Current Updates (as of 8/3/2021)

Medicare-Medicaid Integration

On April 30, 2021 the Illinois Department of Healthcare and Family Services (IHFS) announced that the Medicare-Medicaid Alignment Initiative (MMAI) would expand statewide. Illinois received approval for the MMAI program from CMS in 2013 and the program was implemented in Central Illinois and the Chicagoland area. Beginning July 1, 2021, the program will be available to all dually eligible individuals statewide. Eligible beneficiaries may choose to opt-in to a MMAI plan or be passively enrolled in a plan.

(Source: Illinois DHFS Press Release; 4-30-2021)

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Past Updates

Managed LTSS Programs

In 2011, the Illinois General Assembly adopted a Medicaid reform law (P.A. 96-1

501) mandating the state to move 50% of Illinois Medicaid recipients from fee-for-service to risk-based care coordination by January 

2015. Currently, the state has two Medicaid managed LTSS programs. (Source: State Website on Integrated Care Program)

In May 2011, the state implemented its first integrated health care program, a mandatory managed care program for the non-dual ABD population known as the Integrated Care Program (ICP), in 5 pilot counties. (Source: State Integrated Care Program website) In February 2013, health plans began covering LTSS benefits for ICP enrollees. In mid- 2013, the state began its ICP enrollment expansion. In March 2014, the state began ICP enrollment expansion in the City of Chicago, the state’s final region for ICP expansion. (Source: HMA Weekly Roundup, 4/4/2014)

In early 2013, the state implemented its second managed care program, known as the Care Coordination Innovations Project. Eligible populations include older adults, adults with physical disabilities, and children with complex needs. The managed care entities include Care Coordination Entities (CCEs) and Managed Care Community Networks (MCCNs). CCEs are provider-organized networks providing care coordination for risk- and performance-based fees; medical and other services are paid on a fee-for-service basis. Some CCEs have already begun serving beneficiaries, while others will go live later in 2014. MCCNs are provider-sponsored organizations that contract Medicaid covered services through a risk-based capitated fee model. Participation in a CCE or MCCN is voluntary. (Source: State Presentation on Innovations Project, 10/31/2011; HMA Weekly Roundup, 4/23/2014)
Care Coordination Information and Fact Sheet
State Website on Care Coordination initiative

In early June 2014, the state postponed the July 1, 2014 launch date for its Medicaid managed care programs, in order to finalize contracts and mail out patient information packages. On June 17, 2014, the state updated its care coordination rollout map. (Source: Chicago Tribune, 6/10/2014; HMA Weekly Roundup, 6/11/2014; HMA Weekly Roundup, 6/18/2014).
Care Coordination Expansion Map (6/25/2014)
Care Coordination Webcast Presentation (6/30/2014)

On June 4, 2014, Illinois submitted to CMS a §1115 Waiver for its Path to Transformation demonstration. The waiver proposes comprehensive reforms to the state’s Medicaid program that will impact all Medicaid eligible populations, including seniors and people with disabilities. The waiver proposes significant changes to Medicaid LTSS, including consolidating the nine existing waivers into a single §1115 waiver; reducing waiting lists; moving individuals from sheltered workshops into integrated employment; and expanding availability of behavioral health services. The waiver also proposes to create a fund to reimburse institutions that close or reduce capacity, and to establish an assessment of HCBS providers. Lastly, the waiver suggests that Illinois may examine institutional eligibility criteria to ensure that policies prioritize services in other settings. (Source: website; Draft Waiver Concept Paper, 11/7/13)
§1115 Waiver Proposal (Link no longer available)

As of the January 6, 2015 meeting of the Medicaid Advisory Committee (MAC) Care Coordination Subcommittee, the state had enrolled more than 1.4 million Medicaid beneficiaries in care coordination plans, which include Managed Care Organizations (MCOs), Accountable Care Entities (ACEs), and Care Coordination Entities (CCEs).  State Healthcare and Family Services (HFS) officials estimate that an additional 700,000 Medicaid beneficiaries will be enrolled in care coordination plans by May 2015.  (Source:  HMA Weekly Roundup, 1/14/2015)

As of April 2015, roughly 2 million individuals are enrolled in managed care programs, up from 75,000 in April 2014. The Family Health Program serves 1.8 million individuals; 120,000 non-dual eligible seniors or disabled are enrolled in the state’s Integrated Care Program (ICP); and 58,000 dual eligibles are enrolled in the state’s Medicare-Medicaid Alignment Initiative (MMAI). (Source: HMA Weekly Roundup, 5/13/2015)

On February 27, 2017, the Illinois Department of Healthcare and Family Services (HFS) posted a request for proposals (RFP) for MCOs that are interested in providing services for the state’s Medicaid managed care program, which includes MLTSS. HFS is seeking between four and seven MCOs to operate contracts statewide. MCOs will be responsible for providing the full spectrum of Medicaid services under this contract.
This procurement aims to enhance population health, the experience of the Medicaid consumer, and lower costs. In that vein, the RFP has the following themes:  

o    Preventative care and population health;
o    Paying for value rather than volume;
o    Rebalancing away from institutions and towards the community;
o    Improving data integration and predictive capabilities; and
o    Bettering education and outreach efforts to improve self-sufficiency.

Beginning in 2014, Illinois transitioned two million of its 3.1 million Medicaid enrollees into managed care, or approximately 65 percent, surpassing the states’ initial goal of 50 percent. Under the RFP, HFS now aims to enroll 80 percent of Medicaid members into managed care. In order to reduce administrative burden,   
HFS will combine the states’ current three managed care programs: Integrated Care Program (ICP), Family Health Plans/ACA Adults (FHP/ACA), and Managed Long Term Services and Supports. The state’s dual eligible financial alignment demonstration does not fall under this RFP, but the state reserves the right to include it at a later date.

The RFP includes two major changes to the current program. For the following populations, enrollment in managed care will now be mandatory and also be statewide (increasing the footprint from the current 30 counties to all 101 in Illinois):

o    Families and children eligible for Medicaid through Title XIX or Title XXI;
o    Affordable Care Act (ACA) expansion adults;
o    Medicaid-eligible adults with disabilities who are not eligible for Medicare;
o    Medicaid-eligible older adults who are not eligible for Medicare;
o    Dual eligible adults receiving institutional or HCBS LTSS aside from those receiving partial benefits, or those enrolled in the Illinois Medicare-Medicaid Alignment Initiative; and
o    Special needs children.

There are three service packages that pertain to the RFP. Service Package I includes all Medicaid-eligible services unless excluded in the Model Contract or included in Service Packages II or III. Service Package II includes nursing facility services and services provided under the state’s HCBS waivers, except for waivers designated for individuals with developmental disabilities. Service Package III includes developmental disability waiver services and intermediate care facility providers for developmental disabilities (ICF/DD). Illinois does not intend to include Service Package III under the current RFP, but MCOs should be prepared to implement such services within 180 days if HFS chooses to do so.

The new Medicaid managed care program will encompass five geographic regions. 
Region 1     Northwestern counties 
Region 2     Central counties 
Region 3     Southern counties 
Region 4     Cook county 
Region 5     Collar counties 

Proposals are due by May 15, 2017. HFS hopes to make award announcements on June 30, 2017, with an effective date for the new contracts of January 1, 2018. (Source: RFP 2/27/2017)

HFS has posted an attendee list from the mandatory offeror conference for statewide Medicaid managed care that took place on March 10, 2017. The list of potential bidders included:

Addus HomeCare Aetna Better Health of Illinois  Agilon Health AltaStaff, LLC. 
Annthem, Inc.  Beacon Health Options BlueCross BlueShield of Illinois  Canary Telehealth 
Cigna HealthSpring  Community Care Alliance of Illinois  CountyCare/CCHHS Engaging Solutions, LLC
Family Health Network  Fineline Printing Group FoCoS Innovations  Harmony/WellCare
Humana Illinicare Health  MCNA insurance Co.  Molina Healthcare 
Meridian Health PLan  NextLevel Health Partners Inc.  Trusted Health Plan Unitef Healthcare Community & State 
United Health Care Community/State Optum  Valence Health/Evolent Health 

 (Source: Attendee List 3/21/2017)

On May 2, 2017, the State Journal-Register reported on a letter from Illinois’ Comptroller to the state’s governor expressing concerns regarding expanding the state’s Medicaid managed care program. The proposal, which was released in February 2017, would expand managed care statewide and include additional populations not previously enrolled in Medicaid managed care.

The proposal would also reduce the number of MCOs the state contracts with. Illinois has been without an official state budget for approximately two years and owes current MCOs $2 billion in back payments. (Source: State Journal-Register 5/2/2017; Comptroller Letter 5/2/2017)

On May 15, 2017 the Chicago Tribune reported that nine MCOs responded to Illinois’ request for proposals (RFP) to reprocure the state’s Medicaid managed care program, which includes increasing the geographic footprint of MLTSS statewide. Illinois also intends to decrease the number of MCOs participating in the program from the current 12 to seven following the reprocurement. Four of the current MCOs in Illinois’ Medicaid managed care program did not submit responses to the RFP, including: Family Health Network, Humana, Cigna-HealthSpring, and Community Care Alliance of Illinois. The nine plans that did respond to the RFP include:

  • Aetna Better Health;
  • Blue Cross Blue Shield of Illinois;
  • County Care Health Plan;
  • Harmony Health Plan;
  • IlliniCare Health Plan;
  • Meridian Health;
  • Molina Healthcare of Illinois Inc,;
  • NextLevel Health; and
  • Trusted Health Plan (District of Columbia) Inc. 

Eight of the nine respondents are incumbents in the current program, except for Trusted Health Plan. (Source: Chicago Tribune 5/15/2017; List of RFP Respondents 5/15/2017)   

On August 11, 2017, the Chicago Tribune reported that the Illinois Department of Healthcare and Family Services announced the six MCOs selected to manage the state’s Medicaid managed care program, which includes MLTSS. MLTSS will also now be expanding statewide, as it was previously only available regionally. Illinois selected the following MCOs for the program:

  • BlueCross BlueShield of Illinois;
  • Harmony Health Plan;
  • IlliniCare Health (Centene Corp.);
  • Meridian Health Plan;
  • Molina HealthCare; and
  • CountyCare Health Plan.

The state estimates that it will save between $200 and $300 million dollars a year under the new, expanded program. (Source: Chicago Tribune 8/11/2017)

On October 13, 2017, U.S. News reported that Illinois’ governor vetoed a bill that would have required a lengthier and more stringent procurement process for the recently-awarded managed care organizations (MCOs) tasked with managing care for the majority of the states’ Medicaid population. The governor believed that the five-month procurement process was adequate, and that forcing the state to go through the Illinois Procurement Code process would be duplicative. (Source: U.S. News 10/13/2017)

On November 29, 2017, Crain’s Chicago Business reported that Illinois has completed contracts with the seven MCOs chosen to manage the state’s Medicaid managed care program, HealthChoice, which expects to enroll approximately 80 percent of the state’s Medicaid population into managed care. The state estimates that it will save between $200 and $300 million every year under the new contracts, largely through reduced rates paid to health plans. These estimates, however, have been questioned by some state lawmakers, as well as in a report by the Menges Group, which was commissioned by a stakeholder in Illinois that wants to see the program get into financial balance.  The Menges Group report notes that current MCOs lost money in 2016 and 2017.  (Source: Crain’s Chicago Business 11/29/2017; the Menges Group 12/5/2017; Crain's Chicago Business 12/18/17)

Two of Illinois’ managed care insurers have consolidated into one health plan. Effective January 1, 2019, Harmony Health Plan is becoming part of Meridian Health Plan. Members of Harmony will automatically be enrolled with Meridian at this time, unless they opt out. Harmony was previously under sanctions because it did not have enough doctors and hospitals in its network to ensure adequate access, according to the state. It is unclear what will now happen with these sanctions following Harmony’s acquisition. There will be a total of six managed care companies in Illinois following this consolidation. (Source: Modern Healthcare, 11-06-2018)

Managed LTSS 

The Illinois Department of Healthcare and Family Services announced that MLTSS will be implemented statewide for residents in nursing facilities and individuals enrolled in 1915(c) waivers, as well as dual eligibles beginning July 1, 2019. Individuals dually eligible for Medicare and Medicaid will be enrolled in the HealthChoice Illinois MLTSS program unless they are already enrolled in Illinois’ Medicare-Medicaid Alignment Initiative (MMAI). . The HealthChoice Illinois MLTSS program is served by six MCOs: Blue Cross Blue Shield of Illinois, County Care, IlliniCare Health Plan, Meridian Health, Molina Healthcare of Illinois, and NextLevel Health. 

State Demonstration to Integreate Care for Dual Eligible Individuals 

In April 2012, the state submitted a Medicare-Medicaid Alignment Initiative (MAAI) proposal for a demonstration to provide coordinated care under a capitated model in limited geographic areas to full benefit dual eligibles age 21 and over who are aged, blind, or disabled. Persons with I/DD are carved out, and enrollment is voluntary with an opt out option. (Source: Demonstration Proposal; Illinois Care Coordination website; Illinois Medicare-Medicaid Alignment Initiative website)

In February 2013, the state and CMS signed a Memorandum of Understanding to provide coordinated care to more than 135,000 dual eligibles in the Chicago area and throughout central Illinois under the MMAI demonstration, beginning on October 1, 2013. (Source: Centers for Medicare and Medicaid Services) Opt in enrollment began on April 1, 2014. Passive enrollment began on June 1, 2014. (Source: Illinois HFS website; HMA Weekly Roundup, 5/7/2014)
Memorandum of Understanding
Three-Way Contract for Demonstration
State Duals Demonstration website

On June 17, 2018, CMS published the “Financial Alignment Initiative” results for Demonstration Year 2 in the Illinois State-Specific Medicare-Medicaid plans.  All Financial Alignment Demonstrations include a provision to ‘withhold’ a portion of the Medicare-Medicaid Plans’ capitation rate that can be recaptured if the MMPs meet quality measures.  After dropping Health Alliance Connect from the Central Illinois Region in January 2017, the remaining seven plans received 50% or greater of their “withhold” in CY2016 with an average of 71%. One plan, Health Spring of Tennessee, Inc. received 100%. Previously, in Year 1 (CY 2015), the Illinois average for eight plans was 50%, with three plans receiving only 25%. (Source: CMS Illinois Medicare-Medicaid Plan Quality Withhold Analysis Results-Demonstration Year 1 and Demonstration Year 2, 06-19-2018; and Health Alliance Connect, 01-01-2017)

Changes in the Illinois Medicare-Medicaid Alignment Initiative (MMAI) Demonstration Three-Way Contract (Illinois-US Department HHS-Plan Provider) included technical corrections and clarification of terms.

  • Aligned policies for notification when providers leave a MPP.
  • Revised credentialing process to require MMP’s to use the state’s IMPACT system and to align with the Medicaid program process in that state.
  • Added state law requirements for provider and pharmacy network directories.
  • Updated CMS reporting regulations
  • Updated state payment requirements for enrollees in Institutions of Mental Disease.
  • Updated “Medical Loss Ratio” (MLR) and calculation.
  • Added requirements for Medicare Reconciliation and Settlement

(Source: Illinois and US Department HHS-Contract form, Summary of Contract Changes, 6-10-2018)

Effective October 1, 2018, the Illinois Department of Healthcare and Family Services will no longer automatically assign people to the Blue Cross Community Medicare-Medicaid Alignment Initiative plan. This practice has been terminated because the insurer has not completed health risk assessments and care plans for enrollees at a satisfactory rate. The state also expressed concern over appeals and grievance issues. The Illinois Department of Healthcare and Family Services and the Centers for Medicare & Medicaid Services wrote a letter to the insurer informing them that future enrollment practices will depend on improvement of completion rates and improved practices related to appeals and grievances. (Source: Chicago Tribune, 08-28-2018) 

CMS has recently released a new evaluation report describing the launch of the MedicareMedicaid Alignment Initiative (MMAI) demonstration in March 2014. This demonstration integrated care for Medicare-Medicaid beneficiaries in two regions. This first Evaluation Report describes implementation of the MMAI demonstration and provides early analysis of the demonstration’s impacts.

Utilization analysis showed a 15% decrease in inpatient utilization. This demonstration also showed significant reductions in skilled nursing facility (SNF) admissions, with a reduction of nearly 9%. However, despite this reduction, the Illinois demonstration did show a nearly 3% increase in long-stay nursing facility use.

Comments from State officials, focus group participants, and enrollee and provider representatives suggest that enrollees’ care coordination experiences have varied. The plan did participate in the Consumer Assessment of Healthcare Providers and Systems beneficiary survey, where results showed improvement from 2015 to 2016 in beneficiaries rating their health plans at the highest levels, a 9 or 10. There was also significant savings associated with this demonstration, with savings rates of 5% each year from year three through five. (Source: Illinois Medicare-Medicaid Alignment Initiative: First Evaluation Report, 11-29-2018

CMS released Illinois’ results from a quality withhold analysis of the state’s Medicare-Medicaid Plans (MMPs) under the Financial Alignment Initiative (FAI) for the program’s third demonstration year (CY 2017).  A percentage of state Medicaid and federal Medicare capitation rates are withheld from the MMPs to ensure quality for dually eligible individuals. MMPs can earn back those withheld funds based on whether they meet Federal, CMS Core measures, and state specific quality performance measures.  MMPs in Illinois met 70 percent of overall withhold measures, 69 percent of the CMS Core measures, and 71 percent of Illinois-specific measures.

(Source: Illinois Medicare-Medicaid Plan Quality Withhold Analysis Results; 8-14-2019)

The Illinois Department of Healthcare and Family Services announced on September 17, 2019 that the department has requested to expand their Medicare-Medicaid Alignment Initiative (MMAI) demonstration throughout the state. The statewide demonstration would become effective January 1, 2021. Currently, the MMAI program and MLTSS programs are available to beneficiaries in the Greater Chicago and Central Illinois service areas. The expansion of the MMAI demonstration would provide all dually eligible individuals to receive the opportunity to have their Medicare and Medicaid services integrated in one health plan.

(Source: Request to Expand MMAI Demonstration Statewide; 9-17-2019)

Balancing Incentive Program

In June 2012, CMS awarded the state an estimated $90 million in enhanced Medicaid funds (a 2% enhanced FMAP rate) from July 1, 2013 through September 30, 2015.  (Source: CMS Balancing Incentive Program website)
BIP Application, link no longer available (3/27/2013)
Structural Change Work Plan, link no longer available (12/18/2013)

Health Homes

In 2013, the state submitted a draft Health Home State Plan Amendment to CMS.  However, as of April 2014, the state has not submitted a State Plan Amendment to CMS.  (Source: CMS Health Home Proposal Status website, 4/2013) As of June 2014, the state has not officially submitted a Proposed Health Home State Plan Amendment to CMS, but the state plans to participate in the Health Home State Plan Option in FY 2014.  (Source:  CMS Health Home Proposal Status website, 6/2014; Kaiser Health Home website, 6/2014)

As of February 2015, Illinois Medicaid has submitted to CMS a proposed Health Home State Plan Amendment to implement Health Homes for individuals with two chronic conditions or one chronic condition and at risk for developing another chronic condition.  HFS officials expect the Health Homes to be developed and operating by October 2015.  (Source:  Illinois HFS website)  
Illinois Health Home State Plan Amendment Concept Paper (1/9/2015)

On January 24, 2020 the Illinois Department of Healthcare and Family Services (IHFS) announced its proposal to begin coverage for Integrated Health Home Services for children and adults who are Medicaid beneficiaries with chronic conditions. These health home would integrate physical and behavioral health needs and social care needs and use care coordinators to manage and individual’s services. State Medicaid Managed Care organizations would be reimbursed through a capitation fee for care coordination services with an increased $390 million in capitated payment expenditures. Coverage for Integrated Health Home Services was expected to begin April 1, 2020 subject to approval by CMS.

(Source: Illinois DHFS Press Release; 1-24-2020)