ILLINOIS: CARE COORDINATION AND

HEALTHCARE REFORM

August 2014

Illinois Department of Healthcare and Family

Services

Medicaid Reform Law

The Medicaid reform law [PA 96-1501], 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.

Care coordination is the centerpiece of Illinois’

Medicaid reform. It’s aligned with Illinois’ Medicaid reform law and the federal Affordable

Care Act

What HFS is doing to implement care coordination

Initially focus on the most complex, expensive clients Take an ‘integrated’ approach to care

Bringing 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 outcomes Continue to work closely with stakeholders and sister

agencies on the most effective way to bring this new healthcare delivery system to Illinois

WHAT EXISTS NOW

Current HFS Managed Care Programs

Current Programs – Primary Care Case Management

(PCCM) Called Illinois Health Connect (IHC)

Became fully operational in November 2007

A mandatory program; eligible enrollees may opt out of IHC if enrolling in a managed care plan

Operates statewide for most individuals covered by an HFS Medicaid Program

1.7 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

HFS implemented the first Integrated Care Program (ICP) on May 1, 2011

For seniors and persons with disabilities (SPD) who have Medicaid, but not Medicare (cannot be a ‘dual’)

Mandatory program for SPD 19 and over Enrollment occurs through client

enrollment broker Individuals have at least two plans to

choose from

Current Programs – Integrated Care Program (ICP)

ICP is a mandatory program currently operating in:

Greater Chicago Region – began 5-1-11, expanded to include City of Chicago 3-1-14

Rockford Region – began 7-1-13 Central Illinois Region – began 9-1-13 Metro East Region – began 9-1-13 Quad Cities Region – began 11-1-13

ICP –Geography and Timeline

ICP Managed Care Organizations (MCOs)

HFS contracts with several health plans to serve the ICP population. Different regions are served by different health plans

1. Aetna Better Health2. IlliniCare Health Plan (Centene)3. Meridian Health Plan of Illinois4. Molina Healthcare5. Health Alliance Medical Plan

6. Blue Cross Blue Shield 7. Cigna-HealthSpring 8. Humana Health Plan

Managed Care Community Networks (MCCNs)1. Community Care Alliance of Illinois (CCAI)2. County Care

ICP –MCOs and MCCNs

How are MCOs and MCCNs different? MCOs are licensed Health Maintenance Organizations

(HMOs) by the Dept of Insurance MCCNs are provider‐owned and governed entities that

operate like MCOs, but are certified by HFS rather than Dept of Insurance

How are MCOs and MCCNs the same? MCOs and MCCNs both operate on a full‐risk capitated

basis HFS eligibility systems look identical for both MCOs and

MCCNs To the member, the enrollment process is the same and

so is the level of benefits provided

ICP Care Coordination Entities (CCEs)

Care Coordination Entities are provider based networks that offer care coordination to clients

Clients remain Fee-For-Service HFS contracts with several of CCEs to serve the

ICP population. Different regions are served by different CCEs.1. Be Well Partners in Health

2. Healthcare Consortium of Illinois (Entire Care)

3. Macon County Care Coordination (My Health Care Consortium)

4. Precedence Care Coordination

5. Together4Health

6. Next Level

Current Programs – Medicare Medicaid Alignment Initiative (MMAI)

3-way contract between HFS, Federal CMS, and MCO

Impacts those who are dually eligible for full Medicaid & Medicare benefits

Clients will have access to all services under one MCO, another step away from fragmented care

Includes both community and LTSS clients

Individuals 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.

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:1. Elderly (Community Care Program participants)2. Traumatic Brain Injury3. HIV/AIDS4. Physically Disabled5. Supportive Living Facility

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.

MMAI – Number Eligible

Geographic Region

Number of Dual Beneficiaries Eligible for MMAI

Greater Chicago 128,000

Central Illinois 20,000

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 began

June 2014: Passive Enrollment for Community population began

July 2014: Voluntary Enrollment for LTSS population began

October 2014: Passive Enrollment for LTSS population Begins

MMAI - Managed Care Organizations

Greater Chicago Area:1. Aetna Better Health2. IlliniCare Health Plan (Centene)3. Meridian Health Plan of Illinois4. Cigna-HealthSpring5. Humana Health Plan6. BlueCross/Blue Shield of Illinois

Central Illinois:1. Molina Healthcare of Illinois2. Health Alliance Medical Plans

OTHER MANAGED CARE INITIATIVES

Brand New HFS Managed Care Programs

Brand New – Family Health Program (FHP)

FHP is a mandatory program that began in Summer 2014

For children and their families as well as the newly eligible Affordable Care Act (ACA) adults

Estimated 1.5 million potential enrollees

Excluded Populations: DCFS Foster children Children whose case is coordinated by DSCC Those in spenddown, or in other partial benefit

programs, such as the Illinois Breast and Cervical Cancer program

Those who have comprehensive Third Party Insurance

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 2014 Quad Cities Region- estimated October 2014 Rockford Region- estimated October 2014 Greater Chicago Region- estimated November

2014

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 Healthcare

Managed Care Community Networks (MCCNs) 1. County Care

2. Family Health Network (FHN)

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-Service

HFS will contract with three CSN CCEs to serve the FHP population. Different regions will be served by different CSN CCEs.1. La Rabida Coordinated Care Network for CCMN

2. Lurie Children’s Health Partners CCE

3. OSF Healthcare System Children’s CCE

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 provider

Begin as a Fee-For-Service model, but are on a 3 year path to a full-risk capitated payment model

Minimum served: 40,000 clients in Cook County, 20,000 in collar counties, and 10,000 downstate

FHP Accountable Care Entities (ACEs)

HFS will contract with 10 applicants working to become ACEs. Different regions will be served by different ACEs.

1. Accountable Care Chicago

2. Advocate Accountable Care

3. Better Health Network

4. HealthCura

5. Illinois Partnership for Health

6. Loyola Univ health System ACE

7. Population Health of IL (Alexian Brothers)

8. NorthShore Physician Assoc ACE

9. SmartPlan Choice (Presence)

10. UI Health Plus (UIH+)

Brand New- Managed Long-Term Services and Supports

(MLTSS)

Begins fall 2014 For those who opt out of MMAI & receive LTSS Mandatory enrollment in a health plan to receive:

LTSS Behavioral Health Transportation

Same health plans as MMAI Clients are locked in for their LTSS services for

one year and cannot switch health plans until their anniversary month

Care Coordination 2014 Roll Out Plan

February 2014 – Additional CCEs began serving SPD in ICP

March - June 2014 – MMAI (voluntary enrollment began in March, passive enrollment began in June)

March 2014 – ICP Expansion began in the city of Chicago

August 2014 – Family Health Program (FHP) began in the Metro East Region with plans to expand to all remaining mandatory regions

Fall2014 – MLTSS begins for those who opt-out of MMAI

Getting the Word Out

HFS engages various stakeholders to educate, discuss, and get feedback on our managed care initiatives. We give presentations We participate in meetings via conference call

and in person We meet with our sister agencies every week

to improve managed care in IL We are on the web! Stakeholders and providers

can access all sorts of information on our website

TO FIND OUT MORE INFORMATION ON HFS’ CARE COORDINATION

INITIATIVES:

http://www2.illinois.gov/hfs/PublicInvolvement/cc/Pages/default.aspx