State of Illinois
2019 and 2020


Introduced , by Rep. Yehiel M. Kalish


305 ILCS 5/5-5.2  from Ch. 23, par. 5-5.2
305 ILCS 5/5-30
305 ILCS 5/5F-10

    Amends the Illinois Public Aid Code. In provisions concerning payment rates for nursing facilities, provides that a benchmark rate equal to the facility's fee-for-service rate shall be established for any facility receiving payment from a managed care entity for services. Provides that on and after July 1, 2020, no managed care entity shall pay a facility less than the established benchmark rate unless the managed care entity and the facility contractually agree upon a rate different than the established benchmark rate. Requires the benchmark rate to be updated quarterly by the Department of Healthcare and Family Services to recognize any rate adjustments to each facility's fee-for-service rate. Provides that until the State is in compliance with federal deadlines for Medicaid eligibility determinations, the Department must not expand the Medicare-Medicaid Alignment Initiative. Provides that beginning July 1, 2020, or upon federal approval, any enrollee who resides in a facility for more than 90 consecutive days shall no longer be required to enroll with a managed care organization and shall revert to having his or her services covered through a fee-for-service arrangement between the facility and the Department for any services received after 90 consecutive days of service. Effective immediately.

LRB101 18468 KTG 67916 b






HB5248LRB101 18468 KTG 67916 b

1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Sections 5-5.2, 5-30, and 5F-10 as follows:
6    (305 ILCS 5/5-5.2)  (from Ch. 23, par. 5-5.2)
7    Sec. 5-5.2. Payment.
8    (a) All nursing facilities that are grouped pursuant to
9Section 5-5.1 of this Act shall receive the same rate of
10payment for similar services.
11    (b) It shall be a matter of State policy that the Illinois
12Department shall utilize a uniform billing cycle throughout the
13State for the long-term care providers.
14    (c) Notwithstanding any other provisions of this Code, the
15methodologies for reimbursement of nursing services as
16provided under this Article shall no longer be applicable for
17bills payable for nursing services rendered on or after a new
18reimbursement system based on the Resource Utilization Groups
19(RUGs) has been fully operationalized, which shall take effect
20for services provided on or after January 1, 2014.
21    (d) The new nursing services reimbursement methodology
22utilizing RUG-IV 48 grouper model, which shall be referred to
23as the RUGs reimbursement system, taking effect January 1,



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12014, shall be based on the following:
2        (1) The methodology shall be resident-driven,
3    facility-specific, and cost-based.
4        (2) Costs shall be annually rebased and case mix index
5    quarterly updated. The nursing services methodology will
6    be assigned to the Medicaid enrolled residents on record as
7    of 30 days prior to the beginning of the rate period in the
8    Department's Medicaid Management Information System (MMIS)
9    as present on the last day of the second quarter preceding
10    the rate period based upon the Assessment Reference Date of
11    the Minimum Data Set (MDS).
12        (3) Regional wage adjustors based on the Health Service
13    Areas (HSA) groupings and adjusters in effect on April 30,
14    2012 shall be included.
15        (4) Case mix index shall be assigned to each resident
16    class based on the Centers for Medicare and Medicaid
17    Services staff time measurement study in effect on July 1,
18    2013, utilizing an index maximization approach.
19        (5) The pool of funds available for distribution by
20    case mix and the base facility rate shall be determined
21    using the formula contained in subsection (d-1).
22    (d-1) Calculation of base year Statewide RUG-IV nursing
23base per diem rate.
24        (1) Base rate spending pool shall be:
25            (A) The base year resident days which are
26        calculated by multiplying the number of Medicaid



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1        residents in each nursing home as indicated in the MDS
2        data defined in paragraph (4) by 365.
3            (B) Each facility's nursing component per diem in
4        effect on July 1, 2012 shall be multiplied by
5        subsection (A).
6            (C) Thirteen million is added to the product of
7        subparagraph (A) and subparagraph (B) to adjust for the
8        exclusion of nursing homes defined in paragraph (5).
9        (2) For each nursing home with Medicaid residents as
10    indicated by the MDS data defined in paragraph (4),
11    weighted days adjusted for case mix and regional wage
12    adjustment shall be calculated. For each home this
13    calculation is the product of:
14            (A) Base year resident days as calculated in
15        subparagraph (A) of paragraph (1).
16            (B) The nursing home's regional wage adjustor
17        based on the Health Service Areas (HSA) groupings and
18        adjustors in effect on April 30, 2012.
19            (C) Facility weighted case mix which is the number
20        of Medicaid residents as indicated by the MDS data
21        defined in paragraph (4) multiplied by the associated
22        case weight for the RUG-IV 48 grouper model using
23        standard RUG-IV procedures for index maximization.
24            (D) The sum of the products calculated for each
25        nursing home in subparagraphs (A) through (C) above
26        shall be the base year case mix, rate adjusted weighted



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1        days.
2        (3) The Statewide RUG-IV nursing base per diem rate:
3            (A) on January 1, 2014 shall be the quotient of the
4        paragraph (1) divided by the sum calculated under
5        subparagraph (D) of paragraph (2); and
6            (B) on and after July 1, 2014, shall be the amount
7        calculated under subparagraph (A) of this paragraph
8        (3) plus $1.76.
9        (4) Minimum Data Set (MDS) comprehensive assessments
10    for Medicaid residents on the last day of the quarter used
11    to establish the base rate.
12        (5) Nursing facilities designated as of July 1, 2012 by
13    the Department as "Institutions for Mental Disease" shall
14    be excluded from all calculations under this subsection.
15    The data from these facilities shall not be used in the
16    computations described in paragraphs (1) through (4) above
17    to establish the base rate.
18    (e) Beginning July 1, 2014, the Department shall allocate
19funding in the amount up to $10,000,000 for per diem add-ons to
20the RUGS methodology for dates of service on and after July 1,
22        (1) $0.63 for each resident who scores in I4200
23    Alzheimer's Disease or I4800 non-Alzheimer's Dementia.
24        (2) $2.67 for each resident who scores either a "1" or
25    "2" in any items S1200A through S1200I and also scores in
26    RUG groups PA1, PA2, BA1, or BA2.



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1    (e-1) (Blank).
2    (e-2) For dates of services beginning January 1, 2014, the
3RUG-IV nursing component per diem for a nursing home shall be
4the product of the statewide RUG-IV nursing base per diem rate,
5the facility average case mix index, and the regional wage
6adjustor. Transition rates for services provided between
7January 1, 2014 and December 31, 2014 shall be as follows:
8        (1) The transition RUG-IV per diem nursing rate for
9    nursing homes whose rate calculated in this subsection
10    (e-2) is greater than the nursing component rate in effect
11    July 1, 2012 shall be paid the sum of:
12            (A) The nursing component rate in effect July 1,
13        2012; plus
14            (B) The difference of the RUG-IV nursing component
15        per diem calculated for the current quarter minus the
16        nursing component rate in effect July 1, 2012
17        multiplied by 0.88.
18        (2) The transition RUG-IV per diem nursing rate for
19    nursing homes whose rate calculated in this subsection
20    (e-2) is less than the nursing component rate in effect
21    July 1, 2012 shall be paid the sum of:
22            (A) The nursing component rate in effect July 1,
23        2012; plus
24            (B) The difference of the RUG-IV nursing component
25        per diem calculated for the current quarter minus the
26        nursing component rate in effect July 1, 2012



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1        multiplied by 0.13.
2    (f) Notwithstanding any other provision of this Code, on
3and after July 1, 2012, reimbursement rates associated with the
4nursing or support components of the current nursing facility
5rate methodology shall not increase beyond the level effective
6May 1, 2011 until a new reimbursement system based on the RUGs
7IV 48 grouper model has been fully operationalized.
8    (g) Notwithstanding any other provision of this Code, on
9and after July 1, 2012, for facilities not designated by the
10Department of Healthcare and Family Services as "Institutions
11for Mental Disease", rates effective May 1, 2011 shall be
12adjusted as follows:
13        (1) Individual nursing rates for residents classified
14    in RUG IV groups PA1, PA2, BA1, and BA2 during the quarter
15    ending March 31, 2012 shall be reduced by 10%;
16        (2) Individual nursing rates for residents classified
17    in all other RUG IV groups shall be reduced by 1.0%;
18        (3) Facility rates for the capital and support
19    components shall be reduced by 1.7%.
20    (h) Notwithstanding any other provision of this Code, on
21and after July 1, 2012, nursing facilities designated by the
22Department of Healthcare and Family Services as "Institutions
23for Mental Disease" and "Institutions for Mental Disease" that
24are facilities licensed under the Specialized Mental Health
25Rehabilitation Act of 2013 shall have the nursing,
26socio-developmental, capital, and support components of their



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1reimbursement rate effective May 1, 2011 reduced in total by
3    (i) On and after July 1, 2014, the reimbursement rates for
4the support component of the nursing facility rate for
5facilities licensed under the Nursing Home Care Act as skilled
6or intermediate care facilities shall be the rate in effect on
7June 30, 2014 increased by 8.17%.
8    (j) Notwithstanding any other provision of law, subject to
9federal approval, effective July 1, 2019, sufficient funds
10shall be allocated for changes to rates for facilities licensed
11under the Nursing Home Care Act as skilled nursing facilities
12or intermediate care facilities for dates of services on and
13after July 1, 2019: (i) to establish a per diem add-on to the
14direct care per diem rate not to exceed $70,000,000 annually in
15the aggregate taking into account federal matching funds for
16the purpose of addressing the facility's unique staffing needs,
17adjusted quarterly and distributed by a weighted formula based
18on Medicaid bed days on the last day of the second quarter
19preceding the quarter for which the rate is being adjusted; and
20(ii) in an amount not to exceed $170,000,000 annually in the
21aggregate taking into account federal matching funds to permit
22the support component of the nursing facility rate to be
23updated as follows:
24        (1) 80%, or $136,000,000, of the funds shall be used to
25    update each facility's rate in effect on June 30, 2019
26    using the most recent cost reports on file, which have had



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1    a limited review conducted by the Department of Healthcare
2    and Family Services and will not hold up enacting the rate
3    increase, with the Department of Healthcare and Family
4    Services and taking into account subsection (i).
5        (2) After completing the calculation in paragraph (1),
6    any facility whose rate is less than the rate in effect on
7    June 30, 2019 shall have its rate restored to the rate in
8    effect on June 30, 2019 from the 20% of the funds set
9    aside.
10        (3) The remainder of the 20%, or $34,000,000, shall be
11    used to increase each facility's rate by an equal
12    percentage.
13    To implement item (i) in this subsection, facilities shall
14file quarterly reports documenting compliance with its
15annually approved staffing plan, which shall permit compliance
16with Section 3-202.05 of the Nursing Home Care Act. A facility
17that fails to meet the benchmarks and dates contained in the
18plan may have its add-on adjusted in the quarter following the
19quarterly review. Nothing in this Section shall limit the
20ability of the facility to appeal a ruling of non-compliance
21and a subsequent reduction to the add-on. Funds adjusted for
22noncompliance shall be maintained in the Long-Term Care
23Provider Fund and accounted for separately. At the end of each
24fiscal year, these funds shall be made available to facilities
25for special staffing projects.
26    In order to provide for the expeditious and timely



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1implementation of the provisions of Public Act 101-10 this
2amendatory Act of the 101st General Assembly, emergency rules
3to implement any provision of Public Act 101-10 this amendatory
4Act of the 101st General Assembly may be adopted in accordance
5with this subsection by the agency charged with administering
6that provision or initiative. The agency shall simultaneously
7file emergency rules and permanent rules to ensure that there
8is no interruption in administrative guidance. The 150-day
9limitation of the effective period of emergency rules does not
10apply to rules adopted under this subsection, and the effective
11period may continue through June 30, 2021. The 24-month
12limitation on the adoption of emergency rules does not apply to
13rules adopted under this subsection. The adoption of emergency
14rules authorized by this subsection is deemed to be necessary
15for the public interest, safety, and welfare.
16    (k) (j) During the first quarter of State Fiscal Year 2020,
17the Department of Healthcare of Family Services must convene a
18technical advisory group consisting of members of all trade
19associations representing Illinois skilled nursing providers
20to discuss changes necessary with federal implementation of
21Medicare's Patient-Driven Payment Model. Implementation of
22Medicare's Patient-Driven Payment Model shall, by September 1,
232020, end the collection of the MDS data that is necessary to
24maintain the current RUG-IV Medicaid payment methodology. The
25technical advisory group must consider a revised reimbursement
26methodology that takes into account transparency,



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1accountability, actual staffing as reported under the
2federally required Payroll Based Journal system, changes to the
3minimum wage, adequacy in coverage of the cost of care, and a
4quality component that rewards quality improvements.
5    (l) Benchmark rate. For any facility receiving payment from
6a managed care entity for services, a benchmark rate equal to
7the facility's fee-for-service rate shall be established. On
8and after July 1, 2020, no managed care entity shall pay a
9facility less than the established benchmark rate unless the
10managed care entity and the facility contractually agree upon a
11rate different than the established benchmark rate. The
12benchmark rate shall be updated quarterly by the Department to
13recognize any rate adjustments to each facility's
14fee-for-service rate.
15(Source: P.A. 101-10, eff. 6-5-19; 101-348, eff. 8-9-19;
16revised 9-18-19.)
17    (305 ILCS 5/5-30)
18    Sec. 5-30. Care coordination.
19    (a) At least 50% of recipients eligible for comprehensive
20medical benefits in all medical assistance programs or other
21health benefit programs administered by the Department,
22including the Children's Health Insurance Program Act and the
23Covering ALL KIDS Health Insurance Act, shall be enrolled in a
24care coordination program by no later than January 1, 2015. For
25purposes of this Section, "coordinated care" or "care



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1coordination" means delivery systems where recipients will
2receive their care from providers who participate under
3contract in integrated delivery systems that are responsible
4for providing or arranging the majority of care, including
5primary care physician services, referrals from primary care
6physicians, diagnostic and treatment services, behavioral
7health services, in-patient and outpatient hospital services,
8dental services, and rehabilitation and long-term care
9services. The Department shall designate or contract for such
10integrated delivery systems (i) to ensure enrollees have a
11choice of systems and of primary care providers within such
12systems; (ii) to ensure that enrollees receive quality care in
13a culturally and linguistically appropriate manner; and (iii)
14to ensure that coordinated care programs meet the diverse needs
15of enrollees with developmental, mental health, physical, and
16age-related disabilities.
17    (b) Payment for such coordinated care shall be based on
18arrangements where the State pays for performance related to
19health care outcomes, the use of evidence-based practices, the
20use of primary care delivered through comprehensive medical
21homes, the use of electronic medical records, and the
22appropriate exchange of health information electronically made
23either on a capitated basis in which a fixed monthly premium
24per recipient is paid and full financial risk is assumed for
25the delivery of services, or through other risk-based payment



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1    (c) To qualify for compliance with this Section, the 50%
2goal shall be achieved by enrolling medical assistance
3enrollees from each medical assistance enrollment category,
4including parents, children, seniors, and people with
5disabilities to the extent that current State Medicaid payment
6laws would not limit federal matching funds for recipients in
7care coordination programs. In addition, services must be more
8comprehensively defined and more risk shall be assumed than in
9the Department's primary care case management program as of
10January 25, 2011 (the effective date of Public Act 96-1501).
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 Public Act
1696-1501. The Department shall include in its April 2011 report
17a full analysis of federal laws or regulations regarding upper
18payment limitations to providers and the necessary revisions or
19adjustments in rate methodologies and payments to providers
20under this Code that would be necessary to implement
21coordinated care with full financial risk by a party other than
22the 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 June 14, 2012 (the effective date of Public
15Act 97-689) or 60 days after the first mandatory enrollment of
16a beneficiary in a Coordinated Care program. For purposes of
17this subsection, "Coordinated Care Participating Hospital"
18means a hospital that meets one of the following criteria:
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



HB5248- 17 -LRB101 18468 KTG 67916 b

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) Unless otherwise required by federal law, Medicaid
25Managed Care Entities and their respective business associates
26shall not disclose, directly or indirectly, including by



HB5248- 20 -LRB101 18468 KTG 67916 b

1sending a bill or explanation of benefits, information
2concerning the sensitive health services received by enrollees
3of the Medicaid Managed Care Entity to any person other than
4covered entities and business associates, which may receive,
5use, and further disclose such information solely for the
6purposes permitted under applicable federal and State laws and
7regulations if such use and further disclosure satisfies all
8applicable requirements of such laws and regulations. The
9Medicaid Managed Care Entity or its respective business
10associates may disclose information concerning the sensitive
11health services if the enrollee who received the sensitive
12health services requests the information from the Medicaid
13Managed Care Entity or its respective business associates and
14authorized the sending of a bill or explanation of benefits.
15Communications including, but not limited to, statements of
16care received or appointment reminders either directly or
17indirectly to the enrollee from the health care provider,
18health care professional, and care coordinators, remain
19permissible. Medicaid Managed Care Entities or their
20respective business associates may communicate directly with
21their enrollees regarding care coordination activities for
22those enrollees.
23    For the purposes of this subsection, the term "Medicaid
24Managed Care Entity" includes Care Coordination Entities,
25Accountable Care Entities, Managed Care Organizations, and
26Managed Care Community Networks.



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1    For purposes of this subsection, the term "sensitive health
2services" means mental health services, substance abuse
3treatment services, reproductive health services, family
4planning services, services for sexually transmitted
5infections and sexually transmitted diseases, and services for
6sexual assault or domestic abuse. Services include prevention,
7screening, consultation, examination, treatment, or follow-up.
8    For purposes of this subsection, "business associate",
9"covered entity", "disclosure", and "use" have the meanings
10ascribed to those terms in 45 CFR 160.103.
11    Nothing in this subsection shall be construed to relieve a
12Medicaid Managed Care Entity or the Department of any duty to
13report incidents of sexually transmitted infections to the
14Department of Public Health or to the local board of health in
15accordance with regulations adopted under a statute or
16ordinance or to report incidents of sexually transmitted
17infections as necessary to comply with the requirements under
18Section 5 of the Abused and Neglected Child Reporting Act or as
19otherwise required by State or federal law.
20    The Department shall create policy in order to implement
21the requirements in this subsection.
22    (j) Managed Care Entities (MCEs), including MCOs and all
23other care coordination organizations, shall develop and
24maintain a written language access policy that sets forth the
25standards, guidelines, and operational plan to ensure language
26appropriate services and that is consistent with the standard



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1of meaningful access for populations with limited English
2proficiency. The language access policy shall describe how the
3MCEs will provide all of the following required services:
4        (1) Translation (the written replacement of text from
5    one language into another) of all vital documents and forms
6    as identified by the Department.
7        (2) Qualified interpreter services (the oral
8    communication of a message from one language into another
9    by a qualified interpreter).
10        (3) Staff training on the language access policy,
11    including how to identify language needs, access and
12    provide language assistance services, work with
13    interpreters, request translations, and track the use of
14    language assistance services.
15        (4) Data tracking that identifies the language need.
16        (5) Notification to participants on the availability
17    of language access services and on how to access such
18    services.
19    (k) The Department shall actively monitor the contractual
20relationship between Managed Care Organizations (MCOs) and any
21dental administrator contracted by an MCO to provide dental
22services. The Department shall adopt appropriate dental
23Healthcare Effectiveness Data and Information Set (HEDIS)
24measures and shall include the Annual Dental Visit (ADV) HEDIS
25measure in its Health Plan Comparison Tool and Illinois
26Medicaid Plan Report Card that is available on the Department's



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1website for enrolled individuals.
2    The Department shall collect from each MCO specific
3information about the types of contracted, broad-based care
4coordination occurring between the MCO and any dental
5administrator, including, but not limited to, pregnant women
6and diabetic patients in need of oral care.
7    (l) Until the State is in compliance with the federal
8deadlines for eligibility determinations under 42 U.S.C.
91396a(a)(8) and 42 CFR 435, the Department of Healthcare and
10Family Services must not expand the Medicare-Medicaid
11Alignment Initiative under Article V-F.
12(Source: P.A. 99-106, eff. 1-1-16; 99-181, eff. 7-29-15;
1399-566, eff. 1-1-17; 99-642, eff. 7-28-16; 100-587, eff.
15    (305 ILCS 5/5F-10)
16    Sec. 5F-10. Scope. This Article applies to policies and
17contracts amended, delivered, issued, or renewed on or after
18the effective date of this amendatory Act of the 98th General
19Assembly for the nursing home component of the
20Medicare-Medicaid Alignment Initiative and the Managed
21Long-Term Services and Support Program. This Article does not
22diminish a managed care organization's duties and
23responsibilities under other federal or State laws or rules
24adopted under those laws and the 3-way Medicare-Medicaid
25Alignment Initiative contract and the Managed Long-Term



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1Services and Support Program contract.
2    Beginning July 1, 2020, or upon federal approval, any
3enrollee who resides in a facility for more than 90 consecutive
4days shall no longer be required to enroll with a managed care
5organization and shall revert to having his or her services
6covered through a fee-for-service arrangement between the
7facility and the Department for any services received after 90
8consecutive days of service.
9(Source: P.A. 98-651, eff. 6-16-14; 99-719, eff. 1-1-17.)
10    Section 99. Effective date. This Act takes effect upon
11becoming law.