Two health plans are being barred from further enrollment and another is being warned, as state regulators act on promises to ensure access and quality standards for beneficiaries.
Illinois' Department of Healthcare and Family Services is sanctioning two Medicaid managed care organizations in greater Chicago -- nonprofit Family Health Network and Harmony Health Plan, a subsidiary of for-profit WellCare -- and suspending their auto-assignment of beneficiaries until corrective actions are developed and implemented.
As Illinois moves half of its 3.1 million Medicaid population into managed care plans and "accountable care entity" plans, according to DHFS, Family Health Network and Harmony Health Plan have been struggling to meet the state's expectations for the beneficiaries they've already been serving -- more than 60 percent of greater Chicago's Medicaid managed care beneficiaries.
Last year, Harmony Health Plan scored below the 10th percentile in 15 HEDIS quality measures, including children's primary care access, diabetes care, and prenatal and postnatal care. "Such repeated poor performance indicates that Harmony has not adopted practice guidelines that meet the required minimum standards of care" outlined in the Medicaid contract, James Parker, DHFS deputy administrator wrote in a notice of noncompliance.
Harmony currently has around 133,000 Chicago-area Medicaid enrollees. Family Health Network, covering about 92,000 enrollees, scored below the 10th percentile in 18 quality areas, including the same three cited for Harmony, children's primary care access, diabetes care and timeliness of pre-and-post-natal care.
To both companies, Parker wrote that "HFS will only lift the enrollment suspension once it determines there is sufficient evidence that the corrective action plan is implemented and operational and there are signs of improvement."
Another Medicaid contractor involved in a new program in Illinois' managed care expansion -- the accountable care entity demonstration -- has also had its enrollment stopped by state regulators, although for different reasons than Family Health Plan and Harmony.
Illinois Partnership for Health, a Medicaid plan sponsored by a group of northern Illinois physicians and hospitals, has not met expectations of adequate oversight, staffing and information sharing. Specifically, the nonprofit has failed to hire a CEO, care management director, IT director and information analyst, and hasn't issued timely reports disclosing enrollment, which until it was capped surpassed 50,000.
Across Illinois there are more than 22 organizations serving as Medicaid health plans or accountable care entities, and the state legislature is banking on them to ensure access for beneficiaries and sustainable costs for state coffers.
Under a reform law enacted in 2012 and updated this summer, half of Illinois' Medicaid beneficiaries are required to be enrolled in capitated managed care by 2015, either through managed care organizations or new provider-led Medicaid "accountable care entities."
A sort of hybrid HMO-ACO, the accountable care entities are groups of providers who will contract with the state on a three-year basis to serve defined Medicaid populations in specific regions.
Initially, they're being given an 18-month trial period, with reimbursement on a traditional fee-for-service basis along with a care-coordination fee of $9 per member per month. After that trial period, the ACEs will take on full risk under a capitated basis.