Medicaid Managed Care Overview - IPHA MMC Transformation...Managed Care RFP is Issued The RFP...

MedicaidManagedCareOverview

2011Medicaid

ReformLaw

In2011,theGeneralAssemblypassedPA96-1501toaddressincreasingbudgetpressuresintheMedicaidprogram,requiringIllinoistoenroll50%ofitsMedicaidpopulationin“carecoordination”byJanuary1,2015.

MedicaidMCO

Characteristics

• MandatoryEnrollment• Auto-Assignments

• ITStructure&Interface• EncountersSubmission

• CapitatedRatesbasedonFFS• 85%MLR

• DefinedBenefitPackage• DefinedPopulation

• DefinedQualityMeasures&P4Ps

• NetworkCapacityStandards

• DefinedStaffingRatios

• MandatedStaff&ProviderTrainings

• RequiredMemberMaterials• StringentMarketing&OutreachRegulations

• DefinedAppeals&GrievancesProcedures

• MandatedReporting

• DefinedBEPSpend

• RobustFraud,Waste&AbuseStandards

• State&FederalPolicyChanges

MedicaidPrograms&Populations

Medicare-MedicaidAlignmentInitiative(MMAI)• EligibleforMedicare&Medicaid• 100%FederalPovertyLevel(FPL)• 19-64yearsofageonSocialSecurity

DisabilityIncome(SSDI)• 65+receivingSocialSecurity

RetirementIncome

MedicaidLongTermSupports&Services(MLTSS)• EligibleforMedicare&Medicaid• OptOutofMMAI(MedicaidCoverage

Only)• 100%FederalPovertyLevel(FPL)• 19-64yearsofageonSocialSecurity

DisabilityIncome(SSDI)• 65+receivingSocialSecurity

RetirementIncome

IntegratedCareProgram(ICP)• EligibleforMedicaid• 100%FederalPovertyLevel(FPL)• 19-64yearsofage(65+thatdon’t

qualifyforMedicare)• DisabledreceivingSupplemental

SecurityIncome(SSI)

FamilyHealthProgram(FHP)• EligibleforMedicaid• AllKids,0-18yearsofage,300%FPL• FamilyCare,Parents/Guardianswith

LivingwithChildren0-18yearsofage,138%FPL

AffordableCareActAdults(ACA)• EligibleforMedicaidundertheACA• AdultswithoutChildren0-18yearsof

age• 138%FederalPovertyLevel(FPL)• 19-64yearsofage

IllinoisAssociationofMedicaidHealthPlans

IAMHPMedicaidHealthPlans Enrollment1. MeridianHealth 389,0002. BlueCrossBlueShieldofIllinois 382,0003. IlliniCare Health(Centene) 217,0004. MolinaHealthcare 163,0005. CountyCare 140,0006. HarmonyWellCare 138,0007. NextLevel 56,0008. Humana(MMAIOnly1/1/08) 12,0009. AetnaBetterHealth(MMAIOnly1/1/18) 238,00010. FHN/CCAI(Term.12/31/17) 217,00011. Cigna-HealthSpring (Term.12/31/17) 4,00012. HealthAlliance(Term.12/31/16) 0

September2017

HealthandHumanServices

Transformation

TheRaunerAdministrationiscommittedtoanambitiousHealthandHumanServices(HHS)Transformationinitiativethatisgroundedinfivethemes:

• Preventionandpopulationhealth;• Payingforvalue,quality,andoutcomes;• Rebalancingfrominstitutionaltocommunitycare;• DataIntegrationandPredictiveAnalytics;and• EducationandSelf-Sufficiency.

TheissuanceofaPurchaseofCareRequestforProposalsaimedattransformingtheMedicaidmanagedcaresystemiskeyelementoftheHealthandHumanServicesTransformationinitiative.

February27,2017–

MedicaidManagedCareRFPisIssued

TheRFPindicatedsignificantforthcomingchangestotheMedicaidmanagedcaresystem,including:• Expandingmanagedcaretotheentirestate• Reducingthenumberofhealthplans• 3-5statewideplans• 1-2planscoveringjustCookCounty• IssuingonecontracttoastatewideplantocareforchildrenwhoareorhavepreviouslybeenunderthecareoftheDepartmentofChildrenandFamilyServices

IllinoisAssociationofMedicaidHealthPlansNineMCOMembers(2018):

• CountyCare– HealthChoiceIllinois,CookCountyOnly

• NextLevelHealth– HealthChoiceIllinois,CookCountyOnly

• HarmonyWellCare– HealthChoiceIllinois

• BCBSIL– HealthChoiceIllinois,MMAI

• MolinaHealthcare– HealthChoiceIllinois,MMAI

• MeridianHealth– HealthChoiceIllinois,MMAI

• IlliniCare– HealthChoiceIllinois,DCFS,MMAI

• AetnaBetterHealth–MMAI

• Humana–MMAI

Illinois Department of Healthcare and Family ServicesMedicaid Managed Care Program Map

January 1, 2018

Blue Cross Community Health Plan

Harmony Health Plan, Inc.

IlliniCare Health

Meridian Health Plan

Molina Healthcare

Statewide HealthChoice Illinois Plans

CountyCare Health Plan

NextLevel Health Partners

Cook County HealthChoice Illinois Plans

All Statewide HealthChoice Illinois Plans serve Cook County.

Two Cook County HealthChoice Illinois

Plans serve only Cook County. ( )

Medicare Medicaid Alignment Initiative (MMAI)

Aetna Better Health Premier PlanCook, DuPage, Kane, Kankakee, Will

Blue Cross CommunityCook, DuPage, Kane, Kankakee, Lake, Will

Humana Health Plan, IncCook, DuPage, Kane, Kankakee, Lake, Will

IlliniCare HealthCook, DuPage, Kane, Kankakee, Lake, Will

Meridian CompleteCook, DuPage, Kane, Will

Molina Healthcare of IllinoisVoluntary Enrollment only: Champaign, DeWitt, Ford,

Knox, McLean, Peoria, Stark, Tazewell, Vermilion

HealthChoice Illinois

• EnrollmentProcess:PhaseITransitionAssignmentinCurrentMCORegions

• LettersmailedOctober&November2017witheffectivedateofJanuary1,2018

• ClientsassignedtocurrentMCOwith90-dayoptiontochangetoanotherMCO

• Lockedinfor12months

HealthChoice Illinois

• EnrollmentProcess:PhaseIIFullEnrollmentPacketinExpansionRegions

• EnrollmentPacketsmailedbeginningJanuary2018witheffectivedatebeginningApril1,2018

• Clientsgiven30-dayoptiontovoluntarilyenrollwithoneoffivestatewideMCOsbycallingClientEnrollmentBroker(Maximus)

• Ifnochoiceismade,clientwillbeautoassignedtoanMCObasedonanalgorithm

• 90-dayoptionperiodtochangetoanotherMCO

• Lockedinfor12months

HealthChoice Illinois

• EnrollmentProcess:PhaseIIIEnrollmentofSpecialNeedsChildren

• EnrollmentPacketsmailedbeginningMay2018witheffectivedatebeginningJuly1,2018(TENTATIVE)

HealthChoice Illinois Transition and Expansion Mail Schedule October 16, 2017

Description Mail Start Week Mail End Week Effective Enrollment Date*

Auto-Assignment Date* Counties included in mailing

Transition of members currently enrolled with a managed care health plan that was awarded a new contract for January 1, 2018. Members will stay enrolled with their current health plan. Each member will be mailed a HealthChoice Illinois transition notice.

October 30, 2017 November 30, 2017 January 1, 2018 N/A Current Mandatory and Voluntary (VMC) Counties. Only MCO members will be included in the daily transition notice mailings.

Transition of members currently enrolled with a managed care health plan that was not awarded a new contract for January 1, 2018. Members will be transitioned to a new health plan. Each member will be mailed a HealthChoice Illinois transition notice.

November 6, 2017

November 30, 2017

January 1, 2018

N/A

Current Mandatory and Voluntary (VMC) Counties. Only MCO members will be included in the daily transition notice mailings.

Enrollment of newly eligible potential enrollees, previous Illinois Health Connect members, and no-longer excluded populations (does not include Special Needs Children or DCFS Youth in Care). Each individual will be mailed a HealthChoice Illinois enrollment packet. Each individual will have a 30-day enrollment choice period to select a health plan and Primary Care Provider.

January 8, 2018 February 16, 2018 Earliest effective Choice enrollment date is April 1, 2018

Earliest Auto-Assignment date is April 1, 2018

All counties statewide will be included in the daily enrollment packet mailings.

Enrollment of Special Needs Children. Each individual will be mailed a HealthChoice Illinois enrollment packet. Each individual will have a 30-day enrollment choice period to select a health plan and Primary Care Provider.

May 7, 2018 May 16, 2018 TENTATIVE Earliest effective Choice enrollment date is July 1, 2018

TENTATIVE Earliest Auto-Assignment date is July 1, 2018

All counties statewide will be included in the daily enrollment packet mailings.

Enrollment of DCFS Youth in Care into a HealthChoice Illinois plan.

TENTATIVE Earliest effective enrollment date is July 1, 2018

All counties statewide will be included in the assignment process.

*All individuals will have a 90-day switch period to select a different plan. Sample transition and enrollment packet materials are available on the Illinois Client Enrollment Broker Program web site at www.enrollhfs.illinois.gov/

HFSSeries:Succeedingin

theNewManagedCare

• #1.Whatismyrelationshipwithplansthatweren’tawardedacontractforthenewprogram?• #2.Fivekeywaysthenewmanagedcarewillmeanlessworkforproviders• #3.Simplifiedcredentialing:Cuttingbackonprovideroverheadcosts• #4.HowHFSandthehealthplanswillcommunicatetransitiondetailstoclients• #5.Howyoucanhelpyourpatientsunderstandwhattheyneedtoknowaboutthistransition

SimplifiedCredentialing

FromHFS:• Underthenewprogram,registeringwiththeDepartment’sonlineproviderenrollmentprogramwillbecome

theonlyrequirementtobegindevelopingrelationshipswitheveryMedicaidmanagedcarehealthplan…Medicaidproviderswillneedtoonlyregisterwith HFSIMPACTwebsite…

• OnceanapplicationisapprovedbyHFS,theproviderisconsideredcredentialedwiththeHealthPlan.• Pleasebeawareoftwoimportantfeaturesofthisupgrade.First,thechangeappliesonlytoMedicaid,not

Medicareorotherproducts. Second,althoughproviderswillbecredentialedthroughIMPACT,theyshouldcontinuetoprovidespecificinformationrequestedbyMCOsthatisnotincludedinthecredentialingprocessbutisneededforMCOOperations,suchasproviderofficehours.

• Credentialingonit’sowndoesnotmeanaproviderandahealthplanwillbedoingbusinesstogether.Providerandplansmuststillenterintocontractualrelationshipsandsatisfyallnecessaryoperationalrequirements.

IllinoisDepartmentofHealthcareandFamilyServices– CareCoordinationHomepage• TransitionLettersandClientCommunications• ProgramDescriptions• EnrollmentInformation• CareCoordinationQualityMetrics• HealthChoiceIllinois2018ModelContract

IAMHPKeyContacts

IAMHPBillingGuides

IAMHPWebsite– InfoforProviders

• InadditiontotheKeyContactsandBillingGuides,theInfoforProviderssectionalsoincludeslinkstoProviderManualsandPriorAuthorizationlinks• 1/1/18thesesectionswillbeupdatedasneededtoreflectanyURLchanges,documentupdates,etc.• IAMHPalwayswelcomessuggestions,sopleasedon’thesitatetosharewhatadditionalinformationwecancollectfromthehealthplansandposttooursite.

IAMHPContactInformation

SamanthaOldsFrey,ExecutiveDirectorsamantha@iamhpteam.org314-599-0698

CyrusWinnett,AssociateDirectorcyrus@iamhpteam.org217-341-4452