Long-term care providers may want to consider consulting with legal counsel about the many pitfalls associated with managed care/provider contracting.
Currently, Illinois has three Medicaid managed care programs: Primary Care Case Management; Voluntary Managed Care; and the Integrated Care Program. Illinois Medicaid reform requires 50 percent of Illinois' Medicaid clients to be enrolled in care coordination programs by 2015. The state's goal is to create an integrated care program (ICP) that provides quality care without wasteful spending. The Illinois Department of Healthcare and Family Services (IDHFS) implemented Phase I of the ICP on May 1, 2011, for seniors and persons with disabilities who are eligible for Medicaid, but not Medicare. The ICP was mandatory and operates in pilot areas, including suburban Cook, DuPage, Kane, Kankakee, Lake and Will Counties. The ICP initially focused on health and behavioral health needs.
Phase II of the ICP was initiated in January 2013 and will expand to include long-term care services and supports. IDHFS sponsored a town hall meeting on January 24, 2013, to discuss the ICP and other managed care programs. At the meeting, IDHFS representatives explained that an ICP includes primary care physicians, specialists, hospitals and others who provide behavioral health and social needs to Medicaid clients. Long-term care services, both facility and non-facility based, are included in the ICP. At the time of the town hall meeting, Illinois had contracted with two managed care organizations—Aetna and Centene-IlliniCare—to establish the ICP for Medicaid clients.
The ICP will be rolled out to four additional regions this year. The rollout schedule for 2013 includes: (1) the Rockford region (Winnebago, Boone and McHenry Counties); Phase I will be initiated on April 1, 2013, and Phase II on July 1, 2013; (2) also on July 1, 2013, the ICP will be expanded to the Central Illinois Region (Knox, Peoria, Stark, Tazewell, McLean, Logan, Champaign, Vermillion, Ford and Menard Counties); (3) the Quad Cities Region (Rock Island, Mercer and Henry Counties); and (4) the Metro East Region (Madison, Clinton and St. Clair Counties). It is anticipated that Chicago will be incorporated into the ICP, beginning in January 2014.
Illinois submitted a plan to the Centers for Medicare and Medicaid Services (CMS) to coordinate care for individuals eligible for Medicare and Medicaid. The proposal, known as the Medicare-Medicaid Alignment Initiative (MMAI), is a joint effort with CMS and Illinois Medicaid. On February 22, 2013, a Memorandum of Understanding (MOU) was released between CMS and the state of Illinois. The MMAI is designed for clients who are eligible for both Medicare and Medicaid (known as dual-eligibles). IDHFS sought proposals for health plans that will be responsible for providing and coordinating the Medicare and Medicaid benefits and services and comprehensive provider networks to meet the individuals' needs, and selected eight organizations. A total of six managed care organizations will serve MMAI clients in the greater Chicago area (Cook, Lake, Kane, DuPage, Will and Kankakee Counties). They include Aetna, IlliniCare, Meridian Health Plan of Illinois, HealthSpring of Tennessee d/b/a HealthSpring of Illinois, Humana Health Plan, and Healthcare Service Corp. d/b/a Blue Cross Blue Shield of Illinois. Molina Healthcare and Health Alliance Medical Plans were chosen to serve clients in Central Illinois. Now that the MOU has been released, the state and CMS will enter into three-way contracts with the selected organizations that will be responsible for all of the Medicare and Medicaid services afforded to dual-eligibles.
According to IDHFS, the MMAI will be voluntary. If clients do not indicate that they do not want to participate, they will be assigned to a managed care organization. They can later opt out during a normal Medicare enrollment period, which begins in October of each year.
Long-term care providers may want to consider consulting with legal counsel about the many pitfalls associated with managed care/provider contracting. Scare tactics should not prompt a provider to prematurely enter into a contractual relationship with any managed care organization, particularly where none of the managed care organizations have provided protections necessary for facilities.
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