Sen. Heather A. Steans

Filed: 5/19/2015





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2    AMENDMENT NO. ______. Amend Senate Bill 343, AS AMENDED, by
3replacing everything after the enacting clause with the
5    "Section 5. The Illinois Public Aid Code is amended by
6changing 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
10medical benefits in all medical assistance programs or other
11health benefit programs administered by the Department,
12including the Children's Health Insurance Program Act and the
13Covering ALL KIDS Health Insurance Act, shall be enrolled in a
14care coordination program by no later than January 1, 2015. For
15purposes of this Section, "coordinated care" or "care
16coordination" means delivery systems where recipients will



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1receive their care from providers who participate under
2contract in integrated delivery systems that are responsible
3for providing or arranging the majority of care, including
4primary care physician services, referrals from primary care
5physicians, diagnostic and treatment services, behavioral
6health services, in-patient and outpatient hospital services,
7dental services, and rehabilitation and long-term care
8services. The Department shall designate or contract for such
9integrated delivery systems (i) to ensure enrollees have a
10choice of systems and of primary care providers within such
11systems; (ii) to ensure that enrollees receive quality care in
12a culturally and linguistically appropriate manner; and (iii)
13to ensure that coordinated care programs meet the diverse needs
14of enrollees with developmental, mental health, physical, and
15age-related disabilities.
16    (b) Payment for such coordinated care shall be based on
17arrangements where the State pays for performance related to
18health care outcomes, the use of evidence-based practices, the
19use of primary care delivered through comprehensive medical
20homes, the use of electronic medical records, and the
21appropriate exchange of health information electronically made
22either on a capitated basis in which a fixed monthly premium
23per recipient is paid and full financial risk is assumed for
24the delivery of services, or through other risk-based payment
26    (c) To qualify for compliance with this Section, the 50%



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1goal shall be achieved by enrolling medical assistance
2enrollees from each medical assistance enrollment category,
3including parents, children, seniors, and people with
4disabilities to the extent that current State Medicaid payment
5laws would not limit federal matching funds for recipients in
6care coordination programs. In addition, services must be more
7comprehensively defined and more risk shall be assumed than in
8the Department's primary care case management program as of the
9effective date of this amendatory Act of the 96th General
11    (d) The Department shall report to the General Assembly in
12a separate part of its annual medical assistance program
13report, beginning April, 2012 until April, 2016, on the
14progress and implementation of the care coordination program
15initiatives established by the provisions of this amendatory
16Act of the 96th General Assembly. The Department shall include
17in its April 2011 report a full analysis of federal laws or
18regulations regarding upper payment limitations to providers
19and the necessary revisions or adjustments in rate
20methodologies and payments to providers under this Code that
21would be necessary to implement coordinated care with full
22financial risk by a party other than the Department.
23    (e) Integrated Care Program for individuals with chronic
24mental 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
7which the Department mandates some or all of the beneficiaries
8of the Medical Assistance Program residing in the county to
9enroll in a Care Coordination Program, as set forth in Section
105-30 of this Code, shall not be eligible for any non-claims
11based payments not mandated by Article V-A of this Code for
12which it would otherwise be qualified to receive, unless the
13hospital is a Coordinated Care Participating Hospital no later
14than 60 days after the effective date of this amendatory Act of
15the 97th General Assembly or 60 days after the first mandatory
16enrollment of a beneficiary in a Coordinated Care program. For
17purposes of this subsection, "Coordinated Care Participating
18Hospital" means a hospital that meets one of the following
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
8which contracts with the Department to provide services where
9payment for medical services is made on a capitated basis.
10    (g) No later than August 1, 2013, the Department shall
11issue a purchase of care solicitation for Accountable Care
12Entities (ACE) to serve any children and parents or caretaker
13relatives of children eligible for medical assistance under
14this Article. An ACE may be a single corporate structure or a
15network of providers organized through contractual
16relationships with a single corporate entity. The solicitation
17shall 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
20from the date of the posting of the solicitation to submit
21proposals. After the solicitation is released, in addition to
22the MCO rate development data available on the Department's
23website, subject to federal and State confidentiality and
24privacy laws and regulations, the Department shall provide 2
25years of de-identified summary service data on the targeted
26population, split between children and adults, showing the



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



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1providers, and shall require the entity to provide a quality
2assurance and utilization review program. Entities contracted
3with the Department to coordinate healthcare regardless of risk
4shall be measured utilizing the same quality metrics. The
5quality metrics may be population specific. Any contracted
6entity serving at least 5,000 seniors or people with
7disabilities or 15,000 individuals in other populations
8covered by the Medical Assistance Program that has been
9receiving full-risk capitation for a year shall be accredited
10by a national accreditation organization authorized by the
11Department within 2 years after the date it is eligible to
12become accredited. The requirements of this subsection shall
13apply to contracts with MCOs entered into or renewed or
14extended after June 1, 2013.
15    (h-5) The Department shall monitor and enforce compliance
16by MCOs with agreements they have entered into with providers
17on issues that include, but are not limited to, timeliness of
18payment, payment rates, and processes for obtaining prior
19approval. The Department may impose sanctions on MCOs for
20violating provisions of those agreements that include, but are
21not limited to, financial penalties, suspension of enrollment
22of new enrollees, and termination of the MCO's contract with
23the Department. As used in this subsection (h-5), "MCO" has the
24meaning 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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1of providers and community agencies, governed by a lead entity,
2serving primarily persons under the age of 21 which receives a
3care coordination payment with a portion of the payment at risk
4for meeting quality outcome targets, in order to provide care
5coordination services for its enrollees.
6    "Pediatric care coordination plan" means a pediatric care
7coordination entity defined in this subsection or a pediatric
8only managed care community network as defined in subsection
9(b) of Section 5-11.
10    "Children with complex medical needs" means persons under
1121 years of age who are clients of medical assistance programs
12or other health benefit programs administered by the Department
13through the use of the 3MTM Clinical Risk Grouping Software
14(CRG) as Status 6.1 and above, through a clinical screening
15tool, or those who do not have sufficient claims data in order
16to be identified by the Department through the CRG software.
17    Beginning on the effective date of this amendatory Act of
18the 99th General Assembly and until April 1, 2016, the
19Department, where available, shall offer newly eligible
20children with complex medical needs, and currently eligible
21children with complex medical needs making their annual health
22plan choice, the choice of enrollment in a pediatric care
23coordination entity as defined in this subsection. At any time,
24the Department may offer, where available, the choice of
25enrollment in a pediatric only managed care community network
26as defined in subsection (b) of Section 5-11. On and after



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1April 1, 2016, the Department shall offer a pediatric care
2coordination plan where available but may require the plan to
3meet the requirements of subsection (b) of Section 5-11. This
4choice shall be in addition to otherwise available health
5maintenance organizations (HMOs), managed care community
6networks (MCCNs), and accountable care entities (ACEs).
7    Children with complex medical needs under 18 years of age
8shall be eligible to enroll in the pediatric care coordination
9plan as long as such children continue to maintain eligibility
10for medical assistance programs or other health benefit
11programs administered by the Department. The Department may
12choose to extend enrollment to individuals under 21 years of
13age for initial enrollment. Individuals may also be excluded if
14they 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
26eligible enrollees that are children with complex medical needs



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1shall receive notification of their eligibility and an
2explanation of how to elect the pediatric care coordination
3plan option. The Department shall ensure that any third party
4enrollment broker is briefed on the pediatric care coordination
5plan option and that the broker shall ensure that all
6enrollment options are presented to the parents of children
7with complex medical needs.
8(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13;
998-651, eff. 6-16-14.)
10    Section 99. Effective date. This Act takes effect upon
11becoming law.".