1. Presented by: Melissa O. Picciola, Equip for Equality June 27, 2012

2.  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, Wyoming) ◦ 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)

3.  Capitated, Full-Risk ◦ Managed Care Organization (MCO) is paid fixed monthly premium per member and assumes full- risk for delivery of services (PMPM)  Non-Capitated ◦ Providers are paid an additional fee for coordinating care for members  Other Models ◦ Partial Risk ◦ Managed Care Community Networks (MCCN)

4.  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

5.  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.

6.  Integrated Care Program  Phase I of the Innovations Project ◦ Coordinated Care Entities & Managed Care Community Networks: statewide  Medicaid-Medicare Alignment Initiative  Others: ◦ Children? ◦ Voluntary MCOs ◦ Primary Care Case Management

7.  Implemented May 2011 for adult Medicaid- only 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

8.  Solicits proposals from Coordinated Care Entities and Managed Care Community Networks to coordinate care for Medicaid individuals ◦ 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

9.  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

10.  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 enrollment

11.  Up to 5 (at least 2), risk-based contracts awarded to HMOs and MCCNs to provide all Medicare and Medicaid Covered Services to dual-eligibles ◦ 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

12.  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

13.  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 community- based alternatives to institutional care  Providing individualized case management services and disease management services ◦ For some individuals, for the first time in their lives

14.  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

15.  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 services  Increased bureaucracy at every stage ◦ State shifts responsibility for program

16.  How will long-term care services be integrated? ◦ Personal Assistant services and SEIU contract ◦ Will those living in institutions really be given a choice?  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?

17.  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 programs? ◦ Additional restrictions on benefits ◦ Prior Approval Process

18.  Continue to be diligent and educated advocates ◦ Stay informed and know what changes will affect individuals ◦ 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

19.  CMS Innovations Dual Eligible Demonstrations ◦ http://www.innovations.cms.gov/initiatives/State- Demonstrations/index.html http://www.innovations.cms.gov/initiatives/State- Demonstrations/index.html  HFS Care Coordination Innovations Project ◦ http://www2.illinois.gov/hfs/PublicInvolvement/cc/ Pages/default.aspx http://www2.illinois.gov/hfs/PublicInvolvement/cc/ Pages/default.aspx