Illinois Medicaid is Changing April 11, 2013

1. Illinois Medicaid is ChangingApril 11, 2013 John Peller, AIDS Foundation of Chicago Thanks to Ann Fisher, AIDS Legal Council of Chicago Download the slides & materials at www.HIVHealthReform.org/illinois

2. Medicaid is changing • Care coordination • Four prescription policy • “Redetermination project” • Monthly Medicaid card • CountyCare • Handouts & links: www.HIVHealthReform.org/Illinois

3. Medicaid Care Coordination Prepared by Largent Government Solutions, LLC for the AIDS Foundation of Chicago • State Law requires 50% of beneficiaries be enrolled in some form of Care Coordination by 2015. • Payment for services will based on meeting defined quality measures rather than Fee for Service. • Beneficiaries will be aggressively enrolled into risked based, care coordination programs: • Integrated care management (Commercial HMOs) • Care Coordination Entities and Managed Care Community Networks (MCCN) (smaller, provider-driven) • Medicare-Medicaid Alignment Initiative (MMAI) (Commercial HMOs)

5. Care Coordination tips • Duals coming in October; HMOs for seniors & people with disabilities & new Medicaid to Chicago in January • Watch for notices to clients explaining options • CHOOSE A PLAN that includes providers and covers client’s meds – don’t let HFS choose for you! • Help clients learn to use the plan – e.g., need a referral for a specialist • Help clients understand their rights. • Tell us about problems • Download chart and MMW Care Coordination cheat sheet from www.hivhealthreform.org/illinois

6. Four prescription “review” policy • Clients can receive four drugs a month; anything above that needs prior approval. • Some drugs are exempt – e.g., HIV drugs • Some honesty from the Department: “The purpose of the four prescription policy is to have providers review their patients’ entire medication regimen and where possible and clinically appropriate, reduce duplication, unnecessary medications, polypharmacy, etc. The four prescription policy was developed as a result of budget negotiations, but best-practices call for an annual review of the full regimen of prescriptions for any patient.” • We must insist on this: “The four prescription policy is not a “hard” limit. Medicaid patients can and should have access to medications that are medically necessary, even if they exceed four prescriptions per 30 days. The policy simply requires prior approval for prescriptions above the limit, for the purpose set forth above.” http://www.hfs.illinois.gov/pharmacy/script/

7. Initial four prescription review problems • Providers sending people to Walmart instead of working through the pre-approval process • Cumbersome pre-approval process • HFS is working to simplify the process— helps a lot if providers use the MEDI system • Department has taken a lot of heat for this—and is responding. But only because advocates have vigorously reported problems. So keep it up.

8. “Redetermination Project” • Goal is to find people who are not eligible for Medicaid and get them off the rolls, mostly by doing computer matching • Alleged to be up to $350 million in savings • Always unlikely—most fraud is by providers, not by recipients • HFS getting a lot of heat for not moving more quickly on this • SMART Act required state to hire a private company to do this. Hired Maximus in September, who have hired 500(!) workers • Redeterminations began in January 2013

9. How the redetermination project works 1. On-line comparison between what data the recipient has submitted and what’s in databases • living in another state? • Different income? • Died? (probably not spending a lot of money on their health care in that situation) 2. If all okay, then Maximus will recommend continued eligibility without any contact with recipient. 3. If a conflict, or missing info, then a 10 day letter goes out to recipient.

10. Redetermination project, cont’d 4. If within 10 days, send info back to Maximus • If 10 days missed, or info doesn’t satisfy, then the whole case goes back to the local office with a recommendation to change (e.g. take an ineligible child off the case, or put on spenddown) or deny benefits • HFS making a big deal that it’s up to the local office to make the final decision. MOST IMPORTANT: Watch for letters! Huge issue for our clients.

11. Annual Medical Cards DHS is no longer sending out medical cards every month

12. New medical cards, cont’d • If a recipient is in managed care, they will have this card plus a card from the managed care plan plus their i.d. • For a long time now the card has been a formality: providers really check eligibility at every visit. • Having a card won’t prove you are eligible (e.g. spenddown met), but it will make people nervous not to have it. • Can get a replacement by calling DHS 1-800-843-6154 or HFS 1-800-226-0768

13. CountyCare • CountyCare (1115 waiver) • Enrolling now • Eligibility up to 138% FPL ($15,282) • No categorical eligibility requirements, but must live in Cook County and meet citizenship requirements (same as Medicaid and SSI) and be age 19-64 • Restricted network includes county providers and participating federally qualified health centers, including Howard Brown. • This is health insurance—can save someone from bankruptcy • Application info at http://www.countycare.com/

14. CountyCare, cont’d • Lots of things they’re just now starting to try to figure out • Care coordinators? • Persuading people not to use the E.R? • Are they getting enough money from the feds to actually do it?

15. CountyCare and Ryan White services • Ryan White is “payer of last resort” • So if eligible for CountyCare, then not eligible for Ryan White services that could be covered under County Care • Primary care, pharmacy, long-term care services, behavioral and mental health services all covered under CountyCare • Dental, emergency assistance, case management and other services still can get from Ryan White • ADAP will probably start requiring clients to enroll in CountyCare at their next ADAP redetermination (not yet announced) • Clients will get HIV meds from CountyCare once enrolled

16. Support SB 26! • Implements ACA provisions allowing the state to expand Medicaid to 138% of FPL • Passed the Senate 40-19 • Needs to pass the House

17. How to keep up? • Keep your dial pointed right here! www.hivhealthreform.org and www.hivhealthreform.org/illinois • Arrange a training or call for help: AIDS Legal Council of Chicago, 312-427-8990, Ann Fisher: ann@aidslegal.com • More training or help: John Peller: jpeller@aidschicago.org, 312-334-0921