98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
HB5630

 

Introduced , by Rep. Robyn Gabel

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-30

    Amends the Illinois Public Aid Code. Provides that the Department of Healthcare and Family Services' contracts with Managed Care Organizations and other entities reimbursed by risk based capitation shall (i) have a minimum medical loss ratio of 85% prior to December 31, 2014 and a minimum medical loss ratio of 90% thereafter; (ii) require the MCO or other entity to pay claims within 30 days of receiving a bill that contains all the essential information needed to adjudicate the bill; (iii) require the MCO or other entity to pay a penalty that is at least equal to the penalty imposed under the Illinois Insurance Code for any claims not timely paid; (iv) require the MCO or other entity to notify the billing party within 30 days of receiving a bill of any essential information needed to adjudicate the bill; (v) require payments for hospital services in an amount not less than the Department would pay on a fee-for-service basis; (vi) contain a warranty by the MCO or other entity that its network is in place at the time the contract is in effect; (vii) provide for shared savings requirements between the MCO or other entity and its hospital providers; (viii) require that the MCO or other entity post a bond to cover the risk of failure to pay any pass-through payments; and (ix) contain dispute resolution protocols and utilization review or denial management standards consistent with the standards required pursuant to the Medicare Advantage program (rather than shall have a minimum medical loss ratio of 85%, shall require the MCO or other entity to pay claims within 30 days of receiving a bill that contains all the essential information needed to adjudicate the bill, and shall require the entity to pay a penalty that is at least equal to the penalty imposed under the Illinois Insurance Code for any claims not paid within this time period). Effective immediately.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-30 as follows:
 
6    (305 ILCS 5/5-30)
7    Sec. 5-30. Care coordination.
8    (a) At least 50% of recipients eligible for comprehensive
9medical benefits in all medical assistance programs or other
10health benefit programs administered by the Department,
11including the Children's Health Insurance Program Act and the
12Covering ALL KIDS Health Insurance Act, shall be enrolled in a
13care coordination program by no later than January 1, 2015. For
14purposes of this Section, "coordinated care" or "care
15coordination" means delivery systems where recipients will
16receive their care from providers who participate under
17contract in integrated delivery systems that are responsible
18for providing or arranging the majority of care, including
19primary care physician services, referrals from primary care
20physicians, diagnostic and treatment services, behavioral
21health services, in-patient and outpatient hospital services,
22dental services, and rehabilitation and long-term care
23services. The Department shall designate or contract for such

 

 

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1integrated delivery systems (i) to ensure enrollees have a
2choice of systems and of primary care providers within such
3systems; (ii) to ensure that enrollees receive quality care in
4a culturally and linguistically appropriate manner; and (iii)
5to ensure that coordinated care programs meet the diverse needs
6of enrollees with developmental, mental health, physical, and
7age-related disabilities.
8    (b) Payment for such coordinated care shall be based on
9arrangements where the State pays for performance related to
10health care outcomes, the use of evidence-based practices, the
11use of primary care delivered through comprehensive medical
12homes, the use of electronic medical records, and the
13appropriate exchange of health information electronically made
14either on a capitated basis in which a fixed monthly premium
15per recipient is paid and full financial risk is assumed for
16the delivery of services, or through other risk-based payment
17arrangements.
18    (c) To qualify for compliance with this Section, the 50%
19goal shall be achieved by enrolling medical assistance
20enrollees from each medical assistance enrollment category,
21including parents, children, seniors, and people with
22disabilities to the extent that current State Medicaid payment
23laws would not limit federal matching funds for recipients in
24care coordination programs. In addition, services must be more
25comprehensively defined and more risk shall be assumed than in
26the Department's primary care case management program as of the

 

 

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1effective date of this amendatory Act of the 96th General
2Assembly.
3    (d) The Department shall report to the General Assembly in
4a separate part of its annual medical assistance program
5report, beginning April, 2012 until April, 2016, on the
6progress and implementation of the care coordination program
7initiatives established by the provisions of this amendatory
8Act of the 96th General Assembly. The Department shall include
9in its April 2011 report a full analysis of federal laws or
10regulations regarding upper payment limitations to providers
11and the necessary revisions or adjustments in rate
12methodologies and payments to providers under this Code that
13would be necessary to implement coordinated care with full
14financial risk by a party other than the Department.
15    (e) Integrated Care Program for individuals with chronic
16mental health conditions.
17        (1) The Integrated Care Program shall encompass
18    services administered to recipients of medical assistance
19    under this Article to prevent exacerbations and
20    complications using cost-effective, evidence-based
21    practice guidelines and mental health management
22    strategies.
23        (2) The Department may utilize and expand upon existing
24    contractual arrangements with integrated care plans under
25    the Integrated Care Program for providing the coordinated
26    care provisions of this Section.

 

 

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1        (3) Payment for such coordinated care shall be based on
2    arrangements where the State pays for performance related
3    to mental health outcomes on a capitated basis in which a
4    fixed monthly premium per recipient is paid and full
5    financial risk is assumed for the delivery of services, or
6    through other risk-based payment arrangements such as
7    provider-based care coordination.
8        (4) The Department shall examine whether chronic
9    mental health management programs and services for
10    recipients with specific chronic mental health conditions
11    do any or all of the following:
12            (A) Improve the patient's overall mental health in
13        a more expeditious and cost-effective manner.
14            (B) Lower costs in other aspects of the medical
15        assistance program, such as hospital admissions,
16        emergency room visits, or more frequent and
17        inappropriate psychotropic drug use.
18        (5) The Department shall work with the facilities and
19    any integrated care plan participating in the program to
20    identify and correct barriers to the successful
21    implementation of this subsection (e) prior to and during
22    the implementation to best facilitate the goals and
23    objectives of this subsection (e).
24    (f) A hospital that is located in a county of the State in
25which the Department mandates some or all of the beneficiaries
26of the Medical Assistance Program residing in the county to

 

 

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1enroll in a Care Coordination Program, as set forth in Section
25-30 of this Code, shall not be eligible for any non-claims
3based payments not mandated by Article V-A of this Code for
4which it would otherwise be qualified to receive, unless the
5hospital is a Coordinated Care Participating Hospital no later
6than 60 days after the effective date of this amendatory Act of
7the 97th General Assembly or 60 days after the first mandatory
8enrollment of a beneficiary in a Coordinated Care program. For
9purposes of this subsection, "Coordinated Care Participating
10Hospital" means a hospital that meets one of the following
11criteria:
12        (1) The hospital has entered into a contract to provide
13    hospital services to enrollees of the care coordination
14    program.
15        (2) The hospital has not been offered a contract by a
16    care coordination plan that pays at least as much as the
17    Department would pay, on a fee-for-service basis, not
18    including disproportionate share hospital adjustment
19    payments or any other supplemental adjustment or add-on
20    payment to the base fee-for-service rate.
21    (g) No later than August 1, 2013, the Department shall
22issue a purchase of care solicitation for Accountable Care
23Entities (ACE) to serve any children and parents or caretaker
24relatives of children eligible for medical assistance under
25this Article. An ACE may be a single corporate structure or a
26network of providers organized through contractual

 

 

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1relationships with a single corporate entity. The solicitation
2shall require that:
3        (1) An ACE operating in Cook County be capable of
4    serving at least 40,000 eligible individuals in that
5    county; an ACE operating in Lake, Kane, DuPage, or Will
6    Counties be capable of serving at least 20,000 eligible
7    individuals in those counties and an ACE operating in other
8    regions of the State be capable of serving at least 10,000
9    eligible individuals in the region in which it operates.
10    During initial periods of mandatory enrollment, the
11    Department shall require its enrollment services
12    contractor to use a default assignment algorithm that
13    ensures if possible an ACE reaches the minimum enrollment
14    levels set forth in this paragraph.
15        (2) An ACE must include at a minimum the following
16    types of providers: primary care, specialty care,
17    hospitals, and behavioral healthcare.
18        (3) An ACE shall have a governance structure that
19    includes the major components of the health care delivery
20    system, including one representative from each of the
21    groups listed in paragraph (2).
22        (4) An ACE must be an integrated delivery system,
23    including a network able to provide the full range of
24    services needed by Medicaid beneficiaries and system
25    capacity to securely pass clinical information across
26    participating entities and to aggregate and analyze that

 

 

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1    data in order to coordinate care.
2        (5) An ACE must be capable of providing both care
3    coordination and complex case management, as necessary, to
4    beneficiaries. To be responsive to the solicitation, a
5    potential ACE must outline its care coordination and
6    complex case management model and plan to reduce the cost
7    of care.
8        (6) In the first 18 months of operation, unless the ACE
9    selects a shorter period, an ACE shall be paid care
10    coordination fees on a per member per month basis that are
11    projected to be cost neutral to the State during the term
12    of their payment and, subject to federal approval, be
13    eligible to share in additional savings generated by their
14    care coordination.
15        (7) In months 19 through 36 of operation, unless the
16    ACE selects a shorter period, an ACE shall be paid on a
17    pre-paid capitation basis for all medical assistance
18    covered services, under contract terms similar to Managed
19    Care Organizations (MCO), with the Department sharing the
20    risk through either stop-loss insurance for extremely high
21    cost individuals or corridors of shared risk based on the
22    overall cost of the total enrollment in the ACE. The ACE
23    shall be responsible for claims processing, encounter data
24    submission, utilization control, and quality assurance.
25        (8) In the fourth and subsequent years of operation, an
26    ACE shall convert to a Managed Care Community Network

 

 

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1    (MCCN), as defined in this Article, or Health Maintenance
2    Organization pursuant to the Illinois Insurance Code,
3    accepting full-risk capitation payments.
4    The Department shall allow potential ACE entities 5 months
5from the date of the posting of the solicitation to submit
6proposals. After the solicitation is released, in addition to
7the MCO rate development data available on the Department's
8website, subject to federal and State confidentiality and
9privacy laws and regulations, the Department shall provide 2
10years of de-identified summary service data on the targeted
11population, split between children and adults, showing the
12historical type and volume of services received and the cost of
13those services to those potential bidders that sign a data use
14agreement. The Department may add up to 2 non-state government
15employees with expertise in creating integrated delivery
16systems to its review team for the purchase of care
17solicitation described in this subsection. Any such
18individuals must sign a no-conflict disclosure and
19confidentiality agreement and agree to act in accordance with
20all applicable State laws.
21    During the first 2 years of an ACE's operation, the
22Department shall provide claims data to the ACE on its
23enrollees on a periodic basis no less frequently than monthly.
24    Nothing in this subsection shall be construed to limit the
25Department's mandate to enroll 50% of its beneficiaries into
26care coordination systems by January 1, 2015, using all

 

 

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1available care coordination delivery systems, including Care
2Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
3to affect the current CCEs, MCCNs, and MCOs selected to serve
4seniors and persons with disabilities prior to that date.
5    (h) Department contracts with MCOs and other entities
6reimbursed by risk based capitation shall (i) have a minimum
7medical loss ratio of 85% prior to December 31, 2014 and a
8minimum medical loss ratio of 90% thereafter; (ii) require the
9MCO or other entity to pay claims within 30 days of receiving a
10bill that contains all the essential information needed to
11adjudicate the bill; (iii) require the MCO or other entity to
12pay a penalty that is at least equal to the penalty imposed
13under the Illinois Insurance Code for any claims not timely
14paid; (iv) require the MCO or other entity to notify the
15billing party within 30 days of receiving a bill of any
16essential information needed to adjudicate the bill; (v)
17require payments for hospital services in an amount not less
18than the Department would pay on a fee-for-service basis; (vi)
19contain a warranty by the MCO or other entity that its network
20is in place at the time the contract is in effect; (vii)
21provide for shared savings requirements between the MCO or
22other entity and its hospital providers; (viii) require that
23the MCO or other entity post a bond to cover the risk of
24failure to pay any pass-through payments; and (ix) contain
25dispute resolution protocols and utilization review or denial
26management standards consistent with the standards required

 

 

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1pursuant to the Medicare Advantage program. have a minimum
2medical loss ratio of 85%, shall require the MCO or other
3entity to pay claims within 30 days of receiving a bill that
4contains all the essential information needed to adjudicate the
5bill, and shall require the entity to pay a penalty that is at
6least equal to the penalty imposed under the Illinois Insurance
7Code for any claims not paid within this time period. The
8requirements of this subsection shall apply to contracts with
9MCOs entered into or renewed or extended after June 1, 2013.
10(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)
 
11    Section 99. Effective date. This Act takes effect upon
12becoming law.