An Overview: Illinois Health Connect, Voluntary Managed Care and Disease Management

1
An Overview Illinois Health Connect, Voluntary
Managed Care and Disease Management
2
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
  Law takes 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.

3
Who are we? (ctd)

• Automated Health Systems (AHS)
• The State of Illinois (HFS) contracted with
  Automated Health Systems (AHS) to launch and
  administer Illinois Health Connect, the
  Departments 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.

4
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)

5
Why are we here? (ctd)

• Whats In A Name??
• Illinois Health Connect, Harmony Health Plan,
  Family Health Network, Your Healthcare Plus,
  Healthy Kids
  
• PCCM, DM, EPSDT, PCP, HMO, MCO

6
Goals

• 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)

7
Background Illinois Health Connect, PCCM and a
Medical Home
8
Background

• 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

9
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)

10
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

11
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 doctors office, clinic or health center
  where a patient goes to see their Primary Care
  Provider (PCP)
  
• The place where all of a patients medical
  records are stored
  

12
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)

13
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

14
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

15
How will these changes affect patients and
providers in Illinois?
16
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)

17
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

18
Excluded Populations (ctd)

• 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

19
Excluded Populations (ctd)

• 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)

20
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?

21
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?

22
FAQs

• 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?

23
Implementation
24
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

25
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 clients 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

26
Enrollment Timeline (ctd)

• 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
  havent yet chosen a PCP

27
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

28
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

29
Enrollment Choices (ctd)

• Managed Care Organizations Harmony Health Plan
  and Family 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
  

• 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

30
Enrollment Choices (ctd)

• 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

31
Enrollment Choices (ctd)

• 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

32
How to Enroll

• Collar Counties
• Phone [phone]
• Internet www.illinoishealthconnect.com
• In person at a local DHS office (Family
  Community Resource Center)

• Cook County
• Phone [phone]
• Internet www.illinoisceb.com
• In person at a local DHS office (Family
  Community Resource Center)

33
Confirmation of Enrollment

• Enrollees will receive a letter to confirm their
  enrollment (PCPs will not be listed on the
  clients 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.)

34
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 [phone] (TTY
  1-866-565-8576). The call is free.
  
• Call Center hours
• 700 AM - 800 PM Monday through Friday
• 900AM - 500 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.

35
Other Client Enrollment Services Provided by AHS
(ctd)

• AHS staff will be located in 19 of the Cook
  County Family Community Resource Centers (DHS
  offices) available from 830 AM 500 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

36
FAQs

• 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?

37
Referrals
38
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

39
Direct Access Services (ctd)

• 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

40
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
  

41
Referrals

• 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

42
FAQs

• 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 theres an emergency or other situation
  in which the patients PCP cannot be reached for
  a referral?
  
• If outpatient ancillary services like lab tests
  or X-rays dont 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?
  

43
Providers
44
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

45
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.
  

46
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).
  

47
PCP Requirements (ctd)

• 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
  

48
PCP Requirements (ctd)

• 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

49
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.

50
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.

51
Provider Support (ctd)

• 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.

52
Provider Support (ctd)

• Panel Lists inform providers of patients that are
  linked to them and indicate each patients
  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
  PCPs panel to help support the PCPs quality
  assurance efforts.

53
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.
  

54
FAQs

• Do providers need to enroll with Illinois Health
  Connect even if theyre already enrolled with
  HFS?
  
• Can a provider opt out of the auto-assignment
  process?
  
• Can a provider change their panel size once
  theyve 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?
  

55
Disease ManagementYour Healthcare Plus
56
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

57
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.

58
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
  

59
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
  

60
Provider Network
61
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.
  

62
Increasing Provider Network (ctd)

• Enhanced Reimbursement Rates
• HFS has enhanced maternal and child health rates
  for physicians participating as a PCP
  
• Increases up to 160 for some services

63
DISCUSSION

• Culture change?
• Anticipated response from families? Issues?
• What can we do to help families through this
  transition? What do we need?

64
Contact Information

• Cook County
• Illinois Client Enrollment Broker
• Clients 1-877-912-8880 (TTY 1-866-565-8576)
• Administrative 1-888-912-1220
• www.illinoisceb.com
• Providers 1-800-571-8504
• ILPCP_at_automated-health.com

• Collar Counties
• Illinois Health Connect
• Clients 1-877-912-1999 (TTY 1-866-565-8577)
• Administrative 1-888-912-9120
• www.illinoishealthconnect.com
• Providers 1-800-571-8504
• ILPCP_at_automated-health.com

65
Contact Information (ctd)

• Your Healthcare Plus (McKesson)
• Patients 1-800-973-6792 TTY 1-888-317-2697
• Website www.yourhealthcareplus.com
• 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

66
Contact Information (ctd)

• 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)

67
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

68
PROBLEMS?

• If you work with families that have had a
  difficult time with any of the programs
  mentioned, please contact us.
  
• Patrick Keenan-Devlin
• keenan-devlin_at_povertylaw.org
• 312-368-1168
• Joe Weimholt
• coveringkids_at_ilmaternal.org
• 312-491-8161