When Angelica Hernandez received a letter from the state telling her to pick a Medicaid managed-care plan for her daughter, the Naperville, Illinois, woman chose one that included the doctor’s office where she had always taken the 10-year-old girl.
After selecting the plan, Hernandez learned it didn’t cover the audiologist who had fitted her daughter, who is partially deaf, with a hearing aid. A Spanish speaker, Hernandez said through a translator that she was told it would cost at least $400 to see the audiologist under her new plan, and she has not gone back.
Officials at the Illinois Department of Healthcare and Family Services say they have tried to avoid disruptions of care as the state shifts 2.2 million of its 3.1 million Medicaid patients to managed care, a system in which the state pays a fixed amount for each patient instead of reimbursing providers for each test and treatment.
But some patients are reporting difficulties keeping their doctors and confusion navigating plans as they try to make the shift.
The reports include wrong information on websites for insurance plans and hospitals; hours on the phone with insurers, hospitals and a state contractor who helps with enrollment; conflicting letters in the mail; changes to prescriptions, and other frustrations. For Hernandez, the change has meant she will need to find another audiologist for her daughter.
Some doctors say the state is reassigning their patients to new offices and has created new administrative requirements that burden their practices, delay care for patients and slow payments from insurers.
“I hope this works out and is better for patients and more efficient for the state, but right now it’s been extremely challenging for all parties,” said Dr. Donald Luyre, a vice president of the Illinois Academy of Family Physicians and CEO of Elmhurst Clinic.
A state Medicaid official said the confusion is due to the speed and scope of the change — mandated by the Illinois General Assembly in 2011 — and not permanent flaws in the new system.
“Eventually, people will be able to get to the network that best serves them,” said James Parker, acting director of the Department of Healthcare and Family Services’ Division of Medical Programs.
The 2011 law required 50 percent of the state’s Medicaid population to be enrolled in managed care by Jan. 1 of this year. Illinois had enrolled about 1.6 million as of Feb. 1, said Department of Healthcare and Family Services spokesman John Hoffman. Parker has said the department plans to enroll 600,000 more this spring.
Officials have said the change will improve patient care and stabilize spending in a budget that is projected to grow to about $20 billion for fiscal year 2015. Managed care’s per-patient payments encourage providers to try to keep people healthy, which in turn should reduce costly emergency room visits and inpatient hospital stays, proponents of the system say.
But Sharon Post, director of the Health and Medicine Policy Research Group’s Center for Long-Term Care Reform, worries that the program’s rocky start might create lasting mistrust that could hinder managed care’s success.
“If it starts out feeling like this is a thing being done to me — either from the position of the patient or the Medicaid provider — then they’re not going to go along,” she said. “That really starts putting cracks in the foundation of reforming Medicaid.”
The state sends letters to Medicaid recipients listing plans available in their area — often more than a dozen — and informing them they have 60 days to pick one or be automatically assigned. So far, almost exactly half of managed-care patients have selected plans themselves, Parker said.
To help navigate the new system, the state is giving many patients an additional 90 days to switch plans after first enrolling, he said.
Patients who are auto-assigned are enrolled according to an algorithm that is meant to minimize disruptions to care, Parker said.
The algorithm keeps patients with their primary care physician, he said. If they don’t have one, the algorithm assigns them a plan based on more general medical claims data or, if they don’t have claims, usually to a plan with the lowest enrollment within 5 miles of where they live, he said.
But sometimes it doesn’t work as intended, doctors said.
Dr. Eddie Pont, an Elmhurst pediatrician who sits on the state’s Medicaid Advisory Committee, estimates his DuPage County practice has lost about 30 percent of its patients to an auto-assignment quirk.
Pont said the practice’s doctors decided to participate in a new type of care coordination group, called an accountable care entity, in which hospitals and providers take on the billing functions normally handled by an insurer. His practice joined Loyola Family Care, only to learn that the entity doesn’t cover every area in which his patients live. Those living outside the ZIP codes Loyola Family Care covers could not enroll.
His practice chose not to participate in any other health plans. Pont didn’t know about Loyola Family Care’s geographical limitation beforehand, he said, despite closely monitoring the managed-care rollout as an advisory committee member.
“Because things have moved so quickly, and with so little explanation, it’s been very frustrating and confusing for a lot of providers,” Pont said.
Incomplete information on plans and networks has required doctors and their staff to spend more time on administrative tasks, doctors said.
Plans cannot always verify that they cover a given patient, and providers get stuck proving the patient is in the plan before they can get paid, said Dr. Timothy Wall, a pediatrician and founder of Pediatric Health Associates.
Unlike traditional Medicaid, managed care requires patients to get a referral from their primary care physician to see a specialist. But which specialists are covered in each plan can be difficult to determine, doctors said. Wall said his employees sometimes spend up to two hours on the phone, plus added time on paperwork, to complete referrals.
Several doctors said the state could have better prepared them for the switch.
“We were not properly informed about all the inconveniences that were going to be faced,” said Dr. Walter D. Perez, owner of A to Z Pediatric and Youth Healthcare in Addison.
His administrators sometimes spend hours helping confused patients choose plans, Perez said. He estimates about 20 percent of his practice’s 1,000 Medicaid patients — most of whom are Hispanic — have been switched to another plan. He said he has gained new patients too, which shrinks his net loss.
At the start of the managed-care rollout, his office accepted only two plans, Family Health Network and Harmony Health Plan, Perez said. The state halted auto-assignments into both plans for a time because they were not meeting quality requirements, so assignments to his office stopped, he said. The sanctions have since been lifted for both plans, officials said.
State officials say they did all they could on a short timeline set by lawmakers to perform the state’s biggest change in health care in decades.
“Certainly we do understand that there is confusion out there, and I wish we would have had the time to do more education,” said Parker.
But he assigned some of the blame to providers, who he said resisted the change and were slow to join plan networks, despite knowing the 2015 deadline was coming.
“You can’t start educating people about what’s in a network until those networks are developed,” Parker said.
Kyle Holder, a 27-year-old mother of two who lives on the South Side of Chicago, said she has become an expert in recent weeks on managed care’s obscure world of plans and networks. She estimates she has spent around 20 hours trying to find a plan since she got a managed-care letter dated Jan. 9.
Some health plans list hospitals on their websites that aren’t in their networks, and some hospitals list plans that don’t include them, she said. Some listed plans or providers that accept only certain groups of patients, such as senior citizens, people with disabilities or childless adults.
Holder wants a plan that will let her keep her OB-GYN and will cover nearby Silver Cross Hospital in case she needs reproductive surgery or has another child.
Her situation became more complicated when her OB-GYN relocated to a suburb. She hasn’t been able to find a plan that covers both the OB-GYN and the local hospital.
“It’s just really frustrating, and it’s hard,” she said.
Some elements may be removed from this article due to republishing restrictions. If you have questions about available photos or other content, please contact email@example.com.