Medicaid Managed Care

What’s new?

  • The legislature passed SB1321, a Medicaid omnibus bill, to address challenges faced in implementing the Medicaid managed care program in Illinois.  For an extensive review of all the components of SB 1321 see External Resources below.  The key provisions of this measure lay the foundation for reducing inappropriate payment denials and significantly easing administrative burdens on hospitals and health systems including:
    • reimbursement for stays beyond medical necessity
    • expedited payments
    • timely payment interest penalties
    • a dispute resolution process
    • claims rejection/denial management
    • timely filing extension for eligibility errors
    • provider effective dates
    • provider directory updates
    • operational standardization
    • medical loss ratios
    • value-based payment models
  • This is a result of a bi-partisan, bicameral legislative working group led by House Majority Leader Greg Harris that heard from providers, plans and agencies about the challenges in implementing the Medicaid managed care program over the course of several months.
  • AMITA Health was invited to present to the working group and provided detailed information about the challenges we face, in particular, with MCO accountability and transparency in the processing and payment of claims in addition to the lag time on the processing of Medicaid applications.
  • This was a welcome process after years of one-on-one meetings with the individual plans to work on these issues.

What is the issue?

  • In 2018, Illinois expanded the Medicaid managed care program to cover all counties in Illinois.  As of April 2019, 2,097,951 individuals eligible for Medicaid were enrolled.
  • Since the introduction of mandatory managed Medicaid in 2014, the Managed Care Organizations (MCOs) have required hospitals and other providers to jump over numerous administrative hurdles to secure authorization and reimbursement for medically necessary services provided to Medicaid-eligible patients.
  • Coupled with a state budget impasse, providers who were not getting any Medicaid payments from the state and faced multiple hurdles with MCO payment were forced to divert resources away from patient care and towards administrative overhead to combat MCO practices, such as inappropriate service authorization and payment denials and extremely limited care coordination assistance, if any.

Why does it matter?

  • AMITA Health serves a ten percent of the Illinois Medicaid population.
  • Compared to Medicaid fee-for-service in Illinois, Medicaid managed care has resulted in significant payment delays and denials for services provided to Medicaid patients.
  • Other issues Illinois health care providers have experienced with MCOs include issues with credentialing, eligibility determinations and prior authorization.
  • Effective managed care can achieve the triple aim of improved quality with better outcomes at a lower cost.

What is the AMITA Health perspective?

  • Care for the whole person is important.  AMITA Health delivers wholistic care in a highly personal environment. Care coordination, a key component of managed care, is critical to ensuring the physical, mental and spiritual health of an individual.
  • MCO oversight will improve performance. Given our experience, AMITA Health believes the Department of Health and Family Services should provide increased and ongoing oversight, enforcement and audits to address operational issues related to provider credentialing, eligibility verification, prior authorization and claims processing.
  • Medicaid funding helps serve vulnerable populations. The Medicaid program is vital to help us continue our mission of serving vulnerable populations and helping communities be healthier.   Without programs such as Medicaid, health disparities will continue to grow and access to high quality, compassionate care will persist.

 

External Resources

Information from third-party organizations that can be resources for you to continue to learn about the issues at hand.

2019 Technical Summary of Medicaid Omnibus

Illinois Health and Hospital Technical Summary of 2019 Medicaid Omnibus

View Resource

SB 1321 Medicaid Omnibus Fact Sheet

Illinois Health and Hospital summary of SB 1321

View Resource

MANAGED CARE, MARKET REPORTS AND THE STATES

View Resource

Featured News

Featured news includes articles from multiple viewpoints and is designed to keep you abreast of the current debate around this issue. This information should not be construed as our point of view.

View More

New Managed Care Bill Would Shed Transparency On Hospital Processes

State Comptroller Susana Mendoza says an omnibus bill that the legislature approved this past weekend will help hospitals being strangled by the “Managed Care” system.  ...

WBBM 780AM + June 03, 2019 + View Article

Illinois lawmakers pass bill to help Medicaid patients keep coverage, ensure hospitals get paid faster

After years of criticism from patients and hospitals, Illinois lawmakers have passed a bill aimed at fixing a slew of problems within the state’s Medicaid ...

Chicago Tribune + May 31, 2019 + View Article