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 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.