Illinois Medicaid Managed Care Organizations & Family Planning Services. IDPH Family Planning Workshop March 22, 2017
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1 Illinois Medicaid Managed Care Organizations & Family Planning Services IDPH Family Planning Workshop March 22, 2017
2 Current structure of Medicaid managed care programs Managed Care Organizations contract with HFS to cover different programs, which serve different client populations: Integrated Care Program (ICP) serving Seniors and Persons with Disabilities who do not have Medicare (age 19 and over) Family Health Plans/ACA Health Plans (FHP/ACA) serving children, parents/caretakers, pregnant women, and newly eligible adults under the Affordable Care Act (ACA) Medicare Medicaid Alignment Initiative (MMAI) serving duals - clients receiving full Medicare and Medicaid benefits Managed Long Term Supports and Services (MLTSS) Serving duals receiving Long Term Supports and Services who opt out of MMAI. Currently in the Greater Chicago Region only.
3 Enrollment Numbers by Program Program January 2017 December 2016 January 2016 Total ICP Enrollment 112, , ,656 Total MMAI Enrollment 45,511 46,669 47,340 Total FHP/ACA Enrollment 1,772,723 1,857,784 1,900,568 Total MLTSS Enrollment 27,720 27,686 - Total 1,958,809 2,052,965 2,066,564
4 Do all Illinois Medicaid clients enroll with an MCO? 5 mandatory managed care regions (30 counties): Rockford Central Illinois Metro East Quad Cities Greater Chicago Area 15 voluntary counties with managed care representation Some populations currently excluded (Some client groups excluded from managed care (i.e. clients on spenddown, DCFS wards, children with SSI, client with high Third Party Liability insurance). To view the Illinois care coordination map:
5 Covered Services Managed Care Organizations are required to cover all Medicaid covered services, including: Medical Behavioral Nursing facility services Home and Community Based Services (waiver services excluding developmental disability waiver services) These services are performed by affiliated (in-network providers) unless approved otherwise by the MCO. Some services require prior authorization. These are determined by each MCO.
6 Direct Access Services in MCO contracts Direct Access Services means the MCO must cover those services whether provided by an affiliated or non-affiliated provider. Providers can cover family planning services for ICP and FHP/ACA enrollees whether the provider is contracted with the MCO or not. MCOs will pay the same rate HFS would pay for such services, unless a different rate was agreed upon between the MCO and the provider.
7 Required Standards of Care Per HFS/MCO Contract Attachment XXI Required Minimum Standards of Care a. EPSDT Services to Enrollees Under Twenty-One (21) Years b. Preventive Medicine Schedule (Services to Enrollees Twenty- One (21) Years of Age and Over) c. Family Planning and Reproductive Health Care See handout
8 Billing MCOs for family planning services Provider must be enrolled as an HFS Medicaid Provider. Providers do have the option of contacting health plans to negotiate an agreement/sign a contract. A non-affiliated provider can still bill for family planning services. MCOs must accept claims from non-affiliated providers for at least 6 months after the date the services are provided. MCOs are not required to pay for claims submitted by non-affiliated providers more than 6 months after date of service. Do not bill HFS for family planning for MCO clients; claims will reject.
9 Managed Care Organizations - Provider Services Contact Information AETNA BETTER HEALTH (866) , press 2 BLUE CROSS/BLUE SHIELD (888) , press 1 CIGNA HEALTHSPRING (866) , press language choice, then 3 COMMUNITY CARE ALLIANCE OF ILLINOIS (866) , press 3 COUNTY CARE (312) , press 3 FAMILY HEALTH NETWORK (888) , press 5
10 Managed Care Organizations - Provider Services Contact Information HARMONY HEALTH PLAN (800) , press 4 HUMANA (800) (direct to provider relations) ILLINICARE (866) , say provider MERIDIAN HEALTH PLAN (888) , press 2 MOLINA HEALTHCARE (855) (direct to provider services) NEXT LEVEL HEALTH PARTNERS (844) , press 2
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