Medicaid Managed Care Overview
• ICAAP, Jennie Pinkwater & Dru O’Rourke
• ISMS, Ken Ryan • IAFP, Gordana Krkic • IAMHP, Samantha Olds Frey & Cyrus Winnett
Medicaid Managed Care Basics
2011 Medicaid Reform Law
In 2011, the General Assembly passed PA 96-1501 to address increasing budget pressures in the Medicaid program, requiring Illinois to enroll 50% of its Medicaid population in “care coordination” by January 1, 2015.
• Mandatory Enrollment • Auto-Assignments • IT Structure & Interface • Encounters Submission
Medicaid MCO Characteristics
• Capitated Rates based on FFS
• Mandated Staff & Provider Trainings • Required Member Materials • Stringent Marketing & Outreach Regulations
• 85% MLR
• Defined Appeals & Grievances Procedures
• Defined Benefit Package
• Mandated Reporting
• Defined Population
• Defined BEP Spend
• Defined Quality Measures & • Robust Fraud, Waste & P4Ps Abuse Standards • Network Capacity Standards • State & Federal Policy Changes • Defined Staffing Ratios
Illinois Association of Medicaid Health Plans Nine MCO Members (2018): • CountyCare – HealthChoice Illinois, Cook County Only • NextLevel Health – HealthChoice Illinois, Cook County Only • Harmony WellCare – HealthChoice Illinois • BCBSIL – HealthChoice Illinois, MMAI • Molina Healthcare – HealthChoice Illinois, MMAI • Meridian Health – HealthChoice Illinois, MMAI • IlliniCare – HealthChoice Illinois, DCFS, MMAI • Aetna Better Health – MMAI • Humana – MMAI
HealthChoice Illinois • Enrollment Process: Phase I Transition Assignment in Current MCO Regions • Letters mailed October & November 2017 with effective date of January 1, 2018 • Clients assigned to current MCO with 90-day option to change to another MCO • Locked in for 12 months
HealthChoice Illinois • Enrollment Process: Phase II Full Enrollment Packet in Expansion Regions • Enrollment Packets mailed beginning January 2018 with effective date beginning April 1, 2018 • Clients given 30-day option to voluntarily enroll with one of five statewide MCOs by calling Client Enrollment Broker (Maximus) • If no choice is made, client will be auto assigned to an MCO based on an algorithm • 90-day option period to change to another MCO • Locked in for 12 months
HealthChoice Illinois • Enrollment Process: Phase III Enrollment of Special Needs Children • Enrollment anticipated Oct 1, 2018 • Children with Special Needs: • Under age 21 • are eligible for supplemental security income (SSI) under Title XVI;
• receive services under the Specialized Care for Children Act via the Division of Specialized Care for Children (DSCC); • qualify as disabled; or, • are under the legal custody or guardianship of the Illinois Department of Children and Family Services (DCFS).
Specific Population Delays • According to an HFS Provider Notice published on 3/29/18, “the HealthChoice Illinois program for dual-eligible individuals receiving long term care and who are not enrolled in the Medicare-Medicaid Alignment Initiative (MMAI) or individuals receiving waiver services in the expansion counties has been postponed. This change effects only individuals receiving services in one of the following programs and who recently selected or were assigned to a health plan in the HealthChoice Illinois program in the expansion counties for an April 1, 2018 or later effective date. • Community Care Program (Elderly Waiver) • Home Services Program (Division of Rehabilitation Services Waivers) • Supportive Living Program (SLP Waiver) • Nursing home or long term care facility (non-MMAI dual eligible)
Contract & Billing Specifics
Continuity of Care • The MCO Model Contract requires that a member newly enrolled with a health plan may maintain a current course of treatment for a 90-day transition period. This applies to: • All provider types • Out-of-Network providers • Health Plans will pay the same rate HFS would pay for those services under current Fee-For-Service rates • Providers must adhere to health plan procedures regarding referrals and preauthorization for treatment
Simplified Credentialing From HFS: • Under the new program, registering with the Department’s online provider enrollment program will become the only requirement to begin developing relationships with every Medicaid managed care health plan…Medicaid providers will need to only register with HFS IMPACT website… • Once an application is approved by HFS, the provider is considered credentialed with the Health Plan. • Please be aware of two important features of this upgrade. First, the change applies only to the HealthChoice Illinois and MMAI programs. Second, although providers will be credentialed through IMPACT, they should continue to provide specific information requested by MCOs that is not included in the credentialing process but is needed for MCO Operations, such as provider office hours. • Credentialing on it’s own does not mean a provider and a health plan will be doing business together. Provider and plans must still enter into contractual relationships and satisfy all necessary operational requirements.
IAMHP Universal Provider Roster
• Standardized roster to be accepted by all HealthChoice plans. • The Roster and instructions can be found on IAMHP’s website: IAMHP.net under the provider resources page • The template seeks to obtain three categories of information required for contracting and provider directories: • Information that is required • Information that is required only if applicable to your organization • Information that is preferred, but not required
• If your organization would like training on completing the roster please let IAMHP or a Medicaid Health Plan know.
Registering in IMPACT
• How a provider registers in IMPACT will directly affect how a provider is reimbursed by a health plan.
• Ensure that all applicable specialties are selected and submitted to IMPACT. • It is paramount that the taxonomy number(s) registered with IMPACT are the ones listed on claims and rosters to ensure payment.
• HFS requires that clean claims be paid within 30 days. • 90% within 30 days • 99% within 90 days
• A clean claim is a claim submitted on the proper form, to a health plan for an eligible member, by a provider authorized to perform a covered benefit that is medically necessary and appropriate, where no additional information is required to process the claim.
Appeals & Grievances
• Every Health Plan has an approved Appeals and Grievances policy. • Providers are allowed to appeal on behalf of Medicaid members. • This process is monitored by HFS and timelines must be met. • If plans are not meeting contractual obligations then they are subject to sanctions.
• Every plan lists their prior authorization requirements: • http://iamhp.net/resource-center-preauthorization
• Plans review prior authorization requirements regularly. If you notice an outlier notify the health plan. • Electronic Authorization requests are preferred and encouraged.
Known Industry Concerns
• IAMHP is currently working with the Department and Medicaid Plans to clarify the following policies: • Maternal and Child Health Add-on • Streamlining newborn assignment and claims payment • Vaccines for Children policy changes
Illinois Department of Healthcare and Family Services – Care Coordination Homepage • Transition Letters and Client Communications • Program Descriptions • Enrollment Information • Care Coordination Quality Metrics • HealthChoice Illinois 2018 Model Contract
IAMHP Website – Info for Providers
• In addition to the Key Contacts and Billing Guides, the Info for Providers section also includes links to Provider Manuals and Prior Authorization links • Regular updates to reflect any URL changes, document updates, etc. • IAMHP always welcomes suggestions, so please don’t hesitate to share what additional information we can collect from the health plans and post to our site.
HealthChoice Illinois Health Plan Information • An educational document comprised of presentations by each of the HealthChoice Illinois health plans • Navigation: Info for Providers HealthChoice Illinois IAMHP HealthChoice Illinois and Health Plan Information • Covers a wide range of topics, including: • • • • • • • • •
Service Delivery Models Care Coordination Billing/Claims Procedures Reimbursement Methodologies Prior Authorizations Appeals/Grievances Mandated Trainings Timely Filing Provider Portals
IAMHP Billing Guides
IAMHP Key Contacts
IAMHP Contact Information Samantha Olds Frey, Executive Director [email protected]
Cyrus Winnett, Associate Director [email protected]