Overview of the healthcare landscape as it relates to Medicaid managed care

The ISBA Mental Health Law Section Council welcomed Samantha Olds Frey to speak at the Council meeting on April 10, 2017. Ms. Olds Frey is the Executive Director of the Illinois Association of Medicaid Health Plans (IAMHP). She has a Master’s Degree in Public Policy and Administration from Northwestern University. She previously served as Speaker Michael Madigan’s Human Services & Medicaid budget analysist, wherein she helped negotiate and craft legislation for Medicaid in the state of Illinois.

Ms. Olds Frey discussed many of the specific challenges associated with Affordable Care Act (ACA) changes, including Medicaid expansion and the concept of Block Grant or Per Capita Caps. She described many of the challenges to healthcare in the state of Illinois due to the lack of a budget and a very large backlog of bills, as well as significant payment delays from the state to providers. In addition, Medicaid has not increased its fees to some providers for nearly two decades. In some parts of Illinois, Medicaid programs are not covered by any providers. Ironically, there is a decrease in mental health spending because providers are no longer providing services.

One innovation has been the “1115 waiver,” which is a contract between the Federal and state governments that “waives” Federal and Medicaid requirements and gives the Federal government authority to approve experimental, pilot or demonstration projects. The goal of this project is to evaluate new policy approaches by Medicaid, including the creation of innovative service delivery systems that improve care, increase efficiency and reduce costs. There are a number of people who can be affected by the Medicaid changes including seniors, people with disabilities, low-income families, children with special needs and ACA adults. A Request for Proposals (RFP) has been issued to determine what the changes to Medicaid might be.

This RFP is likely to create a number of different changes in Medicaid for the state of Illinois. With the RFP, some likely outcomes include that there will be fewer plans in the Chicago region (though likely more plans in other regions in Illinois), and plans will operate statewide. Also, there may be new health plans in the market and a single formulary available, which means that patients will have access to fewer pharmaceuticals.

As a result of these changes, IAMHP is trying to take steps to improve this situation.

These include: finalizing a single roster for delegated credentialing, creating a more streamlined form for prior authorization requests, creating best practice guidelines for discharge planning, connecting health plans and providers to address existing concerns, working with HFD to better standardize the billing processes, and partnering with providers to collectively improve the Medicaid program. 

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Dara M. Bass is an independent contractor attorney, based out of the Chicago area, who is licensed in Illinois and Missouri. She has been a member of the ISBA’s Mental Health Law Committee since 2006. She may be contacted at: darabasslaw@gmail.com