Consumers Need Protection from Health Insurance Company Plan Year Manipulation

It was disappointing—infuriating actually—to learn that some of the nation’s health insurance companies are trying to take advantage of their current customers by manipulating plan years. They are doing so to avoid having to pass on to these customers the benefits of national health reform.

These insurers are reaching out to current customers, taking advantage of their uncertainties, and luring them to switch to health plan years that begin in 2013. By substituting 2013 plans for their current plans that run through early 2014, customers will lose important Affordable Care Act (ACA) protections that must apply to plans issued on or after January 1, 2014. For example, plans issued in 2014 must offer a comprehensive range of benefits and have rates based only on the customer’s age, geographic location, number in family, and tobacco usage. Discrimination based on gender or pre-existing conditions is banned by federal law in 2014 plans. Health insurance insider turned critic, Wendell Potter, recently wrote in detail about this outrage in the Huffington Post.

So insurers are trying to have the best of both worlds. They want all the goodies the ACA offers them, including hundreds of millions of new customers (many of whom will only be able to afford coverage because they qualify for the federal financial help in the form of advance premium tax credits and cost sharing subsidies available under the ACA), but they also want to deprive their existing customers of the benefit of ACA reforms.

Fortunately, insurance regulators can and are protecting customers from such manipulation. Illinois Department of Insurance Director Andrew Boron issued Bulletin 2013-07 on April 29, 2013, telling Illinois health insurers that they won’t get away with such manipulation. “The Department will not approve…filings for such arrangements,” the bulletin says. That should bring these threatened manipulations to an end in Illinois, and we hope regulators in other states take similar actions.

Health insurance has been baffling to most individuals and small businesses. The federal government, many states, and many non-profit organizations are working hard to inform citizens of the reforms, benefits, and opportunities the Affordable Care Act has already brought and the major improvements coming in 2014. Actions like these plan date manipulations simply have no place in the picture. Thank goodness regulators can and are stepping it to ensure a happy ending.

Margaret Stapleton

Community Justice Director
Sargent Shriver National Center on Poverty Law

Governor Quinn Enacts Largest Increase in Health Care Coverage in State History

Governor Pat Quinn today signed legislation that enacts a critical part of President Obama’s Affordable Care Act (ACA) by making Medicaid coverage available to all low-income adults in Illinois. Today’s action delivers on a major priority announced by Governor Quinn in his 2013 State of the State address and is part of his agenda to improve the health of the people of Illinois and increase access to quality health care.

“In the home state of President Obama, we believe access to quality health care is a fundamental right and we proudly embrace the Affordable Care Act,” Governor Quinn said. “This legislation will greatly improve the health of hundreds of thousands of people across Illinois, strengthen our health care system and create thousands of good jobs in the health care field. Thanks to this law and our shared commitment to increasing access to health care coverage in Illinois, the people of Illinois will be healthier and have a higher quality of life.”

Sponsored by State Senator Heather Steans (D-Chicago) and State Representative Sara Feigenholtz (D-Chicago), Senate Bill 26 will make Medicaid coverage available to adults with annual income below 138 percent of the federal poverty line, which is $15,860 for individuals and $21,408 for couples. The measure is expected to enroll 342,000 people by 2017. Currently, Medicaid is only available to children, their parents or guardians, adults with disabilities or seniors. Enrollment for the newly eligible population will begin Oct. 1 with coverage starting on Jan. 1.

Under the ACA, for the first three years, coverage of newly eligible adults will be 100 percent federally funded. The reimbursement rate will phase down to 90 percent by 2020. State officials estimate this will bring more than $12 billion in new federal funding to support the state’s health care system from 2014 to 2020.

“The Affordable Care Act gives Illinois the resources to provide critical health care services to a population that desperately needs it,” Illinois Department of Healthcare and Family Services Director Julie Hamos said. “Under Governor Quinn’s leadership, we are reforming our health care system so that it focuses on delivering coordinated care and keeping people healthy through better preventive care, not just paying the bills when they become sick.”

Under Governor Quinn's leadership, Illinois is also increasing access to health coverage through the Illinois Health Insurance Marketplace, another major feature of the ACA. The Marketplace, which also launches enrollment Oct. 1 with coverage starting Jan. 1, will be accessed through a user-friendly website where individuals, families and small businesses will be able to compare health care policies and premiums and purchase comprehensive health coverage. Those with income between 138 percent and 400 percent of the federal poverty level will receive subsidies on a sliding scale if they obtain coverage through the marketplace.

Governor Quinn has long championed access to decent health care for all people. In August 2001, he joined his then 78-year-old Doctor, Dr. Quentin Young, to walk 167 miles across Illinois to advocate for health care for all.

For more information about Illinois' implementation of the ACA, go to HealthCareReform.illinois.gov.

Related Documents
Senate Bill 26 and the Affordable Care Act (PDF)

(This post was taken directly from the Illinois Government News Network press release)

Accountable Care Entities (ACEs): A New Coordinated Care Model in Illinois

SB 26 to be signed by the Governor into law on July 22, 2013, will expand Medicaid to over 600,000 new potential enrollees but it will also usher in a new form of coordinated care in Illinois for these new Medicaid enrollees as well as existing families on Medicaid - the Accountable Care Entity.

An Accountable Care Entity (ACE) will be a new Illinois model of an integrated delivery system. This will be the fourth model providing “care coordination services” for Medicaid clients, which now includes Managed Care Organization (MCO), Managed Care Community Network (MCCN) and Care Coordination Entity (CCE). This infographic provides a great overview of the system so far.

The ACE will have these elements:

• Will be a provider-organized network of care -- providers working together collaboratively
• Will be large enough to have impact for a population: initially children and their family members in Illinois Medicaid, at least 40,000 in Cook County, 20,000 in collar counties, 10,000 downstate
• Will have at a minimum the following types of providers: primary care, specialty care, hospitals, and behavioral healthcare; will have a governance structure that includes each type of provider and works to create a shared culture of collaboration/transformation
• Will build an infrastructure to support care management functions among the providers in the network, such as health information technology, risk assessment tools, transparent data and data analytics, communication with Medicaid members, etc.
• Will work toward a new payment structure different from the current fee-for-service: shared savings within first 18 months, partial risk after 18 months and full risk after 3 years, which means capitated payments with financial incentives for the providers within the network

This is an opportunity for the hospital community and other providers to develop integrated delivery systems in Illinois that will manage Medicaid populations but are not traditional MCOs. Under SB 26, HFS will post a solicitation by August 1, and give 5 months to new entities to organize and apply.

The initial population assigned to ACEs will be children and family members (and likely newly eligible Medicaid clients under the Affordable Care Act.)

For more information check out the HFS Care Coordination Site

Stephanie Altman
Health & Disability Advocates

Illinois to Be Awarded Over $90 Million in Medicaid Funds for Home- and Community-Based Care

The Affordable Care Act (ACA) section 10202 establishes the Balancing Incentive Payments Program or BIP. BIP offers State Medicaid programs a financial incentive to offer home- and community-based services (HCBS) as an alternative to institutional care in nursing homes. In exchange for an increased federal matching rate (Medicaid is a State-Federal jointly paid program), States must implement 3 structural changes to their long-term services and supports (LTSS) system:

1. A No Wrong Door–Single Entry Point system (NWD/SEP)

2. Conflict-free case management services

3. A core standardized assessment instrument

In March, 2013, Illinois’ State Medicaid Agency, the Department of Healthcare and Family Services, submitted a proposal to the Centers for Medicare and Medicaid Services (CMS) to participate in BIP. On June 12, 2013, CMS announced their approval of Illinois’ BIP application, which will bring in $90.3 million of Federal matching funds into the State for Illinois projected HCBS expenditures over the next 2 years.

What Does Illinois’ Proposal Look Like?

Illinois’ BIP proposal is the most comprehensive overview of the State’s various LTSS programs: from aging, to development disabilities, to physical disabilities, to mental health, to substance abuse—Illinois’ BIP proposal covers it all. For anyone who wants a crash course on what Illinois is doing in the area of LTSS balancing—the development of a LTSS system that is more home- and community-focused than institutional focused—the BIP application is a great place to start.

In reading through the BIP proposal, you will see that Illinois is planning to integrate LTSS through collaboration across governmental department silos. The BIP operating agency will be the State Medicaid Agency: the Illinois Department of Healthcare and Family Services (HFS). HFS is already working in partnership with its sister agencies on implementing BIP:

• The Illinois Department on Aging (DoA)
• The Illinois Department of Human Services (DHS)
• Division of Developmental Disabilities (DHS/DDD)
• Division of Mental Health (DHS/DMH)
• Division of Rehabilitation Services (DHS/DRS) Division of Alcoholism and Substance Abuse (DHS/DASA)

Further, Illinois’ BIP goals will build off the existing work that Illinois is doing to balance LTSS in favor of HCBS. Existing LTSS balancing projects in Illinois include:

• the closing of State institutions,
• implementation of 3 Olmstead lawsuits [Williams, Ligas and Colbert],
• the Money Follows the Person Program,
• expansion of coordinated/managed care models,
• development of the state-wide community-based Aging and Disability Resource Center (ADRC) system, and
• ongoing provision of HCBS through Medicaid 1915 (c) waivers, of which Illinois currently operates 9 waivers.

The work described in the BIP application details how Illinois will implement the 3 structural requirements of BIP: a no wrong door–single entry point system (NWD/SEP), conflict-free case management services, and core standardized assessment instrument. These 3 areas are described below briefly. It is important to note that currently Illinois has separate systems for each sub-population served in its LTSS programs: aging, physical disability, mental health, substance abuse, development disability. BIP provides Illinois with the opportunity to coordinate across the population groups from the community and consumer level, all the way up to the State government level.

1. Illinois’ No Wrong Door–Single Entry Point system (NWD/SEP)
Entry points for LTSS are not currently coordinated across aging and disability populations. Current access points include: DHS local offices, Aging and Disability Resource Centers (ADRCs), Area Agencies on Aging (AAAs), Division of Rehabilitation Services local offices, Pre-Admission Screening agencies that serve persons with intellectual/developmental disabilities, community mental health centers and regional mental health points of contact, and State agency websites.

The ADRC network offers a starting place to coordinate across all of these different access points. Under the leadership of Illinois Department on Aging, the vision for the ADRC system is “a highly visible and trusted resource for all persons regardless of age, income and disability, to access a coordinated point of entry to public long-term support programs and benefits, and to obtain information on the full range of long-term support options”. [See page 31 of the BIP proposal].

Illinois’ ADRC system is already in development with 7 ADRCs up-and-running across the state—through AAAs in collaboration with disability organizations. It is anticipated that by September 2016, all of Illinois’ 13 Planning-and-Service-Areas (PSAs) will have designated ADRCs through leadership from Illinois’ AAAs. ADRC entities also currently include Care Coordination Units, Community Care Program providers, Centers for Independent Living, and DoA’s Senior Help Line (a State-wide toll-free phone number).

The NWD/SEP system will allow for individuals to receive a level 1 screen to determine which LTSS an individual should be assessed for. Access to this level 1 screen will be available online through a coordinated network of ADRC partners.

2. Illinois’ Conflict-Free Case Management Services
Illinois has different case management systems for each population group served. To ensure conflict-free case management, per Federal guidance, Illinois will work to separate the determination of eligibility process from case management, and from the direct delivery of services.

In the BIP proposal, Illinois describes the current developmental disability and physical disability processes to be conflict-free. However, more work needs to be done in the area of mental health/substance abuse and aging to ensure conflict-free case management [see pages 23-24 of the BIP proposal].

The expansion of managed care models in Illinois will help to promote conflict-free case management. With the help of BIP funds, Illinois will also continue to work with CMS to identify potential conflicts of interest and to develop the proper firewalls between eligibility determination, case management and service delivery.

3. Illinois’ Core Standardized Assessment Instrument
Over the past year, Illinois human service agencies have collaborated with Navigant consulting to review Illinois’ current assessment tools and methodology (each population currently has their own assessment tool). With Navigant, Illinois will develop a uniform assessment tool (UAT) for access to LTSS. Recently, HFS released a Request for Information related to the development of the UAT as the State seeks out vendors who can integrate and coordinate across populations and State departments.

A UAT will allow Illinois’ to develop a more consumer-centered LTSS system. Many individuals with LTSS needs require complex care and fall into more than one category across the current Medicaid HCBS waiver system. This means that consumers with mental health needs who are also 60 years or older must access two separate programs to have their needs meet: one in mental health and the other in aging. This makes it very challenging for consumers, and cumbersome and redundant for State agencies. BIP is intended to fix this, to ease access to LTSS in a more timely and appropriate way.

Further, Illinois is also replacing the 30-year old COBOL-based system that is currently in use to determine eligibility for: Medicaid, the Supplemental Nutrition Assistance Program (SNAP, formerly ‘food stamps’), Temporary Assistance for Needy Families program (TANF), and the new Health Benefits Exchange, or Marketplace, required by the ACA. The new Integrated Eligibility System (IES) is branded as Application for Benefits Eligibility, or ABE.

What all of this means for professionals and consumers is that Illinois is moving towards a system that will significantly streamline the determination of eligibility process for a variety of different programs, including LTSS. Part of this systemic upgrade includes ensuring better Information Technology (IT) integration and easier access to data about these publicly funded programs across population types.

Stay Tuned as Illinois Continues to Balancing LTSS in Favor of HCBS

As Illinois implements BIP and its other LTSS balancing programs, the State’s goal is to develop a new HCBS infrastructure that is consumer driven and easy to access and navigate. We look forward to reporting back as consumers across the State find it easier to live and receive care in their homes and communities.

Please let me know if you have questions, comments or responses to this blog post. You can reach me at: 312.372.4292 or kpavle@hmprg.org.

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