Provider Notice issued 01/04/16

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Care Coordination Health Plan Transitions for Medicaid Participants in ACEs and CCEs

​	​To: Enrolled Medical Assistance Providers
​	​Date: January 4, 2016
​	​Re: Care Coordination Health Plan Transitions for Medicaid Participants in ACEs and CCEs

 

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The purpose of this notice is to provide guidance on changes to the Accountable Care Entity (ACE) and Care Coordination Entity (CCE) programs and the process of transitioning ACE and CCE members to a Managed Care Entity.  In addition, there are Managed Care Organization (MCO) service area changes resulting from member transitions.

ACE and CCE Member Transitions
ACEs and CCEs are in the process of becoming Managed Care Community Networks (MCCNs) or are partnering with MCOs to provide care coordination services within risk-based managed care delivery systems.  Some ACEs and CCEs have already partnered with an MCO.  Generally, through MCO delegation agreements, the ACE or CCE continues to coordinate care for members transitioning to the partner MCO.

ACE and CCE transitions are expected to enhance the ability of provider-based organizations to improve care coordination services through increased access to data and additional services for members.  In addition to continuing to coordinate care for their previous membership, some ACEs and CCEs will coordinate care for additional MCO members.

The Department of Healthcare and Family Services (HFS) expects all ACE and CCE transitions to be complete by July 1, 2016; some partnerships are still being finalized. Below is a list of health plans that ACEs and CCEs have partnered with to date. 

Plan Type	ACE/CCE Name	Membership Transitioning To	Transition Effective Date
ACE	Advocate Accountable Care	TBA	TBA
ACE	Better Health Network	Molina	TBA
ACE	Community Care Partners	TBA	TBA
ACE	HealthCura	BlueCross BlueShield	12/01/15
ACE	Illinois Partnership for Health	Health Alliance	11/01/15 (Central Illinois) 01/01/16 (Quad Cities and Rockford) Members outside of Central Illinois, Quad Cities, and Rockford regions received a new Enrollment Period
ACE	Loyola Family Care	Molina	01/01/16 (Cook County)   Members outside of Cook County received a new Enrollment Period
ACE	MyCare Chicago	Molina	01/01/16
ACE	UI Health Plus	BlueCross BlueShield	01/01/16
ACE	SmartPlan Choice	TBA	TBA
CCE	Be Well Partners in Health	Cigna-HealthSpring	TBA
CCE	EntireCare	NextLevel Health	07/01/15
CCE	La Rabida Children's Hospital	CountyCare	08/01/15
CCE	Lurie Children's Hospital of Chicago	Multiple MCOs	Members received a new Enrollment Period
CCE	My Health Care Coordination	Health Alliance	07/01/15
CCE	NextLevel Health	NextLevel Health MCCN	01/01/16 (SPD and ACA Adult members) Will begin serving FHP members on 03/01/16
CCE	Precedence Care Coordination	Health Alliance	TBA
CCE	Together4Health	Multiple MCOs	Members received a new Enrollment Period

Letters mailed to ACE and CCE members with details about the transitions are posted on the HFS Care Coordination website.  As stated in the transition letter, members have 90 days from the effective date of the transition to change plans.  Because members are not required to stay in a plan that the ACE/CCE partnered with, providers MUST verify plan membership in the Medical Electronic Data Interchange (MEDI) system. 

New Plan Options in Cook County and Rockford and Quad Cities Regions
Effective January 1, 2016, NextLevel Health will become an MCCN in Cook County.  Also, through partnerships with ACEs and CCEs, Health Alliance will serve the Rockford and Quad Cities Regions and Molina Healthcare will serve Cook County.  ACEs and CCEs that are transitioning in 2016 will not receive new enrollments; however, they will continue to provide care coordination services for their current members.

Continuity of Care
Access to care and continuity of care continue to be top priorities for the Department. The Department has directed ACEs/CCEs and their partner MCOs/MCCNs to work collaboratively to bring in-network as many ACE/CCE primary care providers and specialists as possible. MCOs/MCCNs are undergoing Readiness Reviews that include network adequacy in advance of ACE/CCE member transitions. 

 

If an ACE or CCE member is in an active, ongoing course of treatment or is in the third trimester of pregnancy when the transition occurs, and the member’s provider is not in the MCO partner’s provider network, the MCO is required, per their HFS contract, to permit the enrollee to continue the ongoing course of treatment with their physician for up to 90 days or through the postpartum period, or as otherwise required by Section 25 of the Managed Care Reform and Patient’s Rights Act.  This is required as long as the out-of-network provider agrees to:

Provide the ongoing course of treatment;

Accept reimbursement at the MCO’s established rates based on a review of the level of services provided;

Adhere to the MCO’s quality assurance requirements;

Provide necessary medical information related to healthcare; and

Adhere to the MCO’s policies and procedures, including referrals.

 

If coverage changes during an inpatient stay, the coverage in effect at the time of admission will remain in effect for the entire stay if the hospital would otherwise be reimbursed by the Department on a diagnosis-related group (DRG) basis.  For hospitals reimbursed on a per diem basis, the new health plan’s liability begins on the effective date of enrollment.   

Eligibility and Health Plan Verification
It is imperative that providers check Department electronic eligibility systems regularly to determine beneficiaries’ enrollment in a plan and to ensure continuous care for members. The Department recommends that providers join managed care networks to ensure reimbursement for services provided to health plan members. The Recipient Eligibility Verification (REV) System, the Automated Voice Response System (AVRS) at
1-800-842-1461 and the MEDI system will identify the care coordination health plan in which the beneficiary is enrolled.

Mandatory Managed Care Regions and Care Coordination Health Plans
The five mandatory managed care regions will remain the same: the Greater Chicago Region, the Rockford Region, the Central Illinois Regions (North and South), the Metro East Region and the Quad Cities Region.  Appendix I of this notice lists the care coordination health plans operating in the mandatory managed care regions as of January 1, 2016 in any of the three program areas: Family Health Plans/Affordable Care Act (ACA) Adults, Integrated Care Program (ICP), and/or the Medicare Medicaid Alignment Initiative (MMAI).  Four types of care coordination health plans, including how providers will continue to bill for services under each health plan type, are described in Appendix II of this notice. 
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 continues 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 health plans in their region to begin the contracting process so you can continue serving your clients enrolled in care coordination health plans and be reimbursed for your services.  Providers outside the counties listed in each mandatory region who are providing care to individuals residing in counties required to enroll in a care coordination health plan, are encouraged to join care coordination health plan networks.
 
Robert Mendonsa, Deputy Administrator of Care Coordination
Division of Medical Programs

 

Appendix I
Care Coordination Health Plan Contact Information and Service Areas

MCO and MCCN Contact Information Listed by Service Area and County
Greater Chicago Region (Cook, Lake, Kane, DuPage, Kankakee, Will)

​Provider	​Contact Information
Aetna Better Health​ (MCO)	866-212-2851, press 2
Blue Cross BlueShield​ of Illinois (MCO)	888-657-1211, press 1
Cigna HealthSpring of Illinois (MCO)	866-487-4331, press language choice, then 3
Community Care Alliance of Illinois (MCCN)	866-871-2305, press 5
CountyCare (Cook County only) (MCCN)​	312-864-8200, press 3
Family Health Network (MCO)​	888-346-4968, press 5​
Harmony Health Plan​ (MCO)	800-608-8158, press 2
Humana Health Plan (MCO)	800-626-2741 (direct to provider relations)
IlliniCare Health Plan​ (MCO)	866-329-4701, say “provider”
Meridian Health Plan​ (MCO)	888-773-2647, press 2
Molina Healthcare (Cook County Only) (MCO)http://www.molinahealthcare.com/	855-866-5462 (direct to provider services)
NextLevel Health (MCCN)	844-807-9734, press language choice then ask for provider services

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

​Provider	​Contact Information
Health Alliance Medical Plan​ (MCO)	800-851-3379, press 3​
Meridian Health Plan​ (MCO)	866-606-3700, press 2
Molina Healthcare​ (MCO)	855-766-5462 (direct to provider services)​

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

Provider​	​Contact Information
Health Alliance Medical Plan​ (MCO)	800-851-3379, press 3​
Molina Healthcare​ (MCO)	855-766-5462 (direct to provider services)​

Rockford Region (Winnebago, Boone and McHenry)

Provider​	​Contact Information
Aetna Better Health​ (MCO)	866-212-2851, press 2​
Family Health Network (MCCN)​	888-346-4968, press 5​
Community Care Alliance of Illinois (MCCN)	866-871-2305, press 5
Health Alliance (MCO)	800-851-3379, press 3
IlliniCare Health Plan​ (MCO)	866-329-4701, say “provider”
Meridian Health Plan (MCO)	866-606-3700, press 2​

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

Provider​	​Contact Information
Harmony Health Plan​	800-608-8158, press 2​
Meridian Health Plan​	866-606-3700, press 2​
Molina Healthcare​	855-766-5462 (direct to provider services)​

Quad Cities Region (Rock Island, Mercer and Henry)

 

Provider​	​Contact Information
IlliniCare Health Plan​	866-329-4701, say “provider”​
Health Alliance Medical Plan​	800-851-3379, press 3
Meridian Health Plan​	866-606-3700, press 2

 
Accountable Care Entities (ACEs)
Four ACEs will transition to providing care coordination within managed care risk-based delivery systems by July 1, 2016:

ACE Contact​	Service Area
Advocate Accountable Care Franchella Holland Program Director Franchella.holland@advocatehealth.com 847-635-4420	Cook, Lake, Kane, DuPage, and Will counties in the Greater Chicago Region.  McHenry county in the Rockford Region. McLean county in Central Illinois (S) Region.
Better Health Network Cynthia Yannias Executive Director cyannias@stbh.org 1-844-410-2273	Cook County, primarily within the City of Chicago (South and West Sides)​
Community Care Partners Ben Fisk Assistant VP Business Services bfisk@northshore.org 847-982-6735	52 zip codes in Cook and Lake Counties
SmartPlan Choice David Hurter Operations Officer/Medicaid Product Director David.Hurter@presencehealth.org  773-432-1291	Cook, Will, Kankakee, and Kane, counties in the Greater Chicago Region.  Champaign, Vermilion and Ford counties​ in Central Illinois (S) Region.

Care Coordination Entities (CCEs)
Two CCEs will transition to providing care coordination within managed care risk-based delivery systems by July 1, 2016: 

CCE Contact	Service Area
Be Well Partners in Health Sharon Sidell  CEO ssidell@bewellpartnersinhealth.com 866-537-9695 or 312-940-4121.	34 Zip Codes in Cook County
Precedence Care Coordination Vicki Zude Director of Integration & Care Coordination Vicki.Zude@unitypoint.org 309-779-2091	Rock Island and Mercer counties in the Quad Cities Region

 

Appendix II
Four Types of Care Coordination Health Plans

Managed Care Organizations (MCOs):  Traditional insurance-based Health Maintenance Organizations. They are paid on a full-risk capitated basis to cover almost all Medicaid services.  Providers 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 an MCO should work with the Integrated Care Team (ICT) to coordinate care for these individuals.  Illinois Health Connect Primary Care Providers (PCPs) will not receive monthly PCP fees for MCO enrollees.  The Department electronic eligibility systems identify under the ‘Managed Care Organization segment’ which MCO an individual is enrolled.
Managed Care Community Networks (MCCNs):  Provider-owned and governed entities that operate like MCOs on a full-risk capitated basis. Just as with MCOs, providers 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 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 ICT to coordinate care for these individuals.  Illinois Health Connect PCPs will not receive monthly PCP fees for MCCN enrollees.  The Department electronic eligibility systems identify under the ‘Managed Care Organization segment’ which MCCN an individual is enrolled.
Accountable Care Entities (ACEs):  Provider-based organizations that coordinate care for their enrollees.  All Medicaid covered services are covered by the state so providers need to bill the state.  If services require prior approval in the fee-for-service system, they 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 show “no MCO information for this inquiry” and will clearly identify the ACE in which an individual is enrolled under the ‘Accountable Care Entity segment.’ 
All ACEs will transition their membership to MCCNs or partner MCOs by July 1, 2016.   After ACE members transition to MCCNs or MCOs, providers must bill the MCCN or MCO to get paid and must follow the utilization policies and procedures of the MCCN or MCO, including procedures for prior authorization and billing.  ACE members are not required to stay in the MCCN or MCO that the ACE partnered with so providers must verify membership enrollment in MEDI. 

Care Coordination Entities (CCEs): Provider-based organizations that coordinate care for their enrollees.  All Medicaid covered services continue to be covered by the state so providers need to bill the state.  If services require prior approval in the fee-for-service system today, they continue to require it under CCEs.  The process for obtaining prior approval from the Department remains unchanged.  Providers with enrollees in a CCE should work with the CCE Care Team to coordinate care for these individuals.  Illinois Health Connect PCPs will continue to receive monthly PCP fees for CCE enrollees.  The Department electronic eligibility systems will show “no MCO information for this inquiry” and will identify the CCE in which an individual is enrolled under the ‘Care Coordination Entity segment’. 
All CCEs will transition their membership to MCCNs or partner MCOs by July 1, 2016.  After CCE members transition to MCCNs or MCOs, providers need to bill the MCCN or MCO to get paid and need to follow the utilization policies and procedures of the MCCN or MCO, including procedures for prior authorization and billing.  CCE members are not required to stay in the MCCN or MCO that the CCE partnered with so providers must verify membership enrollment in MEDI.