SB1236 95TH GENERAL ASSEMBLY

LRB095 10883 DRJ 31164 b

95TH GENERAL ASSEMBLY
State of Illinois
2007 and 2008
SB1236

Introduced 2/9/2007, by Sen. William Delgado

SYNOPSIS AS INTRODUCED:

305 ILCS 5/5-26 new

Amends the Illinois Public Aid Code. Directs the Department of Healthcare and Family Services to establish a Medicaid pilot program under which prospective capitated payments are made to counties for medical assistance. Provides that the pilot program shall operate for at least 3 years, and provides that the Department shall select at least 3 counties to initially participate in the program. Provides that each of those 3 counties must be served by a single hospital. Requires the State and each participating county to agree to key performance goals. Provides for prospective payments to each participating county for health care services provided to medical assistance enrollees, and provides for payment of a percentage of the "pool of medical assistance funds" to a county that meets its key performance goals. Provides that payments to each county must be made to and disbursed by a "county payer" designated by the county. Provides for oversight. 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 5-26 as follows:

(305 ILCS 5/5-26 new)

Sec. 5-26. Medicaid pilot program; county capitated payments.

(a) The Department of Healthcare and Family Services shall establish a pilot program under which capitated payments are made to counties for medical assistance as provided in this Section.

(b) In this Section, "participating county" means a county that participates in the pilot program established under this Section.

(c) The pilot program shall begin operation as soon as 3 counties have agreed to participate in the program and shall operate for at least 3 years. Counties may apply to the Department to participate in the pilot program, and the Department shall select a minimum of 3 counties, each of which is served by a single hospital, to participate in the pilot program in the program's first year of operation. The Department shall determine the form and manner of application to participate in the pilot program and shall determine the criteria for selecting counties for participation.

(d) The Department and each participating county shall agree to key performance goals for each year of the county's participation in the pilot program. The goals may include, but need not be limited to: (i) performance rates for accepted measures of access, preventive care, ambulatory care, and hospital care and (ii) revised targets for the per-person rates of payment determined under subdivision (e)(2). The Department shall ensure that any such goals do not impose any additional data-collection burdens on providers of health care services in the county.

(e) Before July 1 of each State fiscal year during which the pilot program is in operation, the Department shall determine the pool of medical assistance funds to be paid to each participating county for that fiscal year as follows:

(1) The Department shall determine the average number of medical assistance enrollees in the county during the calendar year immediately preceding that fiscal year.

(2) The Department shall determine the average yearly medical assistance payment per enrollee in the county by dividing (i) the total of all medical assistance claims paid on behalf of such enrollees during the calendar year immediately preceding that fiscal year by (ii) the number determined under paragraph (1).

(3) The Department shall determine the number of anticipated medical assistance enrollees in the county as of July 1 of that fiscal year.

(4) The Department shall determine the pool of medical assistance funds to be paid to the county for that fiscal year by multiplying (i) the number of enrollees determined under paragraph (3) by (ii) the average payment per enrollee determined under paragraph (2).

(f) During each State fiscal year of the pilot program's operation, the Department shall prospectively pay to each participating county an amount equal to 90% of the pool of funds for that county determined under subsection (e). The Department shall pay that amount to the county over the course of the fiscal year in not less than 4 and not more than 12 payments, as agreed to by the Department and the county.

(g) At the conclusion of each State fiscal year of the pilot program's operation, if the Department determines that a participating county has met the key performance goals agreed to by the Department and the county under subsection (d), the Department shall pay to that county the remaining 10% of the pool of funds for that county determined under subsection (e).

(h) If a county does not meet all of the key performance goals agreed to by the Department and the county, the Department shall pay the 10% of the pool of funds for that county described in subsection (g) equally to the county or counties that did meet all of their key performance goals.

(i) Each participating county shall designate an organization to serve as the "county payer" for that county for purposes of the pilot program. The Department shall make all payments on behalf of the county under subsections (f) and (g) to the county payer designated by the county. The county payer shall pay the moneys prospectively paid to it under subsection (f) (i) for health care services delivered within the county and (ii) for health care services referred by county providers located outside the county.

(j) The Department shall monitor the net migration of medical assistance enrollees in and out of each participating county at monthly intervals. Based on the information received as a result of that monitoring, the Department shall revise the pool of medical assistance funds determined under subdivision (e)(4) and shall modify the amount of the subsequent payments to the county under subsection (f) based on the net change in medical assistance enrollees during each interval.

(k) At monthly intervals during the pilot program's operation, the Department shall provide to each participating county a report concerning the county's performance and costs associated with the pilot program. The Department shall use these reports to determine the performance and cost targets for the second and third years of the county's participation in the pilot program.

(l) At the county level, each participating county shall establish a committee to provide oversight of the pilot program's operation in that county. At a minimum, the county committee must include representatives of the hospital serving the county, representatives of physicians serving the county, and members of the general public residing in the county. Each county committee shall determine the organization to serve as the "county payer" as described in subsection (i), the key performance goals for the county as described in subsection (d), the county resources to be used to meet the key performance goals, and how the funds received from the Department are to be distributed. Each year during the 3 years of the pilot program, each county committee shall provide an annual report to the Department and to the legislative committee responsible for monitoring the pilot program's operation and for determining future medical assistance directives. The annual report from each county shall summarize the monthly reports from the Department as described in subsection (k) and shall summarize the quality of care outcomes resulting from this pilot program, as well as the processes and resources used to achieve those outcomes.

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