HB5561 98TH GENERAL ASSEMBLY

LRB098 20209 KTG 55632 b

98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
HB5561

Introduced , by Rep. Robyn Gabel

SYNOPSIS AS INTRODUCED:

305 ILCS 5/5-30a new

Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that a health plan, including an Accountable Care Entity (ACE), a Care Coordination Entity (CCE), a Managed Care Community Network (MCCN), or a Managed Care Organization (MCO), that has met the Department of Healthcare and Family Services' requirements to provide services to Medicaid managed care enrollees must meet minimum specialty pediatric network adequacy requirements. Provides that to meet those requirements (i) a network must include at least one Pediatric Essential Community Provider; (ii) as determined by the Department, the health plan must show that its network has access to the full range of primary, specialty, and ancillary pediatric providers, and must ensure coordination and continuity of care among all providers; and (iii) the health plan must provide annual reports to the Department that demonstrate its assessment of pediatric provider networks and whether gaps in access to care have been identified, accompanied by a plan to remedy those gaps and monitor access to care in those specifically identified areas. Provides that a health plan must demonstrate to the Department that it meets certain minimum pediatric network adequacy requirements and that the Department may only contract with health plans serving children that meet the pediatric network adequacy requirements. Contains a provision concerning certain annual reports submitted by the Office of Health Innovation and Transformation created by Executive Order 14-01. Effective immediately.

FISCAL NOTE ACT MAY APPLY

A BILL FOR

AN ACT concerning public aid.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Illinois Public Aid Code is amended by adding Section 5-30a as follows:

(305 ILCS 5/5-30a new)

Sec. 5-30a. Pediatric network adequacy requirements.

(a) Pediatric network adequacy. A health plan, serving persons less than 21 years of age, including an Accountable Care Entity (ACE), a Care Coordination Entity (CCE), a Managed Care Community Network (MCCN), or a Managed Care Organization (MCO), that has met the Department of Healthcare and Family Services' requirements to provide services to Medicaid managed care enrollees must meet minimum specialty pediatric network adequacy requirements. To meet those requirements (i) a network must include at least one Pediatric Essential Community Provider; (ii) as determined by the Department, the health plan must show that its network has access to the full range of primary, specialty, and ancillary pediatric providers, and must ensure coordination and continuity of care among all providers; and (iii) the health plan must provide annual reports to the Department that demonstrate its assessment of pediatric provider networks and whether gaps in access to care have been identified, accompanied by a plan to remedy those gaps and monitor access to care in those specifically identified areas. For purposes of this Section, "Pediatric Essential Community Provider" means an acute care hospital and its affiliated clinics that meet the following criteria:

(1) if the hospital is located within the State, the hospital must have a pediatric intensive care unit (PICU) that is recognized by the Department of Public Health and the hospital must provide at least 1600 annual pediatric Medicaid discharges; or

(2) if the hospital is located out-of-state, the hospital must have a pediatric intensive care unit (PICU) and the hospital must provide at least 1000 annual pediatric Medicaid discharges.

(b) Demonstration. A health plan must demonstrate to the Department that it meets certain minimum pediatric network adequacy requirements. The Department may only contract with health plans serving children that meet the pediatric network adequacy requirements.

(c) Annual report. The Office of Health Innovation and Transformation created by Executive Order 14-01 shall issue an annual report to the Governor, to the 4 legislative leaders, and to the Directors of the Department of Healthcare and Family Services and the Department of Insurance determining whether the pediatric network adequacy requirements established under this Section should be integrated into the Illinois Health Benefits Exchange's qualification requirements and whether additions to the pediatric network adequacy requirements are needed under the State's Medicaid program.

Section 99. Effective date. This Act takes effect upon becoming law.