|Illinois's Department of Healthcare and Family Services New Health Care Program: Illinois Health Connect||
Last updated: September 2012
Illinois Health Connect is a new health care program of the Illinois Department of Healthcare and Family Services. Illinois Health Connect helps most patients receiving medical public assistance—All Kids, Moms & Babies, and FamilyCare recipients—obtain a medical home for all of their medical needs.
Automated Health Systems
The Illinois Department of Healthcare and Family Services contracted with Automated Health Systems to launch and administer Illinois Health Connect. Automated Health Systems is responsible for recruiting, educating, and supporting providers as well as assisting participants in enrolling with a "best fit" primary care provider.
In the six counties that offer enrollment into voluntary health plans, the Department of Healthcare and Family Services has contracted with Automated Health Systems to be the client enrollment broker to provide unbiased participant education about and enrollment with a health plan and a primary care provider.
A medical home is where patients go to see their primary care provider. A medical home—a solo or group practice, clinic, or health center—houses a patient’s medical records.
Most people with an Illinois Department of Healthcare and Family Services or All Kids medical card must join Illinois Health Connect.
A PCP will provide direct access to enrollees through an answering service/paging mechanism or other approved arrangement for coverage twenty-four hours a day, seven days a week (24/7). Enrollees should contact their PCP for directions on how to contact him/her when the office is closed.
If an enrollee cannot reach their PCP after-hours or one the weekend, the enrollee can call the Illinois Nurse Helpline for help. The Illinois Nurse Helpline phone number is 1-800-571-8094 (TTY: 1-800-571-8419). The call is free.
A referral is an authorization provided by a primary care provider to enable an enrollee to seek medical care from another provider. A PCP will make medically necessary referrals to HFS enrolled providers including specialists, as needed.
Providers can call the Illinois Health Connect Helpline to access the Referral Resource Directory. This useful tool assists providers and enrollees in identifying medical professionals and community-based agencies that can help address the patients’ medical and other (e.g. WIC, transportation) needs.
No. If the physician accepts a client as an Illinois Department of Healthcare and Family Services medical assistance patient, the physician may not charge the patient for covered services.
No. The provider would not be paid for its services until a referral is entered from the client’s primary care provider.
Yes, referrals made by Illinois Health Connect PCPs may be backdated a maximum of 14 days prior to the date the referral is logged into the system. Specialists should attempt to obtain a referral from the primary care provider before providing services; however, if the care is urgent and a prior referral cannot be obtained, the specialist may provide the service, and the primary care provider may enter a referral after the fact. If a specialist believes that a primary care provider is unreasonably refusing to enter a referral, the specialist can request the Illinois Department of Healthcare and Family Services to review the situation.
No. Only the patient’s primary care provider may enter referrals.
Each managed care organization has different criteria for review of medical necessity.
Managed care organizations are required to provide all services covered by their contract, either through an in-network provider or, if necessary, through an out-of-network doctor. Managed care organizations handle situations of this kind on a case-by-case basis.
Illinois Health Connect and the managed care organizations have complaint procedures for clients having difficulty obtaining a referral.
Yes. When physicians enroll with the Illinois Department of Healthcare and Family Services, they agree to accept payment in full from the department for covered services. If a physician accepts a client as an Illinois Department of Healthcare and Family Services medical assistance patient, the physician may not charge the patient for covered services.
Non-emergency patients are triaged and referred to their primary care providers for follow-up. The ER claim will be paid since all ER services are direct access.
Primary care providers can review claims data that the Department of Healthcare and Family Services receives for their patients. Providers should call Automated Health Services at 1-866-912-1999 to request this information.
A patient can pick a Primary Care Provider in 3 ways: calling the Illinois Client Enrollment Broker Helpline at 1-877-912-8880 (TTY: 1-866-565-8576), going online at Illinois Department of Healthcare and Family Services, completing and mailing the enrollment form to the Illinois Client Enrollment Broker.
If a patient calls the Illinois Client Enrollment Broker Helpline, an Illinois Client Enrollment Broker representative will assist the patient by providing education on the patients health care choices, picking a health plan that will best meet their medical needs—Illinois Health Connect, Harmony Health Plan, or Family Health Network, picking a PCP in that health plan and enrolling the patient with the health plan and PCP. Patients can also obtain information on their health care choices, pick a health plan and PCP and enroll online at Illinois Department of Healthcare and Family Services.
A patient can pick a Primary Care Provider in 3 ways: calling the Illinois Client Enrollment Broker Helpline at 1-877-912-8880 (TTY: 1-866-565-8576), going online at Illinois Department of Healthcare and Family Services, or completing and mailing the enrollment form to the Illinois Client Enrollment Broker.
If a patient calls the Illinois Client Enrollment Broker Helpline, an Illinois Client Enrollment Broker representative will assist the patient by providing education on the patients health care choices, picking a health plan that will best meet their medical needs—Illinois Health Connect OR Harmony Health Plan, picking a PCP in that health plan and enrolling the patient with the health plan and PCP. Patients can also obtain information on their health care choices, pick a health plan and PCP and enroll online at Illinois Department of Healthcare and Family Services.
Illinois Health Connect is a Primary Care Case Management (PCCM) model of health care that combines some components of managed care and fee-for-service. Unlike the Managed Care Organization, the PCP is not at financial risk for the services provided.
Family Health Network and Harmony Health Plan are Managed Care Organizations (MCOs), which is a model of health care that is based upon managing care to improve quality and reduce costs. The MCO is at financial risk for the services provided and is paid a monthly premium or capitation payment for each member enrolled in the health plan.
Patients in Cook, Madison, Perry, Randolph, St. Clair, and Washington Counties can switch their health plan by calling the Illinois client enrollment broker at 1-877-912-8880 (TTY: 1-866-565-8576). The call is free. Patients who want to change their health plan from an MCO to another MCO, or from Illinois Health Connect to a MCO may need to allow two to six weeks for the change to become effective.
A patient can pick a Primary Care Provider in 3 ways: calling the Illinois Health Connect Helpline at 1-877-912-1999 (TTY: 1-866-565-8577), going online at Illinois Health Connect, or completing and mailing the enrollment form to Illinois Health Connect.
If a patient calls the Illinois Health Connect Helpline, an Illinois Health Connect representative will assist the patient by providing education on the patient’s health care choices, picking a PCP in Illinois Health Connect and enrolling the patient with the PCP. Patients can also obtain information on their health care choices, pick a PCP and enroll online at Illinois Health Connect.
If a patient has been regularly seeing a primary care provider who accepts the patient’s medical card, and is enrolled as a PCP in Illinois Health Connect, the patient more than likely can pick that provider for their PCP. Automated Health Systems is now actively enrolling HFS enrolled providers in Illinois Health Connect.
Note: If a provider wants to continue seeing Medicaid patients, the provider must enroll in Illinois Health Connect.
Yes. Patients may change their primary care providers for any reason once a month. Patients enrolled in Illinois Health Connect must call 1-877-912-1999 (TTY: 1-866-565-8577). The change is effective within 24 to 48 hours. Patients enrolled in Harmony Health Plan or Family Health Network should call their health plan to change providers.
Yes. The Illinois Health Connect website and the Illinois Client Enrollment website will list the names of primary care providers from whom clients can choose for their medical home.
Yes. A client may choose a primary care provider outside Illinois as long as the primary care provider is enrolled in the Illinois Health Connect Program.
Yes. Patients can see if primary care providers speak languages other than English.
If a client in a managed care organization moves to an area not covered by the client’s managed care organization, the Department of Healthcare and Family Services may immediately disenroll the client from the managed care organization, if necessary, to access care. This is done only on a case-by-case basis with proof of the client’s new address.
If a client does not enroll with Illinois Health Connect, the client will be auto assigned to a provider. When auto-assigning clients, Illinois Health Connect will take into account existing provider-client relationships/health plans, the primary care providers of other family members, location, and language preference.
No. Clients not currently in a managed care organization would be auto assigned only to Illinois Health Connect.
Clients are auto assigned to their respective managed care organizations.
As of February 2007, all enrollments for clients in Cook county will be directed to the Illinois client enrollment broker for processing; however, managed care organizations can continue to market and provide assistance in completion of the Illinois Client Enrollment Broker Enrollment form or otherwise direct participants to the Illinois client enrollment broker to enroll.
For a physician, 1,800 patients, and for a resident, nurse practitioner, midwife, or physician assistant, 900 patients.
PCPs can limit their panel size by age, zip code, or existing patients.
No. The provider sets the limit of how many patients the provider accepts; the provider simply cannot exceed the maximum set by the state. The provider may also opt out of the auto assignment process.
Yes. The faster payment cycles apply to all Illinois Health Connect physicians’ claims for both children (30 days) and adults (60 days).
Should the Department of Healthcare and Family Services allow, for example, advanced nurse practitioners in an area to enroll directly as primary care providers, they would have to meet all of the requirements for a primary care provider.
An optional program, Your Healthcare Plus aims to help clients who suffer from chronic health conditions. Approximately 205,000 patients HFS covered beneficiaries are eligible for the program.
McKesson Health Solutions manages Your Healthcare Plus.
No. Your Healthcare Plus is a resource to support and assist, not replace, the primary care provider.
Chronically ill patients are found through the state’s history of claims for services for individual patients. Your Healthcare Plus reaches out to the targeted patients by mail, phone and visiting their homes, neighborhoods, and the like.
Your Healthcare Plus pairs each patient with a special medical team composed of nurses and health educators. The medical team coordinates care with the patient’s primary care provider and specialists in order to give the patient the best care possible. Depending on a patient’s needs, members of the patient’s health team may visit the patient to ensure that the patient is maintaining a healthy lifestyle and is following doctor’s orders.
The Disease Management program, Your Healthcare Plus, generally serves the chronically ill beneficiaries of Illinois Health Connect – children/adults with asthma, persons with disabilities, and frequent users of the emergency room. Only the state can refer into the program; however, if there are any questions about eligibility please contact Your Healthcare Plus at 1-800-973-6792; (TTY: 1-888-317-2697).
While the Department of Healthcare Family Services and Automated Health Systems are focusing on the enrollment of primary care providers, Automated Health Systems will be recruiting specialists, and will maintain a referral resource directory to assist patients and providers in locating specialist and other services that may be necessary.
Illinois Health Connect and the Illinois Client Enrollment Broker will begin mailing the initial enrollment packets in February 2007 in the Cook and Collar Counties and proceed through the Northwest Region and the Central and Southern Regions of Illinois in the following months.
15 days after the initial enrollment package is mailed, Automated Health Systems will send out a reminder notice informing clients that they need to pick a PCP, and if applicable a health plan. Automated Health Systems will also attempt two outgoing calls to enroll clients. If a client has not picked a PCP within 30 days of the initial enrollment package, a second enrollment package will be mailed. This enrollment package will identify the PCP, and health plan if applicable, the client will be assigned to if they do not make a choice.
The Department of Healthcare and Family Services will not allow implementation in any area without an adequate network.
Automated Health Systems, the Department of Healthcare and Family Services’ administrator for Illinois Health Connect, will have staff located in many Family and Community Resource Centers throughout Illinois. Staff will be strategically placed in offices where the state anticipates a high volume of potential enrollees. The state will provide contact information once the plan for positioning Illinois Health Connect specialists in the local DHS Offices is finalized.
Automated Health Systems is working with HFS to determine if that will be possible and also if Illinois Health Connect can transfer to All Kids.
Outpatient services that require a doctor’s order will not require a referral, such as x-rays, CT scan, MRI, etc.
These children will be considered under the presumptive eligibility program of All Kids and therefore will be excluded from IHC until they receive full All Kids eligibility. Once they do they will need to choose a plan and a PCP.
During the interim, if the guardian calls Illinois Health Connect we will help them find a physician in their area but will not be able to enroll them into Illinois Health Connect and assign a PCP until their All Kids application is approved and they receive their Medicaid number.
Those eligible Medicaid individuals living in Cook County should call 1-877-912-8880 (Illinois Client Enrollment Broker) to choose a plan, but 1-877-912-1999 (Illinois Health Connect) to change their PCP within Illinois Health Connect. Those not in Cook County should call 1-877-912-1999 (Illinois Health Connect) to enroll in Illinois Health Connect and to change PCPs, if necessary.
No, they will receive the same enrollment packets as everyone one else, which has a blank space for patients to choose their PCP.
All Ob/GYN services are direct access, including those provided by a Midwife – no referral is necessary.
The case remains in the adult’s name, but they will either have a legal guardian or simply a responsible person representing them. This person receives their mail, signs the application and takes care of renewals, so they would also make PCP decisions. If there is no legal guardian and an applicant is unable to sign the application for physical or mental reasons, death, or age, a responsible person may represent them and sign.
Specific policies are stated below:
For Cash or Medical, a person applying for someone who is incompetent, incapacitated, deceased, or too young to apply for themselves does not have to be an approved representative. They are acting responsibly for the person and do not need written permission.
The legal guardian must sign if the applicant has one. If there's more than one guardian, the "guardian of the person" decides which guardian will sign. When the client has a "limited" or "temporary" guardian, the client should sign the application. The "limited" or "temporary" guardian may sign the application as an interested party acting on the client's behalf.
As previously stated, all outpatient hospital services are direct access. Ambulatory surgical treatment centers are treated like hospitals for Illinois Health Connect enrollees.
PCPs in Illinois Health Connect are required to transfer an enrollee’s medical record to the new PCP when requested by the new PCP and authorized by the enrollee. This program does not change any laws or rules regarding medical records currently in place.
Home health care is a direct access service. The determination for mobile vans or vehicles (e.g., asthma van and mammography vans) to be considered direct access will be made by the Department on a case-by-case basis.
Enrollment of providers is ongoing and the Department does not want to release a list yet. AHS (1-877-912-1999) can answer questions about the enrollment status of specific providers.
Participants in a home and community based waiver are excluded from Illinois Health Connect. For more information on these waiver programs, visit the Illinois Department of Healthcare and Family Services website.
PCPs do not have to schedule the appointment for the referrals they make. Facilities registered during the voluntary phase were given provider manuals that contained language implying that PCPs would need to make appointments on behalf of their patients to see a specialist. The same language was used in draft versions of the provider handbooks, which were recently sent to a select group of providers. AHS is aware of the mistake, and is in the process of correcting the language for the mandatory phase.
The term “outpatient services” refers to hospital services provided on an outpatient basis. All hospital services are direct access including inpatient, outpatient and emergency department – none of which require a referral.
The database will be posted online for Illinois Health Connect eligible patients to search/browse. Patients will be able to search for providers by location, name of provider, and or specialty type. The general public will be able to search the database as well. However, they will have “read only” capabilities. The database will only show providers that are enrolled as PCPs either in Illinois Health Connect, Harmony or Family health network on the Client Enrollment broker Web site and only Illinois Health Connect PCPs on the Illinois Health Connect Web Site. It will not include all enrolled Medicaid Providers. Eligible Medicaid clients can call the Help Line and obtain additional information about other Medicaid physicians and specialists not listed on the Web sites.
The MEDI system is the HFS eligibility system that providers currently use to verify client eligibility for the HFS Medical Assistance program. MEDI will contain the name of the PCP for each Illinois Health Connect enrollee.
AHS will allow providers access to a secure Illinois Health Connect website that contains individual provider panel rosters that will include EPSDT and adult preventive services history and due dates. Providers will also have access to paid claims history for all Illinois Health Connect patients enrolled with them, and access to the referral system to log new and check on existing referrals.
All hospital services are direct access, including hospital observation.
Basically, the only way SASS is impacted is in the case of psychiatrists, because the hospital services and the community mental health services a SASS client might access are all considered direct access. The Department is presently weighing options about making psychiatrist services direct access or at the very least establishing a ‘work-around’ for specific situations.
Illinois Health Connect
Illinois Nurse Helpline
If you do not know if you have an emergency and cannot reach your primary care provider, you can call the Illinois Nurse Helpline to talk to a nurse after regular work hours or on the weekend. This call is free.
Call to get approval for medical transportation when it is not an emergency. This call is free.
Call for help finding a dentist, or to find out if a dental service is covered. This call is free.
For a list of organizations in your area that may be able to help you, enter your zip code.
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