State of Illinois
90th General Assembly
Legislation

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[ Introduced ][ House Amendment 002 ]

90_HB0781eng

      305 ILCS 5/5-16.3
          Amends the Medicaid Article of the Public Aid  Code.   In
      the  Section  concerning  the integrated health care program,
      provides that if a managed health care entity  is  accredited
      by  a national organization, the Department of Public Aid may
      give  preference  to  that  managed  health  care  entity  in
      selecting participants for the program.   Requires  that  the
      medical   director   of  a  managed  health  care  entity  be
      physician.  Effective immediately.
                                                     LRB9000971DJcd
HB0781 Engrossed                               LRB9000971DJcd
 1        AN ACT to amend the Illinois Public Aid Code by  changing
 2    Sections 5-16.3 and 12-13.1 and adding Section 5-16.8.
 3        Be  it  enacted  by  the People of the State of Illinois,
 4    represented in the General Assembly:
 5        Section  5.  The Illinois Public Aid Code is  amended  by
 6    changing  Sections  5-16.3  and  12-13.1  and  adding Section
 7    5-16.8 as follows:
 8        (305 ILCS 5/5-16.3)
 9        (Text of Section before amendment by P.A. 89-507)
10        Sec. 5-16.3.  System for integrated health care services.
11        (a)  It shall be the public policy of the State to adopt,
12    to  the  extent  practicable,  a  health  care  program  that
13    encourages  the  integration  of  health  care  services  and
14    manages the health care of program enrollees while preserving
15    reasonable choice within  a  competitive  and  cost-efficient
16    environment.   In  furtherance  of  this  public  policy, the
17    Illinois Department shall develop and implement an integrated
18    health care program consistent with the  provisions  of  this
19    Section.   The  provisions  of this Section apply only to the
20    integrated health care program created  under  this  Section.
21    Persons  enrolled  in  the integrated health care program, as
22    determined by the  Illinois  Department  by  rule,  shall  be
23    afforded  a  choice among health care delivery systems, which
24    shall include, but are not limited to, (i)  fee  for  service
25    care managed by a primary care physician licensed to practice
26    medicine  in  all  its  branches,  (ii)  managed  health care
27    entities,  and  (iii)  federally  qualified  health   centers
28    (reimbursed  according  to  a  prospective cost-reimbursement
29    methodology) and rural health clinics  (reimbursed  according
30    to  the  Medicare  methodology),  where  available.   Persons
31    enrolled  in  the  integrated health care program also may be
HB0781 Engrossed            -2-                LRB9000971DJcd
 1    offered indemnity insurance plans, subject to availability.
 2        For purposes of this  Section,  a  "managed  health  care
 3    entity"  means a health maintenance organization or a managed
 4    care community network as defined in this Section.  A "health
 5    maintenance  organization"   means   a   health   maintenance
 6    organization   as   defined   in   the   Health   Maintenance
 7    Organization  Act.   A "managed care community network" means
 8    an entity, other than a health maintenance organization, that
 9    is owned, operated, or governed by providers of  health  care
10    services  within  this  State  and  that provides or arranges
11    primary, secondary, and tertiary managed health care services
12    under contract with the Illinois  Department  exclusively  to
13    enrollees  of  the  integrated health care program. A managed
14    care  community  network  may  contract  with  the   Illinois
15    Department  to provide only pediatric health care services. A
16    county provider as defined in Section 15-1 of this  Code  may
17    contract  with the Illinois Department to provide services to
18    enrollees of the integrated health care program as a  managed
19    care  community  network  without  the  need  to  establish a
20    separate  entity  that  provides  services   exclusively   to
21    enrollees  of the integrated health care program and shall be
22    deemed a managed care community network for purposes of  this
23    Code only to the extent of the provision of services to those
24    enrollees  in  conjunction  with  the  integrated health care
25    program.  A county provider shall  be  entitled  to  contract
26    with  the Illinois Department with respect to any contracting
27    region located in whole or in  part  within  the  county.   A
28    county provider shall not be required to accept enrollees who
29    do not reside within the county.
30        If  a  managed  health  care  entity  is  accredited by a
31    private national organization that performs quality assurance
32    surveys  of  health  maintenance  organizations  or   related
33    organizations,   the   Illinois   Department   may  take  the
34    accreditation  into  consideration  when  selecting   managed
HB0781 Engrossed            -3-                LRB9000971DJcd
 1    health  care  entities  for  participation  in the integrated
 2    health care program.   The  medical  director  of  a  managed
 3    health  care entity must be a physician licensed in the State
 4    to practice medicine in all its branches.
 5        Each managed care community network must demonstrate  its
 6    ability to bear the financial risk of serving enrollees under
 7    this  program.   The  Illinois Department shall by rule adopt
 8    criteria  for  assessing  the  financial  soundness  of  each
 9    managed care community network. These  rules  shall  consider
10    the  extent  to  which  a  managed  care community network is
11    comprised of providers who directly render  health  care  and
12    are  located  within  the  community  in  which  they seek to
13    contract rather than solely arrange or finance  the  delivery
14    of health care.  These rules shall further consider a variety
15    of  risk-bearing  and  management  techniques,  including the
16    sufficiency of quality assurance and  utilization  management
17    programs  and  whether  a  managed care community network has
18    sufficiently demonstrated  its  financial  solvency  and  net
19    worth.  The  Illinois  Department's criteria must be based on
20    sound actuarial, financial, and  accounting  principles.   In
21    adopting  these  rules, the Illinois Department shall consult
22    with the  Illinois  Department  of  Insurance.  The  Illinois
23    Department  is  responsible  for  monitoring  compliance with
24    these rules.
25        This Section may not be implemented before the  effective
26    date  of  these  rules, the approval of any necessary federal
27    waivers, and the completion of the review of  an  application
28    submitted,  at  least  60  days  before the effective date of
29    rules adopted under this Section, to the Illinois  Department
30    by a managed care community network.
31        All  health  care delivery systems that contract with the
32    Illinois Department under the integrated health care  program
33    shall  clearly  recognize  a  health care provider's right of
34    conscience under the Right of Conscience Act.  In addition to
HB0781 Engrossed            -4-                LRB9000971DJcd
 1    the provisions of that Act, no health  care  delivery  system
 2    that   contracts  with  the  Illinois  Department  under  the
 3    integrated health care program shall be required to  provide,
 4    arrange  for,  or pay for any health care or medical service,
 5    procedure, or product if that health care delivery system  is
 6    owned,  controlled,  or  sponsored  by  or  affiliated with a
 7    religious institution or religious  organization  that  finds
 8    that health care or medical service, procedure, or product to
 9    violate its religious and moral teachings and beliefs.
10        (b)  The  Illinois  Department  may, by rule, provide for
11    different  benefit  packages  for  different  categories   of
12    persons  enrolled  in  the  program.  Mental health services,
13    alcohol and substance abuse  services,  services  related  to
14    children   with   chronic   or   acute  conditions  requiring
15    longer-term treatment and follow-up, and rehabilitation  care
16    provided  by  a  free-standing  rehabilitation  hospital or a
17    hospital rehabilitation unit may be excluded from  a  benefit
18    package  if  the  State  ensures that those services are made
19    available through a separate delivery system.   An  exclusion
20    does not prohibit the Illinois Department from developing and
21    implementing demonstration projects for categories of persons
22    or  services.   Benefit  packages  for  persons  eligible for
23    medical assistance under Articles V, VI,  and  XII  shall  be
24    based  on  the  requirements  of  those Articles and shall be
25    consistent with the Title XIX of  the  Social  Security  Act.
26    Nothing  in  this Act shall be construed to apply to services
27    purchased by the Department of Children and  Family  Services
28    and   the  Department  of  Mental  Health  and  Developmental
29    Disabilities under the provisions of Title 59 of the Illinois
30    Administrative Code, Part  132  ("Medicaid  Community  Mental
31    Health Services Program").
32        (c)  The  program  established  by  this  Section  may be
33    implemented by the Illinois Department in various contracting
34    areas at various times.  The health care delivery systems and
HB0781 Engrossed            -5-                LRB9000971DJcd
 1    providers available under the program may vary throughout the
 2    State.  For purposes of contracting with managed health  care
 3    entities   and   providers,  the  Illinois  Department  shall
 4    establish contracting areas similar to the  geographic  areas
 5    designated   by   the  Illinois  Department  for  contracting
 6    purposes  under   the   Illinois   Competitive   Access   and
 7    Reimbursement  Equity  Program (ICARE) under the authority of
 8    Section 3-4 of the Illinois  Health  Finance  Reform  Act  or
 9    similarly-sized  or  smaller  geographic areas established by
10    the Illinois Department by rule. A managed health care entity
11    shall be permitted to contract in any  geographic  areas  for
12    which  it  has  a  sufficient  provider network and otherwise
13    meets the  contracting  terms  of  the  State.  The  Illinois
14    Department  is  not  prohibited from entering into a contract
15    with a managed health care entity at any time.
16        (d)  A managed health care entity that contracts with the
17    Illinois Department for the provision of services  under  the
18    program shall do all of the following, solely for purposes of
19    the integrated health care program:
20             (1)  Provide  that any individual physician licensed
21        to practice medicine in all its branches,  any  pharmacy,
22        any   federally   qualified   health   center,   and  any
23        podiatrist, that consistently meets the reasonable  terms
24        and  conditions  established  by  the managed health care
25        entity,  including  but  not  limited  to   credentialing
26        standards,   quality   assurance   program  requirements,
27        utilization    management     requirements,     financial
28        responsibility     standards,     contracting     process
29        requirements, and provider network size and accessibility
30        requirements, must be accepted by the managed health care
31        entity  for  purposes  of  the Illinois integrated health
32        care program.  Any individual who  is  either  terminated
33        from  or  denied  inclusion in the panel of physicians of
34        the managed health care entity shall be given, within  10
HB0781 Engrossed            -6-                LRB9000971DJcd
 1        business   days   after  that  determination,  a  written
 2        explanation of the reasons for his or  her  exclusion  or
 3        termination  from  the panel. This paragraph (1) does not
 4        apply to the following:
 5                  (A)  A  managed   health   care   entity   that
 6             certifies to the Illinois Department that:
 7                       (i)  it  employs  on a full-time basis 125
 8                  or  more  Illinois   physicians   licensed   to
 9                  practice medicine in all of its branches; and
10                       (ii)  it  will  provide  medical  services
11                  through  its  employees to more than 80% of the
12                  recipients enrolled  with  the  entity  in  the
13                  integrated health care program; or
14                  (B)  A   domestic   stock   insurance   company
15             licensed under clause (b) of class 1 of Section 4 of
16             the  Illinois  Insurance Code if (i) at least 66% of
17             the stock of the insurance company  is  owned  by  a
18             professional   corporation   organized   under   the
19             Professional Service Corporation Act that has 125 or
20             more   shareholders   who  are  Illinois  physicians
21             licensed to practice medicine in all of its branches
22             and (ii) the  insurance  company  certifies  to  the
23             Illinois  Department  that  at  least  80%  of those
24             physician  shareholders  will  provide  services  to
25             recipients  enrolled  with  the   company   in   the
26             integrated health care program.
27             (2)  Provide  for  reimbursement  for  providers for
28        emergency care, as defined by the Illinois Department  by
29        rule,  that  must be provided to its enrollees, including
30        an emergency room screening fee, and urgent care that  it
31        authorizes   for   its   enrollees,   regardless  of  the
32        provider's  affiliation  with  the  managed  health  care
33        entity. Providers shall be reimbursed for emergency  care
34        at   an   amount   equal  to  the  Illinois  Department's
HB0781 Engrossed            -7-                LRB9000971DJcd
 1        fee-for-service rates for those medical services rendered
 2        by providers not under contract with the  managed  health
 3        care entity to enrollees of the entity.
 4             (3)  Provide  that  any  provider  affiliated with a
 5        managed health care entity may also provide services on a
 6        fee-for-service basis to Illinois Department clients  not
 7        enrolled in a managed health care entity.
 8             (4)  Provide client education services as determined
 9        and  approved  by  the Illinois Department, including but
10        not  limited  to  (i)  education  regarding   appropriate
11        utilization  of  health  care  services in a managed care
12        system, (ii) written disclosure of treatment policies and
13        any  restrictions  or  limitations  on  health  services,
14        including,  but  not  limited  to,   physical   services,
15        clinical   laboratory   tests,   hospital   and  surgical
16        procedures,  prescription  drugs   and   biologics,   and
17        radiological  examinations, and (iii) written notice that
18        the enrollee may  receive  from  another  provider  those
19        services covered under this program that are not provided
20        by the managed health care entity.
21             (4.5)  Provide orientation to the caretaker relative
22        or  payee  of  a  medical  assistance  unit  that  has an
23        enrollee as a member.  The  managed  health  care  entity
24        must exercise good faith efforts to provide all caretaker
25        relatives  or  payees  with the orientation.  The managed
26        health care entity shall inform the  Illinois  Department
27        of  the  caretaker relatives or payees who have completed
28        the  orientation.   This  paragraph  applies   to   every
29        caretaker  relative  or  payee  in  a managed health care
30        entity's  system  regardless  of  whether  the  caretaker
31        relative or payee has  chosen  the  system  or  has  been
32        assigned to the system as provided in subsection (e).
33             (5)  Provide  that  enrollees  within its system may
34        choose the site for provision of services and  the  panel
HB0781 Engrossed            -8-                LRB9000971DJcd
 1        of health care providers.
 2             (6)  Not   discriminate   in   its   enrollment   or
 3        disenrollment   practices  among  recipients  of  medical
 4        services or program enrollees based on health status.
 5             (7)  Provide a  quality  assurance  and  utilization
 6        review   program   that   (i)   for   health  maintenance
 7        organizations  meets  the  requirements  of  the   Health
 8        Maintenance  Organization  Act  and (ii) for managed care
 9        community networks meets the requirements established  by
10        the  Illinois  Department in rules that incorporate those
11        standards   set   forth   in   the   Health   Maintenance
12        Organization Act.
13             (8)  Issue   a   managed    health    care    entity
14        identification  card  to  each  enrollee upon enrollment.
15        The card must contain all of the following:
16                  (A)  The enrollee's signature.
17                  (B)  The enrollee's health plan.
18                  (C)  The  name  and  telephone  number  of  the
19             enrollee's primary care physician.
20                  (D)  A  telephone  number  to   be   used   for
21             emergency service 24 hours per day, 7 days per week.
22             The  telephone  number  required  to  be  maintained
23             pursuant to this subparagraph by each managed health
24             care   entity  shall,  at  minimum,  be  staffed  by
25             medically  trained   personnel   and   be   provided
26             directly,  or  under  arrangement,  at  an office or
27             offices in  locations maintained solely  within  the
28             State    of   Illinois.   For   purposes   of   this
29             subparagraph, "medically  trained  personnel"  means
30             licensed   practical  nurses  or  registered  nurses
31             located in the State of Illinois  who  are  licensed
32             pursuant to the Illinois Nursing Act of 1987.
33             (8.5)  The    Illinois   Department   must   include
34        performance  standards   in   contracts   with   entities
HB0781 Engrossed            -9-                LRB9000971DJcd
 1        participating  in  the  integrated health care program to
 2        require contractors to make a good faith effort  to  have
 3        enrollees  evaluated  by  a physician within a reasonable
 4        period of time after enrollment,  as  determined  by  the
 5        Illinois Department.
 6             (9)  Ensure  that  every  primary care physician and
 7        pharmacy in the managed  health  care  entity  meets  the
 8        standards  established  by  the  Illinois  Department for
 9        accessibility  and  quality   of   care.   The   Illinois
10        Department shall arrange for and oversee an evaluation of
11        the  standards  established  under this paragraph (9) and
12        may recommend any necessary changes to  these  standards.
13        The  Illinois Department shall submit an annual report to
14        the Governor and the General Assembly by April 1 of  each
15        year  regarding  the  effect of the standards on ensuring
16        access and quality of care to enrollees.
17             (10)  Provide a procedure  for  handling  complaints
18        that  (i)  for health maintenance organizations meets the
19        requirements of the Health Maintenance  Organization  Act
20        and  (ii)  for  managed care community networks meets the
21        requirements established by the  Illinois  Department  in
22        rules  that  incorporate those standards set forth in the
23        Health Maintenance Organization Act.
24             (11)  Maintain, retain, and make  available  to  the
25        Illinois  Department records, data, and information, in a
26        uniform manner determined  by  the  Illinois  Department,
27        sufficient   for   the  Illinois  Department  to  monitor
28        utilization, accessibility, and quality of care.
29             (12)  Except for providers who are prepaid, pay  all
30        approved  claims  for covered services that are completed
31        and submitted to the managed health care entity within 30
32        days after  receipt  of  the  claim  or  receipt  of  the
33        appropriate capitation payment or payments by the managed
34        health  care entity from the State for the month in which
HB0781 Engrossed            -10-               LRB9000971DJcd
 1        the  services  included  on  the  claim  were   rendered,
 2        whichever  is  later. If payment is not made or mailed to
 3        the provider by the managed health care entity by the due
 4        date under this subsection, an interest penalty of 1%  of
 5        any  amount  unpaid  shall  be  added  for  each month or
 6        fraction of a month  after  the  due  date,  until  final
 7        payment  is  made. Nothing in this Section shall prohibit
 8        managed health care entities and providers from  mutually
 9        agreeing to terms that require more timely payment.
10             (12.5)  Ensure   that   no  payment  is  made  to  a
11        physician or other provider of services  for  withholding
12        from an enrollee any covered services because of the cost
13        of   those  services.   This  requirement  shall  not  be
14        construed to prevent  managed health care  entities  from
15        offering,  nor providers from  accepting, full or partial
16        capitation.
17             (13)  Provide   integration   with   community-based
18        programs provided by certified local  health  departments
19        such  as  Women,  Infants, and Children Supplemental Food
20        Program (WIC), childhood  immunization  programs,  health
21        education  programs, case management programs, and health
22        screening programs.
23             (14)  Provide that the pharmacy formulary used by  a
24        managed  health care entity and its contract providers be
25        no  more  restrictive  than  the  Illinois   Department's
26        pharmaceutical  program  on  the  effective  date of this
27        amendatory Act of 1994 and as amended after that date.
28             (15)  Provide   integration   with   community-based
29        organizations,  including,  but  not  limited   to,   any
30        organization   that   has   operated  within  a  Medicaid
31        Partnership as defined by this Code or  by  rule  of  the
32        Illinois Department, that may continue to operate under a
33        contract with the Illinois Department or a managed health
34        care entity under this Section to provide case management
HB0781 Engrossed            -11-               LRB9000971DJcd
 1        services  to  Medicaid  clients  in  designated high-need
 2        areas.
 3        The  Illinois  Department   may,   by   rule,   determine
 4    methodologies to limit financial liability for managed health
 5    care   entities   resulting  from  payment  for  services  to
 6    enrollees provided under the Illinois Department's integrated
 7    health care program. Any methodology  so  determined  may  be
 8    considered  or implemented by the Illinois Department through
 9    a contract with a  managed  health  care  entity  under  this
10    integrated health care program.
11        The  Illinois Department shall contract with an entity or
12    entities to provide  external  peer-based  quality  assurance
13    review  for  the  integrated  health care program. The entity
14    shall be representative of Illinois  physicians  licensed  to
15    practice  medicine  in  all  its  branches and have statewide
16    geographic representation in all specialties of medical  care
17    that  are provided within the integrated health care program.
18    The entity may not be a third party payer and shall  maintain
19    offices  in  locations  around  the State in order to provide
20    service  and  continuing  medical  education   to   physician
21    participants  within the integrated health care program.  The
22    review process shall be developed and conducted  by  Illinois
23    physicians licensed to practice medicine in all its branches.
24    In  consultation with the entity, the Illinois Department may
25    contract with  other  entities  for  professional  peer-based
26    quality assurance review of individual categories of services
27    other  than  services provided, supervised, or coordinated by
28    physicians licensed to practice medicine in all its branches.
29    The Illinois Department shall establish, by rule, criteria to
30    avoid  conflicts  of  interest  in  the  conduct  of  quality
31    assurance activities consistent with professional peer-review
32    standards.  All  quality  assurance   activities   shall   be
33    coordinated by the Illinois Department.
34        (e)  All   persons  enrolled  in  the  program  shall  be
HB0781 Engrossed            -12-               LRB9000971DJcd
 1    provided   with   a   full   written   explanation   of   all
 2    fee-for-service and managed health care plan  options  and  a
 3    reasonable   opportunity  to  choose  among  the  options  as
 4    provided by rule.  The Illinois Department shall  provide  to
 5    enrollees,  upon  enrollment  in  the  integrated health care
 6    program and at  least  annually  thereafter,  notice  of  the
 7    process   for   requesting   an  appeal  under  the  Illinois
 8    Department's      administrative      appeal      procedures.
 9    Notwithstanding any other Section of this Code, the  Illinois
10    Department may provide by rule for the Illinois Department to
11    assign  a  person  enrolled  in  the  program  to  a specific
12    provider of medical services or to  a  specific  health  care
13    delivery  system if an enrollee has failed to exercise choice
14    in a timely manner. An  enrollee  assigned  by  the  Illinois
15    Department shall be afforded the opportunity to disenroll and
16    to  select  a  specific  provider  of  medical  services or a
17    specific health care delivery system within the first 30 days
18    after the assignment. An enrollee who has failed to  exercise
19    choice in a timely manner may be assigned only if there are 3
20    or  more  managed  health  care entities contracting with the
21    Illinois Department within the contracting area, except that,
22    outside the City of Chicago, this requirement may  be  waived
23    for an area by rules adopted by the Illinois Department after
24    consultation  with all hospitals within the contracting area.
25    The Illinois Department shall establish by rule the procedure
26    for random assignment  of  enrollees  who  fail  to  exercise
27    choice  in  a timely manner to a specific managed health care
28    entity in  proportion  to  the  available  capacity  of  that
29    managed health care entity. Assignment to a specific provider
30    of  medical  services  or  to  a specific managed health care
31    entity may not exceed that provider's or entity's capacity as
32    determined by the Illinois Department.  Any  person  who  has
33    chosen  a specific provider of medical services or a specific
34    managed health care  entity,  or  any  person  who  has  been
HB0781 Engrossed            -13-               LRB9000971DJcd
 1    assigned   under   this   subsection,   shall  be  given  the
 2    opportunity to change that choice or assignment at least once
 3    every 12 months, as determined by the Illinois Department  by
 4    rule.  The  Illinois  Department  shall  maintain a toll-free
 5    telephone number for  program  enrollees'  use  in  reporting
 6    problems with managed health care entities.
 7        (f)  If  a  person  becomes eligible for participation in
 8    the integrated  health  care  program  while  he  or  she  is
 9    hospitalized,  the  Illinois  Department  may not enroll that
10    person in  the  program  until  after  he  or  she  has  been
11    discharged from the hospital.  This subsection does not apply
12    to   newborn  infants  whose  mothers  are  enrolled  in  the
13    integrated health care program.
14        (g)  The Illinois Department shall,  by  rule,  establish
15    for managed health care entities rates that (i) are certified
16    to  be  actuarially sound, as determined by an actuary who is
17    an associate or a fellow of the Society  of  Actuaries  or  a
18    member  of  the  American  Academy  of  Actuaries and who has
19    expertise and experience in  medical  insurance  and  benefit
20    programs,   in  accordance  with  the  Illinois  Department's
21    current fee-for-service payment system, and  (ii)  take  into
22    account  any  difference  of  cost  to provide health care to
23    different populations based on  gender,  age,  location,  and
24    eligibility  category.   The  rates  for  managed health care
25    entities shall be determined on a capitated basis.
26        The Illinois Department by rule shall establish a  method
27    to  adjust  its payments to managed health care entities in a
28    manner intended to avoid providing any financial incentive to
29    a managed health care entity to refer patients  to  a  county
30    provider,  in  an Illinois county having a population greater
31    than  3,000,000,  that  is  paid  directly  by  the  Illinois
32    Department.  The Illinois Department shall by April 1,  1997,
33    and   annually   thereafter,  review  the  method  to  adjust
34    payments. Payments by the Illinois Department to  the  county
HB0781 Engrossed            -14-               LRB9000971DJcd
 1    provider,   for  persons  not  enrolled  in  a  managed  care
 2    community network owned or operated  by  a  county  provider,
 3    shall  be paid on a fee-for-service basis under Article XV of
 4    this Code.
 5        The Illinois Department by rule shall establish a  method
 6    to  reduce  its  payments  to managed health care entities to
 7    take into consideration (i) any adjustment payments  paid  to
 8    hospitals  under subsection (h) of this Section to the extent
 9    those payments, or any part  of  those  payments,  have  been
10    taken into account in establishing capitated rates under this
11    subsection  (g)  and (ii) the implementation of methodologies
12    to limit financial liability for managed health care entities
13    under subsection (d) of this Section.
14        (h)  For hospital services provided by  a  hospital  that
15    contracts  with  a  managed  health  care  entity, adjustment
16    payments shall be  paid  directly  to  the  hospital  by  the
17    Illinois  Department.   Adjustment  payments  may include but
18    need   not   be   limited   to   adjustment   payments    to:
19    disproportionate share hospitals under Section 5-5.02 of this
20    Code;  primary care access health care education payments (89
21    Ill. Adm. Code 149.140); payments for capital, direct medical
22    education, indirect medical education,  certified  registered
23    nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
24    Code  149.150(c));  uncompensated care payments (89 Ill. Adm.
25    Code 148.150(h)); trauma center payments (89 Ill.  Adm.  Code
26    148.290(c));  rehabilitation  hospital payments (89 Ill. Adm.
27    Code 148.290(d)); perinatal center  payments  (89  Ill.  Adm.
28    Code  148.290(e));  obstetrical  care  payments (89 Ill. Adm.
29    Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
30    148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
31    148.290(h)); and outpatient indigent volume  adjustments  (89
32    Ill. Adm. Code 148.140(b)(5)).
33        (i)  For   any   hospital  eligible  for  the  adjustment
34    payments described in subsection (h), the Illinois Department
HB0781 Engrossed            -15-               LRB9000971DJcd
 1    shall maintain, through the  period  ending  June  30,  1995,
 2    reimbursement levels in accordance with statutes and rules in
 3    effect on April 1, 1994.
 4        (j)  Nothing  contained in this Code in any way limits or
 5    otherwise impairs the authority  or  power  of  the  Illinois
 6    Department  to  enter  into a negotiated contract pursuant to
 7    this Section with a managed health  care  entity,  including,
 8    but  not  limited to, a health maintenance organization, that
 9    provides  for  termination  or  nonrenewal  of  the  contract
10    without cause upon notice as provided  in  the  contract  and
11    without a hearing.
12        (k)  Section   5-5.15  does  not  apply  to  the  program
13    developed and implemented pursuant to this Section.
14        (l)  The Illinois Department shall, by rule, define those
15    chronic or acute medical conditions of childhood that require
16    longer-term  treatment  and  follow-up  care.   The  Illinois
17    Department shall ensure that services required to treat these
18    conditions are available through a separate delivery system.
19        A managed health care  entity  that  contracts  with  the
20    Illinois Department may refer a child with medical conditions
21    described in the rules adopted under this subsection directly
22    to  a  children's  hospital  or  to  a hospital, other than a
23    children's hospital, that is qualified to  provide  inpatient
24    and  outpatient  services  to  treat  those  conditions.  The
25    Illinois    Department    shall    provide    fee-for-service
26    reimbursement directly to a  children's  hospital  for  those
27    services  pursuant to Title 89 of the Illinois Administrative
28    Code, Section 148.280(a), at a rate at  least  equal  to  the
29    rate  in  effect on March 31, 1994. For hospitals, other than
30    children's hospitals, that are qualified to provide inpatient
31    and  outpatient  services  to  treat  those  conditions,  the
32    Illinois Department shall  provide  reimbursement  for  those
33    services on a fee-for-service basis, at a rate at least equal
34    to  the rate in effect for those other hospitals on March 31,
HB0781 Engrossed            -16-               LRB9000971DJcd
 1    1994.
 2        A children's hospital shall be  directly  reimbursed  for
 3    all  services  provided  at  the  children's  hospital  on  a
 4    fee-for-service  basis  pursuant  to Title 89 of the Illinois
 5    Administrative Code, Section 148.280(a), at a rate  at  least
 6    equal  to  the  rate  in  effect on March 31, 1994, until the
 7    later of (i) implementation of  the  integrated  health  care
 8    program  under  this  Section  and development of actuarially
 9    sound capitation rates for services other than those  chronic
10    or   acute  medical  conditions  of  childhood  that  require
11    longer-term treatment and follow-up care as  defined  by  the
12    Illinois   Department   in   the  rules  adopted  under  this
13    subsection or (ii) March 31, 1996.
14        Notwithstanding  anything  in  this  subsection  to   the
15    contrary,  a  managed  health  care entity shall not consider
16    sources or methods of payment in determining the referral  of
17    a  child.   The  Illinois  Department  shall  adopt  rules to
18    establish  criteria  for  those  referrals.    The   Illinois
19    Department  by  rule  shall  establish a method to adjust its
20    payments to managed health care entities in a manner intended
21    to avoid providing  any  financial  incentive  to  a  managed
22    health  care  entity  to  refer patients to a provider who is
23    paid directly by the Illinois Department.
24        (m)  Behavioral health services provided or funded by the
25    Department of Mental Health and  Developmental  Disabilities,
26    the   Department  of  Alcoholism  and  Substance  Abuse,  the
27    Department of Children and Family Services, and the  Illinois
28    Department   shall   be  excluded  from  a  benefit  package.
29    Conditions of  an  organic  or  physical  origin  or  nature,
30    including   medical   detoxification,  however,  may  not  be
31    excluded.  In this subsection, "behavioral  health  services"
32    means   mental  health  services  and  subacute  alcohol  and
33    substance  abuse  treatment  services,  as  defined  in   the
34    Illinois  Alcoholism  and Other Drug Dependency Act.  In this
HB0781 Engrossed            -17-               LRB9000971DJcd
 1    subsection, "mental health services" includes, at a  minimum,
 2    the following services funded by the Illinois Department, the
 3    Department  of  Mental Health and Developmental Disabilities,
 4    or the  Department  of  Children  and  Family  Services:  (i)
 5    inpatient  hospital  services,  including  related  physician
 6    services,     related    psychiatric    interventions,    and
 7    pharmaceutical services provided  to  an  eligible  recipient
 8    hospitalized   with   a   primary  diagnosis  of  psychiatric
 9    disorder; (ii) outpatient mental health services  as  defined
10    and  specified  in  Title  59  of the Illinois Administrative
11    Code, Part 132; (iii)  any  other  outpatient  mental  health
12    services  funded  by  the Illinois Department pursuant to the
13    State   of   Illinois    Medicaid    Plan;    (iv)    partial
14    hospitalization;  and  (v) follow-up stabilization related to
15    any of those services.  Additional behavioral health services
16    may be excluded under this subsection as mutually  agreed  in
17    writing  by  the  Illinois  Department and the affected State
18    agency or agencies.  The exclusion of any  service  does  not
19    prohibit   the   Illinois   Department  from  developing  and
20    implementing demonstration projects for categories of persons
21    or  services.   The   Department   of   Mental   Health   and
22    Developmental  Disabilities,  the  Department of Children and
23    Family  Services,  and  the  Department  of  Alcoholism   and
24    Substance   Abuse   shall  each  adopt  rules  governing  the
25    integration of managed care in the  provision  of  behavioral
26    health  services.  The  State  shall  integrate  managed care
27    community networks and affiliated providers,  to  the  extent
28    practicable,  in  any  separate  delivery  system  for mental
29    health services.
30        (n)  The  Illinois  Department  shall  adopt   rules   to
31    establish  reserve  requirements  for  managed care community
32    networks,  as  required  by  subsection   (a),   and   health
33    maintenance  organizations  to protect against liabilities in
34    the event that a  managed  health  care  entity  is  declared
HB0781 Engrossed            -18-               LRB9000971DJcd
 1    insolvent or bankrupt.  If a managed health care entity other
 2    than  a  county  provider  is declared insolvent or bankrupt,
 3    after liquidation and application of  any  available  assets,
 4    resources,  and reserves, the Illinois Department shall pay a
 5    portion of the amounts owed by the managed health care entity
 6    to providers for services rendered  to  enrollees  under  the
 7    integrated  health  care  program under this Section based on
 8    the following schedule: (i) from April 1, 1995  through  June
 9    30,  1998,  90%  of  the amounts owed; (ii) from July 1, 1998
10    through June 30, 2001, 80% of the  amounts  owed;  and  (iii)
11    from  July  1, 2001 through June 30, 2005, 75% of the amounts
12    owed.  The  amounts  paid  under  this  subsection  shall  be
13    calculated  based  on  the  total  amount owed by the managed
14    health care entity to providers  before  application  of  any
15    available  assets,  resources,  and reserves.  After June 30,
16    2005, the Illinois Department may not pay any amounts owed to
17    providers as a result of an insolvency  or  bankruptcy  of  a
18    managed  health  care entity occurring after that date.   The
19    Illinois Department is not obligated, however, to pay amounts
20    owed to a provider that has an ownership or  other  governing
21    interest  in the managed health care entity.  This subsection
22    applies only to managed health care entities and the services
23    they provide under the integrated health care  program  under
24    this Section.
25        (o)  Notwithstanding   any  other  provision  of  law  or
26    contractual agreement to the contrary, providers shall not be
27    required to accept from any other third party payer the rates
28    determined  or  paid  under  this  Code   by   the   Illinois
29    Department,  managed health care entity, or other health care
30    delivery system for services provided to recipients.
31        (p)  The Illinois Department  may  seek  and  obtain  any
32    necessary   authorization   provided  under  federal  law  to
33    implement the program, including the waiver  of  any  federal
34    statutes  or  regulations. The Illinois Department may seek a
HB0781 Engrossed            -19-               LRB9000971DJcd
 1    waiver  of  the  federal  requirement   that   the   combined
 2    membership  of  Medicare  and Medicaid enrollees in a managed
 3    care community network may not exceed 75% of the managed care
 4    community   network's   total   enrollment.    The   Illinois
 5    Department shall not seek a waiver of  this  requirement  for
 6    any  other  category  of  managed  health  care  entity.  The
 7    Illinois Department shall not seek a waiver of the  inpatient
 8    hospital  reimbursement methodology in Section 1902(a)(13)(A)
 9    of Title XIX of the Social Security Act even if  the  federal
10    agency  responsible  for  administering  Title XIX determines
11    that Section 1902(a)(13)(A) applies to  managed  health  care
12    systems.
13        Notwithstanding  any other provisions of this Code to the
14    contrary, the Illinois Department  shall  seek  a  waiver  of
15    applicable federal law in order to impose a co-payment system
16    consistent  with  this  subsection  on  recipients of medical
17    services under Title XIX of the Social Security Act  who  are
18    not  enrolled  in  a  managed health care entity.  The waiver
19    request submitted by the Illinois  Department  shall  provide
20    for co-payments of up to $0.50 for prescribed drugs and up to
21    $0.50 for x-ray services and shall provide for co-payments of
22    up  to  $10 for non-emergency services provided in a hospital
23    emergency room and up  to  $10  for  non-emergency  ambulance
24    services.   The  purpose of the co-payments shall be to deter
25    those  recipients  from  seeking  unnecessary  medical  care.
26    Co-payments may not be used to deter recipients from  seeking
27    necessary  medical  care.   No recipient shall be required to
28    pay more than a total of $150 per year in  co-payments  under
29    the  waiver request required by this subsection.  A recipient
30    may not be required to pay more than $15 of  any  amount  due
31    under this subsection in any one month.
32        Co-payments  authorized  under this subsection may not be
33    imposed when the care was  necessitated  by  a  true  medical
34    emergency.   Co-payments  may  not  be imposed for any of the
HB0781 Engrossed            -20-               LRB9000971DJcd
 1    following classifications of services:
 2             (1)  Services furnished to person under 18 years  of
 3        age.
 4             (2)  Services furnished to pregnant women.
 5             (3)  Services  furnished to any individual who is an
 6        inpatient in a hospital, nursing  facility,  intermediate
 7        care  facility,  or  other  medical  institution, if that
 8        person is required to spend for costs of medical care all
 9        but a minimal amount of his or her  income  required  for
10        personal needs.
11             (4)  Services furnished to a person who is receiving
12        hospice care.
13        Co-payments authorized under this subsection shall not be
14    deducted  from  or  reduce  in  any  way payments for medical
15    services from  the  Illinois  Department  to  providers.   No
16    provider  may  deny  those services to an individual eligible
17    for services based on the individual's inability to  pay  the
18    co-payment.
19        Recipients  who  are  subject  to  co-payments  shall  be
20    provided  notice,  in plain and clear language, of the amount
21    of the co-payments, the circumstances under which co-payments
22    are exempted, the circumstances under which  co-payments  may
23    be assessed, and their manner of collection.
24        The   Illinois  Department  shall  establish  a  Medicaid
25    Co-Payment Council to assist in the development of co-payment
26    policies for the medical assistance  program.   The  Medicaid
27    Co-Payment  Council shall also have jurisdiction to develop a
28    program to provide financial or non-financial  incentives  to
29    Medicaid  recipients in order to encourage recipients to seek
30    necessary health care.  The Council shall be chaired  by  the
31    Director  of  the  Illinois  Department,  and  shall  have  6
32    additional members.  Two of the 6 additional members shall be
33    appointed by the Governor, and one each shall be appointed by
34    the  President  of  the  Senate,  the  Minority Leader of the
HB0781 Engrossed            -21-               LRB9000971DJcd
 1    Senate, the Speaker of the House of Representatives, and  the
 2    Minority Leader of the House of Representatives.  The Council
 3    may be convened and make recommendations upon the appointment
 4    of a majority of its members.  The Council shall be appointed
 5    and convened no later than September 1, 1994 and shall report
 6    its   recommendations   to   the  Director  of  the  Illinois
 7    Department and the General Assembly no later than October  1,
 8    1994.   The  chairperson  of  the Council shall be allowed to
 9    vote only in the case of  a  tie  vote  among  the  appointed
10    members of the Council.
11        The  Council  shall be guided by the following principles
12    as it considers recommendations to be developed to  implement
13    any  approved  waivers that the Illinois Department must seek
14    pursuant to this subsection:
15             (1)  Co-payments should not be used to deter  access
16        to adequate medical care.
17             (2)  Co-payments should be used to reduce fraud.
18             (3)  Co-payment   policies  should  be  examined  in
19        consideration  of  other  states'  experience,  and   the
20        ability   of   successful  co-payment  plans  to  control
21        unnecessary  or  inappropriate  utilization  of  services
22        should be promoted.
23             (4)  All   participants,   both    recipients    and
24        providers,   in   the  medical  assistance  program  have
25        responsibilities to both the State and the program.
26             (5)  Co-payments are primarily a tool to educate the
27        participants  in  the  responsible  use  of  health  care
28        resources.
29             (6)  Co-payments should  not  be  used  to  penalize
30        providers.
31             (7)  A   successful  medical  program  requires  the
32        elimination of improper utilization of medical resources.
33        The integrated health care program, or any part  of  that
34    program,   established   under   this   Section  may  not  be
HB0781 Engrossed            -22-               LRB9000971DJcd
 1    implemented if matching federal funds under Title XIX of  the
 2    Social  Security  Act are not available for administering the
 3    program.
 4        The Illinois Department shall submit for  publication  in
 5    the Illinois Register the name, address, and telephone number
 6    of  the  individual  to  whom a request may be directed for a
 7    copy of the request for a waiver of provisions of  Title  XIX
 8    of  the  Social  Security  Act  that  the Illinois Department
 9    intends to submit to the Health Care Financing Administration
10    in order to implement this Section.  The Illinois  Department
11    shall  mail  a  copy  of  that  request  for  waiver  to  all
12    requestors  at  least  16 days before filing that request for
13    waiver with the Health Care Financing Administration.
14        (q)  After  the  effective  date  of  this  Section,  the
15    Illinois Department may take  all  planning  and  preparatory
16    action  necessary  to  implement this Section, including, but
17    not limited to, seeking requests for  proposals  relating  to
18    the   integrated  health  care  program  created  under  this
19    Section.
20        (r)  In  order  to  (i)  accelerate  and  facilitate  the
21    development of integrated health care  in  contracting  areas
22    outside  counties with populations in excess of 3,000,000 and
23    counties adjacent to those counties  and  (ii)  maintain  and
24    sustain  the high quality of education and residency programs
25    coordinated and associated with  local  area  hospitals,  the
26    Illinois Department may develop and implement a demonstration
27    program  for managed care community networks owned, operated,
28    or governed by State-funded medical  schools.   The  Illinois
29    Department  shall  prescribe by rule the criteria, standards,
30    and procedures for effecting this demonstration program.
31        (s)  (Blank).
32        (s-5)  The Illinois Department may  impose  penalties  or
33    sanctions    permitted  by  law or contract for violations of
34    this Section.
HB0781 Engrossed            -23-               LRB9000971DJcd
 1        (t)  On April 1, 1995 and every 6 months thereafter,  the
 2    Illinois  Department shall report to the Governor and General
 3    Assembly on  the  progress  of  the  integrated  health  care
 4    program   in  enrolling  clients  into  managed  health  care
 5    entities.  The report shall indicate the  capacities  of  the
 6    managed  health care entities with which the State contracts,
 7    the number of clients enrolled by each contractor, the  areas
 8    of  the State in which managed care options do not exist, and
 9    the progress toward  meeting  the  enrollment  goals  of  the
10    integrated health care program.
11        (u)  The  Illinois  Department may implement this Section
12    through the use of emergency rules in accordance with Section
13    5-45 of  the  Illinois  Administrative  Procedure  Act.   For
14    purposes of that Act, the adoption of rules to implement this
15    Section  is  deemed an emergency and necessary for the public
16    interest, safety, and welfare.
17        (v)  The  Auditor  General  shall   conduct   an   annual
18    performance  audit  of  the  integrated  health  care program
19    created under this  Section  and  the  Illinois  Department's
20    implementation  of  this  Section.   The  initial audit shall
21    cover the fiscal year ending June 30,  1997,  and  subsequent
22    audits  shall cover each fiscal year thereafter.  The Auditor
23    General shall issue  reports  of  the  audits  on  or  before
24    December 31 of 1997 and each year thereafter.
25    (Source:  P.A.  88-554,  eff.  7-26-94;  89-21,  eff. 7-1-95;
26    89-673, eff. 8-14-96; revised 8-26-96.)
27        (Text of Section after amendment by P.A. 89-507)
28        Sec. 5-16.3.  System for integrated health care services.
29        (a)  It shall be the public policy of the State to adopt,
30    to  the  extent  practicable,  a  health  care  program  that
31    encourages  the  integration  of  health  care  services  and
32    manages the health care of program enrollees while preserving
33    reasonable choice within  a  competitive  and  cost-efficient
34    environment.   In  furtherance  of  this  public  policy, the
HB0781 Engrossed            -24-               LRB9000971DJcd
 1    Illinois Department shall develop and implement an integrated
 2    health care program consistent with the  provisions  of  this
 3    Section.   The  provisions  of this Section apply only to the
 4    integrated health care program created  under  this  Section.
 5    Persons  enrolled  in  the integrated health care program, as
 6    determined by the  Illinois  Department  by  rule,  shall  be
 7    afforded  a  choice among health care delivery systems, which
 8    shall include, but are not limited to, (i)  fee  for  service
 9    care managed by a primary care physician licensed to practice
10    medicine  in  all  its  branches,  (ii)  managed  health care
11    entities,  and  (iii)  federally  qualified  health   centers
12    (reimbursed  according  to  a  prospective cost-reimbursement
13    methodology) and rural health clinics  (reimbursed  according
14    to  the  Medicare  methodology),  where  available.   Persons
15    enrolled  in  the  integrated health care program also may be
16    offered indemnity insurance plans, subject to availability.
17        For purposes of this  Section,  a  "managed  health  care
18    entity"  means a health maintenance organization or a managed
19    care community network as defined in this Section.  A "health
20    maintenance  organization"   means   a   health   maintenance
21    organization   as   defined   in   the   Health   Maintenance
22    Organization  Act.   A "managed care community network" means
23    an entity, other than a health maintenance organization, that
24    is owned, operated, or governed by providers of  health  care
25    services  within  this  State  and  that provides or arranges
26    primary, secondary, and tertiary managed health care services
27    under contract with the Illinois  Department  exclusively  to
28    enrollees  of  the  integrated health care program. A managed
29    care  community  network  may  contract  with  the   Illinois
30    Department  to provide only pediatric health care services. A
31    county provider as defined in Section 15-1 of this  Code  may
32    contract  with the Illinois Department to provide services to
33    enrollees of the integrated health care program as a  managed
34    care  community  network  without  the  need  to  establish a
HB0781 Engrossed            -25-               LRB9000971DJcd
 1    separate  entity  that  provides  services   exclusively   to
 2    enrollees  of the integrated health care program and shall be
 3    deemed a managed care community network for purposes of  this
 4    Code only to the extent of the provision of services to those
 5    enrollees  in  conjunction  with  the  integrated health care
 6    program.  A county provider shall  be  entitled  to  contract
 7    with  the Illinois Department with respect to any contracting
 8    region located in whole or in  part  within  the  county.   A
 9    county provider shall not be required to accept enrollees who
10    do not reside within the county.
11        If  a  managed  health  care  entity  is  accredited by a
12    private national organization that performs quality assurance
13    surveys  of  health  maintenance  organizations  or   related
14    organizations,   the   Illinois   Department   may  take  the
15    accreditation  into  consideration  when  selecting   managed
16    health  care  entities  for  participation  in the integrated
17    health care program.   The  medical  director  of  a  managed
18    health  care entity must be a physician licensed in the State
19    to practice medicine in all its branches.
20        Each managed care community network must demonstrate  its
21    ability to bear the financial risk of serving enrollees under
22    this  program.   The  Illinois Department shall by rule adopt
23    criteria  for  assessing  the  financial  soundness  of  each
24    managed care community network. These  rules  shall  consider
25    the  extent  to  which  a  managed  care community network is
26    comprised of providers who directly render  health  care  and
27    are  located  within  the  community  in  which  they seek to
28    contract rather than solely arrange or finance  the  delivery
29    of health care.  These rules shall further consider a variety
30    of  risk-bearing  and  management  techniques,  including the
31    sufficiency of quality assurance and  utilization  management
32    programs  and  whether  a  managed care community network has
33    sufficiently demonstrated  its  financial  solvency  and  net
34    worth.  The  Illinois  Department's criteria must be based on
HB0781 Engrossed            -26-               LRB9000971DJcd
 1    sound actuarial, financial, and  accounting  principles.   In
 2    adopting  these  rules, the Illinois Department shall consult
 3    with the  Illinois  Department  of  Insurance.  The  Illinois
 4    Department  is  responsible  for  monitoring  compliance with
 5    these rules.
 6        This Section may not be implemented before the  effective
 7    date  of  these  rules, the approval of any necessary federal
 8    waivers, and the completion of the review of  an  application
 9    submitted,  at  least  60  days  before the effective date of
10    rules adopted under this Section, to the Illinois  Department
11    by a managed care community network.
12        All  health  care delivery systems that contract with the
13    Illinois Department under the integrated health care  program
14    shall  clearly  recognize  a  health care provider's right of
15    conscience under the Right of Conscience Act.  In addition to
16    the provisions of that Act, no health  care  delivery  system
17    that   contracts  with  the  Illinois  Department  under  the
18    integrated health care program shall be required to  provide,
19    arrange  for,  or pay for any health care or medical service,
20    procedure, or product if that health care delivery system  is
21    owned,  controlled,  or  sponsored  by  or  affiliated with a
22    religious institution or religious  organization  that  finds
23    that health care or medical service, procedure, or product to
24    violate its religious and moral teachings and beliefs.
25        (b)  The  Illinois  Department  may, by rule, provide for
26    different  benefit  packages  for  different  categories   of
27    persons  enrolled  in  the  program.  Mental health services,
28    alcohol and substance abuse  services,  services  related  to
29    children   with   chronic   or   acute  conditions  requiring
30    longer-term treatment and follow-up, and rehabilitation  care
31    provided  by  a  free-standing  rehabilitation  hospital or a
32    hospital rehabilitation unit may be excluded from  a  benefit
33    package  if  the  State  ensures that those services are made
34    available through a separate delivery system.   An  exclusion
HB0781 Engrossed            -27-               LRB9000971DJcd
 1    does not prohibit the Illinois Department from developing and
 2    implementing demonstration projects for categories of persons
 3    or  services.   Benefit  packages  for  persons  eligible for
 4    medical assistance under Articles V, VI,  and  XII  shall  be
 5    based  on  the  requirements  of  those Articles and shall be
 6    consistent with the Title XIX of  the  Social  Security  Act.
 7    Nothing  in  this Act shall be construed to apply to services
 8    purchased by the Department of Children and  Family  Services
 9    and  the  Department  of  Human Services (as successor to the
10    Department of Mental Health and  Developmental  Disabilities)
11    under   the   provisions   of   Title   59  of  the  Illinois
12    Administrative Code, Part  132  ("Medicaid  Community  Mental
13    Health Services Program").
14        (c)  The  program  established  by  this  Section  may be
15    implemented by the Illinois Department in various contracting
16    areas at various times.  The health care delivery systems and
17    providers available under the program may vary throughout the
18    State.  For purposes of contracting with managed health  care
19    entities   and   providers,  the  Illinois  Department  shall
20    establish contracting areas similar to the  geographic  areas
21    designated   by   the  Illinois  Department  for  contracting
22    purposes  under   the   Illinois   Competitive   Access   and
23    Reimbursement  Equity  Program (ICARE) under the authority of
24    Section 3-4 of the Illinois  Health  Finance  Reform  Act  or
25    similarly-sized  or  smaller  geographic areas established by
26    the Illinois Department by rule. A managed health care entity
27    shall be permitted to contract in any  geographic  areas  for
28    which  it  has  a  sufficient  provider network and otherwise
29    meets the  contracting  terms  of  the  State.  The  Illinois
30    Department  is  not  prohibited from entering into a contract
31    with a managed health care entity at any time.
32        (d)  A managed health care entity that contracts with the
33    Illinois Department for the provision of services  under  the
34    program shall do all of the following, solely for purposes of
HB0781 Engrossed            -28-               LRB9000971DJcd
 1    the integrated health care program:
 2             (1)  Provide  that any individual physician licensed
 3        to practice medicine in all its branches,  any  pharmacy,
 4        any   federally   qualified   health   center,   and  any
 5        podiatrist, that consistently meets the reasonable  terms
 6        and  conditions  established  by  the managed health care
 7        entity,  including  but  not  limited  to   credentialing
 8        standards,   quality   assurance   program  requirements,
 9        utilization    management     requirements,     financial
10        responsibility     standards,     contracting     process
11        requirements, and provider network size and accessibility
12        requirements, must be accepted by the managed health care
13        entity  for  purposes  of  the Illinois integrated health
14        care program.  Any individual who  is  either  terminated
15        from  or  denied  inclusion in the panel of physicians of
16        the managed health care entity shall be given, within  10
17        business   days   after  that  determination,  a  written
18        explanation of the reasons for his or  her  exclusion  or
19        termination  from  the panel. This paragraph (1) does not
20        apply to the following:
21                  (A)  A  managed   health   care   entity   that
22             certifies to the Illinois Department that:
23                       (i)  it  employs  on a full-time basis 125
24                  or  more  Illinois   physicians   licensed   to
25                  practice medicine in all of its branches; and
26                       (ii)  it  will  provide  medical  services
27                  through  its  employees to more than 80% of the
28                  recipients enrolled  with  the  entity  in  the
29                  integrated health care program; or
30                  (B)  A   domestic   stock   insurance   company
31             licensed under clause (b) of class 1 of Section 4 of
32             the  Illinois  Insurance Code if (i) at least 66% of
33             the stock of the insurance company  is  owned  by  a
34             professional   corporation   organized   under   the
HB0781 Engrossed            -29-               LRB9000971DJcd
 1             Professional Service Corporation Act that has 125 or
 2             more   shareholders   who  are  Illinois  physicians
 3             licensed to practice medicine in all of its branches
 4             and (ii) the  insurance  company  certifies  to  the
 5             Illinois  Department  that  at  least  80%  of those
 6             physician  shareholders  will  provide  services  to
 7             recipients  enrolled  with  the   company   in   the
 8             integrated health care program.
 9             (2)  Provide  for  reimbursement  for  providers for
10        emergency care, as defined by the Illinois Department  by
11        rule,  that  must be provided to its enrollees, including
12        an emergency room screening fee, and urgent care that  it
13        authorizes   for   its   enrollees,   regardless  of  the
14        provider's  affiliation  with  the  managed  health  care
15        entity. Providers shall be reimbursed for emergency  care
16        at   an   amount   equal  to  the  Illinois  Department's
17        fee-for-service rates for those medical services rendered
18        by providers not under contract with the  managed  health
19        care entity to enrollees of the entity.
20             (3)  Provide  that  any  provider  affiliated with a
21        managed health care entity may also provide services on a
22        fee-for-service basis to Illinois Department clients  not
23        enrolled in a managed health care entity.
24             (4)  Provide client education services as determined
25        and  approved  by  the Illinois Department, including but
26        not  limited  to  (i)  education  regarding   appropriate
27        utilization  of  health  care  services in a managed care
28        system, (ii) written disclosure of treatment policies and
29        any  restrictions  or  limitations  on  health  services,
30        including,  but  not  limited  to,   physical   services,
31        clinical   laboratory   tests,   hospital   and  surgical
32        procedures,  prescription  drugs   and   biologics,   and
33        radiological  examinations, and (iii) written notice that
34        the enrollee may  receive  from  another  provider  those
HB0781 Engrossed            -30-               LRB9000971DJcd
 1        services covered under this program that are not provided
 2        by the managed health care entity.
 3             (4.5)  Provide orientation to the caretaker relative
 4        or  payee  of  a  medical  assistance  unit  that  has an
 5        enrollee as a member.  The  managed  health  care  entity
 6        must exercise good faith efforts to provide all caretaker
 7        relatives  or  payees  with the orientation.  The managed
 8        health care entity shall inform the  Illinois  Department
 9        of  the  caretaker relatives or payees who have completed
10        the  orientation.   This  paragraph  applies   to   every
11        caretaker  relative  or  payee  in  a managed health care
12        entity's  system  regardless  of  whether  the  caretaker
13        relative or payee has  chosen  the  system  or  has  been
14        assigned to the system as provided in subsection (e).
15             (5)  Provide  that  enrollees  within its system may
16        choose the site for provision of services and  the  panel
17        of health care providers.
18             (6)  Not   discriminate   in   its   enrollment   or
19        disenrollment   practices  among  recipients  of  medical
20        services or program enrollees based on health status.
21             (7)  Provide a  quality  assurance  and  utilization
22        review   program   that   (i)   for   health  maintenance
23        organizations  meets  the  requirements  of  the   Health
24        Maintenance  Organization  Act  and (ii) for managed care
25        community networks meets the requirements established  by
26        the  Illinois  Department in rules that incorporate those
27        standards   set   forth   in   the   Health   Maintenance
28        Organization Act.
29             (8)  Issue   a   managed    health    care    entity
30        identification  card  to  each  enrollee upon enrollment.
31        The card must contain all of the following:
32                  (A)  The enrollee's signature.
33                  (B)  The enrollee's health plan.
34                  (C)  The  name  and  telephone  number  of  the
HB0781 Engrossed            -31-               LRB9000971DJcd
 1             enrollee's primary care physician.
 2                  (D)  A  telephone  number  to   be   used   for
 3             emergency service 24 hours per day, 7 days per week.
 4             The  telephone  number  required  to  be  maintained
 5             pursuant to this subparagraph by each managed health
 6             care   entity  shall,  at  minimum,  be  staffed  by
 7             medically  trained   personnel   and   be   provided
 8             directly,  or  under  arrangement,  at  an office or
 9             offices in  locations maintained solely  within  the
10             State    of   Illinois.   For   purposes   of   this
11             subparagraph, "medically  trained  personnel"  means
12             licensed   practical  nurses  or  registered  nurses
13             located in the State of Illinois  who  are  licensed
14             pursuant to the Illinois Nursing Act of 1987.
15             (8.5)  The    Illinois   Department   must   include
16        performance  standards   in   contracts   with   entities
17        participating  in  the  integrated health care program to
18        require contractors to make a good faith effort  to  have
19        enrollees  evaluated  by  a physician within a reasonable
20        period of time after enrollment,  as  determined  by  the
21        Illinois Department.
22             (9)  Ensure  that  every  primary care physician and
23        pharmacy in the managed  health  care  entity  meets  the
24        standards  established  by  the  Illinois  Department for
25        accessibility  and  quality   of   care.   The   Illinois
26        Department shall arrange for and oversee an evaluation of
27        the  standards  established  under this paragraph (9) and
28        may recommend any necessary changes to  these  standards.
29        The  Illinois Department shall submit an annual report to
30        the Governor and the General Assembly by April 1 of  each
31        year  regarding  the  effect of the standards on ensuring
32        access and quality of care to enrollees.
33             (10)  Provide a procedure  for  handling  complaints
34        that  (i)  for health maintenance organizations meets the
HB0781 Engrossed            -32-               LRB9000971DJcd
 1        requirements of the Health Maintenance  Organization  Act
 2        and  (ii)  for  managed care community networks meets the
 3        requirements established by the  Illinois  Department  in
 4        rules  that  incorporate those standards set forth in the
 5        Health Maintenance Organization Act.
 6             (11)  Maintain, retain, and make  available  to  the
 7        Illinois  Department records, data, and information, in a
 8        uniform manner determined  by  the  Illinois  Department,
 9        sufficient   for   the  Illinois  Department  to  monitor
10        utilization, accessibility, and quality of care.
11             (12)  Except for providers who are prepaid, pay  all
12        approved  claims  for covered services that are completed
13        and submitted to the managed health care entity within 30
14        days after  receipt  of  the  claim  or  receipt  of  the
15        appropriate capitation payment or payments by the managed
16        health  care entity from the State for the month in which
17        the  services  included  on  the  claim  were   rendered,
18        whichever  is  later. If payment is not made or mailed to
19        the provider by the managed health care entity by the due
20        date under this subsection, an interest penalty of 1%  of
21        any  amount  unpaid  shall  be  added  for  each month or
22        fraction of a month  after  the  due  date,  until  final
23        payment  is  made. Nothing in this Section shall prohibit
24        managed health care entities and providers from  mutually
25        agreeing to terms that require more timely payment.
26             (12.5)  Ensure   that   no  payment  is  made  to  a
27        physician or other provider of services  for  withholding
28        from an enrollee any covered services because of the cost
29        of   those  services.   This  requirement  shall  not  be
30        construed to prevent  managed health care  entities  from
31        offering,  nor providers from  accepting, full or partial
32        capitation.
33             (13)  Provide   integration   with   community-based
34        programs provided by certified local  health  departments
HB0781 Engrossed            -33-               LRB9000971DJcd
 1        such  as  Women,  Infants, and Children Supplemental Food
 2        Program (WIC), childhood  immunization  programs,  health
 3        education  programs, case management programs, and health
 4        screening programs.
 5             (14)  Provide that the pharmacy formulary used by  a
 6        managed  health care entity and its contract providers be
 7        no  more  restrictive  than  the  Illinois   Department's
 8        pharmaceutical  program  on  the  effective  date of this
 9        amendatory Act of 1994 and as amended after that date.
10             (15)  Provide   integration   with   community-based
11        organizations,  including,  but  not  limited   to,   any
12        organization   that   has   operated  within  a  Medicaid
13        Partnership as defined by this Code or  by  rule  of  the
14        Illinois Department, that may continue to operate under a
15        contract with the Illinois Department or a managed health
16        care entity under this Section to provide case management
17        services  to  Medicaid  clients  in  designated high-need
18        areas.
19        The  Illinois  Department   may,   by   rule,   determine
20    methodologies to limit financial liability for managed health
21    care   entities   resulting  from  payment  for  services  to
22    enrollees provided under the Illinois Department's integrated
23    health care program. Any methodology  so  determined  may  be
24    considered  or implemented by the Illinois Department through
25    a contract with a  managed  health  care  entity  under  this
26    integrated health care program.
27        The  Illinois Department shall contract with an entity or
28    entities to provide  external  peer-based  quality  assurance
29    review  for  the  integrated  health care program. The entity
30    shall be representative of Illinois  physicians  licensed  to
31    practice  medicine  in  all  its  branches and have statewide
32    geographic representation in all specialties of medical  care
33    that  are provided within the integrated health care program.
34    The entity may not be a third party payer and shall  maintain
HB0781 Engrossed            -34-               LRB9000971DJcd
 1    offices  in  locations  around  the State in order to provide
 2    service  and  continuing  medical  education   to   physician
 3    participants  within the integrated health care program.  The
 4    review process shall be developed and conducted  by  Illinois
 5    physicians licensed to practice medicine in all its branches.
 6    In  consultation with the entity, the Illinois Department may
 7    contract with  other  entities  for  professional  peer-based
 8    quality assurance review of individual categories of services
 9    other  than  services provided, supervised, or coordinated by
10    physicians licensed to practice medicine in all its branches.
11    The Illinois Department shall establish, by rule, criteria to
12    avoid  conflicts  of  interest  in  the  conduct  of  quality
13    assurance activities consistent with professional peer-review
14    standards.  All  quality  assurance   activities   shall   be
15    coordinated by the Illinois Department.
16        (e)  All   persons  enrolled  in  the  program  shall  be
17    provided   with   a   full   written   explanation   of   all
18    fee-for-service and managed health care plan  options  and  a
19    reasonable   opportunity  to  choose  among  the  options  as
20    provided by rule.  The Illinois Department shall  provide  to
21    enrollees,  upon  enrollment  in  the  integrated health care
22    program and at  least  annually  thereafter,  notice  of  the
23    process   for   requesting   an  appeal  under  the  Illinois
24    Department's      administrative      appeal      procedures.
25    Notwithstanding any other Section of this Code, the  Illinois
26    Department may provide by rule for the Illinois Department to
27    assign  a  person  enrolled  in  the  program  to  a specific
28    provider of medical services or to  a  specific  health  care
29    delivery  system if an enrollee has failed to exercise choice
30    in a timely manner. An  enrollee  assigned  by  the  Illinois
31    Department shall be afforded the opportunity to disenroll and
32    to  select  a  specific  provider  of  medical  services or a
33    specific health care delivery system within the first 30 days
34    after the assignment. An enrollee who has failed to  exercise
HB0781 Engrossed            -35-               LRB9000971DJcd
 1    choice in a timely manner may be assigned only if there are 3
 2    or  more  managed  health  care entities contracting with the
 3    Illinois Department within the contracting area, except that,
 4    outside the City of Chicago, this requirement may  be  waived
 5    for an area by rules adopted by the Illinois Department after
 6    consultation  with all hospitals within the contracting area.
 7    The Illinois Department shall establish by rule the procedure
 8    for random assignment  of  enrollees  who  fail  to  exercise
 9    choice  in  a timely manner to a specific managed health care
10    entity in  proportion  to  the  available  capacity  of  that
11    managed health care entity. Assignment to a specific provider
12    of  medical  services  or  to  a specific managed health care
13    entity may not exceed that provider's or entity's capacity as
14    determined by the Illinois Department.  Any  person  who  has
15    chosen  a specific provider of medical services or a specific
16    managed health care  entity,  or  any  person  who  has  been
17    assigned   under   this   subsection,   shall  be  given  the
18    opportunity to change that choice or assignment at least once
19    every 12 months, as determined by the Illinois Department  by
20    rule.  The  Illinois  Department  shall  maintain a toll-free
21    telephone number for  program  enrollees'  use  in  reporting
22    problems with managed health care entities.
23        (f)  If  a  person  becomes eligible for participation in
24    the integrated  health  care  program  while  he  or  she  is
25    hospitalized,  the  Illinois  Department  may not enroll that
26    person in  the  program  until  after  he  or  she  has  been
27    discharged from the hospital.  This subsection does not apply
28    to   newborn  infants  whose  mothers  are  enrolled  in  the
29    integrated health care program.
30        (g)  The Illinois Department shall,  by  rule,  establish
31    for managed health care entities rates that (i) are certified
32    to  be  actuarially sound, as determined by an actuary who is
33    an associate or a fellow of the Society  of  Actuaries  or  a
34    member  of  the  American  Academy  of  Actuaries and who has
HB0781 Engrossed            -36-               LRB9000971DJcd
 1    expertise and experience in  medical  insurance  and  benefit
 2    programs,   in  accordance  with  the  Illinois  Department's
 3    current fee-for-service payment system, and  (ii)  take  into
 4    account  any  difference  of  cost  to provide health care to
 5    different populations based on  gender,  age,  location,  and
 6    eligibility  category.   The  rates  for  managed health care
 7    entities shall be determined on a capitated basis.
 8        The Illinois Department by rule shall establish a  method
 9    to  adjust  its payments to managed health care entities in a
10    manner intended to avoid providing any financial incentive to
11    a managed health care entity to refer patients  to  a  county
12    provider,  in  an Illinois county having a population greater
13    than  3,000,000,  that  is  paid  directly  by  the  Illinois
14    Department.  The Illinois Department shall by April 1,  1997,
15    and   annually   thereafter,  review  the  method  to  adjust
16    payments. Payments by the Illinois Department to  the  county
17    provider,   for  persons  not  enrolled  in  a  managed  care
18    community network owned or operated  by  a  county  provider,
19    shall  be paid on a fee-for-service basis under Article XV of
20    this Code.
21        The Illinois Department by rule shall establish a  method
22    to  reduce  its  payments  to managed health care entities to
23    take into consideration (i) any adjustment payments  paid  to
24    hospitals  under subsection (h) of this Section to the extent
25    those payments, or any part  of  those  payments,  have  been
26    taken into account in establishing capitated rates under this
27    subsection  (g)  and (ii) the implementation of methodologies
28    to limit financial liability for managed health care entities
29    under subsection (d) of this Section.
30        (h)  For hospital services provided by  a  hospital  that
31    contracts  with  a  managed  health  care  entity, adjustment
32    payments shall be  paid  directly  to  the  hospital  by  the
33    Illinois  Department.   Adjustment  payments  may include but
34    need   not   be   limited   to   adjustment   payments    to:
HB0781 Engrossed            -37-               LRB9000971DJcd
 1    disproportionate share hospitals under Section 5-5.02 of this
 2    Code;  primary care access health care education payments (89
 3    Ill. Adm. Code 149.140); payments for capital, direct medical
 4    education, indirect medical education,  certified  registered
 5    nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
 6    Code  149.150(c));  uncompensated care payments (89 Ill. Adm.
 7    Code 148.150(h)); trauma center payments (89 Ill.  Adm.  Code
 8    148.290(c));  rehabilitation  hospital payments (89 Ill. Adm.
 9    Code 148.290(d)); perinatal center  payments  (89  Ill.  Adm.
10    Code  148.290(e));  obstetrical  care  payments (89 Ill. Adm.
11    Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
12    148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
13    148.290(h)); and outpatient indigent volume  adjustments  (89
14    Ill. Adm. Code 148.140(b)(5)).
15        (i)  For   any   hospital  eligible  for  the  adjustment
16    payments described in subsection (h), the Illinois Department
17    shall maintain, through the  period  ending  June  30,  1995,
18    reimbursement levels in accordance with statutes and rules in
19    effect on April 1, 1994.
20        (j)  Nothing  contained in this Code in any way limits or
21    otherwise impairs the authority  or  power  of  the  Illinois
22    Department  to  enter  into a negotiated contract pursuant to
23    this Section with a managed health  care  entity,  including,
24    but  not  limited to, a health maintenance organization, that
25    provides  for  termination  or  nonrenewal  of  the  contract
26    without cause upon notice as provided  in  the  contract  and
27    without a hearing.
28        (k)  Section   5-5.15  does  not  apply  to  the  program
29    developed and implemented pursuant to this Section.
30        (l)  The Illinois Department shall, by rule, define those
31    chronic or acute medical conditions of childhood that require
32    longer-term  treatment  and  follow-up  care.   The  Illinois
33    Department shall ensure that services required to treat these
34    conditions are available through a separate delivery system.
HB0781 Engrossed            -38-               LRB9000971DJcd
 1        A managed health care  entity  that  contracts  with  the
 2    Illinois Department may refer a child with medical conditions
 3    described in the rules adopted under this subsection directly
 4    to  a  children's  hospital  or  to  a hospital, other than a
 5    children's hospital, that is qualified to  provide  inpatient
 6    and  outpatient  services  to  treat  those  conditions.  The
 7    Illinois    Department    shall    provide    fee-for-service
 8    reimbursement directly to a  children's  hospital  for  those
 9    services  pursuant to Title 89 of the Illinois Administrative
10    Code, Section 148.280(a), at a rate at  least  equal  to  the
11    rate  in  effect on March 31, 1994. For hospitals, other than
12    children's hospitals, that are qualified to provide inpatient
13    and  outpatient  services  to  treat  those  conditions,  the
14    Illinois Department shall  provide  reimbursement  for  those
15    services on a fee-for-service basis, at a rate at least equal
16    to  the rate in effect for those other hospitals on March 31,
17    1994.
18        A children's hospital shall be  directly  reimbursed  for
19    all  services  provided  at  the  children's  hospital  on  a
20    fee-for-service  basis  pursuant  to Title 89 of the Illinois
21    Administrative Code, Section 148.280(a), at a rate  at  least
22    equal  to  the  rate  in  effect on March 31, 1994, until the
23    later of (i) implementation of  the  integrated  health  care
24    program  under  this  Section  and development of actuarially
25    sound capitation rates for services other than those  chronic
26    or   acute  medical  conditions  of  childhood  that  require
27    longer-term treatment and follow-up care as  defined  by  the
28    Illinois   Department   in   the  rules  adopted  under  this
29    subsection or (ii) March 31, 1996.
30        Notwithstanding  anything  in  this  subsection  to   the
31    contrary,  a  managed  health  care entity shall not consider
32    sources or methods of payment in determining the referral  of
33    a  child.   The  Illinois  Department  shall  adopt  rules to
34    establish  criteria  for  those  referrals.    The   Illinois
HB0781 Engrossed            -39-               LRB9000971DJcd
 1    Department  by  rule  shall  establish a method to adjust its
 2    payments to managed health care entities in a manner intended
 3    to avoid providing  any  financial  incentive  to  a  managed
 4    health  care  entity  to  refer patients to a provider who is
 5    paid directly by the Illinois Department.
 6        (m)  Behavioral health services provided or funded by the
 7    Department of Human Services, the Department of Children  and
 8    Family   Services,  and  the  Illinois  Department  shall  be
 9    excluded from a benefit package.  Conditions of an organic or
10    physical origin or nature, including medical  detoxification,
11    however,   may   not   be   excluded.   In  this  subsection,
12    "behavioral health services" means mental health services and
13    subacute alcohol and substance abuse treatment  services,  as
14    defined  in the Illinois Alcoholism and Other Drug Dependency
15    Act.  In this subsection, "mental health services"  includes,
16    at  a  minimum, the following services funded by the Illinois
17    Department, the Department of Human Services (as successor to
18    the   Department   of   Mental   Health   and   Developmental
19    Disabilities), or  the  Department  of  Children  and  Family
20    Services:  (i) inpatient hospital services, including related
21    physician services, related  psychiatric  interventions,  and
22    pharmaceutical  services  provided  to  an eligible recipient
23    hospitalized  with  a  primary   diagnosis   of   psychiatric
24    disorder;  (ii)  outpatient mental health services as defined
25    and specified in Title  59  of  the  Illinois  Administrative
26    Code,  Part  132;  (iii)  any  other outpatient mental health
27    services funded by the Illinois Department  pursuant  to  the
28    State    of    Illinois    Medicaid    Plan;   (iv)   partial
29    hospitalization; and (v) follow-up stabilization  related  to
30    any of those services.  Additional behavioral health services
31    may  be  excluded under this subsection as mutually agreed in
32    writing by the Illinois Department  and  the  affected  State
33    agency  or  agencies.   The exclusion of any service does not
34    prohibit  the  Illinois  Department   from   developing   and
HB0781 Engrossed            -40-               LRB9000971DJcd
 1    implementing demonstration projects for categories of persons
 2    or  services.  The Department of Children and Family Services
 3    and the Department of Human Services shall each  adopt  rules
 4    governing the integration of managed care in the provision of
 5    behavioral health services. The State shall integrate managed
 6    care  community  networks  and  affiliated  providers, to the
 7    extent practicable,  in  any  separate  delivery  system  for
 8    mental health services.
 9        (n)  The   Illinois   Department  shall  adopt  rules  to
10    establish reserve requirements  for  managed  care  community
11    networks,   as   required   by  subsection  (a),  and  health
12    maintenance organizations to protect against  liabilities  in
13    the  event  that  a  managed  health  care entity is declared
14    insolvent or bankrupt.  If a managed health care entity other
15    than a county provider is  declared  insolvent  or  bankrupt,
16    after  liquidation  and  application of any available assets,
17    resources, and reserves, the Illinois Department shall pay  a
18    portion of the amounts owed by the managed health care entity
19    to  providers  for  services  rendered to enrollees under the
20    integrated health care program under this  Section  based  on
21    the  following  schedule: (i) from April 1, 1995 through June
22    30, 1998, 90% of the amounts owed; (ii)  from  July  1,  1998
23    through  June  30,  2001,  80% of the amounts owed; and (iii)
24    from July 1, 2001 through June 30, 2005, 75% of  the  amounts
25    owed.   The  amounts  paid  under  this  subsection  shall be
26    calculated based on the total  amount  owed  by  the  managed
27    health  care  entity  to  providers before application of any
28    available assets, resources, and reserves.   After  June  30,
29    2005, the Illinois Department may not pay any amounts owed to
30    providers  as  a  result  of an insolvency or bankruptcy of a
31    managed health care entity occurring after that  date.    The
32    Illinois Department is not obligated, however, to pay amounts
33    owed  to  a provider that has an ownership or other governing
34    interest in the managed health care entity.  This  subsection
HB0781 Engrossed            -41-               LRB9000971DJcd
 1    applies only to managed health care entities and the services
 2    they  provide  under the integrated health care program under
 3    this Section.
 4        (o)  Notwithstanding  any  other  provision  of  law   or
 5    contractual agreement to the contrary, providers shall not be
 6    required to accept from any other third party payer the rates
 7    determined   or   paid   under  this  Code  by  the  Illinois
 8    Department, managed health care entity, or other health  care
 9    delivery system for services provided to recipients.
10        (p)  The  Illinois  Department  may  seek  and obtain any
11    necessary  authorization  provided  under  federal   law   to
12    implement  the  program,  including the waiver of any federal
13    statutes or regulations. The Illinois Department may  seek  a
14    waiver   of   the   federal  requirement  that  the  combined
15    membership of Medicare and Medicaid enrollees  in  a  managed
16    care community network may not exceed 75% of the managed care
17    community   network's   total   enrollment.    The   Illinois
18    Department  shall  not  seek a waiver of this requirement for
19    any other  category  of  managed  health  care  entity.   The
20    Illinois  Department shall not seek a waiver of the inpatient
21    hospital reimbursement methodology in Section  1902(a)(13)(A)
22    of  Title  XIX of the Social Security Act even if the federal
23    agency responsible for  administering  Title  XIX  determines
24    that  Section  1902(a)(13)(A)  applies to managed health care
25    systems.
26        Notwithstanding any other provisions of this Code to  the
27    contrary,  the  Illinois  Department  shall  seek a waiver of
28    applicable federal law in order to impose a co-payment system
29    consistent with this  subsection  on  recipients  of  medical
30    services  under  Title XIX of the Social Security Act who are
31    not enrolled in a managed health  care  entity.   The  waiver
32    request  submitted  by  the Illinois Department shall provide
33    for co-payments of up to $0.50 for prescribed drugs and up to
34    $0.50 for x-ray services and shall provide for co-payments of
HB0781 Engrossed            -42-               LRB9000971DJcd
 1    up to $10 for non-emergency services provided in  a  hospital
 2    emergency  room  and  up  to  $10 for non-emergency ambulance
 3    services.  The purpose of the co-payments shall be  to  deter
 4    those  recipients  from  seeking  unnecessary  medical  care.
 5    Co-payments  may not be used to deter recipients from seeking
 6    necessary medical care.  No recipient shall  be  required  to
 7    pay  more  than a total of $150 per year in co-payments under
 8    the waiver request required by this subsection.  A  recipient
 9    may  not  be  required to pay more than $15 of any amount due
10    under this subsection in any one month.
11        Co-payments authorized under this subsection may  not  be
12    imposed  when  the  care  was  necessitated by a true medical
13    emergency.  Co-payments may not be imposed  for  any  of  the
14    following classifications of services:
15             (1)  Services  furnished to person under 18 years of
16        age.
17             (2)  Services furnished to pregnant women.
18             (3)  Services furnished to any individual who is  an
19        inpatient  in  a hospital, nursing facility, intermediate
20        care facility, or  other  medical  institution,  if  that
21        person is required to spend for costs of medical care all
22        but  a  minimal  amount of his or her income required for
23        personal needs.
24             (4)  Services furnished to a person who is receiving
25        hospice care.
26        Co-payments authorized under this subsection shall not be
27    deducted from or reduce  in  any  way  payments  for  medical
28    services  from  the  Illinois  Department  to  providers.  No
29    provider may deny those services to  an  individual  eligible
30    for  services  based on the individual's inability to pay the
31    co-payment.
32        Recipients  who  are  subject  to  co-payments  shall  be
33    provided notice, in plain and clear language, of  the  amount
34    of the co-payments, the circumstances under which co-payments
HB0781 Engrossed            -43-               LRB9000971DJcd
 1    are  exempted,  the circumstances under which co-payments may
 2    be assessed, and their manner of collection.
 3        The  Illinois  Department  shall  establish  a   Medicaid
 4    Co-Payment Council to assist in the development of co-payment
 5    policies  for  the  medical assistance program.  The Medicaid
 6    Co-Payment Council shall also have jurisdiction to develop  a
 7    program  to  provide financial or non-financial incentives to
 8    Medicaid recipients in order to encourage recipients to  seek
 9    necessary  health  care.  The Council shall be chaired by the
10    Director  of  the  Illinois  Department,  and  shall  have  6
11    additional members.  Two of the 6 additional members shall be
12    appointed by the Governor, and one each shall be appointed by
13    the President of the  Senate,  the  Minority  Leader  of  the
14    Senate,  the Speaker of the House of Representatives, and the
15    Minority Leader of the House of Representatives.  The Council
16    may be convened and make recommendations upon the appointment
17    of a majority of its members.  The Council shall be appointed
18    and convened no later than September 1, 1994 and shall report
19    its  recommendations  to  the  Director   of   the   Illinois
20    Department  and the General Assembly no later than October 1,
21    1994.  The chairperson of the Council  shall  be  allowed  to
22    vote  only  in  the  case  of  a tie vote among the appointed
23    members of the Council.
24        The Council shall be guided by the  following  principles
25    as  it considers recommendations to be developed to implement
26    any approved waivers that the Illinois Department  must  seek
27    pursuant to this subsection:
28             (1)  Co-payments  should not be used to deter access
29        to adequate medical care.
30             (2)  Co-payments should be used to reduce fraud.
31             (3)  Co-payment  policies  should  be  examined   in
32        consideration   of  other  states'  experience,  and  the
33        ability  of  successful  co-payment  plans   to   control
34        unnecessary  or  inappropriate  utilization  of  services
HB0781 Engrossed            -44-               LRB9000971DJcd
 1        should be promoted.
 2             (4)  All    participants,    both   recipients   and
 3        providers,  in  the  medical  assistance   program   have
 4        responsibilities to both the State and the program.
 5             (5)  Co-payments are primarily a tool to educate the
 6        participants  in  the  responsible  use  of  health  care
 7        resources.
 8             (6)  Co-payments  should  not  be  used  to penalize
 9        providers.
10             (7)  A  successful  medical  program  requires   the
11        elimination of improper utilization of medical resources.
12        The  integrated  health care program, or any part of that
13    program,  established  under  this   Section   may   not   be
14    implemented  if matching federal funds under Title XIX of the
15    Social Security Act are not available for  administering  the
16    program.
17        The  Illinois  Department shall submit for publication in
18    the Illinois Register the name, address, and telephone number
19    of the individual to whom a request may  be  directed  for  a
20    copy  of  the request for a waiver of provisions of Title XIX
21    of the Social  Security  Act  that  the  Illinois  Department
22    intends to submit to the Health Care Financing Administration
23    in  order to implement this Section.  The Illinois Department
24    shall  mail  a  copy  of  that  request  for  waiver  to  all
25    requestors at least 16 days before filing  that  request  for
26    waiver with the Health Care Financing Administration.
27        (q)  After  the  effective  date  of  this  Section,  the
28    Illinois  Department  may  take  all planning and preparatory
29    action necessary to implement this  Section,  including,  but
30    not  limited  to,  seeking requests for proposals relating to
31    the  integrated  health  care  program  created  under   this
32    Section.
33        (r)  In  order  to  (i)  accelerate  and  facilitate  the
34    development  of  integrated  health care in contracting areas
HB0781 Engrossed            -45-               LRB9000971DJcd
 1    outside counties with populations in excess of 3,000,000  and
 2    counties  adjacent  to  those  counties and (ii) maintain and
 3    sustain the high quality of education and residency  programs
 4    coordinated  and  associated  with  local area hospitals, the
 5    Illinois Department may develop and implement a demonstration
 6    program for managed care community networks owned,  operated,
 7    or  governed  by  State-funded medical schools.  The Illinois
 8    Department shall prescribe by rule the  criteria,  standards,
 9    and procedures for effecting this demonstration program.
10        (s)  (Blank).
11        (s-5)  The  Illinois  Department  may impose penalties or
12    sanctions  permitted by law or  contract  for  violations  of
13    this Section.
14        (t)  On  April 1, 1995 and every 6 months thereafter, the
15    Illinois Department shall report to the Governor and  General
16    Assembly  on  the  progress  of  the  integrated  health care
17    program  in  enrolling  clients  into  managed  health   care
18    entities.   The  report  shall indicate the capacities of the
19    managed health care entities with which the State  contracts,
20    the  number of clients enrolled by each contractor, the areas
21    of the State in which managed care options do not exist,  and
22    the  progress  toward  meeting  the  enrollment  goals of the
23    integrated health care program.
24        (u)  The Illinois Department may implement  this  Section
25    through the use of emergency rules in accordance with Section
26    5-45  of  the  Illinois  Administrative  Procedure  Act.  For
27    purposes of that Act, the adoption of rules to implement this
28    Section is deemed an emergency and necessary for  the  public
29    interest, safety, and welfare.
30        (v)  The   Auditor   General   shall  conduct  an  annual
31    performance audit  of  the  integrated  health  care  program
32    created  under  this  Section  and  the Illinois Department's
33    implementation of this  Section.   The  initial  audit  shall
34    cover  the  fiscal  year ending June 30, 1997, and subsequent
HB0781 Engrossed            -46-               LRB9000971DJcd
 1    audits shall cover each fiscal year thereafter.  The  Auditor
 2    General  shall  issue  reports  of  the  audits  on or before
 3    December 31 of 1997 and each year thereafter.
 4    (Source: P.A.  88-554,  eff.  7-26-94;  89-21,  eff.  7-1-95;
 5    89-507, eff. 7-1-97; 89-673, eff. 8-14-96; revised 8-26-96.)
 6        (305 ILCS 5/5-16.8 new)
 7        Sec. 5-16.8.  Administration of managed care program.
 8        (a)  The  Illinois  Department  shall, by rule, establish
 9    guidelines for its administration of a managed  care  program
10    requiring each managed care organization participating in the
11    program   to   provide   education   programs  for  providers
12    participating within the managed care organization's  network
13    and for persons eligible for medical assistance under Article
14    V,  VI,  or  XII  who  are  enrolled  with  the  managed care
15    organization.
16        (b)  A   provider   education   program   must    include
17    information on:
18             (1)  Medicaid   policies,   procedures,  eligibility
19        standards, and benefits;
20             (2)  the specific problems  and  needs  of  Medicaid
21        clients; and
22             (3)  the  rights  and  responsibilities  of Medicaid
23        clients prescribed by this Section.
24        (c)  A client education program must present  information
25    in  a  manner  that  is  easy  to understand.  A program must
26    include information on:
27             (1)  the rights and responsibilities  prescribed  by
28        this Section;
29             (2)  how to access health care services;
30             (3)  how  to  access  complaint  procedures  and the
31        client's rights to bypass the managed care organization's
32        internal complaint system and use the notice  and  appeal
33        procedures otherwise required by the Medicaid program;
HB0781 Engrossed            -47-               LRB9000971DJcd
 1             (4)  Medicaid   policies,   procedures,  eligibility
 2        standards, and benefits;
 3             (5)  the policies and procedures of the managed care
 4        organization; and
 5             (6)  the    importance    of    prevention,    early
 6        intervention, and appropriate use of services.
 7        (d)  The Department or its  designee  shall  inform  each
 8    person  enrolled  in  the  Medicaid  program  of the person's
 9    rights  and  responsibilities  under   that   program.    The
10    information must address the client's right to:
11             (1)  respect, dignity, privacy, confidentiality, and
12        nondiscrimination;
13             (2)  a  reasonable  opportunity  to  choose a health
14        care plan and primary care  provider  and  to  change  to
15        another plan or provider in a reasonable manner;
16             (3)  consent  to  or  refuse  treatment and actively
17        participate in treatment decisions;
18             (4)  ask questions and receive complete  information
19        relating  to the client's medical condition and treatment
20        options, including specialty care;
21             (5)  access  each   available   complaint   process,
22        receive  a  timely response to a complaint, and receive a
23        fair hearing; and
24             (6)  timely access to care that does  not  have  any
25        communication or physical access barriers.
26        (e)  The    information    must    address   a   client's
27    responsibility to:
28             (1)  learn and understand each right the client  has
29        under the Medicaid program;
30             (2)  abide  by the health plan and Medicaid policies
31        and procedures;
32             (3)  share  information  relating  to  the  client's
33        health status with the primary care provider  and  become
34        fully informed about service and treatment options; and
HB0781 Engrossed            -48-               LRB9000971DJcd
 1             (4)  actively  participate  in decisions relating to
 2        service and treatment options, make personal choices  and
 3        take action to maintain the client's health.
 4        (f)  The Department shall provide support and information
 5    services  to a person enrolled in the program or applying for
 6    Medicaid  coverage  who  experiences  barriers  to  receiving
 7    health care services.  The Department may  contract  for  the
 8    provision  of  support and information services. As a part of
 9    the  support  and  information  services  required  by   this
10    subsection, the Department or organization shall:
11             (1)  operate   a   statewide   toll-free  assistance
12        telephone number that includes TDD lines  and  assistance
13        for persons who speak Spanish;
14             (2)  intervene   promptly   with  the  managed  care
15        organizations and providers  and  any  other  appropriate
16        entity  on  behalf of a person who has an urgent need for
17        medical services;
18             (3)  assist a person who is experiencing barriers in
19        the Medicaid application and enrollment process and refer
20        the person for further assistance if appropriate;
21             (4)  educate persons so that they:
22                  (A)  understand the concept of managed care;
23                  (B)  understand their rights under the Medicaid
24             program, including grievance and appeal  procedures;
25             and
26                  (C)  are able to advocate for themselves; and
27             (5)  collect and maintain statistical information on
28        a   regional   basis  regarding  calls  received  by  the
29        assistance lines and publish quarterly reports that:
30                  (A)  list  the  number  of  calls  received  by
31             region;
32                  (B)  identify trends  in  delivery  and  access
33             problems;
34                  (C)  identify   recurring   barriers   in   the
HB0781 Engrossed            -49-               LRB9000971DJcd
 1             Medicaid system; and
 2                  (D)  indicate  other  problems  identified with
 3             Medicaid managed care; and
 4             (6)  assist  the  managed  care  organizations   and
 5        providers   in   identifying   and  correcting  problems,
 6        including site visits to affected regions if necessary.
 7        (305 ILCS 5/12-13.1)
 8        (Text of Section before amendment by P.A. 89-507)
 9        Sec. 12-13.1.  Inspector General.
10        (a)  The Governor shall appoint,  and  the  Senate  shall
11    confirm,  an  Inspector General who shall function within the
12    Illinois Department and report to the Governor. The  term  of
13    the  Inspector  General  shall  expire on the third Monday of
14    January, 1997 and every 4 years thereafter.
15        (b)  In order to prevent, detect,  and  eliminate  fraud,
16    waste,  abuse,  mismanagement,  and misconduct, the Inspector
17    General shall oversee  the  Illinois  Department's  integrity
18    functions,  which  include,  but  are  not  limited  to,  the
19    following:
20             (1)  Investigation   of   misconduct  by  employees,
21        vendors, contractors and medical providers.
22             (2)  Audits of medical providers related to ensuring
23        that appropriate payments are made for services  rendered
24        and to the recovery of overpayments.
25             (3)  Monitoring   of   quality   assurance  programs
26        generally related to the medical assistance  program  and
27        specifically related to any managed care program.
28             (4)  Quality  control  measurements  of the programs
29        administered by the Illinois Department.
30             (5)  Investigations of fraud or intentional  program
31        violations   committed   by   clients   of  the  Illinois
32        Department.
33             (6)  Actions  initiated   against   contractors   or
HB0781 Engrossed            -50-               LRB9000971DJcd
 1        medical providers for any of the following reasons:
 2                  (A)  Violations   of   the  medical  assistance
 3             program.
 4                  (B)  Sanctions  against  providers  brought  in
 5             conjunction with the Department of Public Health  or
 6             the  Department  of  Mental Health and Developmental
 7             Disabilities.
 8                  (C)  Recoveries    of    assessments    against
 9             hospitals and long-term care facilities.
10                  (D)  Sanctions mandated by  the  United  States
11             Department  of  Health  and  Human  Services against
12             medical providers.
13                  (E)  Violations of  contracts  related  to  any
14             managed care programs.
15             (7)  Representation  of  the  Illinois Department at
16        hearings with the  Illinois  Department  of  Professional
17        Regulation in actions taken against professional licenses
18        held  by persons who are in violation of orders for child
19        support payments.
20        (b-7)  The Inspector General may  establish  within  that
21    Office   a  special  administrative  subdivision  to  monitor
22    managed health care entities participating in the  integrated
23    health  care program established under Section 5-16.3 of this
24    Code to ensure that the entities comply with the requirements
25    of that Section.  This special administrative subdivision may
26    receive and investigate complaints made by  persons  enrolled
27    in  a  managed  health  care  entity's  health  care delivery
28    system.  If the Inspector General investigates  a  complaint,
29    the  Inspector  General  shall  determine  whether  a managed
30    health care entity has  complied  with  the  requirements  of
31    Section 5-16.3 and the rules implementing that Section to the
32    extent that those issues are raised by the complaint.
33        The  Inspector  General  may  also  monitor  the Enrolled
34    Managed Care  Provider program  to  ensure  that  appropriate
HB0781 Engrossed            -51-               LRB9000971DJcd
 1    management of patient care  occurs and that services provided
 2    are   medically   necessary.   The  special    administrative
 3    subdivision authorized under this subsection may receive  and
 4    investigate  complaints  made  by  persons receiving services
 5    under Section 5-16.3.
 6        (c)  The Inspector  General  shall  have  access  to  all
 7    information,   personnel   and  facilities  of  the  Illinois
 8    Department, its employees, vendors, contractors  and  medical
 9    providers and any federal, State or local governmental agency
10    that  are  necessary  to  perform the duties of the Office as
11    directly related to public assistance  programs  administered
12    by  the  Illinois  Department.   No medical provider shall be
13    compelled, however, to provide individual medical records  of
14    patients  who  are  not  clients  of  the  Medical Assistance
15    Program.   State  and   local   governmental   agencies   are
16    authorized and directed to provide the requested information,
17    assistance or cooperation.
18        (d)  The  Inspector  General  shall serve as the Illinois
19    Department's   primary   liaison   with   law    enforcement,
20    investigatory  and  prosecutorial agencies, including but not
21    limited to the following:
22             (1)  The Department of State Police.
23             (2)  The Federal Bureau of Investigation  and  other
24        federal law enforcement agencies.
25             (3)  The   various  Inspectors  General  of  federal
26        agencies overseeing  the  programs  administered  by  the
27        Illinois Department.
28             (4)  The  various  Inspectors  General  of any other
29        State agencies  with  responsibilities  for  portions  of
30        programs   primarily   administered   by   the   Illinois
31        Department.
32             (5)  The   Offices  of  the  several  United  States
33        Attorneys in Illinois.
34             (6)  The several State's Attorneys.
HB0781 Engrossed            -52-               LRB9000971DJcd
 1        The Inspector General shall meet on a regular basis  with
 2    these   entities  to  share  information  regarding  possible
 3    misconduct by any  persons  or  entities  involved  with  the
 4    public aid programs administered by the Illinois Department.
 5        (e)  All   investigations   conducted  by  the  Inspector
 6    General shall be conducted  in  a  manner  that  ensures  the
 7    preservation  of  evidence  for use in criminal prosecutions.
 8    If the Inspector General determines that a possible  criminal
 9    act  relating  to fraud in the provision or administration of
10    the  medical  assistance  program  has  been  committed,  the
11    Inspector General shall immediately notify the Medicaid Fraud
12    Control Unit.  If the Inspector  General  determines  that  a
13    possible   criminal   act   has  been  committed  within  the
14    jurisdiction of the Office, the Inspector General may request
15    the special expertise of the Department of State Police.  The
16    Inspector General may present for prosecution the findings of
17    any criminal investigation to  the  Office  of  the  Attorney
18    General, the Offices of the several United State Attorneys in
19    Illinois or the several State's Attorneys.
20        (f)  To  carry out his or her duties as described in this
21    Section, the Inspector General and his or her designees shall
22    have the power to  compel  by  subpoena  the  attendance  and
23    testimony   of   witnesses   and  the  production  of  books,
24    electronic records and papers as directly related  to  public
25    assistance  programs administered by the Illinois Department.
26    No medical provider shall be compelled, however,  to  provide
27    individual medical records of patients who are not clients of
28    the Medical Assistance Program.
29        (g)  The  Inspector General shall report all convictions,
30    terminations,  and   suspensions   taken   against   vendors,
31    contractors  and medical providers to the Illinois Department
32    and to any agency responsible  for  licensing  or  regulating
33    those persons or entities.
34        (h)  The  Inspector General shall make quarterly reports,
HB0781 Engrossed            -53-               LRB9000971DJcd
 1    findings,  and   recommendations   regarding   the   Office's
 2    investigations   into   reports   of   fraud,  waste,  abuse,
 3    mismanagement, or  misconduct  relating  to  any  public  aid
 4    programs  administered  by  the  Illinois  Department  to the
 5    General Assembly  and  the  Governor.   These  reports  shall
 6    include, but not be limited to, the following information:
 7             (1)  Aggregate    provider   billing   and   payment
 8        information, including the number of providers at various
 9        Medicaid earning levels.
10             (2)  The number of audits of the medical  assistance
11        program  and  the  dollar  savings  resulting  from those
12        audits.
13             (3)  The number of prescriptions  rejected  annually
14        under  the  Illinois Department's Refill Too Soon program
15        and the dollar savings resulting from that program.
16             (4)  Provider sanctions, in the aggregate, including
17        terminations and suspensions.
18             (5)  A  detailed  summary  of   the   investigations
19        undertaken  in the previous fiscal year.  These summaries
20        shall  comply  with  all   laws   and   rules   regarding
21        maintaining confidentiality in the public aid programs.
22        (i)  Nothing  in  this Section shall limit investigations
23    by the Illinois Department that may otherwise be required  by
24    law  or  that  may  be necessary in the Illinois Department's
25    capacity as the central administrative authority  responsible
26    for administration of public aid programs in this State.
27    (Source: P.A. 88-554, eff. 7-26-94.)
28        (Text of Section after amendment by P.A. 89-507)
29        Sec. 12-13.1.  Inspector General.
30        (a)  The  Governor  shall  appoint,  and the Senate shall
31    confirm, an Inspector General who shall function  within  the
32    Illinois Department of Public Aid and report to the Governor.
33    The  term  of the Inspector General shall expire on the third
34    Monday of January, 1997 and every 4 years thereafter.
HB0781 Engrossed            -54-               LRB9000971DJcd
 1        (b)  In order to prevent, detect,  and  eliminate  fraud,
 2    waste,  abuse,  mismanagement,  and misconduct, the Inspector
 3    General shall oversee the Illinois Department of Public Aid's
 4    integrity functions, which include, but are not  limited  to,
 5    the following:
 6             (1)  Investigation   of   misconduct  by  employees,
 7        vendors, contractors and medical providers.
 8             (2)  Audits of medical providers related to ensuring
 9        that appropriate payments are made for services  rendered
10        and to the recovery of overpayments.
11             (3)  Monitoring   of   quality   assurance  programs
12        generally related to the medical assistance  program  and
13        specifically related to any managed care program.
14             (4)  Quality  control  measurements  of the programs
15        administered by the Illinois Department of Public Aid.
16             (5)  Investigations of fraud or intentional  program
17        violations   committed   by   clients   of  the  Illinois
18        Department of Public Aid.
19             (6)  Actions  initiated   against   contractors   or
20        medical providers for any of the following reasons:
21                  (A)  Violations   of   the  medical  assistance
22             program.
23                  (B)  Sanctions  against  providers  brought  in
24             conjunction with the Department of Public Health  or
25             the  Department  of  Human Services (as successor to
26             the Department of Mental  Health  and  Developmental
27             Disabilities).
28                  (C)  Recoveries    of    assessments    against
29             hospitals and long-term care facilities.
30                  (D)  Sanctions  mandated  by  the United States
31             Department of  Health  and  Human  Services  against
32             medical providers.
33                  (E)  Violations  of  contracts  related  to any
34             managed care programs.
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 1             (7)  Representation of the  Illinois  Department  of
 2        Public  Aid  at  hearings with the Illinois Department of
 3        Professional  Regulation   in   actions   taken   against
 4        professional   licenses   held  by  persons  who  are  in
 5        violation of orders for child support payments.
 6        (b-5)  At the request of the Secretary of Human Services,
 7    the Inspector General shall,  in  relation  to  any  function
 8    performed by the Department of Human Services as successor to
 9    the  Department  of  Public  Aid, exercise one or more of the
10    powers provided under this Section as if those powers related
11    to the Department of Human Services;  in  such  matters,  the
12    Inspector  General  shall  report  his or her findings to the
13    Secretary of Human Services.
14        (b-7)  The Inspector General may  establish  within  that
15    Office   a  special  administrative  subdivision  to  monitor
16    managed health care entities participating in the  integrated
17    health  care program established under Section 5-16.3 of this
18    Code to ensure that the entities comply with the requirements
19    of that Section.  This special administrative subdivision may
20    receive and investigate complaints made by  persons  enrolled
21    in  a  managed  health  care  entity's  health  care delivery
22    system.  If the Inspector General investigates  a  complaint,
23    the  Inspector  General  shall  determine  whether  a managed
24    health care entity has  complied  with  the  requirements  of
25    Section 5-16.3 and the rules implementing that Section to the
26    extent that those issues are raised by the complaint.
27        The  Inspector  General  may  also  monitor  the Enrolled
28    Managed Care  Provider program  to  ensure  that  appropriate
29    management of patient care  occurs and that services provided
30    are   medically   necessary.   The  special    administrative
31    subdivision authorized under this subsection may receive  and
32    investigate  complaints  made  by  persons receiving services
33    under Section 5-16.3.
34        (c)  The Inspector  General  shall  have  access  to  all
HB0781 Engrossed            -56-               LRB9000971DJcd
 1    information,   personnel   and  facilities  of  the  Illinois
 2    Department of Public Aid and the Department of Human Services
 3    (as  successor  to  the  Department  of  Public  Aid),  their
 4    employees, vendors, contractors and medical providers and any
 5    federal,  State  or  local  governmental  agency   that   are
 6    necessary  to  perform  the  duties of the Office as directly
 7    related to public assistance programs administered  by  those
 8    departments.    No   medical  provider  shall  be  compelled,
 9    however, to provide individual medical  records  of  patients
10    who are not clients of the Medical Assistance Program.  State
11    and  local  governmental agencies are authorized and directed
12    to  provide  the   requested   information,   assistance   or
13    cooperation.
14        (d)  The  Inspector  General  shall serve as the Illinois
15    Department  of  Public  Aid's  primary   liaison   with   law
16    enforcement,   investigatory   and   prosecutorial  agencies,
17    including but not limited to the following:
18             (1)  The Department of State Police.
19             (2)  The Federal Bureau of Investigation  and  other
20        federal law enforcement agencies.
21             (3)  The   various  Inspectors  General  of  federal
22        agencies overseeing  the  programs  administered  by  the
23        Illinois Department of Public Aid.
24             (4)  The  various  Inspectors  General  of any other
25        State agencies  with  responsibilities  for  portions  of
26        programs   primarily   administered   by   the   Illinois
27        Department of Public Aid.
28             (5)  The   Offices  of  the  several  United  States
29        Attorneys in Illinois.
30             (6)  The several State's Attorneys.
31        The Inspector General shall meet on a regular basis  with
32    these   entities  to  share  information  regarding  possible
33    misconduct by any  persons  or  entities  involved  with  the
34    public  aid  programs administered by the Illinois Department
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 1    of Public Aid.
 2        (e)  All  investigations  conducted  by   the   Inspector
 3    General  shall  be  conducted  in  a  manner that ensures the
 4    preservation of evidence for use  in  criminal  prosecutions.
 5    If  the Inspector General determines that a possible criminal
 6    act relating to fraud in the provision or  administration  of
 7    the  medical  assistance  program  has  been  committed,  the
 8    Inspector General shall immediately notify the Medicaid Fraud
 9    Control  Unit.   If  the  Inspector General determines that a
10    possible  criminal  act  has  been   committed   within   the
11    jurisdiction of the Office, the Inspector General may request
12    the special expertise of the Department of State Police.  The
13    Inspector General may present for prosecution the findings of
14    any  criminal  investigation  to  the  Office of the Attorney
15    General, the Offices of the several United State Attorneys in
16    Illinois or the several State's Attorneys.
17        (f)  To carry out his or her duties as described in  this
18    Section, the Inspector General and his or her designees shall
19    have  the  power  to  compel  by  subpoena the attendance and
20    testimony  of  witnesses  and  the   production   of   books,
21    electronic  records  and papers as directly related to public
22    assistance programs administered by the  Illinois  Department
23    of  Public  Aid  or  the  Department  of  Human  Services (as
24    successor to the  Department  of  Public  Aid).   No  medical
25    provider  shall  be compelled, however, to provide individual
26    medical records of  patients  who  are  not  clients  of  the
27    Medical Assistance Program.
28        (g)  The  Inspector General shall report all convictions,
29    terminations,  and   suspensions   taken   against   vendors,
30    contractors  and medical providers to the Illinois Department
31    of Public Aid and to any agency responsible for licensing  or
32    regulating those persons or entities.
33        (h)  The  Inspector General shall make quarterly reports,
34    findings,  and   recommendations   regarding   the   Office's
HB0781 Engrossed            -58-               LRB9000971DJcd
 1    investigations   into   reports   of   fraud,  waste,  abuse,
 2    mismanagement, or  misconduct  relating  to  any  public  aid
 3    programs  administered  by  the Illinois Department of Public
 4    Aid or the Department of Human Services (as successor to  the
 5    Department  of  Public  Aid)  to the General Assembly and the
 6    Governor.  These reports shall include, but  not  be  limited
 7    to, the following information:
 8             (1)  Aggregate    provider   billing   and   payment
 9        information, including the number of providers at various
10        Medicaid earning levels.
11             (2)  The number of audits of the medical  assistance
12        program  and  the  dollar  savings  resulting  from those
13        audits.
14             (3)  The number of prescriptions  rejected  annually
15        under  the Illinois Department of Public Aid's Refill Too
16        Soon program and the dollar savings resulting  from  that
17        program.
18             (4)  Provider sanctions, in the aggregate, including
19        terminations and suspensions.
20             (5)  A   detailed   summary  of  the  investigations
21        undertaken in the previous fiscal year.  These  summaries
22        shall   comply   with   all   laws  and  rules  regarding
23        maintaining confidentiality in the public aid programs.
24        (i)  Nothing in this Section shall  limit  investigations
25    by the Illinois Department of Public Aid or the Department of
26    Human  Services that may otherwise be required by law or that
27    may  be  necessary  in  their   capacity   as   the   central
28    administrative  authorities responsible for administration of
29    public aid programs in this State.
30    (Source: P.A. 88-554, eff. 7-26-94; 89-507, eff. 7-1-97.)
31        Section 95.  No acceleration or delay.   Where  this  Act
32    makes changes in a statute that is represented in this Act by
33    text  that  is not yet or no longer in effect (for example, a
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 1    Section represented by multiple versions), the  use  of  that
 2    text  does  not  accelerate or delay the taking effect of (i)
 3    the changes made by this Act or (ii) provisions derived  from
 4    any other Public Act.
 5        Section  99.  Effective date.  This Act takes effect upon
 6    becoming law.

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