Illinois’ All Kids Program

Illinois Department of Healthcare and Family Services

Stephen E. Saunders, MD, MPH

Child Health Services Research Meeting

June 24, 2006

About All Kids First and only state program in the nation to

make sure that every child in Illinois has access to comprehensive and affordable healthcare

Allows most of the 253,000 uninsured children in Illinois who need health coverage to get it

Helps children get to the doctor before they get sick and before a simple problem becomes a major illness

Provides health insurance and prescription coverage at affordable rates

Begins July 2006

Qualifications for All Kids 18 and under Illinois residents No citizenship requirements No income limit Monthly premiums and co-

payments based on a sliding scale, based on income

Current Illinois Medicaid Program

Combined Medicaid and SCHIP Program Income threshold 200% of poverty Family Care 185% of poverty Primarily Fee for Service Voluntary managed care in six counties Over 2 million beneficiaries currently

enrolled One year continuous eligibility

Program Structure An extension of current Medicaid and SCHIP

program; Medicaid and SCHIP - now ALL KIDS Same Medicaid benefit package (minus non

emergency transportation or waiver services) No income limit or asset test, no deductibles Co-pays, premiums and out-of-pocket limits sliding

scale 12-months continuous eligibility No pre existing condition limitations Includes dental Provider reimbursement - same as Medicaid

Eligibility Process One application for entire program Application process:

Mail-in Web Community-based Application Agent At Department of Human Services local office,

located in each county Outreach and PR campaign One eligibility card for entire program

Crowd Out Provisions Must be uninsured since January 1,

2006, or 12 months after December 31, 2006

Exceptions: Parent looses employer sponsored health

insurance Newborn Exhausted life time benefit Child covered by COBRA

Crowd Out Provisions (continued)

Exceptions (continued) Child was covered by Title XIX or Title

XXI and family income changes Custodial parent cannot access non-

custodial parent’s insurance Affordable health insurance

definition applies at redetermination

Premium/Co-Pay 200 – 300% poverty Premium $40/child/month; $80/month - max Co-pay

$10 office visit $7/$3 pharmacy $30 ER $100 hospitalization 5% rate for outpatient hospital Yearly maximum - $500 No co-pay for preventive health care, e.g., well

child visits and immunizations

All Kids Monthly PremiumFPL Per Child Maximum Per

Month

200% - 300% $40 $80

300% - 400% $70 $140

400% - 500% $100 $200

500% - 600% $150 No Max

600% - 700% $200 No Max

700% - 800% $250 No Max

Over 800% $300 No Max

Financing Governor’s key initiative passed General Assembly November 2005 GRF funded – no waivers Cost Savings through implementation of the:

PCCM Program – FY 07 for most Medicaid/SCHIP beneficiaries Disease Management Program -July 1, 2006

Disabled Adults Family Health Population with Persistent Asthma Family Health Population – Frequent Emergency Room users

Implementing PCCM program mid FY’07

Anticipated cost saving secondary to reduction unnecessary ER and Hospitalzation

Provider Buy-In Input into the planning process with

monthly Stakeholders’ meetings 30-day payment cycle for physician

services, starting July 1, 2006 Pediatrics rate increases for selected

preventive visit and E & M codes - January 1, 2006

Support by ICAAP and IAFP

Provider Payment Providers will be responsible for collecting

co-payments under All Kids (similar to private insurance)

Providers may elect not to charge co-pays Providers are not required to deliver

services when co-pays are not paid Provider will be reimbursed under

established rates minus cost sharing co-payments

Reimbursement Rates:Select Examples

CPT 99214 - E & M office visit, established patient ($72.97)

CPT 99381 – Preventive office visit, initial evaluation, healthy infant ($91.90)

CPT 99384 – Preventive office visit, initial evaluation, adolescent ($104.96)

Conclusion Healthcare reform is possible with political

will and buy-in Medicaid package of services

comprehensive and is a model benefit package

Medicaid structure provides an efficient platform to build upon – has an established payment, claims processing system and provider enrollment processes

Conclusion (continued) Packaging the program to look like

health insurance should further eliminate “stigma” of welfare

Sliding fee scale allows higher income families who lack insurance for their children to purchase affordable health care with the benefit of a large risk pool

Outreach and simplified enrollment is key