Medicaid Managed Care in Illinois: An Overview

1. Medicaid Managed Care in Illinois:An Overview Presented by: Melissa O. Picciola, Equip for Equality June 27, 2012

2. The Basics of Managed Care • The concept of managed care in the Medicaid context is no different than in the private insurance market • A.K.A. Coordinated Care, Integrated Care • Most states have a Medicaid Managed Care program (all but Alaska, New Hampshire, Wyoming) • 71% of the Medicaid population (and growing) • Until recently, people with disabilitieswere not widely included in Managed Care programs • Recent Federal support (CMS, ACA)

3. Types of Managed Care • Capitated, Full-Risk • Managed Care Organization (MCO) is paid fixed monthly premium per member and assumes full-risk for delivery of services (PMPM) • Non-Capitated • Providers are paid an additional fee for coordinating care for members • Other Models • Partial Risk • Managed Care Community Networks (MCCN)

4. Illinois: Medicaid Reform & Coordinated Care • In January 2010, the Illinois Legislature passed a Medicaid Reform Bill. • Requires that 50% of Medicaid clients be enrolled in coordinated care programs by 2015 • Coordinated Care defined broadly to include either capitated, full-risk payment or other risk-based payment arrangements • Not just traditional managed care companies, but also new alternative models of care organized and managed by hospitals, Physician groups, Federally Qualified Health Centers (FQHC) or social service organizations • Requires payments to be made based on performance related to health outcomes

5. Care Coordination Innovations Project • HFS created Innovations Project to comply • The Innovations Project consists of several phases through which the State seeks a redesigned health care delivery system that is more patient-centered with a focus on improved health outcomes, enhanced patient access, and patient safety. • To achieve these goals, the State seeks entities to coordinate care across the spectrum of the healthcare system with a particular emphasis on managing transitions between levels of care and coordination between physical and mental health and substance abuse.

6. Coordinated Care Programs in Illinois • Integrated Care Program • Phase I of the Innovations Project • Coordinated Care Entities & Managed Care Community Networks: statewide • Medicaid-Medicare Alignment Initiative • Others: • Children? • Voluntary MCOs • Primary Care Case Management

7. Integrated Care Program (ICP) • Implemented May 2011 for adult Medicaid-only enrollees known as Aged, Blind, Disabled • Adults with disabilities and older adults not enrolled in Medicare • Two companies selected: Aetna and IlliniCare • Service Package I includes all acute medical and behavioral healthcare • Service Package II & III: Includes all long term-care and waiver services • To be implemented Fall 2012

8. Phase I of the Innovations Project • Solicits proposals from Coordinated Care Entities and Managed Care Community Networks to coordinate care for Medicaid individuals • Must include portion of AABD Population • Statewide initiative, not including ICP clients • Voluntary enrollment with 12 month lock-in • Will award 10 contracts in Cook County and 10 Contracts outside of Cook County • Received 75 letters of intent in February 2012 • Proposals due June 15, 2012

9. Coordinated Care Entities (CCE) • Provider groups and other organizations: must include PCPs, hospitals, mental health and substance abuse providers • May include others and offer other services outside of care coordination • Receives enhanced fee for care coordination • Does not assume full risk • Medical services remain Fee-For-Service • Proposal must be cost-neutral over 3 years • 3 financial models available: • Care Coordination Fee: PMPM fee • Shared Savings: Over baseline established by HFS/CMS • Other Payment methodology: Proposed by CCE • Only for adults already enrolled in Illinois Health Connect • 1.8 million adults as of May 2012

10. Managed Care Community Networks (MCCN) • Entity, other than HMO, that is owned, operated, or governed by providers and provides all Medicaid-covered services • May include others and offer other services • Full-risk, capitated payment • Assume full-risk for all acute medical and behavioral healthcare • May include dental and pharmacy • May include long-term care and waiver services • Enrollees do not have to be enrolled in Illinois Health Connect, but may be • HFS has filed proposed rules amending the financial requirements for a MCCN • Essentially lowering financial thresholds and allowing HFS to limit enrollment

11. Medicaid-Medicare Alignment Initiative • Up to 5 (at least 2), risk-based contracts awarded to HMOs and MCCNs to provide all Medicare and Medicaid Covered Services to dual-eligibles • Individuals with Developmental Disabilities that receive services in an institutional setting or through a HCBS waiver are excluded • Excludes those already enrolled in CCE or MCCN • Full-risk, capitated payment • Implementation by January 2013 • Greater Chicago and Central Illinois • 2 separate solicitations • Enrollment is Passive, but voluntary • No lock-in period; i.e. can disenroll at any time

12. Benefits of Managed Care • Studies have shown that managed care models have had positive impact on access and continuity of care while reducing overall medical costs • Avoid unnecessary medical services • Provide coordination and integration of services • Decrease “silos” • Pay for Performance Measures and Bonus Payments for achieving certain outcomes • Encourages providers to be accountable and allows states to set benchmarks

13. Benefits, Continued • Incentive to care for the whole individual • Focus on overall health and prevention • Prompt Provider Payment ! • More predictable costs for Illinois • Encourage use of home and community-based alternatives to institutional care • Providing individualized case management services and disease management services • For some individuals, for the first time in their lives

14. Pitfalls of Managed Care • Little to no evidence and no model regarding managed care for people with disabilities • Particularly those with developmental disabilities and others who require long-term care • Medical Model v. Person-Centered Model • Treated as a diagnosis and not as a person • Care is already coordinated by the individual • Loss of consumer control

15. Pitfalls, Continued • Problems with access and disruptions of care • Especially in early stages of program • ICP experienced problems with hospital network • Access to specialists may be restricted • Prior Authorization and Utilization Review translate into restricting benefits • Cost savings are realized through restriction of services • Increased bureaucracy at every stage • State shifts responsibility for program

16. Unknowns in Illinois • How will long-term care services be integrated? • Personal Assistant services and SEIU contract • Will those living in institutions really be given a choice? • How does this affect Illinois’ stated commitment to rebalancing? • Will causing MCOs to contract with institutional providers create a conflict of interest that will prevent rebalancing?

17. Unknowns, Continued • How does managed care interact with Williams, Ligas, and Colbert? • HFS has so far been vague but offered assurances that individuals will not be denied any services to which they are entitled. • How will recent changes to the Medicaid program affect the ICP and subsequent programs? • Additional restrictions on benefits • Prior Approval Process

18. Where do we go from here? • Continue to be diligent and educated advocates • Stay informed and know what changes will affect individuals • Be ready to pursue grievance and appeals when services are denied or restricted • Become involved in consumer advisory councils and know who to call with questions and concerns

19. Additional Information • CMS Innovations Dual Eligible Demonstrations • http://www.innovations.cms.gov/initiatives/State-Demonstrations/index.html • HFS Care Coordination Innovations Project  • http://www2.illinois.gov/hfs/PublicInvolvement/cc/Pages/default.aspx