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Cheatography

Types of Managed Care Entities Cheat Sheet (DRAFT) by [deleted]

Expalnation of the latest Entities in Managed care

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Accoun­table Care Entities (ACEs)

New model of an integrated delivery system created under Public Act 98-104 that must have the following elements:
Organized by providers and able to coordinate a network of Medicaid services.
Initially enroll children and their family members.
Large enough to have impact on popula­tions
A minimum number of providers in certain areas: primary care, specialty care, and behavioral care, including a hospital.
A governance structure that includes each provider type.
An infras­tru­cture to support care management functions
ACEs providers will get reimbu­rsement through the fee-fo­r-s­ervice program.

Care Coordi­nation Entities (CCEs)

An altern­ative model of delivering care to Medicaid clients through provid­er-­org­anized networks.
A collab­oration of providers and community agencies, governed by a lead entity that receives a care coordi­nation payment in order to provide care coordi­nation services for its Enrollees.
Medical services are paid on a fee-fo­r-s­ervice basis.
CCEs serve Seniors and Persons with Disabi­lities (SPD) population

Children with Special Needs (CSNs)

Alternative model of delivering care to Medicaid clients through provid­er-­org­anized networks, initially organized around the needs of our most complex children.
These provid­er-­based networks will be organized as Care Coordi­nation Entities (CCEs).
Enrollees in a CSN CCE will be limited to children that the Department has identified through claims data or other inform­ation as having complex medical needs.
 

Managed Care Types

Managed Care Organi­zations (MCOs)

As defined under the Health Mainte­nance Organi­zation Act (215 ILCS 125/1-1 et seq.).
They are paid on a full-risk, capitated basis, and therefore pay all claims for services for the enrollees in their Health Plan.

Managed Care Community Networks (MCCN)

A MCCN is an entity, other than a Health Mainte­nance Organi­zation (HMO), that is owned, operated, or governed by providers of health care services within the state and that provides or arranges primary, secondary and tertiary managed health care services under contract with the Department exclus­ively to persons partic­ipating in programs admini­stered by the Depart­ment.
The MCCN contract for care coordi­nation is very similar to the HMO contracts, with variances in the financial requir­ements of the MCCN and regulatory oversight by HFS instead of the Department of Insurance.