Chart of Medicaid Managed Care and Coordinated

Illinois Medicaid Managed Care
and Care Coordination Projects for Older Adults
and People with Disabilities 2014
KEY TERMS
Capitated Payment – a form of payment in which an entity is paid a flat amount (per member/individual) to provide care or coverage,
regardless of how many services those members actually use in a period of time. Capitated payment is the opposite of “fee for service” in
which providers receive individual payments for each specific service that is performed.
Care Coordination – a method of managing a patient’s health care in which an individual (or in some cases, a team of individuals) helps a
patient organize and streamline their care. In a care coordination model, a “Care Manager” or “Care Coordinator” may communicate with
the patient’s health care providers to ensure that the patient receives all of the information and care they need, and that the care being
received from different providers is not duplicated or conflicting. The Care Manager/Care Coordinator may also provide ongoing follow-up
with the patient to ensure that the patient understands what s/he needs to do to manage his/her health conditions.
Care Coordination Entity (CCE) – CCE’s are provider-organized networksthat will provide Care Coordination to certain groups of people
on Medicaid. CCE’s accept partial risk for their members’ care. CCE’s will receive capitated payments to provide care coordination to
members, but CCE members’ medical care will still be paid using a fee-for-service model.
Department of Healthcare and Family Services (HFS) – the Illinois agency that is responsible for overseeing Medicaid. HFS is in charge
of all of the projects described in this chart.
Dual Eligible – someone who has both Medicare and Medicaid.
Enrollment Broker – an entity that facilitates enrollment into insurance plans. An Enrollment Broker may assist consumers in finding a
plan that will work for them by helping them analyze the available plans’ networks or other relevant factors.
Federal Poverty Level (FPL) – an income cutoff developed by the federal government that is used to determine who qualifies for many
government benefit programs.
The Make Medicare Work Coalition
Updated August 20, 2014
1
KEY TERMS (Continued)
Long Term Services and Supports (LTSS) –care that helps individuals perform activities of daily living (eating, cooking, bathing, getting
dressed, cleaning, etc.) This care may be provided in a long term care facility or through home and community based services. In Illinois,
many individuals receive home and community based LTSS services through “Waiver” programs (such as the Community Care Program
for older adults). These programs provide a variety of in-home supports to older adults, people with disabilities, and individuals with specific
conditions, such as brain injuries or HIV/AIDS. For more information about the home and community based Waiver programs in Illinois,
visit the Department of Healthcare and Family Services website here:
http://www2.illinois.gov/hfs/MedicalPrograms/HCBS/Pages/default.aspx
Managed Care – a method of financing and delivering health care that uses a variety of techniques to reduce the cost of care (often with
the goal of improving quality of care, as well). These techniques often include care coordination, the use of “integrated delivery systems”
(systems in which patients must use specified networks of providers), utilization review (such as limits on the use of certain services or
requiring prior authorization), or financial incentives to encourage members to use care efficiently. In a managed care system, individuals
are enrolled in a Managed Care Organization (MCO) that is responsible for paying for and monitoring their care. MCO’s are traditionally
run by insurance companies and use a variety of network models (for example, Health Maintenance Organizations (HMO’s), Preferred
Provider Organizations (PPO’s), and Private Fee For Service (PFFS) plans).
Managed Care Community Network (MCCN) –An MCCN is a network that is created and run by health care providers (as opposed to a
traditional MCO, which are run by insurance companies). MCCN’s accept full financial risk for members’ care. This means that MCCN’s will
receive capitated payments from the state to provide care coordination AND all necessary medical care.
Mandatory Enrollment – a model in which individuals must enroll in a plan or project in order to receive services.
Medicaid – a federal/state health insurance program for individuals who are low income. Currently, to qualify for Medicaid, an individual
must meet income and asset requirements AND be in a covered category (children, pregnant women, some parents, adults with
disabilities, or older adults). The federal government pays for part of the costs of Medicaid coverage, and states pay the rest.
Medicare – a federal health insurance program that provides coverage for most people over age 65 and some under 65 with disabilities.
Passive Enrollment – a model in which individuals are automatically enrolled into plans by another entity. If a project is mandatory and
individuals are passively enrolled into a plan, the individuals may be ‘stuck’ in the plan until the next Open Enrollment Period. However, if a
project is voluntary and individuals are passively enrolled, those individuals may still choose to change plans or opt out of the project after
they have been automatically placed into a plan.
Voluntary Enrollment – a model in which individuals only enroll in a plan or project if they choose to enroll.
The Make Medicare Work Coalition
Updated August 20, 2014
2
2014 Managed Care and Care Coordination Projects for Older Adults and People with Disabilities
Project: Integrated Care Program (ICP)
Description
Managed care program for seniors and adults with
disabilities who have Medicaid only (no Medicare). MCO’s
are responsible for covering members’ medical and hospital
care, prescriptions, mental health/behavioral health and
LTSS. MCO’s also provides care coordination for members.
The state pays the MCO a capitated amount, and the MCO
pays the members’ health care providers for services.
ICP is being implemented in three Service Packages:
Service Package I - Medicaid medical services
Service Package II - LTSS and waiver services added
(excluding Developmentally Disabled (DD) waiver)
Service Package III - Developmentally Disabled Waiver
services
The ICP MCO’s are:
 Cook, DuPage, Kane, Kankakee, Lake, and Will
Counties: Aetna Better Health, IlliniCare

Rockford area: Aetna Better Health, IlliniCare,
Community Care Alliance MCCN*

Central Illinois: Molina Healthcare, Meridian, Health
Alliance, Macon County CCE*

Quad Cities: HealthSpring, IlliniCare, Precedence
CCE*

Metro East: Meridian, Molina Healthcare
Who is Affected
Seniors and adults
with disabilities who
are on Medicaid only
(no Medicare).
In Service Package 3
(not yet in place), ICP
MCO’s will also
become responsible
for individuals with
developmental
disabilities. (For a
definition of
“developmental
disabilities,” see the
HFS website here:
http://www2.illinois.go
v/hfs/agency/Transpar
ency/Pages/Transpar
encyGlossary.aspx
*Note Some individuals in Rockford, Central Illinois and the
Chicago area may be assigned to a Care Coordination
project (MCCN or CCE) instead of an MCO (see page 5 for
more information).
The Make Medicare Work Coalition
Updated August 20, 2014
Enrollment
ICP enrollment is
mandatory. Individuals
have 60 days to choose a
plan; otherwise they will
be passively enrolled into
a plan. They can switch
plans in the first 90 days
of enrollment. If an
individual switches plans
in the first 90 days, s/he
has 90 additional days to
switch back to the original
plan. After that, they are
“locked in” to the plan for
12 months.
Once each year,
individuals in ICP will have
a 60 day Open Enrollment
Period to change plans.
(Each individual receives
a letter that tells them
when their Open
Enrollment Period will be.)
Implementation
Date/Geographic Area

Service Packages 1
(medical) & 2
(LTSS) are currently
active in Cook,
DuPage, Kane,
Kankakee, Lake,
and Will Counties,
Rockford area,
Central Illinois area,
Quad Cities and
Metro East.

Service Package 3
implementation is
still to be
determined.
To enroll in an ICP MCO,
individuals should contact
the ICP Enrollment Broker
by calling 1-877-912-8880
or visiting
http://enrollhfs.illinois.gov/
3
2014 Managed Care and Care Coordination Projects for Older Adults and People with Disabilities
Project: Medicare Medicaid Financial Alignment Initiative (MMAI)
Description
Managed care program for dual
eligibles. MCO’s will be responsible
for covering medical and hospital
care, prescriptions, mental
health/behavioral health and LTSS,
as well as for providing care
coordination to members.
The state will pay each MCO a
capitated amount, and the MCO will
pay the members’ health care
providers for services.
Who is Affected
People who are
receiving FULL
Medicare (Parts A, B,
and D) and Medicaid
benefits (without
spenddown), are over
the age of 21, and live
in the project areas.
Individuals who receive
the following benefits
are excluded from
MMAI:
The MCO’s that will be participating in  Medicaid
the MMAI project are:
Spenddown
 Temporary
Chicago Area: Aetna Better Health,
Medicaid benefits
IlliniCare, Meridian Health Plan of
 Care through the
Illinois, HealthSpring, Humana, Blue
Illinois Breast &
Cross/Blue Shield of Illinois
Cervical Cancer
Program
Central Illinois: Molina Healthcare,
 Private third party
Health Alliance
insurance (such as
employer or retiree
coverage)
 Care through an
Illinois waiver
program for people
with Developmental
Disabilities
The Make Medicare Work Coalition
Enrollment
Enrollment will be voluntary and
passive. This project will utilize a
Client Enrollment Broker (like
ICP).
Individuals not receiving LTSS:
 May change MCO’s at any
time during the year. (even
those who are passively
enrolled)
 Individuals not receiving
LTSS may also choose to opt
out of the MMAI program
entirely at any time of the
year
Individuals receiving LTSS:
 Can opt out for medical
services any time of the year,
but not for LTSS
 If people with LTSS opt out of
MMAI for medical services,
they will use traditional
Medicare & Medicaid for all
hospital and medical claims,
but they will need to join an
MCO for LTSS services.
Once they join an MCO for
LTSS, they will be locked into
that MCO for their LTSS
services for 12 months.
Updated August 20, 2014
Implementation Date/Geographic
Area
Individuals not receiving LTSS:
 Voluntary Enrollment began
March 2014
 Passive Enrollment began in
phases in June 2014 (Individuals
will begin to be automatically
enrolled into an MCO if they did
not make a choice of coverage by
May 31, 2014)
Individuals receiving LTSS:
 Voluntary Enrollment begins fall
2014
 Passive Enrollment begins fall
2014 (Individuals will be
automatically enrolled into an
MCO if they did not make a
choice during Voluntary
Enrollment)
MMAI enrollment will affect the
following counties:
Cook, Lake, Kane, DuPage, Will,
Kankakee, Knox, Peoria, Tazewell,
McLean, Logan, DeWitt, Sangamon,
Macon, Christian, Piatt, Champaign,
Vermillion, Stark, Ford, and Menard.
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2014 Managed Care and Care Coordination Projects for Older Adults and People with Disabilities
Care Coordination Projects for Older Adults and People with Disabilities
Description
Several demonstration projects that will
provide care coordination for certain target
populations in the Chicago area and Central
Illinois.
Projects may be Managed Care Community
Networks (MCCN’s) or Care Coordination
Entities (CCE’s).
HFS has chosen six Innovations projects to
coordinate care for older adults, people with
disabilities, and individuals with complex
medical conditions:
Chicago Area: Be Well Partners in Health
(CCE), Healthcare Consortium of Illinois
(CCE), Together4Health (CCE), Community
Care Alliance of Illinois (MCCN)
Rockford: Community Care Alliance of
Illinois (MCCN)
Central Illinois: Macon County Care
Coordination (CCE), Precedence Care
Coordination (CCE).
Who is Affected
Enrollment
Various targeted groups
of Medicaid
beneficiaries in the
Chicago area and
central Illinois. (Please
note: These groups
may include individuals
who have Medicaid only
or dual eligibles
(Medicare and
Medicaid). Therefore,
some people who
would otherwise be in
ICP or MMAI (see
pages 3 and 4) may be
able to choose to enroll
in a Care Coordination
project instead of an
MCO.)
Enrollment is voluntary.
*Note: Enrollment into an
Innovations project may be
mandatory for a small
group of individuals who
are eligible for ICP in
Rockford, Central Illinois
and the Quad Cities area.
These individuals will be
assigned to an Innovations
project instead of one of
the ICP MCOs (See page 3
for ICP eligibility)
Each project may only
enroll 500-1,000
people in the first
year.
Implementation Date/Geographic
Area
Expected start dates for these
projects vary, but all were expected
to begin between April and July
2013.
For more information about Care
Coordination projects in Illinois, visit
the HFS website:
http://www2.illinois.gov/hfs/PublicIn
volvement/cc/Pages/default.aspx
Once someone enrolls,
they will be ‘locked in’ to
the project for 12 months.
Individuals will enroll in
these projects using an
Enrollment Broker (just like
the ICP and MMAI
programs discussed on
pages 3 and 4).
The state of Illinois is also implementing managed care and care coordination projects that affect children, families, and the
new ACA Adult Medicaid population. Those projects are not included in this chart.
Also, individuals who are enrolled in the Illinois Health Connect Program will remain enrolled in that program – Illinois Health
Connect is not changing as a result of these additional initiatives.
The Make Medicare Work Coalition
Updated August 20, 2014
5

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