Simplifying Administration, Strengthening Care: Insights from Illinois’ Medicaid Continuity of Care 1115 Demonstration

Background and Purpose

Managed care organization (MCO) enrollment continuity is critical for Medicaid beneficiaries because transitions out of MCOs disrupt established provider relationships, interrupt care coordination, and impose navigational burdens on enrollees. The Illinois Continuity of Care (CoC) and Administrative Simplification Section 1115 demonstration implemented two key policy changes: extending the MCO re-enrollment period from 60 to 90 days, and waiving Hospital Presumptive Eligibility (HPE). This study evaluated the demonstration’s success in enhancing healthcare quality and reducing administrative barriers by qualitatively assessing stakeholder experiences. The study’s research questions were: (1) How does the 90-day re-enrollment extension impact continuity of coverage and care coordination? (2) What systemic barriers contribute to persistent Medicaid churn despite these policy changes? (3) How does waiving HPE affect administrative complexity and enrollment efficiency?

Method

We employed a qualitative approach, thematically analyzing primary data collected from 32 key stakeholders in the Illinois Medicaid system, spanning three groups: 12 current staff from the Illinois Department of Healthcare and Family Services, participating in two focus groups; 10 employees of Medicaid MCOs, in individual interviews; and 10 staff members who worked as Medical Presumptive Eligibility (MPE) providers, in individual interviews. All participants had professional experience spanning pre- and post-demonstration periods. Transcripts were transcribed using Zoom and analyzed using NVivo 15, following a five-step thematic analysis process; analysis revealed five core qualitative themes (continuity of enrollment, HPE waiver impact, continuity of care experience, care coordination, and administrative burden) aligned with the demonstration’s goals.

Results

Stakeholders widely viewed the 90-day re-enrollment extension as a successful administrative simplification. They reported the additional time increased the likelihood of timely renewal, reduced disenrollment, and minimized coverage gaps. They also reported direct re-enrollment into the original MCO, further supporting care coordination by preventing disruptive transitions to Fee-for-Service, which lacks care coordination. However, analysis revealed that high Medicaid churn persisted due to systemic barriers beyond the demonstration’s scope. Stakeholders identified four such barriers: low beneficiary awareness of renewal deadlines, unstable housing, unreliable communication channels, and internal enrollment system errors causing incorrect drops or slow processing. Churn imposed a substantial administrative burden on MCO case managers, who had to restart assessments, documentation, and care plans after each reinstatement. It also disrupted services, delayed care, and created significant mental stress—confusion, worry, and panic—among beneficiaries. Findings on waiving HPE were mixed. While HPE can provide urgent temporary coverage, stakeholders noted that expanding HPE could increase processing costs and administrative workload associated with a short-term eligibility pathway.

Discussion

Qualitative findings confirmed that the 90-day re-enrollment extension promoted the demonstration goals of improving continuity of coverage and care and simplifying administration. Yet existing system challenges—primarily, high Medicaid churn and low customer awareness—greatly limited resulting benefits. To fully realize the demonstration’s objectives, future efforts should move beyond policy-level changes to focus on churn’s operational and customer-facing root causes, including by coordinating MCO and beneficiary-facing outreach to ensure reliable communication with and education for customers regarding their coverage and renewal responsibilities.