[ Search ] [ Legislation ] [ Bill Summary ]
[ Home ] [ Back ] [ Bottom ]
90_HB2074
215 ILCS 5/356t new
5 ILCS 375/6.9 new
215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
215 ILCS 165/10 from Ch. 32, par. 604
305 ILCS 5/5-16.3
Amends the Illinois Insurance Code to prohibit requiring
mastectomies to be done on an outpatient basis unless
authorized by the treating physician. Makes the requirements
applicable to coverages under the State Employees Group
Insurance Act of 1971, the Health Maintenance Organization
Act, and the Voluntary Health Services Plans Act. Effective
June 1, 1997.
LRB9004797JSmg
LRB9004797JSmg
1 AN ACT concerning medical coverage for mastectomies,
2 amending named Acts.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Illinois Insurance Code is amended by
6 adding Section 356t as follows:
7 (215 ILCS 5/356t new)
8 Sec. 356t. Post-mastectomy care.
9 (a) An issuer of an individual or group policy of
10 accident and health insurance that provides surgical benefits
11 and is delivered, issued, amended, or renewed in this State
12 after the effective date of this amendatory Act of 1997 may
13 not require that the surgical removal of the breast be done
14 on an outpatient basis unless, after consultation with the
15 patient, the treating physician so determines. The decision
16 to perform the surgery on an outpatient basis and the
17 corresponding length of stay shall be made by the treating
18 physician based on medical necessity.
19 (b) The insurer shall inform all insureds or enrollees
20 in writing of this coverage as part of evidence of insurance
21 or certificate of coverage.
22 (c) For purposes of this Section:
23 (1) "Treating physician" means a physician licensed
24 to practice medicine in all its branches providing care
25 to the patient.
26 (2) "Surgical removal of the breast" means the
27 simple, modified radical, and radical mastectomy as
28 defined in American Medical Association's (AMA) Current
29 Procedural Terminology (CPT).
30 Section 10. The State Employees Group Insurance Act of
-2- LRB9004797JSmg
1 1971 is amended by adding Section 6.9 as follows:
2 (5 ILCS 375/6.9 new)
3 Sec. 6.9. Post-mastectomy care. The program of health
4 benefits shall provide the post-mastectomy care benefits
5 required to be covered by a policy of accident and health
6 insurance under Section 356t of the Illinois Insurance Code.
7 Section 15. The Health Maintenance Organization Act is
8 amended by changing Section 5-3 as follows:
9 (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
10 Sec. 5-3. Insurance Code provisions.
11 (a) Health Maintenance Organizations shall be subject to
12 the provisions of Sections 133, 134, 137, 140, 141.1, 141.2,
13 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
14 154.6, 154.7, 154.8, 155.04, 355.2, 356m, 356t, 367i, 401,
15 401.1, 402, 403, 403A, 408, 408.2, and 412, paragraph (c) of
16 subsection (2) of Section 367, and Articles VIII 1/2, XII,
17 XII 1/2, XIII, XIII 1/2, and XXVI of the Illinois Insurance
18 Code.
19 (b) For purposes of the Illinois Insurance Code, except
20 for Articles XIII and XIII 1/2, Health Maintenance
21 Organizations in the following categories are deemed to be
22 "domestic companies":
23 (1) a corporation authorized under the Medical
24 Service Plan Act, the Dental Service Plan Act, the Vision
25 Service Plan Act, the Pharmaceutical Service Plan Act,
26 the Voluntary Health Services Plan Act, or the Nonprofit
27 Health Care Service Plan Act;
28 (2) a corporation organized under the laws of this
29 State; or
30 (3) a corporation organized under the laws of
31 another state, 30% or more of the enrollees of which are
-3- LRB9004797JSmg
1 residents of this State, except a corporation subject to
2 substantially the same requirements in its state of
3 organization as is a "domestic company" under Article
4 VIII 1/2 of the Illinois Insurance Code.
5 (c) In considering the merger, consolidation, or other
6 acquisition of control of a Health Maintenance Organization
7 pursuant to Article VIII 1/2 of the Illinois Insurance Code,
8 (1) the Director shall give primary consideration
9 to the continuation of benefits to enrollees and the
10 financial conditions of the acquired Health Maintenance
11 Organization after the merger, consolidation, or other
12 acquisition of control takes effect;
13 (2)(i) the criteria specified in subsection (1)(b)
14 of Section 131.8 of the Illinois Insurance Code shall not
15 apply and (ii) the Director, in making his determination
16 with respect to the merger, consolidation, or other
17 acquisition of control, need not take into account the
18 effect on competition of the merger, consolidation, or
19 other acquisition of control;
20 (3) the Director shall have the power to require
21 the following information:
22 (A) certification by an independent actuary of
23 the adequacy of the reserves of the Health
24 Maintenance Organization sought to be acquired;
25 (B) pro forma financial statements reflecting
26 the combined balance sheets of the acquiring company
27 and the Health Maintenance Organization sought to be
28 acquired as of the end of the preceding year and as
29 of a date 90 days prior to the acquisition, as well
30 as pro forma financial statements reflecting
31 projected combined operation for a period of 2
32 years;
33 (C) a pro forma business plan detailing an
34 acquiring party's plans with respect to the
-4- LRB9004797JSmg
1 operation of the Health Maintenance Organization
2 sought to be acquired for a period of not less than
3 3 years; and
4 (D) such other information as the Director
5 shall require.
6 (d) The provisions of Article VIII 1/2 of the Illinois
7 Insurance Code and this Section 5-3 shall apply to the sale
8 by any health maintenance organization of greater than 10% of
9 its enrollee population (including without limitation the
10 health maintenance organization's right, title, and interest
11 in and to its health care certificates).
12 (e) In considering any management contract or service
13 agreement subject to Section 141.1 of the Illinois Insurance
14 Code, the Director (i) shall, in addition to the criteria
15 specified in Section 141.2 of the Illinois Insurance Code,
16 take into account the effect of the management contract or
17 service agreement on the continuation of benefits to
18 enrollees and the financial condition of the health
19 maintenance organization to be managed or serviced, and (ii)
20 need not take into account the effect of the management
21 contract or service agreement on competition.
22 (f) Except for small employer groups as defined in the
23 Small Employer Rating, Renewability and Portability Health
24 Insurance Act and except for medicare supplement policies as
25 defined in Section 363 of the Illinois Insurance Code, a
26 Health Maintenance Organization may by contract agree with a
27 group or other enrollment unit to effect refunds or charge
28 additional premiums under the following terms and conditions:
29 (i) the amount of, and other terms and conditions
30 with respect to, the refund or additional premium are set
31 forth in the group or enrollment unit contract agreed in
32 advance of the period for which a refund is to be paid or
33 additional premium is to be charged (which period shall
34 not be less than one year); and
-5- LRB9004797JSmg
1 (ii) the amount of the refund or additional premium
2 shall not exceed 20% of the Health Maintenance
3 Organization's profitable or unprofitable experience with
4 respect to the group or other enrollment unit for the
5 period (and, for purposes of a refund or additional
6 premium, the profitable or unprofitable experience shall
7 be calculated taking into account a pro rata share of the
8 Health Maintenance Organization's administrative and
9 marketing expenses, but shall not include any refund to
10 be made or additional premium to be paid pursuant to this
11 subsection (f)). The Health Maintenance Organization and
12 the group or enrollment unit may agree that the
13 profitable or unprofitable experience may be calculated
14 taking into account the refund period and the immediately
15 preceding 2 plan years.
16 The Health Maintenance Organization shall include a
17 statement in the evidence of coverage issued to each enrollee
18 describing the possibility of a refund or additional premium,
19 and upon request of any group or enrollment unit, provide to
20 the group or enrollment unit a description of the method used
21 to calculate (1) the Health Maintenance Organization's
22 profitable experience with respect to the group or enrollment
23 unit and the resulting refund to the group or enrollment unit
24 or (2) the Health Maintenance Organization's unprofitable
25 experience with respect to the group or enrollment unit and
26 the resulting additional premium to be paid by the group or
27 enrollment unit.
28 In no event shall the Illinois Health Maintenance
29 Organization Guaranty Association be liable to pay any
30 contractual obligation of an insolvent organization to pay
31 any refund authorized under this Section.
32 (Source: P.A. 88-313; 89-90, eff. 6-30-95.)
33 Section 20. The Voluntary Health Services Plans Act is
-6- LRB9004797JSmg
1 amended by changing Section 10 as follows:
2 (215 ILCS 165/10) (from Ch. 32, par. 604)
3 Sec. 10. Application of Insurance Code provisions.
4 Health services plan corporations and all persons interested
5 therein or dealing therewith shall be subject to the
6 provisions of Article XII 1/2 and Sections 3.1, 133, 140,
7 143, 143c, 149, 354, 355.2, 356r, 356t, 367.2, 401, 401.1,
8 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7) and
9 (15) of Section 367 of the Illinois Insurance Code.
10 (Source: P.A. 89-514, eff. 7-17-96.)
11 Section 25. The Illinois Public Aid Code is amended by
12 changing Section 5-16.3 as follows:
13 (305 ILCS 5/5-16.3)
14 (Text of Section before amendment by P.A. 89-507)
15 Sec. 5-16.3. System for integrated health care services.
16 (a) It shall be the public policy of the State to adopt,
17 to the extent practicable, a health care program that
18 encourages the integration of health care services and
19 manages the health care of program enrollees while preserving
20 reasonable choice within a competitive and cost-efficient
21 environment. In furtherance of this public policy, the
22 Illinois Department shall develop and implement an integrated
23 health care program consistent with the provisions of this
24 Section. The provisions of this Section apply only to the
25 integrated health care program created under this Section.
26 Persons enrolled in the integrated health care program, as
27 determined by the Illinois Department by rule, shall be
28 afforded a choice among health care delivery systems, which
29 shall include, but are not limited to, (i) fee for service
30 care managed by a primary care physician licensed to practice
31 medicine in all its branches, (ii) managed health care
-7- LRB9004797JSmg
1 entities, and (iii) federally qualified health centers
2 (reimbursed according to a prospective cost-reimbursement
3 methodology) and rural health clinics (reimbursed according
4 to the Medicare methodology), where available. Persons
5 enrolled in the integrated health care program also may be
6 offered indemnity insurance plans, subject to availability.
7 For purposes of this Section, a "managed health care
8 entity" means a health maintenance organization or a managed
9 care community network as defined in this Section. A "health
10 maintenance organization" means a health maintenance
11 organization as defined in the Health Maintenance
12 Organization Act. A "managed care community network" means
13 an entity, other than a health maintenance organization, that
14 is owned, operated, or governed by providers of health care
15 services within this State and that provides or arranges
16 primary, secondary, and tertiary managed health care services
17 under contract with the Illinois Department exclusively to
18 enrollees of the integrated health care program. A managed
19 care community network may contract with the Illinois
20 Department to provide only pediatric health care services. A
21 county provider as defined in Section 15-1 of this Code may
22 contract with the Illinois Department to provide services to
23 enrollees of the integrated health care program as a managed
24 care community network without the need to establish a
25 separate entity that provides services exclusively to
26 enrollees of the integrated health care program and shall be
27 deemed a managed care community network for purposes of this
28 Code only to the extent of the provision of services to those
29 enrollees in conjunction with the integrated health care
30 program. A county provider shall be entitled to contract
31 with the Illinois Department with respect to any contracting
32 region located in whole or in part within the county. A
33 county provider shall not be required to accept enrollees who
34 do not reside within the county.
-8- LRB9004797JSmg
1 Each managed care community network must demonstrate its
2 ability to bear the financial risk of serving enrollees under
3 this program. The Illinois Department shall by rule adopt
4 criteria for assessing the financial soundness of each
5 managed care community network. These rules shall consider
6 the extent to which a managed care community network is
7 comprised of providers who directly render health care and
8 are located within the community in which they seek to
9 contract rather than solely arrange or finance the delivery
10 of health care. These rules shall further consider a variety
11 of risk-bearing and management techniques, including the
12 sufficiency of quality assurance and utilization management
13 programs and whether a managed care community network has
14 sufficiently demonstrated its financial solvency and net
15 worth. The Illinois Department's criteria must be based on
16 sound actuarial, financial, and accounting principles. In
17 adopting these rules, the Illinois Department shall consult
18 with the Illinois Department of Insurance. The Illinois
19 Department is responsible for monitoring compliance with
20 these rules.
21 This Section may not be implemented before the effective
22 date of these rules, the approval of any necessary federal
23 waivers, and the completion of the review of an application
24 submitted, at least 60 days before the effective date of
25 rules adopted under this Section, to the Illinois Department
26 by a managed care community network.
27 All health care delivery systems that contract with the
28 Illinois Department under the integrated health care program
29 shall clearly recognize a health care provider's right of
30 conscience under the Right of Conscience Act. In addition to
31 the provisions of that Act, no health care delivery system
32 that contracts with the Illinois Department under the
33 integrated health care program shall be required to provide,
34 arrange for, or pay for any health care or medical service,
-9- LRB9004797JSmg
1 procedure, or product if that health care delivery system is
2 owned, controlled, or sponsored by or affiliated with a
3 religious institution or religious organization that finds
4 that health care or medical service, procedure, or product to
5 violate its religious and moral teachings and beliefs.
6 (b) The Illinois Department may, by rule, provide for
7 different benefit packages for different categories of
8 persons enrolled in the program. Mental health services,
9 alcohol and substance abuse services, services related to
10 children with chronic or acute conditions requiring
11 longer-term treatment and follow-up, and rehabilitation care
12 provided by a free-standing rehabilitation hospital or a
13 hospital rehabilitation unit may be excluded from a benefit
14 package if the State ensures that those services are made
15 available through a separate delivery system. An exclusion
16 does not prohibit the Illinois Department from developing and
17 implementing demonstration projects for categories of persons
18 or services. Benefit packages for persons eligible for
19 medical assistance under Articles V, VI, and XII shall be
20 based on the requirements of those Articles and shall be
21 consistent with the Title XIX of the Social Security Act.
22 Nothing in this Act shall be construed to apply to services
23 purchased by the Department of Children and Family Services
24 and the Department of Mental Health and Developmental
25 Disabilities under the provisions of Title 59 of the Illinois
26 Administrative Code, Part 132 ("Medicaid Community Mental
27 Health Services Program").
28 (c) The program established by this Section may be
29 implemented by the Illinois Department in various contracting
30 areas at various times. The health care delivery systems and
31 providers available under the program may vary throughout the
32 State. For purposes of contracting with managed health care
33 entities and providers, the Illinois Department shall
34 establish contracting areas similar to the geographic areas
-10- LRB9004797JSmg
1 designated by the Illinois Department for contracting
2 purposes under the Illinois Competitive Access and
3 Reimbursement Equity Program (ICARE) under the authority of
4 Section 3-4 of the Illinois Health Finance Reform Act or
5 similarly-sized or smaller geographic areas established by
6 the Illinois Department by rule. A managed health care entity
7 shall be permitted to contract in any geographic areas for
8 which it has a sufficient provider network and otherwise
9 meets the contracting terms of the State. The Illinois
10 Department is not prohibited from entering into a contract
11 with a managed health care entity at any time.
12 (d) A managed health care entity that contracts with the
13 Illinois Department for the provision of services under the
14 program shall do all of the following, solely for purposes of
15 the integrated health care program:
16 (1) Provide that any individual physician licensed
17 to practice medicine in all its branches, any pharmacy,
18 any federally qualified health center, and any
19 podiatrist, that consistently meets the reasonable terms
20 and conditions established by the managed health care
21 entity, including but not limited to credentialing
22 standards, quality assurance program requirements,
23 utilization management requirements, financial
24 responsibility standards, contracting process
25 requirements, and provider network size and accessibility
26 requirements, must be accepted by the managed health care
27 entity for purposes of the Illinois integrated health
28 care program. Any individual who is either terminated
29 from or denied inclusion in the panel of physicians of
30 the managed health care entity shall be given, within 10
31 business days after that determination, a written
32 explanation of the reasons for his or her exclusion or
33 termination from the panel. This paragraph (1) does not
34 apply to the following:
-11- LRB9004797JSmg
1 (A) A managed health care entity that
2 certifies to the Illinois Department that:
3 (i) it employs on a full-time basis 125
4 or more Illinois physicians licensed to
5 practice medicine in all of its branches; and
6 (ii) it will provide medical services
7 through its employees to more than 80% of the
8 recipients enrolled with the entity in the
9 integrated health care program; or
10 (B) A domestic stock insurance company
11 licensed under clause (b) of class 1 of Section 4 of
12 the Illinois Insurance Code if (i) at least 66% of
13 the stock of the insurance company is owned by a
14 professional corporation organized under the
15 Professional Service Corporation Act that has 125 or
16 more shareholders who are Illinois physicians
17 licensed to practice medicine in all of its branches
18 and (ii) the insurance company certifies to the
19 Illinois Department that at least 80% of those
20 physician shareholders will provide services to
21 recipients enrolled with the company in the
22 integrated health care program.
23 (2) Provide for reimbursement for providers for
24 emergency care, as defined by the Illinois Department by
25 rule, that must be provided to its enrollees, including
26 an emergency room screening fee, and urgent care that it
27 authorizes for its enrollees, regardless of the
28 provider's affiliation with the managed health care
29 entity. Providers shall be reimbursed for emergency care
30 at an amount equal to the Illinois Department's
31 fee-for-service rates for those medical services rendered
32 by providers not under contract with the managed health
33 care entity to enrollees of the entity.
34 (3) Provide that any provider affiliated with a
-12- LRB9004797JSmg
1 managed health care entity may also provide services on a
2 fee-for-service basis to Illinois Department clients not
3 enrolled in a managed health care entity.
4 (4) Provide client education services as determined
5 and approved by the Illinois Department, including but
6 not limited to (i) education regarding appropriate
7 utilization of health care services in a managed care
8 system, (ii) written disclosure of treatment policies and
9 any restrictions or limitations on health services,
10 including, but not limited to, physical services,
11 clinical laboratory tests, hospital and surgical
12 procedures, prescription drugs and biologics, and
13 radiological examinations, and (iii) written notice that
14 the enrollee may receive from another provider those
15 services covered under this program that are not provided
16 by the managed health care entity.
17 (5) Provide that enrollees within its system may
18 choose the site for provision of services and the panel
19 of health care providers.
20 (6) Not discriminate in its enrollment or
21 disenrollment practices among recipients of medical
22 services or program enrollees based on health status.
23 (7) Provide a quality assurance and utilization
24 review program that (i) for health maintenance
25 organizations meets the requirements of the Health
26 Maintenance Organization Act and (ii) for managed care
27 community networks meets the requirements established by
28 the Illinois Department in rules that incorporate those
29 standards set forth in the Health Maintenance
30 Organization Act.
31 (8) Issue a managed health care entity
32 identification card to each enrollee upon enrollment.
33 The card must contain all of the following:
34 (A) The enrollee's signature.
-13- LRB9004797JSmg
1 (B) The enrollee's health plan.
2 (C) The name and telephone number of the
3 enrollee's primary care physician.
4 (D) A telephone number to be used for
5 emergency service 24 hours per day, 7 days per week.
6 The telephone number required to be maintained
7 pursuant to this subparagraph by each managed health
8 care entity shall, at minimum, be staffed by
9 medically trained personnel and be provided
10 directly, or under arrangement, at an office or
11 offices in locations maintained solely within the
12 State of Illinois. For purposes of this
13 subparagraph, "medically trained personnel" means
14 licensed practical nurses or registered nurses
15 located in the State of Illinois who are licensed
16 pursuant to the Illinois Nursing Act of 1987.
17 (9) Ensure that every primary care physician and
18 pharmacy in the managed health care entity meets the
19 standards established by the Illinois Department for
20 accessibility and quality of care. The Illinois
21 Department shall arrange for and oversee an evaluation of
22 the standards established under this paragraph (9) and
23 may recommend any necessary changes to these standards.
24 The Illinois Department shall submit an annual report to
25 the Governor and the General Assembly by April 1 of each
26 year regarding the effect of the standards on ensuring
27 access and quality of care to enrollees.
28 (10) Provide a procedure for handling complaints
29 that (i) for health maintenance organizations meets the
30 requirements of the Health Maintenance Organization Act
31 and (ii) for managed care community networks meets the
32 requirements established by the Illinois Department in
33 rules that incorporate those standards set forth in the
34 Health Maintenance Organization Act.
-14- LRB9004797JSmg
1 (11) Maintain, retain, and make available to the
2 Illinois Department records, data, and information, in a
3 uniform manner determined by the Illinois Department,
4 sufficient for the Illinois Department to monitor
5 utilization, accessibility, and quality of care.
6 (12) Except for providers who are prepaid, pay all
7 approved claims for covered services that are completed
8 and submitted to the managed health care entity within 30
9 days after receipt of the claim or receipt of the
10 appropriate capitation payment or payments by the managed
11 health care entity from the State for the month in which
12 the services included on the claim were rendered,
13 whichever is later. If payment is not made or mailed to
14 the provider by the managed health care entity by the due
15 date under this subsection, an interest penalty of 1% of
16 any amount unpaid shall be added for each month or
17 fraction of a month after the due date, until final
18 payment is made. Nothing in this Section shall prohibit
19 managed health care entities and providers from mutually
20 agreeing to terms that require more timely payment.
21 (13) Provide integration with community-based
22 programs provided by certified local health departments
23 such as Women, Infants, and Children Supplemental Food
24 Program (WIC), childhood immunization programs, health
25 education programs, case management programs, and health
26 screening programs.
27 (14) Provide that the pharmacy formulary used by a
28 managed health care entity and its contract providers be
29 no more restrictive than the Illinois Department's
30 pharmaceutical program on the effective date of this
31 amendatory Act of 1994 and as amended after that date.
32 (15) Provide integration with community-based
33 organizations, including, but not limited to, any
34 organization that has operated within a Medicaid
-15- LRB9004797JSmg
1 Partnership as defined by this Code or by rule of the
2 Illinois Department, that may continue to operate under a
3 contract with the Illinois Department or a managed health
4 care entity under this Section to provide case management
5 services to Medicaid clients in designated high-need
6 areas.
7 The Illinois Department may, by rule, determine
8 methodologies to limit financial liability for managed health
9 care entities resulting from payment for services to
10 enrollees provided under the Illinois Department's integrated
11 health care program. Any methodology so determined may be
12 considered or implemented by the Illinois Department through
13 a contract with a managed health care entity under this
14 integrated health care program.
15 The Illinois Department shall contract with an entity or
16 entities to provide external peer-based quality assurance
17 review for the integrated health care program. The entity
18 shall be representative of Illinois physicians licensed to
19 practice medicine in all its branches and have statewide
20 geographic representation in all specialties of medical care
21 that are provided within the integrated health care program.
22 The entity may not be a third party payer and shall maintain
23 offices in locations around the State in order to provide
24 service and continuing medical education to physician
25 participants within the integrated health care program. The
26 review process shall be developed and conducted by Illinois
27 physicians licensed to practice medicine in all its branches.
28 In consultation with the entity, the Illinois Department may
29 contract with other entities for professional peer-based
30 quality assurance review of individual categories of services
31 other than services provided, supervised, or coordinated by
32 physicians licensed to practice medicine in all its branches.
33 The Illinois Department shall establish, by rule, criteria to
34 avoid conflicts of interest in the conduct of quality
-16- LRB9004797JSmg
1 assurance activities consistent with professional peer-review
2 standards. All quality assurance activities shall be
3 coordinated by the Illinois Department.
4 (e) All persons enrolled in the program shall be
5 provided with a full written explanation of all
6 fee-for-service and managed health care plan options and a
7 reasonable opportunity to choose among the options as
8 provided by rule. The Illinois Department shall provide to
9 enrollees, upon enrollment in the integrated health care
10 program and at least annually thereafter, notice of the
11 process for requesting an appeal under the Illinois
12 Department's administrative appeal procedures.
13 Notwithstanding any other Section of this Code, the Illinois
14 Department may provide by rule for the Illinois Department to
15 assign a person enrolled in the program to a specific
16 provider of medical services or to a specific health care
17 delivery system if an enrollee has failed to exercise choice
18 in a timely manner. An enrollee assigned by the Illinois
19 Department shall be afforded the opportunity to disenroll and
20 to select a specific provider of medical services or a
21 specific health care delivery system within the first 30 days
22 after the assignment. An enrollee who has failed to exercise
23 choice in a timely manner may be assigned only if there are 3
24 or more managed health care entities contracting with the
25 Illinois Department within the contracting area, except that,
26 outside the City of Chicago, this requirement may be waived
27 for an area by rules adopted by the Illinois Department after
28 consultation with all hospitals within the contracting area.
29 The Illinois Department shall establish by rule the procedure
30 for random assignment of enrollees who fail to exercise
31 choice in a timely manner to a specific managed health care
32 entity in proportion to the available capacity of that
33 managed health care entity. Assignment to a specific provider
34 of medical services or to a specific managed health care
-17- LRB9004797JSmg
1 entity may not exceed that provider's or entity's capacity as
2 determined by the Illinois Department. Any person who has
3 chosen a specific provider of medical services or a specific
4 managed health care entity, or any person who has been
5 assigned under this subsection, shall be given the
6 opportunity to change that choice or assignment at least once
7 every 12 months, as determined by the Illinois Department by
8 rule. The Illinois Department shall maintain a toll-free
9 telephone number for program enrollees' use in reporting
10 problems with managed health care entities.
11 (f) If a person becomes eligible for participation in
12 the integrated health care program while he or she is
13 hospitalized, the Illinois Department may not enroll that
14 person in the program until after he or she has been
15 discharged from the hospital. This subsection does not apply
16 to newborn infants whose mothers are enrolled in the
17 integrated health care program.
18 (g) The Illinois Department shall, by rule, establish
19 for managed health care entities rates that (i) are certified
20 to be actuarially sound, as determined by an actuary who is
21 an associate or a fellow of the Society of Actuaries or a
22 member of the American Academy of Actuaries and who has
23 expertise and experience in medical insurance and benefit
24 programs, in accordance with the Illinois Department's
25 current fee-for-service payment system, and (ii) take into
26 account any difference of cost to provide health care to
27 different populations based on gender, age, location, and
28 eligibility category. The rates for managed health care
29 entities shall be determined on a capitated basis.
30 The Illinois Department by rule shall establish a method
31 to adjust its payments to managed health care entities in a
32 manner intended to avoid providing any financial incentive to
33 a managed health care entity to refer patients to a county
34 provider, in an Illinois county having a population greater
-18- LRB9004797JSmg
1 than 3,000,000, that is paid directly by the Illinois
2 Department. The Illinois Department shall by April 1, 1997,
3 and annually thereafter, review the method to adjust
4 payments. Payments by the Illinois Department to the county
5 provider, for persons not enrolled in a managed care
6 community network owned or operated by a county provider,
7 shall be paid on a fee-for-service basis under Article XV of
8 this Code.
9 The Illinois Department by rule shall establish a method
10 to reduce its payments to managed health care entities to
11 take into consideration (i) any adjustment payments paid to
12 hospitals under subsection (h) of this Section to the extent
13 those payments, or any part of those payments, have been
14 taken into account in establishing capitated rates under this
15 subsection (g) and (ii) the implementation of methodologies
16 to limit financial liability for managed health care entities
17 under subsection (d) of this Section.
18 (h) For hospital services provided by a hospital that
19 contracts with a managed health care entity, adjustment
20 payments shall be paid directly to the hospital by the
21 Illinois Department. Adjustment payments may include but
22 need not be limited to adjustment payments to:
23 disproportionate share hospitals under Section 5-5.02 of this
24 Code; primary care access health care education payments (89
25 Ill. Adm. Code 149.140); payments for capital, direct medical
26 education, indirect medical education, certified registered
27 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
28 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
29 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
30 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
31 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
32 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
33 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
34 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
-19- LRB9004797JSmg
1 148.290(h)); and outpatient indigent volume adjustments (89
2 Ill. Adm. Code 148.140(b)(5)).
3 (i) For any hospital eligible for the adjustment
4 payments described in subsection (h), the Illinois Department
5 shall maintain, through the period ending June 30, 1995,
6 reimbursement levels in accordance with statutes and rules in
7 effect on April 1, 1994.
8 (j) Nothing contained in this Code in any way limits or
9 otherwise impairs the authority or power of the Illinois
10 Department to enter into a negotiated contract pursuant to
11 this Section with a managed health care entity, including,
12 but not limited to, a health maintenance organization, that
13 provides for termination or nonrenewal of the contract
14 without cause upon notice as provided in the contract and
15 without a hearing.
16 (k) Section 5-5.15 does not apply to the program
17 developed and implemented pursuant to this Section.
18 (l) The Illinois Department shall, by rule, define those
19 chronic or acute medical conditions of childhood that require
20 longer-term treatment and follow-up care. The Illinois
21 Department shall ensure that services required to treat these
22 conditions are available through a separate delivery system.
23 A managed health care entity that contracts with the
24 Illinois Department may refer a child with medical conditions
25 described in the rules adopted under this subsection directly
26 to a children's hospital or to a hospital, other than a
27 children's hospital, that is qualified to provide inpatient
28 and outpatient services to treat those conditions. The
29 Illinois Department shall provide fee-for-service
30 reimbursement directly to a children's hospital for those
31 services pursuant to Title 89 of the Illinois Administrative
32 Code, Section 148.280(a), at a rate at least equal to the
33 rate in effect on March 31, 1994. For hospitals, other than
34 children's hospitals, that are qualified to provide inpatient
-20- LRB9004797JSmg
1 and outpatient services to treat those conditions, the
2 Illinois Department shall provide reimbursement for those
3 services on a fee-for-service basis, at a rate at least equal
4 to the rate in effect for those other hospitals on March 31,
5 1994.
6 A children's hospital shall be directly reimbursed for
7 all services provided at the children's hospital on a
8 fee-for-service basis pursuant to Title 89 of the Illinois
9 Administrative Code, Section 148.280(a), at a rate at least
10 equal to the rate in effect on March 31, 1994, until the
11 later of (i) implementation of the integrated health care
12 program under this Section and development of actuarially
13 sound capitation rates for services other than those chronic
14 or acute medical conditions of childhood that require
15 longer-term treatment and follow-up care as defined by the
16 Illinois Department in the rules adopted under this
17 subsection or (ii) March 31, 1996.
18 Notwithstanding anything in this subsection to the
19 contrary, a managed health care entity shall not consider
20 sources or methods of payment in determining the referral of
21 a child. The Illinois Department shall adopt rules to
22 establish criteria for those referrals. The Illinois
23 Department by rule shall establish a method to adjust its
24 payments to managed health care entities in a manner intended
25 to avoid providing any financial incentive to a managed
26 health care entity to refer patients to a provider who is
27 paid directly by the Illinois Department.
28 (m) Behavioral health services provided or funded by the
29 Department of Mental Health and Developmental Disabilities,
30 the Department of Alcoholism and Substance Abuse, the
31 Department of Children and Family Services, and the Illinois
32 Department shall be excluded from a benefit package.
33 Conditions of an organic or physical origin or nature,
34 including medical detoxification, however, may not be
-21- LRB9004797JSmg
1 excluded. In this subsection, "behavioral health services"
2 means mental health services and subacute alcohol and
3 substance abuse treatment services, as defined in the
4 Illinois Alcoholism and Other Drug Dependency Act. In this
5 subsection, "mental health services" includes, at a minimum,
6 the following services funded by the Illinois Department, the
7 Department of Mental Health and Developmental Disabilities,
8 or the Department of Children and Family Services: (i)
9 inpatient hospital services, including related physician
10 services, related psychiatric interventions, and
11 pharmaceutical services provided to an eligible recipient
12 hospitalized with a primary diagnosis of psychiatric
13 disorder; (ii) outpatient mental health services as defined
14 and specified in Title 59 of the Illinois Administrative
15 Code, Part 132; (iii) any other outpatient mental health
16 services funded by the Illinois Department pursuant to the
17 State of Illinois Medicaid Plan; (iv) partial
18 hospitalization; and (v) follow-up stabilization related to
19 any of those services. Additional behavioral health services
20 may be excluded under this subsection as mutually agreed in
21 writing by the Illinois Department and the affected State
22 agency or agencies. The exclusion of any service does not
23 prohibit the Illinois Department from developing and
24 implementing demonstration projects for categories of persons
25 or services. The Department of Mental Health and
26 Developmental Disabilities, the Department of Children and
27 Family Services, and the Department of Alcoholism and
28 Substance Abuse shall each adopt rules governing the
29 integration of managed care in the provision of behavioral
30 health services. The State shall integrate managed care
31 community networks and affiliated providers, to the extent
32 practicable, in any separate delivery system for mental
33 health services.
34 (n) The Illinois Department shall adopt rules to
-22- LRB9004797JSmg
1 establish reserve requirements for managed care community
2 networks, as required by subsection (a), and health
3 maintenance organizations to protect against liabilities in
4 the event that a managed health care entity is declared
5 insolvent or bankrupt. If a managed health care entity other
6 than a county provider is declared insolvent or bankrupt,
7 after liquidation and application of any available assets,
8 resources, and reserves, the Illinois Department shall pay a
9 portion of the amounts owed by the managed health care entity
10 to providers for services rendered to enrollees under the
11 integrated health care program under this Section based on
12 the following schedule: (i) from April 1, 1995 through June
13 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
14 through June 30, 2001, 80% of the amounts owed; and (iii)
15 from July 1, 2001 through June 30, 2005, 75% of the amounts
16 owed. The amounts paid under this subsection shall be
17 calculated based on the total amount owed by the managed
18 health care entity to providers before application of any
19 available assets, resources, and reserves. After June 30,
20 2005, the Illinois Department may not pay any amounts owed to
21 providers as a result of an insolvency or bankruptcy of a
22 managed health care entity occurring after that date. The
23 Illinois Department is not obligated, however, to pay amounts
24 owed to a provider that has an ownership or other governing
25 interest in the managed health care entity. This subsection
26 applies only to managed health care entities and the services
27 they provide under the integrated health care program under
28 this Section.
29 (o) Notwithstanding any other provision of law or
30 contractual agreement to the contrary, providers shall not be
31 required to accept from any other third party payer the rates
32 determined or paid under this Code by the Illinois
33 Department, managed health care entity, or other health care
34 delivery system for services provided to recipients.
-23- LRB9004797JSmg
1 (p) The Illinois Department may seek and obtain any
2 necessary authorization provided under federal law to
3 implement the program, including the waiver of any federal
4 statutes or regulations. The Illinois Department may seek a
5 waiver of the federal requirement that the combined
6 membership of Medicare and Medicaid enrollees in a managed
7 care community network may not exceed 75% of the managed care
8 community network's total enrollment. The Illinois
9 Department shall not seek a waiver of this requirement for
10 any other category of managed health care entity. The
11 Illinois Department shall not seek a waiver of the inpatient
12 hospital reimbursement methodology in Section 1902(a)(13)(A)
13 of Title XIX of the Social Security Act even if the federal
14 agency responsible for administering Title XIX determines
15 that Section 1902(a)(13)(A) applies to managed health care
16 systems.
17 Notwithstanding any other provisions of this Code to the
18 contrary, the Illinois Department shall seek a waiver of
19 applicable federal law in order to impose a co-payment system
20 consistent with this subsection on recipients of medical
21 services under Title XIX of the Social Security Act who are
22 not enrolled in a managed health care entity. The waiver
23 request submitted by the Illinois Department shall provide
24 for co-payments of up to $0.50 for prescribed drugs and up to
25 $0.50 for x-ray services and shall provide for co-payments of
26 up to $10 for non-emergency services provided in a hospital
27 emergency room and up to $10 for non-emergency ambulance
28 services. The purpose of the co-payments shall be to deter
29 those recipients from seeking unnecessary medical care.
30 Co-payments may not be used to deter recipients from seeking
31 necessary medical care. No recipient shall be required to
32 pay more than a total of $150 per year in co-payments under
33 the waiver request required by this subsection. A recipient
34 may not be required to pay more than $15 of any amount due
-24- LRB9004797JSmg
1 under this subsection in any one month.
2 Co-payments authorized under this subsection may not be
3 imposed when the care was necessitated by a true medical
4 emergency. Co-payments may not be imposed for any of the
5 following classifications of services:
6 (1) Services furnished to person under 18 years of
7 age.
8 (2) Services furnished to pregnant women.
9 (3) Services furnished to any individual who is an
10 inpatient in a hospital, nursing facility, intermediate
11 care facility, or other medical institution, if that
12 person is required to spend for costs of medical care all
13 but a minimal amount of his or her income required for
14 personal needs.
15 (4) Services furnished to a person who is receiving
16 hospice care.
17 Co-payments authorized under this subsection shall not be
18 deducted from or reduce in any way payments for medical
19 services from the Illinois Department to providers. No
20 provider may deny those services to an individual eligible
21 for services based on the individual's inability to pay the
22 co-payment.
23 Recipients who are subject to co-payments shall be
24 provided notice, in plain and clear language, of the amount
25 of the co-payments, the circumstances under which co-payments
26 are exempted, the circumstances under which co-payments may
27 be assessed, and their manner of collection.
28 The Illinois Department shall establish a Medicaid
29 Co-Payment Council to assist in the development of co-payment
30 policies for the medical assistance program. The Medicaid
31 Co-Payment Council shall also have jurisdiction to develop a
32 program to provide financial or non-financial incentives to
33 Medicaid recipients in order to encourage recipients to seek
34 necessary health care. The Council shall be chaired by the
-25- LRB9004797JSmg
1 Director of the Illinois Department, and shall have 6
2 additional members. Two of the 6 additional members shall be
3 appointed by the Governor, and one each shall be appointed by
4 the President of the Senate, the Minority Leader of the
5 Senate, the Speaker of the House of Representatives, and the
6 Minority Leader of the House of Representatives. The Council
7 may be convened and make recommendations upon the appointment
8 of a majority of its members. The Council shall be appointed
9 and convened no later than September 1, 1994 and shall report
10 its recommendations to the Director of the Illinois
11 Department and the General Assembly no later than October 1,
12 1994. The chairperson of the Council shall be allowed to
13 vote only in the case of a tie vote among the appointed
14 members of the Council.
15 The Council shall be guided by the following principles
16 as it considers recommendations to be developed to implement
17 any approved waivers that the Illinois Department must seek
18 pursuant to this subsection:
19 (1) Co-payments should not be used to deter access
20 to adequate medical care.
21 (2) Co-payments should be used to reduce fraud.
22 (3) Co-payment policies should be examined in
23 consideration of other states' experience, and the
24 ability of successful co-payment plans to control
25 unnecessary or inappropriate utilization of services
26 should be promoted.
27 (4) All participants, both recipients and
28 providers, in the medical assistance program have
29 responsibilities to both the State and the program.
30 (5) Co-payments are primarily a tool to educate the
31 participants in the responsible use of health care
32 resources.
33 (6) Co-payments should not be used to penalize
34 providers.
-26- LRB9004797JSmg
1 (7) A successful medical program requires the
2 elimination of improper utilization of medical resources.
3 The integrated health care program, or any part of that
4 program, established under this Section may not be
5 implemented if matching federal funds under Title XIX of the
6 Social Security Act are not available for administering the
7 program.
8 The Illinois Department shall submit for publication in
9 the Illinois Register the name, address, and telephone number
10 of the individual to whom a request may be directed for a
11 copy of the request for a waiver of provisions of Title XIX
12 of the Social Security Act that the Illinois Department
13 intends to submit to the Health Care Financing Administration
14 in order to implement this Section. The Illinois Department
15 shall mail a copy of that request for waiver to all
16 requestors at least 16 days before filing that request for
17 waiver with the Health Care Financing Administration.
18 (q) After the effective date of this Section, the
19 Illinois Department may take all planning and preparatory
20 action necessary to implement this Section, including, but
21 not limited to, seeking requests for proposals relating to
22 the integrated health care program created under this
23 Section.
24 (r) In order to (i) accelerate and facilitate the
25 development of integrated health care in contracting areas
26 outside counties with populations in excess of 3,000,000 and
27 counties adjacent to those counties and (ii) maintain and
28 sustain the high quality of education and residency programs
29 coordinated and associated with local area hospitals, the
30 Illinois Department may develop and implement a demonstration
31 program for managed care community networks owned, operated,
32 or governed by State-funded medical schools. The Illinois
33 Department shall prescribe by rule the criteria, standards,
34 and procedures for effecting this demonstration program.
-27- LRB9004797JSmg
1 (s) (Blank).
2 (t) On April 1, 1995 and every 6 months thereafter, the
3 Illinois Department shall report to the Governor and General
4 Assembly on the progress of the integrated health care
5 program in enrolling clients into managed health care
6 entities. The report shall indicate the capacities of the
7 managed health care entities with which the State contracts,
8 the number of clients enrolled by each contractor, the areas
9 of the State in which managed care options do not exist, and
10 the progress toward meeting the enrollment goals of the
11 integrated health care program.
12 (u) The Illinois Department may implement this Section
13 through the use of emergency rules in accordance with Section
14 5-45 of the Illinois Administrative Procedure Act. For
15 purposes of that Act, the adoption of rules to implement this
16 Section is deemed an emergency and necessary for the public
17 interest, safety, and welfare.
18 (w) The program of health benefits established under
19 this Section shall provide the post-mastectomy care benefits
20 required to be covered by a policy of accident and health
21 insurance under Section 356t of the Illinois Insurance Code.
22 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
23 89-673, eff. 8-14-96; revised 8-26-96.)
24 (Text of Section after amendment by P.A. 89-507)
25 Sec. 5-16.3. System for integrated health care services.
26 (a) It shall be the public policy of the State to adopt,
27 to the extent practicable, a health care program that
28 encourages the integration of health care services and
29 manages the health care of program enrollees while preserving
30 reasonable choice within a competitive and cost-efficient
31 environment. In furtherance of this public policy, the
32 Illinois Department shall develop and implement an integrated
33 health care program consistent with the provisions of this
34 Section. The provisions of this Section apply only to the
-28- LRB9004797JSmg
1 integrated health care program created under this Section.
2 Persons enrolled in the integrated health care program, as
3 determined by the Illinois Department by rule, shall be
4 afforded a choice among health care delivery systems, which
5 shall include, but are not limited to, (i) fee for service
6 care managed by a primary care physician licensed to practice
7 medicine in all its branches, (ii) managed health care
8 entities, and (iii) federally qualified health centers
9 (reimbursed according to a prospective cost-reimbursement
10 methodology) and rural health clinics (reimbursed according
11 to the Medicare methodology), where available. Persons
12 enrolled in the integrated health care program also may be
13 offered indemnity insurance plans, subject to availability.
14 For purposes of this Section, a "managed health care
15 entity" means a health maintenance organization or a managed
16 care community network as defined in this Section. A "health
17 maintenance organization" means a health maintenance
18 organization as defined in the Health Maintenance
19 Organization Act. A "managed care community network" means
20 an entity, other than a health maintenance organization, that
21 is owned, operated, or governed by providers of health care
22 services within this State and that provides or arranges
23 primary, secondary, and tertiary managed health care services
24 under contract with the Illinois Department exclusively to
25 enrollees of the integrated health care program. A managed
26 care community network may contract with the Illinois
27 Department to provide only pediatric health care services. A
28 county provider as defined in Section 15-1 of this Code may
29 contract with the Illinois Department to provide services to
30 enrollees of the integrated health care program as a managed
31 care community network without the need to establish a
32 separate entity that provides services exclusively to
33 enrollees of the integrated health care program and shall be
34 deemed a managed care community network for purposes of this
-29- LRB9004797JSmg
1 Code only to the extent of the provision of services to those
2 enrollees in conjunction with the integrated health care
3 program. A county provider shall be entitled to contract
4 with the Illinois Department with respect to any contracting
5 region located in whole or in part within the county. A
6 county provider shall not be required to accept enrollees who
7 do not reside within the county.
8 Each managed care community network must demonstrate its
9 ability to bear the financial risk of serving enrollees under
10 this program. The Illinois Department shall by rule adopt
11 criteria for assessing the financial soundness of each
12 managed care community network. These rules shall consider
13 the extent to which a managed care community network is
14 comprised of providers who directly render health care and
15 are located within the community in which they seek to
16 contract rather than solely arrange or finance the delivery
17 of health care. These rules shall further consider a variety
18 of risk-bearing and management techniques, including the
19 sufficiency of quality assurance and utilization management
20 programs and whether a managed care community network has
21 sufficiently demonstrated its financial solvency and net
22 worth. The Illinois Department's criteria must be based on
23 sound actuarial, financial, and accounting principles. In
24 adopting these rules, the Illinois Department shall consult
25 with the Illinois Department of Insurance. The Illinois
26 Department is responsible for monitoring compliance with
27 these rules.
28 This Section may not be implemented before the effective
29 date of these rules, the approval of any necessary federal
30 waivers, and the completion of the review of an application
31 submitted, at least 60 days before the effective date of
32 rules adopted under this Section, to the Illinois Department
33 by a managed care community network.
34 All health care delivery systems that contract with the
-30- LRB9004797JSmg
1 Illinois Department under the integrated health care program
2 shall clearly recognize a health care provider's right of
3 conscience under the Right of Conscience Act. In addition to
4 the provisions of that Act, no health care delivery system
5 that contracts with the Illinois Department under the
6 integrated health care program shall be required to provide,
7 arrange for, or pay for any health care or medical service,
8 procedure, or product if that health care delivery system is
9 owned, controlled, or sponsored by or affiliated with a
10 religious institution or religious organization that finds
11 that health care or medical service, procedure, or product to
12 violate its religious and moral teachings and beliefs.
13 (b) The Illinois Department may, by rule, provide for
14 different benefit packages for different categories of
15 persons enrolled in the program. Mental health services,
16 alcohol and substance abuse services, services related to
17 children with chronic or acute conditions requiring
18 longer-term treatment and follow-up, and rehabilitation care
19 provided by a free-standing rehabilitation hospital or a
20 hospital rehabilitation unit may be excluded from a benefit
21 package if the State ensures that those services are made
22 available through a separate delivery system. An exclusion
23 does not prohibit the Illinois Department from developing and
24 implementing demonstration projects for categories of persons
25 or services. Benefit packages for persons eligible for
26 medical assistance under Articles V, VI, and XII shall be
27 based on the requirements of those Articles and shall be
28 consistent with the Title XIX of the Social Security Act.
29 Nothing in this Act shall be construed to apply to services
30 purchased by the Department of Children and Family Services
31 and the Department of Human Services (as successor to the
32 Department of Mental Health and Developmental Disabilities)
33 under the provisions of Title 59 of the Illinois
34 Administrative Code, Part 132 ("Medicaid Community Mental
-31- LRB9004797JSmg
1 Health Services Program").
2 (c) The program established by this Section may be
3 implemented by the Illinois Department in various contracting
4 areas at various times. The health care delivery systems and
5 providers available under the program may vary throughout the
6 State. For purposes of contracting with managed health care
7 entities and providers, the Illinois Department shall
8 establish contracting areas similar to the geographic areas
9 designated by the Illinois Department for contracting
10 purposes under the Illinois Competitive Access and
11 Reimbursement Equity Program (ICARE) under the authority of
12 Section 3-4 of the Illinois Health Finance Reform Act or
13 similarly-sized or smaller geographic areas established by
14 the Illinois Department by rule. A managed health care entity
15 shall be permitted to contract in any geographic areas for
16 which it has a sufficient provider network and otherwise
17 meets the contracting terms of the State. The Illinois
18 Department is not prohibited from entering into a contract
19 with a managed health care entity at any time.
20 (d) A managed health care entity that contracts with the
21 Illinois Department for the provision of services under the
22 program shall do all of the following, solely for purposes of
23 the integrated health care program:
24 (1) Provide that any individual physician licensed
25 to practice medicine in all its branches, any pharmacy,
26 any federally qualified health center, and any
27 podiatrist, that consistently meets the reasonable terms
28 and conditions established by the managed health care
29 entity, including but not limited to credentialing
30 standards, quality assurance program requirements,
31 utilization management requirements, financial
32 responsibility standards, contracting process
33 requirements, and provider network size and accessibility
34 requirements, must be accepted by the managed health care
-32- LRB9004797JSmg
1 entity for purposes of the Illinois integrated health
2 care program. Any individual who is either terminated
3 from or denied inclusion in the panel of physicians of
4 the managed health care entity shall be given, within 10
5 business days after that determination, a written
6 explanation of the reasons for his or her exclusion or
7 termination from the panel. This paragraph (1) does not
8 apply to the following:
9 (A) A managed health care entity that
10 certifies to the Illinois Department that:
11 (i) it employs on a full-time basis 125
12 or more Illinois physicians licensed to
13 practice medicine in all of its branches; and
14 (ii) it will provide medical services
15 through its employees to more than 80% of the
16 recipients enrolled with the entity in the
17 integrated health care program; or
18 (B) A domestic stock insurance company
19 licensed under clause (b) of class 1 of Section 4 of
20 the Illinois Insurance Code if (i) at least 66% of
21 the stock of the insurance company is owned by a
22 professional corporation organized under the
23 Professional Service Corporation Act that has 125 or
24 more shareholders who are Illinois physicians
25 licensed to practice medicine in all of its branches
26 and (ii) the insurance company certifies to the
27 Illinois Department that at least 80% of those
28 physician shareholders will provide services to
29 recipients enrolled with the company in the
30 integrated health care program.
31 (2) Provide for reimbursement for providers for
32 emergency care, as defined by the Illinois Department by
33 rule, that must be provided to its enrollees, including
34 an emergency room screening fee, and urgent care that it
-33- LRB9004797JSmg
1 authorizes for its enrollees, regardless of the
2 provider's affiliation with the managed health care
3 entity. Providers shall be reimbursed for emergency care
4 at an amount equal to the Illinois Department's
5 fee-for-service rates for those medical services rendered
6 by providers not under contract with the managed health
7 care entity to enrollees of the entity.
8 (3) Provide that any provider affiliated with a
9 managed health care entity may also provide services on a
10 fee-for-service basis to Illinois Department clients not
11 enrolled in a managed health care entity.
12 (4) Provide client education services as determined
13 and approved by the Illinois Department, including but
14 not limited to (i) education regarding appropriate
15 utilization of health care services in a managed care
16 system, (ii) written disclosure of treatment policies and
17 any restrictions or limitations on health services,
18 including, but not limited to, physical services,
19 clinical laboratory tests, hospital and surgical
20 procedures, prescription drugs and biologics, and
21 radiological examinations, and (iii) written notice that
22 the enrollee may receive from another provider those
23 services covered under this program that are not provided
24 by the managed health care entity.
25 (5) Provide that enrollees within its system may
26 choose the site for provision of services and the panel
27 of health care providers.
28 (6) Not discriminate in its enrollment or
29 disenrollment practices among recipients of medical
30 services or program enrollees based on health status.
31 (7) Provide a quality assurance and utilization
32 review program that (i) for health maintenance
33 organizations meets the requirements of the Health
34 Maintenance Organization Act and (ii) for managed care
-34- LRB9004797JSmg
1 community networks meets the requirements established by
2 the Illinois Department in rules that incorporate those
3 standards set forth in the Health Maintenance
4 Organization Act.
5 (8) Issue a managed health care entity
6 identification card to each enrollee upon enrollment.
7 The card must contain all of the following:
8 (A) The enrollee's signature.
9 (B) The enrollee's health plan.
10 (C) The name and telephone number of the
11 enrollee's primary care physician.
12 (D) A telephone number to be used for
13 emergency service 24 hours per day, 7 days per week.
14 The telephone number required to be maintained
15 pursuant to this subparagraph by each managed health
16 care entity shall, at minimum, be staffed by
17 medically trained personnel and be provided
18 directly, or under arrangement, at an office or
19 offices in locations maintained solely within the
20 State of Illinois. For purposes of this
21 subparagraph, "medically trained personnel" means
22 licensed practical nurses or registered nurses
23 located in the State of Illinois who are licensed
24 pursuant to the Illinois Nursing Act of 1987.
25 (9) Ensure that every primary care physician and
26 pharmacy in the managed health care entity meets the
27 standards established by the Illinois Department for
28 accessibility and quality of care. The Illinois
29 Department shall arrange for and oversee an evaluation of
30 the standards established under this paragraph (9) and
31 may recommend any necessary changes to these standards.
32 The Illinois Department shall submit an annual report to
33 the Governor and the General Assembly by April 1 of each
34 year regarding the effect of the standards on ensuring
-35- LRB9004797JSmg
1 access and quality of care to enrollees.
2 (10) Provide a procedure for handling complaints
3 that (i) for health maintenance organizations meets the
4 requirements of the Health Maintenance Organization Act
5 and (ii) for managed care community networks meets the
6 requirements established by the Illinois Department in
7 rules that incorporate those standards set forth in the
8 Health Maintenance Organization Act.
9 (11) Maintain, retain, and make available to the
10 Illinois Department records, data, and information, in a
11 uniform manner determined by the Illinois Department,
12 sufficient for the Illinois Department to monitor
13 utilization, accessibility, and quality of care.
14 (12) Except for providers who are prepaid, pay all
15 approved claims for covered services that are completed
16 and submitted to the managed health care entity within 30
17 days after receipt of the claim or receipt of the
18 appropriate capitation payment or payments by the managed
19 health care entity from the State for the month in which
20 the services included on the claim were rendered,
21 whichever is later. If payment is not made or mailed to
22 the provider by the managed health care entity by the due
23 date under this subsection, an interest penalty of 1% of
24 any amount unpaid shall be added for each month or
25 fraction of a month after the due date, until final
26 payment is made. Nothing in this Section shall prohibit
27 managed health care entities and providers from mutually
28 agreeing to terms that require more timely payment.
29 (13) Provide integration with community-based
30 programs provided by certified local health departments
31 such as Women, Infants, and Children Supplemental Food
32 Program (WIC), childhood immunization programs, health
33 education programs, case management programs, and health
34 screening programs.
-36- LRB9004797JSmg
1 (14) Provide that the pharmacy formulary used by a
2 managed health care entity and its contract providers be
3 no more restrictive than the Illinois Department's
4 pharmaceutical program on the effective date of this
5 amendatory Act of 1994 and as amended after that date.
6 (15) Provide integration with community-based
7 organizations, including, but not limited to, any
8 organization that has operated within a Medicaid
9 Partnership as defined by this Code or by rule of the
10 Illinois Department, that may continue to operate under a
11 contract with the Illinois Department or a managed health
12 care entity under this Section to provide case management
13 services to Medicaid clients in designated high-need
14 areas.
15 The Illinois Department may, by rule, determine
16 methodologies to limit financial liability for managed health
17 care entities resulting from payment for services to
18 enrollees provided under the Illinois Department's integrated
19 health care program. Any methodology so determined may be
20 considered or implemented by the Illinois Department through
21 a contract with a managed health care entity under this
22 integrated health care program.
23 The Illinois Department shall contract with an entity or
24 entities to provide external peer-based quality assurance
25 review for the integrated health care program. The entity
26 shall be representative of Illinois physicians licensed to
27 practice medicine in all its branches and have statewide
28 geographic representation in all specialties of medical care
29 that are provided within the integrated health care program.
30 The entity may not be a third party payer and shall maintain
31 offices in locations around the State in order to provide
32 service and continuing medical education to physician
33 participants within the integrated health care program. The
34 review process shall be developed and conducted by Illinois
-37- LRB9004797JSmg
1 physicians licensed to practice medicine in all its branches.
2 In consultation with the entity, the Illinois Department may
3 contract with other entities for professional peer-based
4 quality assurance review of individual categories of services
5 other than services provided, supervised, or coordinated by
6 physicians licensed to practice medicine in all its branches.
7 The Illinois Department shall establish, by rule, criteria to
8 avoid conflicts of interest in the conduct of quality
9 assurance activities consistent with professional peer-review
10 standards. All quality assurance activities shall be
11 coordinated by the Illinois Department.
12 (e) All persons enrolled in the program shall be
13 provided with a full written explanation of all
14 fee-for-service and managed health care plan options and a
15 reasonable opportunity to choose among the options as
16 provided by rule. The Illinois Department shall provide to
17 enrollees, upon enrollment in the integrated health care
18 program and at least annually thereafter, notice of the
19 process for requesting an appeal under the Illinois
20 Department's administrative appeal procedures.
21 Notwithstanding any other Section of this Code, the Illinois
22 Department may provide by rule for the Illinois Department to
23 assign a person enrolled in the program to a specific
24 provider of medical services or to a specific health care
25 delivery system if an enrollee has failed to exercise choice
26 in a timely manner. An enrollee assigned by the Illinois
27 Department shall be afforded the opportunity to disenroll and
28 to select a specific provider of medical services or a
29 specific health care delivery system within the first 30 days
30 after the assignment. An enrollee who has failed to exercise
31 choice in a timely manner may be assigned only if there are 3
32 or more managed health care entities contracting with the
33 Illinois Department within the contracting area, except that,
34 outside the City of Chicago, this requirement may be waived
-38- LRB9004797JSmg
1 for an area by rules adopted by the Illinois Department after
2 consultation with all hospitals within the contracting area.
3 The Illinois Department shall establish by rule the procedure
4 for random assignment of enrollees who fail to exercise
5 choice in a timely manner to a specific managed health care
6 entity in proportion to the available capacity of that
7 managed health care entity. Assignment to a specific provider
8 of medical services or to a specific managed health care
9 entity may not exceed that provider's or entity's capacity as
10 determined by the Illinois Department. Any person who has
11 chosen a specific provider of medical services or a specific
12 managed health care entity, or any person who has been
13 assigned under this subsection, shall be given the
14 opportunity to change that choice or assignment at least once
15 every 12 months, as determined by the Illinois Department by
16 rule. The Illinois Department shall maintain a toll-free
17 telephone number for program enrollees' use in reporting
18 problems with managed health care entities.
19 (f) If a person becomes eligible for participation in
20 the integrated health care program while he or she is
21 hospitalized, the Illinois Department may not enroll that
22 person in the program until after he or she has been
23 discharged from the hospital. This subsection does not apply
24 to newborn infants whose mothers are enrolled in the
25 integrated health care program.
26 (g) The Illinois Department shall, by rule, establish
27 for managed health care entities rates that (i) are certified
28 to be actuarially sound, as determined by an actuary who is
29 an associate or a fellow of the Society of Actuaries or a
30 member of the American Academy of Actuaries and who has
31 expertise and experience in medical insurance and benefit
32 programs, in accordance with the Illinois Department's
33 current fee-for-service payment system, and (ii) take into
34 account any difference of cost to provide health care to
-39- LRB9004797JSmg
1 different populations based on gender, age, location, and
2 eligibility category. The rates for managed health care
3 entities shall be determined on a capitated basis.
4 The Illinois Department by rule shall establish a method
5 to adjust its payments to managed health care entities in a
6 manner intended to avoid providing any financial incentive to
7 a managed health care entity to refer patients to a county
8 provider, in an Illinois county having a population greater
9 than 3,000,000, that is paid directly by the Illinois
10 Department. The Illinois Department shall by April 1, 1997,
11 and annually thereafter, review the method to adjust
12 payments. Payments by the Illinois Department to the county
13 provider, for persons not enrolled in a managed care
14 community network owned or operated by a county provider,
15 shall be paid on a fee-for-service basis under Article XV of
16 this Code.
17 The Illinois Department by rule shall establish a method
18 to reduce its payments to managed health care entities to
19 take into consideration (i) any adjustment payments paid to
20 hospitals under subsection (h) of this Section to the extent
21 those payments, or any part of those payments, have been
22 taken into account in establishing capitated rates under this
23 subsection (g) and (ii) the implementation of methodologies
24 to limit financial liability for managed health care entities
25 under subsection (d) of this Section.
26 (h) For hospital services provided by a hospital that
27 contracts with a managed health care entity, adjustment
28 payments shall be paid directly to the hospital by the
29 Illinois Department. Adjustment payments may include but
30 need not be limited to adjustment payments to:
31 disproportionate share hospitals under Section 5-5.02 of this
32 Code; primary care access health care education payments (89
33 Ill. Adm. Code 149.140); payments for capital, direct medical
34 education, indirect medical education, certified registered
-40- LRB9004797JSmg
1 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
2 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
3 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
4 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
5 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
6 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
7 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
8 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
9 148.290(h)); and outpatient indigent volume adjustments (89
10 Ill. Adm. Code 148.140(b)(5)).
11 (i) For any hospital eligible for the adjustment
12 payments described in subsection (h), the Illinois Department
13 shall maintain, through the period ending June 30, 1995,
14 reimbursement levels in accordance with statutes and rules in
15 effect on April 1, 1994.
16 (j) Nothing contained in this Code in any way limits or
17 otherwise impairs the authority or power of the Illinois
18 Department to enter into a negotiated contract pursuant to
19 this Section with a managed health care entity, including,
20 but not limited to, a health maintenance organization, that
21 provides for termination or nonrenewal of the contract
22 without cause upon notice as provided in the contract and
23 without a hearing.
24 (k) Section 5-5.15 does not apply to the program
25 developed and implemented pursuant to this Section.
26 (l) The Illinois Department shall, by rule, define those
27 chronic or acute medical conditions of childhood that require
28 longer-term treatment and follow-up care. The Illinois
29 Department shall ensure that services required to treat these
30 conditions are available through a separate delivery system.
31 A managed health care entity that contracts with the
32 Illinois Department may refer a child with medical conditions
33 described in the rules adopted under this subsection directly
34 to a children's hospital or to a hospital, other than a
-41- LRB9004797JSmg
1 children's hospital, that is qualified to provide inpatient
2 and outpatient services to treat those conditions. The
3 Illinois Department shall provide fee-for-service
4 reimbursement directly to a children's hospital for those
5 services pursuant to Title 89 of the Illinois Administrative
6 Code, Section 148.280(a), at a rate at least equal to the
7 rate in effect on March 31, 1994. For hospitals, other than
8 children's hospitals, that are qualified to provide inpatient
9 and outpatient services to treat those conditions, the
10 Illinois Department shall provide reimbursement for those
11 services on a fee-for-service basis, at a rate at least equal
12 to the rate in effect for those other hospitals on March 31,
13 1994.
14 A children's hospital shall be directly reimbursed for
15 all services provided at the children's hospital on a
16 fee-for-service basis pursuant to Title 89 of the Illinois
17 Administrative Code, Section 148.280(a), at a rate at least
18 equal to the rate in effect on March 31, 1994, until the
19 later of (i) implementation of the integrated health care
20 program under this Section and development of actuarially
21 sound capitation rates for services other than those chronic
22 or acute medical conditions of childhood that require
23 longer-term treatment and follow-up care as defined by the
24 Illinois Department in the rules adopted under this
25 subsection or (ii) March 31, 1996.
26 Notwithstanding anything in this subsection to the
27 contrary, a managed health care entity shall not consider
28 sources or methods of payment in determining the referral of
29 a child. The Illinois Department shall adopt rules to
30 establish criteria for those referrals. The Illinois
31 Department by rule shall establish a method to adjust its
32 payments to managed health care entities in a manner intended
33 to avoid providing any financial incentive to a managed
34 health care entity to refer patients to a provider who is
-42- LRB9004797JSmg
1 paid directly by the Illinois Department.
2 (m) Behavioral health services provided or funded by the
3 Department of Human Services, the Department of Children and
4 Family Services, and the Illinois Department shall be
5 excluded from a benefit package. Conditions of an organic or
6 physical origin or nature, including medical detoxification,
7 however, may not be excluded. In this subsection,
8 "behavioral health services" means mental health services and
9 subacute alcohol and substance abuse treatment services, as
10 defined in the Illinois Alcoholism and Other Drug Dependency
11 Act. In this subsection, "mental health services" includes,
12 at a minimum, the following services funded by the Illinois
13 Department, the Department of Human Services (as successor to
14 the Department of Mental Health and Developmental
15 Disabilities), or the Department of Children and Family
16 Services: (i) inpatient hospital services, including related
17 physician services, related psychiatric interventions, and
18 pharmaceutical services provided to an eligible recipient
19 hospitalized with a primary diagnosis of psychiatric
20 disorder; (ii) outpatient mental health services as defined
21 and specified in Title 59 of the Illinois Administrative
22 Code, Part 132; (iii) any other outpatient mental health
23 services funded by the Illinois Department pursuant to the
24 State of Illinois Medicaid Plan; (iv) partial
25 hospitalization; and (v) follow-up stabilization related to
26 any of those services. Additional behavioral health services
27 may be excluded under this subsection as mutually agreed in
28 writing by the Illinois Department and the affected State
29 agency or agencies. The exclusion of any service does not
30 prohibit the Illinois Department from developing and
31 implementing demonstration projects for categories of persons
32 or services. The Department of Children and Family Services
33 and the Department of Human Services shall each adopt rules
34 governing the integration of managed care in the provision of
-43- LRB9004797JSmg
1 behavioral health services. The State shall integrate managed
2 care community networks and affiliated providers, to the
3 extent practicable, in any separate delivery system for
4 mental health services.
5 (n) The Illinois Department shall adopt rules to
6 establish reserve requirements for managed care community
7 networks, as required by subsection (a), and health
8 maintenance organizations to protect against liabilities in
9 the event that a managed health care entity is declared
10 insolvent or bankrupt. If a managed health care entity other
11 than a county provider is declared insolvent or bankrupt,
12 after liquidation and application of any available assets,
13 resources, and reserves, the Illinois Department shall pay a
14 portion of the amounts owed by the managed health care entity
15 to providers for services rendered to enrollees under the
16 integrated health care program under this Section based on
17 the following schedule: (i) from April 1, 1995 through June
18 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
19 through June 30, 2001, 80% of the amounts owed; and (iii)
20 from July 1, 2001 through June 30, 2005, 75% of the amounts
21 owed. The amounts paid under this subsection shall be
22 calculated based on the total amount owed by the managed
23 health care entity to providers before application of any
24 available assets, resources, and reserves. After June 30,
25 2005, the Illinois Department may not pay any amounts owed to
26 providers as a result of an insolvency or bankruptcy of a
27 managed health care entity occurring after that date. The
28 Illinois Department is not obligated, however, to pay amounts
29 owed to a provider that has an ownership or other governing
30 interest in the managed health care entity. This subsection
31 applies only to managed health care entities and the services
32 they provide under the integrated health care program under
33 this Section.
34 (o) Notwithstanding any other provision of law or
-44- LRB9004797JSmg
1 contractual agreement to the contrary, providers shall not be
2 required to accept from any other third party payer the rates
3 determined or paid under this Code by the Illinois
4 Department, managed health care entity, or other health care
5 delivery system for services provided to recipients.
6 (p) The Illinois Department may seek and obtain any
7 necessary authorization provided under federal law to
8 implement the program, including the waiver of any federal
9 statutes or regulations. The Illinois Department may seek a
10 waiver of the federal requirement that the combined
11 membership of Medicare and Medicaid enrollees in a managed
12 care community network may not exceed 75% of the managed care
13 community network's total enrollment. The Illinois
14 Department shall not seek a waiver of this requirement for
15 any other category of managed health care entity. The
16 Illinois Department shall not seek a waiver of the inpatient
17 hospital reimbursement methodology in Section 1902(a)(13)(A)
18 of Title XIX of the Social Security Act even if the federal
19 agency responsible for administering Title XIX determines
20 that Section 1902(a)(13)(A) applies to managed health care
21 systems.
22 Notwithstanding any other provisions of this Code to the
23 contrary, the Illinois Department shall seek a waiver of
24 applicable federal law in order to impose a co-payment system
25 consistent with this subsection on recipients of medical
26 services under Title XIX of the Social Security Act who are
27 not enrolled in a managed health care entity. The waiver
28 request submitted by the Illinois Department shall provide
29 for co-payments of up to $0.50 for prescribed drugs and up to
30 $0.50 for x-ray services and shall provide for co-payments of
31 up to $10 for non-emergency services provided in a hospital
32 emergency room and up to $10 for non-emergency ambulance
33 services. The purpose of the co-payments shall be to deter
34 those recipients from seeking unnecessary medical care.
-45- LRB9004797JSmg
1 Co-payments may not be used to deter recipients from seeking
2 necessary medical care. No recipient shall be required to
3 pay more than a total of $150 per year in co-payments under
4 the waiver request required by this subsection. A recipient
5 may not be required to pay more than $15 of any amount due
6 under this subsection in any one month.
7 Co-payments authorized under this subsection may not be
8 imposed when the care was necessitated by a true medical
9 emergency. Co-payments may not be imposed for any of the
10 following classifications of services:
11 (1) Services furnished to person under 18 years of
12 age.
13 (2) Services furnished to pregnant women.
14 (3) Services furnished to any individual who is an
15 inpatient in a hospital, nursing facility, intermediate
16 care facility, or other medical institution, if that
17 person is required to spend for costs of medical care all
18 but a minimal amount of his or her income required for
19 personal needs.
20 (4) Services furnished to a person who is receiving
21 hospice care.
22 Co-payments authorized under this subsection shall not be
23 deducted from or reduce in any way payments for medical
24 services from the Illinois Department to providers. No
25 provider may deny those services to an individual eligible
26 for services based on the individual's inability to pay the
27 co-payment.
28 Recipients who are subject to co-payments shall be
29 provided notice, in plain and clear language, of the amount
30 of the co-payments, the circumstances under which co-payments
31 are exempted, the circumstances under which co-payments may
32 be assessed, and their manner of collection.
33 The Illinois Department shall establish a Medicaid
34 Co-Payment Council to assist in the development of co-payment
-46- LRB9004797JSmg
1 policies for the medical assistance program. The Medicaid
2 Co-Payment Council shall also have jurisdiction to develop a
3 program to provide financial or non-financial incentives to
4 Medicaid recipients in order to encourage recipients to seek
5 necessary health care. The Council shall be chaired by the
6 Director of the Illinois Department, and shall have 6
7 additional members. Two of the 6 additional members shall be
8 appointed by the Governor, and one each shall be appointed by
9 the President of the Senate, the Minority Leader of the
10 Senate, the Speaker of the House of Representatives, and the
11 Minority Leader of the House of Representatives. The Council
12 may be convened and make recommendations upon the appointment
13 of a majority of its members. The Council shall be appointed
14 and convened no later than September 1, 1994 and shall report
15 its recommendations to the Director of the Illinois
16 Department and the General Assembly no later than October 1,
17 1994. The chairperson of the Council shall be allowed to
18 vote only in the case of a tie vote among the appointed
19 members of the Council.
20 The Council shall be guided by the following principles
21 as it considers recommendations to be developed to implement
22 any approved waivers that the Illinois Department must seek
23 pursuant to this subsection:
24 (1) Co-payments should not be used to deter access
25 to adequate medical care.
26 (2) Co-payments should be used to reduce fraud.
27 (3) Co-payment policies should be examined in
28 consideration of other states' experience, and the
29 ability of successful co-payment plans to control
30 unnecessary or inappropriate utilization of services
31 should be promoted.
32 (4) All participants, both recipients and
33 providers, in the medical assistance program have
34 responsibilities to both the State and the program.
-47- LRB9004797JSmg
1 (5) Co-payments are primarily a tool to educate the
2 participants in the responsible use of health care
3 resources.
4 (6) Co-payments should not be used to penalize
5 providers.
6 (7) A successful medical program requires the
7 elimination of improper utilization of medical resources.
8 The integrated health care program, or any part of that
9 program, established under this Section may not be
10 implemented if matching federal funds under Title XIX of the
11 Social Security Act are not available for administering the
12 program.
13 The Illinois Department shall submit for publication in
14 the Illinois Register the name, address, and telephone number
15 of the individual to whom a request may be directed for a
16 copy of the request for a waiver of provisions of Title XIX
17 of the Social Security Act that the Illinois Department
18 intends to submit to the Health Care Financing Administration
19 in order to implement this Section. The Illinois Department
20 shall mail a copy of that request for waiver to all
21 requestors at least 16 days before filing that request for
22 waiver with the Health Care Financing Administration.
23 (q) After the effective date of this Section, the
24 Illinois Department may take all planning and preparatory
25 action necessary to implement this Section, including, but
26 not limited to, seeking requests for proposals relating to
27 the integrated health care program created under this
28 Section.
29 (r) In order to (i) accelerate and facilitate the
30 development of integrated health care in contracting areas
31 outside counties with populations in excess of 3,000,000 and
32 counties adjacent to those counties and (ii) maintain and
33 sustain the high quality of education and residency programs
34 coordinated and associated with local area hospitals, the
-48- LRB9004797JSmg
1 Illinois Department may develop and implement a demonstration
2 program for managed care community networks owned, operated,
3 or governed by State-funded medical schools. The Illinois
4 Department shall prescribe by rule the criteria, standards,
5 and procedures for effecting this demonstration program.
6 (s) (Blank).
7 (t) On April 1, 1995 and every 6 months thereafter, the
8 Illinois Department shall report to the Governor and General
9 Assembly on the progress of the integrated health care
10 program in enrolling clients into managed health care
11 entities. The report shall indicate the capacities of the
12 managed health care entities with which the State contracts,
13 the number of clients enrolled by each contractor, the areas
14 of the State in which managed care options do not exist, and
15 the progress toward meeting the enrollment goals of the
16 integrated health care program.
17 (u) The Illinois Department may implement this Section
18 through the use of emergency rules in accordance with Section
19 5-45 of the Illinois Administrative Procedure Act. For
20 purposes of that Act, the adoption of rules to implement this
21 Section is deemed an emergency and necessary for the public
22 interest, safety, and welfare.
23 (w) The program of health benefits established under
24 this Section shall provide the post-mastectomy care benefits
25 required to be covered by a policy of accident and health
26 insurance under Section 356t of the Illinois Insurance Code.
27 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
28 89-507, eff. 7-1-97; 89-673, eff. 8-14-96; revised 8-26-96.)
29 Section 99. Effective date. This Act takes effect June
30 1, 1997.