The Transition to Medicaid Managed Care in Illinois

1
The Transition to Medicaid Managed Care in
Illinois

• October 7, 2013

Presented by Sharon R. Miller
2
Transition to Medicaid Managed Care

• Welcome
• Who Am I ?
• 30 yrs. Experience in Managed Care
• Adjunct Professor at Benedictine University
  teaching Managed Care and Business of Health Care
  Classes (MPH program)

3
What We Will Cover
4
What We Will Cover
What We Will Cover
The Basics of Managed Care
Medicaid Now
Taking You Inside the Payer World
Different Departments and Rules
Managed Care Reimbursement Capitation
Capitation vs. Risk
Medicaid Managed Care Your Shifting Roles
5
Why are We Covering This ????

• Managed Care programs are not just unique to
  Illinoisthis is a nationwide movement.
• I Heard that Managed Care Does Not Work.not
  true
• As a Care Coordinator, what does this have to do
  with me and my job ?
• State will oversee compliance

6
The Basics of Managed Care
Our Focus
HMO style
7
The Basics of Managed Care (HMO model)

• Managed Care is NOT new.been around since the
  1920s then became popular in the late 70s.
• Health Insurance Companies establish networks
  of providers
• Patient selects a Health Plan
• Patient selects a Primary Care Provider (PCP)
• All medical services approved through this PCP
• Other rules referrals, pre-cert needed for ER
  visits and certain medical procedures
• Tight controls over services

8
The Basics of Managed Care (HMO model)

• There are also different types of HMOs
• Staff Models (physicians are salaried employees
  Humana)
• Network Models (works with a variety of doctors
  including individual and group practices)
• Group Models (a payer that works with only one
  multispecialty physician group)
• IPA Models (payer with contractual relationships
  with individual and group practices, as well as
  large Independent Physician Associations (IPAs))

9
Medicaid Now
10
Taking You Inside the Payer World
State Contracts with Insurance Companies to
Manage all aspects of the Patients Experience
11
Working with Payers the new Medicaid
configuration
12
Review of Medicaid Changes to Managed Care

• Changing Patient Relationship
• New patient relationship is with the insurance
  company, not the State
• Changing Claims Processing done by Insurance
  Companies
• New State pays lump sum to insurance company
  (more on this later)
• State keeps eligibility function and takes on
  oversight function
• Day-to-day handled by insurance company

13
Taking You Inside the Payer World
Insurance Company
14
Managed Care Reimbursement Capitation

• Capitation
• This is a payment methodology where a fixed
  amount of money is paid in advance to the
  insurance company for the delivery of health care
  services.
• New term PMPM Per Member Per Month

15
Managed Care Reimbursement Capitation

• Capitation Example
• 1,000 patients (members)
• Capitation rate 1063.76 per month
• Total pre-paid per month to insurance company
  1,063,760
• Sounds good, right ????

16
Managed Care Reimbursement Capitation

• What Does the Insurance Company Need to Do for
  this Advance Payment ?
• Everything in their contract !!!!
• Doctor Services
• Hospital Services
• Long Term Care Services
• Ancillary Care Services
• Anything/Everything Else

17
Managed Care Reimbursement Capitation

• And..the Insurance Company does NOT get 100 of
  the capitation because of something called a
  Risk Pool
• Insurers will get paid 80 capitation with 20
  withheld. In order to collect on the withhold,
  the insurance company needs to meet certain
  quality measures set by the State. If they meet
  the measures, they get the 20 back at the end of
  the year.

18
Capitation vs. Risk

• RISK CONTRACTS
• This is what capitation is all about RISK
• If the insurance company controls the risk, they
  profit.
• If the insurance company does not control the
  risk, they lose money.

19
Medicaid Managed Care Your Shifting
Roles

• OVERSIGHT
• OVERSIGHT
• OVERSIGHT

20
Questions
21
Contact InformationSharon Millersharon.mille
rhci_at_gmail.com