Medicaid Managed Care for Providers

The Illinois Department of Healthcare and Family Services (HFS) has expanded its Medicaid managed care program.

Effective Feb. 1, 2020, enrollment in a HealthChoice Illinois plan will be mandatory for children with special healthcare needs. This includes children receiving SSI, disabled children and most children receiving care coordination through the DSCC Core Program. Children who are Home Care Program participants (Medically Fragile Technology Dependent Waiver) or who are enrolled in the Nursing and Personal Care Services program continue to be excluded from managed care.

We strongly encourage you to consider establishing a contract with each of the HealthChoice Illinois health plans in your coverage area. Through these contracts, you will be able to continue to care for your patients who transition to managed care.

Please note there is a 180-day transition period beginning Feb. 1, 2020, for out-of-network providers. During the transition period, health plans will pay all Medicaid claims at the current fee-for-service rate. Providers must adhere to health plan procedures regarding referrals and preauthorization of treatment.

After the 180-day transition period ends, participants will not be able to continue care or receive services from a provider who has not contracted with the health plans to provide care unless they sign a Single Case Agreement or are granted prior authorization from the health plan responsible for the participant.

We encourage you to discuss this transition with your patients and direct them to helpful resources. DSCC has developed a list of questions to help families select the best health plan for their unique needs. It is called the “MCO Selection Tip Sheet for Families.”