Provider Notice issued 06/24/14

REVISED - Care Coordination Enrollment for Children, Families and ACA Adults

 Beginning in the summer of 2014, the Department of Healthcare and Family Services (HFS) will continue amajor roll-out of managed care in many areas of the state. Upwards of 1.5 million people on Medicaid and All Kids living in mandatory managed care regions will be moved into some form of Care Coordination, as required under Public Act 96-1501 (The Medicaid Reform Law). This law requires the department to move at least 50% of Medicaid clients into care coordination by January 1, 2015. The four forms of Care Coordination entities are described below, including how providers will need to bill for services depending on the type of entity in which a beneficiary is enrolled. This roll-out will cover children, their family members, and the newly eligible Affordable Care Act (ACA) Adults who reside in one of five managed care regions.

The five mandatory managed care regions are: the Greater Chicago Region, the Rockford Region, the Central Illinois Region, the Metro East Region and the Quad Cities Region. See the chart at the end of this notice to see the exact counties affected and the plans operating in those counties.

It is imperative that providers check Department electronic eligibility systems regularly to determine beneficiaries’ enrollment in a plan and to ensure your clients can continue care with you. The Recipient Eligibility Verification (REV) System, the Automated Voice Response System (AVRS), and the Medical Electronic Data Interchange (MEDI) system will identify the care coordination plan in which the beneficiary is enrolled. It is also imperative that providers of all types join managed care networks in order to ensure timely payment.

The types of organizations that beneficiaries may be enrolled with are as follows:

Managed Care Organizations (MCOs) These are the traditional insurance-based Health Maintenance

Organizations. They are paid on a full-risk capitated basis to cover almost all Medicaid services. Providers will need to bill these entities directly in order to get paid. Providers will also have to make sure they follow the MCOs’ utilization policies and procedures, including procedures for prior authorization and

billing. Providers with enrollees in anMCO should work with the Integrated Care Team to coordinate care

for these individuals. Illinois Health Connect PCPs will not receive monthly PCP fees for MCO enrollees.

The Department electronic eligibility systems clearly identify under the ‘Managed Care Organization

segment’ which MCO an individual is enrolled.

Managed Care Community Networks (MCCNs) These are provider-owned and governed entities that

operate like MCOs on a full-risk capitated basis. Just as with MCOs, providers will need to bill these entities directly in order to get paid. MCCN enrollment in the HFS eligibility systems will look identical to MCO enrollment. Providers will also have to make sure they follow the MCCNs’ utilization policies and

procedures, including procedures for prior authorization and billing. Providers with enrollees in an MCCN

should work with the Integrated Care Team to coordinate care for these individuals. Illinois Health

Connect PCPs will not receive monthly PCP fees for MCCN enrollees. The Department electronic eligibility systems clearly identify under the ‘Managed Care Organization segment’ which MCCN an individual is enrolled.

Accountable Care Entities (ACEs) These entities are provider-based organizations that will be paid a fee by the Department to coordinate care for their enrollees. All Medicaid covered services will continue to be covered by the state. Providers will need to bill the state as they do today. If services require prior

approval in the fee-for-service system today, they will continue to require it under ACEs. The process for

obtaining prior approval from the state remains unchanged. Providers with enrollees in an ACE should

work with the ACE’s Care Team to coordinate care for these individuals. Illinois Health Connect PCPs will

continue to receive monthly PCP fees for ACE enrollees. The Department electronic eligibility systems will state “no MCO information for this inquiry” and will clearly identify the ACE in which an individual is

enrolled under the ‘Accountable Care Entity segment.’

Care Coordination Entities for Children with Special Needs (CSN CCEs) These entities are provider-based organizations that will be paid a fee by the Department to coordinate care for their enrollees. Their enrollees will be limited to children that the Department has identified through claims data or other information as having complex medical needs. All Medicaid covered services will continue to be covered by the state. Providers will need to bill the state as they do today. If services require prior approval in the feefor-service system today, they will continue to require it under CSN CCEs. The process for obtaining prior approval from the state remains unchanged. Providers with enrollees in a CSN CCE should work with the CSN CCE Care Team to coordinate care for these individuals. Illinois Health Connect PCPs will continue to receive monthly PCP fees for CSN CCE enrollees. The Department electronic eligibility systems will state “no MCO information for this inquiry” and will clearly identify the CSN CCE in which an individual is enrolled under the ‘Care Coordination Entity segment.’

Counties not included in the five managed care regions will continue to include Illinois Health Connect as

a plan choice for most individuals enrolled in the HFS Medical program. Illinois Health Connect will

continue to operate in areas outside the five mandatory counties, and in some counties, voluntary

managed care will also be available.

The Department encourages providers to contact the care coordination plans in your region and begin

the contracting process so you can continue serving your clients who will be mandated to join a care

coordination plan. The contact information for ACEs, CSN CCEs, and MCOs is below.

If you are a provider outside the counties listed in each region but you provide care to individuals residing

in the counties which will be required to enroll in a care coordination plan, you are still encouraged to

join the networks.

James Parker, Deputy Administrator

Division of Medical Programs

MCO, MCCN, ACE, and CSN CCE CONTACT INFORMATION

The contact information below lists the Provider Services Hotline Numbers for the Managed Care

Organizations and Managed Care Community Networks that will serve the Family Health Plan clients:

Greater Chicago Region (Cook, Lake, Kane, DuPage, Kankakee, Will)

Central Illinois North Region (Tazewell, Knox, Peoria and Stark)

Central Illinois South Region (McLean, Logan, DeWitt, Sangamon, Macon, Christian, Piatt, Champaign, Vermilion, Ford and Menard Counties)

Rockford Region (Winnebago, Boone and McHenry counties)

Metro East Region (Madison, Clinton and St. Clair counties)

Quad Cities Region (Rock Island, Mercer and Henry counties)

Accountable Care Entities 

The list of 9 applicants that are working to become Accountable Care Entities is listed below and posted on the HFS Web site at the following link:

http://www.illinois.gov/hfs/SiteCollectionDocuments/ACEContacts.pdf

CSN CCE Lead Entity

The information below provides the name and contact information of the three CSN CCEs: