Illinois Medicaid is Changing April 11, 2013

Illinois Medicaid is Changing

April 11, 2013

John Peller, AIDS Foundation of Chicago

Thanks to Ann Fisher, AIDS Legal Council of Chicago

Download the slides & materials at www.HIVHealthReform.org/illinois

Medicaid is changing

• Care coordination• Four prescription policy• “Redetermination project”• Monthly Medicaid card• CountyCare

• Handouts & links: www.HIVHealthReform.org/Illinois

04/22/2023 Prepared by Largent Government Solutions, LLC for the AIDS Foundation of Chicago

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Medicaid Care Coordination• State Law requires 50% of beneficiaries be enrolled in some

form of Care Coordination by 2015.• Payment for services will based on meeting defined quality

measures rather than Fee for Service.• Beneficiaries will be aggressively enrolled into risked based,

care coordination programs:– Integrated care management (Commercial HMOs)– Care Coordination Entities and Managed Care Community

Networks (MCCN) (smaller, provider-driven)– Medicare-Medicaid Alignment Initiative (MMAI)

(Commercial HMOs)

Care Coordination tips• Duals coming in October; HMOs for seniors & people with

disabilities & new Medicaid to Chicago in January• Watch for notices to clients explaining options• CHOOSE A PLAN that includes providers and covers client’s

meds – don’t let HFS choose for you!• Help clients learn to use the plan – e.g., need a referral for a

specialist• Help clients understand their rights.• Tell us about problems• Download chart and MMW Care Coordination cheat sheet

from www.hivhealthreform.org/illinois

Four prescription “review” policy• Clients can receive four drugs a month; anything above that needs prior

approval.

• Some drugs are exempt – e.g., HIV drugs

• Some honesty from the Department: “The purpose of the four prescription policy is to have providers review their patients’ entire medication regimen and where possible and clinically appropriate, reduce duplication, unnecessary medications, polypharmacy, etc. The four prescription policy was developed as a result of budget negotiations, but best-practices call for an annual review of the full regimen of prescriptions for any patient.”

• We must insist on this: “The four prescription policy is not a “hard” limit. Medicaid patients can and should have access to medications that are medically necessary, even if they exceed four prescriptions per 30 days. The policy simply requires prior approval for prescriptions above the limit, for the purpose set forth above.” http://www.hfs.illinois.gov/pharmacy/script/

Initial four prescription review problems

• Providers sending people to Walmart instead of working through the pre-approval process

• Cumbersome pre-approval process– HFS is working to simplify the process— helps a

lot if providers use the MEDI system• Department has taken a lot of heat for this—

and is responding. But only because advocates have vigorously reported problems. So keep it up.

“Redetermination Project”

• Goal is to find people who are not eligible for Medicaid and get them off the rolls, mostly by doing computer matching

• Alleged to be up to $350 million in savings– Always unlikely—most fraud is by providers, not by recipients– HFS getting a lot of heat for not moving more quickly on this

• SMART Act required state to hire a private company to do this. Hired Maximus in September, who have hired 500(!) workers

• Redeterminations began in January 2013

How the redetermination project works

1. On-line comparison between what data the recipient has submitted and what’s in databases – living in another state? – Different income? – Died? (probably not spending a lot of money on their

health care in that situation)

2. If all okay, then Maximus will recommend continued eligibility without any contact with recipient. 3. If a conflict, or missing info, then a 10 day letter goes out to recipient.

Redetermination project, cont’d

4. If within 10 days, send info back to Maximus5. If 10 days missed, or info doesn’t satisfy, then the

whole case goes back to the local office with a recommendation to change (e.g. take an ineligible child off the case, or put on spenddown) or deny benefits

6. HFS making a big deal that it’s up to the local office to make the final decision.

MOST IMPORTANT: Watch for letters! Huge issue for our clients.

Annual Medical Cards

DHS is no longer sending out medical cards every month

New medical cards, cont’d

• If a recipient is in managed care, they will have this card plus a card from the managed care plan plus their i.d.

• For a long time now the card has been a formality: providers really check eligibility at every visit.

• Having a card won’t prove you are eligible (e.g. spenddown met), but it will make people nervous not to have it.

• Can get a replacement by calling DHS 1-800-843-6154 or HFS 1-800-226-0768

CountyCare

• CountyCare (1115 waiver)– Enrolling now– Eligibility up to 138% FPL ($15,282)– No categorical eligibility requirements, but must live in Cook

County and meet citizenship requirements (same as Medicaid and SSI) and be age 19-64

– Restricted network includes county providers and participating federally qualified health centers, including Howard Brown.

– This is health insurance—can save someone from bankruptcy– Application info at http://www.countycare.com/

CountyCare, cont’d

• Lots of things they’re just now starting to try to figure out– Care coordinators?– Persuading people not to use the E.R?– Are they getting enough money from the feds to

actually do it?

CountyCare and Ryan White services• Ryan White is “payer of last resort”– So if eligible for CountyCare, then not eligible for Ryan

White services that could be covered under County Care• Primary care, pharmacy, long-term care services, behavioral

and mental health services all covered under CountyCare• Dental, emergency assistance, case management and other

services still can get from Ryan White

• ADAP will probably start requiring clients to enroll in CountyCare at their next ADAP redetermination (not yet announced)– Clients will get HIV meds from CountyCare once enrolled

Support SB 26!

• Implements ACA provisions allowing the state to expand Medicaid to 138% of FPL

• Passed the Senate 40-19• Needs to pass the House

How to keep up?• Keep your dial pointed right here!

www.hivhealthreform.org and www.hivhealthreform.org/illinois

• Arrange a training or call for help: AIDS Legal Council of Chicago, 312-427-8990, Ann Fisher: [email protected]

• More training or help: John Peller: [email protected], 312-334-0921