305 ILCS 5/5-16

(305 ILCS 5/5-16) (from Ch. 23, par. 5-16)

Sec. 5-16. Managed Care. The Illinois Department may develop and implement a Primary Care Sponsor System consistent with the provisions of this Section. The purpose of this managed care delivery system shall be to contain the costs of providing medical care to Medicaid recipients by having one provider responsible for managing all aspects of a recipient's medical care. This managed care system shall have the following characteristics:

(a) The Department, by rule, shall establish criteria to determine which clients must participate in this program;

(b) Providers participating in the program may be paid an amount per patient per month, to be set by the Illinois Department, for managing each recipient's medical care;

(c) Providers eligible to participate in the program shall be physicians licensed to practice medicine in all its branches, and the Illinois Department may terminate a provider's participation if the provider is determined to have failed to comply with any applicable program standard or procedure established by the Illinois Department;

(d) Each recipient required to participate in the program must select from a panel of primary care providers or networks established by the Department in their communities;

(e) A recipient may change his designated primary care provider:

(1) when the designated source becomes unavailable, as the Illinois Department shall determine by rule; or

(2) when the designated primary care provider notifies the Illinois Department that it wishes to withdraw from any obligation as primary care provider; or

(3) in other situations, as the Illinois Department shall provide by rule;

(f) The Illinois Department shall, by rule, establish procedures for providing medical services when the designated source becomes unavailable or wishes to withdraw from any obligation as primary care provider taking into consideration the need for emergency or temporary medical assistance and ensuring that the recipient has continuous and unrestricted access to medical care from the date on which such unavailability or withdrawal becomes effective until such time as the recipient designates a primary care source;

(g) Only medical care services authorized by a recipient's designated provider, except for emergency services, services performed by a provider that is owned or operated by a county and that provides non-emergency services without regard to ability to pay and such other services as provided by the Illinois Department, shall be subject to payment by the Illinois Department. The Illinois Department shall enter into an intergovernmental agreement with each county that owns or operates such a provider to develop and implement policies to minimize the provision of medical care services provided by county owned or operated providers pursuant to the foregoing exception.

The Illinois Department shall seek and obtain necessary authorization provided under federal law to implement such a program including the waiver of any federal regulations.

The Illinois Department may implement the amendatory changes to this Section made by this amendatory Act of 1991 through the use of emergency rules in accordance with the provisions of Section 5.02 of the Illinois Administrative Procedure Act. For purposes of the Illinois Administrative Procedure Act, the adoption of rules to implement the amendatory changes to this Section made by this amendatory Act of 1991 shall be deemed an emergency and necessary for the public interest, safety and welfare.

The Illinois Department may establish a managed care system demonstration program, on a limited basis, as described in this Section. The demonstration program shall terminate on June 30, 1997. Within 30 days after the end of each year of the demonstration program's operation, the Illinois Department shall report to the Governor and the General Assembly concerning the operation of the demonstration program.

(Source: P.A. 87-14; 88-490.)