Presentation on theme: "SmartPlan Choice Provider Orientation"— Presentation transcript:
1SmartPlan Choice Provider Orientation Overview and Timeline
2Agenda Introduction and Opening Remarks Chicago Market and Projections Health Plan and Contract SelectionSmartPlan Choice Distinction
3Introductions and Opening Remarks Overview of SmartPlan Choice
4Who is SmartPlan Choice? Joint venture of Presence Health Partners & Independent Physician Alliance of Illinois, plus several other providers/clinics.An Accountable Care Entity (ACE), the category for a provider-sponsored and governed organization, managing quality, cost and care of IL Medicaid enrolleesServes women/caregivers, children and newly eligible Medicaid enrollees resulting from ACA.
5Who is SmartPlan Choice? A health plan created by and governed by providers like you.A managed care organization with a collaborative culture and one where you can have input into policies.Joint venture of providers/clinics driven by a mission of helping the underserved.A team of providers with shared values working with and in the community to improve health for all.A group with a strategy to embrace innovation and change the delivery of health care.
6SmartPlan Choice Timeline Enrollment scheduled to begin in Central, IL and move North. Cook County enrolls by zip codes & begins: Sept 8, 15, 29, Oct 6, Jan 12Aug 11, 2014SmartPlan Choice Enrollment BeginsOct 11, 2014Auto-enrollment BeginsJan – Dec 2015Shared Savings Measurement PeriodJan June MCO On-Site Readiness ReviewJul 1, 2017MCO Effective date/ Capitation Full Risk60 days after enrollment, any Medicaid recipient who did not choose a PCP or medical home will have one assigned to them. A PCP must be enrolled in Illinois Health Connect (IHC) to have patients assigned to them.
7State Requirements for Providers participating in SmartPlan Choice? Enroll with State of IL Health and Family Services (HFS)– Enables you to send claims and receive paymentRegister with IL Health Connect (IHC) – Agreement to terms of medical home– Responsibility of primary care provider (PCP)– Registry for providers and office sites– Database for patient panels and patient allocationHFS audits the network and processes of SmartPlan Choice to ensure compliance to regulations. We may need verification from you.
8Strategic Direction: State of Illinois - SB 26 - Medicaid Expansion bill passes - projecting approximately 600,000 new enrolleesSmartPlan Choice Counties of operations:1. Champaign2. Ford3. Vermilion4. Kankakee5. Kane6. Will7. CookCare Coordination Expansion (July 24, 2013)Source: Illinois Department of Healthcare and Family Services
9SmartPlan Choice Service Area and Enroll Dates CountyChampaignFordVermilionKankakeeKaneWillCook (by Zip Code)Iroquois (voluntary enroll) ----Enroll Start: 8 wks to chooseAug 11 – Aug 16Aug 18 – Aug 23Aug 25 – Aug 30Sep 29 – Oct 4Sept 8, Sep 15, Sep 29, Oct 6 (ACA), Jan 12 (ACA)Not mandatory – no date
10State of ILAll enrollment marketing material and activity must be prior approved by the State of IL Health and Family Services (HFS). Including:Community Health Fairs & EventsPublic AnnouncementsPhysician Office Materials
11Enrollment Do’s & Don’ts CAN SAYCANNOT SAYThank patients for privilege of serving them and to consider you when selecting a provider for future health needs and when enrolling in a health plan.Choose SmartPlan Choice or any specific Health Plan.Visit to see letter of preference for SmartPlan Choice approved by HFS Aug 20,2014I am/this medical practice is part of SmartPlan Choice (must include any and all other Medicaid health plans office contracted)
12Enrollment Do’s and Don’ts CAN DOCANNOT DOProvide telephone for patients to contact Client Enrollment Services ( ) directly to enrollCannot provide ONLINE enrollment at any provider setting, health fair, or other gatheringProvide information on ALL health plans offered in the service area - - must use State supplied/approved material.Persuade enrollment in a specific Health PlanMail Outreach using materials supplied by State of IL (found on )Face to Face Outreach (door-to-door, telephone or other cold-call activity)
13Pathway to Working Together HFS Guidelines hereHFS approved letter for IPAProvider Manual found hereCare Management Manual hereHFS approved letter for PHP
14Dept. of IL Approved Letter preferring SmartPlan Choice (PHP)
15Dept. of IL Approved Letter preferring SmartPlan Choice (IPA)
21Types of Managed Care Organizations MCOMCCNCCEACECorporate owned. Full riskProvider owned. Full RiskProvider Organized. Network onlyProvider owned. 3 yr to Full risk- become MCO or MCCN
22SmartPlan Choice vs MCO? A health plan comprised of and governed by your peers.Opportunity to earn your fee for service over next 18 months plus incentives for quality performanceContribute to MCO policy vs mandated by MCO policyHave input into regional care coordination and management of high risk patients vs mandated by policy derived distantly
23SmartPlan Choice ACE offers: Fee-for-service for first one and half years. Providers bill and are reimbursed by the State of Illinois for the first 18 months.Partial risk after 18 months; full risk after three years (An ACE is expected to become a MCCN or MCO).Patient Member Per Month (PMPM) payment for each covered member to manage the care coordination for physicians and help with future ACE infrastructure and growthOpportunity for performance incentive year one and shared savings after 18 months
24Who should I contract?Do you want a fully developed, predefined structure with fixed policies and procedures?Do you want a developing organization having input into policies and procedures? – SmartPlan Choice!Which organization shares your values and understands your perspective? –SmartPlan Choice!More contracts = more policies and procedures = greater administrative burden. SmartPlan Choice! One community and one goal - improving health for all.
26Why SmartPlan ChoiceMission Driven - Serving the Medicaid population is driven by the Mission of key partner of SmartPlan Choice.Local Management - Community is better managed by an active participant in the local communityStakeholder alignment – Local governance by peers who will protect your interestsCulture – Transparency, Collaboration, Innovation and AccountabilityBecause of the ACE providers have tools and resources to support the tenants of the Medical home which they would otherwise not have.** From Network Review Criteria#18 Medical Homes – The ACE’s Affiliated Provider network shall include Providers that act as Medical Homes, with a focus on FQHCs, CMHCs and multi-specialty PCP-centered medical groups and private practice PCP offices. Desk review: Information not found- not provided as part of pre-on-site documentation submission request.Q: How many of your PCPs are medical homes? What services and technical assistance are you providing to help those clinics and PCP practices who are interested in becoming medical homes?Currently, [# ] of our PCPs are medical homes. In addition, SmartPlan Choice will be providing supports for many of the key components of medical homes, including: strong information technology supports, analytic resources (such as frequent ED utilizers), and embedded care coordination. Our care coordination model includes the support of a care coordinator/care manager based on medium/high risk.#19 Patient-Centered Medical Homes shall be patient-centered medical homes that provide and coordinate:High quality, planned, family-centered health promotion;Wellness Programs; acute illness care; andChronic Health Condition management.Medical Homes shall provide all PCP services and be supported by Integrated Care Teams and Health Information Technology. Contractor will support Medical Homes and the integration of behavioral and physical health care by providing embedded Care Coordinators, as appropriate, onsite at FQHCs, CMHCs and high volume Providers that agree to this approach.Desk review: Information not found- not provided as part of pre-on-site documentation submission request.#20 Support for Medical Homes Medical Homes shall provide all PCP services and be supported by Integrated Care Teams and Health Information Technology.Q: What support and services as the ACE will you provide to medical home providers that are part of your integrated delivery network?Currently, [# ] of our PCPs are medical homes. In addition, SmartPlan Choice will be providing supports for many of the key components of medical homes, including: strong information technology supports, analytic resources (such as frequent ED utilizers), and embedded care coordination. Our care coordination model includes the support of a care coordinator/care manager based on medium/high risk. This will be too difficult to gather? Or is there a way to estimate?#21 Embedded Care Coordinators The ACE will support Medical Homes and the integration of behavioral and physical health care by providing embedded Care Coordinators, as appropriate, onsite at FQHCs, CMHCs and high volume Providers that agree to this approach. Desk review: Information not found- not provided as part of pre-on-site documentation submission request.Q: What are your plans to support medical home and the integration of physical and behavioral health services?We know that some of this work has already begun with our FQHC partners. In addition, we’ve begun discussions with our behavioral health partners to provide this type of integration. We’ve recently added this to our implementation plan.
27SmartPlan Choice Contacts For ProvidersCare Coordination CARE (2273)Questions, Info, OtherTools to assist officesFor MembersSmartPlanChoice.org Contact usMember Services CARE (2273)Member Services TTY