Dual Eligibles Next to Move into Managed Care in Illinois

On February 22, the U.S. Department of Health and Human Services announced a Memorandum of Understanding (MOU) with the state of Illinois for a demonstration project that will enroll approximately 136,000 dual eligibles in northeastern and central Illinois into managed care plans. (“Dual eligibles” are individuals who have coverage through both Medicare and Medicaid.) Illinois is the fourth state to receive an MOU for this demonstration, known nationally as the Medicare Medicaid Financial Alignment Initiative (MMAI).

AgeOptions and other organizations that serve older adults have been following the development of this new project, as it will significantly affect the lives of our clients. Here is what we have learned about this new initiative from our research and communications with the entities involved, including the Illinois Department of Healthcare and Family Services and various managed care organizations:

The MMAI project is part of a national effort to better coordinate care for dual eligible beneficiaries. Dual eligibles tend to be sicker and cost more than other Medicare and Medicaid beneficiaries. To address this, as part of the Affordable Care Act, the Centers for Medicare and Medicaid Services created a Medicare-Medicaid Coordination Office (MMCO) to “make sure Medicare-Medicaid enrollees have full access to seamless, high quality health care and to make the system as cost-effective as possible.” One of the MMCO’s first projects has been working with states to implement initiatives to coordinate care for dual eligibles.

Currently, dual eligibles must navigate and manage multiple systems of coverage in order to access the health care they need (Medicare, Medicare Part D prescription drug plans, and Medicaid). This can be very complex and taxing for individuals who have multiple complex health needs. Therefore, the goals of the MMAI project are to simplify this process and provide higher quality and more coordinated care for dual eligibles.

In January 2014, dual eligibles in the greater Chicago area and parts of Central Illinois will be enrolled into managed care plans. These plans must provide care managers and other supports to coordinate their members’ care, in addition to paying for members’ medical services and long term services and supports (LTSS). In exchange, these plans will be paid a capitated rate by the state of Illinois and CMS. (“Capitated rate” means the plans will receive a flat rate for each member that they serve, instead of being paid for each individual service that a member receives.) The inclusion of long term services and supports in this project is significant, as these services may be ‘new territory’ to some managed care organizations. In addition to providing coverage for LTSS provided in long term care facilities, MMAI plans will be responsible for covering home and community based services, such as the Community Care Program. This may cause confusion for dual eligible beneficiaries who are used to receiving Community Care Program services through the existing system, so agencies working with older adults will have to provide education and assistance to help our clients understand these new changes.

Illinois has selected eight managed care plans to provide MMAI coverage. Those eight plans are:

• Chicago area: Aetna Better Health, Blue Cross/Blue Shield of Illinois, HealthSpring, Humana, IlliniCare (Centene), and Meridian Health Plan of Illinois
• Central Illinois: Molina Healthcare, Health Alliance

Dual eligible beneficiaries in the target counties will be able to enroll in these plans voluntarily beginning October 2013. In January 2014, the state will begin passively enrolling additional beneficiaries into the plans. This passive enrollment will be conducted in phases, so it will take about 6 months to enroll everyone who will be affected. After a beneficiary has been passively enrolled into a plan, s/he may change plans at any time and will have some ability to opt out of the program (though this opt out privilege may be limited in certain cases).

Counties that will be part of the MMAI project:

• Greater Chicago area: Cook, DuPage, Lake, Kane, Kankakee, and Will counties

• Central Illinois: Christian, Champaign, DeWitt, Ford, Knox, Logan, Macon, McLean, Menard, Peoria, Piatt, Sangamon, Stark, Tazewell, and Vermilion counties

For more information about the Illinois MMAI project, please see the following resources:

CMS fact sheet
Illinois Memorandum of Understanding
Illinois Department of Healthcare and Family Services webpage on Illinois Care Coordination Initiatives (see section on MMAI)

Written by Erin Weir, Manager of Health Care Access at AgeOptions
erin.weir@ageoptions.org

Update:Illinois’ Care Coordination and Managed Care System

In January 2011, the Illinois legislature passed a bill that requires 50% of the State’s Medicaid population to be covered in a risk-based care coordination program by 2015. Subsequently, in May 2012, the State Legislature passed the SMART Act, cutting Medicaid services and projecting cost savings through various care coordination initiatives.

The care coordination, or managed care, initiatives referenced through this bill are: the Integrated Care Program, the Dual Eligibles Capitation Demonstration and the Innovations Program. All three of these initiatives have a goal to better coordinate primary, acute, behavioral health and long-term supports and services thereby improving the delivery of health services and lowering health costs.

The move to better coordinate care across primary, acute, behavioral health and long-term supports and services is in alignment with the federal Affordable Care Act (ACA), passed in March 2010. In fact, Illinois has made an effort to take advantage of several of the ACA provisions to move towards a better coordinated and integrated health system.

One of the ACA provisions Illinois is interested in is called Medicaid health homes for individuals with chronic conditions. To date, Illinois has filed a draft Medicaid state plan amendment to create health homes. The other federal ACA inititiave relating to care coordination that Illinois interested in is the Medicare-Medicaid Alignment Initiative, or the Dual Eligibles Demonstration Project. Illinois has submitted a proposal for this demonstration project.

For more details about the various care coordination, or managed care, initiatives in Illinois, please reference the document “Illinois Health Reform 2012: Care Coordination, Managed Care and Long-Term Services and Supports” developed by Health & Medicine Policy Research Group.

Kristen Pavle
Associate Director, Center for Long-Term Care Reform
Health & Medicine Policy Research Group

Medicare Improving Fast

There is an intense debate over Rep. Paul Ryan’s (R. WI) proposal to scrap Medicare and turn it into a voucher program shifting costs to seniors, a debate that became even more intense when it was passed by the Republican-controlled House of Representatives. The Senate has not passed it, and the President has registered his opposition. The American people are also firmly opposed.

But that debate has taken news focus away from the substantial improvements to the Medicare program that have been accomplished in just the last year under the Affordable Care Act, with more improvements soon to come. Costs are lower and care is better for seniors all over the country.

Here is what happened in 2010 and is about to happen in 2011 in Medicare under the Affordable Care Act. The numbers apply to Illinois, but the same impact is happening everywhere in America.

1. Prescription drugs are more affordable. In 2010, 152,170 Illinois residents hit the Medicare prescription drug “donut hole” and received at $250 rebate check to defray their costs. Across the state, this came to $38 million in savings for seniors. In 2011, everyone in Illinois who hits the donut hole will receive a 50% discount on their brand name and generic prescription drugs. As of March, Illinois Medicare beneficiaries who had triggered into this benefit were getting about $800 a month in savings.
2. Preventive services are free. In 2010, when this section of the new law had not yet taken effect, Medicare charged co-pays for preventive services like mammograms and other cancer screenings. In 2011 all of the 1.9 million Medicare beneficiaries in Illinois now get all recommended preventive services with no out-of-pocket costs.
3. The annual checkup is free. In 2010, when this section of the new law had not yet taken effect, Medicare charged a co-payment for the annual checkup. Starting in 2011, Medicare beneficiaries can go to an annual wellness visit with no out-of-pocket cost. As of April 20, 17,508 Illinoisans have had a free wellness visit. 
4. Premiums are lower. Under the new law, in 2010 Medicare Part B premiums were nearly $8 less per month than projected by the Medicare trustees. In 2011, the premiums are almost $5 less per month than projected by the Medicare trustees. The lower premium translates to $107 million in savings for Illinois Medicare beneficiaries in 2011.
5. Medicare Advantage. In 2010 and 2011 all beneficiaries still retain the option of joining a Medicare Advantage plan if they so desire.

This is a story typical of many things in the Affordable Care Act. Improvements to the system are constantly rolling out, but the general public remains unaware of them. In part, this is because the subject matter is complex and hard to absorb unless you are directly affected. And in part it is a deliberate strategy of the opponents to keep the focus elsewhere and downplay the accomplishments of the law as they endeavor to repeal it and roll back its benefits. The intense reaction to Rep. Ryan’s proposal shows that at least the people directly affected – seniors who depend on Medicare – are well aware of the increasing quality of their program.

John Bouman
President, Sargent Shriver National Center on Poverty Law (originally posted in the Shriver Brief)