SB3025 94TH GENERAL ASSEMBLY

LRB094 18981 DRJ 54449 b

94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006
SB3025

Introduced 1/20/2006, by Sen. Dale A. Righter - Christine Radogno

SYNOPSIS AS INTRODUCED:

215 ILCS 106/27 new
305 ILCS 5/5-16.14 new

Amends the Children's Health Insurance Program Act and the Illinois Public Aid Code. Under the Children's Health Insurance Program Act, provides that on and after July 1, 2006, the Department of Healthcare and Family Services shall implement the following: (1) a capitated managed care system for selected populations of persons in certain counties surrounding Cook County and in certain counties in southern Illinois, under which the State pays a fixed amount per individual per month to a third-party entity to manage the program of health care benefits and assume the risk associated with the payment of medical bills without regard to the actual medical claims incurred; (2) a primary care case management (PCCM) system for selected populations of persons in the remaining counties of the State other than Cook County, under which each participant has one health care provider who is responsible for managing all aspects of the participant's medical care; and (3) a PCCM system for selected populations of persons in Cook County. Requires the Department to file a report describing a mechanism for achieving a transition to a capitated managed care system for persons in Cook County by July 1, 2007. Requires that the populations selected for participation in the various systems must include, at a minimum, all persons eligible for benefits under the Children's Health Insurance Program Act. Provides that the Department may implement similar capitated managed care systems and primary care case management systems for Medicaid recipients under the Illinois Public Aid Code. Effective immediately.

FISCAL NOTE ACT MAY APPLY

A BILL FOR

AN ACT concerning health.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Children's Health Insurance Program Act is amended by adding Section 27 as follows:

(215 ILCS 106/27 new)

Sec. 27. Transition to capitated managed care or primary care case management systems.

(a) Designated counties. On and after July 1, 2006, in counties determined by the Department of Healthcare and Family Services by rule, the Department shall implement a capitated managed care system for selected populations of persons. Under the capitated managed care system, the State shall pay a fixed amount per individual per month to a third-party entity to manage the program of health care benefits and assume the risk associated with the payment of medical bills without regard to the actual medical claims incurred. At a minimum, the counties in which the Department implements the capitated managed care system must include the following:

(1) The counties of Winnebago, Boone, McHenry, Lake, DeKalb, Kane, DuPage, Kendall, Grundy, Will, and Kankakee.

(2) The counties of Madison, St. Clair, Monroe, Randolph, Perry, Franklin, Jackson, and Williamson.

In counties of the State in which the Department implements the capitated managed care system under this subsection, the Department may provide for the payment of capitated payments within a time period that is consistent with the time period within which payments are made to fee-for-service providers in counties in which the Department uses a primary care case management system.

The Department shall adopt rules establishing the populations in the designated counties that must participate in the capitated managed care system. At a minimum, those populations must include all persons eligible for benefits under Sections 25 and 40. The Department shall adopt rules providing for the implementation and continued oversight of the capitated managed care system.

(b) Remaining counties, other than Cook. On and after July 1, 2006, in the counties of the State other than Cook County and other than the counties designated under subsection (a), the Department of Healthcare and Family Services shall implement a primary care case management system for selected populations of persons. Under the primary care case management system, each individual enrolled in the system shall have one health care provider who is responsible for managing all aspects of the individual's medical care.

An individual who is required to participate in the primary care case management system must select a primary care provider from a panel of primary care physicians designated by the Department. An individual may change his or her primary care provider when the provider selected by the individual becomes unavailable, as provided by the Department in rules, or in other situations as provided by the Department in rules. At a minimum, an individual must be given an opportunity to change his or her primary care provider at least once during each State fiscal year.

The Department shall adopt rules establishing the populations in these counties that must participate in the primary care case management system. At a minimum, those populations must include all persons eligible for benefits under Sections 25 and 40.

A health care provider serving as a primary care physician in the primary care case management system is entitled to a care coordination fee, as determined by the Department, for managing each patient's medical care. The fee may be contingent on performance measures as determined by the Department in rules. In addition, a health care provider is entitled to reimbursement for specific services rendered to a patient.

The Department shall adopt rules providing for the implementation and continued oversight of the primary care case management system.

(c) Cook County. On and after July 1, 2006, in Cook County, the Department of Healthcare and Family Services shall implement a primary care case management system for selected populations of persons. The Department shall implement the primary care case management system in Cook County in a manner consistent with the implementation of a primary care case management system in other counties under subsection (b).

The Department shall adopt rules establishing the populations in Cook County that must participate in the primary care case management system. At a minimum, those populations must include all persons eligible for benefits under Sections 25 and 40.

The Department shall adopt rules providing for the implementation and continued oversight of the primary care case management system.

No later than January 1, 2007, the Department shall file with the General Assembly a report setting forth a proposed means of transferring the individuals participating in the primary care case management system to a capitated managed care system by July 1, 20007.

(d) Waivers. The Department of Healthcare and Family Services shall promptly apply for all waivers of federal law and regulations that are necessary to allow the full implementation of this Section.

Section 10. The Illinois Public Aid Code is amended by adding Section 5-16.14 as follows:

(305 ILCS 5/5-16.14 new)

Sec. 5-16.14. Transition to capitated managed care or primary care case management systems.

(a) Designated counties. On and after July 1, 2006, in counties determined by the Department of Healthcare and Family Services by rule, the Department may implement a capitated managed care system for selected populations of recipients of medical assistance under this Article. Under the capitated system, the State shall pay a fixed amount per member per month to a third-party entity to manage the program of medical assistance benefits and assume the risk associated with the payment of medical bills without regard to the actual medical claims incurred. If the Department implements a capitated managed care system as provided in this subsection, the counties in which the Department implements the system must be the same as the counties in which the Department implements a capitated managed care system under subsection (a) of Section 27 of the Children's Health Insurance Program Act and must include, at a minimum, the following:

(1) The counties of Winnebago, Boone, McHenry, Lake, DeKalb, Kane, DuPage, Kendall, Grundy, Will, and Kankakee.

(2) The counties of Madison, St. Clair, Monroe, Randolph, Perry, Franklin, Jackson, and Williamson.

In the counties in which the Department implements a capitated managed care system under this subsection, the Department may provide for the payment of capitated payments within a time period that is consistent with the time period within which payments are made to fee-for-service providers in areas where the Department uses a primary care case management system.

The Department shall adopt rules establishing the medical assistance recipient populations in the designated counties that must participate in the capitated managed care system. The Department shall adopt rules providing for the implementation and continued oversight of the capitated managed care system. The rules shall provide for the implementation of the system in a manner consistent with the Department's implementation of a capitated managed care system under subsection (a) of Section 27 of the Children's Health Insurance Program Act.

(b) Remaining counties, other than Cook. On and after July 1, 2006, in the counties of the State other than Cook County and other than the counties designated under subsection (a), the Department of Healthcare and Family Services may implement a primary care case management system for selected populations of recipients of medical assistance under this Article. Under the primary care case management system, each individual enrolled in the system shall have one health care provider who is responsible for managing all aspects of the individual's medical care.

An individual who is required to participate in the primary care case management system must select a primary care provider from a panel of primary care physicians designated by the Department. An individual may change his or her primary care provider when the provider selected by the individual becomes unavailable, as provided by the Department in rules, or in other situations as provided by the Department in rules. At a minimum, an individual must be given an opportunity to change his or her primary care provider at least once during each State fiscal year.

The Department shall adopt rules establishing the medical assistance recipient populations in these counties that must participate in the primary care case management system.

A health care provider serving as a primary care physician in the primary care case management system is entitled to a care coordination fee, as determined by the Department, for managing each patient's medical care. The fee may be contingent on performance measures as determined by the Department in rules. In addition, a health care provider is entitled to reimbursement for specific services rendered to a patient.

The Department shall adopt rules providing for the implementation and continued oversight of the primary care case management system. The rules shall provide for the implementation of the system in a manner consistent with the Department's implementation of a primary care casse management system under subsection (b) of Section 27 of the Children's Health Insurance Program Act.

(c) Cook County. On and after July 1, 2006, in Cook County, the Department of Healthcare and Family Services may implement a primary care case management system for selected populations of recipients of medical assistance under this Article. The Department shall implement the primary care case management system in Cook County in a manner consistent with (i) the implementation of a primary care case management system in other counties under subsection (b) and (ii) the implementation of a primary care case management system in under subsection (c) of Section 27 of the Children's Health Insurance Program Act.

The Department shall adopt rules establishing the populations in Cook County that must participate in the primary care case management system.

The Department shall adopt rules providing for the implementation and continued oversight of the primary care case management system. The rules shall provide for the implementation of the system in a manner consistent with the Department's implementation of a primary care case management system under subsection (c) of Section 27 of the Children's Health Insurance Program Act.

(d) Waivers. If the Department of Healthcare and Family Services implements any of the health care benefit systems authorized under this Section for recipients of medical assistance, the Department shall promptly apply for all waivers of federal law and regulations that are necessary to allow the full implementation of those provisions.

Section 99. Effective date. This Act takes effect upon becoming law.