IRHA August 13 th, 2015 Alvia Siddiqi, MD, FAAFP Medical Director, Advocate Accountable Care MCCN & Ken Ryan IRHA President and ISMS VP Member Services

 Illinois Medicaid & Illinois Health Connect PCCM  Managed Care Roll-Out Updates and Managed Care Entities Overview ◦ ACE/CCE/CSN CCE ◦ MCO/MCCN  Tips for Navigating Care for your Patients  IMPACT  Provider FAQ  Panel Discussion

 Illinois Health Connect (IHC) administered by Automated Health Systems (AHS) ◦ Initially rolled-out in 2006 as a program that combines elements of managed care and fee-for-service (FFS) ◦ Currently ~875,000 children and adults enrolled in PCCM ◦ Primary Care Case Management (PCCM) – “medical home” model where patients are assigned to a PCP/provider site ◦ Continues to operate in non-mandatory managed care regions  Managed Care Roll-out – 1.8M recipients now enrolled in a Managed Care Entity includes ACE/CCE/CSN CCE, MCO/MCCN ◦ mandate to shift 50% of Medicaid clients in Illinois to Managed care plans as of 01/2015 -> now ~58% in MCEs  Open enrollment packets MetroEast/Central IL

 MANAGED CARE ORGANIZATIONS and MANAGED CARE COMMUNITY NETWORKS (MCO/MCCNs) ◦ Traditional full-risk capitated plans like “HMOs” ◦ Providers must bill the health plan directly and provide services in accordance with each MCO/MCCN utilization policies/procedures, including Prior auth/billing  ACCOUNTABLE CARE ENTITIES (ACEs) ◦ Provider-organized plan option for children and their family members with an option to enroll "newly eligible" adults under ACA  CARE COORDINATION ENTITIES (CCEs) ◦ Specialize in mental health/SPD population and operate similar to ACEs  CHILDREN WITH SPECIAL NEEDS CARE COORDINATION ENTITIES (CSN CCEs) ◦ Serving children with special needs ◦ LaRabida’s CSN CCE (<1K) and Lurie’s CSN CCE (<2K in Chicago Area) *Majority of ~45K CSN CCE eligible children are enrolled in ACEs and MCCN/MCOs*

5 mandatory managed care regions in Illinois: Greater Chicago Region – 6 counties Rockford Region – 3 counties Quad Cities Region – 3 counties Central Illinois Region – 15 counties Metro East Region – 3 counties

Total Care Coordination Enrollment for All Programs source:

Enrollment for FHP/ACA plans

ACA Enrollment by Age, Race, & Gender March 2015 source:

 PCPs in ACEs/CCEs are enrolled as active IHC PCPs  IHC processes PCP changes within assigned plan  Providers are reimbursed usual FFS for ACEs/CCEs  No referrals “required” by HFS for specialty care  Future of ACE/CCEs given proposed FY 2016 budget cuts: ◦ CCEs likely will not continue to be funded past Fall 2015 ◦ ACEs need to expedite to MCCN/MCO  Advocate ACE has an extension MCCN by 1/1/2016  HFS will likely announce formal plan for ACEs and transitions of care for ACE/CCE patients

  Select purple “Care Coordination box”  Find HFS links to HFS Care Coord webpage, Expansion map, roll-out flow chart, roll-out schedule, HFS Q&A, roll-out HFS provider notices  Subscribe to HFS Notices: ◦

 If you live in or near a mandatory managed care region, contract with more than one plan ASAP to improve continuity of care for your current existing Medicaid patients  Check eligibility (MEDI/AVRS/REV) to determine the patient’s plan assignment in order to make appropriate referrals for specialty care and identification needed for billing  Work with Care Coordinators in each Managed Care Entity using Provider Services contact info from HFS notice 3/9/15  Report any unresolved problems/issues to ICAAP, IAFP, myself, and/or HFS Bureau of Managed Care directly

 MCO/MCCN contractual language guides transition of care for their members: ◦ 90 days for ongoing course of treatment ◦ Pregnant and in third trimester, including postpartum delivery care ◦ Provider/client plan agreement  Contract language for continuity of care and Managed Care Patient Rights Act available upon request

 Patients can make a “for cause” switch request by calling Client Enrollment Services (CES) EnrollHFS for the following reason: ◦ PCP is no longer enrolled in the patient’s enrolled plan  CES Customer Service Representative (CSR) will take information down to send to HFS for review  HFS will review and approve “for cause” plan switches to maintain client/PCP relationships  EnrollHFS contact info:

 If mom is enrolled in an MCO/MCCO -> newborn is enrolled to the same plan as mom  If mom is in enrolled in an ACE/CCE -> newborn is direct access for 90 days and mom will need to pick a plan from the newborn enrollment packet  If mom is switching health plans directly after the birth, the current health plan is still going to be responsible to pay back to the date of birth for the baby and the mom until the change actually occurs (if newborn is within 90 days old)

Alvia Siddiqi, MD, FAAFP Medical Director, Advocate Accountable Care MCCN & Ken Ryan, IRHA President & VP Member Services ISMS