Health and Hospital Systems Board Meeting March 28, 2014

Once committee reports were approved, all without disagreement, most of the meeting consisted of a presentation by Steven Glass, Executive Director, Managed Care, on the board approval request for services by IlliniCare Health Plan, Inc. to provide third party administrative services, managed care, and clinical services for CountyCare at a cost not to exceed $1,795,970,071.00 over the five year contract term.  Dr. Raju prefaced the presentation by explaining that CCHHS anticipates having more than 100,000 patients enrolled in CountyCare, but lacks the expertise to manage this population.  The funding will come from the federal government, and 88% of funds will be used for patient care, rather than administration.  Already 567,000 claims have been validated for CountyCare services.

In his presentation, Glass explained that, under this contract, IlliniCare Health Plan, Inc. will provide managed care expertise and services as well as business support for the operations of CountyCare. The contract consolidates and transitions three existing contracts for: claims processing and payment, provider and member services; behavioral health benefits management services; and pharmacy benefits management services into one.  Since optometry is now a Medicaid approved service, optometry benefits management is also included in this contract.  The four pieces of the contract are:

1.  Administrative services, including claims adjudication, processing and payment; financial reporting and support; provider and member services.  These and similar services total 11.8% or an estimated $212,744,000 over the 5-year contract term, calculated on a per member per month (PMPM) assuming 115,000 CountyCare members.
2. Managed Care Services and Support. As CountyCare's TPA (Third Party Administrator), IlliniCare will provide care coordination and case management, nurse hotline, quality assurance, and utilization management, totaling 14.4% or an estimated $257,646,000 over the 5-year contract term, again assuming a PMPM payment basis for 115,000 CountyCare members.
3. IlliniCare subcontracted benefits management services: IlliniCare will subcontract for benefits management services for pharmacy, behavioral health and optometry through the existing subsidiaries' management networks of IlliniCare's parent company, Centene Corp.  These services total 7.2% or an estimated $129,168,000 over the 5-year contract term.
4. Payments to CountyCare network providers and approved out-of-network  providers.  IlliniCare will transmit payments owed by CountyCare to network providers, including contracted FQHCs, participating hospitals, ancillary providers, pharmacies, as well as to approved out-of-network providers.  These costs represent 66.6% or an estimated $1,195,850,842 over the 5-year contract term.

Once board member questions were addressed, the approval request was unanimously approved.  During the second quarter of 2014 CountyCare will transition to a Managed Care Community Network (MCCN), and additional contract and procurement item requests were approved without disagreement to process claims payments and provide managed care services through June 30, 2014. 

Currently, 147,000 CountyCare applications have been initiated, 118,000 submitted, and 87,000 approved.  CountyCare is compensated at a per member payment rate of $632.48 x 87,000 current members = approximately $70,000,000 per month to cover all services.  CountyCare has 138 primary care sites and 38 hospitals in its network

Currently: 43+% of care provided by CCHHS is uncompensated; 22+% is covered by Medicaid; 20+% by CountyCare, and 11+% by Medicare.

Dr. Raju, departing now for his new position as CEO of New York City's health and hospital system, spoke movingly of his experience with CCHHS as the "greatest job of my professional career" and acknowledged the board for its support in maintaining the CCHHS mission of service while getting its financial house in order.  Chairman Carvalho introduced a resolution of appreciation to Dr. Raju, as board members affirmed Dr. Raju's transformation of CCHHS in his 2 1/2 years and warmly applauded his contribution.  Dr. Raju received a rousing standing ovation by all meeting attendees before the meeting adjourned to closed session at 10:30.

submitted by Linda Christianson