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Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared – Appendix – Illinois – 8426-06 « » The Henry J. Kaiser Family Foundation

Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS


MOU Signed: Feb. 22, 2013
3-way contract signed Nov. 5, 20131
Demonstration Duration: 3 years
March 1, 20142 to Dec. 31, 2016
Target Group:
Includes:  an estimated 135,825 full benefit dual eligible beneficiaries age 21 and older in 21 counties grouped into 2 regions are eligible to enroll; Medicare Advantage enrollees in a plan whose parent organization is not offering a demonstration plan may participate if they disenroll from their existing plan
Excludes: dual eligible beneficiaries with other comprehensive coverage, those with developmental disabilities who are served through an ICF/DD or § 1915(c) HCBS waiver, those on a Medicaid spend down, and those in the Medicaid breast and cervical cancer program
Geographic Area:
21 counties grouped into 2 regions:
Greater Chicago region: Cook, Lake, Kane, DuPage, Will, and Kankakee counties
Central Illinois region:  Knox, Peoria, Tazewell, McLean, Logan, DeWitt, Sangamon, Macon, Christian, Piatt, Champaign, Vermilion, Ford, Menard, and Stark counties
Initial enrollment period is voluntary, followed by a six month passive enrollment period in which the remaining beneficiaries in the target population will be automatically enrolled;3 passive enrollment not to exceed 5,000 beneficiaries per plan per month in Greater Chicago and 3,000 in Central Illinois
The MOU provides that beneficiaries may begin to elect voluntary enrollment 60 days prior to an effective date of March 2014 (as revised), followed by six groups of passive enrollment over six months:  initial notice will be sent to one group per month, with passive enrollment effective for one group per month 60 days after notice (with the enrollment for the first passive group effective, as revised, in June 2014)4

Beneficiaries may opt out of the demonstration prior to passive enrollment and thereafter on a monthly basis
The MOU provides that Illinois must submit a Medicaid state plan amendment to implement managed care and concurrent authority for its § 1915(c) waiver – while the MOU does not mention mandatory Medicaid managed care, questions and answers released by the state indicate that beneficiaries receiving LTSS will be required to enroll in a Medicaid managed care plan;5 in addition, Illinois has a draft § 1115 waiver application seeking to require Medicaid managed care enrollment6
Intelligent assignment for passive enrollment will consider previous managed care enrollment, historic provider utilization, and in year one will equalize enrollment in all MCOs
Financing: Capitated with savings percentage (1% in year one, 3% in year two, and 5% in year three) applied upfront to baseline Medicare and Medicaid contributions; capitation rate quality withhold same as in California (1% in year 1, 2% in year 2, 3% in year 3)
Medicare baseline for capitated payments:  Same as California, except that Medicare Advantage risk score coding intensity adjustment factor will apply after calendar year 2014
Medicare risk adjustment:  Same as California
Medicaid baseline for capitated payments: Historical state spending for state plan and HCBS waiver services trended forward
Medicaid risk adjustment: Rating categories with financial incentives for HCBS over nursing facility care7
Risk sharing: Required minimum medical loss ratio of 85%
Care Delivery Model: Medicare-Medicaid Alignment Initiative plans will provide medical homes, integrated primary and behavioral health care services, and care management; the intensity of care management services will depend on the beneficiary’s risk level
Participating Health Plans:
-Greater Chicago region:  Aetna (not participating in Lake County; participation approval on hold in Kankakee County), HealthSpring (not participating in Kankakee County), Healthcare Service Company/Blue Cross Blue Shield, Humana, IlliniCare/Centene, and Meridian (not participating in Kankakee County; participation approval on hold in DuPage and Lake Counties)
-Central Illinois region:  Health Alliance Medical Plan and Molina (participation approval on hold in McLean, Sangamon, and Macon counties)8
Benefits: Includes all Medicare and Medicaid services except Medicare hospice; includes Medicaid home and community-based waiver services except for beneficiaries with developmental disabilities; plans have discretion to offer flexible benefits as appropriate to beneficiary needs
Continuity of Care: Beneficiaries have a 180 day transition period for continuing a current course of treatment with out-of-network providers including behavioral health and LTSS
Ombuds Program: Illinois’s MOU indicates that it intends to support an independent ombuds program for the demonstration.  Illinois has been awarded CMS funding to support its ombuds program.9
Stakeholder Engagement: Plans must establish an independent beneficiary advisory committee that meets quarterly
Notice:  same as California (single integrated notice)
Timeframe to request initial appeal:  60 daysInternal health plan appeal:  all initial appeals must be filed with health plan; appeals to be resolved within 15 business days (standard) or 24 hours (expedited)
External Medicare appeals:  same as California (health plan automatically sends appeal to Medicare IRE if initial denial upheld; beneficiary may then request Office of Medicare Hearing and Appeals review)
External Medicaid appeals:  beneficiary may request fair hearing within 30 days of plan appeal decision for Medicaid services and within 30 days of IRE decision for overlapping Medicare-Medicaid services; to be resolved within 90 days
Appeals where Medicare and Medicaid services overlap:  to be defined in 3-way contract; will automatically be sent to IRE, and if IRE decision not wholly favorable to beneficiary, may request fair hearing or ALJ hearing
Continued benefits pending appeal:  health plans must provide continuing benefits for Medicare Parts A and B and Medicaid services while internal health plan appeals are pending; beneficiaries may request continuing benefits (within 10 days) for Medicaid and overlapping Medicare-Medicaid services while fair hearings are pending
Medicare Part D:  same as California (existing Medicare Part D appeals process continues)


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