Rep. Christian L. Mitchell
Filed: 3/20/2015
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1 | AMENDMENT TO HOUSE BILL 2812
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2 | AMENDMENT NO. ______. Amend House Bill 2812 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 5. The Illinois Public Aid Code is amended by | ||||||
5 | changing 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 | ||||||
9 | medical benefits in all medical assistance programs or other | ||||||
10 | health benefit programs administered by the Department, | ||||||
11 | including the Children's Health Insurance Program Act and the | ||||||
12 | Covering ALL KIDS Health Insurance Act, shall be enrolled in a | ||||||
13 | care coordination program by no later than January 1, 2015. For | ||||||
14 | purposes of this Section, "coordinated care" or "care | ||||||
15 | coordination" means delivery systems where recipients will | ||||||
16 | receive their care from providers who participate under |
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1 | contract in integrated delivery systems that are responsible | ||||||
2 | for providing or arranging the majority of care, including | ||||||
3 | primary care physician services, referrals from primary care | ||||||
4 | physicians, diagnostic and treatment services, behavioral | ||||||
5 | health services, in-patient and outpatient hospital services, | ||||||
6 | dental services, and rehabilitation and long-term care | ||||||
7 | services. The Department shall designate or contract for such | ||||||
8 | integrated delivery systems (i) to ensure enrollees have a | ||||||
9 | choice of systems and of primary care providers within such | ||||||
10 | systems; (ii) to ensure that enrollees receive quality care in | ||||||
11 | a culturally and linguistically appropriate manner; and (iii) | ||||||
12 | to ensure that coordinated care programs meet the diverse needs | ||||||
13 | of enrollees with developmental, mental health, physical, and | ||||||
14 | age-related disabilities. | ||||||
15 | (b) Payment for such coordinated care shall be based on | ||||||
16 | arrangements where the State pays for performance related to | ||||||
17 | health care outcomes, the use of evidence-based practices, the | ||||||
18 | use of primary care delivered through comprehensive medical | ||||||
19 | homes, the use of electronic medical records, and the | ||||||
20 | appropriate exchange of health information electronically made | ||||||
21 | either on a capitated basis in which a fixed monthly premium | ||||||
22 | per recipient is paid and full financial risk is assumed for | ||||||
23 | the delivery of services, or through other risk-based payment | ||||||
24 | arrangements. | ||||||
25 | (c) To qualify for compliance with this Section, the 50% | ||||||
26 | goal shall be achieved by enrolling medical assistance |
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1 | enrollees from each medical assistance enrollment category, | ||||||
2 | including parents, children, seniors, and people with | ||||||
3 | disabilities to the extent that current State Medicaid payment | ||||||
4 | laws would not limit federal matching funds for recipients in | ||||||
5 | care coordination programs. In addition, services must be more | ||||||
6 | comprehensively defined and more risk shall be assumed than in | ||||||
7 | the Department's primary care case management program as of the | ||||||
8 | effective date of this amendatory Act of the 96th General | ||||||
9 | Assembly. | ||||||
10 | (d) The Department shall report to the General Assembly in | ||||||
11 | a separate part of its annual medical assistance program | ||||||
12 | report, beginning April, 2012 until April, 2016, on the | ||||||
13 | progress and implementation of the care coordination program | ||||||
14 | initiatives established by the provisions of this amendatory | ||||||
15 | Act of the 96th General Assembly. The Department shall include | ||||||
16 | in its April 2011 report a full analysis of federal laws or | ||||||
17 | regulations regarding upper payment limitations to providers | ||||||
18 | and the necessary revisions or adjustments in rate | ||||||
19 | methodologies and payments to providers under this Code that | ||||||
20 | would be necessary to implement coordinated care with full | ||||||
21 | financial risk by a party other than the Department.
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22 | (e) Integrated Care Program for individuals with chronic | ||||||
23 | mental 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 | ||||||
6 | which the Department mandates some or all of the beneficiaries | ||||||
7 | of the Medical Assistance Program residing in the county to | ||||||
8 | enroll in a Care Coordination Program, as set forth in Section | ||||||
9 | 5-30 of this Code, shall not be eligible for any non-claims | ||||||
10 | based payments not mandated by Article V-A of this Code for | ||||||
11 | which it would otherwise be qualified to receive, unless the | ||||||
12 | hospital is a Coordinated Care Participating Hospital no later | ||||||
13 | than 60 days after the effective date of this amendatory Act of | ||||||
14 | the 97th General Assembly or 60 days after the first mandatory | ||||||
15 | enrollment of a beneficiary in a Coordinated Care program. For | ||||||
16 | purposes of this subsection, "Coordinated Care Participating | ||||||
17 | Hospital" means a hospital that meets one of the following | ||||||
18 | criteria: | ||||||
19 | (1) The hospital has entered into a contract to provide | ||||||
20 | hospital services with one or more MCOs to enrollees of the | ||||||
21 | care coordination program. | ||||||
22 | (2) The hospital has not been offered a contract by a | ||||||
23 | care coordination plan that the Department has determined | ||||||
24 | to be a good faith offer and that pays at least as much as | ||||||
25 | the 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, except to the | ||||||
3 | extent such adjustments or add-on payments are | ||||||
4 | incorporated into the development of the applicable MCO | ||||||
5 | capitated rates. | ||||||
6 | As used in this subsection (f), "MCO" means any entity | ||||||
7 | which contracts with the Department to provide services where | ||||||
8 | payment for medical services is made on a capitated basis. | ||||||
9 | (g) No later than August 1, 2013, the Department shall | ||||||
10 | issue a purchase of care solicitation for Accountable Care | ||||||
11 | Entities (ACE) to serve any children and parents or caretaker | ||||||
12 | relatives of children eligible for medical assistance under | ||||||
13 | this Article. An ACE may be a single corporate structure or a | ||||||
14 | network of providers organized through contractual | ||||||
15 | relationships with a single corporate entity. The solicitation | ||||||
16 | shall require that: | ||||||
17 | (1) An ACE operating in Cook County be capable of | ||||||
18 | serving at least 40,000 eligible individuals in that | ||||||
19 | county; an ACE operating in Lake, Kane, DuPage, or Will | ||||||
20 | Counties be capable of serving at least 20,000 eligible | ||||||
21 | individuals in those counties and an ACE operating in other | ||||||
22 | regions of the State be capable of serving at least 10,000 | ||||||
23 | eligible individuals in the region in which it operates. | ||||||
24 | During initial periods of mandatory enrollment, the | ||||||
25 | Department shall require its enrollment services | ||||||
26 | contractor to use a default assignment algorithm that |
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1 | ensures if possible an ACE reaches the minimum enrollment | ||||||
2 | levels set forth in this paragraph. | ||||||
3 | (2) An ACE must include at a minimum the following | ||||||
4 | types of providers: primary care, specialty care, | ||||||
5 | hospitals, and behavioral healthcare. | ||||||
6 | (3) An ACE shall have a governance structure that | ||||||
7 | includes the major components of the health care delivery | ||||||
8 | system, including one representative from each of the | ||||||
9 | groups listed in paragraph (2). | ||||||
10 | (4) An ACE must be an integrated delivery system, | ||||||
11 | including a network able to provide the full range of | ||||||
12 | services needed by Medicaid beneficiaries and system | ||||||
13 | capacity to securely pass clinical information across | ||||||
14 | participating entities and to aggregate and analyze that | ||||||
15 | data in order to coordinate care. | ||||||
16 | (5) An ACE must be capable of providing both care | ||||||
17 | coordination and complex case management, as necessary, to | ||||||
18 | beneficiaries. To be responsive to the solicitation, a | ||||||
19 | potential ACE must outline its care coordination and | ||||||
20 | complex case management model and plan to reduce the cost | ||||||
21 | of care. | ||||||
22 | (6) In the first 18 months of operation, unless the ACE | ||||||
23 | selects a shorter period, an ACE shall be paid care | ||||||
24 | coordination fees on a per member per month basis that are | ||||||
25 | projected to be cost neutral to the State during the term | ||||||
26 | of their payment and, subject to federal approval, be |
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1 | eligible to share in additional savings generated by their | ||||||
2 | care coordination. | ||||||
3 | (7) In months 19 through 36 of operation, unless the | ||||||
4 | ACE selects a shorter period, an ACE shall be paid on a | ||||||
5 | pre-paid capitation basis for all medical assistance | ||||||
6 | covered services, under contract terms similar to Managed | ||||||
7 | Care Organizations (MCO), with the Department sharing the | ||||||
8 | risk through either stop-loss insurance for extremely high | ||||||
9 | cost individuals or corridors of shared risk based on the | ||||||
10 | overall cost of the total enrollment in the ACE. The ACE | ||||||
11 | shall be responsible for claims processing, encounter data | ||||||
12 | submission, utilization control, and quality assurance. | ||||||
13 | (8) In the fourth and subsequent years of operation, an | ||||||
14 | ACE shall convert to a Managed Care Community Network | ||||||
15 | (MCCN), as defined in this Article, or Health Maintenance | ||||||
16 | Organization pursuant to the Illinois Insurance Code, | ||||||
17 | accepting full-risk capitation payments. | ||||||
18 | The Department shall allow potential ACE entities 5 months | ||||||
19 | from the date of the posting of the solicitation to submit | ||||||
20 | proposals. After the solicitation is released, in addition to | ||||||
21 | the MCO rate development data available on the Department's | ||||||
22 | website, subject to federal and State confidentiality and | ||||||
23 | privacy laws and regulations, the Department shall provide 2 | ||||||
24 | years of de-identified summary service data on the targeted | ||||||
25 | population, split between children and adults, showing the | ||||||
26 | historical type and volume of services received and the cost of |
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1 | those services to those potential bidders that sign a data use | ||||||
2 | agreement. The Department may add up to 2 non-state government | ||||||
3 | employees with expertise in creating integrated delivery | ||||||
4 | systems to its review team for the purchase of care | ||||||
5 | solicitation described in this subsection. Any such | ||||||
6 | individuals must sign a no-conflict disclosure and | ||||||
7 | confidentiality agreement and agree to act in accordance with | ||||||
8 | all applicable State laws. | ||||||
9 | During the first 2 years of an ACE's operation, the | ||||||
10 | Department shall provide claims data to the ACE on its | ||||||
11 | enrollees on a periodic basis no less frequently than monthly. | ||||||
12 | Nothing in this subsection shall be construed to limit the | ||||||
13 | Department's mandate to enroll 50% of its beneficiaries into | ||||||
14 | care coordination systems by January 1, 2015, using all | ||||||
15 | available care coordination delivery systems, including Care | ||||||
16 | Coordination Entities (CCE), MCCNs, or MCOs, nor be construed | ||||||
17 | to affect the current CCEs, MCCNs, and MCOs selected to serve | ||||||
18 | seniors and persons with disabilities prior to that date. | ||||||
19 | Nothing in this subsection precludes the Department from | ||||||
20 | considering future proposals for new ACEs or expansion of | ||||||
21 | existing ACEs at the discretion of the Department. | ||||||
22 | (h) Department contracts with MCOs and other entities | ||||||
23 | reimbursed by risk based capitation shall have a minimum | ||||||
24 | medical loss ratio of 85%, shall require the entity to | ||||||
25 | establish an appeals and grievances process for consumers and | ||||||
26 | providers, and shall require the entity to provide a quality |
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1 | assurance and utilization review program. Entities contracted | ||||||
2 | with the Department to coordinate healthcare regardless of risk | ||||||
3 | shall be measured utilizing the same quality metrics. The | ||||||
4 | quality metrics may be population specific. Any contracted | ||||||
5 | entity serving at least 5,000 seniors or people with | ||||||
6 | disabilities or 15,000 individuals in other populations | ||||||
7 | covered by the Medical Assistance Program that has been | ||||||
8 | receiving full-risk capitation for a year shall be accredited | ||||||
9 | by a national accreditation organization authorized by the | ||||||
10 | Department within 2 years after the date it is eligible to | ||||||
11 | become accredited. The requirements of this subsection shall | ||||||
12 | apply to contracts with MCOs entered into or renewed or | ||||||
13 | extended after June 1, 2013. | ||||||
14 | (h-5) The Department shall monitor and enforce compliance | ||||||
15 | by MCOs with agreements they have entered into with providers | ||||||
16 | on issues that include, but are not limited to, timeliness of | ||||||
17 | payment, payment rates, and processes for obtaining prior | ||||||
18 | approval. The Department may impose sanctions on MCOs for | ||||||
19 | violating provisions of those agreements that include, but are | ||||||
20 | not limited to, financial penalties, suspension of enrollment | ||||||
21 | of new enrollees, and termination of the MCO's contract with | ||||||
22 | the Department. As used in this subsection (h-5), "MCO" has the | ||||||
23 | meaning ascribed to that term in Section 5-30.1 of this Code. | ||||||
24 | (i) Unless otherwise required by federal law, Medicaid | ||||||
25 | Managed Care Entities shall not divulge, directly or | ||||||
26 | indirectly, including by sending a bill or explanation of |
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1 | benefits, information concerning the sensitive health services | ||||||
2 | received by enrollees of the Medicaid Managed Care Entity to | ||||||
3 | any person other than providers and care coordinators caring | ||||||
4 | for the enrollee and employees of the entity in the course of | ||||||
5 | the entity's internal operations. The Medicaid Managed Care | ||||||
6 | Entity may divulge information concerning the sensitive health | ||||||
7 | services if the enrollee who received the sensitive health | ||||||
8 | services requests the information from the Medicaid Managed | ||||||
9 | Care Entity and authorized the sending of a bill or explanation | ||||||
10 | of benefits. Communications including, but not limited to, | ||||||
11 | statements of care received or appointment reminders either | ||||||
12 | directly or indirectly to the enrollee from the health care | ||||||
13 | provider, health care professional, and care coordinators, | ||||||
14 | remain permissible. | ||||||
15 | For the purposes of this subsection, the term "Medicaid | ||||||
16 | Managed Care Entity" includes Care Coordination Entities, | ||||||
17 | Accountable Care Entities, Managed Care Organizations, and | ||||||
18 | Managed Care Community Networks. | ||||||
19 | For purposes of this subsection, the term "sensitive health | ||||||
20 | services" means mental health services, substance abuse | ||||||
21 | treatment services, reproductive health services, family | ||||||
22 | planning services, services for sexually transmitted | ||||||
23 | infections and sexually transmitted diseases, and services for | ||||||
24 | sexual assault or domestic abuse. Services include prevention, | ||||||
25 | screening, consultation, examination, treatment, or follow-up. | ||||||
26 | Nothing in this subsection shall be construed to relieve a |
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1 | Medicaid Managed Care Entity or the Department of any duty to | ||||||
2 | report incidents of sexually transmitted infections to the | ||||||
3 | Department of Public Health or to the local board of health in | ||||||
4 | accordance with regulations adopted under a statute or | ||||||
5 | ordinance or to report incidents of sexually transmitted | ||||||
6 | infections as necessary to comply with the requirements under | ||||||
7 | Section 5 of the Abused and Neglected Child Reporting Act or as | ||||||
8 | otherwise required by State or federal law. | ||||||
9 | The Department shall create policy in order to implement | ||||||
10 | the requirements in this subsection. | ||||||
11 | (Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13; | ||||||
12 | 98-651, eff. 6-16-14.)
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13 | Section 99. Effective date. This Act takes effect upon | ||||||
14 | becoming law.".
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