Illinois Braces Itself for a Change in Public Health Care System

Beginning as early as mid-January 2008, a change in Illinois’s health insurance programs will affect all people enrolled in Medicaid, All Kids, and FamilyCare. Once this change is put into effect, patients wishing to seek medical care (such as treatment from a specialist) outside their “medical home” must first receive a referral from their regular doctor.

The “medical home” model ensures that all are connected to a regular doctor or clinic aware of their medical history and therefore able to coordinate the best possible medical care for them. Although this change is essentially a positive one in that it offers a system of accountability and creates more reliable patient-physician relationships, people must be well informed of this upcoming change in order to avoid problems.

If patients do not get proper referrals from their regular providers, they may be refused care from doctors outside their “medical home.” Doctors must check the referral status of any new patients coming into their offices, particularly in the case of specialists. Once this system change is put into effect, doctors will be denied payment by the state for treatment of patients seen without referrals. 

How the Program Will Work

Patients enrolled in Medicaid, All Kids, or FamilyCare are simultaneously enrolled in a program called Illinois Health Connect. Patients choose a health plan and primary care provider (PCP) to act as their regular doctor. The PCP’s office is the patient’s “medical home,” the place where the patient goes for all basic medical needs and necessary referrals to other physicians and specialists.

Patients living in Cook, Madison, Perry, Randolph, St. Clair, and Washington counties may choose from two different kinds of health plans. The first is a fee-for-service plan under which the state pays doctors back for every service provided. The second is a Managed Care Plan  where doctors receive a flat rate for each patient regardless of the treatments they provide.

In the other 98 counties in Illinois, people enrolled in state health insurance programs will receive fee-for-service care.
 

How to Avoid Noncompliance

According to representatives from the Illinois Department of Healthcare and Family Services (IDHFS), state computers as early as mid-January will begin rejecting claims if they are not accompanied by a PCP referral. In order to make a referral, a PCP must  register the referral with Automated Health Systems—the administrator contracted by Illinois to recruit doctors, enroll patients with a “best fit” provider, and track referrals to ensure that appropriate payments are made. Doctors can register referrals via the Internet, phone, or fax. PCPs should give the patient’s name, ID number, address, and phone number and the PCP’s IDHFS provider number and that of the referred doctor. Once a referral is made, the patient has the responsibility of following up with the specialist and making an appointment. The PCP must include a date range for the referral. When a referral expires, patients must renew it with their PCP or risk being denied care.

Referrals Not Required for All Services

Some services do not require referrals and are considered direct access services. Health care needs that necessitate immediate care such as emergency room and ambulatory services or direct inpatient admissions to hospitals may be served without first obtaining a PCP referral. Family planning, obstetrics and gynecology visits, mental health care, substance abuse care, and sexually transmitted disease treatments do not require referrals from PCPs because they are considered personal health care. Visit www.illinoishealthconnect.com for more information on which services do not require referrals. 

Providers will receive notice from IDHFS when the official start date of the “no-referral, no-payment policy” is determined. According to IDHFS representatives, there may be a month-long test period to ensure that things run smoothly. However, this is unconfirmed. The state has been rolling out this new system for over a year, matching people up with regular doctors or clinics and getting them used to the idea that they need to start getting referrals to see any doctor who is not their primary care physician. IDHFS has implemented this new system such that patients in Illinois can continue to count on their doctors for coordinated, appropriate health coverage focused on primary care, prevention, and appropriate treatment.

For more information, contact Melissa Cubria at 312.368.1168