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Illinois Medicaid Initiatives 2014

Get ready for the next big wave of change impacting providers
By Cathy Johnson

In January 2011, the State of Illinois enacted Public Act 96-1501, which essentially requires the State to move at least 50% of Medicaid clients into “care coordination” by Jan. 1, 2015. In Illinois, this care coordination will be provided to most Medicaid clients by a variety of “managed care entities,” including Coordinated Care Entities (CCEs), Managed Care Community Networks (MCCNs), Managed Care Organizations (MCOs), and Accountable Care Entities (ACEs). The State developed separate programs to serve the various categories of the Medicaid population.

Voluntary Managed Care Organizations (VMCOs) is an HMO or HMO-like health plan with its own network of doctors and hospitals. The VMCOs in Illinois are Family Health Network, Harmony, and Meridian.

Care Coordination Entities (CCEs) work to form alternative models of delivering care through provider-organized networks, centered on the needs of the most complex patients. The CCEs are CountyCare, Medical Home Network, and Together4Health in Cook County. Certain zip codes include Be Well and Entire Care. My Health Care Coordination and Precedence are downstate.

Children with Complex Medical Needs (CCMNs) is a care coordination model with LaRabida Children’s Hospital, Lurie Children’s Hospital, and OSF Healthcare.

Integrated Care Program (ICP) includes seniors and persons with disabilities who are eligible for Medicaid but not Medicare. This program establishes a medical home where the primary care physician and team of ancillary providers manage the care of enrollees. A pilot program began in May 2011 with Aetna Better Health and IlliniCare. Participation expanded to include Blue Cross Blue Shield, Cigna HealthSpring, Community Care Alliance, Humana, and Meridian in the greater Chicago region. This program is mandatory. The State mailed letters to members to opt-in. If no plan is chosen by the deadline, the member is automatically assigned to a PCP/plan. Members can change plans during the first 90 days, and change back to the original plan within 60 days. After then, no changes are allowed until end of year.

Medicare-Medicaid Alignment Initiative (MMAI) is an initiative for those eligible for both Medicare and Medicaid or “Dual Eligibles.” Participating plans in the greater Chicago region are Blue Cross Blue Shield, Cigna HealthSpring, Humana, IlliniCare, Meridian, and Molina. This program is not mandatory. Patients may enroll in a plan or opt-out of the program. For those who do not opt-out, the State will assign them to one of the participating plans. Patients can change plans every 30 days.

Accountable Care Entity (ACE) is an integrated delivery system that must have the following elements:

  • Organized by providers and able to coordinate a network of Medicaid services.
  • Initially enroll children and their family members.
  • Large enough to have impact on populations; at least 40,000 patients in Cook County; 20,000 in collar counties; and 10,000 downstate.
  • A minimum number of providers in certain areas: primary care, specialty care, and behavioral care, including a hospital.
  • A governance structure that includes each provider type.
  • An infrastructure to support care management functions.

ACE providers include Accountable Care Chicago, SmartPlan Choice (Presence), Advocate Accountable Care, Better Health Network, HealthCura (Access Community), Illinois Partnership for Health, Loyola University Health System ACE, Population Health of Illinois (Alexian Brothers), NorthShore Physician Associates ACE, and U of I Health Plus.

Temporary Assistance for Needy Families (TANF) has been offered to the following plan types: ICP, MMAI, CCE, ACE, and VMCO plans. The list of awarded plans is still being developed; however, it is confirmed that Cigna HealthSpring and Humana have declined participation. The State expects the member opt-in process to be similar to the recent ICP/MMAI enrollment package.

With all the new programs and members’ ability to frequently change plans, providers must check eligibility for every appointment and comply with plan requirements to ensure an efficient revenue cycle process. To learn more, please contact us.

Cathy Johnson, a senior health care consultant at PBC Advisors, writes about understanding Illinois Medicaid initiatives and getting ready for the next big change impacting health care in 2014.

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