An Overview: Illinois Health Connect, Voluntary Managed Care and Disease Management
Who are we? • The Illinois Maternal and Child Health Coalition works to promote and improve the health and well-being of infants, children, mothers and families throughout the state. We accomplish these objectives, in partnership with out 90+ organizational members, through a combination of advocacy, education, community empowerment and policy development. • The Sargent Shriver National Center on Poverty Lawtakes action to end poverty. From idea to law to practice to monitoring, we work to overcome the myriad issues that combine to cause poverty. Our tools are advocacy, policy development, and communications. Together our work creates an information channel among advocates, grassroots groups, researchers, policymakers and lawmakers.
Who are we? (ct’d) • Automated Health Systems (AHS) • The State of Illinois (HFS) contracted with Automated Health Systems (AHS) to launch and administer Illinois Health Connect, the Department’s Primary Care Case Management (PCCM) program. • Under Illinois Health Connect, AHS is responsible for recruiting, educating, and supporting providers as well as assisting participants enroll with a "best fit" Primary Care Provider (PCP). • In the six counties that offer enrollment into voluntary health plans, HFS has contracted with AHS to be the Client Enrollment Broker, to provide unbiased participant education about and enrollment with a health plan and PCP.
Why are we here? • Beginning this month, most people in Cook and Collar Counties who receive Medical Assistance through HFS will be required to choose a Primary Care Provider (PCP)
Why are we here? (ct’d) • What’s In A Name?? • “Illinois Health Connect,” “Harmony Health Plan,” “Family Health Network,” “Your Healthcare Plus,” “Healthy Kids” • PCCM, DM, EPSDT, PCP, HMO, MCO
Goals • Give you the information you need to answer questions about Illinois Health Connect from the patients/clients you serve • Give you the resources you need to get your questions answered in the future (including phone numbers for AHS, Illinois Maternal and the Shriver Center)
Background • Illinois adopted Medicaid managed care early, but in a limited way • MediPlan Plus (1996) – mandatory managed care waiver that was never implemented • Voluntary managed care has been part of the Medical Assistance program since 1976, and peaked in 1998 with 15 MCOs participating. • Illinois is now turning to the Primary Care Case Management (PCCM) model of health care to address cost and quality issues. • Illinois’ PCCM program is called Illinois Health Connect. • It is sponsored by the Illinois Department of Healthcare and Family Services (HFS). • Automated Health Systems (AHS) administers the program for HFS
What is Primary Care Case Management (PCCM) ? • A model of health care that combines managed care and fee-for-service, but is more than simply managed care. • Incorporates the concept of providing each participant in the program with a “medical home” • In a medical home, Primary Care Providers (PCPs) are responsible for coordinating the provision of health services needed by the consumer (“gatekeepers” and “gate openers”)
Why is a Change Needed? • Basic Tenets of PCCM • Increased utilization of primary care and preventive services (including immunization and screening tests) • Currently, many people receive the majority of their health care from the ER • Better continuity, coordination and, thus, quality of care • Greater consumer compliance and responsibility • Improved consumer education and understanding about health-promoting behaviors • Decreased costs • Paves the way for expanded coverage initiatives such as All Kids • Medical Home
What is a Medical Home? • An approach to providing primary care • According to the American Academy of Pediatrics, a medical home is “primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective” • The doctor’s office, clinic or health center where a patient goes to see their Primary Care Provider (PCP) • The place where all of a patient’s medical records are stored
Why is having a medical home important? • A medical home provides partnership and support for the entire family • Simply put, having a medical home means having better health care • The best care is given when an individual goes to the same doctor for every visit(The ER is NOT a medical home)
Other Illinois Health Care Programs and Terms • All Kids • Comprehensive, affordable health insurance for children, regardless of family income, immigration status, or preexisting medical condition (previously known as KidCare) • Family Care • An eligibility program based on income that offers comprehensive, affordable health insurance to parents living with their children age 18 years or younger. Also covers relatives who are caring for the children in place of their parents • Moms & Babies • An eligibility program based on income that offers health care coverage to pregnant women and their babies
Other Illinois Health Care Programs and Terms • Fee-for-Service • A model of health care where services are not coordinated and from a variety of providers (i.e., no medical home) • Voluntary Managed Care • 2 Managed Care Organizations (MCOs) in Illinois • Harmony Health Plan, Family Health Network • Option for clients living in Cook, Madison, Perry, Randolph, St. Clair and Washington counties • Participants who decide to be in an MCO choose a health plan and a PCP • Your Healthcare Plus • Optional Disease Management (DM) program that helps participants better manage their chronic conditions
Covered Populations • Eligible population = 1.2 million statewide (out of 1.7 million who receive a medical card from HFS) • Includes: • Most people in All Kids and FamilyCare (1.1 million) • Disabled adults (95,000) • Some elderly (13,000)
Excluded Populations • Individuals who have Medicare • Children under age 21 who get Supplemental Security Income (SSI) • Children in foster care and children who get Subsidized Guardianship or Adoption Assistance from DCFS (Department of Children and Family Services) • Children under age 21 who are blind or who have a disability • People who live in nursing facilities • American Indians and Alaska Natives • Individuals with Spend-down
Excluded Populations (ct’d) • People who get Home and Community-Based services like the Community Care Program, the Home Services Program, or community services for persons with developmental disabilities • Refugees • Individuals residing in Community Integrated Living Arrangements (CILAs) • Individuals in Presumptive Eligibility programs
Excluded Populations (ct’d) • Individuals in limited benefit programs such as: • Illinois Healthy Women • All Kids Rebate and FamilyCare Rebate • Illinois Cares Rx (formerly SeniorCare/Circuit Breaker) • Transitional Assistance, age 19 and older • Emergency Medical Only • Hospice • Sexual Assault, Renal, and Hemophilia programs • Populations already managed such as: • High level third party liability (TPL)/private insurance • Program for All-Inclusive Care for the Elderly (PACE)
What will this change mean for patients? • Patients will be required to choose a Primary Care Provider (PCP) • Can be individual doctor or a group/clinic • Patients will need a referral for some services or to see a specialist • Change in behavior/expectations?
What will this change mean for providers? • Most providers will need to enroll as a PCP in Illinois Health Connect. PCPs in Illinois Health Connect: • Will receive a care management fee of $2-4 per patient per month, regardless of care given • Can set their panel size, up to 1800 patients • Will have access to various support services provided by Illinois Health Connect, including the Provider Helpline and the Referral Resource Directory • Referrals • Change in behavior/expectations?
FAQs • What is the relationship between Illinois Health Connect and All Kids (formerly KidCare)? • Will there be a change in benefits or eligibility? • What about those people excluded from Illinois Health Connect? • When will these changes take effect?
Illinois Health Connect Implementation • Phase 1 – Voluntary • Began July 2006 • PCPs are limited to FQHCs, RHCs, and CCBHS • Phase 2 – Mandatory • Geographical statewide implementation • Cook and Collar Counties: Jan* 2007
Enrollment Timeline • Postcard Primer • Initial Enrollment Packet • Packets will be mailed to households with potential enrollees • Packets will explain the program, PCP choices, timeframe for making a choice • Packets will contain an enrollment form personalized with each client’s name, DOB, and a postage-paid return envelope • Clients may choose a PCP by mail, phone, fax, in person, or via the Internet • We are strongly recommending enrollment via our toll-free Illinois Health Connect Helpline
Enrollment Timeline (ct’d) • Reminder Notice – 15 days after the Initial Enrollment Packet • 2nd Enrollment Packet – 15 days after the Reminder Notice • Will include the name of the PCP to which each client will be auto-assigned if they do not make a choice within the next 30 days • Auto-assignment to PCP – 30 days after 2nd enrollment packet • Prior to auto-assignment, AHS will place 2 outgoing phone calls to try to reach those who haven’t yet chosen a PCP
Auto-Assignment • The auto-assignment algorithm will take into account: • Existing provider-client relationships (based on voluntary phase enrollment and claims data) • PCPs of other family members • Location • Provider specialty • Capacity limits
Enrollment Choices • In Collar Counties, enrollees will choose a PCP in Illinois Health Connect • In Cook County, enrollees will choose one of the following 3 health plans: • Illinois Health Connect • Harmony Health Plan • Family Health Network • The enrollee will also choose a PCP within the health plan they choose
PCCM: Illinois Health Connect HFS program that combines some components of managed care and fee-for-service Provider Network = Physicians that have enrolled as PCPs and all specialists participating with HFS Providers paid fee-for-service by HFS Managed Care Organizations: Harmony Health Plan andFamily Health Network Different provider networks recruited by health plan Referral process may include medical necessity review Health Plans receive monthly premium or capitation payment for each member enrolled Enrollment Choices (ct’d)
Enrollment Choices (ct’d) As the Illinois Client Enrollment Broker (for Cook County), AHS is responsible for: • Educating potential enrollees regarding their health care choices in an unbiased manner • Enrolling potential enrollees in the “best fit” health plan and PCP of their choice • Educating enrollees on how to access services and manage their health care in the health plan they choose • Processing requests to change PCPs and/or health plans
Enrollment Choices (ct’d) • Enrollees may change their PCP or health plan, for any reason, once per month • PCP changes will take effect within 24 to 48 hours • Enrolling and disenrolling from Harmony or Family Health Network will take 2-6 weeks • Again, these changes are processed by the Illinois Client Enrollment Broker (CEB), NOT by Harmony or FHN • 1-877-912-8880
Cook County Phone: 1-877-912-8880 Internet: www.illinoisceb.com In person: at a local DHS office (Family Community Resource Center) Collar Counties Phone: 1-877-912-1999 Internet: www.illinoishealthconnect.com In person: at a local DHS office (Family Community Resource Center) How to Enroll
Confirmation of Enrollment • Enrollees will receive a letter to confirm their enrollment (PCPs will not be listed on the client’s medical card) • Each PCP will receive a monthly client roster for all clients enrolled with that PCP as of the first of each month • Providers should always check client eligibility/PCP assignment prior to providing service through the MEDI system or other REV vendor (Nebo, E-Care, etc.)
Other Client Enrollment Services Provided by AHS • AHS Call Center staff are available and ready to assist with questions and to enroll clients. • Call Center Phone #: 1-877-912-8880 (TTY: 1-866-565-8576). The call is free. • Call Center hours: • 7:00 AM - 8:00 PM – Monday through Friday • 9:00AM - 5:00 PM – Saturday • Bilingual representatives will be available to assist clients with limited English proficiency. • Clients will have access to translation services via the Language Line. • Information is available in other formats (like audio tape) upon request.
Other Client Enrollment Services Provided by AHS (ct’d) • AHS staff will be located in 19 of the Cook County Family Community Resource Centers (DHS offices) available from 8:30 AM – 5:00 PM, Monday through Friday. • AHS staff are available to conduct presentations for staff and/or consumers at community-based organizations. • AHS will hold community meetings to educate clients on the upcoming changes
FAQs • How does someone know which doctors they can choose from in their area? • Does a family have to pick one PCP for the whole family? • Will materials be printed in more than one language? • Will enrollees be auto-assigned to one of the MCOs (Harmony or FHN)? • Will the MCOs still be allowed to enroll patients? • What role will AKAAs, social service providers and other CBOs play in the client enrollment process? • Will we be able to see copies of the enrollment packets that are sent to clients?
Direct Access Services (do NOT require a referral) • Services to newborns up to 91 days after birth • OB/GYN and Family Planning services • Shot/immunizations • Emergency Room Visits • Emergency and non-emergency transportation services • Pharmaceuticals • Dental services • Vision services • Mental health and substance abuse services • Lead screening & Epidemiological Services
Direct Access Services (ct’d) • Outpatient ancillary services (radiology, pathology, lab, anesthesia) • Direct inpatient admissions • Services to treat STDs and tuberculosis • Early intervention services • Therapies • Service provided by: • School-Based/Linked clinics (under age 21) • School Based clinics through Local Education Auth. (under age 21) • Local Health Departments • Mobile vans, with HFS approval • FQHC homeless sites
Services That Require a Referral • Services provided by: • Physicians, including another PCP (w/ exception of OB/GYNs) • Nurse practitioners, midwives, and physician assistants • Podiatrists and Chiropractors • RHCs, FQHCs, other clinics and ambulatory surgical treatment centers • Audiologists • All other services that are not Direct Access services
Referrals • PCPs order and authorize referrals • PCPs can access the Referral Resource Directory to locate specialists. • AHS only tracks referrals to guarantee payment is appropriately made to the specialist or other provider. • Referrals may be registered by Internet, phone, or fax beginning in January 2007. • Referral information will be available on a real-time basis so providers can verify a referral has been made. • Provider claims will not be rejected for lack of PCP referrals until mid-2007 at the earliest
FAQs • What if a patient has a chronic condition or other special healthcare need and must visit a specialist regularly? Will they need a referral for each visit? • Do specialists need to enroll with Illinois Health Connect? • What if there’s an emergency or other situation in which the patient’s PCP cannot be reached for a referral? • If outpatient ancillary services like lab tests or X-rays don’t require a referral, does that mean anyone can get them at any time? • Will patients need referrals for inpatient procedures? • Will PCPs be able to monitor which direct access services their patients receive?
Providers Eligible to Serve as PCPs (must meet all PCP requirements) • FQHCs, RHCs, other clinics including certain specified hospitals, and CCBHS clinics • General Practitioners, Internists, Pediatricians, Family Practitioners, OB/GYNs, Osteopaths, and other Specialists • Certified local health departments • School-based/linked clinics that meet PCP requirements • Other qualified health professionals as determined by HFS
Providers Eligible to Serve as PCPs (must meet all PCP requirements) • HFS will allow nurse practitioners, midwives, and physician assistants to participate by providing services with an affiliated physician. • In counties or service areas where there may be a limited availability of PCPs to sufficiently meet the demand, HFS may approve advanced practice nurses to directly enroll as PCPs. • Eligible provider types may be expanded if it is determined by HFS to be in the best interest of the program.
PCP Requirements • Be enrolled with HFS as one of the allowed provider types • Maintain hospital admitting and/or deliver privileges or arrangements for admission to a nearby hospital • Make medically necessary referrals to enrolled providers, including specialists, as needed • Provide or arrange for coverage of services, consultation, or referral for medical conditions 24 hours/day, 7 days/week. Automatic referral to an emergency room does not qualify. • Maintain office hours of at least 24 hours/week (solo) or 32 hours/week (group).
PCP Requirements (ct’d) • Maintain appointment standards • Routine, preventive care appointments available within 5 weeks (within 2 weeks for infants under 6 months) from the date of request for care • Urgent care conditions not deemed emergency must be triaged within 24 hours • Appointments for enrollee problems/complaints not deemed serious available within 3 weeks from request
PCP Requirements (ct’d) • Maintain appointment standards • Initial prenatal appointments without expressed problems • 1st trimester: within 2 weeks • 2nd trimester: within 1 week • 3rd trimester: within 3 days • Upon notification of hospitalization or ER visit, follow-up appointment available within 7 days of discharge
Care Management Fee • PCPs will be paid a special monthly care management fee for each person whose care they are responsible for managing. • $2.00 per child • $3.00 per adult • $4.00 per disabled or elderly enrollee • The monthly Care Management Fee will be paid even if the enrollee does not get services that month and will not be subject to the payment cycle. PCPs will continue to receive their regular fee-for-service reimbursement from HFS.
Provider Support • Support services made available to providers in their role as PCP include: • The Illinois Health Connect Provider Helpline assists PCPs with Enrollee outreach and education, appointment scheduling and getting answers to questions about Illinois Health Connect • Referral Resource Directory, a useful tool to assist providers and participants in identifying medical professionals and community-based agencies that can help address patients’ medical and other (e.g., WIC, transportation) needs.