Ensuring Affordable Healthcare for All Children in Illinois through the All Kids Program

2. Illinois’ All Kids Program Illinois Department of Healthcare and Family Services Stephen E. Saunders, MD, MPH Child Health Services Research Meeting June 24, 2006

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. All Kids Monthly Premium

12. 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

13. 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

14. 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

15. 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)

16. 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

17. 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