Welcome to the Illinois Health Matters Blog

Welcome to the Illinois Health Matters Blog. Our blog discusses various topics around how health care reform is affecting the people of Illinois. We present a variety of different perspectives from health care experts, both from our state, and nationally. For more information please visit IllinoisHealthMatters.org.

Thursday, October 9, 2014

Illinois Granted Early Access to SHOP Marketplace

Yes, the Affordable Care Act offers individuals and families quality health insurance, but did you know small employers with less than 50 full-time equivalent employees can take full advantage of the Health Insurance Marketplace? Online functionality for the SHOP, aka the Small Business Health Options Program, is available starting later this October as part of SHOP early access, which is only available to 5 states. Illinois is one of the lucky few. Brokers and Small Businesses, check it out at Healthcare.gov!

This incremental launch will help identify issues early and assist brokers and businesses in building confidence in utilizing the SHOP online system. The SHOP Call Center can be reached at 1-800-706-7893 (TTY: 711) Monday through Friday, 9 a.m. to 7 p.m. EST.

During SHOP early access, Illinoisians can do the following to initiate enrollment:

  •         Establish a Marketplace SHOP account
  •         Establish an agent or broker to their account if they wish
  •         Complete an employer application
  •        Obtain an eligibility determination
  •         Upload an employee roster when enrollment functionality is available
  •          Starting in November, browse health plans with coverage starting in 2015


While small businesses have always had group plan options, many even available online, there were challenges that got in the way of providing group coverage to their employees. Premiums were expensive and small businesses lacked the purchasing power of larger organizations. The SHOP makes some pretty substantial changes to the ways in which small businesses can buy plans.
First, financial assistance is now available in the form of a tax credit. This can substantially help employers by covering up to 50% of employer contributions towards employee premiums. This assistance provides the opportunity for businesses to offer employee coverage where it would have previously been unaffordable. Second, the SHOP helps small businesses harness the purchasing power of other small businesses, thus letting them play in the big leagues along with larger organizations.

Small businesses do not have to offer health benefits under the Affordable Care Act, but it is in their best interest to check out options and see what is possible, particularly if they are concerned with employee retention. Whether or not they decide to provide group health insurance coverage, small businesses are nonetheless required to inform employees of the Health Insurance Marketplace, so that individual coverage options can be explored.
Brokers and Small Businesses take note. The time is now to explore options, prepare, and get ready for a new system opening up possibilities for small businesses in Illinois.  

For more information on the SHOP:
TAKE OUR SURVEY HDA and Crain’s Chicago Business are teaming up to poll local small businesses about new health benefit options. Why participate? By taking this short survey about the changing healthcare landscape, you can inform policymakers, insurers and other small business owners. Results will run in a November 17 article in Crain’s. Take the survey now.

Emily Gelber MSW, LSW
Health Policy Analyst
  Health & Disability Advocates

Blogger Tricks

Thursday, September 4, 2014

Providers Will Make Medicaid Care Coordination a Success

If the opening of the health insurance marketplace taught people anything, it’s that choosing health insurance is tough. Suddenly, people had to make a thorough evaluation of their finances, the types of care they depended on, the medications they needed, and more.

Equally important, but receiving a lot less attention are the similar challenges facing people who are trying to pick a coordinated care plan under Medicaid. Generally, having choices is a good thing, but being unarmed to make the best decision is scary. So, how does one pick? No doubt, case managers, doctors, social workers, and community organizations hear this question all the time. When the system of health care is changing so rapidly, how are front-line professionals prepared to handle the number of questions and the confusion when they may not have a grasp on what this new system is going to look like in the first place?

Almost everyone who has Medicaid in Illinois will be required to pick a coordinated care plan. These plans are offered by managed care organizations (such as Aetna and Blue Cross) and by provider groups (such as Be Well Partners in Health) that have chosen to start innovations projects, which try new ways of managing care. Collectively, they are referred to as managed care entities, but for the sake of discussion, we will refer to them here as Medicaid health plans.

Medicaid health plans must include all of the benefits traditionally offered by Medicaid, a plan can also choose to provide more benefits than Medicaid. In addition, all plans require that members choose a primary care physician. Members with more complex care needs will also be assigned a case manager, either a nurse or social worker.

Why the Change

This shift is happening because 50% of Medicaid recipients are required by law to enter into coordinated care by 2015. But aside from the legal requirement, the move into coordinated care has a number of additional drivers, including cost containment. Medicaid costs are high, often a result of inefficiencies, uncoordinated care, and a fee-for-service reimbursement structure. The hope is that the move to coordinated care will reduce costs.

As part of the move to coordinated care, the payment structure is changing. Many, but not all, Medicaid health plans will receive a capitated rate to coordinate and provide care for Medicaid members, meaning a per-member monthly reimbursement regardless of the services provided. Providers will then contract with Medicaid health plans and can negotiate their rates of reimbursement. So, Medicaid health plans receive a capitated rate, providers then negotiate reimbursement rates with the particular Medicaid health plan. Medicaid health plans are thus incentivized to control costs, because they are going to make money based upon members receiving quality care at a lower cost, rather than based upon the number of services provided.

What will all of this mean for Medicaid recipients? Each Medicaid member will receive a letter detailing health plan options available through Medicaid (many have already received them) from the Illinois Department of Healthcare and Family Services. Most will have to choose one of the plan options detailed in that letter. If they fail to choose a plan, a selection will be made for them based on their past providers, location, and previous health plan affiliation.

The choices in the letter will be based upon the Medicaid population group and where that particular member lives. For example, ACA adults have different options than Medicaid enrollees that qualified based upon disability or age; people who live in metro Chicago will choose from a different set of plans from those who live downstate. As members of these plans, there will be new rules to follow, such as using networks specific to their plan. But the plans are all Medicaid, so all of the services an individual previously had access to will remain available. And this is when the provider gets asked for help. How do they help someone choose?

The Client Enrollment Broker

Fortunately, the Illinois Department of Healthcare and Family Services has created something called the client enrollment broker. This is service that helps Medicaid members get connected to a Medicaid health plan. The client enrollment broker website (enrollhfs.illinois.gov) is where one can find information on all of the available plans, including any extra benefits that might be available, such as an allowance for over the counter products. The site has links to the website of each specific plan, where consumers can review the details of each plan.

Of course, not everyone is tech savvy, or even has internet access. So the client enrollment broker is also available to assist with enrollment by phone. The client enrollment broker can be reached at 877-912-8880 Monday to Friday from 8 am to 7 pm and on Saturdays 9 am to 3 pm. The call is free.

Before speaking with the client enrollment broker, Medicaid members will want to focus on the questions to ask. They may want to write them down – much like people are advised to write down what they want to ask the doctor during an office visit. Here are some things they will need to consider when choosing a Medicaid coordinated care plan, and to discuss with the client enrollment broker if they call:

  • The letter received in the mail will have a primary care provider listed. That is the provider that will be assigned to them if they do not choose a primary care provider and plan themselves. If the person has a primary care physician at present, it will be important to ask about plans with this provider in network. Otherwise, they may want to choose one before calling the client enrollment broker.
  • Anyone with special healthcare needs should ask if their specialists are in-network.
  • Anyone who visits facilities like skilled nursing or hospitals should ask whether those facilities are in-network.
  • The person also should consider what medications they are taking. Although Medicaid-covered drugs should be included in the formulary for every plan, there could be variations in copays or in generics vs. brand-name availability.

The client enrollment broker will ask for a social security number and the Medicaid member should have that available for the call.

This is a lot to consider, and the Medicaid population was not prepared to make these decisions alone. For someone who has never enrolled in a health plan before, or has only ever had one choice, these changes may prove overwhelming.

Provider Participation Is Essential

So it is not surprising that providers will be called upon to assist clients in making smart choices. Without provider participation, individuals may not be able to make appropriate and educated enrollment decisions that directly impact access to and continuity of care. And just as important, providers can do their best to simplify these decisions by joining networks and being knowledgeable about their own health plan network membership. Even after members are enrolled, providers can help them navigate the new and narrower networks to avoid the costs of going out of network for care.

If one thing is clear it's that providers need to be engaged in the evolution of Medicaid. Without their involvement, foreign language speakers will not find providers that can speak to them, people with complex illness will not connect with physicians and specialists who have experience with those conditions, and patients with long-established doctor-patient relationships will suddenly be unable to see their doctor. Provider participation and networking is the solution to all of these issues.

But ultimately, providers need to be participating in the coordinated care system for reasons that go above and beyond making health plan choices easier for people on Medicaid. Right now, the entire Medicaid system – both traditional and expanded Medicaid – is rapidly transforming into a coordinated care system. That means that many clients or patients will be in that system, and they will be restricted to those networks. To keep their Medicaid patients, providers need to be in that system as well.

Another benefit is that billing can be simplified with Medicaid health plans. Back office billing functions – which are notoriously complicated and slow with fee-for-service Medicaid – could start to become more straightforward. In fact, Medicaid health plans should actually reimburse efficiently since they are contractually obligated to pay in a timely manner. Wouldn’t that be nice?

Care coordination is here and it is happening now. It’s time to participate. Providers can either play a part, or patients will feel the consequences. And really, so will providers.

By Emily Gelber MSW, LSW
Health Policy Analyst
Health & Disability Advocates

Learn more about Medicaid Care Coordination.

Friday, July 25, 2014

Did Obamacare Destroy Competition in the Private Insurance Market?

One of the biggest criticisms of the Affordable Care Act was that it would be the death of the private insurance marketplace. Opponents of healthcare reform cautioned that the law change would crowd out private innovation in the market and make insurance carriers less interested in competing.

If we take a closer look back at the progression of insurance company involvement in Illinois, I think we’ll find that not only was this not the case – but in reality, the reverse was true.

Prior to the 2014 open enrollment period, the small business market in Illinois was extremely limited. If you had fewer than 50 employees, the options for group coverage were four to five carrier choices (depending on your county). These companies continued to churn business, and employers would change carriers every two to three years as their premium rate increases continued to increase. There were significant barriers to entry - and every time we saw a new carrier attempt to provide competitive options, the larger more traditional players quickly chased them out of the state.

For sole proprietors and the self-employed, the outlook was even bleaker. There were two or three competitive options, and the underwriting guidelines were so rigid that even those plans were unrealistic for many individuals hoping to gain private insurance coverage.

Reviewing the change to the market, we see that sole proprietors and the self-employed saw the biggest gain in options. The opening of the ACA Marketplaces in 2014 offered up to seven carrier choices for individuals in some regions of Illinois. Although many of the players were familiar faces, one – Land of Lincoln - was brand-new to Illinois consumers. Land of Lincoln is a co-op (oonsumer oriented and operated), a new type of insurance organization made allowable by the ACA.

The federal government has now awarded nearly $2 billion in loans to help create 24 new CO-OPs in 24 states. The CO-OP sponsors - consumer-run groups, membership associations, and other nonprofit organizations - are now moving forward to offer health coverage in competition with established commercial and nonprofit insurance companies. (Health Affairs Policy Briefs)

What about small employers? While the SHOP Marketplace faced many more struggles in Illinois, there were some indications of future hope in improving competitive choices for our state. First, Land of Lincoln did offer and enroll small employer options. This added a new type of plan for employers to consider – and because it was offered on the SHOP, employers that qualified and enrolled in their SHOP plans could take advantage of the Small Business Tax Credit.

Second, we began to see the creation and evolution of private marketplaces and partially self-funded programs being marketed to small employers. In the past, third party administrators had reserved these innovative solutions for larger clients. The need for financial solutions and minimum essential coverage has spurred creative thinking and new progressive options for forward-thinking small employers to test out. Although these solutions are in their early stages of development, they do reflect a market expansion - not contraction.

Finally, and perhaps most importantly, the existing small business market remained intact. All of the same original carriers that offered plans historically continued to do so in 2014. We didn’t see one single insurance company leave the state of Illinois - instead many of them continued to market aggressively to small businesses and create new plan offerings that would be both compliant with ACA rules and competitive.

As we begin to look forward to the 2015 open enrollment cycle, the question remains of whether this trend will continue or reverse. Early indications point to a growing market. Last month, the Department of Insurance in Illinois released a statement noting that 10 carriers have submitted applications to offer plans in the second year of the Marketplace. This representing a significant growth in choices in the insurance carriers and the numbers of plans they will offer from Year 1. (Get Covered Illinois). Here are the exact numbers:

Illinois Healthcare Marketplace Plan Options – Year 1 and 2
Year 1
Year 2
Submitted Options
Individual Plans120306
Small Group Plans 45198
The Illinois Department of Insurance is not expected to announce which plans it has approved until early August. However, given the significant increase in possible options, we can expect that both the individual market and small group market will see growth for 2015. Although this is positive movement, my hope is that the department will focus its expansion of plan approvals on the small group marketplace, which was significantly under-represented in choices in 2014.

In any case, the numbers show promising evidence of expanded insurance plan competition under Obamacare – something that small employers and the self-employed desperately needed prior to its enactment. We can and should consider this component of the legislation a true economic win for Illinois business.

– By Michele Thornton, MBA
Insurance and Benefits Consultant

Monday, July 7, 2014

Learn. Connect. Share. PTSD Treatment can help.

June was PTSD Awareness Month. And although spotlighting it throughout the month of June brings a lot of great information to the public, it is important to remember that PTSD is something that many individuals struggle with throughout the year.

Take the Fourth of July as an example: This great American holiday is only four days past the end of PTSD Awareness Month, but many people are not aware of the impact this holiday has on combat veterans with PTSD. For many of them, these exuberant displays of sound and light trigger combat flashbacks that last long after the last sparkler has fizzed out for the night.

This year, there has been more publicity around the effect that fireworks can have on returned vets. And there has been a growing campaign to increase PTSD awareness by placing signs in front lawns that read: "Combat Veteran Lives Here, Please Be Courteous with Your Fireworks." The experience of combat veterans on the Fourth of July is a prime example of the type of awareness that needs to continue beyond the month of June, and that is an awareness that centers on respect for those who suffered trauma in the past, and who continue to feel the effects to this day.

That being said, it’s hard to know how to be courteous of those with PSTD when you don’t have a very firm grasp on what PTSD is. Although it is most commonly associated with combat veterans – and vets as a population experience PTSD at a much higher rate – it also occurs in those who have lived through other violent experiences. The National Center for PTSD defines it as "a mental health problem that can occur after someone goes through a traumatic event like war, assault, an accident or disaster."

Understanding that PTSD is not limited only to combat veterans is an important step in learning how to be mindful of things that may trigger flashbacks or any other cognitive or bodily symptoms. Things that might seem part of the norm – like fireworks on the Fourth of July – can actually cause a painful reliving of a traumatic moment.

The way each person experiences their PTSD is different, and the only way to be able to really get a grasp on what these individuals experience is through talking with them. However, it is understandably difficult for many to recount their stories, so it is important to be patient and supportive. Reach out if you see that your friend or family member with PTSD wants to talk and be sure to listen to their story.

If you or a loved one struggles with PTSD, or if you just want to learn more about how you can help support someone with PTSD, the Department of Veterans Affairs' websie has a comprehensive section devoted to the condition, the National Center for PTSD (ptsd.va.gov). The section has resources for everything from treatment options like exposure therapy to a section specifically geared toward friends and family members.

Also, let people know that treatment is covered! The Affordable Care Act requires qualified health plans to include mental health services as an essential health benefit. The ACA also outlaws discrimination based on pre-existing conditions, so individuals with PTSD or other mental health symptoms need not be worried that they will be denied coverage or that their coverage will be cancelled.

This year’s PTSD Awareness Month motto was aptly put and is something to keep in mind throughout the year: "Learn. Connect. Share. PTSD treatment can help." Connect by reaching out to someone around you. And finally, share your experiences and knowledge with others.

By Julia Ortner
Health & Disability Advocates
To learn more:

Monday, June 2, 2014

Supporting Chicago's Entrepreneurs: Marketplace Brings New Health Coverage Options

Finding the right healthcare plan can be stressful, and with all the noise surrounding the new healthcare law, it may seem downright overwhelming. But there’s good news coming out of Illinois. The state’s new health insurance marketplace is open for business, and it’s already providing small business owners and their employees with improved options for affordable coverage.

The new marketplace, Get Covered Illinois, is a partnership marketplace, which means the state and federal government run the marketplace together while Illinois prepares to run the marketplace on its own beginning in 2015. Get Covered Illinois has two branches – one for individuals, the other for small businesses. The individual marketplace is available to any self-employed individual or small business employee whose employer doesn’t offer insurance. Open enrollment for 2015 begins on November 15. In the meantime, employees and self-employed folks can use an online calculator to determine if they’re eligible for a subsidy to help cover the cost of insurance for coverage in 2015.

Many self-employed Chicagoans have already discovered the benefits of enrolling through the state’s marketplace, including Jade Phillips, a local children’s book author. After a brief stint with a precipitously high monthly premium and deductible from a private insurance company, Phillips says she spent the majority of her 20s uncovered. But this year, the self-employed entrepreneur was able to sign up for coverage through the individual market. For the first time in years, she’s enrolled in an affordable plan that allows her to continue doing what she loves while enjoying the peace of mind her new insurance brings.

There’s even more good news for small employers. The small business marketplace has year-round enrollment, so small business owners with fewer than 50 employees looking for a plan have plenty of time to determine if the new marketplace is the right choice. There are more than 230,000 small businesses in the Chicago metropolitan area, but in order for them to take advantage of this new option, entrepreneurs need to know what Get Covered Illinois’ small business marketplace can do for their businesses.

Here are some key facts about the marketplace to help get small employers up to speed.

  • The new health insurance marketplace is one of the most important components of the Affordable Care Act for Chicago small employers. The small business marketplace allows small businesses with fewer than 50 employees to band together when buying coverage – giving them the kind of purchasing clout large businesses enjoy.
  • The marketplace offers businesses more competitive choices, which can help lower premium costs, thus improving their bottom lines.
  • Small employers that do offer coverage through the marketplace may also be eligible for a tax credit of up to 50 percent of your premiums. Check out our tax credit calculator to see if you’re eligible and to receive a tax credit estimate. 
  • Illinois’ small business marketplace will offer employee choice in the future, which means small business workers will be able to choose from a number of plans from different carriers.

In order to begin the enrollment process, Chicago entrepreneurs can visit Get Covered Illinois’ site or Healthcare.gov and begin filling out a paper application, or visit contact a certified health insurance broker who can assist with the enrollment process.

What’s more, Small Business Majority’s certified educators can help answer questions regarding the enrollment process. Check out our state outreach calendar or the Small Business Health Care Consortium’s events page to find an event in your area.

To learn more about the small business marketplace, enrollment dates and coverage plans, visit our Health Coverage Guide (healthcoverageguide.org), which contains a wealth of information for small business owners regarding enrollment, the Affordable Care Act and the healthcare system in general.

The more small business owners know about the new marketplace, the easier it will be for them to get their employees and businesses more affordable insurance coverage. And then, instead of worrying about health insurance, they can do what they do best: run the companies that make up the backbone of our state and our nation. 
By Mary Timmel
 Midwest Outreach Manager
Small Business Majority

Tuesday, May 27, 2014

On COBRA? New Announcement from HHS Could Save you Thousands of Dollars

In mid-April, I received a call from a 62-year-old woman named Alice who had been laid off from her job quite a while back. She was paying around $650 each month to maintain her COBRA coverage. Turns out she got my number from her brother, Carl, whom I had helped enroll into a Marketplace plan. He, too, was paying a lot of money each month for COBRA coverage after his employer had cut his hours in half, making him ineligible for employer-offered coverage. By enrolling into a subsidized Marketplace plan, Carl saved more than $400 a month in premium costs. He hoped I could also help his sister. Unfortunately, she called me just a few weeks after open enrollment had ended.

Normally, this would mean that she would have to wait until the next open enrollment period or until she exhausted her COBRA coverage before she could qualify for a Special Enrollment Period which would allow her to enroll into a much more affordable Marketplace plan. It seemed she had missed this window of opportunity – that is until HHS announced new Special Enrollment Periods for folks currently enrolled into COBRA coverage.

As I mentioned, normally a consumer has four options regarding COBRA coverage:
  • Decline an initial offer of COBRA coverage
  • Get a Special Enrollment Period and enroll in marketplace coverage
  • Switch from COBRA coverage to marketplace coverage during open enrollment
  • Wait until the exhaustion of COBRA coverage to get an Special Enrollment Period

Well, HHS recognized that folks just like Alice were confused about their options. So they decided to offer COBRA enrollees a Special Enrollment Period. If you or someone you know is on COBRA, he or she can qualify for a Special Enrollment Period to shop for a plan on the Marketplace until July 1 of this year.

Simply call the Marketplace call center at 1-800-318-2596 and tell them you are currently on COBRA and that you would like to explore your options in the Marketplace. Then fill out an application at healthcare.gov to see if you’re eligible for financial help. This could very well save you hundreds of dollars each month in premium costs. You have nothing to lose. I’ve already called Alice.

By Jillian Phillips, Chicagoland Organizer
Campaign for Better Health Care

Monday, May 5, 2014

Can Non-Profits leverage the ACA to bring down health insurance costs?

The non-profit sector is a leading source of job growth in the United States and currently employs just under 11 million people nationally.[1]  Locally here in Illinois, we see  direct growth in this sector – now holding 10.6% of the private employment, up from 9% in 2005.[2]   However, in a recent survey of 600 national non-profit organizations, recent increases in employee turnover are indicated to be an ongoing concern.[3]  One of the greatest tools that organizations have available to them to attract and retain high quality employees is the compensation and benefits package.  Providing high value, yet affordable benefits is part of the ethos of most non-profit organizations.  However, as the cost curve of health insurance continues to rise, this proposition has become increasingly more challenging.  The Affordable Care Act created a small employer tax credit to help offset some of these costs – but many non-profits are left wondering how this might benefit them.

The ACA includes a provision that gives small employers, including nonprofits with fewer than 25 employees (with average salaries below $50,000), the right to access a tax credit for insurance premiums paid by the employer for their employees' health insurance.  For tax-exempt nonprofits the credit is treated as a refund on quarterly payments that the nonprofit has made to the IRS for income tax withholdings or Medicare withholdings from employee wages. For 2010-2013 the refund is 25% of the expenses paid by the employer towards employees' health insurance premiums; the refund increases to 35% after January 1, 2014.[4]  Non-profits should know that they are still able to retroactively apply for previous year’s tax credit if they meet all of the eligibility guidelines.
            To better understand the tax credit and available provisions under the ACA, you may want to explore the new small business page of Illinois Health Matters.  Here you can find additional information about the small employer tax credit and other key resources.
            Beginning in 2014, to obtain the tax credit – employers must enroll in a qualified health plan through the SHOP Marketplace.  These plans are competitively priced and cover all of the EssentialHealth Benefits that are important to you and the employees you are trying to retain. The Illinois SHOP Marketplace can be found at GetCoveredIllinois.gov.  Here you can find additional information about the plans available – but more importantly through their Get Help feature you can search for registered brokers in your neighborhood.  Brokers can assist you in applying for the small employer tax credit, evaluate your health insurance and employee benefit package, and assist you in enrolling in a plan that qualifies for the tax credit reduction.
The ACA offers two important tools to assist small employers – the SHOP marketplace, and the small business tax credits. Together, these two strategies can help non-profits begin or continue to offer quality benefit programs at an affordable price. As nonprofit organizations continue to play an integral role in the workforce and in the communities they serve – finding business partners that can assist in helping to leverage these resources will continue to be paramount for long term workforce and budgetary planning. Creating stability and financial sustainability in these areas will ultimately allow non-profits more freedom to focus on what’s important – fulfilling the mission of their organization and continuing to serve the community around them.

By Michele Thornton, M.B.A
Insurance & Benefits Consultant

[1] Salamon, LM, SW Sokolowski and SL Geller. Holding the Fort: Nonprofit employment during a decade of turmoil. Nonprofit Employment Bulletin 39, Johns Hopkins University. January 2012.

[2] Salamon, LM, SW Sokolowski and SL Geller. Illinois Nonprofit Employment: An Update.  Nonprofit Employment Bulletin 21, Johns Hopkins University. January 2005.

[3] 2013 Nonprofit Employment Trends Survey Report. Nonprofit HR Solutions. Accessed at: http://www.nonprofithr.com/wp-content/uploads/2013/03/2013-Employment-Trends-Survey-Report.pdf

[4] Small Business Healthcare Tax Credit for Small Employers. IRS (2014).  Accessed at: http://www.irs.gov/uac/Small-Business-Health-Care-Tax-Credit-for-Small-Employers