State eases sanctions against Blue Cross, partly reopening Medicaid managed care enrollment

Nov. 05--Illinois residents eligible for Medicaid will again be allowed to choose a Blue Cross and Blue Shield of Illinois plan for coverage after the state decided to lift a sanction against the health insurer.

Blue Cross, however, isn't totally in the clear.

The insurer is part of the state's recently revamped Medicaid managed care program, in which private insurers administer benefits. Medicaid is a state- and federally funded health insurance program for low-income and disabled patients, and it also serves many elderly people.

Earlier this year, the Illinois Department of Healthcare and Family Services decided to no longer automatically assign Medicaid managed care participants to the insurer and no longer allow newly enrolled participants to choose it.

The state said Blue Cross' Medicaid managed care network of doctors and hospitals was inadequate and that the insurer wasn't properly responding to grievances and appeals.

However, late last month the state notified Blue Cross that it will allow Medicaid managed care members to again choose the insurer. Blue Cross "was able to point to changes the health plan has made to come into compliance," according to a letter sent by Teresa Hursey, acting administrator of the department's Division of Medical Programs.

The letter also noted that automatic enrollments will remain on hold for now. Follow-up with the insurer will be conducted in December, at which point the state could reinstate the full enrollment sanctions if Blue Cross does not show "necessary improvements." The state could also start penalizing the insurer $50,000 a month.

"We demonstrated our commitment to make things right for our members and we continue to make improvements in our technology, process, staffing and training," Blue Cross spokeswoman Colleen Miller said Monday in an email.

Blue Cross had 415,887 people enrolled in Medicaid managed care as of September, according to the state. That's down from more than 469,000 members in April, when the enrollment hold went into effect. The state had also fined Blue Cross $150,000 over the matter.

lschencker@chicagotribune.com

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