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Managed Care 

 

Illinois Department of Healthcare and Family Services (HFS) operates a voluntary managed care program for participants in three northern counties, including Cook County, and several downstate counties. The two types of Managed Care Organizations are Health Maintenance Organizations (HMOs) and Managed Care Community Networks (MCCNs), and they are all contracted to provide comprehensive, medically-necessary services to clients.

HMOs are risk-bearing entities licensed through the Illinois Department of Insurance. MCCNs are risk-bearing provider-sponsored organizations within Illinois that have been certified as such by HFS. HMOs and MCCNs are paid a flat monthly rate for each participant enrolled. The rate paid is based upon the client's age and gender, without regard to the amount or cost of services provided.

The Illinois Department of Healthcare and Family Services operates a mandatory managed care program called the Integrated Care Program for participants in Suburban Cook (in zip codes that do not begin with 606), DuPage, Kane, Kankakee, Lake and Will Counties. Two Health Maintenance Organizations (HMOs) are contracted to provide the full spectrum of Medicaid covered services to older adults and adjults with disabilities who are eligible for Medicaid but are not eligible for Medicare.

HMOs are risk-bearing entities licensed through the Illinois Department of Insurance. Reimbursement to the HMOs is a flat monthly rate for each participant enrolled. The rate paid is based upon the client's condition, without regard to the amount or cost of services provided.

Contracts with the HMOs contain performance measures, some of which are pay-for-performance measures, under which the HMOs can earn up to five percent of their capitation payment in incentives. Performance measures are pre-established targets the HMOs can be rewarded for when delivering quality healthcare services.