Illinois sanctions Blue Cross for Medicaid program violations

April 17, 2018

The state has slapped sanctions on Blue Cross and Blue Shield of Illinois, saying its Medicaid managed care network of doctors and hospitals is inadequate and it isn’t responding to grievances and appeals as it should.

 

Blue Cross is part of the state’s recently revamped Medicaid managed care program, in which private insurers administer Medicaid benefits. Medicaid is a state and federally funded health insurance program for the poor.

 

According to the state, insurers in the program are supposed to provide members certain access to primary care doctors, behavioral health providers, dentists, obstetricians/gynecologists, hospitals, specialists and pharmacies. Members should be able to see those providers within certain time frames and not have to travel beyond certain distances.

 

But Blue Cross’s Medicaid managed care network doesn’t meet those standards in some areas of the northwest, central and southern parts of the state, according to a letter to the insurer from Robert Mendonsa, a deputy administrator with the Illinois Department of Healthcare and Family Services.

 

As a result of that and an alleged failure to adequately respond to grievances and appeals, Medicaid patients are no longer being automatically assigned to the insurer, and newly enrolled Medicaid managed care members can no longer choose it. The state also is fining Blue Cross $150,000.

 

The ban on new members will remain in effect until Blue Cross complies with the program’s requirements, said John Hoffman, a spokesman for the Illinois Department of Healthcare and Family Services, in an email.

 

Blue Cross will comply with the actions outlined by the state, company spokeswoman Colleen Miller said in an email. “We are dedicating the resources and personnel needed to provide the level of service our government program members expect from us,” Miller said.

 

Blue Cross has about 470,000 Medicaid members in Illinois and about 20,000 members who are eligible for Medicare and Medicaid.

 

Gov. Bruce Rauner recently revamped the state’s Medicaid managed care program, aiming to cover 80 percent of people on Medicaid across Illinois' 102 counties, or about 2.7 million people. Previously, managed care covered about two-thirds of Illinois Medicaid recipients in 30 counties, or 2 million people.

 

The new program also reduced the number of insurers participating from 12 to seven, which Rauner said would streamline administration and improve care.

 

via Chicago Tribune

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