Illinois General Assembly - Full Text of HB2641
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Full Text of HB2641  102nd General Assembly




State of Illinois
2021 and 2022


Introduced 2/19/2021, by Rep. William Davis


305 ILCS 5/5-30

    Amends the Illinois Public Aid Code. Requires managed care organizations (MCOs) to participate in the Non-Emergency Transportation Services Prior Approval Program (NETSPAP) established under the Code beginning 90 days after the effective date of the amendatory Act. Requires each MCO to submit through NETSPAP for adjudication every unpaid non-emergency transportation claim incurred since January 1, 2012; and requires a NETSPAP contractor to adjudicate such claims without regard to any deadlines for submission or processing that are otherwise applicable. Provides that all non-emergency ambulance service providers seeking reimbursement for prior claims must submit documentation of the transport no later than 150 days after the effective date of the amendatory Act. Provides that upon receipt of approval from the NETSPAP contractor, each MCO shall process and pay all approved claims within 30 days, without requiring any further action by the non-emergency transportation services provider; and that any denial of reimbursement by the NETSPAP contractor may be appealed. Provides that any costs incurred in connection with the review of claims by the NETSPAP contractor are the sole responsibility of the MCO. Provides that MCOs shall not unreasonably refuse to contract with ground ambulance services providers and medi-car services providers, shall not unreasonably restrict access to and the availability of ground ambulance services and medi-car services, and shall ensure that recipients of benefits provided under the Department of Healthcare and Family Services' programs are not liable for ground ambulance services and medi-car services expenses consistent with federal law and specified provisions of the Illinois Insurance Code and the Illinois Administrative Code. Effective immediately.

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1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
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.
14For purposes of this Section, "coordinated care" or "care
15coordination" means delivery systems where recipients will
16receive their care from providers who participate under
17contract in integrated delivery systems that are responsible
18for providing or arranging the majority of care, including
19primary care physician services, referrals from primary care
20physicians, diagnostic and treatment services, behavioral
21health services, in-patient and outpatient hospital services,
22dental services, and rehabilitation and long-term care
23services. The Department shall designate or contract for such



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1integrated delivery systems (i) to ensure enrollees have a
2choice of systems and of primary care providers within such
3systems; (ii) to ensure that enrollees receive quality care in
4a culturally and linguistically appropriate manner; and (iii)
5to ensure that coordinated care programs meet the diverse
6needs of enrollees with developmental, mental health,
7physical, and age-related disabilities.
8    (b) Payment for such coordinated care shall be based on
9arrangements where the State pays for performance related to
10health care outcomes, the use of evidence-based practices, the
11use of primary care delivered through comprehensive medical
12homes, the use of electronic medical records, and the
13appropriate exchange of health information electronically made
14either on a capitated basis in which a fixed monthly premium
15per recipient is paid and full financial risk is assumed for
16the delivery of services, or through other risk-based payment
18    (c) To qualify for compliance with this Section, the 50%
19goal shall be achieved by enrolling medical assistance
20enrollees from each medical assistance enrollment category,
21including parents, children, seniors, and people with
22disabilities to the extent that current State Medicaid payment
23laws would not limit federal matching funds for recipients in
24care coordination programs. In addition, services must be more
25comprehensively defined and more risk shall be assumed than in
26the Department's primary care case management program as of



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1January 25, 2011 (the effective date of Public Act 96-1501).
2    (d) The Department shall report to the General Assembly in
3a separate part of its annual medical assistance program
4report, beginning April, 2012 until April, 2016, on the
5progress and implementation of the care coordination program
6initiatives established by the provisions of Public Act
796-1501. The Department shall include in its April 2011 report
8a full analysis of federal laws or regulations regarding upper
9payment limitations to providers and the necessary revisions
10or adjustments in rate methodologies and payments to providers
11under this Code that would be necessary to implement
12coordinated care with full financial risk by a party other
13than the Department.
14    (e) Integrated Care Program for individuals with chronic
15mental health conditions.
16        (1) The Integrated Care Program shall encompass
17    services administered to recipients of medical assistance
18    under this Article to prevent exacerbations and
19    complications using cost-effective, evidence-based
20    practice guidelines and mental health management
21    strategies.
22        (2) The Department may utilize and expand upon
23    existing contractual arrangements with integrated care
24    plans under the Integrated Care Program for providing the
25    coordinated care provisions of this Section.
26        (3) Payment for such coordinated care shall be based



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1    on arrangements where the State pays for performance
2    related to mental health outcomes on a capitated basis in
3    which a fixed monthly premium per recipient is paid and
4    full financial risk is assumed for the delivery of
5    services, or through other risk-based payment arrangements
6    such as provider-based care coordination.
7        (4) The Department shall examine whether chronic
8    mental health management programs and services for
9    recipients with specific chronic mental health conditions
10    do any or all of the following:
11            (A) Improve the patient's overall mental health in
12        a more expeditious and cost-effective manner.
13            (B) Lower costs in other aspects of the medical
14        assistance program, such as hospital admissions,
15        emergency room visits, or more frequent and
16        inappropriate psychotropic drug use.
17        (5) The Department shall work with the facilities and
18    any integrated care plan participating in the program to
19    identify and correct barriers to the successful
20    implementation of this subsection (e) prior to and during
21    the implementation to best facilitate the goals and
22    objectives of this subsection (e).
23    (f) A hospital that is located in a county of the State in
24which the Department mandates some or all of the beneficiaries
25of the Medical Assistance Program residing in the county to
26enroll in a Care Coordination Program, as set forth in Section



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15-30 of this Code, shall not be eligible for any non-claims
2based payments not mandated by Article V-A of this Code for
3which it would otherwise be qualified to receive, unless the
4hospital is a Coordinated Care Participating Hospital no later
5than 60 days after June 14, 2012 (the effective date of Public
6Act 97-689) or 60 days after the first mandatory enrollment of
7a beneficiary in a Coordinated Care program. For purposes of
8this subsection, "Coordinated Care Participating Hospital"
9means a hospital that meets one of the following criteria:
10        (1) The hospital has entered into a contract to
11    provide hospital services with one or more MCOs to
12    enrollees of the care coordination program.
13        (2) The hospital has not been offered a contract by a
14    care coordination plan that the Department has determined
15    to be a good faith offer and that pays at least as much as
16    the Department would pay, on a fee-for-service basis, not
17    including disproportionate share hospital adjustment
18    payments or any other supplemental adjustment or add-on
19    payment to the base fee-for-service rate, except to the
20    extent such adjustments or add-on payments are
21    incorporated into the development of the applicable MCO
22    capitated rates.
23    As used in this subsection (f), "MCO" means any entity
24which contracts with the Department to provide services where
25payment for medical services is made on a capitated basis.
26    (g) No later than August 1, 2013, the Department shall



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1issue a purchase of care solicitation for Accountable Care
2Entities (ACE) to serve any children and parents or caretaker
3relatives of children eligible for medical assistance under
4this Article. An ACE may be a single corporate structure or a
5network of providers organized through contractual
6relationships with a single corporate entity. The solicitation
7shall require that:
8        (1) An ACE operating in Cook County be capable of
9    serving at least 40,000 eligible individuals in that
10    county; an ACE operating in Lake, Kane, DuPage, or Will
11    Counties be capable of serving at least 20,000 eligible
12    individuals in those counties and an ACE operating in
13    other regions of the State be capable of serving at least
14    10,000 eligible individuals in the region in which it
15    operates. During initial periods of mandatory enrollment,
16    the Department shall require its enrollment services
17    contractor to use a default assignment algorithm that
18    ensures if possible an ACE reaches the minimum enrollment
19    levels set forth in this paragraph.
20        (2) An ACE must include at a minimum the following
21    types of providers: primary care, specialty care,
22    hospitals, and behavioral healthcare.
23        (3) An ACE shall have a governance structure that
24    includes the major components of the health care delivery
25    system, including one representative from each of the
26    groups listed in paragraph (2).



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



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



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1Department shall provide claims data to the ACE on its
2enrollees on a periodic basis no less frequently than monthly.
3    Nothing in this subsection shall be construed to limit the
4Department's mandate to enroll 50% of its beneficiaries into
5care coordination systems by January 1, 2015, using all
6available care coordination delivery systems, including Care
7Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
8to affect the current CCEs, MCCNs, and MCOs selected to serve
9seniors and persons with disabilities prior to that date.
10    Nothing in this subsection precludes the Department from
11considering future proposals for new ACEs or expansion of
12existing ACEs at the discretion of the Department.
13    (h) Department contracts with MCOs and other entities
14reimbursed by risk based capitation shall have a minimum
15medical loss ratio of 85%, shall require the entity to
16establish an appeals and grievances process for consumers and
17providers, and shall require the entity to provide a quality
18assurance and utilization review program. Entities contracted
19with the Department to coordinate healthcare regardless of
20risk shall be measured utilizing the same quality metrics. The
21quality metrics may be population specific. Any contracted
22entity serving at least 5,000 seniors or people with
23disabilities or 15,000 individuals in other populations
24covered by the Medical Assistance Program that has been
25receiving full-risk capitation for a year shall be accredited
26by a national accreditation organization authorized by the



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1Department within 2 years after the date it is eligible to
2become accredited. The requirements of this subsection shall
3apply to contracts with MCOs entered into or renewed or
4extended after June 1, 2013.
5    (h-5) The Department shall monitor and enforce compliance
6by MCOs with agreements they have entered into with providers
7on issues that include, but are not limited to, timeliness of
8payment, payment rates, and processes for obtaining prior
9approval. The Department may impose sanctions on MCOs for
10violating provisions of those agreements that include, but are
11not limited to, financial penalties, suspension of enrollment
12of new enrollees, and termination of the MCO's contract with
13the Department. As used in this subsection (h-5), "MCO" has
14the meaning ascribed to that term in Section 5-30.1 of this
16    (i) Unless otherwise required by federal law, Medicaid
17Managed Care Entities and their respective business associates
18shall not disclose, directly or indirectly, including by
19sending a bill or explanation of benefits, information
20concerning the sensitive health services received by enrollees
21of the Medicaid Managed Care Entity to any person other than
22covered entities and business associates, which may receive,
23use, and further disclose such information solely for the
24purposes permitted under applicable federal and State laws and
25regulations if such use and further disclosure satisfies all
26applicable requirements of such laws and regulations. The



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1Medicaid Managed Care Entity or its respective business
2associates may disclose information concerning the sensitive
3health services if the enrollee who received the sensitive
4health services requests the information from the Medicaid
5Managed Care Entity or its respective business associates and
6authorized the sending of a bill or explanation of benefits.
7Communications including, but not limited to, statements of
8care received or appointment reminders either directly or
9indirectly to the enrollee from the health care provider,
10health care professional, and care coordinators, remain
11permissible. Medicaid Managed Care Entities or their
12respective business associates may communicate directly with
13their enrollees regarding care coordination activities for
14those enrollees.
15    For the purposes of this subsection, the term "Medicaid
16Managed Care Entity" includes Care Coordination Entities,
17Accountable Care Entities, Managed Care Organizations, and
18Managed Care Community Networks.
19    For purposes of this subsection, the term "sensitive
20health services" means mental health services, substance abuse
21treatment services, reproductive health services, family
22planning services, services for sexually transmitted
23infections and sexually transmitted diseases, and services for
24sexual assault or domestic abuse. Services include prevention,
25screening, consultation, examination, treatment, or follow-up.
26    For purposes of this subsection, "business associate",



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1"covered entity", "disclosure", and "use" have the meanings
2ascribed to those terms in 45 CFR 160.103.
3    Nothing in this subsection shall be construed to relieve a
4Medicaid Managed Care Entity or the Department of any duty to
5report incidents of sexually transmitted infections to the
6Department of Public Health or to the local board of health in
7accordance with regulations adopted under a statute or
8ordinance or to report incidents of sexually transmitted
9infections as necessary to comply with the requirements under
10Section 5 of the Abused and Neglected Child Reporting Act or as
11otherwise required by State or federal law.
12    The Department shall create policy in order to implement
13the requirements in this subsection.
14    (j) Managed Care Entities (MCEs), including MCOs and all
15other care coordination organizations, shall develop and
16maintain a written language access policy that sets forth the
17standards, guidelines, and operational plan to ensure language
18appropriate services and that is consistent with the standard
19of meaningful access for populations with limited English
20proficiency. The language access policy shall describe how the
21MCEs will provide all of the following required services:
22        (1) Translation (the written replacement of text from
23    one language into another) of all vital documents and
24    forms as identified by the Department.
25        (2) Qualified interpreter services (the oral
26    communication of a message from one language into another



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1    by a qualified interpreter).
2        (3) Staff training on the language access policy,
3    including how to identify language needs, access and
4    provide language assistance services, work with
5    interpreters, request translations, and track the use of
6    language assistance services.
7        (4) Data tracking that identifies the language need.
8        (5) Notification to participants on the availability
9    of language access services and on how to access such
10    services.
11    (k) The Department shall actively monitor the contractual
12relationship between Managed Care Organizations (MCOs) and any
13dental administrator contracted by an MCO to provide dental
14services. The Department shall adopt appropriate dental
15Healthcare Effectiveness Data and Information Set (HEDIS)
16measures and shall include the Annual Dental Visit (ADV) HEDIS
17measure in its Health Plan Comparison Tool and Illinois
18Medicaid Plan Report Card that is available on the
19Department's website for enrolled individuals.
20    The Department shall collect from each MCO specific
21information about the types of contracted, broad-based care
22coordination occurring between the MCO and any dental
23administrator, including, but not limited to, pregnant women
24and diabetic patients in need of oral care.
25    (l) Beginning 90 days after the effective date of this
26amendatory Act of the 102nd General Assembly, MCOs, as defined



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1in Section 5-30.1, including managed care community networks,
2as defined in Section 5-11, shall participate in the
3Non-Emergency Transportation Services Prior Approval Program
4(NETSPAP) established in accordance with Section 5-4.2. Each
5MCO shall submit through NETSPAP for adjudication every unpaid
6non-emergency transportation claim incurred since January 1,
72012. The NETSPAP contractor shall adjudicate all claims
8received without regard to any deadlines for submission or
9processing that are otherwise applicable to such claims. In
10reviewing claims under this subsection, the NETSPAP contractor
11may accept a certification of medical necessity, a medical
12certification for ambulance services, a physician
13certification statement, or such other documentation of
14medical necessity as would be accepted by the Department in an
15appeal brought in accordance with Section 5-4.2.
16    All non-emergency ambulance service providers seeking
17reimbursement for prior claims under this subsection must
18submit documentation of the transport no later than 150 days
19after the effective date of this amendatory Act of the 102nd
20General Assembly.
21    Upon receipt of approval from the NETSPAP contractor, each
22MCO shall process and pay all approved claims within 30 days,
23without requiring any further action by the non-emergency
24transportation services provider.
25    Any denial of reimbursement by the NETSPAP contractor may
26be appealed under the process established in Section 5-4.2.



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1    Any costs incurred in connection with the review of claims
2by the NETSPAP contractor shall be the sole responsibility of
3the MCO.
4    (m) Beginning on the effective date of this amendatory Act
5of the 102nd General Assembly, MCOs shall not unreasonably
6refuse to contract with ground ambulance services providers as
7defined in Section 5-4.2 and medi-car services providers as
8defined in Section 5-4.2, shall not unreasonably restrict
9access to and the availability of ground ambulance services
10and medi-car services, and shall ensure that recipients of
11benefits provided under the Department's programs shall not be
12liable for ground ambulance services and medi-car services
13expenses consistent with federal law, Sections 370h and 370i
14of the Illinois Insurance Code, and any amendments,
15regulations, policies, and guidelines thereto, including, but
16not limited to, 50 Ill. Adm. Code 2051.280(b) and any
17amendments thereto.
18(Source: P.A. 99-106, eff. 1-1-16; 99-181, eff. 7-29-15;
1999-566, eff. 1-1-17; 99-642, eff. 7-28-16; 100-587, eff.
21    Section 99. Effective date. This Act takes effect upon
22becoming law.