Illinois: care coordination and healthcare reform

1. Illinois Department of Healthcare and Family Services Illinois: care coordination and healthcare reform August 2014

2. 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.

3. Care coordination is the centerpiece of Illinois’ Medicaid reform. It’s aligned with Illinois’ Medicaid reform law and the federal Affordable Care Act

4. 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

5. What EXISTS NOW Current HFS Managed Care Programs

6. 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

7. Current Programs – Integrated Care Program (ICP) • 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

8. ICP –Geography and Timeline 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

9. 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 Health 2. IlliniCare Health Plan (Centene) 3. Meridian Health Plan of Illinois 4. Molina Healthcare 5. 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

10. 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

11. 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. • Be Well Partners in Health • Healthcare Consortium of Illinois (Entire Care) • Macon County Care Coordination (My Health Care Consortium) • Precedence Care Coordination • Together4Health • Next Level

12. 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.

13. 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: • Elderly (Community Care Program participants) • Traumatic Brain Injury • HIV/AIDS • Physically Disabled • Supportive Living Facility

14. 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.

15. MMAI – Number Eligible

16. 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

17. MMAI - Managed Care Organizations • Greater Chicago Area: • Aetna Better Health • IlliniCare Health Plan (Centene) • Meridian Health Plan of Illinois • Cigna-HealthSpring • Humana Health Plan • BlueCross/Blue Shield of Illinois • Central Illinois: • Molina Healthcare of Illinois • Health Alliance Medical Plans

18. Other managed care initiatives Brand New HFS Managed Care Programs

19. 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

20. FHP- Geography and Timeline • InAugust 2014, FHP began enrollment in the Metro East Region (Clinton, Madison, and St Clair counties)firstand 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

21. 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 Health 2. Blue Cross Blue Shield 3. Harmony Health Alliance Medical Plan 4. IlliniCare Health Plan (Centene) 5. Meridian Health Plan of Illinois 6. Molina Healthcare • Managed Care Community Networks (MCCNs) 1. County Care 2. Family Health Network (FHN)

22. 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. • La Rabida Coordinated Care Network for CCMN • Lurie Children’s Health Partners CCE • OSF Healthcare System Children’s CCE

23. 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

24. FHP Accountable Care Entities (ACEs) • HFS will contract with 10 applicants working to become ACEs. Different regions will be served by different ACEs. • Accountable Care Chicago • Advocate Accountable Care • Better Health Network • HealthCura • Illinois Partnership for Health • Loyola Univ health System ACE • Population Health of IL (Alexian Brothers) • NorthShore Physician Assoc ACE • SmartPlan Choice (Presence) • UI Health Plus (UIH+)

25. 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

26. 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

27. 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

28. To find out more information on hfs’ care coordination initiatives: http://www2.illinois.gov/hfs/PublicInvolvement/cc/Pages/default.aspx