Full Text of SB1273 99th General Assembly
SB1273sam001 99TH GENERAL ASSEMBLY | Sen. Antonio Muñoz Filed: 4/28/2015
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| 1 | | AMENDMENT TO SENATE BILL 1273
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 1273 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 1. Legislative intent. With the expansion of the | 5 | | State's Medical Assistance Program pursuant to the Patient | 6 | | Protection and Affordable Care Act (Public Law 111-148) and the | 7 | | increasing number of individuals enrolling in managed care | 8 | | organizations, it is the intent of this amendatory Act of the | 9 | | 99th General Assembly to provide a comprehensive managed care | 10 | | network that is administered uniformly and simply and that | 11 | | ensures access to and provides efficient, economic, and quality | 12 | | care to individuals enrolled in programs administered by the | 13 | | Department of Healthcare and Family Services. | 14 | | Section 5. The Illinois Public Aid Code is amended by | 15 | | changing Section 5-30 as follows: |
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| 1 | | (305 ILCS 5/5-30) | 2 | | Sec. 5-30. Care coordination. | 3 | | (a) At least 50% of recipients eligible for comprehensive | 4 | | medical benefits in all medical assistance programs or other | 5 | | health benefit programs administered by the Department, | 6 | | including the Children's Health Insurance Program Act and the | 7 | | Covering ALL KIDS Health Insurance Act, shall be enrolled in a | 8 | | care coordination program by no later than January 1, 2015. For | 9 | | purposes of this Section, "coordinated care" or "care | 10 | | coordination" means delivery systems where recipients will | 11 | | receive their care from providers who participate under | 12 | | contract in integrated delivery systems that are responsible | 13 | | for providing or arranging the majority of care, including | 14 | | primary care physician services, referrals from primary care | 15 | | physicians, diagnostic and treatment services, behavioral | 16 | | health services, in-patient and outpatient hospital services, | 17 | | dental services, and rehabilitation and long-term care | 18 | | services. The Department shall designate or contract for such | 19 | | integrated delivery systems (i) to ensure enrollees have a | 20 | | choice of systems and of primary care providers within such | 21 | | systems; (ii) to ensure that enrollees receive quality care in | 22 | | a culturally and linguistically appropriate manner; and (iii) | 23 | | to ensure that coordinated care programs meet the diverse needs | 24 | | of enrollees with developmental, mental health, physical, and | 25 | | age-related disabilities. | 26 | | (b) Payment for such coordinated care shall be based on |
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| 1 | | arrangements where the State pays for performance related to | 2 | | health care outcomes, the use of evidence-based practices, the | 3 | | use of primary care delivered through comprehensive medical | 4 | | homes, the use of electronic medical records, and the | 5 | | appropriate exchange of health information electronically made | 6 | | either on a capitated basis in which a fixed monthly premium | 7 | | per recipient is paid and full financial risk is assumed for | 8 | | the delivery of services, or through other risk-based payment | 9 | | arrangements. | 10 | | (c) To qualify for compliance with this Section, the 50% | 11 | | goal shall be achieved by enrolling medical assistance | 12 | | enrollees from each medical assistance enrollment category, | 13 | | including parents, children, seniors, and people with | 14 | | disabilities to the extent that current State Medicaid payment | 15 | | laws would not limit federal matching funds for recipients in | 16 | | care coordination programs. In addition, services must be more | 17 | | comprehensively defined and more risk shall be assumed than in | 18 | | the Department's primary care case management program as of the | 19 | | effective date of this amendatory Act of the 96th General | 20 | | Assembly. | 21 | | (d) The Department shall report to the General Assembly in | 22 | | a separate part of its annual medical assistance program | 23 | | report, beginning April, 2012 until April, 2016, on the | 24 | | progress and implementation of the care coordination program | 25 | | initiatives established by the provisions of this amendatory | 26 | | Act of the 96th General Assembly. The Department shall include |
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| 1 | | in its April 2011 report a full analysis of federal laws or | 2 | | regulations regarding upper payment limitations to providers | 3 | | and the necessary revisions or adjustments in rate | 4 | | methodologies and payments to providers under this Code that | 5 | | would be necessary to implement coordinated care with full | 6 | | financial risk by a party other than the Department.
| 7 | | (e) Integrated Care Program for individuals with chronic | 8 | | mental health conditions. | 9 | | (1) The Integrated Care Program shall encompass | 10 | | services administered to recipients of medical assistance | 11 | | under this Article to prevent exacerbations and | 12 | | complications using cost-effective, evidence-based | 13 | | practice guidelines and mental health management | 14 | | strategies. | 15 | | (2) The Department may utilize and expand upon existing | 16 | | contractual arrangements with integrated care plans under | 17 | | the Integrated Care Program for providing the coordinated | 18 | | care provisions of this Section. | 19 | | (3) Payment for such coordinated care shall be based on | 20 | | arrangements where the State pays for performance related | 21 | | to mental health outcomes on a capitated basis in which a | 22 | | fixed monthly premium per recipient is paid and full | 23 | | financial risk is assumed for the delivery of services, or | 24 | | through other risk-based payment arrangements such as | 25 | | provider-based care coordination. | 26 | | (4) The Department shall examine whether chronic |
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| 1 | | mental health management programs and services for | 2 | | recipients with specific chronic mental health conditions | 3 | | do any or all of the following: | 4 | | (A) Improve the patient's overall mental health in | 5 | | a more expeditious and cost-effective manner. | 6 | | (B) Lower costs in other aspects of the medical | 7 | | assistance program, such as hospital admissions, | 8 | | emergency room visits, or more frequent and | 9 | | inappropriate psychotropic drug use. | 10 | | (5) The Department shall work with the facilities and | 11 | | any integrated care plan participating in the program to | 12 | | identify and correct barriers to the successful | 13 | | implementation of this subsection (e) prior to and during | 14 | | the implementation to best facilitate the goals and | 15 | | objectives of this subsection (e). | 16 | | (f) A hospital that is located in a county of the State in | 17 | | which the Department mandates some or all of the beneficiaries | 18 | | of the Medical Assistance Program residing in the county to | 19 | | enroll in a Care Coordination Program, as set forth in Section | 20 | | 5-30 of this Code, shall not be eligible for any non-claims | 21 | | based payments not mandated by Article V-A of this Code for | 22 | | which it would otherwise be qualified to receive, unless the | 23 | | hospital is a Coordinated Care Participating Hospital no later | 24 | | than 60 days after the effective date of this amendatory Act of | 25 | | the 97th General Assembly or 60 days after the first mandatory | 26 | | enrollment of a beneficiary in a Coordinated Care program. For |
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| 1 | | purposes of this subsection, "Coordinated Care Participating | 2 | | Hospital" means a hospital that meets one of the following | 3 | | criteria: | 4 | | (1) The hospital has entered into a contract to provide | 5 | | hospital services with one or more MCOs to enrollees of the | 6 | | care coordination program. | 7 | | (2) The hospital has not been offered a contract by a | 8 | | care coordination plan that the Department has determined | 9 | | to be a good faith offer and that pays at least as much as | 10 | | the Department would pay, on a fee-for-service basis, not | 11 | | including disproportionate share hospital adjustment | 12 | | payments or any other supplemental adjustment or add-on | 13 | | payment to the base fee-for-service rate, except to the | 14 | | extent such adjustments or add-on payments are | 15 | | incorporated into the development of the applicable MCO | 16 | | capitated rates. | 17 | | As used in this subsection (f), "MCO" means any entity | 18 | | which contracts with the Department to provide services where | 19 | | payment for medical services is made on a capitated basis. | 20 | | (g) No later than August 1, 2013, the Department shall | 21 | | issue a purchase of care solicitation for Accountable Care | 22 | | Entities (ACE) to serve any children and parents or caretaker | 23 | | relatives of children eligible for medical assistance under | 24 | | this Article. An ACE may be a single corporate structure or a | 25 | | network of providers organized through contractual | 26 | | relationships with a single corporate entity. The solicitation |
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| 1 | | shall require that: | 2 | | (1) An ACE operating in Cook County be capable of | 3 | | serving at least 40,000 eligible individuals in that | 4 | | county; an ACE operating in Lake, Kane, DuPage, or Will | 5 | | Counties be capable of serving at least 20,000 eligible | 6 | | individuals in those counties and an ACE operating in other | 7 | | regions of the State be capable of serving at least 10,000 | 8 | | eligible individuals in the region in which it operates. | 9 | | During initial periods of mandatory enrollment, the | 10 | | Department shall require its enrollment services | 11 | | contractor to use a default assignment algorithm that | 12 | | ensures if possible an ACE reaches the minimum enrollment | 13 | | levels set forth in this paragraph. | 14 | | (2) An ACE must include at a minimum the following | 15 | | types of providers: primary care, specialty care, | 16 | | hospitals, and behavioral healthcare. | 17 | | (3) An ACE shall have a governance structure that | 18 | | includes the major components of the health care delivery | 19 | | system, including one representative from each of the | 20 | | groups listed in paragraph (2). | 21 | | (4) An ACE must be an integrated delivery system, | 22 | | including a network able to provide the full range of | 23 | | services needed by Medicaid beneficiaries and system | 24 | | capacity to securely pass clinical information across | 25 | | participating entities and to aggregate and analyze that | 26 | | data in order to coordinate care. |
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| 1 | | (5) An ACE must be capable of providing both care | 2 | | coordination and complex case management, as necessary, to | 3 | | beneficiaries. To be responsive to the solicitation, a | 4 | | potential ACE must outline its care coordination and | 5 | | complex case management model and plan to reduce the cost | 6 | | of care. | 7 | | (6) In the first 18 months of operation, unless the ACE | 8 | | selects a shorter period, an ACE shall be paid care | 9 | | coordination fees on a per member per month basis that are | 10 | | projected to be cost neutral to the State during the term | 11 | | of their payment and, subject to federal approval, be | 12 | | eligible to share in additional savings generated by their | 13 | | care coordination. | 14 | | (7) In months 19 through 36 of operation, unless the | 15 | | ACE selects a shorter period, an ACE shall be paid on a | 16 | | pre-paid capitation basis for all medical assistance | 17 | | covered services, under contract terms similar to Managed | 18 | | Care Organizations (MCO), with the Department sharing the | 19 | | risk through either stop-loss insurance for extremely high | 20 | | cost individuals or corridors of shared risk based on the | 21 | | overall cost of the total enrollment in the ACE. The ACE | 22 | | shall be responsible for claims processing, encounter data | 23 | | submission, utilization control, and quality assurance. | 24 | | (8) In the fourth and subsequent years of operation, an | 25 | | ACE shall convert to a Managed Care Community Network | 26 | | (MCCN), as defined in this Article, or Health Maintenance |
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| 1 | | Organization pursuant to the Illinois Insurance Code, | 2 | | accepting full-risk capitation payments. | 3 | | The Department shall allow potential ACE entities 5 months | 4 | | from the date of the posting of the solicitation to submit | 5 | | proposals. After the solicitation is released, in addition to | 6 | | the MCO rate development data available on the Department's | 7 | | website, subject to federal and State confidentiality and | 8 | | privacy laws and regulations, the Department shall provide 2 | 9 | | years of de-identified summary service data on the targeted | 10 | | population, split between children and adults, showing the | 11 | | historical type and volume of services received and the cost of | 12 | | those services to those potential bidders that sign a data use | 13 | | agreement. The Department may add up to 2 non-state government | 14 | | employees with expertise in creating integrated delivery | 15 | | systems to its review team for the purchase of care | 16 | | solicitation described in this subsection. Any such | 17 | | individuals must sign a no-conflict disclosure and | 18 | | confidentiality agreement and agree to act in accordance with | 19 | | all applicable State laws. | 20 | | During the first 2 years of an ACE's operation, the | 21 | | Department shall provide claims data to the ACE on its | 22 | | enrollees on a periodic basis no less frequently than monthly. | 23 | | Nothing in this subsection shall be construed to limit the | 24 | | Department's mandate to enroll 50% of its beneficiaries into | 25 | | care coordination systems by January 1, 2015, using all | 26 | | available care coordination delivery systems, including Care |
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| 1 | | Coordination Entities (CCE), MCCNs, or MCOs, nor be construed | 2 | | to affect the current CCEs, MCCNs, and MCOs selected to serve | 3 | | seniors and persons with disabilities prior to that date. | 4 | | Nothing in this subsection precludes the Department from | 5 | | considering future proposals for new ACEs or expansion of | 6 | | existing ACEs at the discretion of the Department. | 7 | | (h) Department contracts with MCOs and other entities | 8 | | reimbursed by risk based capitation shall have a minimum | 9 | | medical loss ratio of 85%, shall require the entity to | 10 | | establish an appeals and grievances process for consumers and | 11 | | providers, and shall require the entity to provide a quality | 12 | | assurance and utilization review program. Entities contracted | 13 | | with the Department to coordinate healthcare regardless of risk | 14 | | shall be measured utilizing the same quality metrics. The | 15 | | quality metrics may be population specific. Any contracted | 16 | | entity serving at least 5,000 seniors or people with | 17 | | disabilities or 15,000 individuals in other populations | 18 | | covered by the Medical Assistance Program that has been | 19 | | receiving full-risk capitation for a year shall be accredited | 20 | | by a national accreditation organization authorized by the | 21 | | Department within 2 years after the date it is eligible to | 22 | | become accredited. The requirements of this subsection shall | 23 | | apply to contracts with MCOs entered into or renewed or | 24 | | extended after June 1, 2013. | 25 | | (h-4) | 26 | | (1) MCOs, as defined in Section 5-30.1 of this Code, |
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| 1 | | including managed care community networks as defined in | 2 | | Section 5-11 of this Code, shall be subject to Section | 3 | | 5-4.2 of this Code and any amendments, regulations, | 4 | | policies, and guidelines thereto concerning the following | 5 | | matters: mileage criteria and methodology, emergency and | 6 | | urgently needed methodology and criteria, appeals | 7 | | processes including post authorization for | 8 | | non-prescheduled, non-emergency transportation, and | 9 | | uniform certification of medical necessity for | 10 | | non-emergency ambulance transportation. Appeal decisions | 11 | | issued by MCOs pursuant to Section 5-4.2 shall be | 12 | | appealable to the Director, and the Director's decision on | 13 | | these appeals shall be a final administrative decision | 14 | | subject to review under the Administrative Review Law. The | 15 | | uniform certification of medical necessity for | 16 | | non-emergency transportation requirements shall be | 17 | | effective for dates of service beginning no later than 90 | 18 | | days after the effective date of this amendatory Act of the | 19 | | 99th General Assembly. The mileage criteria and | 20 | | methodology, emergency and urgently needed methodology, | 21 | | and criteria and appeals processes, including post | 22 | | authorization for non-prescheduled, non-emergency | 23 | | transportation, shall be effective for dates of service | 24 | | beginning no later than July 1, 2015 and for any and all | 25 | | outstanding claims that exist at the time of implementation | 26 | | of the methodologies, appeals, and post authorization |
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| 1 | | processes. | 2 | | Effective immediately upon the effective date of this | 3 | | amendatory Act of the 99th General Assembly, MCOs shall not | 4 | | unreasonably refuse to contract with ground ambulance | 5 | | services providers as defined in Section 5-4.2 of this Code | 6 | | and medi-car services providers as defined in Section 5-4.2 | 7 | | of this Code, shall not unreasonably restrict access to and | 8 | | the availability of ground ambulance services and medi-car | 9 | | services, and shall ensure that recipients of the | 10 | | Department's programs shall not be liable for ground | 11 | | ambulance services and medi-car services expenses | 12 | | consistent with federal law, Sections 370h and 370i of the | 13 | | Illinois Insurance Code, and any amendments, regulations, | 14 | | policies, and guidelines thereto, including, but not | 15 | | limited to, 50 Ill. Admin. Code 2051.280(b) and any | 16 | | amendments thereto. | 17 | | (2) It is the intention of the General Assembly that | 18 | | the State action exemption to the application of federal | 19 | | and State antitrust statutes be fully available to the | 20 | | Department and MCOs and their agents and designees, and all | 21 | | employees, officers, subsidiaries, and designees thereof, | 22 | | to the extent the activities are authorized by the | 23 | | provisions of Section 5-4.2 to which the MCOs are subject | 24 | | under this amendatory Act of the 99th General Assembly. The | 25 | | State action exemption shall be liberally construed in | 26 | | favor of the Department and MCOs and their agents and |
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| 1 | | designees and all employees, officers, subsidiaries, and | 2 | | designees thereof, and such exemption shall be available | 3 | | notwithstanding that the action constitutes an irregular | 4 | | exercise of constitutional or statutory powers. It is the | 5 | | policy of this State that the following powers may be | 6 | | exercised by the Department and MCOs and their agents and | 7 | | designees and all employees, officers, subsidiaries, and | 8 | | designees thereof notwithstanding the effects on | 9 | | competition and notwithstanding any displacement of | 10 | | competition: (i) all powers that are within the traditional | 11 | | areas of the Department's activity but that are authorized | 12 | | by the provisions of Section 5-4.2 to which the MCOs are | 13 | | subject under this amendatory Act of the 99th General | 14 | | Assembly and that are to be implemented by the MCOs and | 15 | | their agents and designees and all employees, officers, | 16 | | subsidiaries, and designees thereof; (ii) all powers | 17 | | granted, either expressly or by necessary implication, by | 18 | | the provisions of Section 5-4.2 to which the MCOs are | 19 | | subject under this amendatory Act of the 99th General | 20 | | Assembly or any administrative rules, policies, or | 21 | | procedures that implement the provisions of Section 5-4.2 | 22 | | to which the MCOs are subject under this amendatory Act of | 23 | | the 99th General Assembly; or (iii) all powers that are the | 24 | | inherent, logical, or ordinary results of the powers | 25 | | granted by the provisions of Section 5-4.2 to which the | 26 | | MCOs are subject under this amendatory Act of the 99th |
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| 1 | | General Assembly and any administrative rules, policies, | 2 | | or procedures that implement the provisions of Section | 3 | | 5-4.2 to which the MCOs are subject under this amendatory | 4 | | Act of the 99th General Assembly. In order to ensure that | 5 | | MCOs and their agents and designees and all employees, | 6 | | officers, subsidiaries, and designees thereof promote | 7 | | State policy and not individual interest, the Department | 8 | | shall actively supervise their activities, including, but | 9 | | not limited to, their decisions. The Department's active | 10 | | supervision shall include, but not be limited to, a review | 11 | | of the substance of any activities or decisions and the | 12 | | power to veto or modify particular activities or decisions | 13 | | to ensure they accord with State policy. The mere potential | 14 | | for State supervision shall not be a sufficient substitute | 15 | | for an actual decision by the Department. Department | 16 | | supervisors shall not be active market participants. | 17 | | (h-5) The Department shall monitor and enforce compliance | 18 | | by MCOs with agreements they have entered into with providers | 19 | | on issues that include, but are not limited to, timeliness of | 20 | | payment, payment rates, and processes for obtaining prior | 21 | | approval. The Department may impose sanctions on MCOs for | 22 | | violating provisions of those agreements that include, but are | 23 | | not limited to, financial penalties, suspension of enrollment | 24 | | of new enrollees, and termination of the MCO's contract with | 25 | | the Department. As used in this subsection (h-5), "MCO" has the | 26 | | meaning ascribed to that term in Section 5-30.1 of this Code. |
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| 1 | | (Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13; | 2 | | 98-651, eff. 6-16-14.)
| 3 | | Section 99. Effective date. This Act takes effect upon | 4 | | becoming law.".
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