Sen. Iris Y. Martinez

Filed: 3/28/2014

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 221

2    AMENDMENT NO. ______. Amend Senate Bill 221 by replacing
3everything after the enacting clause with the following:
 
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

 

 

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1contract in integrated delivery systems that are responsible
2for providing or arranging the majority of care, including
3primary care physician services, referrals from primary care
4physicians, diagnostic and treatment services, behavioral
5health services, in-patient and outpatient hospital services,
6dental services, and rehabilitation and long-term care
7services. The Department shall designate or contract for such
8integrated delivery systems (i) to ensure enrollees have a
9choice of systems and of primary care providers within such
10systems; (ii) to ensure that enrollees receive quality care in
11a culturally and linguistically appropriate manner; and (iii)
12to ensure that coordinated care programs meet the diverse needs
13of enrollees with developmental, mental health, physical, and
14age-related disabilities.
15    (b) Payment for such coordinated care shall be based on
16arrangements where the State pays for performance related to
17health care outcomes, the use of evidence-based practices, the
18use of primary care delivered through comprehensive medical
19homes, the use of electronic medical records, and the
20appropriate exchange of health information electronically made
21either on a capitated basis in which a fixed monthly premium
22per recipient is paid and full financial risk is assumed for
23the delivery of services, or through other risk-based payment
24arrangements.
25    (c) To qualify for compliance with this Section, the 50%
26goal shall be achieved by enrolling medical assistance

 

 

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1enrollees from each medical assistance enrollment category,
2including parents, children, seniors, and people with
3disabilities to the extent that current State Medicaid payment
4laws would not limit federal matching funds for recipients in
5care coordination programs. In addition, services must be more
6comprehensively defined and more risk shall be assumed than in
7the Department's primary care case management program as of the
8effective date of this amendatory Act of the 96th General
9Assembly.
10    (d) The Department shall report to the General Assembly in
11a separate part of its annual medical assistance program
12report, beginning April, 2012 until April, 2016, on the
13progress and implementation of the care coordination program
14initiatives established by the provisions of this amendatory
15Act of the 96th General Assembly. The Department shall include
16in its April 2011 report a full analysis of federal laws or
17regulations regarding upper payment limitations to providers
18and the necessary revisions or adjustments in rate
19methodologies and payments to providers under this Code that
20would be necessary to implement coordinated care with full
21financial risk by a party other than the Department.
22    (e) Integrated Care Program for individuals with chronic
23mental health conditions.
24        (1) The Integrated Care Program shall encompass
25    services administered to recipients of medical assistance
26    under this Article to prevent exacerbations and

 

 

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1    complications using cost-effective, evidence-based
2    practice guidelines and mental health management
3    strategies.
4        (2) The Department may utilize and expand upon existing
5    contractual arrangements with integrated care plans under
6    the Integrated Care Program for providing the coordinated
7    care provisions of this Section.
8        (3) Payment for such coordinated care shall be based on
9    arrangements where the State pays for performance related
10    to mental health outcomes on a capitated basis in which a
11    fixed monthly premium per recipient is paid and full
12    financial risk is assumed for the delivery of services, or
13    through other risk-based payment arrangements such as
14    provider-based care coordination.
15        (4) The Department shall examine whether chronic
16    mental health management programs and services for
17    recipients with specific chronic mental health conditions
18    do any or all of the following:
19            (A) Improve the patient's overall mental health in
20        a more expeditious and cost-effective manner.
21            (B) Lower costs in other aspects of the medical
22        assistance program, such as hospital admissions,
23        emergency room visits, or more frequent and
24        inappropriate psychotropic drug use.
25        (5) The Department shall work with the facilities and
26    any integrated care plan participating in the program to

 

 

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1    identify and correct barriers to the successful
2    implementation of this subsection (e) prior to and during
3    the implementation to best facilitate the goals and
4    objectives of this subsection (e).
5    (f) A hospital that is located in a county of the State in
6which the Department mandates some or all of the beneficiaries
7of the Medical Assistance Program residing in the county to
8enroll in a Care Coordination Program, as set forth in Section
95-30 of this Code, shall not be eligible for any non-claims
10based payments not mandated by Article V-A of this Code for
11which it would otherwise be qualified to receive, unless the
12hospital is a Coordinated Care Participating Hospital no later
13than 60 days after the effective date of this amendatory Act of
14the 97th General Assembly or 60 days after the first mandatory
15enrollment of a beneficiary in a Coordinated Care program. For
16purposes of this subsection, "Coordinated Care Participating
17Hospital" means a hospital that meets one of the following
18criteria:
19        (1) The hospital has entered into a contract to provide
20    hospital services to enrollees of the care coordination
21    program.
22        (2) The hospital has not been offered a contract by a
23    care coordination plan that pays at least as much as the
24    Department would pay, on a fee-for-service basis, not
25    including disproportionate share hospital adjustment
26    payments or any other supplemental adjustment or add-on

 

 

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1    payment to the base fee-for-service rate.
2    (g) No later than August 1, 2013, the Department shall
3issue a purchase of care solicitation for Accountable Care
4Entities (ACE) to serve any children and parents or caretaker
5relatives of children eligible for medical assistance under
6this Article. An ACE may be a single corporate structure or a
7network of providers organized through contractual
8relationships with a single corporate entity. The solicitation
9shall require that:
10        (1) An ACE operating in Cook County be capable of
11    serving at least 40,000 eligible individuals in that
12    county; an ACE operating in Lake, Kane, DuPage, or Will
13    Counties be capable of serving at least 20,000 eligible
14    individuals in those counties and an ACE operating in other
15    regions of the State be capable of serving at least 10,000
16    eligible individuals in the region in which it operates.
17    During initial periods of mandatory enrollment, the
18    Department shall require its enrollment services
19    contractor to use a default assignment algorithm that
20    ensures if possible an ACE reaches the minimum enrollment
21    levels set forth in this paragraph.
22        (2) An ACE must include at a minimum the following
23    types of providers: primary care, specialty care,
24    hospitals, and behavioral healthcare.
25        (3) An ACE shall have a governance structure that
26    includes the major components of the health care delivery

 

 

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1    system, including one representative from each of the
2    groups listed in paragraph (2).
3        (4) An ACE must be an integrated delivery system,
4    including a network able to provide the full range of
5    services needed by Medicaid beneficiaries and system
6    capacity to securely pass clinical information across
7    participating entities and to aggregate and analyze that
8    data in order to coordinate care.
9        (5) An ACE must be capable of providing both care
10    coordination and complex case management, as necessary, to
11    beneficiaries. To be responsive to the solicitation, a
12    potential ACE must outline its care coordination and
13    complex case management model and plan to reduce the cost
14    of care.
15        (6) In the first 18 months of operation, unless the ACE
16    selects a shorter period, an ACE shall be paid care
17    coordination fees on a per member per month basis that are
18    projected to be cost neutral to the State during the term
19    of their payment and, subject to federal approval, be
20    eligible to share in additional savings generated by their
21    care coordination.
22        (7) In months 19 through 36 of operation, unless the
23    ACE selects a shorter period, an ACE shall be paid on a
24    pre-paid capitation basis for all medical assistance
25    covered services, under contract terms similar to Managed
26    Care Organizations (MCO), with the Department sharing the

 

 

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1    risk through either stop-loss insurance for extremely high
2    cost individuals or corridors of shared risk based on the
3    overall cost of the total enrollment in the ACE. The ACE
4    shall be responsible for claims processing, encounter data
5    submission, utilization control, and quality assurance.
6        (8) In the fourth and subsequent years of operation, an
7    ACE shall convert to a Managed Care Community Network
8    (MCCN), as defined in this Article, or Health Maintenance
9    Organization pursuant to the Illinois Insurance Code,
10    accepting full-risk capitation payments.
11    The Department shall allow potential ACE entities 5 months
12from the date of the posting of the solicitation to submit
13proposals. After the solicitation is released, in addition to
14the MCO rate development data available on the Department's
15website, subject to federal and State confidentiality and
16privacy laws and regulations, the Department shall provide 2
17years of de-identified summary service data on the targeted
18population, split between children and adults, showing the
19historical type and volume of services received and the cost of
20those services to those potential bidders that sign a data use
21agreement. The Department may add up to 2 non-state government
22employees with expertise in creating integrated delivery
23systems to its review team for the purchase of care
24solicitation described in this subsection. Any such
25individuals must sign a no-conflict disclosure and
26confidentiality agreement and agree to act in accordance with

 

 

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1all applicable State laws.
2    During the first 2 years of an ACE's operation, the
3Department shall provide claims data to the ACE on its
4enrollees on a periodic basis no less frequently than monthly.
5    Nothing in this subsection shall be construed to limit the
6Department's mandate to enroll 50% of its beneficiaries into
7care coordination systems by January 1, 2015, using all
8available care coordination delivery systems, including Care
9Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
10to affect the current CCEs, MCCNs, and MCOs selected to serve
11seniors and persons with disabilities prior to that date.
12    (h) Department contracts with MCOs and other entities
13reimbursed by risk based capitation shall have a minimum
14medical loss ratio of 85%, shall require the MCO or other
15entity to pay claims within 30 days of receiving a bill that
16contains all the essential information needed to adjudicate the
17bill, and shall require the entity to pay a penalty that is at
18least equal to the penalty imposed under the Illinois Insurance
19Code for any claims not paid within this time period. The
20requirements of this subsection shall apply to contracts with
21MCOs entered into or renewed or extended after June 1, 2013.
22    (i) Managed Care Entities (MCEs), including MCOs and all
23other care coordination organizations, shall develop and
24maintain a written language access policy that sets forth the
25standards, guidelines, and operational plan to ensure language
26appropriate services and that is consistent with the standard

 

 

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1of meaningful access for populations with limited English
2proficiency. The language access policy shall describe how the
3MCEs will provide all of the following required services:
4        (1) Translation (the written replacement of text from
5    one language into another) of all vital documents and forms
6    as identified by the Department.
7        (2) Qualified interpreter services (the oral
8    communication of a message from one language into another
9    by a qualified interpreter).
10        (3) Staff training on the language access policy,
11    including how to identify language needs, access and
12    provide language assistance services, work with
13    interpreters, request translations, and track the use of
14    language assistance services.
15        (4) Data tracking that identifies the language need.
16        (5) Notification to participants on the availability
17    of language access services and on how to access such
18    services.
19(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)".