The process for determining whether individuals in the state are eligible for Medicaid is a key issue for both health plans and providers—two groups that are often at odds over Illinois’ revamped Medicaid managed care program.
The medical redetermination process, which reviews eligibility for the state’s nearly 3 million Medicaid beneficiaries, doesn’t always ensure patients have uninterrupted access to care, panelists said today during a Health Care Council of Chicago event. Lapses in coverage are hard on patients, especially those managing chronic conditions, and health systems that don’t get reimbursed for medical services when claims are denied by health plans.
While eligibility can be determined automatically in some cases, like when an individual’s income can be found and verified electronically, other cases require people to submit paper forms within 30 days or lose their medical benefits. A 90-day reinstatement period is required if coverage is canceled.
Lapses in coverage are a top reason claims submitted by doctors are denied by health plans, said Samantha Olds Frey, executive director of the Illinois Association of Medicaid Health Plans, which represents the six Medicaid managed care insurers operating in the state. “That disruption truly impacts people’s lives in a real way,” Olds Frey added during the event.
Claims for Medicaid beneficiaries are denied about 26 percent of the time, resulting in delayed payments to hospitals for medically necessary services, the Illinois Health & Hospital Association has said.
IHA President and CEO A.J. Wilhelmi said during the event that the time and resources health systems expend managing denied claims divert “attention away from providing care.”
Jordan Powell, president and CEO of the Illinois Primary Health Care Association, which represents federally qualified health centers in the state, agrees Medicaid redetermination is one of the biggest issues the managed care program faces. During the event, he referenced S.B. 2021, introduced last month by Democratic state Sen. Health Steans of Chicago. The Medicaid Eligibility Determination & Renewal Reform Act would leverage technology to prevent delayed access to benefits and disruptions in care, among other updates.
“Not every problem requires a legislative fix, but some of these issues cannot continue,” Powell added.
A priority for the Illinois Department of Healthcare & Family Services, the agency that oversees Medicaid, is to “work with the (state) Department of Human Services and other partners to significantly reduce timeframes for initial eligibility determinations as well as redeterminations,” department spokesman John Hoffman said in an email.
An investment in new information technology systems would enable changes made by health plans and hospitals to be tracked at the state level, Olds Frey said, adding that using payroll data to determine eligibility could “decrease administrative costs for state providers and plans, and decrease disruption for the people we’re trying to serve.”
For example, it can take 45 to 60 days to get newborns on their family plans, which is challenging for health plans and patients, she said.
Another topic covered during the panel discussion was reimbursement rates and the impact such payments have on access to care.
Olds Frey acknowledged that the rates, which are well below what Medicare and commercial insurance pay, lead some doctors to decline Medicaid patients or limit the number of patients they see.
Wilhelmi noted that Gov. J.B. Pritzker’s recommended budget includes a managed care insurer assessment that would allow Healthcare & Family Services to more efficiently manage payments, among other things.
Another point on which all stakeholders can agree is that patients need to come first. As Powell said: “The patient should be the focus when we’re considering changes to this program.”