Full Text of HB1457 98th General Assembly
HB1457sam001 98TH GENERAL ASSEMBLY | Sen. James F. Clayborne, Jr. Filed: 5/20/2013
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| 1 | | AMENDMENT TO HOUSE BILL 1457
| 2 | | AMENDMENT NO. ______. Amend House Bill 1457 by replacing | 3 | | everything after the enacting clause with the following:
| 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.
| 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 to enrollees of the care coordination | 21 | | program. | 22 | | (2) The hospital has not been offered a contract by a | 23 | | care coordination plan that pays at least as much as the | 24 | | Department would pay, on a fee-for-service basis, not | 25 | | including disproportionate share hospital adjustment | 26 | | payments or any other supplemental adjustment or add-on |
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| 1 | | payment to the base fee-for-service rate. | 2 | | (g) The Department shall ensure consistency in the | 3 | | contractual arrangements between the integrated care system | 4 | | and the providers of long term care services for services to | 5 | | those individuals who qualify for Medicare and Medicaid | 6 | | services. The Department shall define by rule the terms and | 7 | | conditions of the contracts, including, but not limited to, the | 8 | | following: | 9 | | (1) clean claims; | 10 | | (2) accreditation requirements; | 11 | | (3) billing codes; | 12 | | (4) reporting requirements; and | 13 | | (5) appeal and grievance procedures for providers and | 14 | | residents. | 15 | | The Department shall prohibit integrated care systems from | 16 | | requiring regulations in excess of those required by federal | 17 | | and State law. The Department, in designing its auto enrollment | 18 | | program, shall not assign an individual currently receiving | 19 | | long term care services to an integrated care system that does | 20 | | not have a contractual arrangement with the provider currently | 21 | | providing services to the individual. | 22 | | (Source: P.A. 96-1501, eff. 1-25-11; 97-689, eff. 6-14-12.)".
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