Sen. Antonio Muņoz

Filed: 4/28/2015

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 1273

2    AMENDMENT NO. ______. Amend Senate Bill 1273 by replacing
3everything after the enacting clause with the following:
 
4    "Section 1. Legislative intent. With the expansion of the
5State's Medical Assistance Program pursuant to the Patient
6Protection and Affordable Care Act (Public Law 111-148) and the
7increasing number of individuals enrolling in managed care
8organizations, it is the intent of this amendatory Act of the
999th General Assembly to provide a comprehensive managed care
10network that is administered uniformly and simply and that
11ensures access to and provides efficient, economic, and quality
12care to individuals enrolled in programs administered by the
13Department of Healthcare and Family Services.
 
14    Section 5. The Illinois Public Aid Code is amended by
15changing Section 5-30 as follows:
 

 

 

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1    (305 ILCS 5/5-30)
2    Sec. 5-30. Care coordination.
3    (a) At least 50% of recipients eligible for comprehensive
4medical benefits in all medical assistance programs or other
5health benefit programs administered by the Department,
6including the Children's Health Insurance Program Act and the
7Covering ALL KIDS Health Insurance Act, shall be enrolled in a
8care coordination program by no later than January 1, 2015. For
9purposes of this Section, "coordinated care" or "care
10coordination" means delivery systems where recipients will
11receive their care from providers who participate under
12contract in integrated delivery systems that are responsible
13for providing or arranging the majority of care, including
14primary care physician services, referrals from primary care
15physicians, diagnostic and treatment services, behavioral
16health services, in-patient and outpatient hospital services,
17dental services, and rehabilitation and long-term care
18services. The Department shall designate or contract for such
19integrated delivery systems (i) to ensure enrollees have a
20choice of systems and of primary care providers within such
21systems; (ii) to ensure that enrollees receive quality care in
22a culturally and linguistically appropriate manner; and (iii)
23to ensure that coordinated care programs meet the diverse needs
24of enrollees with developmental, mental health, physical, and
25age-related disabilities.
26    (b) Payment for such coordinated care shall be based on

 

 

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1arrangements where the State pays for performance related to
2health care outcomes, the use of evidence-based practices, the
3use of primary care delivered through comprehensive medical
4homes, the use of electronic medical records, and the
5appropriate exchange of health information electronically made
6either on a capitated basis in which a fixed monthly premium
7per recipient is paid and full financial risk is assumed for
8the delivery of services, or through other risk-based payment
9arrangements.
10    (c) To qualify for compliance with this Section, the 50%
11goal shall be achieved by enrolling medical assistance
12enrollees from each medical assistance enrollment category,
13including parents, children, seniors, and people with
14disabilities to the extent that current State Medicaid payment
15laws would not limit federal matching funds for recipients in
16care coordination programs. In addition, services must be more
17comprehensively defined and more risk shall be assumed than in
18the Department's primary care case management program as of the
19effective date of this amendatory Act of the 96th General
20Assembly.
21    (d) The Department shall report to the General Assembly in
22a separate part of its annual medical assistance program
23report, beginning April, 2012 until April, 2016, on the
24progress and implementation of the care coordination program
25initiatives established by the provisions of this amendatory
26Act of the 96th General Assembly. The Department shall include

 

 

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1in its April 2011 report a full analysis of federal laws or
2regulations regarding upper payment limitations to providers
3and the necessary revisions or adjustments in rate
4methodologies and payments to providers under this Code that
5would be necessary to implement coordinated care with full
6financial risk by a party other than the Department.
7    (e) Integrated Care Program for individuals with chronic
8mental health conditions.
9        (1) The Integrated Care Program shall encompass
10    services administered to recipients of medical assistance
11    under this Article to prevent exacerbations and
12    complications using cost-effective, evidence-based
13    practice guidelines and mental health management
14    strategies.
15        (2) The Department may utilize and expand upon existing
16    contractual arrangements with integrated care plans under
17    the Integrated Care Program for providing the coordinated
18    care provisions of this Section.
19        (3) Payment for such coordinated care shall be based on
20    arrangements where the State pays for performance related
21    to mental health outcomes on a capitated basis in which a
22    fixed monthly premium per recipient is paid and full
23    financial risk is assumed for the delivery of services, or
24    through other risk-based payment arrangements such as
25    provider-based care coordination.
26        (4) The Department shall examine whether chronic

 

 

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1    mental health management programs and services for
2    recipients with specific chronic mental health conditions
3    do any or all of the following:
4            (A) Improve the patient's overall mental health in
5        a more expeditious and cost-effective manner.
6            (B) Lower costs in other aspects of the medical
7        assistance program, such as hospital admissions,
8        emergency room visits, or more frequent and
9        inappropriate psychotropic drug use.
10        (5) The Department shall work with the facilities and
11    any integrated care plan participating in the program to
12    identify and correct barriers to the successful
13    implementation of this subsection (e) prior to and during
14    the implementation to best facilitate the goals and
15    objectives of this subsection (e).
16    (f) A hospital that is located in a county of the State in
17which the Department mandates some or all of the beneficiaries
18of the Medical Assistance Program residing in the county to
19enroll in a Care Coordination Program, as set forth in Section
205-30 of this Code, shall not be eligible for any non-claims
21based payments not mandated by Article V-A of this Code for
22which it would otherwise be qualified to receive, unless the
23hospital is a Coordinated Care Participating Hospital no later
24than 60 days after the effective date of this amendatory Act of
25the 97th General Assembly or 60 days after the first mandatory
26enrollment of a beneficiary in a Coordinated Care program. For

 

 

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1purposes of this subsection, "Coordinated Care Participating
2Hospital" means a hospital that meets one of the following
3criteria:
4        (1) The hospital has entered into a contract to provide
5    hospital services with one or more MCOs to enrollees of the
6    care coordination program.
7        (2) The hospital has not been offered a contract by a
8    care coordination plan that the Department has determined
9    to be a good faith offer and that pays at least as much as
10    the Department would pay, on a fee-for-service basis, not
11    including disproportionate share hospital adjustment
12    payments or any other supplemental adjustment or add-on
13    payment to the base fee-for-service rate, except to the
14    extent such adjustments or add-on payments are
15    incorporated into the development of the applicable MCO
16    capitated rates.
17    As used in this subsection (f), "MCO" means any entity
18which contracts with the Department to provide services where
19payment for medical services is made on a capitated basis.
20    (g) No later than August 1, 2013, the Department shall
21issue a purchase of care solicitation for Accountable Care
22Entities (ACE) to serve any children and parents or caretaker
23relatives of children eligible for medical assistance under
24this Article. An ACE may be a single corporate structure or a
25network of providers organized through contractual
26relationships with a single corporate entity. The solicitation

 

 

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

 

 

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

 

 

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

 

 

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1Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
2to affect the current CCEs, MCCNs, and MCOs selected to serve
3seniors and persons with disabilities prior to that date.
4    Nothing in this subsection precludes the Department from
5considering future proposals for new ACEs or expansion of
6existing ACEs at the discretion of the Department.
7    (h) Department contracts with MCOs and other entities
8reimbursed by risk based capitation shall have a minimum
9medical loss ratio of 85%, shall require the entity to
10establish an appeals and grievances process for consumers and
11providers, and shall require the entity to provide a quality
12assurance and utilization review program. Entities contracted
13with the Department to coordinate healthcare regardless of risk
14shall be measured utilizing the same quality metrics. The
15quality metrics may be population specific. Any contracted
16entity serving at least 5,000 seniors or people with
17disabilities or 15,000 individuals in other populations
18covered by the Medical Assistance Program that has been
19receiving full-risk capitation for a year shall be accredited
20by a national accreditation organization authorized by the
21Department within 2 years after the date it is eligible to
22become accredited. The requirements of this subsection shall
23apply to contracts with MCOs entered into or renewed or
24extended after June 1, 2013.
25    (h-4)
26        (1) MCOs, as defined in Section 5-30.1 of this Code,

 

 

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1    including managed care community networks as defined in
2    Section 5-11 of this Code, shall be subject to Section
3    5-4.2 of this Code and any amendments, regulations,
4    policies, and guidelines thereto concerning the following
5    matters: mileage criteria and methodology, emergency and
6    urgently needed methodology and criteria, appeals
7    processes including post authorization for
8    non-prescheduled, non-emergency transportation, and
9    uniform certification of medical necessity for
10    non-emergency ambulance transportation. Appeal decisions
11    issued by MCOs pursuant to Section 5-4.2 shall be
12    appealable to the Director, and the Director's decision on
13    these appeals shall be a final administrative decision
14    subject to review under the Administrative Review Law. The
15    uniform certification of medical necessity for
16    non-emergency transportation requirements shall be
17    effective for dates of service beginning no later than 90
18    days after the effective date of this amendatory Act of the
19    99th General Assembly. The mileage criteria and
20    methodology, emergency and urgently needed methodology,
21    and criteria and appeals processes, including post
22    authorization for non-prescheduled, non-emergency
23    transportation, shall be effective for dates of service
24    beginning no later than July 1, 2015 and for any and all
25    outstanding claims that exist at the time of implementation
26    of the methodologies, appeals, and post authorization

 

 

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1    processes.
2        Effective immediately upon the effective date of this
3    amendatory Act of the 99th General Assembly, MCOs shall not
4    unreasonably refuse to contract with ground ambulance
5    services providers as defined in Section 5-4.2 of this Code
6    and medi-car services providers as defined in Section 5-4.2
7    of this Code, shall not unreasonably restrict access to and
8    the availability of ground ambulance services and medi-car
9    services, and shall ensure that recipients of the
10    Department's programs shall not be liable for ground
11    ambulance services and medi-car services expenses
12    consistent with federal law, Sections 370h and 370i of the
13    Illinois Insurance Code, and any amendments, regulations,
14    policies, and guidelines thereto, including, but not
15    limited to, 50 Ill. Admin. Code 2051.280(b) and any
16    amendments thereto.
17        (2) It is the intention of the General Assembly that
18    the State action exemption to the application of federal
19    and State antitrust statutes be fully available to the
20    Department and MCOs and their agents and designees, and all
21    employees, officers, subsidiaries, and designees thereof,
22    to the extent the activities are authorized by the
23    provisions of Section 5-4.2 to which the MCOs are subject
24    under this amendatory Act of the 99th General Assembly. The
25    State action exemption shall be liberally construed in
26    favor of the Department and MCOs and their agents and

 

 

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1    designees and all employees, officers, subsidiaries, and
2    designees thereof, and such exemption shall be available
3    notwithstanding that the action constitutes an irregular
4    exercise of constitutional or statutory powers. It is the
5    policy of this State that the following powers may be
6    exercised by the Department and MCOs and their agents and
7    designees and all employees, officers, subsidiaries, and
8    designees thereof notwithstanding the effects on
9    competition and notwithstanding any displacement of
10    competition: (i) all powers that are within the traditional
11    areas of the Department's activity but that are authorized
12    by the provisions of Section 5-4.2 to which the MCOs are
13    subject under this amendatory Act of the 99th General
14    Assembly and that are to be implemented by the MCOs and
15    their agents and designees and all employees, officers,
16    subsidiaries, and designees thereof; (ii) all powers
17    granted, either expressly or by necessary implication, by
18    the provisions of Section 5-4.2 to which the MCOs are
19    subject under this amendatory Act of the 99th General
20    Assembly or any administrative rules, policies, or
21    procedures that implement the provisions of Section 5-4.2
22    to which the MCOs are subject under this amendatory Act of
23    the 99th General Assembly; or (iii) all powers that are the
24    inherent, logical, or ordinary results of the powers
25    granted by the provisions of Section 5-4.2 to which the
26    MCOs are subject under this amendatory Act of the 99th

 

 

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1    General Assembly and any administrative rules, policies,
2    or procedures that implement the provisions of Section
3    5-4.2 to which the MCOs are subject under this amendatory
4    Act of the 99th General Assembly. In order to ensure that
5    MCOs and their agents and designees and all employees,
6    officers, subsidiaries, and designees thereof promote
7    State policy and not individual interest, the Department
8    shall actively supervise their activities, including, but
9    not limited to, their decisions. The Department's active
10    supervision shall include, but not be limited to, a review
11    of the substance of any activities or decisions and the
12    power to veto or modify particular activities or decisions
13    to ensure they accord with State policy. The mere potential
14    for State supervision shall not be a sufficient substitute
15    for an actual decision by the Department. Department
16    supervisors shall not be active market participants.
17    (h-5) The Department shall monitor and enforce compliance
18by MCOs with agreements they have entered into with providers
19on issues that include, but are not limited to, timeliness of
20payment, payment rates, and processes for obtaining prior
21approval. The Department may impose sanctions on MCOs for
22violating provisions of those agreements that include, but are
23not limited to, financial penalties, suspension of enrollment
24of new enrollees, and termination of the MCO's contract with
25the Department. As used in this subsection (h-5), "MCO" has the
26meaning ascribed to that term in Section 5-30.1 of this Code.

 

 

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1(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13;
298-651, eff. 6-16-14.)
 
3    Section 99. Effective date. This Act takes effect upon
4becoming law.".