Starting Strong for Community Health! Webinar:

An Overview of the Alternative Benefit Package and

Care Coordination in Medicaid for ACA Adults

March 25, 2014

Illinois Health Matters HelpHub

To request an invite to HelpHub, email helphub@illinoishealthmatters.orgwith the name of your organization, lead agency (if part of IPC or

Navigator grant) and /or details of your ACA involvement.

Story Contest!

For the month of March, for every story posted on HelpHub’s “Stories” section we will enter the storyteller in a drawing for a chance to win a $50 Visa gift card!

We don’t need clients’ names, we just want to hear how the ACA has impacted your clients and your communities. If necessary, we may follow up with you for more details if we want to print the story.

Spring Chapter Meetings

Join EverThrive Illinois and our partners at one of our quarterly chapter meetings! The spring meeting will give you an opportunity to:

• Review EverThrive Illinois’ recent policy memos and updates• Take a look at the progress of the ACA after the end of open enrollment

• Network with like-minded individuals from a variety of fields

A special presentation will be held by Nadeen Israel, Policy Associate with Heartland Alliance for Human Needs & Human Rights, on Medicaid Care

Coordination and how to support your clients during this transition.

Register for any of the following chapter meetings on our website: www.ilmaternal.org.

Lake CountyApril 15th

ChicagoApril 16th

Southern IllinoisApril 23rd

Speakers for Today’s Webinar:• Amy Harris-Roberts, Bureau of Managed

Care, HFS

• Gabriela Moroney, Manager, HFS

Questions?Ask questions using the chat box feature

If we are unable to answer your question during the webinar we will make sure to get an answer and email

it to you.

Agenda

1. Alternative Benefit Package for ACA Adult Medicaid enrollees

2. Care Coordination for ACA Adult Medicaid enrollees

3. Q & A

4. Wrap up

Alternative Benefit Plan

Gabriela Moroney, Manager, HFS

Alternative Benefit Plan• ACA Adults are receiving a Medicaid benefit/service

package called the Alternative Benefit Plan (ABP).

• HFS invited public input on the ABP in the fall of 2012 and 2013.

– Generally, most respondents indicated that Illinois’ ABP should include the same services available to already eligible Medicaid clients

– Federal regulations require some degree of continuity with the Essential Health Benefits (EHBs) offered by commercial health plans through the Marketplace

Alternative Benefit Plan• The ABP for ACA adults is required to include:

– Essential Health Benefits: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative and habilitative services; laboratory services; and preventive and wellness services

– Early and Periodic Screening, Diagnosis, and Treatment services (EPSDT) for 19 and 20 year olds

– Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) services

– Non-emergency transportation

– Family planning services and supplies

ABP - State Plan Alignment

• Illinois must submit to federal CMS an amendment to its Medicaid State Plan to establish the ABP for ACA Adults.

• Proposed amendment seeks to establish full alignment between current Medicaid state plan services and the ABP.

• Anticipated outcome is that benefits for ACA Adults in the ABP and benefits for other eligibility groups will be the same.

ABP: Includes Emergency Dental Benefit• Current state of Adult Dental in Illinois:

– SMART Act eliminated adult dental

– Emergency dental services were subsequently restored to adults in Medicaid. Emergency services limited to:

• Dental services necessary for an individual to be cleared for a medical procedure, such as a transplant;

• Extractions and dentures necessary for a diabetic to receive proper nutrition;

• Extractions and dentures necessary as a result of cancer treatment; and

• Dental services necessary for the health of a pregnant woman prior to delivery of her baby.

• The State, through pending legislation, can fully restore adult dental treatment services

Alternative Benefit Plan: Cost sharing

• ACA Adults will have the same co-payments as other Medicaid adults, such as:

– Hospital inpatient services: $3.90

– Prescription drugs: brand $3.90, generic $2.00

– Primary care provider visit: $3.90

• No co-payment for Immunizations, Preventive Services, Diagnostic Services or Family Planning. Family planning related medical services require a co-pay for office visits.

• For more information: http://www2.illinois.gov/hfs/SiteCollectionDocuments/100app12.pdf

Care Coordination in Illinois

Amy Harris-Roberts

Bureau of Managed Care, HFS

Care Coordination for Medicaid• Care Coordination is the centerpiece of Illinois’s Medicaid

reform. It is aligned with the Medicaid Reform Law (PA 96-1501 and 97-689) and the federal Affordable Care Act.

• Illinois’ Medicaid Program has been traditionally a primarily fee for service system, moving to “capitated, risk-based” payments.

• HFS’stated goal is to create integrated delivery systems that provide quality care and result in better health outcomes for Medicaid recipients at reduced costs.

• Many Care Coordination Initiatives will be implemented - have different names and different choices of providers.

Care Coordination Expansion Map 3/20/14

Three Models of Managed Care Entities (MCEs)

As of July 1, 2014, most of the individuals in the 5 mandatory regions will receive care coordination services from primarily one of three types of MCEs:

1.MCO - Health Maintenance Organizations (HMOs) or Managed Care Community Networks (MCCNs)

2.CCE – Care Coordination Entity

3.ACE – Accountable Care Entity

Common set of quality measures to evaluate all MCEs

ACA Adult Plan Choices

• On July 1, 2014, ACA Adults will have several MCEs to select for their care coordination; primarily MCOs and ACEs, based on county of residence, possibly by zip code.

• MCEs available to most individuals by mandatory region is provided on the Care Coordination Expansion Map on slide 12.

• HFS encourages Providers to work with the various MCEs –MCOs, ACEs and CCEs.

ACA Adult Plan Choices (cont.)• ACEs will enroll children/families, with an option to

enroll ACA adults;

• ACEs organized by providers; will coordinate a network of Medicaid services; and

• ACE networks will include at a minimum the following types of providers: primary care, specialty care, hospitals, and behavioral healthcare.

• HFS will publish the initial ACE awardees on its web site.

• Providers participating in ACEs as PCPs will be required to be enrolled in Illinois Health Connect as a PCP.

Current Enrollment for ACA Adults• Currently, ACA adults in all counties except Cook can select a

PCP in Illinois Health Connect (IHC).

• In Cook County, ACA adults can enroll with CountyCare or remain in Fee-For-Service (until July, 2014).

• The CEB sends enrollment packets – 60 day choice period, if no choice is made the individual is auto assigned to an IHC PCP.

• HFS will start enrolling the ACA adults in MCEs on or before July 1, 2014 (and the months thereafter – gradual roll-out). Includes ACA adults that have enrolled in IHC.

• Currently ACA adults in Cook County can contact Illinois Health Connect for assistance in finding providers.

How does Expansion affect CountyCare?

• CountyCare is currently operating through a temporary extension of the Medicaid waiver –through June 30, 2014.

• Will operate as a managed care community network (MCCN) upon expiration of the waiver.

• The CountyCare MCCN will be a managed care entity option available to most Cook County residents - children, families and ACA adults

Expansion Enrollment Process

• Individuals will select a plan and provider for care coordination services through the Client Enrollment Services call center or website.

• Once an individual selects a Plan and Provider:– 90-day switch period

– Locked into that entity for one year (Can change plans during Open Enrollment Period)

• PCP switches = Illinois Health Connect

I am approved for Medicaid! When and how do I pick a Plan and Provider?

Receive Medicaid Approval Letter

Within 10 days, receive piece of

paper with Recipient

Identification Number (RIN)

Soon after you receive your RIN card, receive an

enrollment package in the

mail (CEB)

Review your enrollment

package explaining your plan choices

and how to choose a PCP

When and how do I pick a Plan and Provider (cont).

Reminder notice mailed

Day 14

2nd client enrollment packet mailed (if client did not respond to first packet

– day 30); information about auto-assignment

enclosed (Plan and PCP).

Welcome packet to confirm enrollment into

chosen or assigned

Plan and PCP (Sent by Plan)

Choosing a Plan and ProviderInitial Plan and Provider Choice, 90-day Switch Period and Open Enrollment Period:

•Phone the HFS Client Enrollment Broker (CEB) (MAXIMUS) at 1-877-912-8880 (TTY: 1-866-565-8576), Free Call, OR

•Online http://enrollhfs.illinois.gov (Sample enrollment materials available online)

•View providers participating in each Plan, by County, on the CEB Program Web Site

Provider Switches:

•Phone Illinois Health Connect (IHC) at 1-877-912-1999 (TTY: 1-866-565-8577), Free Call, OR

•Online: www.illinoishealthconnect.com

•Currently – Cook County residents can contact IHC for assistance in finding providers

Switching Providers in an ACE

Provider Switches:

•Phone Illinois Health Connect (IHC) at 1-877-912-1999 (TTY: 1-866-565-8577), Free Call, OR

•Online: www.illinoishealthconnect.com

•Currently – Cook County residents can contact IHC for assistance in finding providers

Enrollment TipsJuly 1, 2014 Expansion

• Call the client enrollment broker if you have specialty care provider, hospital or nursing facility that you have an ongoing care relationship with and ask them to search the available managed care networks to see what plans the provider is enrolled/participating.

• Can also ask your provider which network they are in or if they are willing to join a network; however, sometimes hospital systems control the physician group and the physicians cannot join without the hospital.

• Call the client enrollment broker for more information about each Plan, including extra benefits each Plan offers.

• It is important to respond to Enrollment Packets. We want you to select your Plan and Provider.

• Can switch plans within first 90 days of enrollment through the client enrollment broker.

Resources• Care Coordination Summary

http://www2.illinois.gov/hfs/SiteCollectionDocuments/CareCoorPlan.pdf

• Care Coordination Expansion Map

http://www2.illinois.gov/hfs/SiteCollectionDocuments/CCExpansionMap.pdf

• Care Coordination Roll-Out by Health Plan

http://www2.illinois.gov/hfs/SiteCollectionDocuments/CCRollOutPlan.pdf

• List and short description of 5 CCEs and 1 MCCN

http://www3.illinois.gov/PressReleases/ShowPressRelease.cfm? ubjectID=2&RecNum=10634

• ACE Background and Overview

http://www2.illinois.gov/hfs/SiteCollectionDocuments/ACE_overview.pdf

Questions?Ask questions using the chat box feature

If we are unable to answer your question during the webinar we will make sure to get an answer and email it

to you.

Contact Us:andreakovach@povertylaw.org

Next Webinar:Enrollment for the Justice

Involved PopulationApril 22nd