Many lawmakers in Illinois, a state that has been operating without a budget since last July, want to audit Medicaid managed-care insurers to ensure payments and patient outcomes are living up to expectations.
A bipartisan bill, House Resolution 1123, would prompt the Illinois auditor general to examine Medicaid insurers. The audit would evaluate the appropriateness of the lump-sum, capitated rates paid to the insurers as well as the healthcare outcomes of Medicaid enrollees who are in a managed-care plan.
The bill has more than 60 co-sponsors and was initiated because “there has been little information disseminated to the General Assembly” about how the state's Medicaid managed-care program has fared financially and clinically. A 2012 law overhauled Illinois' Medicaid program and pushed for more managed-care enrollment. Approximately two-thirds of the state's 3.1 million Medicaid beneficiaries are now in a managed-care plan.
The few states that have audited Medicaid managed-care programs have found some defects, including overpayments to health plans. The federal government's new Medicaid rule calls for more audits to ensure plans and administrators are being held accountable.
Democratic State Rep. Fred Crespo, who filed the bill with Republican colleague Rep. Ron Sandack, said the point of the resolution is to take a “close look” at the progression of the Medicaid program, which cost about $17 billion in 2014. Hospitals, doctors and other providers have reached out to Crespo and other policymakers, saying there has been a proliferation of claims denials, inaccurate payments and untimely medical reviews from insurers since the state moved more people into managed-care plans.
“If you talk to any of the providers, they will tell you some horror stories in terms of what they have to do,” Crespo said. There also have been some worries Medicaid enrollees are having trouble finding specialists.
But Crespo said that he understood there are multiple angles to the issue, and that health plans were adjusting to the new changes. “The best way to figure this out was to call for an audit, to look at the process and see how this is working,” he said.
Crespo said the auditor general's office told him they can conduct the audit despite the budget impasse. It's just a matter of legislative approval.
Several for-profit HMOs work with Illinois' Medicaid program, including Aetna, Centene Corp., Humana, Meridian, Molina Healthcare and WellCare Health Plans. Other plans include Blue Cross and Blue Shield of Illinois and CountyCare, a Medicaid plan owned by Chicago's safety net health system.
The Illinois Association of Medicaid Health Plans, which represents many of those insurers, did not immediately respond to an interview request.
The Illinois Health and Hospital Association supports HR 1123, as well as a separate state Senate bill that promotes oversight and transparency of the Medicaid program. IHA spokesman Danny Chun said that bill, which passed the Senate and now awaits a vote in the House, is a “collaborative” effort among legislators, the state Medicaid agency, providers and insurers.
“Everyone's aware of these issues, and we're working together to resolve them,” Chun said.