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Explore the shift to Medicaid managed care in Illinois, covering basics of HMO models, reimbursement methods, and the evolving payer-patient relationships in the healthcare landscape. Gain insights into capitation, risk contracts, and the changing roles in this transition.
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The Transition to Medicaid Managed Care in Illinois October 7, 2013 Presented by: Sharon R. Miller
Transition to Medicaid Managed Care • Welcome • Who Am I ? • 30 yrs. Experience in Managed Care • Adjunct Professor at Benedictine University teaching Managed Care and Business of Health Care Classes (MPH program)
Why are We Covering This ???? • Managed Care programs are not just unique to Illinois…this is a nationwide movement. • “I Heard that Managed Care Does Not Work”….not true • As a Care Coordinator, what does this have to do with me and my job ? • State will oversee compliance
The Basics of Managed Care Our Focus HMO style
The Basics of Managed Care (HMO model) • Managed Care is NOT “new”….been around since the 1920’s; then became popular in the late ‘70s. • Health Insurance Companies establish “networks” of providers • Patient selects a “Health Plan” • Patient selects a “Primary Care Provider (PCP)” • All medical services approved through this PCP • Other rules: referrals, pre-cert needed for ER visits and certain medical procedures • Tight controls over services
The Basics of Managed Care (HMO model) • There are also different “types” of HMOs: • Staff Models (physicians are salaried employees – Humana) • Network Models (works with a variety of doctors including individual and group practices) • Group Models (a payer that works with only one multispecialty physician group) • IPA Models (payer with contractual relationships with individual and group practices, as well as large Independent Physician Associations (IPAs))
Taking You “Inside” the Payer World State Contracts with Insurance Companies to Manage all aspects of the Patient’s Experience
Working with Payers – the “new” Medicaid configuration
Review of Medicaid Changes to Managed Care • Changing Patient Relationship • New: patient relationship is with the insurance company, not the State • Changing: Claims Processing done by Insurance Companies • New: State pays “lump sum” to insurance company (more on this later) • State keeps eligibility function and takes on oversight function • Day-to-day handled by insurance company
Taking You “Inside” the Payer World Insurance Company
Managed Care Reimbursement: Capitation Capitation • This is a payment methodology where a fixed amount of money is paid in advance to the insurance company for the delivery of health care services. • New term: PMPM – Per Member Per Month
Managed Care Reimbursement: Capitation Capitation Example • 1,000 patients (members) • Capitation rate = $1063.76 per month • Total pre-paid per month to insurance company = $1,063,760 Sounds good, right ????
Managed Care Reimbursement: Capitation What Does the Insurance Company Need to Do for this Advance Payment ? • Everything in their contract !!!! • Doctor Services • Hospital Services • Long Term Care Services • Ancillary Care Services • Anything/Everything Else
Managed Care Reimbursement: Capitation And…..the Insurance Company does NOT get 100% of the capitation because of something called a “Risk Pool” Insurers will get paid 80% capitation with 20% withheld. In order to collect on the “withhold”, the insurance company needs to meet certain quality measures set by the State. If they meet the measures, they get the 20% back at the end of the year.
Capitation vs. Risk RISK CONTRACTS • This is what capitation is all about: RISK • If the insurance company controls the risk, they profit. • If the insurance company does not control the risk, they lose money.
Medicaid Managed Care: Your Shifting Roles OVERSIGHT OVERSIGHT OVERSIGHT
