IAFP/ICAAP WebinarApril 29th, 2016Alvia Siddiqi, MD, FAAFPPresident, Illinois Academy of Family Physicians
AccreditationThe Illinois Academy of Family Physicians / Family Practice Education Network is accredited by the Accreditation Councilfor Continuing Medical Education (ACCME) to provide continuing medical education for physicians.Credit DesignationAMA PRA Category 1 ‐ The Illinois Academy of Family Physicians/Family Practice Education Network designates this liveactivity for a maximum of 1.00 AMA PRA Category 1 credit .Faculty Disclosure StatementThe Illinois Academy of Family Physicians adheres to the conflict of interest policy of the ACCME and the AMA. It is thepolicy of Illinois AFP to ensure balance, independence, objectivity, and scientific rigor in all its educational activities. Allindividuals in a position to control the content in our programs are expected to disclose any relationships they may havewith commercial companies whose products or Services may be mentioned so that participants may evaluate theobjectivity of the presentations. In addition, any discussion of off‐label, experimental, or investigational use of drugs ordevices will be disclosed by the faculty. Only those participants who have no conflict of interest or who agree to an identifiedresolution process prior to their participation were involved in the CME activity.Speaker & Faculty DisclosuresAlvia Siddiqi, MD disclosed two relevant financial relationship or interest with a proprietary entity producing health caregoods or services:1) Employed by Advocate Physician Partners, Advocate Healthcare and 2) Spouse employed by CVS HealthThis program does not include any discussion or demonstration of any pharmaceuticals or medical devices that are notapproved by the Food and Drug Administration (FDA) or that are considered “off‐label.”
Managed Care Roll-Out Updates and ManagedCare Entities Overview HFS enrollment data ACE Transitions to Managed Care Tips for navigating care for your patients andonline resourcesSubscribe to HFS Provider NoticesHFS Future goalsProvider Q&A, including Illinois Association ofMedicaid Health Plans (IAMHP) responses fromHFS/MCO/Provider meeting 10/2015
Illinois Health Connect (IHC) administered byAutomated Health Systems (AHS) Initially rolled-out in 2006 as a program that combineselements of managed care and fee-for-service (FFS) Currently 330,000 children and adults enrolled in PCCM Primary Care Case Management (PCCM) – “medical home” modelwhere patients are assigned to a PCP/provider site Continues to operate in non-mandatory managed care regions Managed Care Roll-out nearly 1.9M recipients nowenrolled in a Managed Care Entity includesACE/MCO/MCCN PA 96-1501 mandate to shift 50% of Medicaid clients in Illinoisto managed care as of 01/2015 - now 60% in MCEs
MANAGED CARE ORGANIZATIONS and MANAGEDCARE COMMUNITY NETWORKS (MCO/MCCNs) Traditional full-risk capitated plans like “HMOs” Providers must bill the health plan directly and provideservices in accordance with each MCO/MCCN utilizationpolicies/procedures, including Prior authorization/billingand formulary management ACCOUNTABLE CARE ENTITIES (ACEs) Provider-organized plan option for children and their familymembers with option to enroll "newly eligible" adults underACA with expectations to transition to an MCCN or partnerwith an MCO by 7/1/2016
HFS Care Coordination Map2/1/16
Accountable Care EntitiesManaged Care OrganizationCourtesy of HFS Managed Care Oversight Committee presentation 4/6/2016 by Director Norwood
ACE/CCE Alignment with MCOsAccountable Care EntitiesManaged Care OrganizationNorthern IL onlyCentral Illinois, Quad Cities and Rockford only. NoMCO partner for the collar countiesCourtesy of HFS Managed Care Oversight Committee presentation 4/6/2016 by Director Norwood
ACE/CCE Alignment with MCOsAccountable Care EntitiesManaged Care OrganizationCourtesy of HFS Managed Care Oversight Committee presentation 4/6/2016 by Director Norwood
ACE/CCE Alignment with MCOsAccountable Care EntitiesManaged Care EntityPartnered with Molina for Cook County. Nomembership for collar countiesCourtesy of HFS Managed Care Oversight Committee presentation 4/6/2016 by Director Norwood
ACE/CCE Alignment with MCOsCare Coordination EntitiesManaged Care OrganizationPlan closed 10/31/2015.All Members ManuallyDisenrolledAnd Provided 60 Day EnrollmentPeriodsCourtesy of HFS Managed Care Oversight Committee presentation 4/6/2016 by Director Norwood
ACE/CCE Alignment with MCOsCare Coordination EntityManaged Care EntitiesContracted with Blue Cross/Blue Shield(BCBS) to provide care coordination forBCBS children with special needs. Luriemembers did not transition to Blue Cross.Contracted with IlliniCare to providecare coordination for children withspecial needsCourtesy of HFS Managed Care Oversight Committee presentation 4/6/2016 by Director Norwood
ACE/CCE Alignment with MCOsCare Coordination EntitiesManaged Care OrganizationCourtesy of HFS Managed Care Oversight Committee presentation 4/6/2016 by Director Norwood
ACE/CCE Alignment with MCOsCare Coordination EntityManaged Care EntityCourtesy of HFS Managed Care Oversight Committee presentation 4/6/2016 by Director Norwood
Check eligibility (MEDI/AVRS/REV) to determine the patient’s planassignment in order to make appropriate referrals for specialty careand identification needed for billingNotify the MCO plan when you need care coordination for your patient,including maternity (call/email/portal)Open enrollment is at the end of one-year lock-in period, when clientshave option to change to a different health plan or stay with currentplanIAMHP Provider Guide (MCO provider relations/vendor FS Medicaid managed care cuments/MCOManual.pdfHFS Medical Provider rs/Pages/default.aspxReport specific MCO concerns to IAFP/ICAAP
HFS plans to publish a Consumer Dashboardthat shows health plan comparisons in keyperformance areas (eg. Star ratings)Current auto-assignment algorithm is basedon existing PCP relationship, claims history,family member closest in age plan/PCPassignment, geomapping. Future autoassignment will also be based on plan qualityratingsProvider network transparency legislation
Including responses from Illinois Association of Medicaid HealthPlans (IAMHP) from HFS/MCO/Provider meeting 10/14/2015http://iamhp.org
Contact the MCO when you believe the patient is high riskand/or needs care management (portal/email/phone)Care coordinators should be sending care plans to the PCPs viaprovider portal, fax, or mail. If a PCP is not receiving those careplans or if the care plans are incorrect or inaccurate, the MCOMedical Director should be contacted (as of 10/2015): Aetna – Bruce Himelstein, MD, [email protected] – Anita Steward, MD, Anita [email protected] – Tariq Butt, MD, [email protected] – Elmer Abbo, MD – [email protected] – Susan Oyetunde, MD, [email protected] – Traci Ferguson, MD – [email protected] Alliance – Robert Parker, MD – [email protected] – Melanie Hunter, MD – [email protected] – Neal Fischer, MD – [email protected] – Angela R. Perry, MD – [email protected] – Cynthia Sanders, MD – [email protected] – Traci Powell – [email protected]
Mileage restrictions may vary per MCO. MCOs areresponsible for transportation for covered servicesno matter how far the in-network provider’sdistance. MCO representatives noted that there is a lack ofsome specialists to serve the Medicaid population.MCOs do actively recruit physicians, but requestthat if PCPs know of a specialist who is not with apatient’s MCO, refer to the MCO for enrollment.
Due to NCQA accreditation, credentialing cannot bebackdated; however MCOs do have workarounds inplace such as provisional credentialing.CAQH is the preferred system for submittingcredential paperwork and can greatly ease process.
MCOs are allowed to follow the same guidelines as the MedicaidFFS for their panels. PAs and Psychologist are not enrolled withthe Department.States allow Advanced Practice Nurses (APNs) who are licensedas registered professional nurses, hold a valid license in the stateof practice and are legally authorized under state law or rule topractice as an advanced practice nurse, so long as that practiceis not in conflict with the Nurse Practice Act [225 ILCS 65], theMedical Practice Act of 1987 [225 ILCS 60], the Podiatric MedicalPractice Act of 1987 [225 ILCS 100], the Dental Practice Act [225ILCS 25] and implementing rules is eligible to be considered forenrollment to participate in the department’s Medical Programs.Categories of APNs include: Certified Registered Nurse Anesthetist (CRNA);Certified Nurse Midwife (CNM);Certified Nurse Practitioner (CNP); andClinical Nurse Specialist (CNS).
MCO/MCCN contractual language guidestransition of care for their members: 90 days for ongoing course of treatment Pregnant and in third trimester, including postpartumdelivery care Provider/client plan agreement Contract language for continuity of care andManaged Care Patient Rights ActContact the MCO to inquire about priorauthorization requirements and/or Single CaseAgreements
Tell your patient to contact the Client EnrollmentBroker EnrollHFS for any enrollment questions,including when the patient is able to select a newMCO during the patient’s annual open enrollmentwindow and to make an MCO selectionENROLLHFS – Client Enrollment Brokerhttp://enrollhfs.illinois.gov1-817-912-8880
If mom is enrolled in an MCO/MCCO - newborn isenrolled to the same plan as mom If mom is in enrolled in an ACE/CCE - newborn isdirect access for 90 days and mom will need to pick aplan from the newborn enrollment packet If mom is switching health plans directly after the birth,the current health plan is still going to be responsibleto pay back to the date of birth for the baby and themom until the change actually occurs (if newborn iswithin 90 days old) MCO representatives recommended proactivelyreaching out to the MCOs for any denied claims.
Alvia Siddiqi, MD, FAAFPPresidentIllinois Academy of Family Physicians
policies/procedures, including Prior authorization/billing and formulary management ACCOUNTABLE CARE ENTITIES (ACEs) Provider-organized plan option for children and their family members with option to enroll "newly eligible" adults under ACA with expectations to transition to an MCCN or partner with an MCO by 7/1/2016