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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 uses medical care centers like skilled nursing facilities 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.


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



Learn more about Medicaid Care Coordination.

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