Illinois All Kids Program Illinois Department of Healthcare

Illinois’ All Kids Program Illinois Department of Healthcare and Family Services Stephen E. Saunders, MD, MPH State Coverage Initiatives National Workshop State Innovations in Health Coverage “Covering Kids” January 26, 2007

About All Kids n n n First state program in the nation to make sure that every child in Illinois has access to comprehensive and affordable healthcare Allows most of the 253, 000 uninsured children in Illinois who need health coverage to get it Helps children get to the doctor before they get sick and before a simple problem becomes a major illness Provides health insurance and prescription coverage at affordable rates Began July 2006

Qualifications for All Kids n n n 18 and under Illinois residents No citizenship requirements No income limit Monthly premiums and co-payments based on a sliding scale, based on income

Current Illinois Medicaid Program n n n n Combined Medicaid and SCHIP Program Income threshold 200% of poverty Family Care 185% of poverty Primarily Fee for Service Implementing PCCM Voluntary managed care in six counties Over 2 million beneficiaries currently enrolled

Program Structure n n n n An extension of current Medicaid and SCHIP program; Medicaid and SCHIP - now ALL KIDS Same Medicaid benefit package (minus non emergency transportation or waiver services) No income limit or asset test, no deductibles Co-pays, premiums and out-of-pocket limits sliding scale 12 -months continuous eligibility No pre existing condition limitations Includes dental Provider reimbursement - same as Medicaid

All Kids Comprehensive Health Benefits Identical to Kid. Care except non-emergency transportation and waiver services will not be covered -Doctor services Care at health clinics -Hospital care (inpat/outpat) -Prescription drugs Dental care -Vision and hearing Lab and radiology -Family Planning Medical equip/supplies -Mental Health/Sub Abuse -Podiatry/Chiropractic PT/OT/Speech therapy -Home nursing care Kidney dialysis -Nursing home care Hospice Care n

Eligibility Process n n One application for entire program Application process: n n n Mail-in Web Community-based Application Agent At Department of Human Services local office, located in each county Outreach and PR campaign One eligibility card for entire program

Crowd Out Provisions n n Must be uninsured for 12 months Exceptions: n n Parent loses employer sponsored health insurance Newborn Exhausted life time benefit Child covered by COBRA

Crowd Out Provisions (continued) n Exceptions (continued) n n Child was covered by Title XIX or Title XXI and family income changes Custodial parent cannot access non-custodial parent’s insurance

Premium/Co-Pay Example n n n 200 – 300% poverty Premium $40/child/month; $80/month - max Co-pay n n n n $10 office visit $7/$3 pharmacy $30 ER $100 hospitalization 5% rate for outpatient hospital Yearly maximum - $500 No co-pay for preventive health care, e. g. , well child visits and immunizations

All Kids Monthly Premium FPL Per Child Maximum Per Month 200% - 300% - 400% - 500% - 600% - 700% - 800% Over 800% $40 $70 $100 $150 $200 $250 $300 $80 $140 $200 No Max

Financing n n n Governor’s key initiative passed General Assembly November 2005 GRF funded – no waivers Cost Savings through implementation of the: n n PCCM Program – FY 07 for most Medicaid/SCHIP beneficiaries Disease Management Program -July 1, 2006 n Disabled Adults n Family Health Population with Persistent Asthma n Family Health Population – Frequent Emergency Room users

Provider Buy-In n n Input into the planning process with monthly Stakeholders’ meetings 30 -day payment cycle for physician services, starting July 1, 2006 Pediatrics rate increases for selected preventive visit and E & M codes - January 1, 2006 Support by ICAAP and IAFP

Provider Payment n n Providers will be responsible for collecting co-payments under All Kids (similar to private insurance) Providers may elect not to charge co-pays Providers are not required to deliver services when co-pays are not paid Provider will be reimbursed under established rates minus cost sharing copayments

Reimbursement Rates: Select Examples n n n CPT 99214 - E & M office visit, established patient ($72. 97) CPT 99381 – Preventive office visit, initial evaluation, healthy infant ($91. 90) CPT 99384 – Preventive office visit, initial evaluation, adolescent ($104. 96)

Challenges n n n Major outreach resulted in significant volumes of applications that require processing Some provider resistance Expectations of expanded population sometimes different Premium payment process issues Making sure newborn is covered immediately after birth Building trust in program regarding immigration issues

Number Enrolled (as of December 15, 2006) n n Total All Kids Children 1. 3 million New since July 1, 2006 100, 000 n n 64, 000 Medicaid/SCHIP 36, 000 Expansion

Conclusion n Healthcare reform is possible with political will and buy-in Medicaid package of services comprehensive and is a model benefit package Medicaid structure provides an efficient platform to build upon – has an established payment, claims processing system and provider enrollment processes

Conclusion (continued) n n n Packaging the program to look like health insurance should further eliminate “stigma” of welfare Sliding fee scale allows higher income families who lack insurance for their children to purchase affordable health care with the benefit of a large risk pool Outreach and simplified enrollment is key