Managed Care - EFE

June 27, 2012
Presented by:
Melissa O. Picciola,
Equip for Equality
The concept of managed care in the Medicaid
context is no different than in the private
insurance market
◦ A.K.A. Coordinated Care, Integrated Care
Most states have a Medicaid Managed Care
program (all but Alaska, New Hampshire,
◦ 71% of the Medicaid population (and growing)
◦ Until recently, people with disabilities were not
widely included in Managed Care programs
◦ Recent Federal support (CMS, ACA)
Capitated, Full-Risk
◦ Managed Care Organization (MCO) is paid fixed
monthly premium per member and assumes fullrisk for delivery of services (PMPM)
◦ Providers are paid an additional fee for coordinating
care for members
Other Models
◦ Partial Risk
◦ Managed Care Community Networks (MCCN)
In January 2010, the Illinois Legislature
passed a Medicaid Reform Bill.
◦ Requires that 50% of Medicaid clients be enrolled in
coordinated care programs by 2015
◦ Coordinated Care defined broadly to include either
capitated, full-risk payment or other risk-based
payment arrangements
 Not just traditional managed care companies, but also new alternative models of
care organized and managed by hospitals, Physician groups, Federally Qualified
Health Centers (FQHC) or social service organizations
◦ Requires payments to be made based on
performance related to health outcomes
HFS created Innovations Project to comply
The Innovations Project consists of several phases
through which the State seeks a redesigned health
care delivery system that is more patient-centered
with a focus on improved health outcomes,
enhanced patient access, and patient safety.
To achieve these goals, the State seeks entities to
coordinate care across the spectrum of the
healthcare system with a particular emphasis on
managing transitions between levels of care and
coordination between physical and mental health
and substance abuse.
Integrated Care Program
Phase I of the Innovations Project
◦ Coordinated Care Entities & Managed Care
Community Networks: statewide
Medicaid-Medicare Alignment Initiative
◦ Children?
◦ Voluntary MCOs
◦ Primary Care Case Management
Implemented May 2011 for adult Medicaidonly enrollees known as Aged, Blind, Disabled
◦ Adults with disabilities and older adults not
enrolled in Medicare
Two companies selected: Aetna and IlliniCare
Service Package I includes all acute medical
and behavioral healthcare
Service Package II & III: Includes all long
term-care and waiver services
◦ To be implemented Fall 2012
Solicits proposals from Coordinated Care
Entities and Managed Care Community
Networks to coordinate care for Medicaid
◦ Must include portion of AABD Population
◦ Statewide initiative, not including ICP clients
◦ Voluntary enrollment with 12 month lock-in
Will award 10 contracts in Cook County and
10 Contracts outside of Cook County
◦ Received 75 letters of intent in February 2012
◦ Proposals due June 15, 2012
Provider groups and other organizations: must include PCPs,
hospitals, mental health and substance abuse providers
◦ May include others and offer other services outside of care coordination
Receives enhanced fee for care coordination
◦ Does not assume full risk
 Medical services remain Fee-For-Service
 Proposal must be cost-neutral over 3 years
◦ 3 financial models available:
 Care Coordination Fee: PMPM fee
 Shared Savings: Over baseline established by HFS/CMS
 Other Payment methodology: Proposed by CCE
Only for adults already enrolled in Illinois Health Connect
◦ 1.8 million adults as of May 2012
Entity, other than HMO, that is owned, operated, or governed
by providers and provides all Medicaid-covered services
◦ May include others and offer other services
Full-risk, capitated payment
◦ Assume full-risk for all acute medical and behavioral healthcare
 May include dental and pharmacy
 May include long-term care and waiver services
Enrollees do not have to be enrolled in Illinois Health
Connect, but may be
HFS has filed proposed rules amending the financial
requirements for a MCCN
◦ Essentially lowering financial thresholds and allowing HFS to limit
Up to 5 (at least 2), risk-based contracts
awarded to HMOs and MCCNs to provide all
Medicare and Medicaid Covered Services to
◦ Individuals with Developmental Disabilities that receive services in an
institutional setting or through a HCBS waiver are excluded
◦ Excludes those already enrolled in CCE or MCCN
◦ Full-risk, capitated payment
Implementation by January 2013
Greater Chicago and Central Illinois
◦ 2 separate solicitations
Enrollment is Passive, but voluntary
◦ No lock-in period; i.e. can disenroll at any time
Studies have shown that managed care
models have had positive impact on access
and continuity of care while reducing overall
medical costs
◦ Avoid unnecessary medical services
◦ Provide coordination and integration of services
 Decrease “silos”
Pay for Performance Measures and Bonus
Payments for achieving certain outcomes
◦ Encourages providers to be accountable and allows
states to set benchmarks
Incentive to care for the whole individual
◦ Focus on overall health and prevention
Prompt Provider Payment!
◦ More predictable costs for Illinois
Encourage use of home and communitybased alternatives to institutional care
Providing individualized case management
services and disease management services
◦ For some individuals, for the first time in their lives
Little to no evidence and no model regarding
managed care for people with disabilities
◦ Particularly those with developmental disabilities
and others who require long-term care
Medical Model v. Person-Centered Model
◦ Treated as a diagnosis and not as a person
◦ Care is already coordinated by the individual
◦ Loss of consumer control
Problems with access and disruptions of care
◦ Especially in early stages of program
◦ ICP experienced problems with hospital network
◦ Access to specialists may be restricted
Prior Authorization and Utilization Review
translate into restricting benefits
◦ Cost savings are realized through restriction of
Increased bureaucracy at every stage
◦ State shifts responsibility for program
How will long-term care services be
◦ Personal Assistant services and SEIU contract
◦ Will those living in institutions really be given a
How does this affect Illinois’ stated
commitment to rebalancing?
◦ Will causing MCOs to contract with institutional
providers create a conflict of interest that will
prevent rebalancing?
How does managed care interact with
Williams, Ligas, and Colbert?
◦ HFS has so far been vague but offered assurances
that individuals will not be denied any services to
which they are entitled.
How will recent changes to the Medicaid
program affect the ICP and subsequent
◦ Additional restrictions on benefits
◦ Prior Approval Process
Continue to be diligent and educated
◦ Stay informed and know what changes will affect
◦ Be ready to pursue grievance and appeals when
services are denied or restricted
◦ Become involved in consumer advisory councils and
know who to call with questions and concerns
CMS Innovations Dual Eligible
HFS Care Coordination Innovations Project