PM 20-24-01: Enrolling in an MCO

WAG 20-24-01.

New Text Begin.Once a customer is determined eligible for Medicaid, Healthcare and Family Services (HFS), through Illinois Client Enrollment Services (ICES), will determine which managed care program type the customer is required or eligible to join. ICES uses a systematic process to auto-assign the customer to a best-fit managed care plan and Primary Care Provider (PCP). (NOTE: Dual eligible customers required to enroll in the HealthChoice LTSS program are not assigned a PCP since physician services will continue to be covered under the Medicare program and not by the HealthChoice LTSS plan.) The systematic process takes a number of factors into account, but HFS encourages customers to make a voluntary choice of a managed care plan as they know their healthcare needs best. ICES will mail an enrollment packet to customers informing them of the managed care plan and PCP to which they will be assigned if they do not make a voluntary choice by the due date in the letter. The enrollment packet includes information on the customers plan choices, additional benefits offered by each plan and information on how to enroll.

Once assigned to a HealthChoice Illinois plan, customers have 90 days from the effective date of their initial enrollment to change to a different plan. Customers may change plans only once during this initial 90 day period. If the customer does not change plans within those 90 days, they are locked into that plan for one year. Once enrolled, customers can change their health plan one time each year during Open Enrollment. ICES will mail an Open Enrollment letter to the customer telling them when they may switch plans.

Once enrolled in a HealthChoice Illinois plan, the plan provides information about their programs directly to customers, including a membership card, and member handbook. Customers may change Primary Care Providers (PCPs) at any time as long as the provider is within the plan's network. Customers may change PCPs by calling their plan's member services line. Select the following link for information on how the customer can contact their MCO:

When a plan member gives birth, and the newborn is added to the case before the newborn is 45 days old, plan coverage for the newborn is retroactive to the date of birth. Managed care plan coverage for all other newborns is prospective. The newborn is assigned to the same plan as the mother if she is enrolled. If the mother is not enrolled in a plan, or the mother's RIN is not on the IES transaction, then the newborn will be assigned to the same plan as the next youngest sibling. If there is no mother's RIN or sibling's RIN on the IES transaction, the newborn will be assigned to the same plan as the Head of Household or the best plan based on the assignment process. Newborns added to a case after 45 days of birth, will be added to the same MCO as the head of household prospectively, and will be fee-for-service until the MCO effective date. Refer all inquiries regarding newborn enrollment to the ICES.

Enrollment in the Medicare-Medicaid Alignment Initiative (MMAI) program is very similar to HealthChoice Illinois enrollment. Customers are automatically assigned using a systematic process and are mailed an enrollment letter by ICES. The 90-day switch period from enrollment effective date and open enrollment period does not apply as customers in the MMAI program are allowed to opt out of the program or switch MMAI plans at any time. Dual eligible customers who opt out of the MMAI program and are receiving waiver services or long-term care services must enroll with an HealthChoice Illinois Managed Long Term Services and Supports (MLTSS) health plan for their MLTSS services only.New Text End.