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Sen. David Koehler
Filed: 5/30/2013
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1 | | AMENDMENT TO SENATE BILL 740
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2 | | AMENDMENT NO. ______. Amend Senate Bill 740 by replacing |
3 | | everything after the enacting clause with the following:
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4 | | "Section 5. If and only if Senate Bill 26 of
the 98th |
5 | | General Assembly becomes law, then the Illinois Public Aid Code |
6 | | is amended by changing Section 5-30 as follows: |
7 | | (305 ILCS 5/5-30) |
8 | | Sec. 5-30. Care coordination. |
9 | | (a) At least 50% of recipients eligible for comprehensive |
10 | | medical benefits in all medical assistance programs or other |
11 | | health benefit programs administered by the Department, |
12 | | including the Children's Health Insurance Program Act and the |
13 | | Covering ALL KIDS Health Insurance Act, shall be enrolled in a |
14 | | care coordination program by no later than January 1, 2015. For |
15 | | purposes of this Section, "coordinated care" or "care |
16 | | coordination" means delivery systems where recipients will |
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1 | | receive their care from providers who participate under |
2 | | contract in integrated delivery systems that are responsible |
3 | | for providing or arranging the majority of care, including |
4 | | primary care physician services, referrals from primary care |
5 | | physicians, diagnostic and treatment services, behavioral |
6 | | health services, in-patient and outpatient hospital services, |
7 | | dental services, and rehabilitation and long-term care |
8 | | services. The Department shall designate or contract for such |
9 | | integrated delivery systems (i) to ensure enrollees have a |
10 | | choice of systems and of primary care providers within such |
11 | | systems; (ii) to ensure that enrollees receive quality care in |
12 | | a culturally and linguistically appropriate manner; and (iii) |
13 | | to ensure that coordinated care programs meet the diverse needs |
14 | | of enrollees with developmental, mental health, physical, and |
15 | | age-related disabilities. |
16 | | (b) Payment for such coordinated care shall be based on |
17 | | arrangements where the State pays for performance related to |
18 | | health care outcomes, the use of evidence-based practices, the |
19 | | use of primary care delivered through comprehensive medical |
20 | | homes, the use of electronic medical records, and the |
21 | | appropriate exchange of health information electronically made |
22 | | either on a capitated basis in which a fixed monthly premium |
23 | | per recipient is paid and full financial risk is assumed for |
24 | | the delivery of services, or through other risk-based payment |
25 | | arrangements. |
26 | | (c) To qualify for compliance with this Section, the 50% |
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1 | | goal shall be achieved by enrolling medical assistance |
2 | | enrollees from each medical assistance enrollment category, |
3 | | including parents, children, seniors, and people with |
4 | | disabilities to the extent that current State Medicaid payment |
5 | | laws would not limit federal matching funds for recipients in |
6 | | care coordination programs. In addition, services must be more |
7 | | comprehensively defined and more risk shall be assumed than in |
8 | | the Department's primary care case management program as of the |
9 | | effective date of this amendatory Act of the 96th General |
10 | | Assembly. |
11 | | (d) The Department shall report to the General Assembly in |
12 | | a separate part of its annual medical assistance program |
13 | | report, beginning April, 2012 until April, 2016, on the |
14 | | progress and implementation of the care coordination program |
15 | | initiatives established by the provisions of this amendatory |
16 | | Act of the 96th General Assembly. The Department shall include |
17 | | in its April 2011 report a full analysis of federal laws or |
18 | | regulations regarding upper payment limitations to providers |
19 | | and the necessary revisions or adjustments in rate |
20 | | methodologies and payments to providers under this Code that |
21 | | would be necessary to implement coordinated care with full |
22 | | financial risk by a party other than the Department.
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23 | | (e) Integrated Care Program for individuals with chronic |
24 | | mental health conditions. |
25 | | (1) The Integrated Care Program shall encompass |
26 | | services administered to recipients of medical assistance |
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1 | | under this Article to prevent exacerbations and |
2 | | complications using cost-effective, evidence-based |
3 | | practice guidelines and mental health management |
4 | | strategies. |
5 | | (2) The Department may utilize and expand upon existing |
6 | | contractual arrangements with integrated care plans under |
7 | | the Integrated Care Program for providing the coordinated |
8 | | care provisions of this Section. |
9 | | (3) Payment for such coordinated care shall be based on |
10 | | arrangements where the State pays for performance related |
11 | | to mental health outcomes on a capitated basis in which a |
12 | | fixed monthly premium per recipient is paid and full |
13 | | financial risk is assumed for the delivery of services, or |
14 | | through other risk-based payment arrangements such as |
15 | | provider-based care coordination. |
16 | | (4) The Department shall examine whether chronic |
17 | | mental health management programs and services for |
18 | | recipients with specific chronic mental health conditions |
19 | | do any or all of the following: |
20 | | (A) Improve the patient's overall mental health in |
21 | | a more expeditious and cost-effective manner. |
22 | | (B) Lower costs in other aspects of the medical |
23 | | assistance program, such as hospital admissions, |
24 | | emergency room visits, or more frequent and |
25 | | inappropriate psychotropic drug use. |
26 | | (5) The Department shall work with the facilities and |
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1 | | any integrated care plan participating in the program to |
2 | | identify and correct barriers to the successful |
3 | | implementation of this subsection (e) prior to and during |
4 | | the implementation to best facilitate the goals and |
5 | | objectives of this subsection (e). |
6 | | (f) A hospital that is located in a county of the State in |
7 | | which the Department mandates some or all of the beneficiaries |
8 | | of the Medical Assistance Program residing in the county to |
9 | | enroll in a Care Coordination Program, as set forth in Section |
10 | | 5-30 of this Code, shall not be eligible for any non-claims |
11 | | based payments not mandated by Article V-A of this Code for |
12 | | which it would otherwise be qualified to receive, unless the |
13 | | hospital is a Coordinated Care Participating Hospital no later |
14 | | than 60 days after the effective date of this amendatory Act of |
15 | | the 97th General Assembly or 60 days after the first mandatory |
16 | | enrollment of a beneficiary in a Coordinated Care program. For |
17 | | purposes of this subsection, "Coordinated Care Participating |
18 | | Hospital" means a hospital that meets one of the following |
19 | | criteria: |
20 | | (1) The hospital has entered into a contract to provide |
21 | | hospital services to enrollees of the care coordination |
22 | | program. |
23 | | (2) The hospital has not been offered a contract by a |
24 | | care coordination plan that pays at least as much as the |
25 | | Department would pay, on a fee-for-service basis, not |
26 | | including disproportionate share hospital adjustment |
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1 | | payments or any other supplemental adjustment or add-on |
2 | | payment to the base fee-for-service rate. |
3 | | (g) No later than August 1, 2013, the Department shall |
4 | | issue a purchase of care solicitation for Accountable Care |
5 | | Entities (ACE) to serve any children and parents or caretaker |
6 | | relatives of children eligible for medical assistance under |
7 | | this Article. An ACE may be a single corporate structure or a |
8 | | network of providers organized through contractual |
9 | | relationships with a single corporate entity. The solicitation |
10 | | shall require that: |
11 | | (1) An ACE operating in Cook County be capable of |
12 | | serving at least 40,000 eligible individuals in that |
13 | | county; an ACE operating in Lake, Kane, DuPage, or Will |
14 | | Counties be capable of serving at least 20,000 eligible |
15 | | individuals in those counties and an ACE operating in other |
16 | | regions of the State be capable of serving at least 10,000 |
17 | | eligible individuals in the region in which it operates. |
18 | | During initial periods of mandatory enrollment, the |
19 | | Department shall require its enrollment services |
20 | | contractor to use a default assignment algorithm that |
21 | | ensures if possible an ACE reaches the minimum enrollment |
22 | | levels set forth in this paragraph. |
23 | | (2) An ACE must include at a minimum the following |
24 | | types of providers: primary care, specialty care, |
25 | | hospitals, and behavioral healthcare. |
26 | | (3) An ACE shall have a governance structure that |
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1 | | includes the major components of the health care delivery |
2 | | system, including one representative from each of the |
3 | | groups listed in paragraph (2). |
4 | | (4) An ACE must be an integrated delivery system, |
5 | | including a network able to provide the full range of |
6 | | services needed by Medicaid beneficiaries and system |
7 | | capacity to securely pass clinical information across |
8 | | participating entities and to aggregate and analyze that |
9 | | data in order to coordinate care. |
10 | | (5) An ACE must be capable of providing both care |
11 | | coordination and complex case management, as necessary, to |
12 | | beneficiaries. To be responsive to the solicitation, a |
13 | | potential ACE must outline its care coordination and |
14 | | complex case management model and plan to reduce the cost |
15 | | of care. |
16 | | (6) In the first 18 months of operation, unless the ACE |
17 | | selects a shorter period, an ACE shall be paid care |
18 | | coordination fees on a per member per month basis that are |
19 | | projected to be cost neutral to the State during the term |
20 | | of their payment and, subject to federal approval, be |
21 | | eligible to share in additional savings generated by their |
22 | | care coordination. |
23 | | (7) In months 19 through 36 of operation, unless the |
24 | | ACE selects a shorter period, an ACE shall be paid on a |
25 | | pre-paid capitation basis for all medical assistance |
26 | | covered services, under contract terms similar to Managed |
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1 | | Care Organizations (MCO), with the Department sharing the |
2 | | risk through either stop-loss insurance for extremely high |
3 | | cost individuals or corridors of shared risk based on the |
4 | | overall cost of the total enrollment in the ACE. The ACE |
5 | | shall be responsible for claims processing, encounter data |
6 | | submission, utilization control, and quality assurance. |
7 | | (8) In the fourth and subsequent years of operation, an |
8 | | ACE shall convert to a Managed Care Community Network |
9 | | (MCCN), as defined in this Article, or Health Maintenance |
10 | | Organization pursuant to the Illinois Insurance Code, |
11 | | accepting full-risk capitation payments. |
12 | | The Department shall allow potential ACE entities 5 months |
13 | | from the date of the posting of the solicitation to submit |
14 | | proposals. After the solicitation is released, in addition to |
15 | | the MCO rate development data available on the Department's |
16 | | website, subject to federal and State confidentiality and |
17 | | privacy laws and regulations, the Department shall provide 2 |
18 | | years of de-identified summary service data on the targeted |
19 | | population, split between children and adults, showing the |
20 | | historical type and volume of services received and the cost of |
21 | | those services to those potential bidders that sign a data use |
22 | | agreement. The Department may add up to 2 non-state government |
23 | | employees with expertise in creating integrated delivery |
24 | | systems to its review team for the purchase of care |
25 | | solicitation described in this subsection. Any such |
26 | | individuals must sign a no-conflict disclosure and |
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1 | | confidentiality agreement and agree to act in accordance with |
2 | | all applicable State laws. |
3 | | During the first 2 years of an ACE's operation, the |
4 | | Department shall provide claims data to the ACE on its |
5 | | enrollees on a periodic basis no less frequently than monthly. |
6 | | Nothing in this subsection shall be construed to limit the |
7 | | Department's mandate to enroll 50% of its beneficiaries into |
8 | | care coordination systems by January 1, 2015, using all |
9 | | available care coordination delivery systems, including Care |
10 | | Coordination Entities (CCE), MCCNs, or MCOs, as long as such |
11 | | movement is done in a manner that meets with federal approval |
12 | | and does not result in a reduction of federal revenues garnered |
13 | | through the Hospital Assessment program, nor be construed to |
14 | | affect the current CCEs, MCCNs, and MCOs selected to serve |
15 | | seniors and persons with disabilities prior to that date as |
16 | | long as such movement is done in a manner that meets with |
17 | | federal approval and does not result in a reduction of federal |
18 | | revenues garnered through the Hospital Assessment program . |
19 | | (h) Department contracts with MCOs and other entities |
20 | | reimbursed by risk based capitation shall have a minimum |
21 | | medical loss ratio of 85%, shall require the MCO or other |
22 | | entity to pay claims within 30 days of receiving a bill that |
23 | | contains all the essential information needed to adjudicate the |
24 | | bill, and shall require the entity to pay a penalty that is at |
25 | | least equal to the penalty imposed under the Illinois Insurance |
26 | | Code for any claims not paid within this time period. The |