Health Information Center

Illinois Medicaid Integrated Care Program Advocacy Toolkit

 

Illinois Medicaid Integrated Care Program Advocacy Toolkit

May 2011

Table of Contents Page Number

  1.  Guide for Consumers and Families 2
  2.  Timeline for Transition to the Illinois Integrated Care Program 3
  3. Contact Guide 4
  4. HMO Information Summary Chart 6
  5.  Choosing an Integrated Care Plan: A Worksheet
  6. For Illinois Integrated Care Plan Participants 11
  7.  Sample Letter Requesting Single Case Agreement 12
  8. Your Appeal Rights in the Medicaid Integrated Care Program 14

Additional Helpful Information/Links:

1. Background information on the Integrated Care Program (HFS handouts)

http://familyvoicesil.wpengine.com/documents/documentdetails.asp?did=2746

2. Record keeping forms from DSCC website:

http://internet.dscc.uic.edu/dsccroot/parents/ccr.asp (Word and PDF versions)

Physicians/therapists/dentists: http://internet.dscc.uic.edu/forms/ccr/ccr4.pdf,

Hospitalizations: http://internet.dscc.uic.edu/forms/ccr/Ccr30.PDF

Medications: http://internet.dscc.uic.edu/forms/ccr/Ccr28.PDF

Equipment/supplies: http://internet.dscc.uic.edu/forms/ccr/Ccr32.PDF

Family Voices of Illinois

The Arc of Illinois

Family to Family Health Information and Education Center

www.familyvoicesillinois.org familytofamily@thearcofil.org

708-560-6703 (voice) 866-931-1110 (toll free for Illinois families)

2

Illinois Medicaid’s Integrated Care Program (ICP)

for Adults with Disabilities – Guide for Consumers and Families:

Resources to Help You Select The Most Appropriate Provider

May 2011

The Illinois Medicaid program now has a special program for adults, age 19 and older, who

have disabilities and receive SSI. This program is called the Integrated Care Program (ICP).

Participation in this program is mandatory. Eligible people who live in the target areas for this

program are getting letters from HFS in the mail. You will have 60 days from the date you

receive your letter to choose one of the two health plans contracted through HFS. The names of

the health plans are Aetna Better Health and IlliniCare Health Plan.

This consumer guide can help you choose the health plan that may work best for you. The

resources provided here will help you gather important information about your healthcare

needs. It will also allow you to compare the two plans based on how they may meet your

needs. You will then need to decide which health plan to select, or whether you need to ask

HFS for a “Single Case Agreement”, explained below.

The worksheet on page 12 of this toolkit can help you gather information to compare plans.

You can find the needed information on the health plan provider websites and/or call them on

their toll-free numbers. You may also want to call one of the Enrollment Facilitator agencies for

more help. Fill in the worksheet with your personal information. Get answers from each of the

health plans (also called MCOs or managed care organizations) about your personal situation.

Compare the information to see which health plan covers more of your needs and includes

more of the doctors and hospitals you prefer in their network.

Help!! My doctors and/or health plans are not in either network. What should I do?

Consumers who are enrolled in Medicaid and are required to participate in the Integrated Care

Program have the right to request a “single case agreement” in order to stay with their

current doctor(s) and hospital(s). If you do not request a single case agreement, and the

doctors/hospitals you use are not “in the network” of one or both of the MCOs, you will only

be allowed to continue with your current providers for 90 days. After that time period, you must

begin seeing enrolled network providers.

3

Timeline for Transition to the Illinois Integrated Care Program

Getting Ready – Now Through Summer 2011

Integrated Care Provider Outreach – The two organizations under contract with Illinois

HFS will be offering information to potential clients. Attend an informational meeting

and/or gather as much information as possible. Call Aetna Better Health at 1-866-212-

2851 and/ or IlliniCare at 1-866-329-4701, or visit their website (listed below).

Collect information about both plans including whether or not each plan includes the

doctors, hospitals, services and supplies that are important to you. Record this

information on the chart included in this toolkit

Watch your mail for your enrollment letter from HFS.

Review a complete copy of the “enrollment packet” on the Family to Family Health

Information Center website:

http://familyvoicesil.wpengine.com/documents/documentdetails.asp?did=2746

Tell all of your doctors and other providers about the Integrated Care Program in which

you are going to be required to participate.

When you receive your enrollment letter . . .

Record the date you received the letter here: ______________________

Find and record detailed information about each health plan. Use information from their

websites, call them and/or call the enrollment facilitator agencies.

Remember that you will need to search the managed care company websites that are

specific to their contracts with the Illinois Department of Healthcare and Family Services

(HFS). Each of the two insurance companies has established a division for this purpose,

as listed below. Do not use the main corporate websites to search for providers

participating in the Medicaid-only Integrated Care Program.

Aetna Better Health: http://www.aetnabetterhealth.com/Illinois/default.aspx

IlliniCare: http://www.illinicare.com/

Enrollment Facilitator Agencies:

http://illinoiscebicp.com/files/Community_Helper_list.pdf

Illinois Client Enrollment Broker (Automated Health Systems):

http://illinoiscebicp.com/

You will have 60 days to choose a health plan and Primary Care Provider or ask in

writing for a “single case agreement”.

If you have an ongoing course of treatment and your provider is not in

network, you will have 90 days to continue with your current providers once you are

enrolled with one of the Managed Care Organizations.

4

Illinois Department of Healthcare and Family Services

Integrated Care Program Contact Guide

Illinois Department of Healthcare and Family Services

Division of Medical Programs

Department of Healthcare and Family Services

201 South Grand Avenue East

Springfield, Illinois 62763-0001

Telephone number: 217-782-2570

Fax number: 217-782-5672

E-mail: Medical Programs

Medical Programs – Bureau of Managed Care

The Bureau of Managed Care is responsible for implementing managed care programs,

developing policy and procedures for those programs, procuring and monitoring

contracts. Illinois has three managed care delivery systems: Integrated Care Program

(ICP), Primary Care Case Management (PCCM), and Voluntary Managed Care (VMC).

Telephone number: 217-524-7478

Fax number: 217-524-7535

http://www.hfs.illinois.gov/managedcare/

Managed Care Providers Participating in the Integrated Care Program

1. Aetna Better Health

866-212-2851

www.aetnabetterhealth.com/illinois

One South Wacker

Chicago, IL 60606

The following addresses are for the corporate offices of Aetna and Aetna Better

Health. Aetna Better Health is the division of Aetna that addresses Medicaid

managed care programs. These addresses are included for your convenience in

the event that communication with corporate leadership is desired.

Aetna (corporate headquarters)

151 Farmington Avenue

Hartford, CT 06156

1-800-87-AETNA or 860-273-0123

http://www.aetna.com/index.html

Aetna Better Health

P.O. Box 8156

Newark, DE 19714-8156

5

2. Centene Corporation- IlliniCare Health Plan

IlliniCare Health Plan

999 Oakmont Plaza Drive

Westmont, IL 60559

866-329-4701

www.illinicare.com

This corporate address has been included for your convenience.

Centene Corporation

National Headquarters

Centene Plaza

7700 Forsyth Blvd.

St. Louis, MO 63105

(314) 725-4477

http://www.centene.com/contact-us/

Illinois Client Enrollment Broker – Automated Health Systems

Hours: Monday – Friday 8 a.m. to 7 p.m. & Saturday 9 a.m. to 1 p.m.

1-877-912-8880 (TTY: 1-866-565-8576) The call is free.

You can get help/information in other languages or formats (like audiotape).

Free interpretation services!

Call 1-877-912-8880 (TTY: 1-866-565-8576)

Hay informacion en español. ¡Servicio de intérprete gratis!

Llame al 1-877-912-8880 (TTY: 1-866-565-8576)

Automated Health Systems

1375 E Woodfield Rd Ste 600

Schaumburg, IL 60173

847-995-1021

6

Integrated Care Provider

Information Summary

Resource Aetna Better Health IlliniCare

Health Plan

IL Client

Enrollment

Broker

Website English:

www.aetnabetterhealth.c

om/illinois

Spanish:

http://trans5.convertlang

uage.com/delawarepc/en

es/24/_www_aetnabetter

health_com/Illinois/Illinoi

sMembers.aspx?menu=2

English:

www.illinicare.com

English:

http://www.illinoisce

bicp.com/Default.asp

x

Spanish:

http://illinoiscebicp.c

om/files/Program_Be

nefits_for_the_ICP_S

panish_Link.pdf

Contact

Information

Aetna Better Health,

Illinois

One South Wacker

Chicago, IL 60606

312-821-0502

IlliniCare Health Plan

999 Oakmont Plaza

Drive

Westmont, IL 60559

866-329-4701

Automated Health

Systems

1375 E Woodfield Rd

Ste 600

Schaumburg, IL 601

73

847-995-1021

http://www.automat

ed-health.com/

Hours of

Operation

Monday-Friday, 8 AM – 5

PM (except for State

holidays)

Member services 24/7

Member Services

(866) 329-4701

TDD/TTY (866) 811-

2452

8 AM – 5 PM

Nurse Line – After Hours

(866) 329-4701

Monday – Friday 8

AM – 7 PM

Saturday 9 AM – 1

PM

7

Member

Handbook

a. English

b. Spanish

a. http://www.aetna

betterhealth.com/

ILLINOIS/PDFDoc

s/IllinoisHandbook

.pdf

b. http://www.aetna

betterhealth.com/

ILLINOIS/PDFDoc

s/IllinoisHandbook

Spanish.pdf

a. http://www.illinic

are.com/files/20

11/04/IlliniCare-

Member-

Handbook_Draft

_3-29-11-

finalWITHCOVER

.pdf

b. Not availablelliniCare

can help

translate your

health coverage

benefits.

IlliniCare can

also help

translate availabl

e services. If

you need

something

translated into

another

language than

English, please

call

IlliniCare.http://

www.illinicare.co

m/members/dive

rsity-resources/

a. http://illinoisc

ebicp.com/file

s/ICP_Infoma

tion_Guide.pd

f

b. http://illinoisc

ebicp.com/file

s/ICP_Infoma

tion_Guide_S

panish.pdf

Pharmacy

Information

Prescription:

http://www.aetnabetterh

ealth.com/ILLINOIS/PDF

Docs/Aetna_Better_Healt

h_IL_Formulary_5.1.11.p

df

Over-the-Counter:

http://www.aetnabetterh

ealth.com/ILLINOIS/PDF

Docs/Aetna_Better_Healt

h_IL_OTC_List_2_23_11.

pdf

Prescription and OTC

http://www.illinicare.co

m/files/2010/12/IlliniCar

e-Health-Plan-PDL-May-

2011_042011.pdf

HFS notice to

participating

pharmacies 5/19/11:

http://www.hfs.illinois.g

ov/assets/051911n.pdf

Provider/

Hospital Finder

http://www.aetnabetterh

ealth.com/Illinois/FindPro

vider.aspx?menu=1

http://www.illinicare.co

m/find-a-provider/

http://www.illinoisce

bicp.com/PCPSearch/

ICSearchLogin.aspx

8

Provider

Manuals

http://www.aetnabetterh

ealth.com/Illinois/PDFDoc

s/IL_Provider_Handbook_

Version_1.pdf

http://www.illinicare.co

m/files/2011/04/IlliniCar

e-Provider-Manual.pdf

http://www.illinoishe

althconnect.com/pro

viderinfo.aspx

Benefits

Summary

a. English

b. Spanish

a. a.http://www.aetn

abetterhealth.com

/Illinois/PDFDocs/

DescOfCare.pdf

b. http://www.aetna

betterhealth.com/

Illinois/PDFDocs/D

escOfCareSpanish.

pdf

a. http://www.illinic

are.com/files/20

10/12/Benefit-

Grid-Standalone4-

61.pdf

(English only)

a. http://illinoisc

ebicp.com/file

s/ICP_Compa

rison_Charts.

pdf

Transportation

Options

Contracted with Medical

Transportation

Management, Inc:

1-888-513-1612

Medical Transportation

Management, Inc.

16 Hawk Ridge Drive

Lake St. Louis, Missouri

63367-1829

Phone: 636-561-5686

TOLL-FREE at: 1-888-

561-8747

Fax: 636-561-2962

E-mail

at: marketing@mtminc.

net

Monday-Saturday 8 AM –

6 PM

Mileage reimbursement

also available if you use

your own car or get a

ride. Contact member

services w/in 7 days after

appointment to request

reimbursement.

Non-emergency

Transportation Services

are covered by IlliniCare

for medically necessary

services. IlliniCare will

also provide an escort, if

authorized in advance.

To schedule

transportation, please

call 866-329-4701

Call Member Services to

schedule rides at least 2

days in advance.

First Transit is the

vendor.

First Transit Inc.

Corporate

Headquarters | 600 Vine

Street, Suite

1400| Cincinnati, OH

45202 | 513-241-2200

https://www.firsttransit.

com/contact-us

NA

9

Dental Care

Options

(Oral Health)

DentaQuest

1-800-416-9185 (toll

free)

12121 Corporate Parkway

Mequon, WI 53092-9838

Toll Free

1.800.417.7140

Local

1.262.241.7140

http://www.dentaquestgo

v.com/

Contractor not specified.

Call Member Services

NA

Behavioral

Health

Services

(Mental

Health)

Call Member Services http://www.illinicare.co

m/stay-healthy/healthservices/

mental-healthservices/

IlliniCare offers

members access to all

covered, medically

necessary behavioral

health services through

Cenpatico.

IlliniCare members

seeking mental health

or substance abuse

services may self-refer

to a network provider

for thirty (30) standard

outpatient sessions per

member but prior

authorization is required

for subsequent visits.

For assistance in

identifying a behavioral

health provider or for

prior authorization for

inpatient or outpatient

services, Cenpatico may

be reached at 1-866-

329-4701.

In the event that the

physician or practitioner

is unable to provide

timely access for a

10

member, IlliniCare will

assist in securing

authorization to a

physician or practitioner

to meet the member’s

needs in a timely

manner.

Behavioral Health

Provider Finder:

http://www.cenpatico.c

om/find-a-provider/

Cenpatico, a subsidiary

of Centene, is the

contractor:

http://www.cenpatico.c

om/contact-us/

Cenpatico

504 Lavaca St., Suite#

850

Austin, TX 78701

(512) 406-7200

Self-Referrals/

Direct Access

Members may selfrefer/

directly access

some services without an

authorization from the

PCP. These services

include behavioral health

care, vision care, dental

care, family planning and

services provided by

Women’s Health Care

Providers (WHCPs). The

member must obtain

these self referred

services from Aetna

Better Health’s provider

network.

http://www.aetnabetterh

ealth.com/Illinois/PDFDoc

s/IL_Provider_Handbook_

Version_1_1%20_(5_4_1

1).pdf

11

Choosing A Medicaid Integrated Care Program Plan:

A Worksheet For ICP Participants

Before you choose one of the providers contracted by HFS’s Integrated Care Plan, study their information

carefully and record your data on this chart. When the chart is filled in, you will have detailed information

to assist you in choosing the plan that fits your needs. It may also allow you to recognize the need for a

written request to HFS for a Single Case Agreement.

Current

Providers/Information

Aetna Better

Health Network

IlliniCare Health

Plan Network

Comments/Questions

My Medical

Center/Hospital

Primary Doctor

(PCP)

Specialists (list)

Specialists

My Prescription

Medicines

My Over-the-

Counter Medicines

(OTC)

Transportation to

Appointments

Dental Care

(Oral Health)

Mental Health

(Behavioral Health)

My Medical

Equipment

My Medical Supplies

Disability-

Specific/Accessibility

Needs

Co-pays for

Services

Tests and

Evaluations (and

how often)

Other Health Care

Needs (specify)

12

Sample Letter to Request Single Case Agreement

for Integrated Care Plan Participant

Date

Bureau of Contract Management

Division of Medical Programs

Illinois Department of Healthcare and Family Services

201 South Grand Avenue East

Springfield, Illinois 62763-0001

(Fax number: 217-782-5672)

Re: (name of person enrolled in Medicaid, birth date, Recipient Identification Number and Case

ID #)

To Whom It May Concern:

I am writing on behalf of (person’s name) who received the attached letter from HFS on

(specify date) regarding enrollment in the Integrated Care Program. I am (person’s name)

(specify relationship: parent, guardian, case manager, etc.). (Person’s name) diagnoses are

(list all diagnosed medical, disability and behavioral health conditions.)

We have reviewed the provider lists supplied by both of the health plans – Aetna Better Health

and IlliniCare – and have found that neither (person’s name) doctors or the hospital where

(person’s name) receives treatment is in either network. A list of the doctors and hospitals

(person’s name) uses is attached to this letter. Due to (person’s name)‘s special health care

needs, it is very important to continue services with his/her current providers, doctors and

hospitals.

Therefore, we need your intervention with the Integrated Care Program providers to please

establish Single Case Agreements with the providers on (person’s name) list.

Please contact me at (phone number) if you have any questions or need more information.

Thank you for your assistance with this request.

Sincerely,

Your name

Your address

Your email

Attachments:

1. Current provider list

2. Current medication list

3. Copy of ICP letter received

4. Copy of current Medicaid card (both sides)

5. Copy of guardianship order (if applicable)

13

Cc: Person’s primary care physician

Tony Paulauski, The Arc of Illinois

Person’s State Senator and State Representative

Others

Send your letter with all attachments via certified mail and request a return receipt.

You can also fax a copy of the letter and attachments to HFS.

14

Appeal Rights in the Medicaid

Integrated Care Program

Everyone who is enrolled in Medicaid has the right to appeal. This includes people who are enrolled in a

managed care organization (MCO) as part of the Integrated Care Program. Enrollees in Medicaid

Managed Care have legal rights and responsibilities, including the right to appeal.

The Kaiser Family Foundation has a detailed fact sheet about Medicaid appeal rights:

http://www.kff.org/medicare/7240/medicaid.cfm

The following link provides basic appeal information from the Illinois Department of Healthcare and

Family Services (HFS): http://www.hfs.illinois.gov/medicalbrochures/hfs591.html

What do I do if I have a complaint about the care I received under the Medical

Programs or if I know someone is misusing the benefits of the Medical Programs?

If you receive poor medical care, have problems getting medical care or are charged for medical

services that are covered by HFS Medical Programs, call:

Welfare and Medical Fraud Hotline

Monday – Friday (except state holidays)

8:30 a.m. – 5:00 p.m.

1-800-252-8903 Persons using a TTY can call 1-800-447-6404. The call is free.

Also, call this telephone number if you know someone who is withholding information or not

telling the truth about the medical services they need or if you know someone who is charging

the HFS Medical Programs for medical care that he or she did not give.

You may also file a written appeal. Since you are enrolled in an HMO or health maintenance organization,

also called an MCO or managed care organization, you must first follow the procedures outlined in the

member handbook provided to you by your HMO. The HMOs are required to give you their member

handbook in your preferred language/method of communication (for example, in a language other than

English and/or in large print or Braille). Their member handbooks must include detailed information about

grievance and appeal rights.

You can file a written appeal with your HMO. You can also fax your appeal, as well as sending it by

certified mail. http://www.usps.com/send/waystosendmail/extraservices/certifiedmailservice.htm

Here is the contact information for the Illinois Managed Care Providers:

For Aetna Better Health enrollees:

http://www.aetnabetterhealth.com/Illinois/PDFDocs/IllinoisHandbook.pdf

Aetna Better Health

Attn: Appeals and Grievance Manager

One South Wacker Drive

Mail Stop F646

Chicago, IL 60606

Phone 866-212-2851

Fax: 855-545-5197

15

Illinois Relay 7-1-1 (hearing impaired)

For IlliniCare Health Plan Enrollees:

http://www.illinicare.com/files/2011/04/IlliniCare-Member-Handbook_Draft_3-29-11-

finalWITHCOVER.pdf

Member Appeals

IlliniCare Health Plan

999 Oakmont Plaza Drive

Westmont, IL 60559

Phone 866-329-4701

Fax: 877-646-6056

Who can help me with my appeal?

Here in Illinois, there are several advocacy and legal assistance organizations that may be able to assist

you with your appeal. Listed below is the contact information for some of these organizations:

For problems related to services, programs and State of Illinois agencies:

Illinois Life Span Project at The Arc of Illinois

www.illinoislifespan.org

800-588-7002 voice

For problems related to SSI, Medicaid, Medicare and Health Benefits for Workers with

Disabilities

Health and Disability Advocates

www.hdadvocates.org

312-223-9600 voice

800-427-0766 TTY

For problems related to youth transition and health (including access and coverage)

Family Voices of Illinois

The Arc of Illinois Family to Family Health Information Center

www.thearcofil.org/familytofamily

866-931-1110/708-560-6703 (voice)

711 Illinois Relay

For legal problems, including problems with services for people with disabilities from

state agencies:

Equip for Equality

www.equipforequality.org

800.537.2632(voice)

800 -610-2779(TTY)

For problems related to continuation of home-based nursing care after age 21,

including problems with services from state agencies:

US Department of Justice Joins Farley Lawsuit

www.thearcofil.org/pastissues/document.asp?did=2379 and http://www.farley1.com/news.html