You Need To Read This If Your Practice Is In Illinois

A few weeks ago, I went to a luncheon at our local hospital to learn about the IL Managed Care rollout. I left the luncheon with one thought, this is going to be messy. Perhaps worst of all, the expectations is for doctor offices to clean up the State’s unorganized, information lacking, poorly executed rollout.

The transition to Manage Care is affecting 1.5 million people in the State. Many of those children that are potentially in jeopardy of losing their primary care provider.

Messy is still the word d’jour. Although information is coming out slowly, rollout is complicated and confusing.

Many Unaware

I know many practices are unaware of the Manage Care rollout despite having a healthy number of Medicaid patients. Others have yet begun the credentialing process with the plans.

Patients are also lost. They just want to make sure they keep their primary care provider. But the enrolling process is confusing and practices don’t know what to tell patients or how to help them. At least the ones I’m aware of.

I’ve put together a summary that I’m hoping will help you and your practice get a better idea of the managed care rollout out. If you are a bit turned around and need clarity, read on.

What We Know So Far

  • All Medicaid patients who live in or around Chicago will need to enroll in a new Medicaid managed/coordinated care plan and select a participating PCP. The State of Illinois has mailed letters informing patients to choose from as many as 19 plans.
  • Medicaid eligible patients have 60 days to decide on a plan. If they don’t chose a plan before the 60 day deadline, patients will be auto-assigned to a plan using an algorithm.

The State says their priority with the algorithm is to keep patients with their PCP to ensure continuity of care. But many pediatric practices have yet to enroll with the new plan. What then?

  • Your practice must sign up with at least one of the new Medicaid plans if the practice wants to continue seeing Medicaid patients.
  • Be aware that it might take a few weeks for the plan to submit provider names once the practice is credentialed. Consequently providers may not be listed in the broker enrollment system which will confuse patients.
  • Be aware that Medicaid enrollment brokers are calling patients directly urging them to enroll in a plan while on the phone. Advise patients, verbally in person, they should avoid making decision in haste while on the phone until they know which plan will allow them to keep your practice as their PCP.
  • Your practice can send a letter to their Medicaid patients with a list of the plans the practice has chosen to work with, but you must use a template provided by the State. Click here to see the template.
  • Practices can advise patients “in person” that if they encounter problems during the enrollment process, they ought to wait before signing up with a plan. Patients have up to 60 days after they received the letter to enroll. Auto enrollment will begin mid November 2014.
  • If your patients have already enrolled in a plan that doesn’t include your practice as a PCP, they are able to switch plans within 90 days after enrollment. After the 90 day period, they will only be allowed to switch plans once a year.
  • If you are having trouble being listed in a Medicaid plan provider network in the broker’s enrollment systems, contact the plan administrator.

Illinois Department of Healthcare and Family Services has a website with resources. I found the resources to be confusing. It seems most of the information is for the manage care plans, not for providers. But you may have better luck than me. Link

Please Share

If you come across information that you think may be helpful, please share it in the comment section.

I hope this information is helpful.

On a Related Note: Where is the AAP’s IL Chapter in all of this? As of the date I published this post, the chapter’s
website had no mention of the manage care transition.

In their 2013 annual summary, the chapter reported that the most substantial challenge they need to overcome is understand an address why members are not renewing their membership. Clearly, providers don’t see the value in being a member.  It seems to me that the chapter missed a big opportunity to guide and help IL practices navigate this messy rollout, thus showing members and non-members the chapter’s value.

I also think they could have used their influence as child advocates to shed light on how the lack of clarity is jeopardizing the continuity of care for numerous IL children.

(This blog was originally posted on Pediatric Inc)

Brandon Betancourt is a business director for a pediatric practice in Chicago. He is a speaker, consultant and blogger. You can follow him on Twitter @PediatricInc or visit his blog at