Full Text of SB0343 99th General Assembly
SB0343sam002 99TH GENERAL ASSEMBLY | Sen. Heather A. Steans Filed: 5/19/2015
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| 1 | | AMENDMENT TO SENATE BILL 343
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 343, AS AMENDED, by | 3 | | replacing everything after the enacting clause with the | 4 | | following:
| 5 | | "Section 5. The Illinois Public Aid Code is amended by | 6 | | changing Section 5-30 as follows: | 7 | | (305 ILCS 5/5-30) | 8 | | Sec. 5-30. Care coordination. | 9 | | (a) At least 50% of recipients eligible for comprehensive | 10 | | medical benefits in all medical assistance programs or other | 11 | | health benefit programs administered by the Department, | 12 | | including the Children's Health Insurance Program Act and the | 13 | | Covering ALL KIDS Health Insurance Act, shall be enrolled in a | 14 | | care coordination program by no later than January 1, 2015. For | 15 | | purposes of this Section, "coordinated care" or "care | 16 | | coordination" means delivery systems where recipients will |
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| 1 | | receive their care from providers who participate under | 2 | | contract in integrated delivery systems that are responsible | 3 | | for providing or arranging the majority of care, including | 4 | | primary care physician services, referrals from primary care | 5 | | physicians, diagnostic and treatment services, behavioral | 6 | | health services, in-patient and outpatient hospital services, | 7 | | dental services, and rehabilitation and long-term care | 8 | | services. The Department shall designate or contract for such | 9 | | integrated delivery systems (i) to ensure enrollees have a | 10 | | choice of systems and of primary care providers within such | 11 | | systems; (ii) to ensure that enrollees receive quality care in | 12 | | a culturally and linguistically appropriate manner; and (iii) | 13 | | to ensure that coordinated care programs meet the diverse needs | 14 | | of enrollees with developmental, mental health, physical, and | 15 | | age-related disabilities. | 16 | | (b) Payment for such coordinated care shall be based on | 17 | | arrangements where the State pays for performance related to | 18 | | health care outcomes, the use of evidence-based practices, the | 19 | | use of primary care delivered through comprehensive medical | 20 | | homes, the use of electronic medical records, and the | 21 | | appropriate exchange of health information electronically made | 22 | | either on a capitated basis in which a fixed monthly premium | 23 | | per recipient is paid and full financial risk is assumed for | 24 | | the delivery of services, or through other risk-based payment | 25 | | arrangements. | 26 | | (c) To qualify for compliance with this Section, the 50% |
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| 1 | | goal shall be achieved by enrolling medical assistance | 2 | | enrollees from each medical assistance enrollment category, | 3 | | including parents, children, seniors, and people with | 4 | | disabilities to the extent that current State Medicaid payment | 5 | | laws would not limit federal matching funds for recipients in | 6 | | care coordination programs. In addition, services must be more | 7 | | comprehensively defined and more risk shall be assumed than in | 8 | | the Department's primary care case management program as of the | 9 | | effective date of this amendatory Act of the 96th General | 10 | | Assembly. | 11 | | (d) The Department shall report to the General Assembly in | 12 | | a separate part of its annual medical assistance program | 13 | | report, beginning April, 2012 until April, 2016, on the | 14 | | progress and implementation of the care coordination program | 15 | | initiatives established by the provisions of this amendatory | 16 | | Act of the 96th General Assembly. The Department shall include | 17 | | in its April 2011 report a full analysis of federal laws or | 18 | | regulations regarding upper payment limitations to providers | 19 | | and the necessary revisions or adjustments in rate | 20 | | methodologies and payments to providers under this Code that | 21 | | would be necessary to implement coordinated care with full | 22 | | financial risk by a party other than the Department.
| 23 | | (e) Integrated Care Program for individuals with chronic | 24 | | mental health conditions. | 25 | | (1) The Integrated Care Program shall encompass | 26 | | services administered to recipients of medical assistance |
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| 1 | | under this Article to prevent exacerbations and | 2 | | complications using cost-effective, evidence-based | 3 | | practice guidelines and mental health management | 4 | | strategies. | 5 | | (2) The Department may utilize and expand upon existing | 6 | | contractual arrangements with integrated care plans under | 7 | | the Integrated Care Program for providing the coordinated | 8 | | care provisions of this Section. | 9 | | (3) Payment for such coordinated care shall be based on | 10 | | arrangements where the State pays for performance related | 11 | | to mental health outcomes on a capitated basis in which a | 12 | | fixed monthly premium per recipient is paid and full | 13 | | financial risk is assumed for the delivery of services, or | 14 | | through other risk-based payment arrangements such as | 15 | | provider-based care coordination. | 16 | | (4) The Department shall examine whether chronic | 17 | | mental health management programs and services for | 18 | | recipients with specific chronic mental health conditions | 19 | | do any or all of the following: | 20 | | (A) Improve the patient's overall mental health in | 21 | | a more expeditious and cost-effective manner. | 22 | | (B) Lower costs in other aspects of the medical | 23 | | assistance program, such as hospital admissions, | 24 | | emergency room visits, or more frequent and | 25 | | inappropriate psychotropic drug use. | 26 | | (5) The Department shall work with the facilities and |
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| 1 | | any integrated care plan participating in the program to | 2 | | identify and correct barriers to the successful | 3 | | implementation of this subsection (e) prior to and during | 4 | | the implementation to best facilitate the goals and | 5 | | objectives of this subsection (e). | 6 | | (f) A hospital that is located in a county of the State in | 7 | | which the Department mandates some or all of the beneficiaries | 8 | | of the Medical Assistance Program residing in the county to | 9 | | enroll in a Care Coordination Program, as set forth in Section | 10 | | 5-30 of this Code, shall not be eligible for any non-claims | 11 | | based payments not mandated by Article V-A of this Code for | 12 | | which it would otherwise be qualified to receive, unless the | 13 | | hospital is a Coordinated Care Participating Hospital no later | 14 | | than 60 days after the effective date of this amendatory Act of | 15 | | the 97th General Assembly or 60 days after the first mandatory | 16 | | enrollment of a beneficiary in a Coordinated Care program. For | 17 | | purposes of this subsection, "Coordinated Care Participating | 18 | | Hospital" means a hospital that meets one of the following | 19 | | criteria: | 20 | | (1) The hospital has entered into a contract to provide | 21 | | hospital services with one or more MCOs to enrollees of the | 22 | | care coordination program. | 23 | | (2) The hospital has not been offered a contract by a | 24 | | care coordination plan that the Department has determined | 25 | | to be a good faith offer and that pays at least as much as | 26 | | the Department would pay, on a fee-for-service basis, not |
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| 1 | | including disproportionate share hospital adjustment | 2 | | payments or any other supplemental adjustment or add-on | 3 | | payment to the base fee-for-service rate, except to the | 4 | | extent such adjustments or add-on payments are | 5 | | incorporated into the development of the applicable MCO | 6 | | capitated rates. | 7 | | As used in this subsection (f), "MCO" means any entity | 8 | | which contracts with the Department to provide services where | 9 | | payment for medical services is made on a capitated basis. | 10 | | (g) No later than August 1, 2013, the Department shall | 11 | | issue a purchase of care solicitation for Accountable Care | 12 | | Entities (ACE) to serve any children and parents or caretaker | 13 | | relatives of children eligible for medical assistance under | 14 | | this Article. An ACE may be a single corporate structure or a | 15 | | network of providers organized through contractual | 16 | | relationships with a single corporate entity. The solicitation | 17 | | shall require that: | 18 | | (1) An ACE operating in Cook County be capable of | 19 | | serving at least 40,000 eligible individuals in that | 20 | | county; an ACE operating in Lake, Kane, DuPage, or Will | 21 | | Counties be capable of serving at least 20,000 eligible | 22 | | individuals in those counties and an ACE operating in other | 23 | | regions of the State be capable of serving at least 10,000 | 24 | | eligible individuals in the region in which it operates. | 25 | | During initial periods of mandatory enrollment, the | 26 | | Department shall require its enrollment services |
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| 1 | | contractor to use a default assignment algorithm that | 2 | | ensures if possible an ACE reaches the minimum enrollment | 3 | | levels set forth in this paragraph. | 4 | | (2) An ACE must include at a minimum the following | 5 | | types of providers: primary care, specialty care, | 6 | | hospitals, and behavioral healthcare. | 7 | | (3) An ACE shall have a governance structure that | 8 | | includes the major components of the health care delivery | 9 | | system, including one representative from each of the | 10 | | groups listed in paragraph (2). | 11 | | (4) An ACE must be an integrated delivery system, | 12 | | including a network able to provide the full range of | 13 | | services needed by Medicaid beneficiaries and system | 14 | | capacity to securely pass clinical information across | 15 | | participating entities and to aggregate and analyze that | 16 | | data in order to coordinate care. | 17 | | (5) An ACE must be capable of providing both care | 18 | | coordination and complex case management, as necessary, to | 19 | | beneficiaries. To be responsive to the solicitation, a | 20 | | potential ACE must outline its care coordination and | 21 | | complex case management model and plan to reduce the cost | 22 | | of care. | 23 | | (6) In the first 18 months of operation, unless the ACE | 24 | | selects a shorter period, an ACE shall be paid care | 25 | | coordination fees on a per member per month basis that are | 26 | | projected to be cost neutral to the State during the term |
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| 1 | | of their payment and, subject to federal approval, be | 2 | | eligible to share in additional savings generated by their | 3 | | care coordination. | 4 | | (7) In months 19 through 36 of operation, unless the | 5 | | ACE selects a shorter period, an ACE shall be paid on a | 6 | | pre-paid capitation basis for all medical assistance | 7 | | covered services, under contract terms similar to Managed | 8 | | Care Organizations (MCO), with the Department sharing the | 9 | | risk through either stop-loss insurance for extremely high | 10 | | cost individuals or corridors of shared risk based on the | 11 | | overall cost of the total enrollment in the ACE. The ACE | 12 | | shall be responsible for claims processing, encounter data | 13 | | submission, utilization control, and quality assurance. | 14 | | (8) In the fourth and subsequent years of operation, an | 15 | | ACE shall convert to a Managed Care Community Network | 16 | | (MCCN), as defined in this Article, or Health Maintenance | 17 | | Organization pursuant to the Illinois Insurance Code, | 18 | | accepting full-risk capitation payments. | 19 | | The Department shall allow potential ACE entities 5 months | 20 | | from the date of the posting of the solicitation to submit | 21 | | proposals. After the solicitation is released, in addition to | 22 | | the MCO rate development data available on the Department's | 23 | | website, subject to federal and State confidentiality and | 24 | | privacy laws and regulations, the Department shall provide 2 | 25 | | years of de-identified summary service data on the targeted | 26 | | population, split between children and adults, showing the |
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| 1 | | historical type and volume of services received and the cost of | 2 | | those services to those potential bidders that sign a data use | 3 | | agreement. The Department may add up to 2 non-state government | 4 | | employees with expertise in creating integrated delivery | 5 | | systems to its review team for the purchase of care | 6 | | solicitation described in this subsection. Any such | 7 | | individuals must sign a no-conflict disclosure and | 8 | | confidentiality agreement and agree to act in accordance with | 9 | | all applicable State laws. | 10 | | During the first 2 years of an ACE's operation, the | 11 | | Department shall provide claims data to the ACE on its | 12 | | enrollees on a periodic basis no less frequently than monthly. | 13 | | Nothing in this subsection shall be construed to limit the | 14 | | Department's mandate to enroll 50% of its beneficiaries into | 15 | | care coordination systems by January 1, 2015, using all | 16 | | available care coordination delivery systems, including Care | 17 | | Coordination Entities (CCE), MCCNs, or MCOs, nor be construed | 18 | | to affect the current CCEs, MCCNs, and MCOs selected to serve | 19 | | seniors and persons with disabilities prior to that date. | 20 | | Nothing in this subsection precludes the Department from | 21 | | considering future proposals for new ACEs or expansion of | 22 | | existing ACEs at the discretion of the Department. | 23 | | (h) Department contracts with MCOs and other entities | 24 | | reimbursed by risk based capitation shall have a minimum | 25 | | medical loss ratio of 85%, shall require the entity to | 26 | | establish an appeals and grievances process for consumers and |
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| 1 | | providers, and shall require the entity to provide a quality | 2 | | assurance and utilization review program. Entities contracted | 3 | | with the Department to coordinate healthcare regardless of risk | 4 | | shall be measured utilizing the same quality metrics. The | 5 | | quality metrics may be population specific. Any contracted | 6 | | entity serving at least 5,000 seniors or people with | 7 | | disabilities or 15,000 individuals in other populations | 8 | | covered by the Medical Assistance Program that has been | 9 | | receiving full-risk capitation for a year shall be accredited | 10 | | by a national accreditation organization authorized by the | 11 | | Department within 2 years after the date it is eligible to | 12 | | become accredited. The requirements of this subsection shall | 13 | | apply to contracts with MCOs entered into or renewed or | 14 | | extended after June 1, 2013. | 15 | | (h-5) The Department shall monitor and enforce compliance | 16 | | by MCOs with agreements they have entered into with providers | 17 | | on issues that include, but are not limited to, timeliness of | 18 | | payment, payment rates, and processes for obtaining prior | 19 | | approval. The Department may impose sanctions on MCOs for | 20 | | violating provisions of those agreements that include, but are | 21 | | not limited to, financial penalties, suspension of enrollment | 22 | | of new enrollees, and termination of the MCO's contract with | 23 | | the Department. As used in this subsection (h-5), "MCO" has the | 24 | | meaning ascribed to that term in Section 5-30.1 of this Code. | 25 | | (i) As used in this subsection: | 26 | | "Pediatric care coordination entity" means a collaboration |
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| 1 | | of providers and community agencies, governed by a lead entity, | 2 | | serving primarily persons under the age of 21 which receives a | 3 | | care coordination payment with a portion of the payment at risk | 4 | | for meeting quality outcome targets, in order to provide care | 5 | | coordination services for its enrollees. | 6 | | "Pediatric care coordination plan" means a pediatric care | 7 | | coordination entity defined in this subsection or a pediatric | 8 | | only managed care community network as defined in subsection | 9 | | (b) of Section 5-11. | 10 | | "Children with complex medical needs" means persons under | 11 | | 21 years of age who are clients of medical assistance programs | 12 | | or other health benefit programs administered by the Department | 13 | | through the use of the 3M TM Clinical Risk Grouping Software | 14 | | (CRG) as Status 6.1 and above, through a clinical screening | 15 | | tool, or those who do not have sufficient claims data in order | 16 | | to be identified by the Department through the CRG software. | 17 | | Beginning on the effective date of this amendatory Act of | 18 | | the 99th General Assembly and until April 1, 2016, the | 19 | | Department, where available, shall offer newly eligible | 20 | | children with complex medical needs, and currently eligible | 21 | | children with complex medical needs making their annual health | 22 | | plan choice, the choice of enrollment in a pediatric care | 23 | | coordination entity as defined in this subsection. At any time, | 24 | | the Department may offer, where available, the choice of | 25 | | enrollment in a pediatric only managed care community network | 26 | | as defined in subsection (b) of Section 5-11. On and after |
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| 1 | | April 1, 2016, the Department shall offer a pediatric care | 2 | | coordination plan where available but may require the plan to | 3 | | meet the requirements of subsection (b) of Section 5-11. This | 4 | | choice shall be in addition to otherwise available health | 5 | | maintenance organizations (HMOs), managed care community | 6 | | networks (MCCNs), and accountable care entities (ACEs). | 7 | | Children with complex medical needs under 18 years of age | 8 | | shall be eligible to enroll in the pediatric care coordination | 9 | | plan as long as such children continue to maintain eligibility | 10 | | for medical assistance programs or other health benefit | 11 | | programs administered by the Department. The Department may | 12 | | choose to extend enrollment to individuals under 21 years of | 13 | | age for initial enrollment. Individuals may also be excluded if | 14 | | they are: | 15 | | (1) enrolled in the Medically Fragile Technology | 16 | | Dependent Waiver; | 17 | | (2) receiving private duty nursing; | 18 | | (3) eligible for high third party liability coverage as | 19 | | defined by the Department; | 20 | | (4) residing in institutions including pediatric | 21 | | skilled nursing facilities; | 22 | | (5) enrolled in the DSCC Core Program; or | 23 | | (6) placed in foster care with the Department of | 24 | | Children and Family Services. | 25 | | The Department shall ensure that the parents of all | 26 | | eligible enrollees that are children with complex medical needs |
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| 1 | | shall receive notification of their eligibility and an | 2 | | explanation of how to elect the pediatric care coordination | 3 | | plan option. The Department shall ensure that any third party | 4 | | enrollment broker is briefed on the pediatric care coordination | 5 | | plan option and that the broker shall ensure that all | 6 | | enrollment options are presented to the parents of children | 7 | | with complex medical needs. | 8 | | (Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13; | 9 | | 98-651, eff. 6-16-14.)
| 10 | | Section 99. Effective date. This Act takes effect upon | 11 | | becoming law.".
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