Recommendations for How Illinois's Medicaid Managed Care System Can Positively Impact Care for Children with Special Healthcare Needs

Abstract

Introduction: Illinois aims to introduce 29,000 Children with Special Healthcare Needs (CSHCN) into its Medicaid Managed Care (MMC) program starting in 2018. In theory, the care coordination and quality-based incentives in MMC could improve care and reduce healthcare costs for this population. However, other states have experienced issues bringing such complex patients into a system that aims to be streamlined and cost-effective. Due to the large medical costs and complexities of CSHCN, improving care for this population in MMC could lead to a significant number of pediatric health improvements and cost savings across Medicaid. This paper aims to draw on experiences from previous implementations and provide recommendations for states considering this transition, specifically around what requirements to include in insurer contracts and how to ensure insurers are meeting their obligations.Methods: Five areas of focus were selected: reduction of racial and income disparities, ability to monitor and ensure network adequacy, ease of transition into and between managed care providers, adequacy of provider payments, and protection of EPSDT benefits. In each area, a literature review was conducted to identify best practices among states who previously went through this transition. These strategies were separated into recommendations for insurer contracts and recommendations for implementation, and apply to all states who are still looking to integrate CSHCN into MMC. These recommendations were then compared to the Illinois model contract with insurers, to create suggestions specific to Illinois.Results: Contract and implementation recommendations for all states, as well as specific suggestions for Illinois, were provided for each focus area. In each focus area, Illinois had already integrated at least one of the reviews recommendations, but was also missing at least one.Conclusion: Across all focus areas, there were three principal recommendations for states looking to introduce CSHCN to MMC. States would ideally provide CSHCN-specific exceptions in MMC contracts when necessary, attempt to align insurer and state goals through incentive updates, and employ comprehensive monitoring systems to oversee insurer behaviors. These recommendations can be used as a platform for discussion between organizations within the Child Health Policy Collaborative to help shape future research and strategies of the collaborative.

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