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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. HB0781 Engrossed -55- LRB9000971DJcd 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 HB0781 Engrossed -57- LRB9000971DJcd 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 HB0781 Engrossed -59- LRB9000971DJcd 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.