Illinois Granted Early Access to SHOP Marketplace

Yes, the Affordable Care Act offers individuals and families quality health insurance, but did you know small employers with less than 50 full-time equivalent employees can take full advantage of the Health Insurance Marketplace? Online functionality for the SHOP, aka the Small Business Health Options Program, is available starting later this October as part of SHOP early access, which is only available to 5 states. Illinois is one of the lucky few. Brokers and Small Businesses, check it out at HealthCare.gov!

This incremental launch will help identify issues early and assist brokers and businesses in building confidence in utilizing the SHOP online system.

During SHOP early access, Illinoisians can do the following to initiate enrollment:

• Establish a Marketplace SHOP account
• Establish an agent or broker to their account if they wish
• Complete an employer application
• Obtain an eligibility determination
• Upload an employee roster when enrollment functionality is available
• Starting in November, browse health plans with coverage starting in 2015

The SHOP Call Center can be reached at 1-800-706-7893 (TTY: 711) Monday through Friday, 9 a.m. to 7 p.m. EST.

While small businesses have always had group plan options, many even available online, there were challenges that got in the way of providing group coverage to their employees. Premiums were expensive and small businesses lacked the purchasing power of larger organizations. The SHOP makes some pretty substantial changes to the ways in which small businesses can buy plans.

Why SHOP?

First, financial assistance is now available in the form of a tax credit. This can substantially help employers by covering up to 50% of employer contributions towards employee premiums. This assistance provides the opportunity for businesses to offer employee coverage where it would have previously been unaffordable. Second, the SHOP helps small businesses harness the purchasing power of other small businesses, thus letting them play in the big leagues along with larger organizations.

Small businesses do not have to offer health benefits under the Affordable Care Act, but it is in their best interest to check out options and see what is possible, particularly if they are concerned with employee retention. Whether or not they decide to provide group health insurance coverage, small businesses are nonetheless required to inform employees of the Health Insurance Marketplace, so that individual coverage options can be explored.

Brokers and Small Businesses take note. The time is now to explore options, prepare, and get ready for a new system opening up possibilities for small businesses in Illinois.

Emily Gelber MSW, LSW
Health Policy Analyst
Health & Disability Advocates

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TAKE OUR SURVEY HDA and Crain’s Chicago Business are teaming up to poll local small businesses about new health benefit options. Why participate? By taking this short survey about the changing healthcare landscape, you can inform policymakers, insurers and other small business owners. Results will run in a November 17 article in Crain’s. Take the survey now

What Happens to the Pre-Existing Condition Plans on Jan. 1, 2014?

This post is the first in a series on the Illinois State Partnership Exchange Blueprint Application, which is pending approval by the Federal Government. 

For years, health insurance carriers refused to sell coverage to individuals with pre-existing medical conditions. The Affordable Care Act (ACA) created federally funded high risk pools across the country, including the Illinois Pre-Existing Condition Insurance Plan (IPXP) so that people denied for that reason would not have to go without health insurance. Starting on January 1, 2014, the ACA bans insurance companies from denying coverage based on pre-existing conditions. As a result, IPXP will no longer be needed, and coverage under the plan will be terminated.

So what happens to the enrollees of IPXP on January 1, 2014? 

The ACA dictates that anyone currently enrolled in IPXP will be transitioned into a private insurance plan via the state health insurance exchange. This transition process will happen at the end of 2013. According to the Illinois State Partnership Exchange Blueprint Application, the state has mechanisms in place to prevent lapses in health coverage, as follows:

• Illinois will send at least three letters to IPXP enrollees containing information on the transition process;
• The state will conduct proactive outreach to IPXP participants and update the IPXP website with relevant information; and
• The Illinois health insurance exchange will have extra personnel at the call center specifically to assist with the IPXP transition.

IPXP will only extend coverage for health services until December 31, 2013, which means that all current IPXP enrollees will need to find an alternative health plan before January 1, 2014.  Claims dating from before December 31, 2013 will need to be filed in the close-out period, which will run until June 30, 2015. If deferral funding for the IPXP program has run out, however, even claims filed before that date will not be payable.

Open enrollment into the state health insurance exchange will begin on October 1, 2013, with insurance coverage beginning on January 1, 2014. If current IPXP enrollees purchase a plan during open enrollment, there should be no gaps in their health coverage. Since Illinois is still in the process of establishing its health insurance exchange, check back here for details on how and where to enroll in a health insurance exchange plan, as well as future updates on the IPXP transition process. If you have questions now, contact IPXP at (877) 210-9167, or e-mail your question directly to IPXPInquiry@healthalliance.org

The Cook County Health & Hospitals System (CCHHS) 1115 Medicaid Waiver—What is CountyCare?

Blog Post by Margie Schaps, Executive Director, Health & Medicine Policy Research Group 

Last month the Cook County Health & Hospitals System received word from the Federal Centers for Medicaid and Medicare that their request for an 1115 Waiver to the Illinois Medicaid system had been conditionally approved, pending the State of Illinois officially accepting the “terms and conditions” of the Waiver. So, as of right now, the expectation is that the State will make this official within the next couple of weeks.

CountyCare, as the new Medicaid program will be known, has been provided for through the Affordable Care Act. CountyCare will allow the CCHHS to enroll tens of thousands of currently uninsured people into this Medicaid Program. People can begin applying on November 5th by phone 312-8648200 or toll free at 855-6718883. Coverage will start January 1, 2013.

This provides a great opportunity and enormous challenge for the health system to transform care by creating patient-centered medical homes rather than relying on expensive and inefficient use of emergency rooms. The focus of the program will be primary care centric with all specialty care, diagnostic and inpatient services coordinated through the medical home.

Eligible people include:

• Live in Cook County 

• Be 19-64 years old 

• Have income at or below 133% FPL 

• Not be eligible for “state Plan” Medicaid 

• Not be eligible for Medicare 

• Be a legal immigrant for 5 years of more or a US citizen 

• Have a social security number of have applied for one 

Not all doctors within the CCHHS system will be part of the network, and there will be many community health centers that will be part of the network (this list has not officially been released yet)

The CCHHS website has a list of answers to Frequently Asked Questions: http://www.cookcountyhhs.org/patient-services/county-care/


Advocates, providers and patients still have unanswered questions, many of which have been submitted by us to the CCHHS leadership and consultants. We anticipate getting answers to these in the coming weeks and will provide updates to this blog post as we get the information.

Who Has Pre-existing Conditions in Illinois?

A new study by Families USA has delved deep into Obamacare's patient protection provisions, which prevent anyone from being turned down or charged exorbitant rates for a pre-existing condition.

According to the study, over one in four Illinoisans under the age of 65 (the age where they become eligible for Medicare) have a pre-existing condition that could result in denial of coverage prior to the exchanges coming into effect in 2014. That's nearly 2.9 million people!

People with pre-existing conditions live in all counties in Illinois: the proportion of people affected ranges from 24.5 percent in Lake County to 31.1 percent in Jefferson, Marion, Randolph, and Washington Counties. One common factor is that pre-existing conditions tend to become more prevalent as we age: nearly half (49.2 percent) of adults aged 55 to 64 have a pre-existing condition that could lead to a denial of coverage. Right now, the presence of a pre-existing condition at any point in your life can be a reason for health insurance companies to discriminate against you.

To me, the implications are very clear: Obamacare gives people with pre-existing conditions access to affordable insurance. In fact, 59.5% of people with pre-existing conditions in Illinois are within the threshold (below 400% FPL) where either subsidies will be available to help them purchase health insurance or they will qualify for Medicaid. That's a tremendous relief for anyone without or in danger of losing their health care.

Also, as Families USA discusses in the study, not knowing what can happen with you or your family members' health insurance can result in "job lock" where one keeps an inferior job for fear of losing their coverage. Implementation of Obamacare will relieve that fear, and it could even lead to more people taking risks that were impossible before, such as starting a new business. This can lead to a more natural flow of the labor market and towards more job creation, giving Illinois an economic boost.

These are real benefits that people with pre-existing conditions, like me, can look forward to in 2014. In the meantime, IPXP, Illinois's temporary pre-existing conditions plan for the uninsured that was created and subsidized by Obamacare, is doing an incredible job as a stopgap measure to help us get through the next year and a half. I encourage you to spread the word about IPXP to ensure that everyone who needs to can take advantage of these benefits. As we can see from the Families study, there are a lot of Illinoisans with pre-existing conditions who have the chance to take advantage of a great program right now.

David Zoltan,
Guest Blogger, Illinois Health Matters

Scariest thing in the world

Wes Craven has certainly tried hard over the years to give us scary. Joss Whedon sprinkled it with humor. Edgar Allen Poe taught us all some lessons in horror.

Then there is real scary. The kind you don't find in books or movies. The slow fear that doesn't have a release in a moment involving some guy in a mask.

For two years, I was a diabetic without health insurance. Doesn't sound like the kind of thing John Carpenter would toss out there for 90 minutes, does it? But it is, without a doubt, the scariest thing on Earth.

I was laid off in 2008, one week precisely before Lehman Brothers crumbled and the global economy with it. While I was offered COBRA and searched desperately for some way to keep my insurance, there was nothing I could qualify for as a diabetic for less than $700 a month. Unemployment insurance only added up to about $1400 a month, so to pay for insurance, I'd have to skip rent or utilities or food.

Medicaid was no help either. Illinois is a great state, but our Medicaid system here is currently set up to help only the lowest of the low. I "made too much money" on unemployment, even as a diabetic, to qualify for the program.

Yet without insurance, insulin, the very thing I need to take multiple times a day just to live, would cost me insane amounts of money. I take two types of insulin. Each bottle of insulin lasts me about two to three weeks. Each bottle without insurance costs over $110-120. It would cost me over $450 a month just for my insulin. That doesn't begin to take into account the syringes, the other pills I take to help control aspects of my health as a diabetic, or any of the other conditions that I have related to my diabetes or not.

Taking care of my health looked impossible. I was lucky though. I had some amazing doctors and nurses that did everything they could to get me insulin, that helped me navigate the systems to eventually get set up for charity care where we could, and even cajoled a few pharmacy reps I think into making sure I survived. I would not be here but for their incredible hard work and help.

Despite all that hard work, it was still not always enough. I had to pay out of pocket once, early on when I still had a small emergency reserve of money, and visit the emergency room three times to get insulin when we couldn't get it fast enough from our various alternate sources. That's three ER visits that the state had to pay for, and therefore, in the end, you footed the bill through your tax dollars in the most inefficient way possible.

The Affordable Care Act changed all of that. I was one of the first to sign up for the "high-risk pool", IPXP here in Illinois, that was set up to help get those of us with pre-existing conditions in the individual market into plans that could help us until the health insurance exchanges start in 2014. I stood side-by-side with Governor Quinn as he announced the program to the public, and I defend it to this day as an important stop-gap measure.

Thanks to the subsidies made available through Obamacare, IPXP only costs me about $150 a month instead of the $700 I was quoted before. It'll be more now that I've celebrated my 35th birthday, going up to $200 a month, but that's still far better than not having insurance at all.

I got a job after three years of looking, one year after I got into the IPXP plan, but it was a contractor position that didn't offer benefits. I kept the IPXP plan through that year of employment, and I didn't have to worry about trying to wait until a job came along that offered health benefits. Now that I'm once again in the job market, I seamlessly have nothing to worry about from IPXP as it stays with me. This is what everyone can look forward to with the exchanges starting in January 2014.

One of the last fears I had left was washed away when the Supreme Court declared the ACA constitutional and upheld the law. (See my reaction to the ruling here) It's not the last hurdle, but it is one of the most important ones. There is no doubt now that Obamacare is the rightful law of the land and can help 32 million previously uninsured Americans just like me to ensure that health care is a right, not a privilege.

There are still challenges, and I hope you'll stand with me to ensure that I, and so many more just like me, never face that fear again. We will talk about many of those challenges in the days ahead, no doubt. Thank you for being interested in my story and for doing your part to ensure health care for all.

David Zoltan,
Guest Blogger for Illinois Health Matters

Strengthen Home Care

Recently, legislators made the prudent decision to pass the Budgeting for Results law, holding Illinois accountable to fund only programs with proven effectiveness. Budgeting for Results lays out the state’s commitment to home and community-based care, including through Medicaid programs.

The development of Illinois home-care system has been a challenging venture over the past several decades; and yet the home-care system is hardly prepared for the aging of the baby boom generation. The proposed cuts to home-care programs through Medicaid budget proposals contradict the call to responsibility outlined in Budgeting for Results.

Proposals include increasing the eligibility threshold for Medicaid community-living waivers. However, our recent research for a report reveals that community-living waiver cuts will result in an increase in utilization of hospitals, emergency rooms and nursing facilities — more costly options than home care.

We call upon our legislators to strengthen, not weaken, their commitment to community living for Illinois’ most vulnerable citizens.

Kristen Pavle, 

Associate Director, Center for Long-Term Care Reform

Health & Medicine Policy Research Group

(originally posted as a Letter to the Editor here in the 5/23/12 Chicago Sun Times)

A Helping Hand for Small Businesses: Health Insurance Tax Credits

The Affordable Care Act (ACA) established a tax credit to help small businesses provide health insurance for their employees. According to a new study released today from Families USA and the Small Business Majority, 3.2 million small businesses, employing 19.3 million Americans, will benefit from these tax credits. Out of the 198,910 small businesses in Illinois, 137,900 will be eligible for a small business tax credit—that’s 69.3%.

The cost of health insurance is often the prohibitive factor when it comes to coverage for small business employees. Whereas almost all businesses—99 percent—with 200 or more employees offer coverage for their workers, small business have a much lower rate: 71% of businesses with 10-24 workers, and 48% of businesses with fewer than 10 workers offered employee health coverage.

The small business tax credit is an integral part of the ACA – created in order to help small businesses provide coverage for their employees. The credit is designed to provide assistance to the smallest businesses that face the highest premiums. In order to qualify, all businesses must cover at least 50% of each employee’s health insurance.

• Businesses with up to 25 FTEs and average wages of less than $50,000 will receive credits on a sliding scale. To see if your business qualifies, go to the Small Business Majority Tax Calculator here. 

• Businesses with 10 or fewer employees and average wages of less than $25,000 are eligible for the maximum 35% tax credit.. 

• Non-profit businesses are eligible for a 25% refund. In 2014, when health care reform is in full-force, the tax credits will cover up to 50% of small businesses’ health coverage plans, and non-profits will receive a refund up to 35%. 

Unlike individuals, whom the ACA mandates to have coverage, small businesses are not mandated to provide coverage to their employees. However, if a business of 50 or more workers has an employee who receives an individual subsidy to cover the purchase of individual plan insurance, that business will be levied a fee.

What does the small business tax credit mean for Illinois small businesses and their employees? 

1,206,000 Illinoisans are employed at small businesses. Out of that number, 757,300 (62.8%) are employed at businesses that are eligible for a tax credit, making it easier for their employers to provide health coverage for them. Overall, the state will receive $634,615,800 in tax credits, or about $838 per employee, on average.

54,130 (39.3%) of Illinois small businesses will be eligible for the Maximum (35%) credit. 220,400 people will benefit from the maximum credits, or 29.1% of those employed by a small business.

The country suffers from large ethnic and racial disparities in health care, and coverage is no different in small businesses, where a disproportionate number of African American and Latino small business employees are without insurance, as compared to white, non-Latino employees. Many of these workers could benefit from the small business tax credit. In Illinois, 188,090 Latino workers are employed by small businesses. 74.5% (140,040) of those workers will benefit from small business tax credits. 118,310 African American, non-Latino workers are employed at small businesses, of which 78,170 (66.1%) will benefit from tax credits.

As with many other aspects of the Affordable Care Act, the small business tax credit is still underused and unknown. We found in our Neighborhood Stories series last year that many small business owners and chambers of commerce in the South and West Sides of Chicago had not heard of the small business tax credit. The Families USA and Small Business Majority Report released today will help to continue to publicize the availability of the credit.

Choose Wisely, Illinois: Alternatives for Balancing the Medicaid Budget

On Thursday, April 19, 2012, the Governor released a proposal for the reduction of the current $2.7 billion Medicaid budget deficit. The proposal, developed with a group of legislators on the Medicaid Commission, includes $2 billion in cuts to eligibility levels, benefits, and payment rates to providers, and a $1 per pack increase in the cigarette tax. Some of the Governor’s most concerning proposals include eliminating the Illinois Cares Rx program, reducing eligibility for FamilyCare, eliminating the General Assistance Medical Program, eliminating the adult dental program, and requiring a co-pay from vulnerable populations utilizing federally qualified community health centers.

Many of these cuts will not be “fixed” by the implementation of the Affordable Care Act in 2014. For example, Illinois Cares Rx covers costs not covered under Medicare or the ACA such as premiums, deductibles, lower co-pays, and medications not covered in the Medicare formulary. The biggest misconception is that the ACA will fill the Medicare “donut hole.” It gradually reduces costs in the donut hole over the next 8 years but never completely eliminates that cost-sharing as Illinois Cares Rx does.

Other cuts may be “repaired” by the implementation of health care reform, such as coverage for low income parents, but at what cost? How much preventative care will be missed in the next 18 months which will cost the state more in expensive emergency or acute care after January 1, 2014?

Medicaid is a vital source of health care for many Illinoisans. Although the Medicaid program must become more efficient to safeguard taxpayer dollars, there are other alternatives to the proposed cuts. Solutions such as cutting prescription drug coverage, eligibility, or optional services are unacceptable and will drive up long-term state costs. The General Assembly and Governor have underfunded Medicaid for 20 years and the cuts do not need to all happen immediately; a multi-year solution is needed to balance the program budget. Furthermore, short term solutions, such as cutting prescription drug coverage, eligibility or optional services are unacceptable, and will only drive up long-term state costs. It is important for Illinois legislators to keep in mind that transformative Medicaid reforms currently being implemented and require time to work, and that The Medicaid budget cannot be balanced with Medicaid cuts alone. New revenue and savings from legislative changes in other budget areas must be applied to Medicaid.

Some of the proposed alternatives are:

Medicaid system Delivery reforms: Reforms such as the Care Coordination Innovations Project, Integrated Care Program, and other projects to better manage the care of some of the highest-need Medicaid patients need time to be implemented to see the full scope of savings and improved health outcomes.

Changes for Nursing Home and IMDs: Nursing homes and Institutions for Mental Disorders (IMDs) have excess capacity, resulting in thousands of empty beds across the state. Reducing the number of licensed beds could save Medicaid money. Refocusing efforts on community-based services, rather than institutional placement, would also reduce costs, and in some cases, qualify for more Federal funding. Also, Illinois could implement the nursing home bed tax, already approved by the federal government, which has not yet been implemented because the nursing home industry has not agreed on a formula to redistribute funds.

Stop paying for medically unnecessary, elective C-sections: C-sections are significantly more costly, require a longer recovery time for both the mother and often the infant, and can lead to complications due to premature birth. Nearly half of all C-sections in the U.S. are medically unnecessary, and it is estimated that Illinois’ Medicaid program spent between $54M and $76M on medically unnecessary C-sections in 2009.

For more information, see the Responsible Budget Coalition's fact sheet on alternatives to the cuts here.

Stephanie Altman
Program and Policy Director
Health & Disability Advocates

Keep Illinois Medicaid Strong: Principles for Financial Stability

The Illinois Medicaid program provides life-saving health coverage to nearly 2.7 million
low-income children, parents, seniors, and people with disabilities and behavioral health
needs, including addiction and mental illness. However, the program faces a $2.7 billion deficit this year, and legislators are exploring a range of solutions. We all need to ask: How much does each of these “solutions” actually cost us in health and long-term care outcomes and state funds? Our organizations endorse the following principles for stabilizing the Illinois Medicaid program.

Solutions such as cutting prescription drug coverage, eligibility, or optional services are unacceptable and will drive up long-term state costs. The services people on Medicaid receive now reduce future state health spending by providing prevention services and early intervention. 

Transformative Medicaid reforms are being implemented but need time to work. To improve the health and lives of Medicaid recipients while reducing costs, Illinois is contracting with commercial managed care companies and networks of providers to implement robust care coordination models. However, these programs cannot be in place overnight.

The General Assembly and Governor have underfunded Medicaid for 20 years; a multi-year solution is needed to balance the program budget. Medicaid reforms enacted in 2011 already establish a decade-long glide path to pay old bills, and this plan should be followed.

The Medicaid budget cannot be balanced with Medicaid cuts alone. New revenue and savings from legislative changes in other budget areas must be applied to Medicaid. Medicaid cannot be firewalled from the rest of the state budget; it is an economic engine that supports families, creates jobs, and helps children learn.

Supporters of this Statement: AARP Illinois, Access Living, AgeOptions, AIDS Foundation of Chicago, 

American Cancer Society (Illinois Division), Campaign for Better Health Care, Chicago ADAPT, Citizen Action Illinois, CJE SeniorLife, Doctors Council SEIU, Haymarket Center, Health and Disability Advocates, Health and Medicine Policy Research Group, Heartland Alliance for Human Needs & Human Rights, IL Alcoholism and Drug Dependence Association, IL Alliance for Retired Americans, IL Association of Public Health Administrators, IL Association of Rehabilitation Facilities, IL Chiropractic Society, IL Coalition for Immigrant and Refugee Rights, IL Iowa Center for Independent Living, IL Maternal and Child Health Coalition, IL Partners for Human Service, IL Primary Health Care Association, IL Public Health Association, IL Society for Advanced Practice Nursing, Illinois Society for Public Health Education, IL Valley Center for Independent Living, Illinois Network of Centers for Independent Living, Impact CIL, Latino Policy Forum, National Organization of Nurses with Disabilities, New Age Services, Ounce of Prevention Fund, 

Planned Parenthood of Illinois, Sargent Shriver National Center on Poverty Law, SEIU Healthcare Illinois Indiana, SEIU Illinois Council, SEIU Local 73, Statewide Independent Living Council of Illinois.

Moving Forward: Current Waivers for Coordinated Care Projects in Illinois

“Care Coordination,” along with related terms like “managed care” and “medical home” have become the buzz words of health care reform. The terms refer to new types of health care delivery models that many states and programs are turning to as the key to reforming the costly and arguably inefficient health care system.  Currently, the health care system mostly operates as a “fee-for-service” model, which critics argue incentivizes overutilization of medical services and shifts the focus away from effective preventative care, leading to excessive costs. Organizing groups of health care providers around patients, with a greater level of communication between doctors and a greater focus on care that keeps patients from getting ill could streamline health care delivery in a way that lowers costs and improving quality of care (for a more in-depth look at coordinated and managed care, go here or here).

In recent years, federal health programs, like CMS, have started to investigate the potential of care coordination via demonstration projects, grants and waivers for states or health care providers willing to participate. The Affordable Care Act also encourages exploration of these new care delivery models. In 2011, Illinois passed Public Act 096-1501, also known as Medicaid Reform, and began the Illinois Innovations project. As a part of that reform, the state is currently utilizing these waivers and grants:

The Integrated Care Program (ICP) is a 5-year pilot program that transfers all Medicaid (but not Medicare) eligible adults in Suburban Cook County to a Managed Care organization (MCOs). The 40,000 people included in the program, have two MCOs to choose from, one Aetna Better Health and IlliniCare Health Plan, Inc. The program is currently in Phase I, which focused on medical care. Phase II will focus on long-term care (set to begin September 2012), excluding long term care for those with developmental disabilities, which will be the focus of Phase III (no current implementation date).

Coordinated Care Entities (CCE) is a project intended to help Illinois enroll 50% of Medicaid clients into coordinated care projects (as called for by Public Act 096-1501). The CCEs are looking to cover at least 500 enrollees in a Health Home, FFS, Shared Savings or Bundled Payment model of care delivery. Illinois decided to release a request for proposals to medical care providers, in order to test the interest and capacity of community health organizations to offer coordinated care to patients, instead of simply enrolling Medicaid clients into Health Maintenance Organizations (HMOs). In January, Illinois released requests for proposals for Health Homes for chronically ill adults. Awards are expected to be announced by May 2012. HFS plans to release requests for proposals for CCEs to target children with complex medical needs by June 2012.

The proposed Cook County 1115 Waiver, currently pending with CMS, seeks to cover up to 200,000 uninsured patients who will become eligible for Medicaid once Affordable Care Act Medicaid Expansion takes place in 2014.

The Dual Eligibles program targets those who are eligible for both Medicaid and Medicare. The program would integrate the care that dual eligibles receive into one Managed Care Program. The proposal was open to a 30-day public comment period that closed in late March, and will be sent to CMS for approval.

Under the We Choose Health Community Transformations grant, the Center for Disease control has given the Illinois Department of Public Health $4,781,121 to serve the state of Illinois, excluding large counties. Work will focus on expanding efforts in tobacco-free living, active living and healthy eating, quality clinical and other preventive services, social and emotional wellness, and healthy and safe physical environments. This grant will dovetail with Illinois’ State Health Improvement Plan (SHIP), a prevention-focused, comprehensive approach to improving the health of Illinois residents.

The State has proposed changes and possible mergers of the Home and Community Based Waiver programs including the DORS Home Services Program and the Community Care Program. The major proposal affecting the HCBS waivers is a proposed change from a Determination of Need (DON) threshold of 29 to 37 in order to obtain services. DORS has also proposed reducing the Service Cost Maximums in the HSP program to the levels in the CCP program.

What’s Next for Health Care Policy in Illinois?

The past two weeks were a non-stop affair for health care policy—the ACA saw its 2nd anniversary right before the Supreme court heard oral arguments for the historic case against the law, and here at IHM we premiered our data visualization tool. However, health care reform news has not stopped. Here’s a brief overview of what the next few months have in store for health care in Illinois:

Health Insurance Exchange: State legislators made little progress towards votes on the establishment of a competitive health care marketplace, though negotiations on HB 4141 are underway. Legislators still have time to establish an exchange, but the Federal deadlines are looming closer, and to miss deadlines could cause Illinois to lose out on important Federal grant money. If the group waits to move forward with the exchange until the Supreme Court announces its decision on the ACA case -- a prospect that interests some legislators -- , there may not be enough time to set up a functioning exchange. Governor Quinn has said that he would establish the exchange via an executive order if necessary.

Potential Cuts to Medicaid: The Illinois Medicaid program faces a $2.7 billion deficit in the coming fiscal year. In order to deal with that budget, the Department of Healthcare and Family Services has proposed a list of possible cuts to Medicaid services in order to balance the budget. As legislators go into the upcoming spring sessions, many advocates are calling for other methods of fixing the Medicaid budget deficit that do not compromise important health care services that the program provides.

The Illinois General Assembly starts its April sessions on the 17th.. Follow the progress of these health policy issues with IHM!

See into the future of health care reform

Illinois Health Matters has released a new data visualization tool, “Visualizing Health Care Reform in 2014,” for understanding the impact of the Affordable Care Act (ACA) in Illinois. This easy-to-use, interactive tool maps the State and shows who is currently uninsured, how many of those people will become insured, and how they will access health insurance as the major provisions of the ACA go into effect in 2014.

Infographics such as “Visualizing Health Care Reform” are valuable aids for understanding complex concepts, such as the impact of health care reform. By using data to illustrate public policy outcomes, people and policymakers can make informed, data-driven decisions.

This tool is the first of its kind to illustrate the future impact of health care reform at the state level. It also gives a valuable glimpse of how crucial these reforms will be for more than 1.6 million uninsured Illinoisans through Medicaid expansion and the new state Health Care Exchange (or “Marketplace). Clearly, businesses and communities across the state have a lot of work to do to gear up to meet the potential demand.

This is just part of the story. The impact of the new health law is even more far-reaching. For every Illinoisan who will gain access to coverage via Medicaid or the Exchange in 2014, there are others who already benefit, such as the young adults who get to remain insured via their parents’ insurance until age 26 or the children and adults whose health has benefitted from the wide range of preventative care services that insurance companies are now required to cover.

For information on how the law can help you or your community now, go to Illinois Health Matters, sign up for our monthly newsletter, or ask a question. For more on the data used in this tool, go here.

The State of Illinois and Medical Home Network partner for improved care coordination

Last week the Illinois Department of Healthcare and Family Services and the Medical Home Network (MHN) announced an innovative partnership that could mean better care and lower cost of care for Medicaid beneficiaries.

MHN is one of the largest collaborations of safety net providers in the country working to deliver better coordinated care to vulnerable populations. Partnership with the State allows MHN to test promising delivery and payment innovations that impact approximately 170,000 Medicaid beneficiaries, who make up just less than 10 percent of the State’s total Primary Care Case Management (PCCM) Medicaid population and 11 percent of PCCM costs. The vast majority of these beneficiaries live on Chicago’s South and Southwest Sides, areas where healthcare is fragmented and health status is generally poor.

In addition to the State, this public-private partnership includes the second largest public health system (Cook County Health and Hospitals System), a renowned academic medical center (Rush University Medical Center), a hospital focused on chronically-ill children (La Rabida Children’s Hospital), three community hospitals, six Federally Qualified Health Centers (FQHCs) and an extensive physician network.

Already, MHN has begun to implement innovative technology called MHNConnect that drives meaningful improvement in care coordination by virtually connecting disparate providers serving the population. MHNConnect, a secure, web-based portal, sends real-time alerts on patient hospital activity to Medical Homes (primary care sites) and makes historical prescription and medical claims data available to providers at the point of care. Doctors’ moments of “if I only knew” are turning into “now I know.”

MHNConnect is an enhanced version of a platform that reduced hospital admissions by 31%, ED use by 34% and increased patients’ visits to their PCP by 29% when applied to an uninsured population in California. The MHN model of care has the potential to deliver better care at a lower cost. MHNConnect and other MHN initiatives are expected to significantly improve critical transitions of care by using real-time information technology to increase the percentage of patients who follow-up with their Medical Home within seven days of a hospital stay or visit to the emergency department (ED). MHN also anticipates reducing the populations’ annual ED visits (approximately 100,000 in a 12-month period) by preventing over 3,000 avoidable visits.

During the first day MHNConnect went live, a MHN Medical Home was able to identify a patient who frequently went to the ED for asthma complications but had not visited his primary care physician or filled a medication that could keep his condition under better control. New information from MHNConnect allowed the Medical Home to identify the patient, contact him to schedule an appointment and begin to manage the patient’s condition at his Medical Home.

Within the first three weeks of using MHNConnect, care coordinators at a second Medical Home were able to successfully schedule timely follow-up appointments after Inpatient Discharges and ED visits for 93% of patients with MHNConnect hospital activity. MHN is encouraged by dramatic results such as these, as well as initial positive feedback from patients and providers.

MHNConnect and other MHN initiatives are designed to improve care coordination, a key to improving quality and reducing cost. MHN expects to reduce total cost of care by 2-4% in year one. If projected savings are realized, the MHN model could serve as a delivery framework to meet the needs of similar communities across the country.

Funded by the Comer Science and Education Foundation, MHN is currently rolling out MHNConnect to additional sites. Read more at http://www.mhnchicago.org/node/21.

Cheryl Lulias
Executive Director, Medical Home Network

                

The ACA Expands Preventative Care for 2,390,000 Illinoisans

To many, the cornerstone of the Affordable Care Act (ACA) is its  emphasis on providing Americans with access to important preventative care. The benefits of preventative care have been discussed in this blog before, in the context of chronic disease ,  breast cancer and  cervical cancer.

How exactly, then, is the ACA expanding access to preventative health care?

 One instance is a provision under the ACA that requires insurance plans[i] to provide important preventative health procedures to beneficiaries, without any cost-sharing measures (such as co-pays). The U.S. Department of Health and Human Services recently released information on how this provision will benefit Americans.

The list of important preventative health procedures was determined based on guidelines from the U.S. Preventive Services Task Force. Due to the ACA, children have gained access to regular pediatrician visits, immunizations, important vision and hearing screenings and developments assessments, as well as screening for obesity and counseling on how to maintain a healthy weight. Both men and women have gained  access to recommended immunizations and flu shots; cancer screenings (including colonoscopies and, for women, pap smears and mammograms); obesity screening and  healthy diet counseling; screening for high blood pressure and high cholesterol, depression and HIV; and tobacco use counseling. In addition, starting in 2014, women will be covered sexually-transmitted infection screening, and other services specific to women, such as gestational diabetes screening and contraception.

While many people with health insurance were already covered for these preventative health procedures, many were not: 31% of those who had health insurance through their employer have seen an expansion in their benefits—that’s 54 million Americans! In Illinois, the impact is among the biggest: 605,000 children, 898,000 women and 887,000 men have gained new access to expanded preventative health care. That is 2,390,000 Illinoisans, total, who have directly benefitted from the prevention expansions in the ACA!

I am proud to serve on the Administration’s Advisory Group on Prevention, Health Promotion, and Integrative and Public Health, established by the Affordable Care Act, where we will continue to develop policy and program recommendations, and advise the National Prevention Council on lifestyle-based chronic disease prevention and management, integrative health care practices, and health promotion

Barbara Otto

Health & Disability Advocates, Chief Executive Officer

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[i] Excluding plans that have Grandfather status

Toward a More Inclusive, Healthy Union

Two and a half years ago Congressman Joe Wilson called out across the well of Congress, "YOU LIE, Mr. President." If the never-ending news cycles leave you struggling to recall exactly what President Obama was accused of lying about, it was the inclusion of undocumented immigrants in the yet-to-be-passed healthcare reform bill.

Thanks to this comment and the resulting uproar when healthcare reform begins in 2014 undocumented immigrants will be barred from purchasing healthcare on the regulated insurance exchanges -- even with their own money. They won't qualify for Medicaid, contrary to a popular myth. Moreover, many of their legal immigrant spouses, parents, cousins, etc. will also be ineligible for Medicaid. The unbelievably complex rules for immigrant healthcare could easily result in one family having their various members regulated by five separate sets of eligibility rules.

Eventually our nation will need to decide if we really want the people who clean our office buildings, care for our children, serve our food, and whose children attend school with our children to have significantly worse healthcare. Meanwhile, down in Florida, Governor Romney and Speaker Gingrich argue over the laughable notion of "self-deportation" and spar over who the anti-immigrant is.

But Illinois can move ahead, and make sure that healthcare reform is both rational and humane. While we cannot change the enormously complicated federal eligibility guidelines, we can reduce the confusion for families here in Illinois and promote healthcare access to the fullest extent possible.

We can ensure that immigrant families understand what their new healthcare options will be in 2014 by developing an infrastructure of community organizations to assist immigrants to understand their complicated eligibility and guide them towards other options if they don't qualify for or can't purchase health insurance. We must make sure we have a strong, stable safety net that includes not just preventative care but the acute care that left untreated results in high medical bills and throws many low-income individuals into medical debt and hurts our overall economy.

For all those who are still learning English, we can make sure the system supports provides language access so that patients can navigate their healthcare options. Finally, here in Illinois we've made a strong stand that all children should have access to healthcare. Let's keep it that way.

For more info on immigrants and the ACA, check out this IHM Resource.

Written by Joshua Hoyt, Director at the Illinois Coalition for immigrant and Refugee Rights. Follow Joshua Hoyt on twitter at www.twitter.com/icirr

This post originally appeared on the Huffington Post. 

The Essential Health Benefits--Comments from Health and Disability Advocates

On December 16^th 2011, the Department of Health and Human Services released a much-anticipated bulletin on the Essential Health Benefits (EHB) package. Instead of containing information on what the package would contain, the bulletin deferred the task of defining EHB to each state. Supplementary information designed to clarify the approach taken in the bulletin was released on January 25, 2012.

Health & Disability Advocates, the organization which powers Illinois Health Matters, submitted their comments on these bulletins to HHS on January 31, 2012, reflecting specific concerns:

The role of the EHB package was to create a standard of health care covered by insurers for all Americans purchasing insurance through the state exchanges. This would mean a standard of adequate care for all, without discrimination due to age, gender, disability, chronic illness or geographical location.  It is the vehicle that would bring the goal of health care reform, that is, high-quality, comprehensive care, to many citizens.

The proposed plan gives states a vague benchmark system, with no federal oversight currently put in place, to use in defining the EHB. Although it is understandable for states to want flexibility in defining their EHB package, the degree of flexibility HHs is allowing could permit states the freedom to eliminate important benefits or the protection the EHB provides against insurance discrimination. Furthermore, to hand off all of the important decisions regarding the EHB package to the states goes against Congress’s intentions in the ACA of a federal standard, defined by HHS, for minimum coverage. As HDA states in their comments, “Simply said, the HHS EHB Bulletin is inadequate at best, and at worst, is an impediment to effective implementation” of health care reform.

HDA urges HHS to protect the potential of EHB plans by establishing an official, federal oversight process that involves a diverse range of perspectives, including those of people with disabilities and chronic illness. The HDA comments outline specific suggestions for the development of an EHB plan going forward that would safeguard the potential benefit of the EHB package, including the following:

•  Reflects an appropriate balance among the categories describes in such subsection, so that benefits are not unduly weighted toward any category
• Does not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life.
• Takes into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups
• Ensures that health benefits established as essential are not subject to denial to individuals on the basis of the individuals’ age or expected length of life or of the individuals’ present or predicted disability, degree or medical dependency, or quality of life.

To read the full list of HDA’s specific concerns, read the full comments here.

Barbara A. Otto

Chief Executive Officer

Health & Disability Advocates

Neighborhood Stories: The Importance of Community-Based Health Organizations

Today, Illinois Health Matters launched the third release in their ongoing multimedia series, Neighborhood Stories. This installment reveals through video and investigative journalism the importance of community based organizations, such as neighborhood health centers and grassroots health coalitions. Such organizations provide a variety of comprehensive services to people in underserved communities, such as the South and West Sides of Chicago, who often do not have health insurance or access to quality, affordable care.
 

In “Community-Based Organizations Play a Critical Role in Reform,” author Jeffrey Steele finds community organizations act as a vital link between the federal level ACA, the state-level policies that result from the act, and the people who will benefit from the health care reform. Steele describes various ways that community organizations in Chicago are helping to implement the ACA. For example, there is an individual in every community-based organization that Celine Woznica, program director for the Asian Health Coalition in Chicago, calls a “mother hen.” They are usually trusted and respected members of community that people come to and ask questions. Inquiries may range from where to go for a flu shot to how to get heating assistance to when to go for citizenship classes. “These staff are the very people who have to be well versed on the Affordable Care Act, and how to help people take advantage of it -- from preventive care to the health exchange,” Woznica says.

Community organizations are integral to distributing accurate information about the health reform process. At Erie Neighborhood House, a west side social service organization and community service agency, they are focusing on more “in person” workshops while other groups may utilize ethnic media and webinars. As Jim Duffett, Executive Director of Campaign for Better Health Care, sums up, “The more people who take ownership at the local level, the stronger we’ll all be in winning comprehensive reform.”

The video, “Wellness on the West Side,” profiles the story of Eliazar Mejia, a woman diagnosed and treated for diabetes at Lawndale Christian Health Center (LCHC). LCHC is a shining example of “coordinated care” – where they provide a multitude of different types of care and programs all in one place. Many people who do not have insurance, such as the 38% of LCHC’s patients, end up letting a health problem develop and worsen until it sends them to the emergency room. LCHC fills the gap between no care and the emergency room for its 60,000 patients. Bruce Miller, the CEO of LCHC, sums up the organization’s overall commitment to its patients: “Our goal as a community-based organization is to provide care for everybody who needs care. Whether they have insurance, whether they don’t have insurance, we’ve never cared. So, as we think about the future, what the impact could be of health care reform, it’s our hope certainly, that many of our uninsured patients will have…better access to care, and will use that care more frequently.”

“Wellness on the West Side” is just one in the Neighborhood Stories series, presented by Illinois Heath Matters. Previous videos profile individuals and families, small businesses, and the importance of a consumer-focused health policy in Illinois. All videos and articles are featured in the “Neighborhood Stories" section of the Illinois Health Matters website, along with articles that share how community organizations, including Health & Disability Advocates, local Chambers of Commerce and others are educating and informing underserved groups about their health care coverage options under the new law. The multimedia series is part of the Local Reporting Initiative, supported in part by The Chicago Community Trust.

Making Progress Toward a Health Insurance Exchange in Illinois

Last week was an important one for Illinois consumers and small businesses as lawmakers inched closer to establishing a state-run Health Insurance Exchange.  

Why is this important? As Timothy Jost, exchange expert writes in a Commonwealth Fund blog: “The health insurance exchange is the centerpiece of the private insurance reforms in the Affordable Care Act (ACA). If the exchanges function as planned, they will expand coverage to more Americans, reduce insurance costs, and improve the quality of coverage and perhaps of health care itself.”  However, if designed poorly, “experts warn, healthy people could avoid the exchanges, leaving them to sicker people with rising premiums."

First, some background:

On July 14, 2011, Senate bill 1555 was passed and signed by Governor Quinn, which created the Illinois Legislative Health Insurance Exchange Study Committee to aid in going forward with the establishment of a health insurance exchange (also known as the competitive insurance marketplace) in Illinois. The legislative study committee held five meetings, and commissioned two reports, one from Deloitte Consulting on the current state of healthcare in Illinois, and the second from HMA/Wakely Consulting Group, on the possible options and directions the exchange could take. On September 27, 2011, the Committee released a draft report of their findings from the five meetings and the two consultant reports. Although no definite decisions were made in the report, it is still the most substantive picture of the Illinois exchange to date.

Response to the Report:

Most of the report focused on the possibilities that Illinois must consider and decisions that must be made regarding the type of governance and the financing of the exchange. Many organizations weighed in with written comments in response to the report. Below are some of the issues and concerns that have been raised over the policy options outlined in the report:

·         The HMA/Wakely report listed two options for the operating model of the exchange: either as a “market organizer” or “market developer.” The market organizer approach means that the exchange would simply certify any health insurance plan that met the requirements for the exchange, relying on the competition of the marketplace to keep the cost of insurance down. The market developer style would have the exchange taking a more active approach to use their leveraging power in order to get the best possible value of plans from insurance agencies. Much support has been shown for the market developer option, aligning the exchange model with the interests of consumers for quality, affordable insurance.

·         Out of the three options presented for the governmental structure of the exchange, the overwhelming majority of opinions expressed have been in favor of a “quasi-governmental” model, as opposed to the “state-run” and “non-profit” models. The quasi-governmental model would keep the exchange in connection with other state-run agencies that it may need to coordinate with and promote a high level of transparency and accountability, while remaining a higher level of political neutrality.

·         The membership of the exchange governing board is one of the hot button topics in the report. The report underscores that members of the board should be well versed in the domain of health care, but should not have conflicts of interest, specifically noting that insurers, agents/brokers, HMOs, Prepaid Service Providers and other individuals with an interest in the Exchange should not be voting members of the board, though they could be members of an advisory committee. Some groups are advocating for a list of constituencies that must be represented on the board (for example, more representative of minority populations who are over-represented among the uninsured), while others think that a list of that nature would cause more problems for the board than it would solve.  Another major concern is whether or not legislators should be allowed on the board. Many groups have expressed their disapproval of legislators holding seats on the board – so that the exchange could be truly independent, non-partisan, and non-political — although some see their presence as non-voting members as a possibility. 

·         To finance the exchange, there are many options on the table, including charging consumers a fee to access the exchange, assessments on health plans offered in the new marketplace, assessments on all Illinois health insurance companies, the use of state general revenue, levying a fee on all health care stakeholders in the state (a list that could include prescription drug and medical supply companies, providers, hospitals, etc.), or assessing a progressive surtax on the revenues of all insurance providers. Many advocacy groups are against the idea of a fee to consumers, as the exchange targets those who are currently uninsured, who typically tend to have lower incomes, and could be put off or prevented from using the exchange if there is a fee. However, there are doubts that a funding option like the insurance revenue surtax would be approved. Some groups have stated that the best option might be for the enacting legislation to leave open the description of funding, so as to allow for multiple sources. 

Stay tuned! The final report will be issued this week and we’ll let you know if there are any changes.

Policy to the People - Illinois Policymakers Weigh In about ACA Implementation in Illinois

Health care reform in Illinois may originate from the federal law, the Affordable Care Act, but it is up to each state to implement many pieces of the law. For that reason, we made Illinois' implementation of health care reform the focus of our latest multimedia Neighborhood Stories series. The video, Policy to the People (by Jay Dunn) is the third in our series, and is accompanied by an article, Making Health the Best Policy (by Jeff Steele).

As health reform policies take shape in Illinois, it is important to make sure they benefit the citizens of the state. In the video, Senator Donne E. Trotter (IL -17th District) explains what he sees as necessary to keep policy geared towards the people, specifically those who are currently uninsured or underinsured. He advocates a “three pronged attack,” that involves policymakers, medical care providers and the citizens and health care consumers themselves, in the establishment of reform. “What we’re looking at,” Sen. Trotter explains, “is not as much what this law is going to do for people like myself, but for the future of America. We’re going to have a healthier society.”

The accompanying article, Making Health the Best Policy, explains the steps that Illinois policymakers have taken since 2010 to establish health care reforms right here in the Prairie State. Those who back the Affordable Care Act are attempting to impart positive messages, to counter the law's opponents working daily to ensure its provisions never go into effect.

We spoke to key policymakers in the Governor's Office, the Department of Health & Family Services (HFS) and the Illinois General Assembly about their vision of how reform will impact west and south siders' ability to gain insurance. Under the new health care law, HFS Director Julie Hamos says: “We believe there will be one million more people who will have access to private health insurance through the exchange, or public insurance through Medicaid...These are people who have not had a doctor, or a health checkup, in many years.” Michael Gelder, Governor Quinn's senior health policy advisor and Chair of the Illinois Health Care Reform Implementation Council says, “People on the west and south sides should see this as an opportunity to get health insurance. They should also see it as an opportunity to make their elected representatives, both federal and state, hear that they’re enthusiastic about [reform], and that they expect us to deliver on that.”

Check out these two great new pieces, as well as the other articles and videos in the Neighborhood Stories section of the Illinois Health Matters website, or on our new high quality Vimeo channel here. Stay tuned for the next installment where we look at how the Affordable Care Act is impacting local community organizations.