- An ACE is a provider-organized entity on a three-year path from care coordination fees and shared savings to pre-paid capitation with partial risk and finally to full-risk capitation. ACEs are aimed at adults and children, with an option to enroll new eligible adults under the Affordable Care Act
A CCE is a collaboration of providers and community agencies (organizations), governed by a lead entity that receives a care coordination payment in order to provide care coordination services for its Enrollees. The collaboration must include, at a minimum, participation from primary care physicians, hospitals, mental health providers, and substance abuse providers. CCEs are aimed at children with complex medical needs.
A MCCN is an entity other than a Health Maintenance Organization, that is owned, operated, or governed by providers of health care services within Illinois 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. MCCNs are aimed at seniors and persons with disabilities.
Eligible Patient Population: The initial solicitation for provider proposals to form Care Coordination Entities (CCEs) or Managed Care Community Networks (MCCNs) under the Care Coordination Innovations Project identified the eligible patient population as:
Enrollees in a CCE must also be enrolled in Illinois Health Connect, the state’s Medicaid primary care case management program. Medicaid beneficiaries who are enrolled in a managed care organization are not eligible to enroll in a CCE. Initially, the choice to enroll in a CCE or MCCH is voluntary.
Provider population: ACEs must include primary care, specialty care, hospitals, and behavioral health providers. CCEs are required, at a minimum, to include primary care providers, hospitals, mental health providers, and substance abuse providers. The matchmaking tool developed by the Illinois Department of Healthcare and Family Services allows community partners interested in forming a CCE to search for a range of potential partners, including general hospital, primary health clinic, public health, home health, hospice, medical equipment, social service/community-based, and dental partners.
Primary care physicians may be enrolled in more than one CCE or MCCN.
Attribution: Enrollees select an ACE, CCE or MCCN and are locked into their choice for 12 months; they may change CCEs or MCCNs during an annual open enrollment period.
Scope of Services: Entities applying to participate in the Care Coordination Innovations Project as an ACE, CCE or MCCN must be able to coordinate care across the spectrum of the health care system with a particular emphasis on managing transitions between levels of care and coordination between physical and mental health and substance abuse.
Under Public Act 096-1501, care coordination must include providing or arranging for a majority of care around the patient’s needs, including a medical home with a primary care provider, specialist services, diagnostic and treatment services, mental health and substance abuse services, inpatient and outpatient hospital services, and rehabilitation and long-term care services.
The initial solicitation for proposals specifies that MCCNs must, at a minimum, assume risk for services included in Service Package I of the state’s Integrated Care Program: all standard Medicaid medical services, such as physician and specialist care, emergency care, laboratory and X-rays, behavioral health, pharmacy, behavioral health and substance abuse services.
The Care Coordination Innovations Project is an initiative within the Illinois Department of Healthcare and Family Services to meet a legislative mandate that 50 percent of Medicaid beneficiaries be enrolled in coordinated care by 2015. This mandate—and the definition of “coordinated care”—was passed as part of Public Act 096-1501 in 2011.
An Accountable Care Entities (ACE) is defined as “An organization comprised of and governed by its participating providers, with a legally responsible lead entity, that is accountable for the quality, cost, and overall care of its Enrollees.”
Care Coordination Entities (CCEs) are collaborations of community providers and community agencies. Groups of providers that wish to become a CCE may create a new corporate entity or they may designate a lead entity to serve as the legal entity responsible for executing the CCE contract with the state.
Managed Care Community Networks (MCCNs) are entities that are owned, operated, or governed by health care providers; MCCNs must submit their articles of incorporation and by-laws with their application.
Each organization works under contract with the Illinois Department of Healthcare and Family Services.
|Criteria for Participation||
Under the initial solicitation for proposals under the Care Coordination Innovations Project, organizations bidding to become Care Coordination Entities (CCEs) or Managed Care Community Networks (MCCNs) must:
Coordinated Care Entities (CCEs) may choose from three risk-based payment models (full payment is contingent upon adequate performance on specified quality measures):
CCEs may choose more than one of the reimbursement options. CCEs may also propose alternative reimbursement methodologies to fee-for-service for medical services.
Managed Care Community Networks (MCCNs) operate under a capitated payment structure. Portions of the capitation rate are withheld and paid based on the MCCN’s performance in meetings quality measure targets.
Accountable Care Entities will receive care coordination payments and receive shared savings for the first 18 months of their operation. For months 19 through 36, ACEs will transition to pre-paid capitation with pay-for-performance incentives. Beginning in the fourth year of operations, CCEs will receive full risk-based capitation payments.
|Support for Infrastructure||
The state has developed a matchmaking database to help potential collaborators to identify other entities that may be interested in participating in a Coordinated Care Entity (CCE) or Managed Health Care Network (MCCN).
The state may also advance a portion of the care coordination fees to fund start- up costs, such as investments in health information technology (HIT); advance payments made will be recouped from future care coordination payments on a negotiated schedule.
Accountable Care Entities (ACEs) are expected to build infrastructure (including HIT and data analytics) to support care management among providers participating in the ACE’s network.
|Measurement and Evaluation||
Appendices to the initial solicitation for proposals under the Care Coordination Innovations Project contain a number of quality measures that will be used to hold the provider-organized Care Coordination Entities (CCEs) and Managed Care Community Networks (MCCNs) accountable for the quality of care provided to enrollees. Payments under the risk-based payment models for CCEs and full capitation rates for the MCCNs will be tied to seven of these measures in particular. These seven metrics are measures of:
Draft performance measures for Accountable Care Entities (ACEs) contain a number of measures of: