Illinois Department of Healthcare and Family Services Illinois

Illinois Department of Healthcare and Family Services Illinois Continuity of Care & Administrative Simplification 1115 Waiver December 2019 www 2. illinois. gov/hfs www. illinois. gov/hfs

Public Hearing Agenda • The public hearings are an opportunity to learn about and provide input on the Illinois Continuity of Care & Administrative Simplification 1115 Waiver. • All attendees should sign in and indicate whether they will be providing written and/or oral testimony at today’s hearing. • Public Hearing Agenda (10 am-12 pm) – 1115 Waiver Presentation by HFS Staff – Public Testimony – Speakers who submit written testimony will present it orally in the order it was received. – HFS staff will then listen to any additional testimony on a first come, first served basis, as time allows. – Individuals are requested to limit their testimony to three minutes. – Organizations should select one spokesperson to speak on their behalf and are requested to limit their testimony to five minutes. www 2. illinois. gov/hfs www. illinois. gov/hfs

Additional Comments • After the hearing any interested party may share additional comments, data, views, or arguments concerning the changes proposed in the 1115 waiver. • All comments not provided at a public hearing must be submitted in writing and received by December 27, 2019. They should be addressed to: Illinois Department of Healthcare and Family Services Division of Medical Programs Bureau of Program and Policy Coordination 201 South Grand Avenue East Springfield, IL 62794 Email address: hfs. bpra@illinois. gov www 2. illinois. gov/hfs www. illinois. gov/hfs

1115 Waiver Overview • HFS is seeking a five-year Medicaid Section 1115 Research and Demonstration Waiver that promotes continuity of care and administrative simplification. • HFS is proposing three demonstration initiatives to achieve these goals: www 2. illinois. gov/hfs www. illinois. gov/hfs 1. Extending postpartum coverage from 60 days to 12 months; 2. Managed care reinstatements when a Medicaid beneficiary submits late redetermination paperwork within 90 days; and 3. Waiving Hospital Presumptive Eligibility (HPE).

Extending Postpartum Coverage • Illinois proposes to extend Medicaid coverage from 60 days postpartum to 12 months postpartum. – This proposal implements Illinois Public Act 101 -0010, signed into law on June 5, 2019. – Extending Medicaid coverage to 12 months postpartum is recommended by: • The Illinois Department of Public Health Maternal Morbidity and Mortality Report • The U. S. Centers for Disease Control and Prevention (CDC) Vital Signs Report • The American College of Obstetricians and Gynecologists • The American Medical Association • Medicaid Health Plans of America • The extended postpartum coverage would provide full Medicaid benefits for women up to 213% of the Federal Poverty Level (FPL), the income threshold in Illinois for the pregnant women category of eligibility. www 2. illinois. gov/hfs www. illinois. gov/hfs

Extending Postpartum Coverage (cont. ) • Extending postpartum coverage to 12 months prevents the mother from having to switch providers during a medically vulnerable time due to different health plan networks. • Extending postpartum coverage provides continued care coordination support through a Medicaid Managed Care Organization (MCO) for both the mother and baby during the pregnancy, labor and delivery, and the entire postpartum period, defined as 12 months by the CDC. – The DPH Maternal Morbidity and Mortality Report also recommends case management and outreach for high-risk women. – Care coordination is not a standard benefit in Marketplace Qualified Health Plans, but is provided by Medicaid MCOs. www 2. illinois. gov/hfs www. illinois. gov/hfs

Extending Postpartum Coverage (cont. ) • To further promote continuity of coverage and administrative simplification, Illinois proposes to: – Align continuous eligibility for the mom and baby so both are eligible through 12 months after delivery. – Enroll mothers in their 12 month postpartum period into the pregnant women category of eligibility for the remainder of the 12 month postpartum period, even when the delivery occurred more than three months prior to the Medicaid application date. www 2. illinois. gov/hfs www. illinois. gov/hfs

Extending Postpartum Coverage (cont. ) • Costs for U. S. Citizens and qualified immigrants who meet the five year waiting period are considered hypothetical per the August 22, 2018 State Medicaid Director Letter (SMD #18 -009). • Qualified immigrants in their five-year waiting period are currently covered in the pregnant women category of eligibility for 60 days postpartum using Health Services Initiative (HSI) funding. – Illinois proposes to use HSI funding to extend coverage for qualified immigrants in their five-year waiting period from 60 days to 12 months postpartum; the estimated new liability is about $2. 1 million. www 2. illinois. gov/hfs www. illinois. gov/hfs

Extending Postpartum Coverage (cont. ) • For this proposal, Illinois requests to waive § 1902(a)(10)(A) and 1902(e)(5) and (6) of the Social Security Act (SSA) to the extent necessary. • Relevant federal regulation citations: – Waive 42 CFR 435. 4 to define pregnant women through 12 months postpartum instead of 60 days postpartum; – Waive 42 CFR 435. 170 to: • Extend eligibility for pregnant women from 60 days to 12 months postpartum; • Extend continuous eligibility for pregnant women from 60 days to 12 months postpartum; and • Allow coverage under the pregnant woman category of eligibility when the woman applies during the postpartum period more than three months after delivery. – Waive 42 CFR 435. 916(a) to extend the renewal of MAGI-based income to the end of the 12 month postpartum period. www 2. illinois. gov/hfs www. illinois. gov/hfs

Extending Postpartum Coverage (cont. ) Goal Hypothesis Metrics Reduce maternal morbidity and mortality in Illinois. Extending eligibility for pregnant women from 60 days to 12 months postpartum will reduce maternal morbidity and mortality in Illinois by: Number of women between 139 -213% FPL who retained coverage. Providing continued MCO care coordination and continuity in provider networks at a medically vulnerable time. Allowing HFS to leverage its MCO performance management infrastructure to improve health outcomes for postpartum women. www 2. illinois. gov/hfs www. illinois. gov/hfs Maternal morbidity and mortality results from DPH Committee analysis. MCO performance reporting metrics.

MCO Reinstatements within 90 Days • Illinois proposes to allow Medicaid beneficiaries to be retroenrolled into their prior Medicaid MCO within 90 days of losing Medicaid coverage due to late redetermination paperwork. – 42 CFR 435. 916(a)(3)(iii) allows for reconsideration without a new Medicaid application within 90 days of late redetermination paperwork. – 42 CFR 438. 56(g) limits reinstatement into the prior Medicaid MCO within 60 days of late redetermination paperwork. • The proposal eliminates the need for individuals to be reinstated into Medicaid Fee-for-Service (FFS) and then go through the managed care enrollment process again. – This policy does not impact Medicaid eligibility; it only impacts months enrolled in managed care in place of Medicaid FFS. www 2. illinois. gov/hfs www. illinois. gov/hfs

MCO Reinstatements within 90 Days (cont. ) • The goal of this proposal is to increase continuity of coverage and improve MCO quality oversight by minimizing churn between Medicaid FFS and Medicaid managed care. • Reinstating Medicaid beneficiaries into their prior Medicaid MCO instead of FFS will: – Minimize disrupted communication with care coordinators, confusion over standing prior authorizations and transportation arrangements, and gaps in claims history for MCOs. – Allow the state to better manage the performance and quality of health plans through more complete quality reporting. – Prevent the need to send Medicaid beneficiaries through the full managed care enrollment process when their redetermination paperwork was submitted soon enough to be reinstated into Medicaid, but not soon enough to be retro-enrolled into their prior MCO. www 2. illinois. gov/hfs www. illinois. gov/hfs

MCO Reinstatements within 90 Days (cont. ) • The Healthcare Effectiveness Data and Information Set (HEDIS) is a widely used quality and performance improvement tool nationally and in Medicaid managed care, but it has a 12 month continuous enrollment standard. • The churn the Medicaid redetermination process creates between Medicaid managed care and Medicaid FFS leads to a smaller number of MCO enrollees being reflected in HEDIS measure results. • A Center for Health Care Strategies resource paper recommends that states eliminate gaps in MCO enrollment resulting from the redetermination process for more complete HEDIS quality reporting. www 2. illinois. gov/hfs www. illinois. gov/hfs

MCO Reinstatements within 90 Days (cont. ) • For this proposal, Illinois requests to waive § 1902(e)(2) of the Social Security Act, to the extent necessary. • Relevant federal regulation citations: – Waive 42 CFR 438. 56(g) to allow reinstatement in a Medicaid MCO within 90 days, rather than 60 days of late renewal paperwork. – This creates alignment with the Medicaid coverage reinstatement policy in 42 CFR 435. 916(a)(3)(iii). www 2. illinois. gov/hfs www. illinois. gov/hfs

MCO Reinstatements within 90 Days (cont. ) Goal Hypothesis Metrics Increase continuity of coverage and improve MCO quality oversight by minimizing churn between Medicaid FFS and Medicaid managed care. Allowing a 90 day reinstatement period into the prior Medicaid MCO will: Number of reinstatements into prior MCOs. Increase continuity of care by preventing gaps in MCO coverage and care coordination support. Allow for more complete MCO quality measurement through HEDIS reporting. www 2. illinois. gov/hfs www. illinois. gov/hfs MCO enrollees meeting HEDIS 12 month continuous enrollment standard.

Waiving Hospital PE • Illinois proposes to waive the requirement to permit hospitals to make presumptive eligibility determinations as laid out in 42 CFR 435. 1110. • HPE would allow hospitals to submit an application for temporary eligibility for their patients, which would need to be followed by a separate full Medicaid application. • HFS has yet to implement HPE, so the waiver would not change current application procedures. Hospitals would still be permitted to assist patients with the completion of a full Medicaid application, as they are today. www 2. illinois. gov/hfs www. illinois. gov/hfs

Waiving Hospital PE (cont. ) • The federal Center for Medicare and Medicaid Services (CMS) has instructed HFS to either implement an HPE program or request this waiver of the requirement. • Performance issues and other critical priorities designed to reduce backlogs in HFS’ eligibility and enrollment system require delaying HPE implementation. • The goal of this proposal is to promote continuity of care with full benefit Medicaid applications and to avoid the bureaucratic complexities involved with implementing and administering HPE. www 2. illinois. gov/hfs www. illinois. gov/hfs

Waiving Hospital PE (cont. ) • Waiving HPE does not impact Medicaid eligibility requirements. • Waiving HPE promotes the use of full Medicaid applications that allow for longer term Medicaid coverage. – HPE coverage is temporary coverage. – Payments for services during an HPE segment occur through Medicaid FFS. – While an HPE application may be followed by full Medicaid application, the hospital and/or client may not submit the followup application once the initial hospital stay has been covered through HPE. www 2. illinois. gov/hfs www. illinois. gov/hfs

Waiving Hospital PE (cont. ) • Illinois has determined HPE to be overly administratively burdensome for three primary reasons: 1. Increased application volumes due to the need to process an additional full Medicaid application for each client who uses HPE as their access point for Medicaid. 2. Expansion of manual casework due to the matching of HPE applications with full Medicaid applications being overly timeconsuming. 3. Increased monitoring and enforcement resources due to the additional fraud and abuse oversight, performance reporting, and corrective action monitoring activities that HPE requires. www 2. illinois. gov/hfs www. illinois. gov/hfs

Waiving Hospital PE (cont. ) • For this proposal, Illinois requests to waive § 1902(a)(47) of the Social Security Act (SSA) to the extent necessary. • Relevant federal regulation citations: – Waive the requirement to permit hospitals to make presumptive eligibility determinations as laid out in 42 CFR 435. 1110. www 2. illinois. gov/hfs www. illinois. gov/hfs

Waiving Hospital PE (cont. ) Goal Hypothesis Metrics Promote continuity of care through full benefit Medicaid applications and improved application processing times. Waiving hospital PE will: Medicaid approval and denial rates. www 2. illinois. gov/hfs www. illinois. gov/hfs Continue to promote hospitals assisting with full benefit Medicaid applications. Allow HFS to continue to improve application processing times by promoting the submission of full Medicaid applications and prevent the need for duplicative HPE applications. Application processing backlog and turnaround time.

Public Testimony www 2. illinois. gov/hfs www. illinois. gov/hfs

Additional Comments • Comments not provided at a public hearing must be submitted in writing and received by December 27, 2019. They should be addressed to: Illinois Department of Healthcare and Family Services Division of Medical Programs Bureau of Program and Policy Coordination 201 South Grand Avenue East Springfield, IL 62794 Email address: hfs. bpra@illinois. gov www 2. illinois. gov/hfs www. illinois. gov/hfs