 10 applicants working to become ACEs. Different regions will be served by different ACEs.Accountable Care ChicagoAdvocate Accountable CareBetter Health NetworkHealthCuraIllinois Partnership for HealthLoyola Univ health System ACEPopulation Health of IL (Alexian Brothers)NorthShore Physician Assoc ACESmartPlan Choice (Presence)UI Health Plus (UIH+)
25 Brand New- Managed Long-Term Services and Supports (MLTSS) Begins fall 2014For those who opt out of MMAI & receive LTSSMandatory enrollment in a health plan to receive:LTSSBehavioral HealthTransportationSame health plans as MMAIClients are locked in for their LTSS services for one year and cannot switch health plans until their anniversary month
26 Care Coordination 2014 Roll Out Plan February 2014 – Additional CCEs began serving SPD in ICPMarch - June 2014 – MMAI (voluntary enrollment began in March, passive enrollment began in June)March 2014 – ICP Expansion began in the city of ChicagoAugust 2014 – Family Health Program (FHP) began in the Metro East Region with plans to expand to all remaining mandatory regionsFall2014 – MLTSS begins for those who opt-out of MMAI
27 Getting the Word OutHFS engages various stakeholders to educate, discuss, and get feedback on our managed care initiatives.We give presentationsWe participate in meetings via conference call and in personWe meet with our sister agencies every week to improve managed care in ILWe are on the web! Stakeholders and providers can access all sorts of information on our website
28 To find out more information on hfs’ care coordination initiatives:
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