Illinois General Assembly - Full Text of SB3266
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Full Text of SB3266  98th General Assembly




State of Illinois
2013 and 2014


Introduced 2/14/2014, by Sen. William R. Haine


305 ILCS 5/5-30

    Amends the Illinois Public Aid Code. In provisions concerning the Department of Healthcare and Family Services' care coordination program, provides that such provisions shall not be construed (1) to prevent a local health department from receiving fee-for-service reimbursement for providing services covered by the State's medical assistance program to eligible recipients of medical assistance regardless of their enrollment in a managed care plan or care coordination program, or (2) to prevent certified local health departments from receiving matching funds for expenditures of local tax revenues incurred in the efficient and effective administration of the State's medical assistance program.

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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 1. Findings. The Illinois General Assembly finds
6    (a) Local health departments and school-based health
7centers have been providing essential prevention, health
8promotion, primary care, oral health, and behavioral health
9services to low-income, Medicaid eligible families and
10individuals for many years in Illinois.
11    (b) School-based and school-linked health centers provide
12essential behavioral health, health promotion, oral health,
13and primary care services to elementary, middle, and high
14school students in many parts of Illinois, providing unique
15access to services that increase students' ability to be in
16class healthy and learning.
17    (c) Family planning agencies provide access to
18reproductive health and women's health care services for many
19low-income women and men, allowing them to choose the number
20and spacing of their children.
21    (d) Including these established safety-net providers will
22increase the health care system's capacity to serve everyone
23eligible for medical assistance.
24    (e) Since these agencies have been providing health



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1services to eligible recipients of medical assistance for many
2years and have unique access to vulnerable populations,
3excluding local health departments, school-based health
4centers, and family planning providers from participation in
5managed care and care coordination programs for eligible
6recipients of medical assistance will be detrimental to the
7public's health and hamper the State's efforts to reduce infant
8mortality, promote healthy child development, prevent and
9reduce overweight and obesity, discourage teen pregnancy, and
10prevent and control chronic diseases.
11    Section 5. The Illinois Public Aid Code is amended by
12changing Section 5-30 as follows:
13    (305 ILCS 5/5-30)
14    Sec. 5-30. Care coordination.
15    (a) At least 50% of recipients eligible for comprehensive
16medical benefits in all medical assistance programs or other
17health benefit programs administered by the Department,
18including the Children's Health Insurance Program Act and the
19Covering ALL KIDS Health Insurance Act, shall be enrolled in a
20care coordination program by no later than January 1, 2015. For
21purposes of this Section, "coordinated care" or "care
22coordination" means delivery systems where recipients will
23receive their care from providers who participate under
24contract in integrated delivery systems that are responsible



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



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



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



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1    implementation of this subsection (e) prior to and during
2    the implementation to best facilitate the goals and
3    objectives of this subsection (e).
4    (f) A hospital that is located in a county of the State in
5which the Department mandates some or all of the beneficiaries
6of the Medical Assistance Program residing in the county to
7enroll in a Care Coordination Program, as set forth in Section
85-30 of this Code, shall not be eligible for any non-claims
9based payments not mandated by Article V-A of this Code for
10which it would otherwise be qualified to receive, unless the
11hospital is a Coordinated Care Participating Hospital no later
12than 60 days after the effective date of this amendatory Act of
13the 97th General Assembly or 60 days after the first mandatory
14enrollment of a beneficiary in a Coordinated Care program. For
15purposes of this subsection, "Coordinated Care Participating
16Hospital" means a hospital that meets one of the following
18        (1) The hospital has entered into a contract to provide
19    hospital services to enrollees of the care coordination
20    program.
21        (2) The hospital has not been offered a contract by a
22    care coordination plan that pays at least as much as the
23    Department would pay, on a fee-for-service basis, not
24    including disproportionate share hospital adjustment
25    payments or any other supplemental adjustment or add-on
26    payment to the base fee-for-service rate.



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



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



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



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1    During the first 2 years of an ACE's operation, the
2Department shall provide claims data to the ACE on its
3enrollees on a periodic basis no less frequently than monthly.
4    Nothing in this subsection shall be construed to limit the
5Department's mandate to enroll 50% of its beneficiaries into
6care coordination systems by January 1, 2015, using all
7available care coordination delivery systems, including Care
8Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
9to affect the current CCEs, MCCNs, and MCOs selected to serve
10seniors and persons with disabilities prior to that date.
11    (h) Department contracts with MCOs and other entities
12reimbursed by risk based capitation shall have a minimum
13medical loss ratio of 85%, shall require the MCO or other
14entity to pay claims within 30 days of receiving a bill that
15contains all the essential information needed to adjudicate the
16bill, and shall require the entity to pay a penalty that is at
17least equal to the penalty imposed under the Illinois Insurance
18Code for any claims not paid within this time period. The
19requirements of this subsection shall apply to contracts with
20MCOs entered into or renewed or extended after June 1, 2013.
21    (i) Nothing in this Section shall be construed (1) to
22prevent a local health department from receiving
23fee-for-service reimbursement for providing services covered
24by the State's medical assistance program to eligible
25recipients of medical assistance regardless of their
26enrollment in a managed care plan or care coordination program,



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1or (2) to prevent certified local health departments from
2receiving matching funds for expenditures of local tax revenues
3incurred in the efficient and effective administration of the
4State's medical assistance program.
5(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)