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An Overview: Illinois Health Connect, Voluntary Managed Care and Disease Management Who are we?

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who are we
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
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
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
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”
  • 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)
  • 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
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
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
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
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
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 terms14
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
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
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
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 d19
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
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
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?
  • 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
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
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
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
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
enrollment choices ct d
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 d30
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 d31
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
how to enroll
Cook County

Phone: 1-877-912-8880


In person: at a local DHS office (Family Community Resource Center)

Collar Counties

Phone: 1-877-912-1999


In person: at a local DHS office (Family Community Resource Center)

How to Enroll
confirmation of enrollment
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
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
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
  • 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
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
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 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
  • 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
  • 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
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 requirements45
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
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
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 d48
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
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
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.
provider support ct d
Provider Support (ct’d)
  • Provider Services Representatives and Training Specialists are based regionally throughout the state and meet face-to-face with providers to address issues and concerns, and answer billing and other questions. They conduct initial and ongoing training sessions to keep providers and their office staff up-to-date on HFS policies.
  • The Illinois Health Connect Participant Helpline provides care coordination for patients; assists patients in finding a PCP, specialist or health/human services provider; and helps with scheduling appointments.
  • The Illinois Health Connect Website provides program information for both providers and participants, including important links, frequently asked questions, and contact information.
  • The Illinois Nurse Helpline provides back-up support to patients who cannot reach their PCPs after-hours or on weekends as a means of minimizing unnecessary ER use and reconnecting patients to their PCPs.
provider support ct d52
Provider Support (ct’d)
  • Panel Lists inform providers of patients that are linked to them and indicate each patient’s preventive health care status (e.g., EPSDT screen due).
    • PCPs may set panel size limits and opt out of auto-assignment.
    • Illinois Health Connect Profiles provide an overview of service utilization by patients in a PCP’s panel to help support the PCPs’ quality assurance efforts.
terminating patient relationships
Terminating Patient Relationships
  • PCPs may request a change in enrollee assignment in accordance with the Medical Practice Act, 63 F.S., the Principles of Medical Ethics of the American Medical Association and Illinois State Regulations related to abandonment.
  • Any standards established by the PCP for enrollee reassignment must be practice-wide and apply to all enrollees.
  • Under Illinois Health Connect, the PCP must continue to see the enrollee until the request is granted and reassignment occurs.
  • Do providers need to enroll with Illinois Health Connect even if they’re already enrolled with HFS?
  • Can a provider opt out of the auto-assignment process?
  • Can a provider change their panel size once they’ve set it?
  • For big hospitals and healthcare systems, do the doctors need to enroll individually with Illinois Health Connect?
  • Can providers enroll with Illinois Health Connect AND one of the MCOs (Harmony or FHN)?
  • Do physician assistants, midwives and nurse practitioners affect the panel size limits?
disease management your healthcare plus56
Disease Management: Your Healthcare Plus
  • “Your Healthcare Plus” is a program to help clients that have a chronic health problem:
    • Lung Problems like asthma, chronic obstructive pulmonary disease (COPD), emphysema, or bronchitis
    • Heart problems like heart failure, coronary artery disease (CAD), or high blood pressure
    • Diabetes
    • High cholesterol
    • Mental Illness like depression or schizophrenia
how does your healthcare plus work
How Does Your Healthcare Plus Work?
  • Patients are eligible for the program because of their health history
  • The choice to participate, however, remains with the patient
  • Each patient has a special team of nurses and health educators. The team works to:
    • Offer patients helpful information
    • Help patients learn about their illnesses or conditions
    • Help patients make health decisions
    • Help patient to work with their doctor.
what does your healthcare plus accomplish
What Does Your Healthcare Plus Accomplish?
  • Helps patients understand their health problems
  • Gives information to patients to read about how to be healthier
  • Finds medical services for patients
  • Makes sure patients have the right medicines and understand how to take their medicines
coordination between ahs and mckesson
Coordination between AHS and McKesson
  • Identifying potential PCPs and referring them to AHS for outreach and enrollment
  • Flagging DM enrollees within AHS tracking system for additional education activities (e.g., excessive ER usage)
  • Updating McKesson with Illinois Health Connect provider directories
  • Coordinating presentations to larger stakeholder groups
  • Providing each other with demographic information for hard-to-find cases
  • Sharing program materials for distribution to enrollees and providers
increasing the provider network
Increasing the Provider Network
  • Faster Payments
    • HFS has made significant improvements in the payments cycle over the last several months, including:
      • Physicians will be paid weekly for claims for both children and adults.
      • All clean claims for physician services to children aged 18 and under will be paid within 30 days of receipt by HFS.
      • All clean claims for physician services to adults will be paid within 60 days of receipt by HFS.
increasing provider network ct d
Increasing Provider Network (ct’d)
  • Enhanced Reimbursement Rates
    • HFS has enhanced maternal and child health rates for physicians participating as a PCP
      • Increases up to 160% for some services
  • Culture change?
  • Anticipated response from families? Issues?
  • What can we do to help families through this transition? What do we need?
contact information
Cook County

Illinois Client Enrollment Broker

Clients: 1-877-912-8880 (TTY: 1-866-565-8576)

Administrative: 1-888-912-1220

Providers: 1-800-571-8504

Collar Counties

Illinois Health Connect

Clients: 1-877-912-1999 (TTY: 1-866-565-8577)

Administrative: 1-888-912-9120

Providers: 1-800-571-8504

Contact Information
contact information ct d
Contact Information (ct’d)
  • Your Healthcare Plus (McKesson)
    • Patients: 1-800-973-6792; TTY: 1-888-317-2697
    • Website:
  • Illinois Department of Healthcare and Family Services
    • Patients: 1-866-468-7543; TTY: 1-877-204-1012
    • Providers: 1-800-842-1461 (Medi); 1-877-782-5565
contact information ct d66
Contact Information (ct’d)
  • Illinois Nurse Helpline
    • 1-800-571-8094 (TTY: 1-800-571-8419)
  • Transportation Services
    • 1-877-725-0569 (TTY: 1-877-204-1012)
  • Dental Services
    • 1-888-286-2447 (TTY: 1-800-466-7560)
what can you do to help promote preventive care
What can you do to help promote preventive care?
  • SPREAD THE WORD: Inform the families you work with about Illinois Health Connect, the voluntary managed care program in Cook County and Your Healthcare Plus
  • HELP FAMILIES understand the importance of a medical home
  • REMIND FAMILIES to keep their caseworker updated on current address and phone number
  • If you work with families that have had a difficult time with any of the programs mentioned, please contact us.

Patrick Keenan-Devlin


Joe Weimholt