Illinois Department of Healthcare and Family Services Annual Report

              ILLINOIS DEPARTMENT
OF HEALTHCARE AND FAMILY SERVICES
ANNUAL REPORT
MEDICAL ASSISTANCE PROGRAM
Fiscal Years 2009, 2010 and 2011
Submitted March 30, 2012
To the Honorable Pat Quinn, Governor
And Members of the General Assembly:
It is with pleasure that we present to you the Department of Healthcare and Family Services’ Medical Assistance Program Annual Report for fiscal year 2011. This document consolidates the reporting requirements under Sections 5-5, 5-5.8 and 5-5-29 of the Illinois Public Aid Code (305 ILCS 5/), Section 55 of the Disabilities Act of 2003 (20 ILCS 2407/) and Section 23 of the Children’s Health Act (215 ILCS 106/).
This report provides details on specific programs, participant numbers, and provider reimbursement. Medical Assistance Program information is provided for the most recently completed fiscal year 2011 and the two previous years, to allow for comparisons for purposes of trending the services. Long term care-specific information is also contained for fiscal year 2011 in compliance with reporting requirements.
This report also contains updates on the Department’s efforts in implementing Illinois’ Medicaid reform legislation [P. A. 96-1501] that have occurred since April of 2011. It has been a very challenging, enlightening and productive year. The Department has made great strides in implementing Medicaid reform, while at the same time planning for the changes coming under the federal Patient Protection and Affordable Care Act (Pub.L. 111-148). We believe that enhanced coordination of the care our clients receive is the strategic key to a more efficient Medicaid program that still provides care for the most vulnerable among us. A few of the reform milestones the Department achieved include:
• In June of 2011, published Coordinated Care Discussion Paper (pdf) outlining many of the issues that the Department was considering in developing an implementation plan for Medicaid reform. We received about 75 responses representing a variety of organization, opinions and options. The responses can be viewed on-line at Coordinated Care Policy Forum Responses.
• In October of 2011, the Department held a public meeting and Webinar, attended by over 1,000 people, to test community interest, and capacity to provide alternative models of delivering care (as an adjunct to our current managed care programs). The purpose of the meeting was to provide the department with feedback on its proposed concepts to use in the planning and development for this project.
• In January 2012, issued the first solicitation for the Care Coordination “Innovations Project.”
• Created the Care Coordination Matchmaker service, a voluntary Internet based system to help community partners find each other in order to develop potential collaborations for the Innovations Project solicitation.
• Released an unprecedented quantity of data and documentation to allow healthcare organizations proposing new Care Coordination Entities (CCEs) and Managed Care Community Networks (MCCNs) to create high-quality, accessible, and cost-effective healthcare programs for Medicaid recipients.
We hope you find this report informative and useful as we work together to continue providing quality healthcare services to Illinois’ most vulnerable populations.
Sincerely,
Julie Hamos, Director Theresa Eagleson, Administrator
Department of Healthcare and Family Services Division of Medical CONTENTS
I. OVERVIEW.................................................................................... Page 1
II. MEDICAID’S FUTURE – CARE COORDINATION......................... Page 2
III. CHILDREN WITH COMPLEX MEDICAL NEEDS.…………………..Page 5
IV. INFORMATION SYSTEM IMPROVEMENTS………………………. Page 13
V. 2011 HIGHLIGHTS ........................................................................Page 16
VI. FINANCIAL OVERVIEW.................................................................Page 18
VII. MONEY FOLLOWS THE PERSON ANNUAL REPORT ...............Page 23
VIII. LONG TERM CARE .......................................................................Page 25
IX. HOME AND COMMUNITY-BASED SERVICES WAIVERS............Page 27
X. MATERNAL AND CHILD HEALTH ................................................Page 28
XI. DENTAL PROGRAM......................................................................Page 37
XII. CARE MANAGEMENT...................................................................Page 39
XIII. MEDICAID PROVIDER ASSESSMENT PROGRAMS....................Page 44
XIV. PROVIDER REIMBURSEMENT.....................................................Page 45
XV. REIMBURSING HOSPITALS .........................................................Page 46
XVI. REIMBURSING LONG TERM CARE FACILITIES..........................Page 53
XVII. REIMBURSING MANAGED CARE ORGANIZATIONS ..................Page 54
XVIII. REIMBURSING PHARMACY SERVICES ......................................Page 57
XIX. REIMBURSING SCHOOL BASED SERVICES ..............................Page 59
XX. REIMBURSING OTHER PROVIDERS...........................................Page 60
XXI. QUALITY ASSURANCE, UTILIZATION AND CONTROL...............Page 62
XXII. ACRONYMS...................................................................................Page 69
XXIII. APPENDICES ................................................................................Page 71
A. Eligibility Groups and Program Descriptions
B. Overview and current activity of HCBS Waiver Programs
XXIV. GRAPHS .......................................................................................Page 81
I. Medical Program Spending
II. Average Payment Per Adjudicated Unit of Service
III. Medicaid Waiver Persons and Expenditures
XXV. TABLES .........................................................................................Page 84
l. Licensed Medicaid-Certified LTC Beds-FY2011 Actual
II. LTC Total Charges and Liability on Claims Received
lll. Medical Assistance Program Expenditures Against Appropriation
IV. Medicaid Enrolled Providers
V. Medical Assistance Mandatory/Optional Services
VI. Claims Receipts History
VII. Home and Community Based Services Waivers
VIII. Hotlines for Health Benefits, All Kids and Drug Prior Approval/Refill to Soon
BACK COVER – List of Statutory Requirements HFS – 2011 Annual Report Page 1
I. OVERVIEW
The Department of Healthcare and Family Services (HFS), Division of Medical Programs, administers and, in conjunction with the federal government, funds medical services provided to about 20 percent of the State’s population. In fiscal year 2011, Medicaid, and the means tested medical programs associated with it, provided comprehensive health care coverage to approximately 2.74 million Illinoisans and partial benefits to over 300,000.
The Medical Assistance Programs are administered under the provisions of the Illinois Public Aid Code (305 ILCS 5/5 et seq.); the Illinois Children’s Health Insurance Program Act (215 ILCS 106/1 et seq.); Covering All Kids Health Insurance Act (215 ILCS 170/1 et seq.) and Titles XIX and XXI of the federal Social Security Act. Through its role as the designated Medicaid single State agency, HFS works with several other agencies that manage important portions of the program—the Departments of Human Services (DHS); Public Health (DPH); Children and Family Services (DCFS); the Department on Aging (DoA); the University of Illinois at Chicago; and Cook County and other local units of government, including hundreds of local school districts.
Illinois’ Medical Assistance Programs are almost all funded jointly by State and federal governments and, in certain instances, local governments. The Department spent in excess of $13.3 billion (all funds) from fiscal year 2011 appropriations, of which $10.28 billion was GRF/GRF like funds and approximately $5.7 billion was federal matching funds, on health benefits provided to approximately 3.1 million individuals over the course of the year.
Medical coverage is provided to children, parents or relatives caring for children, pregnant women, veterans, seniors, persons who are blind, and persons with disabilities. To be eligible, adults must also be Illinois residents and U.S. citizens or qualified immigrants. (Immigrants who are not permanent legal residents may be covered for emergency medical care only, and are not eligible for transplantation services). Children are eligible regardless of immigration status. Individuals must also meet income and asset requirements. Income and asset limits vary by group. Major eligibility groups and brief descriptions of HFS’ programs are described in Appendix A of this report.
On average, each month HFS’ programs cover approximately 2.7 million enrollees for comprehensive coverage, including close to 1.7 million children, 168,000 seniors, 260,000 persons with disabilities, 636,000 non-disabled, non-senior adults and approximately another 297,000 enrollees with partial benefit packages (such as Illinois Healthy Women, Illinois Cares Rx pharmacy assistance, and insurance premium rebates). The table below shows enrollment as of June 30th for the last three fiscal years.
Comprehensive Benefits
FY2009
FY2010
FY2011
Children
1,553,255
1,630,495
1,677,575
Disabled Adults
244,598
253,973
260,228
Other Adults
563,068
608,659
636,531
Seniors
152,894
161,356
168,943
All Comprehensive
2,513,815
2,654,483
2,743,277
All Partial Benefits
280,067
294,039
309,387
Grand Total All Enrollees
2,793,882
2,948,522
3,052,664HFS – 2011 Annual Report Page 2
lI. MEDICAID’S FUTURE – CARE COORDINATION
Care Coordination ― aligned with the Illinois Medicaid reform law and the federal Affordable Care Act ― is the centerpiece of the Department’s reform efforts. In moving forward, HFS recognizes that the transition from a fee-for-service payment system more accountability based payment system will require major changes for the provider community and clients. Under the new “Medicaid” there must be an infusion of risk and performance into reimbursement in order to transform the Medicaid healthcare delivery system with a focus on improved health outcomes. To accomplish this, the Department has laid out an ambitious timeline for the development of its Care Coordination initiatives:
January, 2012
◊ Innovations Project: issue solicitation with initial focus on adults with complex health needs served by provider-driven models of care only (i.e. not traditional HMOs). Provider collaborations must include, at a minimum, hospital(s), primary care provider(s), and behavioral health program(s).
Spring, 2012
◊ Innovations Project: issue solicitation to include children with complex health needs and high-risk moms and babies.
◊ Expand the Integrated Care Program (ICP) to include long-term care services, for the approximately 40,000 enrolled Seniors and Persons with Disabilities (SPDs) clients who reside in suburbs/collar counties. (Phase 2 services)
◊ Issue proposal for integrated care models to serve approximately 200,000−250,000 dual-eligible (Medicare/Medicaid) clients under dual-capitation.
Fall, 2012
◊ Expand Care Coordination Innovations Project to include care coordination entities of all types, including traditional HMOs.
Care Coordination Innovations Project
The Medicaid reform law, Public Act 96-1501, requires the Department to move at least 50 percent of recipients eligible for comprehensive medical benefits in all programs administered by the HFS to a risk-based care coordination program by January 1, 2015.
Illinois’ goal for the future is a redesigned health care delivery system that is more patient-centered, with focus on improved health outcomes, enhanced patient access, and patient safety. To meet the State goal, the Department, in collaboration with other State Agencies and community partners developed the Care Coordination “Innovations Project”. The Innovations Project is designed to meet the state’s goal by: testing community interest and capacity to provide alternative models of delivering care; aligning with federal Accountable Care Act initiatives; incorporating feedback from stakeholders; and building on interagency collaborations.
The first step in reaching this goal is the release of the Solicitation for Care Coordination Entities (CCEs) and Managed Care Community Networks (MCCNs) for Seniors and Persons with Disabilities (SPDs). SPDs with complex health/behavioral health needs (about 16 percent of HFS’ clients) account for approximately 55 percent of the Medicaid budget (all agencies).HFS – 2011 Annual Report Page 3
The Department released a solicitation seeking qualified and financially sound Care Coordination Entities (CCEs) and Managed Care Community Networks (MCCNs) to
enter into contracts to coordinate care for priority populations across the spectrum of the healthcare system with a particular emphasis on managing transitions between levels of care and coordination between physical and mental health. The solicitation was developed by the Office of the Governor, DHS Divisions of Mental Health, Substance Abuse, Developmental Disabilities, and Rehabilitation Services, the Department of Healthcare and Family Services and the Department on Aging.
This solicitation fulfills a goal to allow providers to design and offer care coordination models other than traditional Health Maintenance Organizations (HMOs). The Department is looking for innovative proposals demonstrating that providers can provide equal or better care coordination services, produce equal or better health outcomes and render equal or better savings than traditional HMOs. In the absence of such successful models, the Department will fulfill the statutory mandate through traditional HMOs.
Coordinated Care in Illinois is contemplated to include a wider range of potential arrangements than traditional, fully capitated managed care. CCEs would be organized by hospitals, physician groups, FQHCs or social service organizations. Proposals for CCEs and MCCNs are due to the Department by May 25, 2012 with an expected implementation on January 1, 2013.
The state is expecting proposals that engage community partners in promoting coordinated quality care, across provider and community settings; offer new risk-based funding incentives and flexibilities; and measure delivery system effectiveness and efficiency. CCE project collaborators must include participation from Primary Care Providers (PCPs), hospitals, and mental health and substance abuse providers.
Priority populations include SPDs (including those in long-term care, those with serious mental illness, and waiver populations); and individuals with Medicare (including duals and long term care). Integrated Care Program clients are excluded from enrollment in CCEs and MCCNs. Enrollment in a CCE or MCCN will be voluntary.
A second solicitation to serve Children with Complex Medical Needs is also in progress. The program is under development and the solicitation is expected to be released sometime in May 2012. Refer to Section III. Children’s Programs for additional information on this initiative.
In addition, work has begun on a Medicare/Medicaid Financial Alignment initiative to integrate care for both Medicare and Medicaid under one managed care program. This initiative will integrate Medicare and Medicaid financing streams to eliminate conflicting incentives between the two programs. The goal is to integrate benefits to create a unified delivery system that is easier for beneficiaries to navigate. HFS and the federal Centers for Medicare and Medicaid Services (CMS) will contract with Managed Care Entities that will assume financial risk for the care delivered to dual eligible beneficiaries with responsibilities for robust care coordination efforts where performance will be measured and tied to quality measurement goals. The targeted areas for implementation of this initiative are Northeast Illinois and Central Illinois. HFS expects to release the Request for Proposal in the spring of 2012.
Rate Redesign
To pursue better care healthcare outcomes, the Department’s reimbursement structures for many providers need to be updated and redesigned − the largest of which are nursing facilities and hospitals.HFS – 2011 Annual Report Page 4
Hospitals
The Department has embarked on a collaborative approach with the broader provider community. Beginning in March 2011, HFS initiated a dialogue on the development of
a reimbursement system for both hospital and long-term care that better promotes coordination of care and quality outcomes. Better management of care should result in more efficient use of State resources by focusing funds on those aspects of care providing the highest return and, in truth, by focusing funds on currently underfunded areas critical to achieve better management of care. This, in turn, can act as a lever to stabilize the cost of care to Medicaid program as well as the private payer and commercial payer community. In order to achieve this, the Department must restructure its reimbursement methodologies to take into consideration the complexity of health care needs, the quality of care and the health outcomes of enrollees.
A hospital Technical Advisory Group (TAG) consisting of CEOs, CFOs, and consultants representing numerous hospitals and hospital systems across the state, was established in July of 2011. To date, there have been nine TAG meetings, at which the Department has shared conceptual ideas of updating the reimbursement system, asked for input from the members and addressed provider concerns. In an effort to maintain a transparent process, the Department has published all presentations and materials form the TAG meetings on the HFS website, along with a FAQ document providing the Department’s response to individual TAG member questions.
Throughout the hospital reimbursement reform process, the Department’s technical consultants have been processing historical claims through the agreed upon systems – the All Patient Refined Diagnosis Related Grouping System (APR DRG) for inpatient and the Enhanced Ambulatory Patient Grouping System (EAPG) for outpatient – to model the payment structure of the proposed system. This is an ongoing task as the Department makes changes to the system by incorporating adjustments derived from analysis and from input collected through the TAG meetings, in order to find the appropriate balance of reimbursement levels across the different types of services and providers.
Nursing Facilities
P.A. 096-1530 sunsets the current reimbursement structure for nursing facilities and directs the Department to develop a replacement structure for implementation on July 1, 2012. It is the Department’s intent to implement a reimbursement system that will be linked directly to an individual’s resource utilization needs and promote quality care and healthier lives for the disabled and frail residents who require nursing facility care.
In 2011, the Department engaged a dialogue with representatives of the nursing home industry on the development of a new reimbursement system that is evidence-based and reflective of the needs of individual nursing facility residents. Work continues on these efforts.HFS – 2011 Annual Report Page 5
III. CHILDREN WITH COMPLEX MEDICAL NEEDS
As required in the Medicaid reform law [P.A. 96-1501], the Department established a stakeholder group for advocates, providers and funders of care to collectively explore program design and delivery systems for children with complex medical needs to lead to more efficient, economical and consumer directed services. The group focused on children with chronic conditions and medically complex children with high cost in-home services. Analyses of the program and recommendations on program changes care are summarized below. Overview of the waivers, amendments, services and expenditures may be found in Section IX. This Section of the Annual Report is the final report as required by law.
Stakeholder Meetings
Seven stakeholder meetings were held between June 2011 and February 2012. Information on the stakeholder groups may be found at: http:///hfs.illinois.gov/ccmn/
Meeting discussions focused on what is and what is not working in the care delivery system for children with complex medical needs and what components a new system should include. Extensive discussions included topics on the universe of children to be served; acuity levels that may drive the service levels and payment system; how to incentivize care coordination entities; range of services that would be covered by care coordination entities; creation of an unique provider type to provide tasks normally provided by licensed nurses; and cost-sharing by parents to pay for services. The last meeting focused on performance outcomes unique to children with complex medical needs.
1. General Consensus of Participants
Participants agreed on several key design points as described below.
Care Coordination (CC)
There was general agreement among the participants that care coordination is a key component for managing care for children with complex medical needs (CCMN). Recognizing the difficulties in identifying children with chronic conditions and high costs, two care coordination options were recommended: 1) a program for children who are ventilator or technology dependent; and 2) one for all other children with multiple chronic conditions.
The first CC program would utilize the Division of Specialized Care for Children (DSCC) as a Single Point of Entry (SPOE) to provide care coordination for all children with complex medical needs seeking in-home services. This will include children currently served under the Medically Fragile, Technology Dependent (MFTD) waiver as well as other children receiving private duty nursing in the home through Nursing and Personal Care Services, which may include children served in other waivers and through the Department of Children and Family Services (DCFS). For the children receiving in-home services, there will be two levels of assessment, 1) eligibility, and if eligible; 2) a further review (comprehensive assessment) to determine risk, develop a plan of care and to determine care coordination intensity levels. It was recommended that the eligibility and resource allocation would be determined separately from care coordination.
The second CC program would provide care coordination for all other children with “multiple” chronic conditions through a Care Coordination Entity (CCE) or Managed Care Community Network (MCCN). As with the Care Coordination Innovations Project serving adults with complex conditions, a second solicitation will seek proposals for CCEs and MCCNs to serve children identified with multiple chronicHFS – 2011 Annual Report Page 6
conditions or high resource utilization; but, are not in need of home services. Children would be identified through the Department’s Client Enrollment Broker and offered enrollment in a CCE specifically designed to meet their needs. Children would receive care coordination either through the CCN/MCCN or DSCC, but not from both programs. Participation in CCE/MCCN programs would be voluntary.
Cost Sharing
There was general consensus among the participants that cost sharing is needed to preserve the program and to incentivize a philosophy of shared responsibility.
New Provider Type
There was general consensus among the participants that a work group be initiated to explore establishing a new provider type to be specifically trained for providing nursing care to children with complex needs.
The major areas of discussion and program analysis from the seven stakeholder meetings are described below under topics 2 through 11. Topic 12 outlines the next steps for this initiative.
2. Components of a new system for Children with Complex Medical Needs
The group discussed the following system changes needed to serve children with complex medical needs.The group recommended a SPOE, but recommended a separation of eligibility determination and care coordination and a separate entity for quality oversight to prevent conflict of interest. The following is an overview of the participants’ suggestions:
Point of Entry (Access and Referral)
• SPOE, such as an agency, managed care entity, or independent entity – where there is single web site, phone number and email address for access.
• Assuring access to the SPOE statewide, such as regional offices as long as standard processes are used.
• Specifically define the population to be served such as all seeking private duty nursing or other medically complex care
• The SPOE should have electronic capabilities of accessing and sharing information needed to track individuals through the application, referral and service implementation.
Eligibility/Assessment of need for services (assuring necessary services)
• The system should include a screening process, referral system for individuals not eligible and a more comprehensive assessment of need for services for those who are deemed eligible.
• Medical necessity needs to be objectively defined considering federal guidance.
• The assessment needs to include medical, psycho-social, environmental and other components as outlined by International Classification guidelines.
• Eligibility determination should be separated from delivery of services and care coordination to avoid conflict of interest.
• The level of services and types of providers should be identified through an objective assessment for all seeking private duty nursing, regardless of age or agency responsible.
• The assessment should identify risks, back-up systems and level of care coordination needed.
• Consideration for outliers should be incorporated along with a human review component.HFS – 2011 Annual Report Page 7
• Evaluators should be qualified and well trained.
• Triggers for reassessment should be developed that more promptly address changes in condition.
Services (flexible and based on all partners working together)
• Services should be based on medical need and a prior approval system that includes either a predictive modeling tool or a defined method to objectively and consistently identify needs for all applicants.
• Payment stratification based on levels of complexity of care should be considered to more appropriately target resources to those with the most complex needs.
• Explore creation of a distinct unlicensed provider type that through client specific training and oversight may allow reduced reliance on licensed staff.
• Option for consumer direction should be included to allow for more flexible use of resources such as allowing families to save hours and use later, like rollover minutes for cell phones.
• Service plans should be flexible enough to adjust services promptly if more hours are needed to prevent hospitalizations or to address other medical needs.
• Sharing resources or pooling resources should be explored such as two families who live in close proximity sharing the same nurse in a day care like fashion.
• Individuals with higher medical needs should be supported appropriately.
• Telemedicine should be utilized more extensively including remote monitoring.
• Services that are reduced should include weaning of hours and discussion of changes before implementation.
• Nursing agencies must be involved to promote independence, reduce reliance on paid services and report changes promptly to care coordinators.
• Training programs for certain services (e.g., ventilator care, trach care) should be developed to assure appropriate understanding and service delivery.
Care Coordination (Expanded role and responsibility)
• Each eligible participant should choose or be assigned to a care coordination entity.
• The level of care coordination should be recommended through the assessment process and be flexible and dynamic increasing or decreasing with changes in condition.
• CCEs must coordinate all care for the child including promoting health, facilitating linkages to services, assuring follow-ups, assisting with housing issues as needed, consider social factors and family dynamics, interfacing and coordinating with other agencies providing services, and identifying changes in condition, Emergency Room or hospital use to promptly address changes in care.
• Care coordination should continue through the life continuum based on individual needs.
• Electronic sharing of services and care coordination activities are essential.
• CCEs must educate all partners including clinical staff, service staff, families and others on maximizing independence and reducing the reliance on paid services.HFS – 2011 Annual Report Page 8
Quality Improvement (Outcomes drive system changes and all partners involved and informed)
• Performance indicators should be developed to assure care coordination meets the needs and improves health outcomes.
• Ongoing training of all partners should be established and monitored.
• Health outcomes and cost of care (utilization review) should be analyzed and used to drive reimbursement or program changes.
• Stakeholders should have access to resources that will inform them on the success of the program and the opportunity to report program experiences.
• Interagency alliances must be formed to partner in the changes needed to develop and oversee services.
• An independent entity should monitor quality improvement.
3. Universe of children to be served
HFS shared a summary of Net Liability for Children under age 19 grouped by ranges of expenditures. The groupings were from zero expenditure with incremental increases up to over $999,000 per year per child. The chart included the net liability amount for the number of children in the range, the average liability per recipient and the cumulative percent of liability for the group. Also included were children with multiple complex chronic conditions as identified by ICD-9 codes, children receiving private duty nursing who were in the Medically Fragile, Technology Dependent waiver and children receiving private duty nursing who are not in a waiver.
It was noted that .15 percent of the 1.8 million served were responsible for over 20 percent of the total net liability. Higher cost children did not necessarily use in-home care. HFS has identified that many of the high cost children include those with high pharmacy costs for hemophilia treatments, high inpatient costs for pre-terms, malignancies and transplants. Although high costs may not predict the in-home need supports, ongoing analysis of liability is an essential part of the program development for care coordination.
4. Acuity levels that may drive the service levels and payment system
Discussion Highlights
• If the eligibility is initially established by a third party, a reassessment should be done by care coordinators who know the service needs in the home within a 60 day period and periodically with annual reviews by the third party.
• Assessments done while in the hospital may not accurately reflect needs in the home.
• Triggers for frequency of reassessment and flexibility of reassessments and service plan changes should be established.
• Point systems may be needed, but there needs to be a human component in determining levels of care as well.
• Other care needs such as disability related and mental health services should be considered in the overall plan and care coordination.
• Durable medical equipment should be coordinated.
• Respiratory Therapists should be included for those on ventilators.
• Service packages that offer flexibility should be considered.
• Utilization of services should be analyzed and considered.
• Screening and assessment tools should be re-evaluated after one year.
• Another level of care for a non-nurse provider may need to be considered.
• Children in the home service programs may be potential candidates for the population served.HFS – 2011 Annual Report Page 9
• Explore paying parents to provide care, while considering back-up systems and preventing creation of dependence on family and situations where children are not willing to accept care from someone other than parents.
5. How to incentivize Care Coordination Entities (CCE)
Participants’ Suggestions
• Identify geographic locations of children with complex medical needs.
• Establish higher reimbursement for seeing children closer to their homes, moving out of centers and into the community.
• Promote telemedicine.
• Must include a care coordination lynch pin, for example, clients respond to what physician tells them, so care coordinator must be connected to the physician.
6. Range of services that would be covered by a CCE
Participants’ Suggestions
• Primary Care and Specialists.
• Care Coordination Nurse – coordinating communications, linkages, and follow-up.
• Hospital services.
• Durable medical equipment.
• Respiratory Therapists (available for those on ventilators).
• Therapies.
• Social service agencies (e.g. Early Intervention, Mental Health, Alcohol and Substance Abuse, etc.).
• Personal attendant care in the home.
7. Options for a unique provider type to provide tasks that are normally provided by skilled nurses
Several of the meetings included discussions of creating a new provider type to be specifically trained for providing nursing care to a child.
AARP recently published a report on states that provided a list of 16 services in the home ranging from ostomy care to ventilator care. Five states provide all 16 services in the home either through delegation or through consumer direction programs. AARP indicates that several states have voiced interest in developing more expansive delegation programs and they will be offering some joint meetings on this subject in the near future. Illinois will be invited to participate.
One participant doing business in several states shared recent experiences of delegation of nursing services to unlicensed staff in New Jersey. This state worked closely with the nursing association, nursing board, nursing agencies and families to create specialized training for unlicensed nursing agency staff through a nurse delegation process. The pilot was a success, but New Jersey decided to move to a Medicaid Block grant and lowered its eligibility from 200 percent of the FPL to 133 percent.
Participant and Family Feedback
• Need to address what we need to do to keep children out of institutions.
• The cornerstone to establishing the need for services is defining medical necessity.
• Developing a system that includes telemedicine, ready access to licensed staff and an infrastructure that will support using non-licensed staff safely.HFS – 2011 Annual Report Page 10
8. Family Cost Share and Income Caps
In response to budget concerns and the sustainability of this program, the group was asked to consider the impact of parental share or income caps for participation in the program and how parental share and cost caps could be reasonably applied to families with higher incomes. The participants were informed that the federal government imposes cost share limits for state and federal partnership programs. With certain exceptions, the federal government generally allows states to apply cost share based on the lesser of five percent of family income or 20 percent of the cost of services on families with income over 150 percent of the federal poverty limit (FPL). For state only programs there are no federal restrictions on cost share. Department analysis estimates that approximately 160 of the 650 children served in the Medically Fragile, Technology Dependent (MFTD) home and community based services (HCBS) waiver have incomes over 150 percent FPL. The cost share approach for
Medicaid eligible families is unlikely to produce significant revenue, but is a philosophical approach showing an effort for participants to contribute toward care and share in the cost when their incomes are above the Medicaid eligibility limits. Data analysis has shown that home based services are not always less expensive than residential services. Further discussion included the following comments.
Participants’ Feedback
• There was general consensus that some type of cost share would be reasonable if the following were considered:
– Other costs of care for special needs such as over the counter medications, certain durable medical equipment, specialized clothing, home modifications, assistive technology, co-payments for insurance
– Reasonable consideration of income caps, so that those with modest incomes are not forced to quit jobs, cannot seek services or drop private insurance.
– The adjusted gross income and other deductions are considered in establishing a cost share amount.
– Need to look at parental share across community and institutional settings, not just in home services.
– Before implementation, analyze dollars saved versus what may think will saved.
• Child care costs for most families average $12,000 to $15,000/year which is not an expense to families in the waiver.
• Consequences of eliminating the waiver are unknown and children could end up costing more if hospitalized, families could drop insurance and quit jobs.
• Health insurance companies need to be responsible for more of the care as almost universally; private duty nursing is not paid through insurance but should be if medically indicated.
9. Mental Health Interface with Care Coordination Innovations
Several voiced the importance of behavioral interventions and questioned how care coordination would interface with the current Screening, Assessment and Support Services (SASS) program. Though the definitive policy on this is still being considered, CCE/MCCNs are expected to identify the target population and service package that they will be responsible for supporting through their network of providers. Once an individual is part of a CCE/MCCN, that program would be responsible for delivering the medically necessary care required, including behavioral HFS – 2011 Annual Report Page 11
health crisis intervention services. Children served under a CCE/MCCN would likely be similar to children and youth with parents that have elected to be part of an HFS funded Managed Care Organization (MCOs). Children currently served under MCOs are not eligible for enrollment into the SASS program.
10. Performance Outcomes for Care Coordination
Performance outcomes were shared from the January 23, 2012 Solicitation for Care Coordination Entities and Managed Care Community Networks for Seniors and Persons with Disabilities. The final Performance Outcomes may be accessed under Attachments A and B of the Solicitation for Care Coordination Entities and Managed Care Community Network for Seniors and Adults with Disabilities
The January 23, 2012 solicitation has two sets of performance measures. One set collected on everyone based on persons served and the second set was linked to pay for performance (P4P), or a share in savings. The first 10 percent of cost savings is automatically shared, with the remaining 40 percent distributed in 10 percent increments in four P4P areas: 1) access to member’s assigned primary care physician, 2) follow-up with a provider within 30 days after an initial behavioral health diagnosis, 3) medication therapy management. Medication review of all enrollees taking more than five prescription medications and 4) a proposed measure offered by the entity and approved by HFS. Risk adjustment will be used in analyzing outcomes.
Other performance measure specifications can be accessed at: Performance Measure Specifications for the Care Coordination Program (pdf)
Performance measures from the Department’s voluntary Managed Care contract for children were also shared. The contract may be accessed at http://www.hfs.illinois.gov/assets/mco.pdf
Participants’ Feedback
• Suggest adopting the Children Health Insurance Program Reauthorization Act of 2009 (CHIPRA) measures.
• Outcomes measured may vary based on populations served.
• Need to define success – cost savings, length of stay reductions, etc., as success for the state may be different than success for families.
• Need to consider outcomes desired by families and start with input from families – outcomes should be fueled by the plans of care.
• Need to define what is important, what to measure and how to measure.
• Establish a focus group to design the structure.
The last stakeholder meeting on February 10, 2012 focused on performance measures for care coordination of the in-home group as proposed to be served by DSCC and those with multiple chronic conditions who would be covered under the children’s care coordination solicitation to be issued in the spring of 2012. The recommendations for the two care coordination options follow.
11. Performance Measures for Care coordination of in-home services
Most of the recommendations were focused on process outcomes. DSCC has drafted additional performance measures for: monitoring of intake; monitoring and assurances of well-child exams; immunizations, and; preventive dental exams. The participants offered the following recommendations:
• Analysis of reasons for emergency room and hospitalizations (unfilled shifts, hard to staff cases, safety, failure to be seen within 7 or 14 days of hospitalization).HFS – 2011 Annual Report Page 12
• Require specialty credentials for nursing agencies providing pediatric and technology care such as certification of nurses in CPR, Pediatric Advanced Life Support, ventilator and tracheostomy care.
• Hold home medical equipment (HME) providers accountable to providing needed and proper functioning equipment and supplies.
• Require proof of family/parent training.
• Ensure communications and interdisciplinary meetings with all providers and the family (physician, therapists, care coordinator, nursing agencies, early intervention, schools, and other social service agencies).
• Require providers to conduct satisfaction surveys (eventually standardized) to measure access, quality and culturally sensitive and diverse care.
Performance measures for care coordination provided by CCEs/MCCNs for children with multiple chronic conditions not needing in-home services include the following:
Claims Data Outcomes
• Timeliness and rate of
− Immunizations
− Developmental Screenings
− Mental Health Screenings
− Obesity Screenings
− Dental Care
− Number of inpatient days
− Number of visits in the Emergency Room
− Percent of children with a physician visit within 7/14 days of discharge
− Percent of children with a readmission within 7 days of discharge
− Percent of procedures that are repeated
− Drug redundancies/inconsistent prescription filling (Select a few sentinel medications to focus on)
− Mean total payments
Process Outcomes
• Chart audits to determine completed referrals, family adherence, completion of plans of care and documentation of planning for transition to adult care.
• Parent Surveys to determine satisfaction with care coordination and access to services and providers
The group also recommended an Evaluation Committee inclusive of all the partners to guide and support the evaluation and quality assurance efforts of the solicitation for the Department’s Innovations Project.
12. Next Steps
The Department will issue a solicitation for a CCE/MCCN to provide care coordination of children with multiple chronic conditions in the spring of 2012.
The Department will work with DSCC to develop a proposal for care coordination of children with technology needs seeking in home services through an intergovernmental agreement.
The Department will work with legislators on budget initiatives considering the renewal of the waiver, cost share and FPLs for children.HFS – 2011 Annual Report Page 13
IV. INFORMATION SYSTEM IMPROVEMENTS
At the end of fiscal year 2011, consistent with terms of the Medicaid Reform Act, HFS was one of the agencies participating in the development a high-level information systems strategy that was submitted to the General Assembly. This section outlines the progress that HFS has made against four important information system elements for which it has lead responsibility.
1. Medicaid Management Information System Modernization
The Department initiated a planning effort in 2009 to replace its 30 year old legacy Medicaid Management Information System (MMIS). This is the core system that HFS uses to process all Medicaid claims, including managing provider relationships and claims to the Federal government. The existing MMIS was fully implemented in 1982 and was primarily built to support a fee-for-service Medicaid program. Throughout the years, HFS has made many enhancements and modifications to the current MMIS; however, it is an older legacy system that is becoming increasingly more difficult to maintain and modify and is out of touch with many of the contemporary needs for cost control in an increasingly care-coordinated environment.
HFS has committed that the new MMIS will be designed in accord with the Medicaid Information Technology Architecture (MITA) developed by federal Department of Health and Human Services (HHS) to increase coordination among states and allow for much greater use of component software. HFS has conducted a MITA state self-assessment (SSA) and determined that the current MMIS is at a very low level of MITA compliance and will need to make major improvements.
HFS will begin the MMIS replacement with the implementation of a Pharmacy Benefits Management System (PBMS). This is essential to improving the management of pharmacy claims, including allowing electronic prescribing and instituting greater utilization review of pharmaceutical usage. The Department has made significant progress on the crafting of the RFP and expects to release it to the public in spring 2012. Immediately following this release, HFS will finalize the RFP for the MMIS core system replacement with an expected release date in late fall 2012.
2. Enterprise Data Warehouse Upgrade
As anticipated in the strategic plan, a new contract for the Enterprise Data Warehouse (EDW) was executed at the end of 2011. The EDW is a repository of information extracted from the MMIS that allows for quick and timely analysis of Medicaid data without interfering with the production system. It was created in the late 1990’s, and at that time was one of the most advanced uses of relational data bases in the state. The new EDW contract provides for a complete upgrade of the hardware currently in use. This increased capacity will provide much needed space and processing capability to meet the needs of the EDW as it becomes a more integrated tool for all the health care agencies in the state.
In addition, the contract adds the position of Metadata Coordinator to the EDW team on the vendor side. Metadata is the technical term for the description of data in a consistent way across all the applications in use. This update will provide for enhanced capture of valuable business rules and metadata as new data sources are added to the EDW, as well as clean-up and enhancement of metadata for existing data structures. While this may sound insignificant, management of data descriptions across the millions of data records in the MMIS and EDW is a major task and this upgrade in our capability will make the data materially easier to use, while at the same time increase consistency in report generation and interpretation.HFS – 2011 Annual Report Page 14
New software is being provided under the new contract as well, including more robust analytical applications that allow for better coding of address information and for mechanisms that enable the system to keep multiple levels of report generation to correspond to changes in the data over time. A new web based version of the current report development software, Business Objects, along with Crystal Reports will be brought on board by the vendor to enhance the Department’s reporting capabilities. An optional element that would provide department analysts enhanced capability to undertake risk analysis and improved quality of care assessments is also being considered.
In addition to changes in the hardware and software, HFS has recognized that the EDW needs active, strategic management to meet the rapidly evolving needs of its medical program management and state and federal requirements. As part of moving toward a more strategic use of the EDW environment, in September of 2011, HFS adopted an EDW vision focusing on the creation of a pro-active, professionally managed data environment that will: 1) enable Department leaders and other stakeholders to make informed decisions and satisfy mandates, and: 2) provide HFS EDW users and external data users, having a variety of skill levels, with consistent, reliable data and descriptive information in a format that is easily and effectively accessed, understood, and used.
3. State Medicaid Health Information Plan
HFS is also responsible for the development and implementation of federally mandated State Medicaid Health Information Plan (SMHP). In the last year, Illinois received approval of its SMHP from federal CMS and has begun implementing the initial phase of the plan. Among other things the plan establishes an Electronic Health Record (EHR) Provider Incentive Payment (PIP) Program, which provides federal subsidies to individual Medicaid providers for the installation of electronic health record (EHR) systems. The SMHP also assesses the current landscape of the state’s EHR adoption and Health Information Exchange (HIE) development among Medicaid providers, the state’s vision for Health Information Technology (HIT) in the year 2014 and specific actions to implement the state’s vision. Finally, the SMHP addresses how the Department’s efforts to promote EHR adoption and meaningful use by its providers will be part of a coordinated, broad-based initiative to promote system interoperability, EHR meaningful use and quality improvements, and health information exchange throughout Illinois’ health care system.
The first payments under the EHR/PIP Program were made in March 2012 when HFS released $24 million in incentive payments to Illinois Medicaid providers. This represents payments to more than 450 providers for the implementation of certified EHR technology. To date, HFS has received more than 2,000 attestations for the program, and expects the numbers to continue to grow. The Department estimates the 100 percent federally funded payments to eligible providers will be $116 million the first year and $489 million over the life of the program, which continues through 2021.
4. Replacement Eligibility System
In another critical area, HFS has been deeply involved with the Department of Human Services (DHS) and the Department of Insurance (DOI) to implement a new eligibility system, known as the Integrated Eligibility System (IES) will span Medicaid, Supplemental Nutrition Assistance Program (SNAP—formerly known as “food stamps”), Temporary Assistance for Needy Families (TANF—formerly known as “welfare” or perhaps AFDC) and the new Health Benefits Exchange that will be created as part of the federal Affordable Care Act (ACA). This system will replace theHFS – 2011 Annual Report Page 15
more than 30-year old, COBOL-based system that is at the core of current eligibility determinations for these services; except the Health Benefits Exchange, which did not previously exist. It is the existence of the ACA that has made it possible to fund the new IES, as it provides additional Medicaid funds and also suspends the usual rules of federal program cost allocation so that a much larger share of SNAP and TANF costs are covered under the enhanced Medicaid match. Work on the system must be completed by the end of 2015, at which time the enhanced federal match sunsets. Current estimates are that Illinois will receive more than $100 million in federal dollars for this effort.
Developmental work on the IES started in the fall of 2010 and a high level strategic plan was developed in the spring of 2011. In September 2011, HHS approved the enhanced match for the development of an RFP for the project and in March, 2012, approved the match for implementation of the system, at which time the RFP was published. It is expected that a vendor will be selected by late summer. The state anticipates implementing the eligibility portion of IES for these programs by October 2013, and being ready to provide coverage for new applicants by January 2014. The remainder of the system, which focuses on account management, will be implemented in a second phase with an estimated completion date of October 1, 2015. Due to the short timeframe, the exact sequencing is uncertain and there may be other ways of structuring the phase in, such as, including some use of a federal-state partnership to help bridge. The state also intends to use this project as the basis for developing a common eligibility system that, within the State’s Framework Project, could extend to other agencies.HFS – 2011 Annual Report Page 16
V. 2011 HIGHLIGHTS
Integrated Care Program
HFS implemented the state’s first integrated healthcare program on May 1, 2011. The Integrated Care Program (ICP) is a program for older adults, and adults with disabilities, who are eligible for Medicaid, but not eligible for Medicare. The program is mandatory and operates in the pilot areas of suburban Cook (all zip codes that do not begin with 606), DuPage, Kane, Kankakee, Lake and Will Counties. The ICP brings together local primary care physicians, specialist, hospital, nursing homes and other providers so that all care is organized around the needs of the client in order to achieve improvements in health through care coordination. As of July 1, 2011, approximately 12,350 clients had been enrolled in the ICP. Additional information on the ICP can be found in Section XII, Care Management, of this report.
Health Benefits/All Kids and Drug Prior Approval Hotline
As of June 30, 2011, the Health Benefits/All Kids and the Drug Prior Approval Hotlines had received and handled over 787,000 calls from enrollees and provider communities. The Drug Prior Approval/Refill Too Soon Hotline answered over 336,000 of the calls, reflecting an increase of approximately 14 percent over fiscal year 2010.
Money Follows the Person
Illinois was selected as a MFP Demonstration Program in 2007. In 2010, the Affordable Care Act extended the demonstration program through 2016. As the lead agency, HFS plans to continue participation in the program along with its sister agencies through the end of the demonstration.
Illinois’ MFP program relies on a strong collaborative and inter-agency approach to the implementation of the program. The Department partners with the Department on Aging (DoA), Department of Human Services’ (DHS) Division of Mental Health, Division of Rehabilitation Services, and Division of Developmental Disabilities, and the Illinois Housing Development Authority on the formation of policy and implementation issues related to MFP. HFS has provided the Department of Human Services’ Division of Developmental Disabilities with the necessary support for their full participation in MFP, which began January 1, 2012. Another critical partner to the MFP Program is the University of Illinois at Chicago – College of Nursing, who oversees the programs quality management initiative and has authored significant work on “lessons learned” from the MFP program. The Department has utilized this work to guide the development and implementation of MFP program innovations.
Supportive Living Program
In 2011, under Illinois’ assisted living waiver, which is considered to be the premier model of its kind in the country, the number of Supportive Living Facilities (SLFs) increased by six percent and the number of apartments available increased by sour percent. As of June 30, 2011, 5,608 Medicaid eligible residents were being served by 128 SLFs, with a total of 9,967 apartments in operation. Throughout fiscal year 2011, over 8,600 unduplicated Medicaid enrollees were served under the program. The program combines affordable apartment-like housing, personal care and health related services in an assisted living setting for individuals who otherwise qualify for residency in a nursing facility. There are currently 31 more facilities in various stages of development. The Supportive Living Program is one of the nine Home and Community-Based Services (HCBS) waivers administered by the Department. For more information on the HCBS waivers, refer to Section IX, Home and Community Based-Services Waivers, of this report.HFS – 2011 Annual Report Page 17
Provider Enrollment and Information
As of June 30, 2011, there were over 67,700 providers enrolled to provide services to participants of the Department’s Medical Assistance Programs, as compared to approximately 62,000 enrolled as of June 30, 2010. For a breakout by major provider type, see Table IV of this report. Providers are encouraged to utilize the Department’s Web site to obtain information on the Department’s Medical Programs. The address for the Division of Medical Programs’ main web page is: http://www.myhfs.illinois.gov/
Claims Processing
During fiscal year 2011, ninety-one million medical claims were received and processed by the Department. This was an increase of 2.3 percent over the number of claims received in fiscal year 2010 and a 5.5 percent increase over claims received during fiscal year 2009.
Of all the claims received in fiscal year 2011, approximately eighty-seven million, or 96.2 percent, were received via electronic transfer, up slightly from 95.9 percent in fiscal year 2010. Table VI shows claims receipt history for fiscal years 2009 through 2011.
Pharmacy claims accounted for the largest share (46 percent) of total claims received during fiscal year 2011, with physician claims (33 percent), Medicare (8 percent), hospitals (6 percent), and claims for medical equipment/supply (3 percent) rounding out the top five receipt categories. Between fiscal years 2009 and 2011, the fastest growing claims category was pharmacy showing approximately a 20 percent increase, followed by medical equipment and supplies increasing by over 17 percent and hospital claims increasing by over 8 percent.
The Department’s PrePay Pricing Unit is responsible for reviewing those medical claims that require specific review by professional medical staff to determine the appropriate reimbursement. During fiscal year 2011, the PrePay Pricing Unit reviewed requests for reimbursement for 7.2 million services, a decrease of 1.6 percent from the number of services reviewed in fiscal year fiscal year 2010. In fiscal year 2011, the claim reviews performed by the PrePay Pricing Unit resulted in savings of approximately $129.5 million.HFS – 2011 Annual Report Page 18
VI. FINANCIAL OVERVIEW
The three tables presented at the end of this section provide a history of liability by estimated funding source for Medical Programs in HFS. It is important to take into account what is included in these tables and how they differ from other presentations.
The tables cover fiscal year 2010 to fiscal year 2012. The data is presented in a similar format so it is possible to observe trends.
The tables reflect HFS liabilities; meaning that all claims HFS has received and accepted through the assignment of a document control number is included. The data does not reflect date of service billings, as HFS receives claims in any given fiscal year for services that were provided in the previous fiscal year. In addition, the information presented in the tables does not include the impact of any annual payment cycle changes (i.e. potential underfunding), as the data simply reflects the estimated funding breakout for bills actually received by the Department.
Using liabilities as the unit for measure has the following advantages:
o HFS is legally liable for services provided. However, claims received are the only measure that it has to determine the liability incurred by the Department over a given time period.
o The flow of claims received is relatively consistent over time. The rate at which claims are submitted is not significantly influenced by the state’s larger cash flow issues.
o The main reason the flow of claims may be different from one year to the next is the rate at which providers submit billings, and there is no reason to assume a systematic change in the speed with which this occurs.
o Because the data are fixed by the time frame of submission, it is possible to obtain information allowing for time-period comparisons quickly. Waiting to get actual liability (date of service claim data, including the “incurred but not reported” liability) would require a wait of twelve months, as providers have that long to submit a claim to the Department.
The tables include all funding sources, not just General Revenue Fund (GRF) expenditures. Since most action by the General Assembly focuses on GRF budgets, many HFS reports only reflect liability from funds that impact GRF spending. But, as reflected in the tables, there are significant non-GRF expenditures. It is difficult to understand the full magnitude of the State’s Medical Assistance Program expenditures without including these funds.
The data only reflect funds spent within HFS. While most of the liability is Medicaid related and qualifies for federal matching dollars under Title 19 or Title 21 (the Children’s Health Insurance Reauthorization Act) of the Social Security Act, some spending is for state-only funded medical programs.
It should also be noted that the tables do not include Medicaid Assistance expenditures made in the budgets of other departments and entities. These are material, amounting to roughly $2 billion per year.
The data contained in the tables provides a high level snapshot of the Medical Assistance Program budget and, particularly, reflects the dynamic elements in the Medicaid program. A few of the important observations that can be made from these tables include the following:HFS – 2011 Annual Report Page 19
• Total liability between fiscal year 2010 and fiscal year 2012 will increase just over 10 percent (or an average of about 5.1 percent per year). Note, however, this includes the costs associated with increased enrollment; over the same period enrollment will also increase by about 5.1 percent per year.
• The Medicaid program is jointly funded by the state, the federal government, local governments and provider assessments. For these three years, the share of total liability paid with state money varies by year, primarily as a function of the enhanced match rate that was part of the American Recovery and Reinvestment Act (ARRA). For fiscal year 2011, the subject of this report, the estimated GRF liability funding is approximately one-fifth of total liability. With the expiration of the ARRA enhanced match, this share will rise considerably for fiscal year 2012, but will still be less than one-third of total liability.
• Revenue sources other than the usual sources of state-money or federal match are important. In fiscal year 2011, assessments on providers and intergovernmental funding arrangements, specifically structured to enhance federal match, accounted for a significant portion of total liability funding. These include the hospital provider assessment, long-term care provider assessment, and the Cook County and U of I intergovernmental transfers. How these funding sources are handled going forward is a crucial issue for the Medicaid program.HFS – 2011 Annual Report Page 20
ILLINOIS DEPARTMENT OF HEALTHCARE & FAMILY SERVICESFY'10 Estimated Liability Funding*($ in Thousands)FY10FY10FY10FY10EstimatedEstimated GRFGross OtherFY10 TotalLiabilityNet GRFFed. MatchFundsLiability Funding*PRACTITIONERS$1,246,588.8$394,048.7$584,781.9$267,758.2$1,246,588.8Physicians 962,402.0292,258.1433,723.6236,420.3962,402.0Dentists233,730.285,589.8127,016.121,124.3233,730.2Optometrists41,766.013,441.619,47.58,376.941,766.0Podiatrists7,183.02,268.63,366.71,547.77,183.0Chiropractors1,507.6490.6728.0289.01,507.6HOSPITALS$3,300,718.0$858,395.8$1,273,833.6$1,168,488.6$3,300,718.0PRESCR. DRUGS$1,794,360.6$327,900.0$486,783.1$979,677.5$1,794,360.6LONG TERM CARE$1,793,010.0$319,938.0$474,793.9$998,278.1$1,793,010.0Geriatric1,538,010.0231,011.5342,826.2964,172.31,538,010.0Institutions for Mental Disease138,205.049,121.172,896.116,187.8138,205.0Supportive Living Facilities116,795.039,805.459,071.617,918.0116,795.0OTHER MEDICAL$1,294,350.3$442,709.0$656,984.3$194,657.0$1,294,350.3Community Health Centers297,683.0101,353.2150,409.245,920.6297,683.0Hospice83,869.021,685.632,181.630,001.883,869.0Laboratories56,418.015,055.82,343.019,019.256,418.0Home Health Care85,036.026,559.338,836.319,640.485,036.0DSCC Waiver62,603.124,969.837,633.30.062,603.1Appliances87,808.023,932.935,516.628,358.587,808.0Transportation93,004.029,096.543,179320,728.293,004.0Other Related189,743.263,910.794,844.230,988.3189,743.2Medicare A Premiums19,513.07,855.411,657.60.019,513.0Medicare B Premiums297,192.0119,642.1177,549.90.0297,192.0Medicare B Premiums Expansion21,481.08,647.712,833.30.021,481.0MANAGED CARE$249,829.0$92,147.5$136,747.6$20,933.9$249,829.0Child Health Rebate6,485.92,611.13,874.80.06,485.9Renal Dialysis Services714.0256.9381.275.9714.0Hemophilia Services13,725.55,525.58,200.00.013,725.5Sexual Assault Treatment1,653.7665.7988.00.01,653.7HFS MEDICAL - GRF & RELATED FUNDS$9,701,435.8$2,444,198.2$3,627,368.4$3,629,869.2$9,701,435.8Hospital Assessment1,514,344.00.00.01,514,344.01,514,344.0Cook County1,383,249.30.00.01,383,249.31,383,249.3University of Illinois Hospital199,074.275,000.00.0124,074.2199,074.2Other Payment Programs**214,071.2400.00.0213,671.2214,071.2HFS MEDICAL - ALL FUNDS$13,012,174.5$2,519,598.2$3,627,368.4$6,865,207.9$13,012,174.5* "FY10 Total Liability Funding" reflects one-year program costs for FY10; excludes unpaid bills from the prior year. Spending figures on this page mainly reflect cash-flow expenditures and will not equal actuals for prior years due to the exclusion of the impact of prior and current year bills on hand.** Other Payment Programs include Trauma Center payments, Excellence in Academic Medicine, Children's SASS and pass-through of federal matching dollars to local school districts and counties.HFS – 2011 Annual Report Page 21
ILLINOIS DEPARTMENT OF HEALTHCARE & FAMILY SERVICESFY'11 Estimated Liability Funding*($ in Thousands)FY11FY11FY11FY11EstimatedEstimated GRFGross OtherFY11 TotalLiabilityNet GRFFed. MatchFundsLiability Funding*PRACTITIONERS$1,339,350.0$511,063.9$654,418.3$173,867.8$1,339,350.0Physicians 1,005,958.6380,515.3487,250.4138,192.91,005,958.6Dentists276,721.7110,269.6141,200.525,251.6276,721.7Optometrists47,234.016,918121,663.78,652.247,234.0Podiatrists7,863.12,802.83,589.11,471.27,863.1Chiropractors1,572.6558.1714.6299.91,572.6HOSPITALS$3,457,049.0$1,063,309.7$1,361,569.9$1,032,169.4$3,457,049.0PRESCR. DRUGS$2,021,544.6$275,548.0$352,839.7$1,393,156.9$2,021,544.6LONG TERM CARE$1,911,919.6$414,491.3$530,756.8$966,671.5$1,911,919.6Geriatric1,654,626.3307,694.8394,003.8952,927.71,654,626.3Institutions for Mental Disease110,529.146,855.459,998.53,675.2110,529.1Supportive Living Facilities146,764.259,941.076,754.610,068.6146,764.2OTHER MEDICAL$1,424,836.1$544,503.2$697,237.3$183,095.6$1,424,836.1Community Health Centers334,750.5116,910.3149,703.968,136.3334,750.5Hospice85,399.427,288.634,943.023,167.885,399.4Laboratories60,392.520,144.32,794.714,453.560,392.5Home Health Care94,715.333,715.143,172.317,827.994,715.3DSCC Waiver69,619.530,528.239,091.30.069,619.5Appliances96,153.133,334.042,684.320,134.896,153.1Transportation87,819.731,249.240,014616,555.987,819.7Other Related205,054.679,910.1102,325.122,819.4205,054.6Medicare A Premiums18,288.68,019.610,269.00.018,288.6Medicare B Premiums349,130.2153,093.6196,036.60.0349,130.2Medicare B Premiums Expansion23,512.710,310.313,202.40.023,512.7MANAGED CARE$246,719.4$107,082.3$137,119.0$2,518.1$246,719.4Child Health Rebate6,834.12,996.83,837.30.06,834.1Renal Dialysis Services461.0165.4211.883.8461.0Hemophilia Services17,784.47,798.59,985.90.017,784.4Sexual Assault Treatment2,276.7998.31,278.40.02,276.7HFS MEDICAL - GRF & RELATED FUNDS$10,428,774.9$2,927,957.4$3,749,254.4$3,751,563.1$10,428,774.9Hospital Assessment1,510,668.00.00.01,510,668.01,510,668.0Cook County1,349,708.20.00.01,349,708.21,349,708.2University of Illinois Hospital269,290.399,054.00.0170,236.3269,290.3Other Payment Programs**264,346.8400.00.0263,946.8264,346.8HFS MEDICAL - ALL FUNDS$13,822,788.2$3,027,411.4$3,749,254.4$7,046,122.4$13,822,788.2* "FY11 Total Liability Funding" reflects one-year program costs for FY11; excludes unpaid bills from the prior year. Spending figures on this page mainly reflect cash-flow expenditures and will not equal actuals for prior years due to the exclusion of the impact of prior and current year bills on hand.** Other Payment Programs include Trauma Center payments, Excellence in Academic Medicine, Children's SASS and pass-through of federal matching dollars to local school districts and counties.HFS – 2011 Annual Report Page 22
ILLINOIS DEPARTMENT OF HEALTHCARE & FAMILY SERVICESFY'12 Estimated Liability Funding*($ in Thousands)FY12FY12FY12FY12EstimatedEstimatedEstimated GRFGross OtherFY12 TotalLiabilityNet GRFFed. MatchFundsLiability Funding*PRACTITIONERS$1,336,558.0$637,336.7$603,825.3$95,396.0$1,336,558.0Physicians 988,158.0458,433.3434,328.795,396.0988,158.0Dentists287,754.2147,761.8139,992.40.0287,754.2Optometrists51,482.426,436.225,046.2.051,482.4Podiatrists7,636.73,921.43,715.30.07,636.7Chiropractors1,526.7784.0742.70.01,526.7HOSPITALS$3,205,048.7$1,496,364.0$1,417,684.7$291,000.0$3,205,048.7PRESCR. DRUGS$2,166,576.6$701,158.2$664,291.1$801,127.3$2,166,576.6LONG TERM CARE$1,939,336.3$693,350.6$656,893.9$589,091.8$1,939,336.3Geriatric1,654,798.8557,478.1528,165.7569,155.01,654,798.8Institutions for Mental Disease128,539.566,005.062,534.50.0128,539.5Supportive Living Facilities155,998.069,867.466,193.819,936.8155,998.0OTHER MEDICAL$1,447,537.2$732,469.0$693,955.6$21,112.6$1,447,537.2Community Health Centers348,884.8179,152.3169,732.50.0348,884.8Hospice91,768.547,123.144,645.40.091,768.5Laboratories54,895.428,188.826,706.60.04,895.4Home Health Care103,315.653,052.650,263.00.0103,315.6DSCC Waiver67,770.534,800.232,970.30.067,770.5Appliances87,604.244,984.842,619.40.087,604.2Transportation71,167.836,544.734,623.10.01,167.8Other Related199,066.091,379.186,574.321,112.6199,066.0Medicare A Premiums17,095.38,778.48,316.90.017,095.3Medicare B Premiums379,497.3194,871.9184,625.40.0379,497.3Medicare B Premiums Expansion26,471.813,593.312,878.50.026,471.8MANAGED CARE$744,038.2$160,337.7$151,907.0$431,793.5$744,038.2Child Health Rebate9,007.93,900.13,695.01,412.89,007.9Renal Dialysis Services462.0237.2224.80.0462.0Hemophilia Services18,375.78,705.08,247.21,423.518,375.7Sexual Assault Treatment2,310.31,186.31,124.00.02,310.3HFS MEDICAL - GRF & RELATED FUNDS$10,869,250.9$4,435,044.8$4,201,848.6$2,232,357.5$10,869,250.9Hospital Assessment1,507,310.80.00.01,507,310.81,507,310.8Cook County1,419,576.30.00.01,419,576.31,419,576.3University of Illinois Hospital238,347.390,000.00.0148,347.3238,347.3Other Payment Programs**282,975.014,175.00.0268,800.0282,975.0HFS MEDICAL - ALL FUNDS$14,317,460.3$4,539,219.8$4,201,848.6$5,576,391.9$14,317,460.3* "FY12 Total Liability Funding" reflects one-year program costs for FY12; excludes unpaid bills from the prior year. Spending figures on this page mainly reflect cash-flow expenditures and will not equal actuals for prior years due to the exclusion of the impact of prior and current year bills on hand.** Other Payment Programs include Trauma Center payments, Excellence in Academic Medicine, Children's SASS and pass-through of federal matching dollars to local school districts and counties.HFS – 2011 Annual Report Page 23
VII. MONEY FOLLOWS THE PERSON – FISCAL YEAR 2011 ANNUAL REPORT
In 2010, the Affordable Care Act extended the Federal Money Follows the Person (MFP) Demonstration Program through 2016. Illinois was selected as a MFP Demonstration Program in 2007. The Department plans to continue participation in the program along with our sister agencies through the end of the demonstration.
The MFP program consists of two parts: a transition component to identify Medicaid beneficiaries living in institutions who wish to live in the community and provide them with the supports to do so, and a rebalancing component through which participating states make system changes that promote and enhance the provision of community-based services and supports.
Illinois’ MFP program relies on a strong collaborative and inter-agency approach to the implementation of the program. The Department partners with the Department on Aging (DoA), Department of Human Services’ (DHS) Division of Mental Health, Division of Rehabilitation Services, and Division of Developmental Disabilities, and the Illinois Housing Development Authority on the formation of policy and implementation issues related to MFP. HFS has provided the Department of Human Services’ Division of Developmental Disabilities with the necessary support for their full participation in MFP, which began January 1, 2012. Another critical partner to the MFP Program is the University of Illinois at Chicago – College of Nursing, who oversees the programs quality management initiative and has authored significant work on “lessons learned” from the MFP program. The Department has utilized this work to guide the development and implementation of MFP program innovations.
In fiscal year 2011, the Federal Centers for Medicare and Medicaid Services provided States with a supplemental funding opportunity to improve the collaboration between the MFP Program and the Aging and Disability Resource Centers (ADRC). The Department was notified that its grant proposal was awarded the full amount that was requested. With this additional $400,000 grant, the Department, in collaboration with DoA, selected three ADRC’s – Age Options, Northeastern Illinois Area on Aging, and Central Illinois Area on Aging to pilot a coordinated, cross disability approach to outreach and engagement of potential MFP participants. Increased transition numbers for the three selected pilot sites is an expectation under the two year grant.
States are required to reinvest rebalancing funds back into the community system of services and supports. The rebalancing funds are the net federal revenues, above the regular Federal Medicaid Assistance Percentage (FMAP), from the enhanced FMAP match rate that states receive for expenditures on Qualified and Demonstration Home and Community Based services provided to MFP participants during their first 365 days of community living.
Using a combination of MFP rebalancing funds and administrative claiming, the Department, along with DHS Division of Mental Health, has selected three areas of the state – Peoria, Springfield and DuPage Counties – for expansion of mental health services under MFP. Selection of these areas was based on their capacity to provide Assertive Community Treatment (ACT) and the nursing home populations necessary to provide an adequate supply of potential MFP enrollees. Increased MFP transitions are an expectation for these three areas.
The Department, in collaboration with our state agency partners and stakeholders, is in the process of updating the MFP marketing and outreach materials. This marketing and outreach initiative includes: the development of a MFP participant packet to be distributed to nursing homes, ombudsman, and other potential referral sources; the activation of the MFP website; and the development of a MFP self-referral form.HFS – 2011 Annual Report Page 24
During calendar year (CY) 2011, the MFP Program completed a total of 237 successful transitions, an increase of 53 transitions over the CY 2010 total. The Department anticipates growth in the number of transitions for CY 2012 due to a
number of factors including: the settlement of two Olmstead related class action lawsuits – Ligas v. Quinn and Colbert v. Quinn; the Administration’s Long Term Care Rebalancing Initiative; the MFP/ADRC collaboration; the expansion of MFP/mental health downstate; and the full participation of DHS Division of Developmental Disabilities in MFP.
Calendar Year 2011 Transitions
Agency/Division
# Transitions
Illinois Department on Aging
75
Illinois Department of Human Services – Division of Rehabilitation Services
67
Illinois Department of Human Services – Division of Mental Health
95
Total:
237
State Medicaid long-term care expenditures and the percentage of such expenditures devoted to community-based long-term care services are summarized in the table below.
Long Term Care (LTC)/Home and Community Based Service (HCBS) Expenditures
State Fiscal Year
Total LTC Expenditures
Total HCBS Expenditures
% of Expenditures for HCBS Services
2009
$4,183,134,560
$1,768,588,092
42.28%
2010
$3,480,969,534
$1,147,859,338
32.98%
2011
$3,796,676,636
$1,473,153,616
38.80%HFS – 2011 Annual Report Page 25
VIII. LONG TERM CARE
In fiscal year 2011, the monthly average of people served in nursing facilities (NFs) remained at approximately 55,000, the same level as in the past several years. The number of nursing facilities serving these people decreased slightly, going from 738 in 2010 to 734 in 2011 (refer to Certification/Decertification topic below for more detail).
Table I, in Section XXV, compares Medicaid certified beds versus licensed beds in NFs and Table II shows long-term care total charges and liability on claims received for fiscal years 2009 through 2011. In an effort to provide alternatives to NF placement, the Department also offered care through nine Home and Community-Based Services (HCBS) waiver programs which served almost 90,000 people. For more information on the HCBS waivers refer to Section IX, Appendix B and Table VII.
Field Activity
The Department continues to use long term care field staff, consisting of registered nurses and medical assistance consultants, to provide facilities with oversight and technical assistance to ensure services provided to residents are appropriate to meet their individual needs and in compliance with state and federal rules. Tasks performed by field staff include: developing and implementing field processes for certification and ongoing monitoring of Supported Living Facilities (SLFs), including investigations of complaints received through the SLF Complaint Hotline; conducting rate review protocols and methodologies, and; completing post-payment audits in NFs to ensure that claims for bed holds are appropriately billed.
Certification/Decertification
During fiscal year 2011, six nursing facilities (NF) and three Intermediate Care Facility for Developmental Disabilities (ICF/DD) closed. Of these facilities, one NF and one ICF/DD were terminated from participating in the Medicare and Medicaid Programs and all residents were relocated to appropriate settings. The remaining seven facilities closed voluntarily. During this same period, four new ICF/DDs were enrolled in the Medical Assistance Program.
MDS-Based Reimbursement Rate System
The Resident Assessment Instrument, commonly referred to as the MDS, is a federally mandated standardized resident assessment, care planning and quality monitoring system that drives care delivery in nursing facilities (NFs). The MDS is the foundation for the federal certification of resident care standards and requirements that the Department of Public Health (DPH) is responsible for enforcing in all Medicaid and/or Medicare certified nursing homes in Illinois. In administering this responsibility, DPH ensures compliance with the MDS program and enforces any sanctions as part of the licensure process.
All Medicare and Medicaid certified nursing facilities are required to complete the MDS on all residents and submit the data to the Department. The Department houses the MDS Data Repository, which is shared with the federal government. The MDS is used to classify residents into the Resource Utilization Groups that are used to calculate Medicare rates. The Department utilizes the MDS-based reimbursement as the rate-setting tool for the nursing component of the Medicaid NF payment.
Effective October 1, 2010, a new version of the MDS Assessment Data was implemented which contained new assessment information. During Calendar Year
2010, the MDS Data Repository stored 3,145,283 NF resident assessments. The system received and processed 179,325 new records, including admissions, quarterlyHFS – 2011 Annual Report Page 26
updates, change of status, and discharge records, for 165,234 unique individuals over the course of the reporting period. The Department monitors the accuracy of the MDS data to ensure correct coding and documentation of services provided by nursing facilities. Since August of 2008, the Department has performed 269 reviews on NF 5,977 residents MDS records; resulting in 215 rate reductions, 3 rate increases and 42 requiring no changes.HFS – 2011 Annual Report Page 27
IX. HOME AND COMMUNITY BASED-SERVICES (HCBS) WAIVERS
Home and Community-Based Services (HCBS) waivers, authorized under 1915(c) of the Social Security Act, allow the State to provide specialized long-term care services in an individual’s home or community. The 1915c waivers were initiated by the federal Centers for Medicare and Medicaid Services (CMS) in 1981. Illinois’ first HCBS waiver programs began in 1983. The waiver programs allow individuals to remain in their homes or community rather than an institution. HCBS waivers must be cost-effective in comparison to institutions and approved by the federal CMS. The waivers are time-limited programs that are under continuous review by federal CMS. States have the discretion to design the waivers as they choose, within certain parameters. For example, State’s may choose the number of consumers to serve, the services provided, whether or not the program is statewide, and whether to waive parental income for children.
In Illinois there are nine HCBS waivers. All but one waiver is operated by another state agency. This means that HFS has delegated the responsibility for day-to-day operations to the waiver operating agency. The Department directly administers the Supportive Living Program. For the other eight, the Department, in its role as the single state Medicaid agency, provides direction, oversight, program monitoring, fiscal monitoring, and administrative coordination to secure federal funding.
The programs operated by sister agencies include the HCBS waivers for: 1) Persons with HIV/AIDS, 2) Persons with Brain Injury, 3) Persons with Physical Disabilities, 4) Adults with Developmental Disabilities Waiver, 5) Children and Young Adults with Developmental Disabilities-Support Waiver, 6) Children and Young Adults with Developmental Disabilities-Residential Waiver, all of which are operated by the Department of Human Services; 7) Persons who are Elderly Waiver, operated by the Department on Aging, and; 8) Medically Fragile Technology Dependent (MFTD) Children Waiver, case managed by the University of Illinois at Chicago, Division of Specialized Care for Children (DSCC). The roles and responsibilities of HFS and the other state agencies in the administration of the waivers are outlined in interagency agreements. In federal fiscal year 2011, 89,439 persons were served in HCBS waivers. The growth history of the waiver program from 2006 through 2010 is shown in the chart below.
Waiver Recipients and Expenditures
Waiver Year (WY)
Unduplicated Served
Waiver Expenditures
WY 2006 LAG
71,316
$836,277,918
WY 2007 LAG
70,621
$877,816,914
WY 2008 LAG
80,202
$1,038,667,293
WY 2009 LAG
84,685
$1,138,724,311
WY 2010 Init
89,192
$1,270,314,002
Note: Information is based on HCFA 372 Reports generated by the Department’s Bureau of
Program and Reimbursement Analysis (BPRA) on a point in time for the previous waiver year, which
varies waiver by waiver. The HCFA 372 data will differ from information reported on a state fiscal year
basis and from federal quarterly claiming reports via the CMS 64. Initial reports are not final.
Fiscal year 2011 was full of activity for HCBS waivers in Illinois. Three of the nine waivers were prepared for renewal; medically fragile and technology dependent, brain injury and adults with developmental disabilities (DD). HFS and the operating agencies worked extensively with the National Quality Enterprise, a federal CMS contractor, to design quality improvement systems, including the addition of new performance measures and for each of the waivers. For additional information on the HCBS waivers, please refer to Appendix B and Table VII of this report. HFS – 2011 Annual Report Page 28
X. MATERNAL AND CHILD HEALTH PROMOTION
Improving the health outcomes of maternal and child beneficiaries continues to be one of the Department’s highest priorities. The Department has a particular focus on preventive maternal and child health services and partners with other state agencies, advocacy groups, private funders, provider organizations, academia, and interested parties to achieve maternal and child health goals. Through these efforts, the Department implements initiatives designed to improve the health status of mothers, women, and children.
Improving Birth Outcomes
The Department covers about half of all Illinois births and over 90 percent of all births to teens in Illinois. Birth outcome data are summarized below:
• The low birth weight rate (<2,500 grams) for HFS covered births is slightly higher than the state rate (8.9 percent and 8.2 percent, respectively, calendar year (CY) 2009 HFS Enterprise Data Warehouse, Birth File Match).
• The Department’s very low birth weight rate (<1,500 grams) is the same as the state rate (at 1.5 percent, CY 2009, HFS Enterprise Data Warehouse, Birth File Match). While very low birth weight represented less than 2 percent of all Medicaid-covered births, it accounts for almost 60 percent of the average costs of births (prenatal, delivery, postpartum, and first year of life).
• The number of births to Illinois teens (less than 20 years of age) has declined annually since 2009. However, the percentage of teen births covered by Medicaid has increased from 91.4 percent in 2007 to 93.6 percent in 2009. In 2001, the percentage of teen births covered by Medicaid was 80.3 percent. The following chart shows the annual number and percentage of Illinois teen births covered by Medicaid for fiscal years 2007 through 2009. 2009 is the most recent year of certified Birth Records from the Department of Public Health.
Annual Number and Percentage of Illinois Teen* Births Covered by Medicaid
Year
# HFS Teen Births
# Illinois Teen Births
% Teen Births Covered by HFS
2007
16,399
17,944
91.4%
2008
16,010
17,266
92.7%
2009
14,994
16,003
93.6%
*Less than 20 years of age
Source: HFS Enterprise Data Warehouse, January 2011, Birth File Match
To improve birth outcomes, the Department is monitoring (tracking and trending) and identifying strategies for program implementation, such as: planned pregnancies/family planning, timely and risk-appropriate prenatal and postpartum care using evidence-based strategies; expanding birth intervals; access to smoking cessation; and behavioral health services, as needed. Prenatal and postpartum care data are summarized below and while further improvement is needed, a positive trend is being realized:
• The HFS unintended pregnancy rate was 66 percent in 2003, but after the implementation of Illinois Healthy Women (IHW), a downward trend has been experienced with a rate of 59.6 percent in 2009.
• Just over one-half of HFS women with full benefits receive family planning services.HFS – 2011 Annual Report Page 29
• During the first six years of IHW, the percentage of women with interpregnancy intervals of greater than 24 months increased 1.2 percentage points.
• The percentage of HFS covered women who received timely prenatal care increased from 53.6 percent in 2008 to 55.5 percent in 2010.
• The number of perinatal depression screenings has continued to increase from 2009 to 2010. Women who received only prenatal screenings increased from 31 percent to 33 percent; women who received only postpartum screenings increased from 26 percent to 28 percent; and women who received both prenatal and postpartum depression screenings increased from 17 percent to 19 percent.
• The percentage of HFS covered women diagnosed with depression is substantially higher than non-HFS covered women (11.2 percent and 6.6 percent respectively in 2009). To address this issue, a provider training/engagement initiative on treating perinatal depression continues.
• During calendar year 2008 and 2009 among women enrolled in HFS nine months pre- and post-delivery who experienced an adverse birth outcome, as defined by low birth weight, very low birth weight, or infant death within the first year of life), nearly 97 percent of these women had one or more pre-existing conditions.
The data above illustrates the need for continued focus on improving birth outcomes. HFS continues to work on developing and implementing strategies to address these findings. Pursuant to P. A. 93-0536, the Department reports on the status of prenatal and perinatal healthcare services to the legislature every two years. The January 2012 Perinatal Report can be found in its entirety at: http://www.hfs.illinois.gov/mch/report.html
Several of the Department’s maternal and child health initiatives are described below.
Perinatal Depression Initiative
Perinatal depression encompasses a wide range of mood disorders that can affect a woman during pregnancy and after the birth of her child. If untreated perinatal depression adversely affects a mother’s health and mental well-being, may cause pregnancy complications, impact adversely on birth weight, may lead to infant mortality and poor parent/infant bonding, and have a negative impact on infant development. Perinatal depression is under-recognized and under-treated.
Since December of 2004, the Department has operated a comprehensive perinatal depression initiative, funded by private grants and federal financial participation, as allowed, as well as reimbursement for perinatal depression risk assessment as a covered service. The initiative includes, but is not limited to, the following: provider consultation services; provider education services, including a perinatal antidepressant medications chart and free primary care provider training; a statewide24-hour crisis hotline available for eligible women experiencing perinatal depression, including referral resource assistance; training of the mental health community to identify and treat mental disorders in pregnant and postpartum women; and collaborative efforts with DHS (Lead agency), advocates and other state agencies to implement Public Act 95-0469, Perinatal Mental Health Disorders Prevention and Treatment Act. As part of the initiative, the Department has a grant agreement with the University of Illinois at Chicago partner to operate a mental health consultation service for physicians serving the Medicaid population on perinatal depression.HFS – 2011 Annual Report Page 30
Smoking Cessation
The Department continues to partner with the Department of Public Health, Department of Human Services and the American Lung Association to promote smoking cessation and use of the Illinois Tobacco Quitline for free confidential counseling services for tobacco users in an effort to improve birth outcomes. The Department provides reimbursement of pharmacological smoking cessation products to assist eligible pregnant and post-partum women, and other eligible persons in quitting smoking. Provider education to encourage referrals to the Illinois Tobacco Quitline is also a component of the program. Smoking cessation education and outreach efforts are contractually required to be performed for HFS members by the managed care organizations. Annually, a notice is sent to beneficiaries regarding the Illinois Tobacco Quitline.
Planned Pregnancies – Illinois Healthy Women (IHW)
The IHW program was implemented in April 2004 and was renewed for a three-year period ending March 2012. In September 2011, the Department submitted a renewal application to the Centers for Medicare and Medicaid Services (CMS) requesting to extend IHW for an additional three-year period or the maximum allowed. CMS has granted a 30-day extension on the waiver through April 30, 2012, while the renewal application is processed.
The federal demonstration waiver is designed to improve women’s health and birth outcomes by expanding access to, and coverage of, publicly funded family planning services. Services, procedures and/or supplies provided for the purpose of family planning, such as, contraceptive initiation or management, which are performed during a family planning visit are claimed at the 90 percent Enhanced Federal Financial Participation (FFP) rate. Family planning related services performed as part of, or as follow-up to a family planning visit, such as services provided to identify or diagnose a family planning-related problem are billed at the Federal Medical Assistance Percentages (FMAP) rate. Screening mammograms and folic acid supplements are paid with State funds.
Since the inception of IHW through June 30, 2011, a total of 132,603 unduplicated women received services, reflecting an increase of over 25,000 women from June 30, 2010. During waiver year 7, the average cost for a woman receiving a year of family planning services was approximately $350, while the average cost for prenatal care, delivery, postpartum care and the first year of the child’s life was approximately $11,900. Using the Guttmacher Institute’s methodology, during the first seven years of the waiver, it is estimated that 19,193 births were averted due to the increased availability and utilization of family planning services through IHW. This resulted in an estimated net cost savings of approximately $153.4 million for those seven years. In addition to cost savings, IHW evaluation findings include the following successes:
• During the first seven years of the waiver, IHW reached its target population. Approximately 57 percent of the women who applied for IHW were ages 19 through 24, and 75 percent had never been pregnant;
• About 80 percent of the women who enrolled in IHW utilized family planning services;
• The fertility rate of women enrolled in IHW remained below 2.5 percent from 2005 through 2009, compared to 10.6 percent in 2009 for women in the general population with incomes less than 200 percent of poverty, and;
• Unintended pregnancies continued to show a downward trend throughout the first six years of the waiver.HFS – 2011 Annual Report Page 31
HFS collaborates with the DHS Family Planning program to improve outreach efforts with statewide community partners and providers to increase enrollment in IHW and to address provider training needs to ensure evidence-based family planning practices are being utilized and to improve billing submissions. Additional information on IHW can be found on the Department’s Web site at: www.illinoishealthywomen.com
Partnerships with Local Health Departments (LHD)
Through agreements with 74 local health departments (LHD) the Department continues to maximize available resources, to the extent allowed by the Department’s State Plan, federal and state law, by assessing and processing data on expenditures incurred by the LHDs in excess of state payments made to them for eligible covered services rendered to Medicaid participants, in order to obtain federal reimbursement for allowable administrative expenses. This process brings in additional federal funds through the federal claiming process, which are passed to the LHD partners, to provide resources for further expansion of services and increased access for Medicaid participants for such services as, but not limited to, maternal and child preventive health and dental care.
Public-Private Partnerships
The Department continues to partner with a number of private foundations to fund pilot- initiatives designed to improve health outcomes and to provide assistance to Medicaid-enrolled providers in complying with new guidelines in the Patient Protection and Affordable Care Act. The private funds are leveraged with federal matching funds, as appropriate. The ultimate goal in piloting initiatives is to determine their effectiveness and to spread them on a statewide basis with ongoing state funds. Initiatives currently funded through public-private partnerships include the following projects: Bright Smiles from Birth (Fluoride Varnish Application); the development, testing and validation of a preconception risk assessment tool; Enhancing Developmentally Oriented Primary Care; Bright Futures as a Standard of Care; Assuring Better Child Health and Development III; and Promoting Health: Improving Quality in Obesity Care.
Healthy Kids
The federally required Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program is the nation’s largest preventive child health initiative. The initiative is named “Healthy Kids” in Illinois. Under EPSDT, the Department provides initial and periodic examinations and medically necessary follow-up care to enrolled individuals younger than 21. Children receive preventive health screenings (including
immunizations, developmental screening, lead screening and risk assessment) vision and hearing screening, and dental care. In 2010, the federal government passed the Patient Protection and Affordable Care Act (ACA) to provide health coverage to all Americans. One of the earliest provisions to take effect is Section 2713, which requires preventive care services to be provided as outlined in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Bright Futures’ goal is to improve the quality of health care services for children through health promotion, disease prevention, and applying evidence-endorsed guidelines in primary care practices serving the population under age 21. HFS entered into an agreement with the Illinois Chapter, American Academy of Pediatrics (ICAAP) to assist HFS in promoting Bright Futures including: Developing infrastructure and materials to promote Bright Futures in Illinois to HFS Primary Care Providers (PCPs, also referred to as “medical homes”), increasing awareness of Bright Futures guidelines among Illinois PCPs, and increasing consumer awareness of Bright Futures as a standard of care.HFS – 2011 Annual Report Page 32
Measuring Progress
The Department monitors key indicators to gauge improvements in preventive healthcare utilization for children. Illinois uses indicators based on the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set (HEDIS) or HEDIS-like indicators, to measure and trend performance in key areas of child health. These measures include, but are not limited to: Well Child Visits in the first 15 months of life; Well Child Visits at ages 3, 4, 5, and 6; Objective Developmental Screening; Objective Vision Screening; Childhood Immunization Status; Childhood Lead Screening Status; EPSDT Preventive Services Participation Rate, and; Dental Services Participation Rate of Individuals up to 21 years of age. Several of the child health measures are highlighted below, and provide baseline information to be used in monitoring and tracking improvements.
Well Child Visits in the First 15 Months of Life. The Department’s experience in this measure, based on an administrative claims data calculation, for continuously enrolled recipients is shown in the chart below.
Well Child Visits in the First 15 months of Life:
Continuously Enrolled
Description
Calendar
Year 2008
Calendar
Year 2009
Calendar Year 2010
15 month olds with 6 or more well child visits
56.9%
58.7%
60.3%
15 month olds with no well child visits
4.2%
4.0%
4.1%
Source HFS Executive Information System, Data as of December 2011
Well Child Visits at ages 3, 4, 5 and 6. This HEDIS measure calculates the percentage of children from one to three years of age who had at least one objective developmental screening (ODS) before the target birth date. These data show that annually, across each age category, the rate of objective developmental screening has increased.
Well Child Visits at 3, 4, 5, and 6 Years of Life: Continuously Enrolled
Calendar Year
Measure
3 Yrs.
4 Yrs.
5 Yrs.
6 Yrs.
Total
2008
Eligible Population
85,446
80,722
77,769
74,542
318,479
Population # with at least 1 WCV
55,711
54,968
56,413
37,677
204,769
Population % with at least 1 WCV
65.2%
68.1%
72.5%
50.5%
64.3%
2009
Eligible Population
96,444
88,117
84,073
81,448
350,082
Population # with at least 1 WCV
63,311
60,321
61,394
43,313
228,339
Population % with at least 1 WCV
65.6%
68.5%
73.0%
53.2%
65.2%
2010
Eligible Population
101,579
99,306
90,892
87,168
378,945
Population # with at least 1 WCV
67,285
65,965
65,721
46,589
245,560
Population % with at least 1 WCV
66.2%
66.4%
72.3%
53.4%
64.8%
Source: HFS Executive Information System, Data as of December 2011. HFS – 2011 Annual Report Page 33
Objective Developmental Screening. This HEDIS measure calculates the percentage of children from one to three years of age who had at least one objective developmental screening (ODS) before the target birth date. These data show that annually, across each age category, the rate of objective developmental screenings has increased.
Objective Developmental Screening at 1, 2 and 3 Years of Age: Continuously Enrolled
Calendar Year
Measure
1 Yr
2 Yrs
3 Yrs
Total
2008
Eligible Population
95,140
92,888
84,486
272,514
Population # with at least 1 ODS
37,405
25,718
17,248
80,371
Population % with at least 1 ODS
39.3%
27.7%
20.4%
29.5%
2009
Eligible Population
93,899
97,197
94,911
286,007
Population # with at least 1 ODS
44,323
34,584
23,753
102,660
Population % with at least 1 ODS
47.2%
35.6%
25.0%
35.9%
2010
Eligible Population
Population # with at least 1 ODS
Population % with at least 1 ODS
94,129
96,389
100,543
291,061
52,311
42,810
31,962
127,083
55.6%
44.4%
31.8%
43.7%
Source: HFS Executive Information System, Data as of December 2011
Childhood Immunization Status. The Department calculates immunization status of children at 36 months of age. The percentage of children immunized over the past three years is reflected in the table below.
Immunization Status* at 36 Months of Age: Continuously Enrolled
Calendar Year
Measure
Title XIX
All Population
2008
Eligible Population
79,642
83,239
Population Fully Immunized
56,922
59,435
Fully Immunized %
71.5%
71.4%
2009
Eligible Population
86,943
90,490
Population Fully Immunized
62,986
65,546
Fully Immunized %
72.4%
72.4%
2010
Eligible Population
92,496
96,157
Population Fully Immunized
67,292
69,859
Fully Immunized %
72.8%
72.7%
* Combo 1: (4) DTaP; (3) IPV; (1) MMR; (3) Hib; (2) Hep B [(4-3-1-3-2)]
Source: HFS Executive Information System, December 2011HFS – 2011 Annual Report Page 34
EPSDT Participation Rate. The Department calculates the EPSDT Participation Rate using the methodology prescribed by the Centers for Medicare & Medicaid Services (CMS), based on the CMS 416 report guidelines. The EPSDT participation rate for the Title XIX (Medicaid) population and for all enrolled children under 21 years of age has continued to increase from federal fiscal year 2005 through 2009, even as the number of children enrolled substantially increased—resulting in more required EPSDT (well child) visits.
Illinois EPSDT Participation Rate*
Federal Fiscal Year
Title XIX (Medicaid) EPSDT Participation Ratio
Number of Title XIX (Medicaid)
Enrolled Children Under 21
All Population
EPSDT Participation Ratio
Number of All
Enrolled Children Under 21
2005
67.1%
1,272,938
67.8%
1,335,597
2006
68.2%
1,336,033
69.0%
1,433,163
2007
69.2%
1,392,361
70.3%
1,539,388
2008
67.0%
1,472,021
68.0%
1,631,532
2009
74.0%
1,561,906
74.9%
1,730,691
Title XIX (Medicaid) and Title XXI (CHIP) EPSDT Participation Ratio
Number of Title XIX (Medicaid) or Title XXI (CHIP)
Enrolled Children Under 21
All Population
EPSDT Participation Ratio
Number of All
Enrolled Children Under 21
2010**
75.0%
1,630,605
76.3%
1,803,823
Source: Illinois CMS-416 Report
*uses an adjusted rate methodology, based on CMS-416 methodology
** Beginning FFY2010, CMS-416 reporting guidance was revised by the Centers for Medicare and Medicaid Services (CMS) to reflect changes in the 2009 Children’s Health Insurance Program Reauthorization Act (CHIPRA), and to include recommendations from CMS, states and external partners to improve the data reported.
Improving the Quality of Children’s Health Care
The Children’s Health Insurance Program Reauthorization Act (CHIPRA) was signed into law on February 4, 2009. Title IV of CHIPRA creates a broad quality mandate for children's health care and authorizes health care quality initiatives for both the Children's Health Insurance Program (CHIP) and the Medicaid program. CHIPRA seeks to improve access to and the quality of health care provided to children. As authorized in Section 401(d) of CHIPRA, in February 2010 the Centers for Medicare & Medicaid Services (CMS) awarded one of ten CHIPRA Quality Demonstration Grant funds to Florida as the lead state and Illinois as the partnering state.
The grant was awarded for a five-year period beginning in February 2010 and continuing to February 2015. The first grant year was devoted to planning and development of an operational work plan. Implementation of grant activities began in Year 2, starting February 2011. In accordance with the terms and conditions of the CHIPRA grant and the work plan developed with stakeholder input, in 2011, HFS began working to test, implement, operationalize, and integrate interventions to improve the quality of children’s health care in the following four areas:HFS – 2011 Annual Report Page 35
Child Health Quality Measure
The Center for Medicare and Medicaid Services (CMS) released a core set of child health measures in February 2011. In Illinois, HFS was collecting, analyzing and reporting on many of the core measures and in 2011 began developing the capacity to report on the remaining measures. In addition to the core measures, Illinois will work to identify, develop and test new measures in priority areas.
In conjunction with implementing the core measure set and developing new measures, Illinois will obtain provider input on data collection and reporting, report design, successes and barriers in using data for improvement activities, and priorities for new measures.
The overall goal for child health measures is for Illinois to report child quality measures (including the federal CMS core measures and additional state-developed measures) and for those measures to be used to drive quality improvement at the state level, within health plans and among providers.
Health Information Technology/Health Information Exchange (HIT/HIE).
Illinois will work to integrate plans for child health quality reporting, tracking, and quality improvement activities into the state’s HIT infrastructure planning and building efforts to complement but not duplicate current HIE plans.
Coordinating with other HIT/HIE efforts such as the Governor’s Office of Health Information Technology (OHIT) and the Electronic Health Record (EHR) Provider Incentive Program/ Meaningful Use, HFS will test technology solutions designed to improve care coordination within the medical home and assure that providers have access to health information that is timely and usable.
Goals HIE/HIT include making quality data more accessible to providers, feeding information back to pediatric and other health care providers and state agencies, and improving the availability of relevant and timely electronic information to improve quality and coordination of children’s health care, reduce redundancy and cost, and improve clinical outcomes and patient satisfaction.
Improving and Enhancing Medical Homes
During the fall of 2011, HFS and the Illinois Chapter of American Academy of Pediatrics (ICAAP) began recruiting 200 practices to participate in the National Committee on Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH) self-assessment survey tool to assess strengths and needs of practices serving as medical homes. ICAAP will use the practices’ scores on the NCQA assessment to develop training specific to the identified needs. Following the self-assessment, practices are able to receive medical home resources, technical assistance, and training at their own pace over a two-year period at no cost.
In addition to the medical home assessment, 30-60 practices will be recruited to participate in quality improvement initiatives targeted to improving care coordination, child health measures and specific medical home domains.
The goals of the medical home initiative include strengthening the capacity of participating medical homes to provide high quality, family-centered care to Medicaid and CHIP-enrolled children, evaluating the impact of the self-assessment and interventions, and developing policy recommendations to improve HFS’ medical home program.HFS – 2011 Annual Report Page 36
Improving Birth Outcomes
HFS intends to improve birth outcomes through a variety of activities, including:
• Developing a prenatal electronic data set of information to be made available to delivery hospitals and all providers involved in a woman’s care;
• Developing at least one health quality measure related to perinatal health;
• Recommending prenatal guidelines, referral protocols, and education;
• Engaging the Perinatal Network in quality improvement initiatives (such as educating providers about prenatal guidelines, referral protocols and education);
• Recommending protocols for care coordination; and
• Developing a public education campaign on the benefits of preconception, prenatal and interconceptional care.
During 2011, CHIPRA stakeholders identified the key information needed for the prenatal electronic data set and HFS is now exploring options for operationalizing the data set. CHIPRA stakeholders also started developing minimum prenatal guidelines that include required clinical elements, labs, education and referrals for non-complicated pregnancies. This work will continue into 2012, and will require HFS decisions on how to operationalize and implement the guidelines. A quality improvement initiative to educate providers about the guidelines is planned and will include the Perinatal Network.HFS – 2011 Annual Report Page 37
XI. DENTAL PROGRAM
The HFS Dental Program is administered by DentaQuest of Illinois, LLC (DentaQuest). Under a competitively procured contract, DentaQuest is responsible for dental claims adjudication and payment, prior approval of services, ongoing reporting to the Department, quality assurance monitoring, and developing and maintaining the Dental Office Reference Manual. DentaQuest provides additional services including provider recruitment and training, enrollee education and referral coordination, interactive Web site, toll-free telephone systems, and other functions required to assure beneficiary access to needed dental services.
The Dental Program offers a comprehensive dental package of services to children, including preventive, diagnostic, and restorative services. Dental coverage is limited to diagnostic and restorative services for the adult population. Over 75 percent of the services/reimbursements provided through HFS’ Dental Program are for children.
Beneficiary Outreach
HFS, in cooperation with DentaQuest, supports and encourages the concept of a “dental home” for all beneficiaries. Through the Beneficiary Outreach Initiative, beneficiary education and outreach programs were implemented in a variety of settings, including dental offices, medical offices, schools and community venues. A brochure is annually mailed to beneficiaries to reinforce the value of seeking treatment at a “dental home”.
These efforts are succeeding, as evidenced by the 2011 HEDIS results. The Department’s 2011 Annual Dental Visit HEDIS measurement shows that 54.55 percent of beneficiaries between 2 and 20 years of age, eligible for services, had at least one dental visit during the reporting period. This is up from 50 percent in 2009 and 51 percent in 2010.
Dental Program Expansion Efforts
HFS continues to work with publicly funded clinics to build the public health infrastructure necessary to improve dental care in underserved areas of the state. In July 2009, P. A. 96-0039 provided $2 million for dental clinic funding to the Capital Development Board over a three year period, as part of the 2010 capital budget. As of June 30, 2011, approximately $1.8 million of the $2 million in funds had been allocated to twenty-five entities to build or expand dental clinics. These grantees will be increasing access to dental services by adding seven new dental clinics and an additional 44 operatories throughout the state.
HFS has also developed a process to allow local health departments to claim Federal Financial Participation for the unreimbursed cost of providing dental services to Title XIX (Medicaid) clients. The cost must have been paid from local dollars and those dollars must not have been used to match any federal awards. To participate in the program the local health department must have a signed Interagency Agreement with HFS. Retroactive claiming from October 1, 2009 forward is allowed.
The All Kids School-based Dental Program offers out-of-office preventive dental services in a school setting to children ages 0-18 years. Providers who enroll with the All Kids School-based Dental Program must be able to render the full scope of preventive dental services including a comprehensive oral examination, prophylaxis, topical application of fluoride, and application of sealants. School-based providers must complete an Illinois Department of Public Health Proof of School Exam Form for each child seen, a School Exam Follow-up Form to be sent home with the student, and provide a referral plan for follow-up care. In addition, the provider must submit an HFS – 2011 Annual Report Page 38
oral health score to HFS for each child examined. The score indicates the urgency level of follow-up care needed. Caregivers of those students whose scores indicate the most urgent need for care receive a letter from HFS reminding them of them of the importance of good oral health. The letter also includes contact information for DentaQuest.
HFS, in cooperation with the Illinois Chapter of the American Academy of Pediatrics (ICAAP), continues to increase its efforts to improve oral health in young children (birth through thirty-six months of age). Under the Bright Smiles from Birth (BSFB) project, physicians, nurse practitioners, and FQHCs are trained by ICAAP to perform oral health screening, assessment, fluoride varnish application, anticipatory guidance and make referrals to dentists for necessary follow-up care and establishment of ongoing dental services. BSFB is currently operating in Cook County, the collar counties, Rockford and Peoria, with expansion efforts spreading downstate, as training resources permit.
A total of 2,219 providers have been trained, including residents under the supervision of a physician, and 397 primary care physicians (PCPs), representing an increase of 911 total providers and 218 PCP from 2009. The initiative has proven successful in improving access to dental care and studies confirm that fluoride varnish application is effective at reducing early childhood caries in young children. During calendar year 2010, over 8,000 unduplicated children under age three received a fluoride varnish application in a pediatric practice.
Reimbursement
DentaQuest reimburses dental providers according to the Department’s fee schedule, with weekly payments received from the HFS based on DentaQuest’s adjudicated claims for the respective week. Payments to dental providers are currently being made within 30 days of the receipt of a clean claim.
During fiscal year 2011, payments for dental care totaled over $256 million. DentaQuest reported that 850,458 individuals under the age of 21 received over 6.4 million dental services, for a total expenditure of approximately $194 million. For the same time period, 261,910 individuals ages 21 and over received 1.7 million dental services for a total expenditure of approximately $62 million.
More information regarding the HFS Dental Program may be obtained at the following Department and DentaQuest websites: <http://www.hfs.illinois.gov/mch/dental.html> or <http://www.dentaquestgov.com>HFS – 2011 Annual Report Page 39
XII. CARE MANAGEMENT
Managed Care
Illinois' Managed Care program currently consists of three delivery systems, the Integrated Care Program, the Primary Care Case Management (PCCM) program and the Voluntary Managed Care program. Each of these programs provides medical homes for their enrollees. Most Medical Assistance Program participants are required to be enrolled in one of these programs.
Integrated Care Program
In September of 2010, the Department awarded contracts to Aetna Better Health and IlliniCare to integrate and manage the care of the nearly 35,000 Seniors and Persons with Disabilities (SPDs) who live in suburban Cook, DuPage, Kane, Kankakee, Lake and Will Counties and are now enrolled in the Integrated Care Program (ICP). The ICP was the first mandatory managed care program for SPDs and was initially met with some resistence from both providers and enrollees. Over the next seven months the Department and the two plans worked extensively to recruit providers into the ICP networks. The final contracts were signed with Aetna Better Health and IlliniCare in April of 2011. Enrollment into the ICP began on May 1, 2011 and the enrollment roll-out was completed on January 1, 2012. The ICP the state’s first integrated health care program was designed to improve the health care and quality of life for Illinois’ SPDs in the Medicaid program. The integrated care delivery system brings together an individual’s physicians, specialists, hospitals, nursing homes and other providers as part of an integrated care team. The care is organized around the patient’s needs to keep him/her healthier and provide a more coordinated medical approach. Integrated care focuses on all of the factors that can affect a person’s health and well-being and puts a plan in place to manage all of their health needs, whether those needs are physical, behavioral or social.
The five-year contracts with Aetna Better Health and IlliniCare will cost an estimated $450 million annually in capitation payments to the two MCOs. The savings/cost avoidance estimates over the five-year contract are estimated to be $200 million, as a result of: automated savings every year due to rates set for the companies at 3.9 percent below what is otherwise estimated to be spent on care for these enrollees; and lower growth rates (or estimated cost inflation) over time because of requirements for enhanced coordination of services and focus on prevention, especially as more services are added in Phase II and III.
Services
Under Phase I of the ICP, all standard Medicaid medical services, such as physician and specialist care, emergency care, laboratory and x-rays, behavioral health, pharmacy, dental, vision and substance abuse services are covered. Case management, an essential part of the ICP, is also a required service.
Phase II of the program, currently under development in consultation with stakeholders, advocates, and individuals in ICP, will go into effect in late summer of 2012. Services to be covered under Phase II will provide persons with disabilities the support they need to live more independently in the community. Those services include long term care services in nursing facilities or in the home through Home and Community-Based Services (HCBS) waivers. Phase II will reinforce Illinois’ system of consumer-directed care for persons with disabilities.
Phase III, to be implemented in the future, will include long term care services for Intermediate Care Facilities for the Developmentally Disabled and Home and Community-Based Serviced waivers for persons with developmental disabilities.HFS – 2011 Annual Report Page 40
Risk Stratification
Under ICP, participants are identified as needing care management or disease management through the use of predictive modeling, referrals, and through risk stratification. Enrollees are stratified once they join an integrated care health plan to determine the appropriate level of intervention. Enrollees are generally stratified into three levels: low, moderate and high risk. There is outreach and intervention at each level. Members identified as complex high risk receive the full range of care management services. Members with moderate risk are put into a standard care management program with service coordination and support as needed. Members who are identified as low risk receive prevention and wellness program services and education on condition-specific issues.
Integrated Care Team
Each health plan has a multidisciplinary integrated care team for enrollees identified as needing care management. The integrated care teams consist of clinical and non-clinical staff whose skills and professional experience complement and support each other in the oversight of enrollees’ needs. Such teams consist of the enrollee, care coordinators, behavioral health care coordinators, community service liaisons, and the enrollee’s providers. Care team functions include, but are not limited to: conducting enrollee assessments; developing an enrollee care plan in collaboration with the enrollee and their caregivers; communicating and coordinating care in a manner that ensure the enrollees physical and behavioral health needs are met.
Ultimately the decision of what type of health care the member receives is in the hands of the member – the ICP was designed to empower members to be in control of their own health care.
Performance Measures
The contracts with Aetna Better Health and IlliniCare Health Plan contain 30 performance measures that create an incentive for the two health plans to spend money on care that produces valued outcomes. They are rewarded for meeting pre-established targets for delivering quality healthcare services with measures such as, but not limited to, ensuring members follow up with a provider within 30 days after receiving a mental health diagnosis, following up with a provider within 14 days after an emergency room visit, and seeing a dentist annually.
Primary Care Case Management – Illinois Health Connect
The Primary Care Case Management Program (PCCM), Illinois Health Connect (IHC), was implemented in July 2006 and became fully operational in November of 2007. The program is based on the American Academy of Pediatrics’ medical home initiative and seeks to provide a medical home for each client. As of June 30, 2011, there were over 2.0 million Medicaid enrollees that had either chosen or been assigned to a Primary Care Provider (PCP) for their medical home. Of these, just over 1.8 million enrollees were enrolled with a PCP in Illinois Health Connect for their medical home. Estimated savings from reduced inpatient hospitalizations and emergency room visits are over $400 million since the program’s inception. Through the Innovations Project, the Department is working to enhance the PCCM program to better coordinate care.
The program is mandatory for most persons covered by the Department’s Medical Programs, including children and adults enrolled through the All Kids and FamilyCare programs and SPDs who are not enrolled in the ICP. Some populations, such as participants that have Medicare, are excluded from enrolling in Illinois Health Connect.HFS – 2011 Annual Report Page 41
The goals of IHC are to improve the quality of health care and increase the utilization of primary and preventive care, reduce the usage of the emergency room for routine medical care, improve access to care through the availability of a provider network and expansion of providers and provide the most appropriate and cost-effective level of care.
Enrollees of IHC have a medical home through a PCP. Enrollees may choose their own doctor or clinic as their PCP if that doctor or clinic is enrolled with the Department as a provider and enrolled as a PCP with IHC. Establishing a medical home encourages the provision of healthcare services in the most appropriate setting and ensures access to preventive healthcare services. PCPs enrolled in IHC serve as an enrollee’s medical home by providing, coordinating and managing the enrollee’s primary and preventive services, including well child visits, immunizations, screening, and follow-up care as needed. The PCP also makes referrals to specialist for additional care or tests as needed. Having a single PCP ensures that enrollees have access to quality care from a provider that understands their unique health care needs. In counties in which the Voluntary Managed Care program is available, eligible enrollees may opt out of IHC to enroll with an MCO for their medical home.
Quality Initiatives
IHC’s quality assurance program focuses on ongoing quality improvement and identifies and responds to opportunities for quality improvement in administrative practices and clinical functions of IHC. This quality improvement program includes strategies to assure access to care, evaluate provider and client education and to monitor and report on care coordination and utilization management. The Department and IHC worked with many provider and consumer groups to develop quality indicators and monitoring strategies to ensure providers receive the support they need to effectively manage the care of their enrollees and to ensure that the enrollees are receiving quality healthcare services. In order to assist PCPs in improving the quality of care for their enrollees, IHC makes the following quality tools available to all PCPs for use in their practice:
• Panel Rosters – Panel rosters help providers manage their patients’ care by identifying patients are due for screening or checkups based on HFS claims data. These are available electronically or by paper copy.
• Claims History Summaries – Physicians treating Medicaid-eligible enrollees can access claims-based client health summaries that include medication and immunization histories, previous lab orders, hospitalizations and other medical procedures, electronically through the Department’s secure MEDI system. With the claims history of a client, the provider can see a client’s medical history, assist in assessing additional medical needs and determine adherence.
• Provider Profiles – Each IHC PCP receives a provider profile on a semi-annual basis (spring and fall) that summarizes the PCP’s performance on specified clinical indicators. The profile is available electronically or via paper copy. The data reflected in the Provider Profiles is gathered from HFS claims data.
• Specialty Resource Datab