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90_HB0781ham002
HDS90HB0781KDa391mm
1 AMENDMENT TO HOUSE BILL 781
2 AMENDMENT NO. . Amend House Bill 781 by replacing
3 the title with the following:
4 "AN ACT to amend the Illinois Public Aid Code by changing
5 Sections 5-16.3 and 12-13.1 and adding Section 5-16.8."; and
6 by replacing everything after the enacting clause with the
7 following:
8 "Section 5. The Illinois Public Aid Code is amended by
9 changing Sections 5-16.3 and 12-13.1 and adding Section
10 5-16.8 as follows:
11 (305 ILCS 5/5-16.3)
12 (Text of Section before amendment by P.A. 89-507)
13 Sec. 5-16.3. System for integrated health care services.
14 (a) It shall be the public policy of the State to adopt,
15 to the extent practicable, a health care program that
16 encourages the integration of health care services and
17 manages the health care of program enrollees while preserving
18 reasonable choice within a competitive and cost-efficient
19 environment. In furtherance of this public policy, the
20 Illinois Department shall develop and implement an integrated
21 health care program consistent with the provisions of this
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1 Section. The provisions of this Section apply only to the
2 integrated health care program created under this Section.
3 Persons enrolled in the integrated health care program, as
4 determined by the Illinois Department by rule, shall be
5 afforded a choice among health care delivery systems, which
6 shall include, but are not limited to, (i) fee for service
7 care managed by a primary care physician licensed to practice
8 medicine in all its branches, (ii) managed health care
9 entities, and (iii) federally qualified health centers
10 (reimbursed according to a prospective cost-reimbursement
11 methodology) and rural health clinics (reimbursed according
12 to the Medicare methodology), where available. Persons
13 enrolled in the integrated health care program also may be
14 offered indemnity insurance plans, subject to availability.
15 For purposes of this Section, a "managed health care
16 entity" means a health maintenance organization or a managed
17 care community network as defined in this Section. A "health
18 maintenance organization" means a health maintenance
19 organization as defined in the Health Maintenance
20 Organization Act. A "managed care community network" means
21 an entity, other than a health maintenance organization, that
22 is owned, operated, or governed by providers of health care
23 services within this State and that provides or arranges
24 primary, secondary, and tertiary managed health care services
25 under contract with the Illinois Department exclusively to
26 enrollees of the integrated health care program. A managed
27 care community network may contract with the Illinois
28 Department to provide only pediatric health care services. A
29 county provider as defined in Section 15-1 of this Code may
30 contract with the Illinois Department to provide services to
31 enrollees of the integrated health care program as a managed
32 care community network without the need to establish a
33 separate entity that provides services exclusively to
34 enrollees of the integrated health care program and shall be
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1 deemed a managed care community network for purposes of this
2 Code only to the extent of the provision of services to those
3 enrollees in conjunction with the integrated health care
4 program. A county provider shall be entitled to contract
5 with the Illinois Department with respect to any contracting
6 region located in whole or in part within the county. A
7 county provider shall not be required to accept enrollees who
8 do not reside within the county.
9 If a managed health care entity is accredited by a
10 private national organization that performs quality assurance
11 surveys of health maintenance organizations or related
12 organizations, the Illinois Department may take the
13 accreditation into consideration when selecting managed
14 health care entities for participation in the integrated
15 health care program. The medical director of a managed
16 health care entity must be a physician licensed in the State
17 to practice medicine in all its branches.
18 Each managed care community network must demonstrate its
19 ability to bear the financial risk of serving enrollees under
20 this program. The Illinois Department shall by rule adopt
21 criteria for assessing the financial soundness of each
22 managed care community network. These rules shall consider
23 the extent to which a managed care community network is
24 comprised of providers who directly render health care and
25 are located within the community in which they seek to
26 contract rather than solely arrange or finance the delivery
27 of health care. These rules shall further consider a variety
28 of risk-bearing and management techniques, including the
29 sufficiency of quality assurance and utilization management
30 programs and whether a managed care community network has
31 sufficiently demonstrated its financial solvency and net
32 worth. The Illinois Department's criteria must be based on
33 sound actuarial, financial, and accounting principles. In
34 adopting these rules, the Illinois Department shall consult
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1 with the Illinois Department of Insurance. The Illinois
2 Department is responsible for monitoring compliance with
3 these rules.
4 This Section may not be implemented before the effective
5 date of these rules, the approval of any necessary federal
6 waivers, and the completion of the review of an application
7 submitted, at least 60 days before the effective date of
8 rules adopted under this Section, to the Illinois Department
9 by a managed care community network.
10 All health care delivery systems that contract with the
11 Illinois Department under the integrated health care program
12 shall clearly recognize a health care provider's right of
13 conscience under the Right of Conscience Act. In addition to
14 the provisions of that Act, no health care delivery system
15 that contracts with the Illinois Department under the
16 integrated health care program shall be required to provide,
17 arrange for, or pay for any health care or medical service,
18 procedure, or product if that health care delivery system is
19 owned, controlled, or sponsored by or affiliated with a
20 religious institution or religious organization that finds
21 that health care or medical service, procedure, or product to
22 violate its religious and moral teachings and beliefs.
23 (b) The Illinois Department may, by rule, provide for
24 different benefit packages for different categories of
25 persons enrolled in the program. Mental health services,
26 alcohol and substance abuse services, services related to
27 children with chronic or acute conditions requiring
28 longer-term treatment and follow-up, and rehabilitation care
29 provided by a free-standing rehabilitation hospital or a
30 hospital rehabilitation unit may be excluded from a benefit
31 package if the State ensures that those services are made
32 available through a separate delivery system. An exclusion
33 does not prohibit the Illinois Department from developing and
34 implementing demonstration projects for categories of persons
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1 or services. Benefit packages for persons eligible for
2 medical assistance under Articles V, VI, and XII shall be
3 based on the requirements of those Articles and shall be
4 consistent with the Title XIX of the Social Security Act.
5 Nothing in this Act shall be construed to apply to services
6 purchased by the Department of Children and Family Services
7 and the Department of Mental Health and Developmental
8 Disabilities under the provisions of Title 59 of the Illinois
9 Administrative Code, Part 132 ("Medicaid Community Mental
10 Health Services Program").
11 (c) The program established by this Section may be
12 implemented by the Illinois Department in various contracting
13 areas at various times. The health care delivery systems and
14 providers available under the program may vary throughout the
15 State. For purposes of contracting with managed health care
16 entities and providers, the Illinois Department shall
17 establish contracting areas similar to the geographic areas
18 designated by the Illinois Department for contracting
19 purposes under the Illinois Competitive Access and
20 Reimbursement Equity Program (ICARE) under the authority of
21 Section 3-4 of the Illinois Health Finance Reform Act or
22 similarly-sized or smaller geographic areas established by
23 the Illinois Department by rule. A managed health care entity
24 shall be permitted to contract in any geographic areas for
25 which it has a sufficient provider network and otherwise
26 meets the contracting terms of the State. The Illinois
27 Department is not prohibited from entering into a contract
28 with a managed health care entity at any time.
29 (d) A managed health care entity that contracts with the
30 Illinois Department for the provision of services under the
31 program shall do all of the following, solely for purposes of
32 the integrated health care program:
33 (1) Provide that any individual physician licensed
34 to practice medicine in all its branches, any pharmacy,
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1 any federally qualified health center, and any
2 podiatrist, that consistently meets the reasonable terms
3 and conditions established by the managed health care
4 entity, including but not limited to credentialing
5 standards, quality assurance program requirements,
6 utilization management requirements, financial
7 responsibility standards, contracting process
8 requirements, and provider network size and accessibility
9 requirements, must be accepted by the managed health care
10 entity for purposes of the Illinois integrated health
11 care program. Any individual who is either terminated
12 from or denied inclusion in the panel of physicians of
13 the managed health care entity shall be given, within 10
14 business days after that determination, a written
15 explanation of the reasons for his or her exclusion or
16 termination from the panel. This paragraph (1) does not
17 apply to the following:
18 (A) A managed health care entity that
19 certifies to the Illinois Department that:
20 (i) it employs on a full-time basis 125
21 or more Illinois physicians licensed to
22 practice medicine in all of its branches; and
23 (ii) it will provide medical services
24 through its employees to more than 80% of the
25 recipients enrolled with the entity in the
26 integrated health care program; or
27 (B) A domestic stock insurance company
28 licensed under clause (b) of class 1 of Section 4 of
29 the Illinois Insurance Code if (i) at least 66% of
30 the stock of the insurance company is owned by a
31 professional corporation organized under the
32 Professional Service Corporation Act that has 125 or
33 more shareholders who are Illinois physicians
34 licensed to practice medicine in all of its branches
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1 and (ii) the insurance company certifies to the
2 Illinois Department that at least 80% of those
3 physician shareholders will provide services to
4 recipients enrolled with the company in the
5 integrated health care program.
6 (2) Provide for reimbursement for providers for
7 emergency care, as defined by the Illinois Department by
8 rule, that must be provided to its enrollees, including
9 an emergency room screening fee, and urgent care that it
10 authorizes for its enrollees, regardless of the
11 provider's affiliation with the managed health care
12 entity. Providers shall be reimbursed for emergency care
13 at an amount equal to the Illinois Department's
14 fee-for-service rates for those medical services rendered
15 by providers not under contract with the managed health
16 care entity to enrollees of the entity.
17 (3) Provide that any provider affiliated with a
18 managed health care entity may also provide services on a
19 fee-for-service basis to Illinois Department clients not
20 enrolled in a managed health care entity.
21 (4) Provide client education services as determined
22 and approved by the Illinois Department, including but
23 not limited to (i) education regarding appropriate
24 utilization of health care services in a managed care
25 system, (ii) written disclosure of treatment policies and
26 any restrictions or limitations on health services,
27 including, but not limited to, physical services,
28 clinical laboratory tests, hospital and surgical
29 procedures, prescription drugs and biologics, and
30 radiological examinations, and (iii) written notice that
31 the enrollee may receive from another provider those
32 services covered under this program that are not provided
33 by the managed health care entity.
34 (4.5) Provide orientation to the caretaker relative
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1 or payee of a medical assistance unit that has an
2 enrollee as a member. The managed health care entity
3 must exercise good faith efforts to provide all caretaker
4 relatives or payees with the orientation. The managed
5 health care entity shall inform the Illinois Department
6 of the caretaker relatives or payees who have completed
7 the orientation. This paragraph applies to every
8 caretaker relative or payee in a managed health care
9 entity's system regardless of whether the caretaker
10 relative or payee has chosen the system or has been
11 assigned to the system as provided in subsection (e).
12 (5) Provide that enrollees within its system may
13 choose the site for provision of services and the panel
14 of health care providers.
15 (6) Not discriminate in its enrollment or
16 disenrollment practices among recipients of medical
17 services or program enrollees based on health status.
18 (7) Provide a quality assurance and utilization
19 review program that (i) for health maintenance
20 organizations meets the requirements of the Health
21 Maintenance Organization Act and (ii) for managed care
22 community networks meets the requirements established by
23 the Illinois Department in rules that incorporate those
24 standards set forth in the Health Maintenance
25 Organization Act.
26 (8) Issue a managed health care entity
27 identification card to each enrollee upon enrollment.
28 The card must contain all of the following:
29 (A) The enrollee's signature.
30 (B) The enrollee's health plan.
31 (C) The name and telephone number of the
32 enrollee's primary care physician.
33 (D) A telephone number to be used for
34 emergency service 24 hours per day, 7 days per week.
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1 The telephone number required to be maintained
2 pursuant to this subparagraph by each managed health
3 care entity shall, at minimum, be staffed by
4 medically trained personnel and be provided
5 directly, or under arrangement, at an office or
6 offices in locations maintained solely within the
7 State of Illinois. For purposes of this
8 subparagraph, "medically trained personnel" means
9 licensed practical nurses or registered nurses
10 located in the State of Illinois who are licensed
11 pursuant to the Illinois Nursing Act of 1987.
12 (8.5) The Illinois Department must include
13 performance standards in contracts with entities
14 participating in the integrated health care program to
15 require contractors to make a good faith effort to have
16 enrollees evaluated by a physician within a reasonable
17 period of time after enrollment, as determined by the
18 Illinois Department.
19 (9) Ensure that every primary care physician and
20 pharmacy in the managed health care entity meets the
21 standards established by the Illinois Department for
22 accessibility and quality of care. The Illinois
23 Department shall arrange for and oversee an evaluation of
24 the standards established under this paragraph (9) and
25 may recommend any necessary changes to these standards.
26 The Illinois Department shall submit an annual report to
27 the Governor and the General Assembly by April 1 of each
28 year regarding the effect of the standards on ensuring
29 access and quality of care to enrollees.
30 (10) Provide a procedure for handling complaints
31 that (i) for health maintenance organizations meets the
32 requirements of the Health Maintenance Organization Act
33 and (ii) for managed care community networks meets the
34 requirements established by the Illinois Department in
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1 rules that incorporate those standards set forth in the
2 Health Maintenance Organization Act.
3 (11) Maintain, retain, and make available to the
4 Illinois Department records, data, and information, in a
5 uniform manner determined by the Illinois Department,
6 sufficient for the Illinois Department to monitor
7 utilization, accessibility, and quality of care.
8 (12) Except for providers who are prepaid, pay all
9 approved claims for covered services that are completed
10 and submitted to the managed health care entity within 30
11 days after receipt of the claim or receipt of the
12 appropriate capitation payment or payments by the managed
13 health care entity from the State for the month in which
14 the services included on the claim were rendered,
15 whichever is later. If payment is not made or mailed to
16 the provider by the managed health care entity by the due
17 date under this subsection, an interest penalty of 1% of
18 any amount unpaid shall be added for each month or
19 fraction of a month after the due date, until final
20 payment is made. Nothing in this Section shall prohibit
21 managed health care entities and providers from mutually
22 agreeing to terms that require more timely payment.
23 (12.5) Ensure that no payment is made to a
24 physician or other provider of services for withholding
25 from an enrollee any covered services because of the cost
26 of those services. This requirement shall not be
27 construed to prevent managed health care entities from
28 offering, nor providers from accepting, full or partial
29 capitation.
30 (13) Provide integration with community-based
31 programs provided by certified local health departments
32 such as Women, Infants, and Children Supplemental Food
33 Program (WIC), childhood immunization programs, health
34 education programs, case management programs, and health
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1 screening programs.
2 (14) Provide that the pharmacy formulary used by a
3 managed health care entity and its contract providers be
4 no more restrictive than the Illinois Department's
5 pharmaceutical program on the effective date of this
6 amendatory Act of 1994 and as amended after that date.
7 (15) Provide integration with community-based
8 organizations, including, but not limited to, any
9 organization that has operated within a Medicaid
10 Partnership as defined by this Code or by rule of the
11 Illinois Department, that may continue to operate under a
12 contract with the Illinois Department or a managed health
13 care entity under this Section to provide case management
14 services to Medicaid clients in designated high-need
15 areas.
16 The Illinois Department may, by rule, determine
17 methodologies to limit financial liability for managed health
18 care entities resulting from payment for services to
19 enrollees provided under the Illinois Department's integrated
20 health care program. Any methodology so determined may be
21 considered or implemented by the Illinois Department through
22 a contract with a managed health care entity under this
23 integrated health care program.
24 The Illinois Department shall contract with an entity or
25 entities to provide external peer-based quality assurance
26 review for the integrated health care program. The entity
27 shall be representative of Illinois physicians licensed to
28 practice medicine in all its branches and have statewide
29 geographic representation in all specialties of medical care
30 that are provided within the integrated health care program.
31 The entity may not be a third party payer and shall maintain
32 offices in locations around the State in order to provide
33 service and continuing medical education to physician
34 participants within the integrated health care program. The
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1 review process shall be developed and conducted by Illinois
2 physicians licensed to practice medicine in all its branches.
3 In consultation with the entity, the Illinois Department may
4 contract with other entities for professional peer-based
5 quality assurance review of individual categories of services
6 other than services provided, supervised, or coordinated by
7 physicians licensed to practice medicine in all its branches.
8 The Illinois Department shall establish, by rule, criteria to
9 avoid conflicts of interest in the conduct of quality
10 assurance activities consistent with professional peer-review
11 standards. All quality assurance activities shall be
12 coordinated by the Illinois Department.
13 (e) All persons enrolled in the program shall be
14 provided with a full written explanation of all
15 fee-for-service and managed health care plan options and a
16 reasonable opportunity to choose among the options as
17 provided by rule. The Illinois Department shall provide to
18 enrollees, upon enrollment in the integrated health care
19 program and at least annually thereafter, notice of the
20 process for requesting an appeal under the Illinois
21 Department's administrative appeal procedures.
22 Notwithstanding any other Section of this Code, the Illinois
23 Department may provide by rule for the Illinois Department to
24 assign a person enrolled in the program to a specific
25 provider of medical services or to a specific health care
26 delivery system if an enrollee has failed to exercise choice
27 in a timely manner. An enrollee assigned by the Illinois
28 Department shall be afforded the opportunity to disenroll and
29 to select a specific provider of medical services or a
30 specific health care delivery system within the first 30 days
31 after the assignment. An enrollee who has failed to exercise
32 choice in a timely manner may be assigned only if there are 3
33 or more managed health care entities contracting with the
34 Illinois Department within the contracting area, except that,
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1 outside the City of Chicago, this requirement may be waived
2 for an area by rules adopted by the Illinois Department after
3 consultation with all hospitals within the contracting area.
4 The Illinois Department shall establish by rule the procedure
5 for random assignment of enrollees who fail to exercise
6 choice in a timely manner to a specific managed health care
7 entity in proportion to the available capacity of that
8 managed health care entity. Assignment to a specific provider
9 of medical services or to a specific managed health care
10 entity may not exceed that provider's or entity's capacity as
11 determined by the Illinois Department. Any person who has
12 chosen a specific provider of medical services or a specific
13 managed health care entity, or any person who has been
14 assigned under this subsection, shall be given the
15 opportunity to change that choice or assignment at least once
16 every 12 months, as determined by the Illinois Department by
17 rule. The Illinois Department shall maintain a toll-free
18 telephone number for program enrollees' use in reporting
19 problems with managed health care entities.
20 (f) If a person becomes eligible for participation in
21 the integrated health care program while he or she is
22 hospitalized, the Illinois Department may not enroll that
23 person in the program until after he or she has been
24 discharged from the hospital. This subsection does not apply
25 to newborn infants whose mothers are enrolled in the
26 integrated health care program.
27 (g) The Illinois Department shall, by rule, establish
28 for managed health care entities rates that (i) are certified
29 to be actuarially sound, as determined by an actuary who is
30 an associate or a fellow of the Society of Actuaries or a
31 member of the American Academy of Actuaries and who has
32 expertise and experience in medical insurance and benefit
33 programs, in accordance with the Illinois Department's
34 current fee-for-service payment system, and (ii) take into
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1 account any difference of cost to provide health care to
2 different populations based on gender, age, location, and
3 eligibility category. The rates for managed health care
4 entities shall be determined on a capitated basis.
5 The Illinois Department by rule shall establish a method
6 to adjust its payments to managed health care entities in a
7 manner intended to avoid providing any financial incentive to
8 a managed health care entity to refer patients to a county
9 provider, in an Illinois county having a population greater
10 than 3,000,000, that is paid directly by the Illinois
11 Department. The Illinois Department shall by April 1, 1997,
12 and annually thereafter, review the method to adjust
13 payments. Payments by the Illinois Department to the county
14 provider, for persons not enrolled in a managed care
15 community network owned or operated by a county provider,
16 shall be paid on a fee-for-service basis under Article XV of
17 this Code.
18 The Illinois Department by rule shall establish a method
19 to reduce its payments to managed health care entities to
20 take into consideration (i) any adjustment payments paid to
21 hospitals under subsection (h) of this Section to the extent
22 those payments, or any part of those payments, have been
23 taken into account in establishing capitated rates under this
24 subsection (g) and (ii) the implementation of methodologies
25 to limit financial liability for managed health care entities
26 under subsection (d) of this Section.
27 (h) For hospital services provided by a hospital that
28 contracts with a managed health care entity, adjustment
29 payments shall be paid directly to the hospital by the
30 Illinois Department. Adjustment payments may include but
31 need not be limited to adjustment payments to:
32 disproportionate share hospitals under Section 5-5.02 of this
33 Code; primary care access health care education payments (89
34 Ill. Adm. Code 149.140); payments for capital, direct medical
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1 education, indirect medical education, certified registered
2 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
3 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
4 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
5 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
6 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
7 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
8 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
9 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
10 148.290(h)); and outpatient indigent volume adjustments (89
11 Ill. Adm. Code 148.140(b)(5)).
12 (i) For any hospital eligible for the adjustment
13 payments described in subsection (h), the Illinois Department
14 shall maintain, through the period ending June 30, 1995,
15 reimbursement levels in accordance with statutes and rules in
16 effect on April 1, 1994.
17 (j) Nothing contained in this Code in any way limits or
18 otherwise impairs the authority or power of the Illinois
19 Department to enter into a negotiated contract pursuant to
20 this Section with a managed health care entity, including,
21 but not limited to, a health maintenance organization, that
22 provides for termination or nonrenewal of the contract
23 without cause upon notice as provided in the contract and
24 without a hearing.
25 (k) Section 5-5.15 does not apply to the program
26 developed and implemented pursuant to this Section.
27 (l) The Illinois Department shall, by rule, define those
28 chronic or acute medical conditions of childhood that require
29 longer-term treatment and follow-up care. The Illinois
30 Department shall ensure that services required to treat these
31 conditions are available through a separate delivery system.
32 A managed health care entity that contracts with the
33 Illinois Department may refer a child with medical conditions
34 described in the rules adopted under this subsection directly
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1 to a children's hospital or to a hospital, other than a
2 children's hospital, that is qualified to provide inpatient
3 and outpatient services to treat those conditions. The
4 Illinois Department shall provide fee-for-service
5 reimbursement directly to a children's hospital for those
6 services pursuant to Title 89 of the Illinois Administrative
7 Code, Section 148.280(a), at a rate at least equal to the
8 rate in effect on March 31, 1994. For hospitals, other than
9 children's hospitals, that are qualified to provide inpatient
10 and outpatient services to treat those conditions, the
11 Illinois Department shall provide reimbursement for those
12 services on a fee-for-service basis, at a rate at least equal
13 to the rate in effect for those other hospitals on March 31,
14 1994.
15 A children's hospital shall be directly reimbursed for
16 all services provided at the children's hospital on a
17 fee-for-service basis pursuant to Title 89 of the Illinois
18 Administrative Code, Section 148.280(a), at a rate at least
19 equal to the rate in effect on March 31, 1994, until the
20 later of (i) implementation of the integrated health care
21 program under this Section and development of actuarially
22 sound capitation rates for services other than those chronic
23 or acute medical conditions of childhood that require
24 longer-term treatment and follow-up care as defined by the
25 Illinois Department in the rules adopted under this
26 subsection or (ii) March 31, 1996.
27 Notwithstanding anything in this subsection to the
28 contrary, a managed health care entity shall not consider
29 sources or methods of payment in determining the referral of
30 a child. The Illinois Department shall adopt rules to
31 establish criteria for those referrals. The Illinois
32 Department by rule shall establish a method to adjust its
33 payments to managed health care entities in a manner intended
34 to avoid providing any financial incentive to a managed
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1 health care entity to refer patients to a provider who is
2 paid directly by the Illinois Department.
3 (m) Behavioral health services provided or funded by the
4 Department of Mental Health and Developmental Disabilities,
5 the Department of Alcoholism and Substance Abuse, the
6 Department of Children and Family Services, and the Illinois
7 Department shall be excluded from a benefit package.
8 Conditions of an organic or physical origin or nature,
9 including medical detoxification, however, may not be
10 excluded. In this subsection, "behavioral health services"
11 means mental health services and subacute alcohol and
12 substance abuse treatment services, as defined in the
13 Illinois Alcoholism and Other Drug Dependency Act. In this
14 subsection, "mental health services" includes, at a minimum,
15 the following services funded by the Illinois Department, the
16 Department of Mental Health and Developmental Disabilities,
17 or the Department of Children and Family Services: (i)
18 inpatient hospital services, including related physician
19 services, related psychiatric interventions, and
20 pharmaceutical services provided to an eligible recipient
21 hospitalized with a primary diagnosis of psychiatric
22 disorder; (ii) outpatient mental health services as defined
23 and specified in Title 59 of the Illinois Administrative
24 Code, Part 132; (iii) any other outpatient mental health
25 services funded by the Illinois Department pursuant to the
26 State of Illinois Medicaid Plan; (iv) partial
27 hospitalization; and (v) follow-up stabilization related to
28 any of those services. Additional behavioral health services
29 may be excluded under this subsection as mutually agreed in
30 writing by the Illinois Department and the affected State
31 agency or agencies. The exclusion of any service does not
32 prohibit the Illinois Department from developing and
33 implementing demonstration projects for categories of persons
34 or services. The Department of Mental Health and
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1 Developmental Disabilities, the Department of Children and
2 Family Services, and the Department of Alcoholism and
3 Substance Abuse shall each adopt rules governing the
4 integration of managed care in the provision of behavioral
5 health services. The State shall integrate managed care
6 community networks and affiliated providers, to the extent
7 practicable, in any separate delivery system for mental
8 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
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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
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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
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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
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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
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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
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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 89-673, eff. 8-14-96; revised 8-26-96.)
6 (Text of Section after amendment by P.A. 89-507)
7 Sec. 5-16.3. System for integrated health care services.
8 (a) It shall be the public policy of the State to adopt,
9 to the extent practicable, a health care program that
10 encourages the integration of health care services and
11 manages the health care of program enrollees while preserving
12 reasonable choice within a competitive and cost-efficient
13 environment. In furtherance of this public policy, the
14 Illinois Department shall develop and implement an integrated
15 health care program consistent with the provisions of this
16 Section. The provisions of this Section apply only to the
17 integrated health care program created under this Section.
18 Persons enrolled in the integrated health care program, as
19 determined by the Illinois Department by rule, shall be
20 afforded a choice among health care delivery systems, which
21 shall include, but are not limited to, (i) fee for service
22 care managed by a primary care physician licensed to practice
23 medicine in all its branches, (ii) managed health care
24 entities, and (iii) federally qualified health centers
25 (reimbursed according to a prospective cost-reimbursement
26 methodology) and rural health clinics (reimbursed according
27 to the Medicare methodology), where available. Persons
28 enrolled in the integrated health care program also may be
29 offered indemnity insurance plans, subject to availability.
30 For purposes of this Section, a "managed health care
31 entity" means a health maintenance organization or a managed
32 care community network as defined in this Section. A "health
33 maintenance organization" means a health maintenance
34 organization as defined in the Health Maintenance
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1 Organization Act. A "managed care community network" means
2 an entity, other than a health maintenance organization, that
3 is owned, operated, or governed by providers of health care
4 services within this State and that provides or arranges
5 primary, secondary, and tertiary managed health care services
6 under contract with the Illinois Department exclusively to
7 enrollees of the integrated health care program. A managed
8 care community network may contract with the Illinois
9 Department to provide only pediatric health care services. A
10 county provider as defined in Section 15-1 of this Code may
11 contract with the Illinois Department to provide services to
12 enrollees of the integrated health care program as a managed
13 care community network without the need to establish a
14 separate entity that provides services exclusively to
15 enrollees of the integrated health care program and shall be
16 deemed a managed care community network for purposes of this
17 Code only to the extent of the provision of services to those
18 enrollees in conjunction with the integrated health care
19 program. A county provider shall be entitled to contract
20 with the Illinois Department with respect to any contracting
21 region located in whole or in part within the county. A
22 county provider shall not be required to accept enrollees who
23 do not reside within the county.
24 If a managed health care entity is accredited by a
25 private national organization that performs quality assurance
26 surveys of health maintenance organizations or related
27 organizations, the Illinois Department may take the
28 accreditation into consideration when selecting managed
29 health care entities for participation in the integrated
30 health care program. The medical director of a managed
31 health care entity must be a physician licensed in the State
32 to practice medicine in all its branches.
33 Each managed care community network must demonstrate its
34 ability to bear the financial risk of serving enrollees under
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1 this program. The Illinois Department shall by rule adopt
2 criteria for assessing the financial soundness of each
3 managed care community network. These rules shall consider
4 the extent to which a managed care community network is
5 comprised of providers who directly render health care and
6 are located within the community in which they seek to
7 contract rather than solely arrange or finance the delivery
8 of health care. These rules shall further consider a variety
9 of risk-bearing and management techniques, including the
10 sufficiency of quality assurance and utilization management
11 programs and whether a managed care community network has
12 sufficiently demonstrated its financial solvency and net
13 worth. The Illinois Department's criteria must be based on
14 sound actuarial, financial, and accounting principles. In
15 adopting these rules, the Illinois Department shall consult
16 with the Illinois Department of Insurance. The Illinois
17 Department is responsible for monitoring compliance with
18 these rules.
19 This Section may not be implemented before the effective
20 date of these rules, the approval of any necessary federal
21 waivers, and the completion of the review of an application
22 submitted, at least 60 days before the effective date of
23 rules adopted under this Section, to the Illinois Department
24 by a managed care community network.
25 All health care delivery systems that contract with the
26 Illinois Department under the integrated health care program
27 shall clearly recognize a health care provider's right of
28 conscience under the Right of Conscience Act. In addition to
29 the provisions of that Act, no health care delivery system
30 that contracts with the Illinois Department under the
31 integrated health care program shall be required to provide,
32 arrange for, or pay for any health care or medical service,
33 procedure, or product if that health care delivery system is
34 owned, controlled, or sponsored by or affiliated with a
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1 religious institution or religious organization that finds
2 that health care or medical service, procedure, or product to
3 violate its religious and moral teachings and beliefs.
4 (b) The Illinois Department may, by rule, provide for
5 different benefit packages for different categories of
6 persons enrolled in the program. Mental health services,
7 alcohol and substance abuse services, services related to
8 children with chronic or acute conditions requiring
9 longer-term treatment and follow-up, and rehabilitation care
10 provided by a free-standing rehabilitation hospital or a
11 hospital rehabilitation unit may be excluded from a benefit
12 package if the State ensures that those services are made
13 available through a separate delivery system. An exclusion
14 does not prohibit the Illinois Department from developing and
15 implementing demonstration projects for categories of persons
16 or services. Benefit packages for persons eligible for
17 medical assistance under Articles V, VI, and XII shall be
18 based on the requirements of those Articles and shall be
19 consistent with the Title XIX of the Social Security Act.
20 Nothing in this Act shall be construed to apply to services
21 purchased by the Department of Children and Family Services
22 and the Department of Human Services (as successor to the
23 Department of Mental Health and Developmental Disabilities)
24 under the provisions of Title 59 of the Illinois
25 Administrative Code, Part 132 ("Medicaid Community Mental
26 Health Services Program").
27 (c) The program established by this Section may be
28 implemented by the Illinois Department in various contracting
29 areas at various times. The health care delivery systems and
30 providers available under the program may vary throughout the
31 State. For purposes of contracting with managed health care
32 entities and providers, the Illinois Department shall
33 establish contracting areas similar to the geographic areas
34 designated by the Illinois Department for contracting
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1 purposes under the Illinois Competitive Access and
2 Reimbursement Equity Program (ICARE) under the authority of
3 Section 3-4 of the Illinois Health Finance Reform Act or
4 similarly-sized or smaller geographic areas established by
5 the Illinois Department by rule. A managed health care entity
6 shall be permitted to contract in any geographic areas for
7 which it has a sufficient provider network and otherwise
8 meets the contracting terms of the State. The Illinois
9 Department is not prohibited from entering into a contract
10 with a managed health care entity at any time.
11 (d) A managed health care entity that contracts with the
12 Illinois Department for the provision of services under the
13 program shall do all of the following, solely for purposes of
14 the integrated health care program:
15 (1) Provide that any individual physician licensed
16 to practice medicine in all its branches, any pharmacy,
17 any federally qualified health center, and any
18 podiatrist, that consistently meets the reasonable terms
19 and conditions established by the managed health care
20 entity, including but not limited to credentialing
21 standards, quality assurance program requirements,
22 utilization management requirements, financial
23 responsibility standards, contracting process
24 requirements, and provider network size and accessibility
25 requirements, must be accepted by the managed health care
26 entity for purposes of the Illinois integrated health
27 care program. Any individual who is either terminated
28 from or denied inclusion in the panel of physicians of
29 the managed health care entity shall be given, within 10
30 business days after that determination, a written
31 explanation of the reasons for his or her exclusion or
32 termination from the panel. This paragraph (1) does not
33 apply to the following:
34 (A) A managed health care entity that
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1 certifies to the Illinois Department that:
2 (i) it employs on a full-time basis 125
3 or more Illinois physicians licensed to
4 practice medicine in all of its branches; and
5 (ii) it will provide medical services
6 through its employees to more than 80% of the
7 recipients enrolled with the entity in the
8 integrated health care program; or
9 (B) A domestic stock insurance company
10 licensed under clause (b) of class 1 of Section 4 of
11 the Illinois Insurance Code if (i) at least 66% of
12 the stock of the insurance company is owned by a
13 professional corporation organized under the
14 Professional Service Corporation Act that has 125 or
15 more shareholders who are Illinois physicians
16 licensed to practice medicine in all of its branches
17 and (ii) the insurance company certifies to the
18 Illinois Department that at least 80% of those
19 physician shareholders will provide services to
20 recipients enrolled with the company in the
21 integrated health care program.
22 (2) Provide for reimbursement for providers for
23 emergency care, as defined by the Illinois Department by
24 rule, that must be provided to its enrollees, including
25 an emergency room screening fee, and urgent care that it
26 authorizes for its enrollees, regardless of the
27 provider's affiliation with the managed health care
28 entity. Providers shall be reimbursed for emergency care
29 at an amount equal to the Illinois Department's
30 fee-for-service rates for those medical services rendered
31 by providers not under contract with the managed health
32 care entity to enrollees of the entity.
33 (3) Provide that any provider affiliated with a
34 managed health care entity may also provide services on a
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1 fee-for-service basis to Illinois Department clients not
2 enrolled in a managed health care entity.
3 (4) Provide client education services as determined
4 and approved by the Illinois Department, including but
5 not limited to (i) education regarding appropriate
6 utilization of health care services in a managed care
7 system, (ii) written disclosure of treatment policies and
8 any restrictions or limitations on health services,
9 including, but not limited to, physical services,
10 clinical laboratory tests, hospital and surgical
11 procedures, prescription drugs and biologics, and
12 radiological examinations, and (iii) written notice that
13 the enrollee may receive from another provider those
14 services covered under this program that are not provided
15 by the managed health care entity.
16 (4.5) Provide orientation to the caretaker relative
17 or payee of a medical assistance unit that has an
18 enrollee as a member. The managed health care entity
19 must exercise good faith efforts to provide all caretaker
20 relatives or payees with the orientation. The managed
21 health care entity shall inform the Illinois Department
22 of the caretaker relatives or payees who have completed
23 the orientation. This paragraph applies to every
24 caretaker relative or payee in a managed health care
25 entity's system regardless of whether the caretaker
26 relative or payee has chosen the system or has been
27 assigned to the system as provided in subsection (e).
28 (5) Provide that enrollees within its system may
29 choose the site for provision of services and the panel
30 of health care providers.
31 (6) Not discriminate in its enrollment or
32 disenrollment practices among recipients of medical
33 services or program enrollees based on health status.
34 (7) Provide a quality assurance and utilization
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1 review program that (i) for health maintenance
2 organizations meets the requirements of the Health
3 Maintenance Organization Act and (ii) for managed care
4 community networks meets the requirements established by
5 the Illinois Department in rules that incorporate those
6 standards set forth in the Health Maintenance
7 Organization Act.
8 (8) Issue a managed health care entity
9 identification card to each enrollee upon enrollment.
10 The card must contain all of the following:
11 (A) The enrollee's signature.
12 (B) The enrollee's health plan.
13 (C) The name and telephone number of the
14 enrollee's primary care physician.
15 (D) A telephone number to be used for
16 emergency service 24 hours per day, 7 days per week.
17 The telephone number required to be maintained
18 pursuant to this subparagraph by each managed health
19 care entity shall, at minimum, be staffed by
20 medically trained personnel and be provided
21 directly, or under arrangement, at an office or
22 offices in locations maintained solely within the
23 State of Illinois. For purposes of this
24 subparagraph, "medically trained personnel" means
25 licensed practical nurses or registered nurses
26 located in the State of Illinois who are licensed
27 pursuant to the Illinois Nursing Act of 1987.
28 (8.5) The Illinois Department must include
29 performance standards in contracts with entities
30 participating in the integrated health care program to
31 require contractors to make a good faith effort to have
32 enrollees evaluated by a physician within a reasonable
33 period of time after enrollment, as determined by the
34 Illinois Department.
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1 (9) Ensure that every primary care physician and
2 pharmacy in the managed health care entity meets the
3 standards established by the Illinois Department for
4 accessibility and quality of care. The Illinois
5 Department shall arrange for and oversee an evaluation of
6 the standards established under this paragraph (9) and
7 may recommend any necessary changes to these standards.
8 The Illinois Department shall submit an annual report to
9 the Governor and the General Assembly by April 1 of each
10 year regarding the effect of the standards on ensuring
11 access and quality of care to enrollees.
12 (10) Provide a procedure for handling complaints
13 that (i) for health maintenance organizations meets the
14 requirements of the Health Maintenance Organization Act
15 and (ii) for managed care community networks meets the
16 requirements established by the Illinois Department in
17 rules that incorporate those standards set forth in the
18 Health Maintenance Organization Act.
19 (11) Maintain, retain, and make available to the
20 Illinois Department records, data, and information, in a
21 uniform manner determined by the Illinois Department,
22 sufficient for the Illinois Department to monitor
23 utilization, accessibility, and quality of care.
24 (12) Except for providers who are prepaid, pay all
25 approved claims for covered services that are completed
26 and submitted to the managed health care entity within 30
27 days after receipt of the claim or receipt of the
28 appropriate capitation payment or payments by the managed
29 health care entity from the State for the month in which
30 the services included on the claim were rendered,
31 whichever is later. If payment is not made or mailed to
32 the provider by the managed health care entity by the due
33 date under this subsection, an interest penalty of 1% of
34 any amount unpaid shall be added for each month or
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1 fraction of a month after the due date, until final
2 payment is made. Nothing in this Section shall prohibit
3 managed health care entities and providers from mutually
4 agreeing to terms that require more timely payment.
5 (12.5) Ensure that no payment is made to a
6 physician or other provider of services for withholding
7 from an enrollee any covered services because of the cost
8 of those services. This requirement shall not be
9 construed to prevent managed health care entities from
10 offering, nor providers from accepting, full or partial
11 capitation.
12 (13) Provide integration with community-based
13 programs provided by certified local health departments
14 such as Women, Infants, and Children Supplemental Food
15 Program (WIC), childhood immunization programs, health
16 education programs, case management programs, and health
17 screening programs.
18 (14) Provide that the pharmacy formulary used by a
19 managed health care entity and its contract providers be
20 no more restrictive than the Illinois Department's
21 pharmaceutical program on the effective date of this
22 amendatory Act of 1994 and as amended after that date.
23 (15) Provide integration with community-based
24 organizations, including, but not limited to, any
25 organization that has operated within a Medicaid
26 Partnership as defined by this Code or by rule of the
27 Illinois Department, that may continue to operate under a
28 contract with the Illinois Department or a managed health
29 care entity under this Section to provide case management
30 services to Medicaid clients in designated high-need
31 areas.
32 The Illinois Department may, by rule, determine
33 methodologies to limit financial liability for managed health
34 care entities resulting from payment for services to
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1 enrollees provided under the Illinois Department's integrated
2 health care program. Any methodology so determined may be
3 considered or implemented by the Illinois Department through
4 a contract with a managed health care entity under this
5 integrated health care program.
6 The Illinois Department shall contract with an entity or
7 entities to provide external peer-based quality assurance
8 review for the integrated health care program. The entity
9 shall be representative of Illinois physicians licensed to
10 practice medicine in all its branches and have statewide
11 geographic representation in all specialties of medical care
12 that are provided within the integrated health care program.
13 The entity may not be a third party payer and shall maintain
14 offices in locations around the State in order to provide
15 service and continuing medical education to physician
16 participants within the integrated health care program. The
17 review process shall be developed and conducted by Illinois
18 physicians licensed to practice medicine in all its branches.
19 In consultation with the entity, the Illinois Department may
20 contract with other entities for professional peer-based
21 quality assurance review of individual categories of services
22 other than services provided, supervised, or coordinated by
23 physicians licensed to practice medicine in all its branches.
24 The Illinois Department shall establish, by rule, criteria to
25 avoid conflicts of interest in the conduct of quality
26 assurance activities consistent with professional peer-review
27 standards. All quality assurance activities shall be
28 coordinated by the Illinois Department.
29 (e) All persons enrolled in the program shall be
30 provided with a full written explanation of all
31 fee-for-service and managed health care plan options and a
32 reasonable opportunity to choose among the options as
33 provided by rule. The Illinois Department shall provide to
34 enrollees, upon enrollment in the integrated health care
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1 program and at least annually thereafter, notice of the
2 process for requesting an appeal under the Illinois
3 Department's administrative appeal procedures.
4 Notwithstanding any other Section of this Code, the Illinois
5 Department may provide by rule for the Illinois Department to
6 assign a person enrolled in the program to a specific
7 provider of medical services or to a specific health care
8 delivery system if an enrollee has failed to exercise choice
9 in a timely manner. An enrollee assigned by the Illinois
10 Department shall be afforded the opportunity to disenroll and
11 to select a specific provider of medical services or a
12 specific health care delivery system within the first 30 days
13 after the assignment. An enrollee who has failed to exercise
14 choice in a timely manner may be assigned only if there are 3
15 or more managed health care entities contracting with the
16 Illinois Department within the contracting area, except that,
17 outside the City of Chicago, this requirement may be waived
18 for an area by rules adopted by the Illinois Department after
19 consultation with all hospitals within the contracting area.
20 The Illinois Department shall establish by rule the procedure
21 for random assignment of enrollees who fail to exercise
22 choice in a timely manner to a specific managed health care
23 entity in proportion to the available capacity of that
24 managed health care entity. Assignment to a specific provider
25 of medical services or to a specific managed health care
26 entity may not exceed that provider's or entity's capacity as
27 determined by the Illinois Department. Any person who has
28 chosen a specific provider of medical services or a specific
29 managed health care entity, or any person who has been
30 assigned under this subsection, shall be given the
31 opportunity to change that choice or assignment at least once
32 every 12 months, as determined by the Illinois Department by
33 rule. The Illinois Department shall maintain a toll-free
34 telephone number for program enrollees' use in reporting
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1 problems with managed health care entities.
2 (f) If a person becomes eligible for participation in
3 the integrated health care program while he or she is
4 hospitalized, the Illinois Department may not enroll that
5 person in the program until after he or she has been
6 discharged from the hospital. This subsection does not apply
7 to newborn infants whose mothers are enrolled in the
8 integrated health care program.
9 (g) The Illinois Department shall, by rule, establish
10 for managed health care entities rates that (i) are certified
11 to be actuarially sound, as determined by an actuary who is
12 an associate or a fellow of the Society of Actuaries or a
13 member of the American Academy of Actuaries and who has
14 expertise and experience in medical insurance and benefit
15 programs, in accordance with the Illinois Department's
16 current fee-for-service payment system, and (ii) take into
17 account any difference of cost to provide health care to
18 different populations based on gender, age, location, and
19 eligibility category. The rates for managed health care
20 entities shall be determined on a capitated basis.
21 The Illinois Department by rule shall establish a method
22 to adjust its payments to managed health care entities in a
23 manner intended to avoid providing any financial incentive to
24 a managed health care entity to refer patients to a county
25 provider, in an Illinois county having a population greater
26 than 3,000,000, that is paid directly by the Illinois
27 Department. The Illinois Department shall by April 1, 1997,
28 and annually thereafter, review the method to adjust
29 payments. Payments by the Illinois Department to the county
30 provider, for persons not enrolled in a managed care
31 community network owned or operated by a county provider,
32 shall be paid on a fee-for-service basis under Article XV of
33 this Code.
34 The Illinois Department by rule shall establish a method
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1 to reduce its payments to managed health care entities to
2 take into consideration (i) any adjustment payments paid to
3 hospitals under subsection (h) of this Section to the extent
4 those payments, or any part of those payments, have been
5 taken into account in establishing capitated rates under this
6 subsection (g) and (ii) the implementation of methodologies
7 to limit financial liability for managed health care entities
8 under subsection (d) of this Section.
9 (h) For hospital services provided by a hospital that
10 contracts with a managed health care entity, adjustment
11 payments shall be paid directly to the hospital by the
12 Illinois Department. Adjustment payments may include but
13 need not be limited to adjustment payments to:
14 disproportionate share hospitals under Section 5-5.02 of this
15 Code; primary care access health care education payments (89
16 Ill. Adm. Code 149.140); payments for capital, direct medical
17 education, indirect medical education, certified registered
18 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
19 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
20 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
21 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
22 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
23 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
24 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
25 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
26 148.290(h)); and outpatient indigent volume adjustments (89
27 Ill. Adm. Code 148.140(b)(5)).
28 (i) For any hospital eligible for the adjustment
29 payments described in subsection (h), the Illinois Department
30 shall maintain, through the period ending June 30, 1995,
31 reimbursement levels in accordance with statutes and rules in
32 effect on April 1, 1994.
33 (j) Nothing contained in this Code in any way limits or
34 otherwise impairs the authority or power of the Illinois
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1 Department to enter into a negotiated contract pursuant to
2 this Section with a managed health care entity, including,
3 but not limited to, a health maintenance organization, that
4 provides for termination or nonrenewal of the contract
5 without cause upon notice as provided in the contract and
6 without a hearing.
7 (k) Section 5-5.15 does not apply to the program
8 developed and implemented pursuant to this Section.
9 (l) The Illinois Department shall, by rule, define those
10 chronic or acute medical conditions of childhood that require
11 longer-term treatment and follow-up care. The Illinois
12 Department shall ensure that services required to treat these
13 conditions are available through a separate delivery system.
14 A managed health care entity that contracts with the
15 Illinois Department may refer a child with medical conditions
16 described in the rules adopted under this subsection directly
17 to a children's hospital or to a hospital, other than a
18 children's hospital, that is qualified to provide inpatient
19 and outpatient services to treat those conditions. The
20 Illinois Department shall provide fee-for-service
21 reimbursement directly to a children's hospital for those
22 services pursuant to Title 89 of the Illinois Administrative
23 Code, Section 148.280(a), at a rate at least equal to the
24 rate in effect on March 31, 1994. For hospitals, other than
25 children's hospitals, that are qualified to provide inpatient
26 and outpatient services to treat those conditions, the
27 Illinois Department shall provide reimbursement for those
28 services on a fee-for-service basis, at a rate at least equal
29 to the rate in effect for those other hospitals on March 31,
30 1994.
31 A children's hospital shall be directly reimbursed for
32 all services provided at the children's hospital on a
33 fee-for-service basis pursuant to Title 89 of the Illinois
34 Administrative Code, Section 148.280(a), at a rate at least
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1 equal to the rate in effect on March 31, 1994, until the
2 later of (i) implementation of the integrated health care
3 program under this Section and development of actuarially
4 sound capitation rates for services other than those chronic
5 or acute medical conditions of childhood that require
6 longer-term treatment and follow-up care as defined by the
7 Illinois Department in the rules adopted under this
8 subsection or (ii) March 31, 1996.
9 Notwithstanding anything in this subsection to the
10 contrary, a managed health care entity shall not consider
11 sources or methods of payment in determining the referral of
12 a child. The Illinois Department shall adopt rules to
13 establish criteria for those referrals. The Illinois
14 Department by rule shall establish a method to adjust its
15 payments to managed health care entities in a manner intended
16 to avoid providing any financial incentive to a managed
17 health care entity to refer patients to a provider who is
18 paid directly by the Illinois Department.
19 (m) Behavioral health services provided or funded by the
20 Department of Human Services, the Department of Children and
21 Family Services, and the Illinois Department shall be
22 excluded from a benefit package. Conditions of an organic or
23 physical origin or nature, including medical detoxification,
24 however, may not be excluded. In this subsection,
25 "behavioral health services" means mental health services and
26 subacute alcohol and substance abuse treatment services, as
27 defined in the Illinois Alcoholism and Other Drug Dependency
28 Act. In this subsection, "mental health services" includes,
29 at a minimum, the following services funded by the Illinois
30 Department, the Department of Human Services (as successor to
31 the Department of Mental Health and Developmental
32 Disabilities), or the Department of Children and Family
33 Services: (i) inpatient hospital services, including related
34 physician services, related psychiatric interventions, and
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1 pharmaceutical services provided to an eligible recipient
2 hospitalized with a primary diagnosis of psychiatric
3 disorder; (ii) outpatient mental health services as defined
4 and specified in Title 59 of the Illinois Administrative
5 Code, Part 132; (iii) any other outpatient mental health
6 services funded by the Illinois Department pursuant to the
7 State of Illinois Medicaid Plan; (iv) partial
8 hospitalization; and (v) follow-up stabilization related to
9 any of those services. Additional behavioral health services
10 may be excluded under this subsection as mutually agreed in
11 writing by the Illinois Department and the affected State
12 agency or agencies. The exclusion of any service does not
13 prohibit the Illinois Department from developing and
14 implementing demonstration projects for categories of persons
15 or services. The Department of Children and Family Services
16 and the Department of Human Services shall each adopt rules
17 governing the integration of managed care in the provision of
18 behavioral health services. The State shall integrate managed
19 care community networks and affiliated providers, to the
20 extent practicable, in any separate delivery system for
21 mental health services.
22 (n) The Illinois Department shall adopt rules to
23 establish reserve requirements for managed care community
24 networks, as required by subsection (a), and health
25 maintenance organizations to protect against liabilities in
26 the event that a managed health care entity is declared
27 insolvent or bankrupt. If a managed health care entity other
28 than a county provider is declared insolvent or bankrupt,
29 after liquidation and application of any available assets,
30 resources, and reserves, the Illinois Department shall pay a
31 portion of the amounts owed by the managed health care entity
32 to providers for services rendered to enrollees under the
33 integrated health care program under this Section based on
34 the following schedule: (i) from April 1, 1995 through June
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1 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
2 through June 30, 2001, 80% of the amounts owed; and (iii)
3 from July 1, 2001 through June 30, 2005, 75% of the amounts
4 owed. The amounts paid under this subsection shall be
5 calculated based on the total amount owed by the managed
6 health care entity to providers before application of any
7 available assets, resources, and reserves. After June 30,
8 2005, the Illinois Department may not pay any amounts owed to
9 providers as a result of an insolvency or bankruptcy of a
10 managed health care entity occurring after that date. The
11 Illinois Department is not obligated, however, to pay amounts
12 owed to a provider that has an ownership or other governing
13 interest in the managed health care entity. This subsection
14 applies only to managed health care entities and the services
15 they provide under the integrated health care program under
16 this Section.
17 (o) Notwithstanding any other provision of law or
18 contractual agreement to the contrary, providers shall not be
19 required to accept from any other third party payer the rates
20 determined or paid under this Code by the Illinois
21 Department, managed health care entity, or other health care
22 delivery system for services provided to recipients.
23 (p) The Illinois Department may seek and obtain any
24 necessary authorization provided under federal law to
25 implement the program, including the waiver of any federal
26 statutes or regulations. The Illinois Department may seek a
27 waiver of the federal requirement that the combined
28 membership of Medicare and Medicaid enrollees in a managed
29 care community network may not exceed 75% of the managed care
30 community network's total enrollment. The Illinois
31 Department shall not seek a waiver of this requirement for
32 any other category of managed health care entity. The
33 Illinois Department shall not seek a waiver of the inpatient
34 hospital reimbursement methodology in Section 1902(a)(13)(A)
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1 of Title XIX of the Social Security Act even if the federal
2 agency responsible for administering Title XIX determines
3 that Section 1902(a)(13)(A) applies to managed health care
4 systems.
5 Notwithstanding any other provisions of this Code to the
6 contrary, the Illinois Department shall seek a waiver of
7 applicable federal law in order to impose a co-payment system
8 consistent with this subsection on recipients of medical
9 services under Title XIX of the Social Security Act who are
10 not enrolled in a managed health care entity. The waiver
11 request submitted by the Illinois Department shall provide
12 for co-payments of up to $0.50 for prescribed drugs and up to
13 $0.50 for x-ray services and shall provide for co-payments of
14 up to $10 for non-emergency services provided in a hospital
15 emergency room and up to $10 for non-emergency ambulance
16 services. The purpose of the co-payments shall be to deter
17 those recipients from seeking unnecessary medical care.
18 Co-payments may not be used to deter recipients from seeking
19 necessary medical care. No recipient shall be required to
20 pay more than a total of $150 per year in co-payments under
21 the waiver request required by this subsection. A recipient
22 may not be required to pay more than $15 of any amount due
23 under this subsection in any one month.
24 Co-payments authorized under this subsection may not be
25 imposed when the care was necessitated by a true medical
26 emergency. Co-payments may not be imposed for any of the
27 following classifications of services:
28 (1) Services furnished to person under 18 years of
29 age.
30 (2) Services furnished to pregnant women.
31 (3) Services furnished to any individual who is an
32 inpatient in a hospital, nursing facility, intermediate
33 care facility, or other medical institution, if that
34 person is required to spend for costs of medical care all
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1 but a minimal amount of his or her income required for
2 personal needs.
3 (4) Services furnished to a person who is receiving
4 hospice care.
5 Co-payments authorized under this subsection shall not be
6 deducted from or reduce in any way payments for medical
7 services from the Illinois Department to providers. No
8 provider may deny those services to an individual eligible
9 for services based on the individual's inability to pay the
10 co-payment.
11 Recipients who are subject to co-payments shall be
12 provided notice, in plain and clear language, of the amount
13 of the co-payments, the circumstances under which co-payments
14 are exempted, the circumstances under which co-payments may
15 be assessed, and their manner of collection.
16 The Illinois Department shall establish a Medicaid
17 Co-Payment Council to assist in the development of co-payment
18 policies for the medical assistance program. The Medicaid
19 Co-Payment Council shall also have jurisdiction to develop a
20 program to provide financial or non-financial incentives to
21 Medicaid recipients in order to encourage recipients to seek
22 necessary health care. The Council shall be chaired by the
23 Director of the Illinois Department, and shall have 6
24 additional members. Two of the 6 additional members shall be
25 appointed by the Governor, and one each shall be appointed by
26 the President of the Senate, the Minority Leader of the
27 Senate, the Speaker of the House of Representatives, and the
28 Minority Leader of the House of Representatives. The Council
29 may be convened and make recommendations upon the appointment
30 of a majority of its members. The Council shall be appointed
31 and convened no later than September 1, 1994 and shall report
32 its recommendations to the Director of the Illinois
33 Department and the General Assembly no later than October 1,
34 1994. The chairperson of the Council shall be allowed to
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1 vote only in the case of a tie vote among the appointed
2 members of the Council.
3 The Council shall be guided by the following principles
4 as it considers recommendations to be developed to implement
5 any approved waivers that the Illinois Department must seek
6 pursuant to this subsection:
7 (1) Co-payments should not be used to deter access
8 to adequate medical care.
9 (2) Co-payments should be used to reduce fraud.
10 (3) Co-payment policies should be examined in
11 consideration of other states' experience, and the
12 ability of successful co-payment plans to control
13 unnecessary or inappropriate utilization of services
14 should be promoted.
15 (4) All participants, both recipients and
16 providers, in the medical assistance program have
17 responsibilities to both the State and the program.
18 (5) Co-payments are primarily a tool to educate the
19 participants in the responsible use of health care
20 resources.
21 (6) Co-payments should not be used to penalize
22 providers.
23 (7) A successful medical program requires the
24 elimination of improper utilization of medical resources.
25 The integrated health care program, or any part of that
26 program, established under this Section may not be
27 implemented if matching federal funds under Title XIX of the
28 Social Security Act are not available for administering the
29 program.
30 The Illinois Department shall submit for publication in
31 the Illinois Register the name, address, and telephone number
32 of the individual to whom a request may be directed for a
33 copy of the request for a waiver of provisions of Title XIX
34 of the Social Security Act that the Illinois Department
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1 intends to submit to the Health Care Financing Administration
2 in order to implement this Section. The Illinois Department
3 shall mail a copy of that request for waiver to all
4 requestors at least 16 days before filing that request for
5 waiver with the Health Care Financing Administration.
6 (q) After the effective date of this Section, the
7 Illinois Department may take all planning and preparatory
8 action necessary to implement this Section, including, but
9 not limited to, seeking requests for proposals relating to
10 the integrated health care program created under this
11 Section.
12 (r) In order to (i) accelerate and facilitate the
13 development of integrated health care in contracting areas
14 outside counties with populations in excess of 3,000,000 and
15 counties adjacent to those counties and (ii) maintain and
16 sustain the high quality of education and residency programs
17 coordinated and associated with local area hospitals, the
18 Illinois Department may develop and implement a demonstration
19 program for managed care community networks owned, operated,
20 or governed by State-funded medical schools. The Illinois
21 Department shall prescribe by rule the criteria, standards,
22 and procedures for effecting this demonstration program.
23 (s) (Blank).
24 (s-5) The Illinois Department may impose penalties or
25 sanctions permitted by law or contract for violations of
26 this Section.
27 (t) On April 1, 1995 and every 6 months thereafter, the
28 Illinois Department shall report to the Governor and General
29 Assembly on the progress of the integrated health care
30 program in enrolling clients into managed health care
31 entities. The report shall indicate the capacities of the
32 managed health care entities with which the State contracts,
33 the number of clients enrolled by each contractor, the areas
34 of the State in which managed care options do not exist, and
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1 the progress toward meeting the enrollment goals of the
2 integrated health care program.
3 (u) The Illinois Department may implement this Section
4 through the use of emergency rules in accordance with Section
5 5-45 of the Illinois Administrative Procedure Act. For
6 purposes of that Act, the adoption of rules to implement this
7 Section is deemed an emergency and necessary for the public
8 interest, safety, and welfare.
9 (v) The Auditor General shall conduct an annual
10 performance audit of the integrated health care program
11 created under this Section and the Illinois Department's
12 implementation of this Section. The initial audit shall
13 cover the fiscal year ending June 30, 1997, and subsequent
14 audits shall cover each fiscal year thereafter. The Auditor
15 General shall issue reports of the audits on or before
16 December 31 of 1997 and each year thereafter.
17 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
18 89-507, eff. 7-1-97; 89-673, eff. 8-14-96; revised 8-26-96.)
19 (305 ILCS 5/5-16.8 new)
20 Sec. 5-16.8. Administration of managed care program.
21 (a) The Illinois Department shall, by rule, establish
22 guidelines for its administration of a managed care program
23 requiring each managed care organization participating in the
24 program to provide education programs for providers
25 participating within the managed care organization's network
26 and for persons eligible for medical assistance under Article
27 V, VI, or XII who are enrolled with the managed care
28 organization.
29 (b) A provider education program must include
30 information on:
31 (1) Medicaid policies, procedures, eligibility
32 standards, and benefits;
33 (2) the specific problems and needs of Medicaid
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1 clients; and
2 (3) the rights and responsibilities of Medicaid
3 clients prescribed by this Section.
4 (c) A client education program must present information
5 in a manner that is easy to understand. A program must
6 include information on:
7 (1) the rights and responsibilities prescribed by
8 this Section;
9 (2) how to access health care services;
10 (3) how to access complaint procedures and the
11 client's rights to bypass the managed care organization's
12 internal complaint system and use the notice and appeal
13 procedures otherwise required by the Medicaid program;
14 (4) Medicaid policies, procedures, eligibility
15 standards, and benefits;
16 (5) the policies and procedures of the managed care
17 organization; and
18 (6) the importance of prevention, early
19 intervention, and appropriate use of services.
20 (d) The Department or its designee shall inform each
21 person enrolled in the Medicaid program of the person's
22 rights and responsibilities under that program. The
23 information must address the client's right to:
24 (1) respect, dignity, privacy, confidentiality, and
25 nondiscrimination;
26 (2) a reasonable opportunity to choose a health
27 care plan and primary care provider and to change to
28 another plan or provider in a reasonable manner;
29 (3) consent to or refuse treatment and actively
30 participate in treatment decisions;
31 (4) ask questions and receive complete information
32 relating to the client's medical condition and treatment
33 options, including specialty care;
34 (5) access each available complaint process,
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1 receive a timely response to a complaint, and receive a
2 fair hearing; and
3 (6) timely access to care that does not have any
4 communication or physical access barriers.
5 (e) The information must address a client's
6 responsibility to:
7 (1) learn and understand each right the client has
8 under the Medicaid program;
9 (2) abide by the health plan and Medicaid policies
10 and procedures;
11 (3) share information relating to the client's
12 health status with the primary care provider and become
13 fully informed about service and treatment options; and
14 (4) actively participate in decisions relating to
15 service and treatment options, make personal choices and
16 take action to maintain the client's health.
17 (f) The Department shall provide support and information
18 services to a person enrolled in the program or applying for
19 Medicaid coverage who experiences barriers to receiving
20 health care services. The Department may contract for the
21 provision of support and information services. As a part of
22 the support and information services required by this
23 subsection, the Department or organization shall:
24 (1) operate a statewide toll-free assistance
25 telephone number that includes TDD lines and assistance
26 for persons who speak Spanish;
27 (2) intervene promptly with the managed care
28 organizations and providers and any other appropriate
29 entity on behalf of a person who has an urgent need for
30 medical services;
31 (3) assist a person who is experiencing barriers in
32 the Medicaid application and enrollment process and refer
33 the person for further assistance if appropriate;
34 (4) educate persons so that they:
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1 (A) understand the concept of managed care;
2 (B) understand their rights under the Medicaid
3 program, including grievance and appeal procedures;
4 and
5 (C) are able to advocate for themselves;
6 (5) collect and maintain statistical information on
7 a regional basis regarding calls received by the
8 assistance lines and publish quarterly reports that:
9 (A) list the number of calls received by
10 region;
11 (B) identify trends in delivery and access
12 problems;
13 (C) identify recurring barriers in the
14 Medicaid system; and
15 (D) indicate other problems identified with
16 Medicaid managed care; and
17 (6) assist the managed care organizations and
18 providers in identifying and correcting problems,
19 including site visits to affected regions if necessary.
20 (305 ILCS 5/12-13.1)
21 (Text of Section before amendment by P.A. 89-507)
22 Sec. 12-13.1. Inspector General.
23 (a) The Governor shall appoint, and the Senate shall
24 confirm, an Inspector General who shall function within the
25 Illinois Department and report to the Governor. The term of
26 the Inspector General shall expire on the third Monday of
27 January, 1997 and every 4 years thereafter.
28 (b) In order to prevent, detect, and eliminate fraud,
29 waste, abuse, mismanagement, and misconduct, the Inspector
30 General shall oversee the Illinois Department's integrity
31 functions, which include, but are not limited to, the
32 following:
33 (1) Investigation of misconduct by employees,
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1 vendors, contractors and medical providers.
2 (2) Audits of medical providers related to ensuring
3 that appropriate payments are made for services rendered
4 and to the recovery of overpayments.
5 (3) Monitoring of quality assurance programs
6 generally related to the medical assistance program and
7 specifically related to any managed care program.
8 (4) Quality control measurements of the programs
9 administered by the Illinois Department.
10 (5) Investigations of fraud or intentional program
11 violations committed by clients of the Illinois
12 Department.
13 (6) Actions initiated against contractors or
14 medical providers for any of the following reasons:
15 (A) Violations of the medical assistance
16 program.
17 (B) Sanctions against providers brought in
18 conjunction with the Department of Public Health or
19 the Department of Mental Health and Developmental
20 Disabilities.
21 (C) Recoveries of assessments against
22 hospitals and long-term care facilities.
23 (D) Sanctions mandated by the United States
24 Department of Health and Human Services against
25 medical providers.
26 (E) Violations of contracts related to any
27 managed care programs.
28 (7) Representation of the Illinois Department at
29 hearings with the Illinois Department of Professional
30 Regulation in actions taken against professional licenses
31 held by persons who are in violation of orders for child
32 support payments.
33 (b-7) The Inspector General may establish within that
34 Office a special administrative subdivision to monitor
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1 managed health care entities participating in the integrated
2 health care program established under Section 5-16.3 of this
3 Code to ensure that the entities comply with the requirements
4 of that Section. This special administrative subdivision may
5 receive and investigate complaints made by persons enrolled
6 in a managed health care entity's health care delivery
7 system. If the Inspector General investigates a complaint,
8 the Inspector General shall determine whether a managed
9 health care entity has complied with the requirements of
10 Section 5-16.3 and the rules implementing that Section to the
11 extent that those issues are raised by the complaint.
12 The Inspector General may also monitor the Enrolled
13 Managed Care Provider program to ensure that appropriate
14 management of patient care occurs and that services provided
15 are medically necessary. The special administrative
16 subdivision authorized under this subsection may receive and
17 investigate complaints made by persons receiving services
18 under Section 5-16.3.
19 (c) The Inspector General shall have access to all
20 information, personnel and facilities of the Illinois
21 Department, its employees, vendors, contractors and medical
22 providers and any federal, State or local governmental agency
23 that are necessary to perform the duties of the Office as
24 directly related to public assistance programs administered
25 by the Illinois Department. No medical provider shall be
26 compelled, however, to provide individual medical records of
27 patients who are not clients of the Medical Assistance
28 Program. State and local governmental agencies are
29 authorized and directed to provide the requested information,
30 assistance or cooperation.
31 (d) The Inspector General shall serve as the Illinois
32 Department's primary liaison with law enforcement,
33 investigatory and prosecutorial agencies, including but not
34 limited to the following:
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1 (1) The Department of State Police.
2 (2) The Federal Bureau of Investigation and other
3 federal law enforcement agencies.
4 (3) The various Inspectors General of federal
5 agencies overseeing the programs administered by the
6 Illinois Department.
7 (4) The various Inspectors General of any other
8 State agencies with responsibilities for portions of
9 programs primarily administered by the Illinois
10 Department.
11 (5) The Offices of the several United States
12 Attorneys in Illinois.
13 (6) The several State's Attorneys.
14 The Inspector General shall meet on a regular basis with
15 these entities to share information regarding possible
16 misconduct by any persons or entities involved with the
17 public aid programs administered by the Illinois Department.
18 (e) All investigations conducted by the Inspector
19 General shall be conducted in a manner that ensures the
20 preservation of evidence for use in criminal prosecutions.
21 If the Inspector General determines that a possible criminal
22 act relating to fraud in the provision or administration of
23 the medical assistance program has been committed, the
24 Inspector General shall immediately notify the Medicaid Fraud
25 Control Unit. If the Inspector General determines that a
26 possible criminal act has been committed within the
27 jurisdiction of the Office, the Inspector General may request
28 the special expertise of the Department of State Police. The
29 Inspector General may present for prosecution the findings of
30 any criminal investigation to the Office of the Attorney
31 General, the Offices of the several United State Attorneys in
32 Illinois or the several State's Attorneys.
33 (f) To carry out his or her duties as described in this
34 Section, the Inspector General and his or her designees shall
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1 have the power to compel by subpoena the attendance and
2 testimony of witnesses and the production of books,
3 electronic records and papers as directly related to public
4 assistance programs administered by the Illinois Department.
5 No medical provider shall be compelled, however, to provide
6 individual medical records of patients who are not clients of
7 the Medical Assistance Program.
8 (g) The Inspector General shall report all convictions,
9 terminations, and suspensions taken against vendors,
10 contractors and medical providers to the Illinois Department
11 and to any agency responsible for licensing or regulating
12 those persons or entities.
13 (h) The Inspector General shall make quarterly reports,
14 findings, and recommendations regarding the Office's
15 investigations into reports of fraud, waste, abuse,
16 mismanagement, or misconduct relating to any public aid
17 programs administered by the Illinois Department to the
18 General Assembly and the Governor. These reports shall
19 include, but not be limited to, the following information:
20 (1) Aggregate provider billing and payment
21 information, including the number of providers at various
22 Medicaid earning levels.
23 (2) The number of audits of the medical assistance
24 program and the dollar savings resulting from those
25 audits.
26 (3) The number of prescriptions rejected annually
27 under the Illinois Department's Refill Too Soon program
28 and the dollar savings resulting from that program.
29 (4) Provider sanctions, in the aggregate, including
30 terminations and suspensions.
31 (5) A detailed summary of the investigations
32 undertaken in the previous fiscal year. These summaries
33 shall comply with all laws and rules regarding
34 maintaining confidentiality in the public aid programs.
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1 (i) Nothing in this Section shall limit investigations
2 by the Illinois Department that may otherwise be required by
3 law or that may be necessary in the Illinois Department's
4 capacity as the central administrative authority responsible
5 for administration of public aid programs in this State.
6 (Source: P.A. 88-554, eff. 7-26-94.)
7 (Text of Section after amendment by P.A. 89-507)
8 Sec. 12-13.1. Inspector General.
9 (a) The Governor shall appoint, and the Senate shall
10 confirm, an Inspector General who shall function within the
11 Illinois Department of Public Aid and report to the Governor.
12 The term of the Inspector General shall expire on the third
13 Monday of January, 1997 and every 4 years thereafter.
14 (b) In order to prevent, detect, and eliminate fraud,
15 waste, abuse, mismanagement, and misconduct, the Inspector
16 General shall oversee the Illinois Department of Public Aid's
17 integrity functions, which include, but are not limited to,
18 the following:
19 (1) Investigation of misconduct by employees,
20 vendors, contractors and medical providers.
21 (2) Audits of medical providers related to ensuring
22 that appropriate payments are made for services rendered
23 and to the recovery of overpayments.
24 (3) Monitoring of quality assurance programs
25 generally related to the medical assistance program and
26 specifically related to any managed care program.
27 (4) Quality control measurements of the programs
28 administered by the Illinois Department of Public Aid.
29 (5) Investigations of fraud or intentional program
30 violations committed by clients of the Illinois
31 Department of Public Aid.
32 (6) Actions initiated against contractors or
33 medical providers for any of the following reasons:
34 (A) Violations of the medical assistance
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1 program.
2 (B) Sanctions against providers brought in
3 conjunction with the Department of Public Health or
4 the Department of Human Services (as successor to
5 the Department of Mental Health and Developmental
6 Disabilities).
7 (C) Recoveries of assessments against
8 hospitals and long-term care facilities.
9 (D) Sanctions mandated by the United States
10 Department of Health and Human Services against
11 medical providers.
12 (E) Violations of contracts related to any
13 managed care programs.
14 (7) Representation of the Illinois Department of
15 Public Aid at hearings with the Illinois Department of
16 Professional Regulation in actions taken against
17 professional licenses held by persons who are in
18 violation of orders for child support payments.
19 (b-5) At the request of the Secretary of Human Services,
20 the Inspector General shall, in relation to any function
21 performed by the Department of Human Services as successor to
22 the Department of Public Aid, exercise one or more of the
23 powers provided under this Section as if those powers related
24 to the Department of Human Services; in such matters, the
25 Inspector General shall report his or her findings to the
26 Secretary of Human Services.
27 (b-7) The Inspector General may establish within that
28 Office a special administrative subdivision to monitor
29 managed health care entities participating in the integrated
30 health care program established under Section 5-16.3 of this
31 Code to ensure that the entities comply with the requirements
32 of that Section. This special administrative subdivision may
33 receive and investigate complaints made by persons enrolled
34 in a managed health care entity's health care delivery
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1 system. If the Inspector General investigates a complaint,
2 the Inspector General shall determine whether a managed
3 health care entity has complied with the requirements of
4 Section 5-16.3 and the rules implementing that Section to the
5 extent that those issues are raised by the complaint.
6 The Inspector General may also monitor the Enrolled
7 Managed Care Provider program to ensure that appropriate
8 management of patient care occurs and that services provided
9 are medically necessary. The special administrative
10 subdivision authorized under this subsection may receive and
11 investigate complaints made by persons receiving services
12 under Section 5-16.3.
13 (c) The Inspector General shall have access to all
14 information, personnel and facilities of the Illinois
15 Department of Public Aid and the Department of Human Services
16 (as successor to the Department of Public Aid), their
17 employees, vendors, contractors and medical providers and any
18 federal, State or local governmental agency that are
19 necessary to perform the duties of the Office as directly
20 related to public assistance programs administered by those
21 departments. No medical provider shall be compelled,
22 however, to provide individual medical records of patients
23 who are not clients of the Medical Assistance Program. State
24 and local governmental agencies are authorized and directed
25 to provide the requested information, assistance or
26 cooperation.
27 (d) The Inspector General shall serve as the Illinois
28 Department of Public Aid's primary liaison with law
29 enforcement, investigatory and prosecutorial agencies,
30 including but not limited to the following:
31 (1) The Department of State Police.
32 (2) The Federal Bureau of Investigation and other
33 federal law enforcement agencies.
34 (3) The various Inspectors General of federal
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1 agencies overseeing the programs administered by the
2 Illinois Department of Public Aid.
3 (4) The various Inspectors General of any other
4 State agencies with responsibilities for portions of
5 programs primarily administered by the Illinois
6 Department of Public Aid.
7 (5) The Offices of the several United States
8 Attorneys in Illinois.
9 (6) The several State's Attorneys.
10 The Inspector General shall meet on a regular basis with
11 these entities to share information regarding possible
12 misconduct by any persons or entities involved with the
13 public aid programs administered by the Illinois Department
14 of Public Aid.
15 (e) All investigations conducted by the Inspector
16 General shall be conducted in a manner that ensures the
17 preservation of evidence for use in criminal prosecutions.
18 If the Inspector General determines that a possible criminal
19 act relating to fraud in the provision or administration of
20 the medical assistance program has been committed, the
21 Inspector General shall immediately notify the Medicaid Fraud
22 Control Unit. If the Inspector General determines that a
23 possible criminal act has been committed within the
24 jurisdiction of the Office, the Inspector General may request
25 the special expertise of the Department of State Police. The
26 Inspector General may present for prosecution the findings of
27 any criminal investigation to the Office of the Attorney
28 General, the Offices of the several United State Attorneys in
29 Illinois or the several State's Attorneys.
30 (f) To carry out his or her duties as described in this
31 Section, the Inspector General and his or her designees shall
32 have the power to compel by subpoena the attendance and
33 testimony of witnesses and the production of books,
34 electronic records and papers as directly related to public
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1 assistance programs administered by the Illinois Department
2 of Public Aid or the Department of Human Services (as
3 successor to the Department of Public Aid). No medical
4 provider shall be compelled, however, to provide individual
5 medical records of patients who are not clients of the
6 Medical Assistance Program.
7 (g) The Inspector General shall report all convictions,
8 terminations, and suspensions taken against vendors,
9 contractors and medical providers to the Illinois Department
10 of Public Aid and to any agency responsible for licensing or
11 regulating those persons or entities.
12 (h) The Inspector General shall make quarterly reports,
13 findings, and recommendations regarding the Office's
14 investigations into reports of fraud, waste, abuse,
15 mismanagement, or misconduct relating to any public aid
16 programs administered by the Illinois Department of Public
17 Aid or the Department of Human Services (as successor to the
18 Department of Public Aid) to the General Assembly and the
19 Governor. These reports shall include, but not be limited
20 to, the following information:
21 (1) Aggregate provider billing and payment
22 information, including the number of providers at various
23 Medicaid earning levels.
24 (2) The number of audits of the medical assistance
25 program and the dollar savings resulting from those
26 audits.
27 (3) The number of prescriptions rejected annually
28 under the Illinois Department of Public Aid's Refill Too
29 Soon program and the dollar savings resulting from that
30 program.
31 (4) Provider sanctions, in the aggregate, including
32 terminations and suspensions.
33 (5) A detailed summary of the investigations
34 undertaken in the previous fiscal year. These summaries
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1 shall comply with all laws and rules regarding
2 maintaining confidentiality in the public aid programs.
3 (i) Nothing in this Section shall limit investigations
4 by the Illinois Department of Public Aid or the Department of
5 Human Services that may otherwise be required by law or that
6 may be necessary in their capacity as the central
7 administrative authorities responsible for administration of
8 public aid programs in this State.
9 (Source: P.A. 88-554, eff. 7-26-94; 89-507, eff. 7-1-97.)
10 Section 95. No acceleration or delay. Where this Act
11 makes changes in a statute that is represented in this Act by
12 text that is not yet or no longer in effect (for example, a
13 Section represented by multiple versions), the use of that
14 text does not accelerate or delay the taking effect of (i)
15 the changes made by this Act or (ii) provisions derived from
16 any other Public Act.
17 Section 99. Effective date. This Act takes effect upon
18 becoming law.".