In Illinois:
  • Physical health services are delivered through Illinois Health Connect, a primary care case management (PCCM) system, as well as voluntary managed care organizations (MCOs) in some areas of the state. Children and adults who are income-eligible for Medicaid are required to enroll in Illinois Health Connect, but if they live in one of the counties where MCOs are an option they can opt out of Illinois Health Connect and select a voluntary MCO.
  • Mental health and substance abuse services are delivered to almost all Medicaid beneficiaries on a fee-for-service basis. The state encourages beneficiaries to receive services through community mental health centers, which bill Illinois Medicaid directly for services.
  • Medicaid dental services are delivered through a contract with DentaQuest, a nationwide oral health company that specializes in administering initiatives.
  • A Medicaid reform law passed in 2011, Public Act 096-1501, requires that 50 percent of beneficiaries in state medical assistance programs be enrolled in risk-based coordinated care programs by January 1, 2015.  
  • There were a total of 2,787,200 beneficiaries enrolled in Illinois Medicaid as of July 2011. Of these, 1,675,100 were enrolled into the PCCM program, and 213,417 were enrolled in the three voluntary managed care organizations. Those not enrolled in either receive health services through a fee-for-service system.
As of 2012, 1,688,010 individuals were eligible for Healthy Kids, Illinois’s Medicaid benefit for children and adolescents (also known as the Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT). According to 416 data from 2012, Healthy Kids achieved a screening ratio of 100% and a participation ratio of 74%. 853,403 children received dental services of any kind, with 799,640 receiving preventive dental services.
Last updated January 2014.
Medical Necessity
Illinois’ administrative code directs that Healthy Kids, the state’s EPSDT program, “shall pay for necessary medical care (see Section 140.2), diagnostic services, treatment or other measures medically necessary (e.g., medical equipment and supplies) to correct or ameliorate defects, and physical and mental illnesses and conditions which are discovered or determined to have increased in severity by medical, vision, hearing or dental screening services.” Section 140.2 defines of “necessary medical care” in the case of EPSDT as care that is “generally recognized as standard medical care required because of disease, disability, infirmity or impairment.”
Initiatives to Improve Access
MCO Network Adequacy Requirements
Illinois requires its managed care organizations (MCOs) to provide at least one pediatrician for each 2,000 enrollees under 19 and at least one full time equivalent physician for each 1,200 enrollees.
Incentive Payments
Illinois makes an annual incentive payment of $30 per patient to enrolled Illinois Health Connect primary care providers, Maternal and Child Health (MCH) physicians, Advanced Practice Nurses and Federally Qualified Health Centers (FQHCs) who render all recommended well child visits during each year of a patient’s life from ages 0-5. 
Reporting & Data Collection
Illinois collects data on several Healthcare Effective Data and Information Set measures pertaining to children, including measures of well-child visits, developmental screenings, and immunizations. The state’s Medicaid agency also collects and reports data on a number of the CHIPRA children’s health quality measures (see the table on page 19 of the state’s annual report on Medicaid for FY10-12).
The majority of CMS-416 data collected in Illinois comes from claims data. The state processes the data through its Medicaid Management Information System (MMIS) and then sends it to a Enterprise Data Warehouse, an analysis tool within Illinois’ MMIS. Illinois uses the CMS-416 data to track and show participant rates, and publishes the data online for others to use.
Oral Health
The state’s Medicaid dental contractor, DentaQuest, processes all dental claims and sends the Department of Healthcare and Family Services a weekly file of all services that were adjudicated during the week. The state then puts this information through its MMIS system for re-adjudication of the data to ensure that all edits are met. 
Behavioral Health

Illinois covers several facets of behavioral health screening with an array of CPT codes, including the 99420 code for mental health screening, substance abuse and chronic conditions.

The state details in section HK203.9.1 of its EPSDT Provider Handbook the codes and the recommended screening tools to accompany those codes. The state also provides appendices (see appendices 3 and 4) to the EPSDT Provider Handbook that includes a mental health screen for children ages 3 – 20, referral information to Division of Mental Health Certified Medicaid Providers by County, and substance abuse screening and referral resources. The Department of Healthcare and Families Services’ (HFS) policy on behavioral health risk assessments for children and adolescents was reiterated in an informational notice to physicians, nurses, FQHCs, hospitals, local education agencies and health departments, and school-based health centers in March 2013.
Under the 2003 Children’s Mental Health Act, Illinois has developed a Screening, Assessment, and Support Services (SASS) initiative designed to improve the coordination and delivery of mental health services to children and adolescents with acute mental health treatment need. This initiative is a cooperative partnership between the Illinois Department of Children and Family Services (in which the Medicaid agency resides) and the Department of Human Services. The initiative seeks to develop a single, statewide system to serve children requiring public funding from one of the three agencies. The program features a single point of entry, Crisis and Referral Entry Service, (CARES) for all children entering the system and ensures that the children receive the appropriate services in the setting most conducive to their wellbeing.
Children with behavioral health treatment needs that do not rise to the level of acuity required for participation in the SASS initiative can receive care from community mental health centers, which can be reimbursed by Medicaid for a range of services. The state’s Community Mental Health Services Service Definition and Reimbursement Guide offers providers service descriptions, describes the applicable populations for each service, lists applicable reimbursement codes, and provides additional information.
For more information about behavioral health services for children enrolled in Medicaid, see: "Behavioral Health in the Medicaid Benefit for Children and Adolescents: Illinois."
Support to Providers and Families
Support to Families
Illinois’ Healthy Kids EPSDT website provides resources to families participating in the EPSDT program and includes links to Children’s Mental Health, the Ounce of Prevention Fund, Zero to 3, and Bright Futures information. The state also has a Healthy Kids mailing that promotes WIC services.
Oral Health
Illinois’ dental program conducts outreach to families when children have not been in for dental services in over a year. The state’s contractor, DentaQuest, provides these services and will do an initial call out and follow up after four months.
The Department of Healthcare and Families Services’ (HFS) also provides a Guide to Children’s Dental Care in Medicaid.
Support to Providers
Illinois Medicaid is working with the Illinois Chapter, American Academy of Pediatrics (ICAAP) to rewrite the Healthy Kids Handbook. The revised handbook will reflect Bright Future’s guidelines and will also be accompanied by more information to make it useful for providers. The revised version of the handbook is expected to be released in 2014. 
Care Coordination
Public Act 96-1501 requires Illinois to move at least 50% of recipients eligible for comprehensive medical benefits in all programs administered by the Department of Healthcare and Families Services’ (HFS) to a risk-based care coordination program by January 1, 2015. To meet the state goal, HFS, in working with other state agencies and community partners developed the Care Coordination Innovations Project,” which includes projects such as:
  • Care Coordination Entities (CCEs)/Managed Care Community Networks (MCCNs)
  • Medicare/Medicaid Financial Alignment Initiative- Capitation and managed FSS demonstrations.
  • Children with Complex and/or Multiple Chronic Medical Needs

The eligible patient population as identified under the initial provider solicitation includes children in the families of adults enrolled in a CCE or MCCN. Enrollees in a CCE must also be enrolled in Illinois Health Connect. Medicaid beneficiaries who are enrolled in a managed care organization will not be eligible to enroll in a CCE. Initially, the choice to enroll in a CCE or MCCH will be voluntary—except for Medicaid beneficiaries in 5 mandatory managed care regions of the state—and is scheduled to begin in July 2014.  The provider solicitation clarifies that the state intends to expanded mandatory enrollments once sufficient plans are available to give beneficiaries a choice.


Behavioral Health
Illinois’ Screening, Assessment, and Support Services (SASS) program is designed to improve the coordination and delivery of mental health services to children and adolescents. SASS often directs children (including those covered by Medicaid) from hospital-based services to the community mental health centers so that they can be treated within the community.

Oral Health
Illinois has had a school-based dental program in place since 2006 in an effort to increase the number of EPSDT children receiving preventive dental services and oral health screens. The state has a separate enrollment procedure for providers to work in the schools. DentaQuest administers this process on behalf of the state.
Providers are required to list the dates and times of scheduled school visits on a Google Calendar. The Department of Healthcare and Families Services’ (HFS) has an interagency agreement with the Illinois Department of Public Health for their oral health consultants (dental hygienists) to provide quality assurance assessments and monitor the school-based dental program on behalf of HFS.