Illinois Health Connect

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• Illinois Health Connect
• Your Home for Healthcare
• Overview of Illinois Health Connect Operations
• 12-22-06

Presented by Automated Health Systems
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Outline of Presentation

• Description of Primary Care Case Management
  (PCCM)
• List of HFS Medical Program recipients who will
  be enrolled in Illinois Health Connect
• Description of the role of Primary Care Providers
  (PCP)
• Overview of Implementation Schedule and Client
  Enrollment Procedures
• Discussion of Referral Process
• Summary of the roles of specialists and hospitals

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Outline of Presentation

• Description of Primary Care Case Management (PCCM)

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Illinois Assuring Medical Care

• Illinois is implementing a Primary Care Case
  Management (PCCM) model of health care to address
  cost and quality issues. The PCCM model assures
  responsive health care delivery that focuses on
  prevention, health promotion, primary care,
  coordinated care and appropriate health care.
• Illinois PCCM program is called Illinois Health
  Connect.
• It is sponsored by the Illinois Department of
  Healthcare and Family Services (HFS).
• Automated Health Systems (AHS) administers the
  program for HFS.
• Illinois will continue operating its voluntary
  MCO program (managed care based on enrollment in
  risk-based capitated health plan).

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What is Primary Care Case Management (PCCM)?

• A model of health care that combines managed care
  and fee-for-service, but is more than simply
  managed care.
• Incorporates the concept of providing each
  participant in the program with a medical home
• In a medical home, Primary Care Providers (PCPs)
  are responsible for coordinating the provision of
  health services needed by the consumer
  (gatekeepers and gate openers)
• Unlike HMOs, the PCP is not at financial risk for
  the services provided

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Health Care Services Research

• 75 of adults surveyed said that it was very
  important that they have one doctor or place
  responsible for providing their primary care and
  coordinating all care.
• Framework for a High Performance Health System
  for the US, The Commonwealth Fund, August 2006

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Health Care Services Research

• Review of PCCM experience in Iowa for 1989 to
  1997
• Medicaid expenses were 3.8 less than previous
  FFS system
• Cost reductions due to substituting outpatient
  care for inpatient care
• Effect became stronger over time
• Momany et al, Health Services Research 414,
  August 2006.

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Health Care Services Research

• Review of Maryland PCCM program
• Overall, enrollment in program resulted in higher
  likelihood that recipients would use the health
  care system, but in lower expenditures per user.
• Increased use of primary and preventive care
• Schoenman et al, Inquiry 34(2)155-70 Summer
  1997.

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Health Care Services Research

• National overview of Medicaid managed care
• Sophisticated multivariate regression models
• Mandatory PCCM/HMO programs improve care for kids
  by increasing probability of usual source of
  care (medical home), decrease ER visits by 5.7,
  increase immunization rates by 16.
• Garrett et al, Health Services Research 382,
  April 2003.

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Outline of Presentation

• List of HFS Medical Program recipients who will
  be enrolled in Illinois Health Connect

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Covered Populations (based on FY 05)

• Eligible population 1.2 million statewide
• Includes
• Children in the current All Kids Program
  (800,000)
• Parents in the FamilyCare Program (300,000)
• Disabled adults (95,000)
• Elderly (13,000)

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Excluded Populations

• Individuals who have Medicare
• Children under age 21 who get Supplemental
  Security Income (SSI)
• Children in foster care and children who get
  Subsidized Guardianship or Adoption Assistance
  from DCFS (Department of Children and Family
  Services)
• Children under age 21 who are blind or who have a
  disability
• People who live in nursing facilities
• American Indians and Alaska Natives
• Individuals with Spend-down

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Excluded Populations

• People who get Home and Community-Based services
  like the Community Care Program, the Home
  Services Program, or community services for
  persons with developmental disabilities
• Refugees
• Individuals residing in Community Integrated
  Living Arrangements (CILAs)
• Individuals in Presumptive Eligibility programs

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Excluded Populations

• Individuals in limited benefit programs such as
• Illinois Healthy Women
• All Kids Rebate and FamilyCare Rebate
• Illinois Cares Rx (formerly SeniorCare/Circuit
  Breaker)
• Transitional Assistance, age 19 and older
• Emergency Medical Only
• Hospice
• Sexual Assault, Renal, and Hemophilia programs
• Populations already managed such as
• High level third party liability (TPL)/private
  insurance
• Program for All-Inclusive Care for the Elderly
  (PACE)
• Children under age 21 whose care is managed by
  the Division of Specialized Care for Children
  (DSCC) of the University of Illinois at Chicago.

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Outline of Presentation

• Description of the role of Primary Care Providers
  (PCP)

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Provider Types Eligible to Serve as PCPs (Must
meet PCP requirements)

• FQHCs, RHCs, other clinics including certain
  specified hospitals, and CCBHS clinics
• General Practitioners, Internists, Pediatricians,
  Family Physicians, OB/GYNs, and other Specialists
• Certified local health departments
• School-based/linked clinics
• Other qualified health professionals as
  determined by HFS

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Connecting PCPs and Patients

• PCPs need to enroll as an Illinois Health Connect
  provider (1-877-912-1999)
• PCPs determine panel size 1 to 1800 pts per FTE
• Can limit panels to existing pts, gender and age
  ranges
• Panel sizes are increased by 900 pts per
  physician asst, advanced practice nurse or
  resident

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PCP Requirements

• Provide direct access to enrollees through an
  answering service/paging mechanism or other
  approved arrangement for coverage twenty-fours
  hours a day, seven days a week. Automatic
  referral to an emergency room does not qualify.
• Maintain office hours of at least 24 hours/week
  (solo) or 32 hours/week (group).

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PCP Requirements

• Be enrolled with HFS as one of the allowed
  provider types
• Maintain hospital admitting and/or delivery
  privileges or arrangements for admission
• Make medically necessary referrals to HFS
  enrolled providers, including specialists, as
  needed

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Care Management Fee

• PCPs will be paid a special monthly care
  management fee for each person whose care they
  are responsible for managing.
• 2.00 per child
• 3.00 per adult
• 4.00 per disabled or elderly enrollee
• The monthly Care Management Fee will be paid even
  if the enrollee does not get services that month
  and will not be subject to the payment cycle.
  PCPs will continue to receive their regular
  fee-for-service reimbursement from HFS.

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Terminating Patient Relationships

• PCPs may request a change in enrollee assignment
  in accordance with the Federal Statute 42 CFR
  438.56 the Principles of Medical Ethics of the
  American Medical Association and Illinois State
  Regulations related to abandonment.
• Any standards established by the PCP for enrollee
  reassignment must be practice-wide and apply to
  all enrollees.
• Under Illinois Health Connect, the PCP must
  continue to see the enrollee until the request is
  granted and reassignment occurs.

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Outline of Presentation

• Overview of Implementation Schedule and Client
  Enrollment Procedures

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Illinois Health Connect Implementation

• Phase 1 Voluntary Illinois Health Connect
  (PCCM)
• Began July 2006
• PCPs are limited to FQHCs, RHCs, and CCBHS
  clinics to allow for an immediate statewide
  presence
• Phase 2 Mandatory Illinois Health Connect
  (PCCM)
• Geographical statewide implementation
• Starting in mid-January in Cook county and then
  proceeding in the Collar Counties, NW Region and
  Central and Southern Regions over 3 to 4 months.

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Mandatory Enrollment Process

• The auto-assignment algorithm will take into
  account
• Existing provider-client relationships (based on
  voluntary phase enrollment and claims data)
• PCPs of other family members
• Location
• Provider specialty
• Capacity limits

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Confirmation of Enrollment

• Enrollees will receive a letter to confirm their
  enrollment. (PCPs will not be listed on the HFS
  medical card.)
• Each PCP will receive a monthly client roster for
  all clients enrolled with that PCP as of the
  first of each month.
• Providers should always check client
  eligibility/PCP assignment prior to providing
  service through the HFS website (MEDI system) or
  through the use of a REV vendor.

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Outline of Presentation

• Discussion of Referral Process

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Services Requiring Referral

• Services provided by
• Physicians, including another PCP (w/ exception
  of OB/GYNs)
• Nurse practitioners, midwives, and physician
  assistants
• Podiatrists and Chiropractors
• RHCs, FQHCs, other clinics and ambulatory
  surgical treatment centers
• Audiologists
• All other services that are not Direct Access
  services

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Referral Information

• Enrollee name, ID number, address and phone
  number
• PCP name and HFS provider number
• Referred provider name and HFS provider number
• Date range of referral authorization
• Referrals may also include diagnosis, reason for
  referral, and any restrictions

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Referrals

• PCPs order and authorize referrals.
• AHS only tracks referrals to guarantee payment is
  appropriately made to the specialist or other
  provider.
• Referrals may be registered by Internet, phone,
  or fax beginning in January 2007.
• Referral information will be available on a
  real-time basis so providers can verify a
  referral has been made.
• Provider claims will not be rejected for lack of
  PCP referrals until mid-2007 at the earliest.

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Direct Access Services

• Services provided to newborns up to 91 days after
  birth
• Family planning and OB/GYN services
• Inpatient Care
• Shots/Immunizations
• Emergency room services
• Emergency and non-emergency transportation
  services
• Pharmaceuticals
• Dental services (handled by dental contractor)
• Vision Services
• Mental health and substance abuse services

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Direct Access Services

• Outpatient ancillary services (radiology,
  pathology, lab, anesthesia)
• Services to treat STDs and tuberculosis
• Early intervention services
• Therapies
• Lead screening and epidemiological services
• Service provided by
• School-Based/Linked clinics (under age 21)
• School Based clinics through Local Education
  Auth. (under age 21)
• Local Health Departments
• Mobile vans, with HFS approval
• FQHC homeless sites

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Outline of Presentation

• Summary of the roles of specialists and hospitals

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How does this impact specialists?

• Specialists will require a referral from the PCP
  to provide outpatient care to patients enrolled
  in Illinois Health Connect.
• Diagnostic test ordered by specialists do NOT
  require a referral
• Inpatient and ED care do NOT require referrals.
• Specialists will be able to access referral
  information and PCP names via AHS internet or
  phone system
• AHS is developing a roster of specialists who are
  willing to increase their capacity to serve
  patients enrolled in Illinois Health Connect.
  AHS will use this roster to assist PCPs in
  accessing specialty care for their pts.

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How does this impact hospitals?

• Employed PCPs need to enroll as PCPs with
  Illinois Health Connect.
• ED services are direct access.
• ED providers can identify pts PCP through the
  MEDI system and refer back to the medical home
  for follow up care.
• Inpatient care and admissions from the ED do NOT
  require a referral.
• AHS will work with hospitals and their medical
  staff services to provide information to medical
  staff members.

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Advisory Subcommittees

• Asthma Chair Art Sprenkle, MD
• arthur.sprenkle_at_mckesson.com
• Behavioral Mental Health Chair Rick Leary, MD
• fredric.leary_at_mckesson.com
• Provider Network Chair Margaret Kirkegaard,
  MD
• mkirkegaard_at_automated-health.com
• Maternal Child Health Chair Margaret
  Kirkegaard, MD
• mkirkegaard_at_automated-health.com
• Quality Management Chair Jody Bierzychudek, RN
• jbierzychudek_at_automated-health.com

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Questions? Info 1-877-912-1999 www.illinoishealth
connect.com