Illinois General Assembly - Full Text of SB0343
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Full Text of SB0343  99th General Assembly


Sen. Heather A. Steans

Filed: 3/19/2015





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2    AMENDMENT NO. ______. Amend Senate Bill 343 by replacing
3everything after the enacting clause with the following:
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. For
14purposes of this Section, "coordinated care" or "care
15coordination" means delivery systems where recipients will
16receive their care from providers who participate under



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1contract in integrated delivery systems that are responsible
2for providing or arranging the majority of care, including
3primary care physician services, referrals from primary care
4physicians, diagnostic and treatment services, behavioral
5health services, in-patient and outpatient hospital services,
6dental services, and rehabilitation and long-term care
7services. The Department shall designate or contract for such
8integrated delivery systems (i) to ensure enrollees have a
9choice of systems and of primary care providers within such
10systems; (ii) to ensure that enrollees receive quality care in
11a culturally and linguistically appropriate manner; and (iii)
12to ensure that coordinated care programs meet the diverse needs
13of enrollees with developmental, mental health, physical, and
14age-related disabilities.
15    (b) Payment for such coordinated care shall be based on
16arrangements where the State pays for performance related to
17health care outcomes, the use of evidence-based practices, the
18use of primary care delivered through comprehensive medical
19homes, the use of electronic medical records, and the
20appropriate exchange of health information electronically made
21either on a capitated basis in which a fixed monthly premium
22per recipient is paid and full financial risk is assumed for
23the delivery of services, or through other risk-based payment
25    (c) To qualify for compliance with this Section, the 50%
26goal shall be achieved by enrolling medical assistance



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1enrollees from each medical assistance enrollment category,
2including parents, children, seniors, and people with
3disabilities to the extent that current State Medicaid payment
4laws would not limit federal matching funds for recipients in
5care coordination programs. In addition, services must be more
6comprehensively defined and more risk shall be assumed than in
7the Department's primary care case management program as of the
8effective date of this amendatory Act of the 96th General
10    (d) The Department shall report to the General Assembly in
11a separate part of its annual medical assistance program
12report, beginning April, 2012 until April, 2016, on the
13progress and implementation of the care coordination program
14initiatives established by the provisions of this amendatory
15Act of the 96th General Assembly. The Department shall include
16in its April 2011 report a full analysis of federal laws or
17regulations regarding upper payment limitations to providers
18and the necessary revisions or adjustments in rate
19methodologies and payments to providers under this Code that
20would be necessary to implement coordinated care with full
21financial risk by a party other than the Department.
22    (e) Integrated Care Program for individuals with chronic
23mental 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
6which the Department mandates some or all of the beneficiaries
7of the Medical Assistance Program residing in the county to
8enroll in a Care Coordination Program, as set forth in Section
95-30 of this Code, shall not be eligible for any non-claims
10based payments not mandated by Article V-A of this Code for
11which it would otherwise be qualified to receive, unless the
12hospital is a Coordinated Care Participating Hospital no later
13than 60 days after the effective date of this amendatory Act of
14the 97th General Assembly or 60 days after the first mandatory
15enrollment of a beneficiary in a Coordinated Care program. For
16purposes of this subsection, "Coordinated Care Participating
17Hospital" means a hospital that meets one of the following
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
7which contracts with the Department to provide services where
8payment for medical services is made on a capitated basis.
9    (g) No later than August 1, 2013, the Department shall
10issue a purchase of care solicitation for Accountable Care
11Entities (ACE) to serve any children and parents or caretaker
12relatives of children eligible for medical assistance under
13this Article. An ACE may be a single corporate structure or a
14network of providers organized through contractual
15relationships with a single corporate entity. The solicitation
16shall 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
19from the date of the posting of the solicitation to submit
20proposals. After the solicitation is released, in addition to
21the MCO rate development data available on the Department's
22website, subject to federal and State confidentiality and
23privacy laws and regulations, the Department shall provide 2
24years of de-identified summary service data on the targeted
25population, split between children and adults, showing the
26historical type and volume of services received and the cost of



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1those services to those potential bidders that sign a data use
2agreement. The Department may add up to 2 non-state government
3employees with expertise in creating integrated delivery
4systems to its review team for the purchase of care
5solicitation described in this subsection. Any such
6individuals must sign a no-conflict disclosure and
7confidentiality agreement and agree to act in accordance with
8all applicable State laws.
9    During the first 2 years of an ACE's operation, the
10Department shall provide claims data to the ACE on its
11enrollees on a periodic basis no less frequently than monthly.
12    Nothing in this subsection shall be construed to limit the
13Department's mandate to enroll 50% of its beneficiaries into
14care coordination systems by January 1, 2015, using all
15available care coordination delivery systems, including Care
16Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
17to affect the current CCEs, MCCNs, and MCOs selected to serve
18seniors and persons with disabilities prior to that date.
19    Nothing in this subsection precludes the Department from
20considering future proposals for new ACEs or expansion of
21existing ACEs at the discretion of the Department.
22    (h) Department contracts with MCOs and other entities
23reimbursed by risk based capitation shall have a minimum
24medical loss ratio of 85%, shall require the entity to
25establish an appeals and grievances process for consumers and
26providers, and shall require the entity to provide a quality



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1assurance and utilization review program. Entities contracted
2with the Department to coordinate healthcare regardless of risk
3shall be measured utilizing the same quality metrics. The
4quality metrics may be population specific. Any contracted
5entity serving at least 5,000 seniors or people with
6disabilities or 15,000 individuals in other populations
7covered by the Medical Assistance Program that has been
8receiving full-risk capitation for a year shall be accredited
9by a national accreditation organization authorized by the
10Department within 2 years after the date it is eligible to
11become accredited. The requirements of this subsection shall
12apply to contracts with MCOs entered into or renewed or
13extended after June 1, 2013.
14    (h-5) The Department shall monitor and enforce compliance
15by MCOs with agreements they have entered into with providers
16on issues that include, but are not limited to, timeliness of
17payment, payment rates, and processes for obtaining prior
18approval. The Department may impose sanctions on MCOs for
19violating provisions of those agreements that include, but are
20not limited to, financial penalties, suspension of enrollment
21of new enrollees, and termination of the MCO's contract with
22the Department. As used in this subsection (h-5), "MCO" has the
23meaning ascribed to that term in Section 5-30.1 of this Code.
24    (i) As used in this subsection:
25    "Care coordination entity" means a collaboration of
26providers and community agencies, governed by a lead entity,



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1which receives a care coordination payment with a portion of
2the payment at risk for meeting quality outcome targets, in
3order to provide care coordination services for its enrollees.
4    "Children with complex medical needs" means persons under
521 years of age who are clients of medical assistance programs
6or other health benefit programs administered by the Department
7through the use of the 3MTM Clinical Risk Grouping Software
8(CRG) as Status 6.1 and above, through a clinical screening
9tool, or those who do not have sufficient claims data in order
10to be identified by the Department through the CRG software.
11    The Department shall offer children with complex medical
12needs the choice of enrollment in a coordinated care entity
13(CCE) to provide services to the children, where available.
14This choice shall be in addition to otherwise available health
15maintenance organizations (HMOs), managed care community
16networks (MCCNs), and accountable care entities (ACEs).
17    Children with complex medical needs under 18 years of age
18shall be eligible to enroll in the CCE as long as such children
19continue to maintain eligibility for medical assistance
20programs or other health benefit programs administered by the
21Department. The Department may choose to extend enrollment to
22individuals under 21 years of age for initial enrollment.
23Individuals may also be excluded if they are:
24        (1) enrolled in the Medically Fragile Technology
25    Dependent Waiver;
26        (2) receiving private duty nursing;



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1        (3) eligible for high third party liability coverage as
2    defined by the Department;
3        (4) residing in institutions including pediatric
4    skilled nursing facilities;
5        (5) enrolled in the DSCC Core Program; or
6        (6) placed in foster care with the Department of
7    Children and Family Services.
8    The Department shall ensure that the parents of all
9eligible enrollees that are children with complex medical needs
10shall receive notification of their eligibility and an
11explanation of how to elect the CCE option. The Department
12shall ensure that any third party enrollment broker is briefed
13on such CCE option and that the broker shall ensure that all
14enrollment options are presented to the parents of children
15with complex medical needs.
16(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13;
1798-651, eff. 6-16-14.)
18    Section 99. Effective date. This Act takes effect upon
19becoming law.".