20 ILCS 505/5.45

(20 ILCS 505/5.45)

Sec. 5.45. Managed care plan services.

(a) As used in this Section:

"Caregiver" means an individual or entity directly providing the day-to-day care of a child ensuring the child's safety and well-being.

"Child" means a child placed in the care of the Department pursuant to the Juvenile Court Act of 1987.

"Department" means the Department of Children and Family Services, or any successor State agency.

"Director" means the Director of Children and Family Services.

"Managed care organization" has the meaning ascribed to that term in Section 5-30.1 of the Illinois Public Aid Code.

"Medicaid managed care plan" means a health care plan operated by a managed care organization under the Medical Assistance Program established in Article V of the Illinois Public Aid Code.

"Workgroup" means the Child Welfare Medicaid Managed Care Implementation Advisory Workgroup.

(b) Every child who is in the care of the Department pursuant to the Juvenile Court Act of 1987 shall receive the necessary services required by this Act and the Juvenile Court Act of 1987, including any child enrolled in a Medicaid managed care plan.

(c) The Department shall not relinquish its authority or diminish its responsibility to determine and provide necessary services that are in the best interest of a child even if those services are directly or indirectly:

(1) provided by a managed care organization, another State agency, or other third parties;

(2) coordinated through a managed care organization, another State agency, or other third parties; or

(3) paid for by a managed care organization, another State agency, or other third parties.

(d) The Department shall:

(1) implement and enforce measures to ensure that a child's enrollment in Medicaid managed care supports continuity of treatment and does not hinder service delivery;

(2) establish a single point of contact for health care coverage inquiries and dispute resolution systemwide without transferring this responsibility to a third party such as a managed care coordinator;

(3) not require any child to participate in Medicaid managed care if the child would otherwise be exempt from enrolling in a Medicaid managed care plan under any rule or statute of this State; and

(4) make recommendations regarding managed care contract measures, quality assurance activities, and performance delivery evaluations in consultation with the Workgroup; and

(5) post on its website:

(A) a link to any rule adopted or procedures changed to address the provisions of this Section, if applicable;

(B) each managed care organization's contract, enrollee handbook, and directory;

(C) the notification process and timeframe requirements used to inform managed care plan enrollees, enrollees' caregivers, and enrollees' legal representation of any changes in health care coverage or change in a child's managed care provider;

(D) defined prior authorization requirements for prescriptions, goods, and services in emergency and non-emergency situations;

(E) the State's current Health Care Oversight and Coordination Plan developed in accordance with federal requirements; and

(F) the transition plan required under subsection (f), including:

(i) the public comments submitted to the Department, the Department of Healthcare and Family Services, and the Workgroup for consideration in development of the transition plan;

(ii) a list and summary of recommendations of the Workgroup that the Director or Director of Healthcare and Family Services declined to adopt or implement; and

(iii) the Department's attestation that the transition plan will not impede the Department's ability to timely identify the service needs of youth in care and the timely and appropriate provision of services to address those identified needs.

(e) The Child Welfare Medicaid Managed Care Implementation Advisory Workgroup is established to advise the Department on the transition and implementation of managed care for children. The Director of Children and Family Services and the Director of Healthcare and Family Services shall serve as co-chairpersons of the Workgroup. The Directors shall jointly appoint members to the Workgroup who are stakeholders from the child welfare community, including:

(1) employees of the Department of Children and Family Services who have responsibility in the areas of (i) managed care services, (ii) performance monitoring and oversight, (iii) placement operations, and (iv) budget revenue maximization;

(2) employees of the Department of Healthcare and Family Services who have responsibility in the areas of (i) managed care contracting, (ii) performance monitoring and oversight, (iii) children's behavioral health, and (iv) budget revenue maximization;

(3) 2 representatives of youth in care;

(4) one representative of managed care organizations serving youth in care;

(5) 4 representatives of child welfare providers;

(6) one representative of parents of children in out-of-home care;

(7) one representative of universities or research institutions;

(8) one representative of pediatric physicians;

(9) one representative of the juvenile court;

(10) one representative of caregivers of youth in care;

(11) one practitioner with expertise in child and adolescent psychiatry;

(12) one representative of substance abuse and mental health providers with expertise in serving children involved in child welfare and their families;

(13) at least one member of the Medicaid Advisory Committee;

(14) one representative of a statewide organization representing hospitals;

(15) one representative of a statewide organization representing child welfare providers;

(16) one representative of a statewide organization representing substance abuse and mental health providers; and

(17) other child advocates as deemed appropriate by the Directors.

To the greatest extent possible, the co-chairpersons shall appoint members who reflect the geographic diversity of the State and include members who represent rural service areas. Members shall serve 2-year terms or until the Workgroup dissolves. If a vacancy occurs in the Workgroup membership, the vacancy shall be filled in the same manner as the original appointment for the remainder of the unexpired term. The Workgroup shall hold meetings, as it deems appropriate, in the northern, central, and southern regions of the State to solicit public comments to develop its recommendations. To ensure the Department of Children and Family Services and the Department of Healthcare and Family Services are provided time to confer and determine their use of pertinent Workgroup recommendations in the transition plan required under subsection (f), the co-chairpersons shall convene at least 3 meetings. The Department of Children and Family Services and the Department of Healthcare and Family Services shall provide administrative support to the Workgroup. Workgroup members shall serve without compensation. The Workgroup shall dissolve 5 years after the Department of Children and Family Services' implementation of managed care.

(f) Prior to transitioning any child to managed care, the Department of Children and Family Services and the Department of Healthcare and Family Services, in consultation with the Workgroup, must develop and post publicly, a transition plan for the provision of health care services to children enrolled in Medicaid managed care plans. Interim transition plans must be posted to the Department's website by July 15, 2018. The transition plan shall be posted at least 28 days before the Department's implementation of managed care. The transition plan shall address, but is not limited to, the following:

(1) an assessment of existing network adequacy, plans to address gaps in network, and ongoing network evaluation;

(2) a framework for preparing and training organizations, caregivers, frontline staff, and managed care organizations;

(3) the identification of administrative changes necessary for successful transition to managed care, and the timeframes to make changes;

(4) defined roles, responsibilities, and lines of authority for care coordination, placement providers, service providers, and each State agency involved in management and oversight of managed care services;

(5) data used to establish baseline performance and quality of care, which shall be utilized to assess quality outcomes and identify ongoing areas for improvement;

(6) a process for stakeholder input into managed care planning and implementation;

(7) a dispute resolution process, including the rights of enrollees and representatives of enrollees under the dispute process and timeframes for dispute resolution determinations and remedies;

(8) the process for health care transition for youth exiting the Department's care through emancipation or achieving permanency; and

(9) protections to ensure the continued provision of health care services if a child's residence or legal guardian changes.

(g) Reports.

(1) On or before February 1, 2019, and on or before each February 1 thereafter, the Department shall submit a report to the House and Senate Human Services Committees, or to any successor committees, on measures of access to and the quality of health care services for children enrolled in Medicaid managed care plans, including, but not limited to, data showing whether:

(A) children enrolled in Medicaid managed care plans have continuity of care across placement types, geographic regions, and specialty service needs;

(B) each child is receiving the early periodic screening, diagnosis, and treatment services as required by federal law, including, but not limited to, regular preventative care and timely specialty care;

(C) children are assigned to health homes;

(D) each child has a health care oversight and coordination plan as required by federal law;

(E) there exist complaints and grievances indicating gaps or barriers in service delivery; and

(F) the Workgroup and other stakeholders have and continue to be engaged in quality improvement initiatives.

The report shall be prepared in consultation with the Workgroup and other agencies, organizations, or individuals the Director deems appropriate in order to obtain comprehensive and objective information about the managed care plan operation.

(2) During each legislative session, the House and Senate Human Services Committees shall hold hearings to take public testimony about managed care implementation for children in the care of, adopted from, or placed in guardianship by the Department. The Department shall present testimony, including information provided in the report required under paragraph (1), the Department's compliance with the provisions of this Section, and any recommendations for statutory changes to improve health care for children in the Department's care.

(h) If any provision of this Section or its application to any person or circumstance is held invalid, the invalidity of that provision or application does not affect other provisions or applications of this Section that can be given effect without the invalid provision or application.

(Source: P.A. 100-646, eff. 7-27-18.)