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90_HB3114
305 ILCS 5/5-16.3
305 ILCS 5/5-16.12 new
305 ILCS 5/12-13.1
Amends the Public Aid Code. In the "Medical Assistance"
Article, makes various changes in the Section concerning a
system for integrated health care services, including: (1)
consideration of accreditation of a managed health care
entity by a private national organization; (2) background
investigations of managed health care entities; (3)
orientation for Medicaid recipient enrollees; (4) evaluation
of enrollees by a physician; (5) reports by managed health
care entities; (6) establishment of a Managed Care
Roundtable; and (7) an annual performance audit of the
integrated health care program. Requires the Department of
Public Aid to establish guidelines for its administration of
a managed care program, including the preceding 7 factors;
also requires participating managed care organizations to
provide education programs for their providers and for their
enrollees who are Medicaid recipients. Authorizes the
Inspector General within the Department of Public Aid to (i)
establish a special administrative subdivision to monitor
managed health care entities and (ii) monitor the Enrolled
Managed Care Provider program. Effective immediately.
LRB9009343DJcd
LRB9009343DJcd
1 AN ACT to amend the Illinois Public Aid Code by changing
2 Sections 5-16.3 and 12-13.1 and adding Section 5-16.12.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Illinois Public Aid Code is amended by
6 changing Sections 5-16.3 and 12-13.1 and adding Section
7 5-16.12 as follows:
8 (305 ILCS 5/5-16.3)
9 Sec. 5-16.3. System for integrated health care services.
10 (a) It shall be the public policy of the State to adopt,
11 to the extent practicable, a health care program that
12 encourages the integration of health care services and
13 manages the health care of program enrollees while preserving
14 reasonable choice within a competitive and cost-efficient
15 environment. In furtherance of this public policy, the
16 Illinois Department shall develop and implement an integrated
17 health care program consistent with the provisions of this
18 Section. The provisions of this Section apply only to the
19 integrated health care program created under this Section.
20 Persons enrolled in the integrated health care program, as
21 determined by the Illinois Department by rule, shall be
22 afforded a choice among health care delivery systems, which
23 shall include, but are not limited to, (i) fee for service
24 care managed by a primary care physician licensed to practice
25 medicine in all its branches, (ii) managed health care
26 entities, and (iii) federally qualified health centers
27 (reimbursed according to a prospective cost-reimbursement
28 methodology) and rural health clinics (reimbursed according
29 to the Medicare methodology), where available. Persons
30 enrolled in the integrated health care program also may be
31 offered indemnity insurance plans, subject to availability.
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1 For purposes of this Section, a "managed health care
2 entity" means a health maintenance organization or a managed
3 care community network as defined in this Section. A "health
4 maintenance organization" means a health maintenance
5 organization as defined in the Health Maintenance
6 Organization Act. A "managed care community network" means
7 an entity, other than a health maintenance organization, that
8 is owned, operated, or governed by providers of health care
9 services within this State and that provides or arranges
10 primary, secondary, and tertiary managed health care services
11 under contract with the Illinois Department exclusively to
12 enrollees of the integrated health care program. A managed
13 care community network may contract with the Illinois
14 Department to provide only pediatric health care services. A
15 county provider as defined in Section 15-1 of this Code may
16 contract with the Illinois Department to provide services to
17 enrollees of the integrated health care program as a managed
18 care community network without the need to establish a
19 separate entity that provides services exclusively to
20 enrollees of the integrated health care program and shall be
21 deemed a managed care community network for purposes of this
22 Code only to the extent of the provision of services to those
23 enrollees in conjunction with the integrated health care
24 program. A county provider shall be entitled to contract
25 with the Illinois Department with respect to any contracting
26 region located in whole or in part within the county. A
27 county provider shall not be required to accept enrollees who
28 do not reside within the county.
29 If a managed health care entity is accredited by a
30 private national organization that performs quality assurance
31 surveys of health maintenance organizations or related
32 organizations, the Illinois Department may take the
33 accreditation into consideration when selecting managed
34 health care entities for participation in the integrated
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1 health care program. The medical director of a managed
2 health care entity must be a physician licensed in the State
3 to practice medicine in all its branches.
4 Each managed care community network must demonstrate its
5 ability to bear the financial risk of serving enrollees under
6 this program. The Illinois Department shall by rule adopt
7 criteria for assessing the financial soundness of each
8 managed care community network. These rules shall consider
9 the extent to which a managed care community network is
10 comprised of providers who directly render health care and
11 are located within the community in which they seek to
12 contract rather than solely arrange or finance the delivery
13 of health care. These rules shall further consider a variety
14 of risk-bearing and management techniques, including the
15 sufficiency of quality assurance and utilization management
16 programs and whether a managed care community network has
17 sufficiently demonstrated its financial solvency and net
18 worth. The Illinois Department's criteria must be based on
19 sound actuarial, financial, and accounting principles. In
20 adopting these rules, the Illinois Department shall consult
21 with the Illinois Department of Insurance. The Illinois
22 Department is responsible for monitoring compliance with
23 these rules.
24 This Section may not be implemented before the effective
25 date of these rules, the approval of any necessary federal
26 waivers, and the completion of the review of an application
27 submitted, at least 60 days before the effective date of
28 rules adopted under this Section, to the Illinois Department
29 by a managed care community network.
30 All health care delivery systems that contract with the
31 Illinois Department under the integrated health care program
32 shall clearly recognize a health care provider's right of
33 conscience under the Health Care Right of Conscience Act. In
34 addition to the provisions of that Act, no health care
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1 delivery system that contracts with the Illinois Department
2 under the integrated health care program shall be required to
3 provide, arrange for, or pay for any health care or medical
4 service, procedure, or product if that health care delivery
5 system is owned, controlled, or sponsored by or affiliated
6 with a religious institution or religious organization that
7 finds that health care or medical service, procedure, or
8 product to violate its religious and moral teachings and
9 beliefs.
10 (a-3) As a condition of participation in the integrated
11 health care program, a managed health care entity shall
12 authorize an investigation to determine whether the entity,
13 any person holding an ownership interest in the entity, or
14 any person employed by the entity in a managerial capacity
15 (i) has ever been sanctioned under Section 12-4.25 of this
16 Code, (ii) has ever had a sanction (such as revocation,
17 suspension, or refusal to renew) imposed against a
18 professional or other license held by the entity or person,
19 or (iii) has ever been charged with a crime and, if so, the
20 disposition of those charges. Upon this authorization, the
21 Illinois Department shall request and receive information and
22 assistance from any federal, State, or local governmental law
23 enforcement or other agency as part of the authorized
24 investigation. The Department of State Police shall provide
25 information concerning any criminal charges, and their
26 disposition, currently or subsequently filed against an
27 entity or person described in this subsection upon the
28 request of the Illinois Department when the request is made
29 in the form and manner required by the Department of State
30 Police. The Illinois Department may contract with a law
31 enforcement agency for the performance of investigations
32 authorized under this subsection.
33 Information concerning convictions of an entity or person
34 investigated under this subsection, including the source of
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1 the information and any conclusions or recommendations
2 derived from the information, shall be provided, upon
3 request, to the entity or person before final action by the
4 Illinois Department on the request to participate in the
5 integrated health care program. Any information concerning
6 criminal charges and the disposition of those charges
7 obtained by the Illinois Department shall be confidential and
8 may not be transmitted outside the Illinois Department,
9 except as required in this subsection, and may not be
10 transmitted to anyone within the Illinois Department except
11 as needed for the purpose of evaluating a request to
12 participate in the integrated health care program. Only
13 information and standards that bear a reasonable and rational
14 relation to the performance of a managed health care entity
15 may be used by the Illinois Department in taking action on a
16 request to participate in the integrated health care program.
17 Any employee of the Illinois Department, Department of State
18 Police, or a managed health care entity receiving
19 confidential information under this subsection who gives or
20 causes to be given any confidential information concerning
21 any criminal convictions of an entity or person described in
22 this subsection is guilty of a Class A misdemeanor unless
23 release of the information is authorized by this subsection.
24 (a-7) A managed health care entity may not participate
25 in the integrated health care program if the entity's license
26 to operate as a managed health care entity has been revoked
27 or is currently under suspension by the Department of
28 Insurance or if the Department of Insurance is currently
29 refusing to renew the entity's license.
30 If any of the following circumstances exist with respect
31 to a managed health care entity, the Illinois Department may
32 consider these circumstances, as they relate to the entity's
33 ability to perform its obligations under the integrated
34 health care program, and other criteria in determining
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1 whether to initially select the entity for participation in
2 the program and whether to renew the entity's participation
3 in the program for another contract term:
4 (1) An owner or officer of the entity is the
5 subject of a professional licensure disciplinary
6 proceeding.
7 (2) An owner or officer of the entity is the
8 subject of a proceeding by the Illinois Department to
9 impose any sanction authorized under this Code.
10 (b) The Illinois Department may, by rule, provide for
11 different benefit packages for different categories of
12 persons enrolled in the program. Mental health services,
13 alcohol and substance abuse services, services related to
14 children with chronic or acute conditions requiring
15 longer-term treatment and follow-up, and rehabilitation care
16 provided by a free-standing rehabilitation hospital or a
17 hospital rehabilitation unit may be excluded from a benefit
18 package if the State ensures that those services are made
19 available through a separate delivery system. An exclusion
20 does not prohibit the Illinois Department from developing and
21 implementing demonstration projects for categories of persons
22 or services. Benefit packages for persons eligible for
23 medical assistance under Articles V, VI, and XII shall be
24 based on the requirements of those Articles and shall be
25 consistent with the Title XIX of the Social Security Act.
26 Nothing in this Act shall be construed to apply to services
27 purchased by the Department of Children and Family Services
28 and the Department of Human Services (as successor to the
29 Department of Mental Health and Developmental Disabilities)
30 under the provisions of Title 59 of the Illinois
31 Administrative Code, Part 132 ("Medicaid Community Mental
32 Health Services Program").
33 (c) The program established by this Section may be
34 implemented by the Illinois Department in various contracting
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1 areas at various times. The health care delivery systems and
2 providers available under the program may vary throughout the
3 State. For purposes of contracting with managed health care
4 entities and providers, the Illinois Department shall
5 establish contracting areas similar to the geographic areas
6 designated by the Illinois Department for contracting
7 purposes under the Illinois Competitive Access and
8 Reimbursement Equity Program (ICARE) under the authority of
9 Section 3-4 of the Illinois Health Finance Reform Act or
10 similarly-sized or smaller geographic areas established by
11 the Illinois Department by rule. A managed health care entity
12 shall be permitted to contract in any geographic areas for
13 which it has a sufficient provider network and otherwise
14 meets the contracting terms of the State. The Illinois
15 Department is not prohibited from entering into a contract
16 with a managed health care entity at any time.
17 (c-5) A managed health care entity may not engage in
18 door-to-door marketing activities or marketing activities at
19 an office of the Illinois Department or a county department
20 in order to enroll in the entity's health care delivery
21 system persons who are enrolled in the integrated health care
22 program established under this Section. The Illinois
23 Department shall adopt rules defining "marketing activities"
24 prohibited by this subsection (c-5).
25 Before a managed health care entity may market its health
26 care delivery system to persons enrolled in the integrated
27 health care program established under this Section, the
28 Illinois Department must approve a marketing plan submitted
29 by the entity to the Illinois Department. The Illinois
30 Department shall adopt guidelines for approving marketing
31 plans submitted by managed health care entities under this
32 subsection. Besides prohibiting door-to-door marketing
33 activities and marketing activities at public aid offices,
34 the guidelines shall include at least the following:
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1 (1) A managed health care entity may not offer or
2 provide any gift, favor, or other inducement in marketing
3 its health care delivery system to integrated health care
4 program enrollees. A managed health care entity may
5 provide health care related items that are of nominal
6 value and pre-approved by the Illinois Department to
7 prospective enrollees. A managed health care entity may
8 also provide to enrollees health care related items that
9 have been pre-approved by the Illinois Department as an
10 incentive to manage their health care appropriately.
11 (2) All persons employed or otherwise engaged by a
12 managed health care entity to market the entity's health
13 care delivery system to integrated health care program
14 enrollees or to supervise that marketing shall register
15 with the Illinois Department.
16 The Inspector General appointed under Section 12-13.1 may
17 conduct investigations to determine whether the marketing
18 practices of managed health care entities participating in
19 the integrated health care program comply with the
20 guidelines.
21 (d) A managed health care entity that contracts with the
22 Illinois Department for the provision of services under the
23 program shall do all of the following, solely for purposes of
24 the integrated health care program:
25 (1) Provide that any individual physician licensed
26 under the Medical Practice Act of 1987, any pharmacy, any
27 federally qualified health center, any therapeutically
28 certified optometrist, and any podiatrist, that
29 consistently meets the reasonable terms and conditions
30 established by the managed health care entity, including
31 but not limited to credentialing standards, quality
32 assurance program requirements, utilization management
33 requirements, financial responsibility standards,
34 contracting process requirements, and provider network
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1 size and accessibility requirements, must be accepted by
2 the managed health care entity for purposes of the
3 Illinois integrated health care program. Notwithstanding
4 the preceding sentence, only a physician licensed to
5 practice medicine in all its branches shall act as a
6 primary care physician within a managed health care
7 entity for purposes of the Illinois integrated health
8 care program. Any individual who is either terminated
9 from or denied inclusion in the panel of physicians of
10 the managed health care entity shall be given, within 10
11 business days after that determination, a written
12 explanation of the reasons for his or her exclusion or
13 termination from the panel. This paragraph (1) does not
14 apply to the following:
15 (A) A managed health care entity that
16 certifies to the Illinois Department that:
17 (i) it employs on a full-time basis 125
18 or more Illinois physicians licensed to
19 practice medicine in all of its branches; and
20 (ii) it will provide medical services
21 through its employees to more than 80% of the
22 recipients enrolled with the entity in the
23 integrated health care program; or
24 (B) A domestic stock insurance company
25 licensed under clause (b) of class 1 of Section 4 of
26 the Illinois Insurance Code if (i) at least 66% of
27 the stock of the insurance company is owned by a
28 professional corporation organized under the
29 Professional Service Corporation Act that has 125 or
30 more shareholders who are Illinois physicians
31 licensed to practice medicine in all of its branches
32 and (ii) the insurance company certifies to the
33 Illinois Department that at least 80% of those
34 physician shareholders will provide services to
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1 recipients enrolled with the company in the
2 integrated health care program.
3 (2) Provide for reimbursement for providers for
4 emergency care, as defined by the Illinois Department by
5 rule, that must be provided to its enrollees, including
6 an emergency room screening fee, and urgent care that it
7 authorizes for its enrollees, regardless of the
8 provider's affiliation with the managed health care
9 entity. Providers shall be reimbursed for emergency care
10 at an amount equal to the Illinois Department's
11 fee-for-service rates for those medical services rendered
12 by providers not under contract with the managed health
13 care entity to enrollees of the entity.
14 (3) Provide that any provider affiliated with a
15 managed health care entity may also provide services on a
16 fee-for-service basis to Illinois Department clients not
17 enrolled in a managed health care entity.
18 (4) Provide client education services as determined
19 and approved by the Illinois Department, including but
20 not limited to (i) education regarding appropriate
21 utilization of health care services in a managed care
22 system, (ii) written disclosure of treatment policies and
23 any restrictions or limitations on health services,
24 including, but not limited to, physical services,
25 clinical laboratory tests, hospital and surgical
26 procedures, prescription drugs and biologics, and
27 radiological examinations, and (iii) written notice that
28 the enrollee may receive from another provider those
29 services covered under this program that are not provided
30 by the managed health care entity.
31 (4.5) Provide orientation to the caretaker relative
32 or payee of a medical assistance unit that has an
33 enrollee as a member. The managed health care entity
34 must exercise good faith efforts to provide all caretaker
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1 relatives or payees with the orientation. The managed
2 health care entity shall inform the Illinois Department
3 of the caretaker relatives or payees who have completed
4 the orientation. This paragraph applies to every
5 caretaker relative or payee in a managed health care
6 entity's system regardless of whether the caretaker
7 relative or payee has chosen the system or has been
8 assigned to the system as provided in subsection (e).
9 (5) Provide that enrollees within its system may
10 choose the site for provision of services and the panel
11 of health care providers.
12 (6) Not discriminate in its enrollment or
13 disenrollment practices among recipients of medical
14 services or program enrollees based on health status.
15 (7) Provide a quality assurance and utilization
16 review program that (i) for health maintenance
17 organizations meets the requirements of the Health
18 Maintenance Organization Act and (ii) for managed care
19 community networks meets the requirements established by
20 the Illinois Department in rules that incorporate those
21 standards set forth in the Health Maintenance
22 Organization Act.
23 (8) Issue a managed health care entity
24 identification card to each enrollee upon enrollment.
25 The card must contain all of the following:
26 (A) The enrollee's signature.
27 (B) The enrollee's health plan.
28 (C) The name and telephone number of the
29 enrollee's primary care physician.
30 (D) A telephone number to be used for
31 emergency service 24 hours per day, 7 days per week.
32 The telephone number required to be maintained
33 pursuant to this subparagraph by each managed health
34 care entity shall, at minimum, be staffed by
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1 medically trained personnel and be provided
2 directly, or under arrangement, at an office or
3 offices in locations maintained solely within the
4 State of Illinois. For purposes of this
5 subparagraph, "medically trained personnel" means
6 licensed practical nurses or registered nurses
7 located in the State of Illinois who are licensed
8 pursuant to the Illinois Nursing Act of 1987.
9 (8.5) The Illinois Department must include
10 performance standards in contracts with entities
11 participating in the integrated health care program to
12 require contractors to make a good faith effort to have
13 enrollees evaluated by a physician within a reasonable
14 period of time after enrollment, as determined by the
15 Illinois Department.
16 (9) Ensure that every primary care physician and
17 pharmacy in the managed health care entity meets the
18 standards established by the Illinois Department for
19 accessibility and quality of care. The Illinois
20 Department shall arrange for and oversee an evaluation of
21 the standards established under this paragraph (9) and
22 may recommend any necessary changes to these standards.
23 The Illinois Department shall submit an annual report to
24 the Governor and the General Assembly by April 1 of each
25 year regarding the effect of the standards on ensuring
26 access and quality of care to enrollees.
27 (10) Provide a procedure for handling complaints
28 that (i) for health maintenance organizations meets the
29 requirements of the Health Maintenance Organization Act
30 and (ii) for managed care community networks meets the
31 requirements established by the Illinois Department in
32 rules that incorporate those standards set forth in the
33 Health Maintenance Organization Act.
34 (11) Maintain, retain, and make available to the
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1 Illinois Department records, data, and information, in a
2 uniform manner determined by the Illinois Department,
3 sufficient for the Illinois Department to monitor
4 utilization, accessibility, and quality of care.
5 (12) Except for providers who are prepaid, pay all
6 approved claims for covered services that are completed
7 and submitted to the managed health care entity within 30
8 days after receipt of the claim or receipt of the
9 appropriate capitation payment or payments by the managed
10 health care entity from the State for the month in which
11 the services included on the claim were rendered,
12 whichever is later. If payment is not made or mailed to
13 the provider by the managed health care entity by the due
14 date under this subsection, an interest penalty of 1% of
15 any amount unpaid shall be added for each month or
16 fraction of a month after the due date, until final
17 payment is made. Nothing in this Section shall prohibit
18 managed health care entities and providers from mutually
19 agreeing to terms that require more timely payment.
20 (12.5) Ensure that no payment is made to a
21 physician or other provider of services for withholding
22 from an enrollee any covered services because of the cost
23 of those services. This requirement shall not be
24 construed to prevent managed health care entities from
25 offering, nor providers from accepting, full or partial
26 capitation.
27 (13) Provide integration with community-based
28 programs provided by certified local health departments
29 such as Women, Infants, and Children Supplemental Food
30 Program (WIC), childhood immunization programs, health
31 education programs, case management programs, and health
32 screening programs.
33 (14) Provide that the pharmacy formulary used by a
34 managed health care entity and its contract providers be
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1 no more restrictive than the Illinois Department's
2 pharmaceutical program on the effective date of this
3 amendatory Act of 1994 and as amended after that date.
4 (15) Provide integration with community-based
5 organizations, including, but not limited to, any
6 organization that has operated within a Medicaid
7 Partnership as defined by this Code or by rule of the
8 Illinois Department, that may continue to operate under a
9 contract with the Illinois Department or a managed health
10 care entity under this Section to provide case management
11 services to Medicaid clients in designated high-need
12 areas.
13 The Illinois Department may, by rule, determine
14 methodologies to limit financial liability for managed health
15 care entities resulting from payment for services to
16 enrollees provided under the Illinois Department's integrated
17 health care program. Any methodology so determined may be
18 considered or implemented by the Illinois Department through
19 a contract with a managed health care entity under this
20 integrated health care program.
21 The Illinois Department shall contract with an entity or
22 entities to provide external peer-based quality assurance
23 review for the integrated health care program. The entity
24 shall be representative of Illinois physicians licensed to
25 practice medicine in all its branches and have statewide
26 geographic representation in all specialties of medical care
27 that are provided within the integrated health care program.
28 The entity may not be a third party payer and shall maintain
29 offices in locations around the State in order to provide
30 service and continuing medical education to physician
31 participants within the integrated health care program. The
32 review process shall be developed and conducted by Illinois
33 physicians licensed to practice medicine in all its branches.
34 In consultation with the entity, the Illinois Department may
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1 contract with other entities for professional peer-based
2 quality assurance review of individual categories of services
3 other than services provided, supervised, or coordinated by
4 physicians licensed to practice medicine in all its branches.
5 The Illinois Department shall establish, by rule, criteria to
6 avoid conflicts of interest in the conduct of quality
7 assurance activities consistent with professional peer-review
8 standards. All quality assurance activities shall be
9 coordinated by the Illinois Department.
10 (e) All persons enrolled in the program shall be
11 provided with a full written explanation of all
12 fee-for-service and managed health care plan options and a
13 reasonable opportunity to choose among the options as
14 provided by rule. The Illinois Department shall provide to
15 enrollees, upon enrollment in the integrated health care
16 program and at least annually thereafter, notice of the
17 process for requesting an appeal under the Illinois
18 Department's administrative appeal procedures.
19 Notwithstanding any other Section of this Code, the Illinois
20 Department may provide by rule for the Illinois Department to
21 assign a person enrolled in the program to a specific
22 provider of medical services or to a specific health care
23 delivery system if an enrollee has failed to exercise choice
24 in a timely manner. An enrollee assigned by the Illinois
25 Department shall be afforded the opportunity to disenroll and
26 to select a specific provider of medical services or a
27 specific health care delivery system within the first 30 days
28 after the assignment. An enrollee who has failed to exercise
29 choice in a timely manner may be assigned only if there are 3
30 or more managed health care entities contracting with the
31 Illinois Department within the contracting area, except that,
32 outside the City of Chicago, this requirement may be waived
33 for an area by rules adopted by the Illinois Department after
34 consultation with all hospitals within the contracting area.
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1 The Illinois Department shall establish by rule the procedure
2 for random assignment of enrollees who fail to exercise
3 choice in a timely manner to a specific managed health care
4 entity in proportion to the available capacity of that
5 managed health care entity. Assignment to a specific provider
6 of medical services or to a specific managed health care
7 entity may not exceed that provider's or entity's capacity as
8 determined by the Illinois Department. Any person who has
9 chosen a specific provider of medical services or a specific
10 managed health care entity, or any person who has been
11 assigned under this subsection, shall be given the
12 opportunity to change that choice or assignment at least once
13 every 12 months, as determined by the Illinois Department by
14 rule. The Illinois Department shall maintain a toll-free
15 telephone number for program enrollees' use in reporting
16 problems with managed health care entities.
17 (f) If a person becomes eligible for participation in
18 the integrated health care program while he or she is
19 hospitalized, the Illinois Department may not enroll that
20 person in the program until after he or she has been
21 discharged from the hospital. This subsection does not apply
22 to newborn infants whose mothers are enrolled in the
23 integrated health care program.
24 (g) The Illinois Department shall, by rule, establish
25 for managed health care entities rates that (i) are certified
26 to be actuarially sound, as determined by an actuary who is
27 an associate or a fellow of the Society of Actuaries or a
28 member of the American Academy of Actuaries and who has
29 expertise and experience in medical insurance and benefit
30 programs, in accordance with the Illinois Department's
31 current fee-for-service payment system, and (ii) take into
32 account any difference of cost to provide health care to
33 different populations based on gender, age, location, and
34 eligibility category. The rates for managed health care
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1 entities shall be determined on a capitated basis.
2 The Illinois Department by rule shall establish a method
3 to adjust its payments to managed health care entities in a
4 manner intended to avoid providing any financial incentive to
5 a managed health care entity to refer patients to a county
6 provider, in an Illinois county having a population greater
7 than 3,000,000, that is paid directly by the Illinois
8 Department. The Illinois Department shall by April 1, 1997,
9 and annually thereafter, review the method to adjust
10 payments. Payments by the Illinois Department to the county
11 provider, for persons not enrolled in a managed care
12 community network owned or operated by a county provider,
13 shall be paid on a fee-for-service basis under Article XV of
14 this Code.
15 The Illinois Department by rule shall establish a method
16 to reduce its payments to managed health care entities to
17 take into consideration (i) any adjustment payments paid to
18 hospitals under subsection (h) of this Section to the extent
19 those payments, or any part of those payments, have been
20 taken into account in establishing capitated rates under this
21 subsection (g) and (ii) the implementation of methodologies
22 to limit financial liability for managed health care entities
23 under subsection (d) of this Section.
24 (g-5) After December 31 of each year and before March 1
25 of the succeeding year, every managed health care entity that
26 participates in the integrated health care program shall file
27 a report with the Illinois Department. The report shall be
28 in the form specified by the Illinois Department. The
29 Illinois Department may specify that the report include,
30 without limitation, all salaries, wages, reimbursements,
31 benefits, and other consideration paid to the entity's
32 owners, officers, employees, and agents during the calendar
33 year just ended.
34 If a physician providing or proposing to provide medical
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1 services to a managed health care entity's enrollees makes a
2 report to the Department of Professional Regulation required
3 under paragraph 34, 35, or 36 of Section 22 of the Medical
4 Practice Act of 1987, the managed health care entity shall
5 cause a copy of the report to be submitted to the Illinois
6 Department.
7 Every managed health care entity required to report under
8 this subsection shall keep records and books that will permit
9 verification of the information required to be reported under
10 this subsection. All such books and records shall be kept in
11 the English language and shall, at all times during business
12 hours of the day, be subject to inspection by the Illinois
13 Department or its authorized agents and employees.
14 In order to prevent profiteering by a managed health care
15 entity as a result of the entity's participation in the
16 integrated health care program, the Illinois Department may,
17 by rule, establish limits on the amounts a managed health
18 care entity may pay to its owners, officers, employees, and
19 agents.
20 On or before April 1 of each year, the Illinois
21 Department shall report the following to the General
22 Assembly:
23 (1) Amounts reported paid to managed health care
24 entity owners, officers, employees, and agents, if
25 required to be reported by managed health care entities
26 under this subsection, for the preceding calendar year.
27 (2) Any limitations on amounts paid by managed
28 health care entities imposed by the Illinois Department
29 under this subsection.
30 (h) For hospital services provided by a hospital that
31 contracts with a managed health care entity, adjustment
32 payments shall be paid directly to the hospital by the
33 Illinois Department. Adjustment payments may include but
34 need not be limited to adjustment payments to:
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1 disproportionate share hospitals under Section 5-5.02 of this
2 Code; primary care access health care education payments (89
3 Ill. Adm. Code 149.140); payments for capital, direct medical
4 education, indirect medical education, certified registered
5 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
6 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
7 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
8 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
9 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
10 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
11 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
12 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
13 148.290(h)); and outpatient indigent volume adjustments (89
14 Ill. Adm. Code 148.140(b)(5)).
15 (i) For any hospital eligible for the adjustment
16 payments described in subsection (h), the Illinois Department
17 shall maintain, through the period ending June 30, 1995,
18 reimbursement levels in accordance with statutes and rules in
19 effect on April 1, 1994.
20 (j) Nothing contained in this Code in any way limits or
21 otherwise impairs the authority or power of the Illinois
22 Department to enter into a negotiated contract pursuant to
23 this Section with a managed health care entity, including,
24 but not limited to, a health maintenance organization, that
25 provides for termination or nonrenewal of the contract
26 without cause upon notice as provided in the contract and
27 without a hearing.
28 (k) Section 5-5.15 does not apply to the program
29 developed and implemented pursuant to this Section.
30 (l) The Illinois Department shall, by rule, define those
31 chronic or acute medical conditions of childhood that require
32 longer-term treatment and follow-up care. The Illinois
33 Department shall ensure that services required to treat these
34 conditions are available through a separate delivery system.
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1 A managed health care entity that contracts with the
2 Illinois Department may refer a child with medical conditions
3 described in the rules adopted under this subsection directly
4 to a children's hospital or to a hospital, other than a
5 children's hospital, that is qualified to provide inpatient
6 and outpatient services to treat those conditions. The
7 Illinois Department shall provide fee-for-service
8 reimbursement directly to a children's hospital for those
9 services pursuant to Title 89 of the Illinois Administrative
10 Code, Section 148.280(a), at a rate at least equal to the
11 rate in effect on March 31, 1994. For hospitals, other than
12 children's hospitals, that are qualified to provide inpatient
13 and outpatient services to treat those conditions, the
14 Illinois Department shall provide reimbursement for those
15 services on a fee-for-service basis, at a rate at least equal
16 to the rate in effect for those other hospitals on March 31,
17 1994.
18 A children's hospital shall be directly reimbursed for
19 all services provided at the children's hospital on a
20 fee-for-service basis pursuant to Title 89 of the Illinois
21 Administrative Code, Section 148.280(a), at a rate at least
22 equal to the rate in effect on March 31, 1994, until the
23 later of (i) implementation of the integrated health care
24 program under this Section and development of actuarially
25 sound capitation rates for services other than those chronic
26 or acute medical conditions of childhood that require
27 longer-term treatment and follow-up care as defined by the
28 Illinois Department in the rules adopted under this
29 subsection or (ii) March 31, 1996.
30 Notwithstanding anything in this subsection to the
31 contrary, a managed health care entity shall not consider
32 sources or methods of payment in determining the referral of
33 a child. The Illinois Department shall adopt rules to
34 establish criteria for those referrals. The Illinois
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1 Department by rule shall establish a method to adjust its
2 payments to managed health care entities in a manner intended
3 to avoid providing any financial incentive to a managed
4 health care entity to refer patients to a provider who is
5 paid directly by the Illinois Department.
6 (m) Behavioral health services provided or funded by the
7 Department of Human Services, the Department of Children and
8 Family Services, and the Illinois Department shall be
9 excluded from a benefit package. Conditions of an organic or
10 physical origin or nature, including medical detoxification,
11 however, may not be excluded. In this subsection,
12 "behavioral health services" means mental health services and
13 subacute alcohol and substance abuse treatment services, as
14 defined in the Illinois Alcoholism and Other Drug Dependency
15 Act. In this subsection, "mental health services" includes,
16 at a minimum, the following services funded by the Illinois
17 Department, the Department of Human Services (as successor to
18 the Department of Mental Health and Developmental
19 Disabilities), or the Department of Children and Family
20 Services: (i) inpatient hospital services, including related
21 physician services, related psychiatric interventions, and
22 pharmaceutical services provided to an eligible recipient
23 hospitalized with a primary diagnosis of psychiatric
24 disorder; (ii) outpatient mental health services as defined
25 and specified in Title 59 of the Illinois Administrative
26 Code, Part 132; (iii) any other outpatient mental health
27 services funded by the Illinois Department pursuant to the
28 State of Illinois Medicaid Plan; (iv) partial
29 hospitalization; and (v) follow-up stabilization related to
30 any of those services. Additional behavioral health services
31 may be excluded under this subsection as mutually agreed in
32 writing by the Illinois Department and the affected State
33 agency or agencies. The exclusion of any service does not
34 prohibit the Illinois Department from developing and
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1 implementing demonstration projects for categories of persons
2 or services. The Department of Children and Family Services
3 and the Department of Human Services shall each adopt rules
4 governing the integration of managed care in the provision of
5 behavioral health services. The State shall integrate managed
6 care community networks and affiliated providers, to the
7 extent practicable, in any separate delivery system for
8 mental health services.
9 (n) The Illinois Department shall adopt rules to
10 establish reserve requirements for managed care community
11 networks, as required by subsection (a), and health
12 maintenance organizations to protect against liabilities in
13 the event that a managed health care entity is declared
14 insolvent or bankrupt. If a managed health care entity other
15 than a county provider is declared insolvent or bankrupt,
16 after liquidation and application of any available assets,
17 resources, and reserves, the Illinois Department shall pay a
18 portion of the amounts owed by the managed health care entity
19 to providers for services rendered to enrollees under the
20 integrated health care program under this Section based on
21 the following schedule: (i) from April 1, 1995 through June
22 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
23 through June 30, 2001, 80% of the amounts owed; and (iii)
24 from July 1, 2001 through June 30, 2005, 75% of the amounts
25 owed. The amounts paid under this subsection shall be
26 calculated based on the total amount owed by the managed
27 health care entity to providers before application of any
28 available assets, resources, and reserves. After June 30,
29 2005, the Illinois Department may not pay any amounts owed to
30 providers as a result of an insolvency or bankruptcy of a
31 managed health care entity occurring after that date. The
32 Illinois Department is not obligated, however, to pay amounts
33 owed to a provider that has an ownership or other governing
34 interest in the managed health care entity. This subsection
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1 applies only to managed health care entities and the services
2 they provide under the integrated health care program under
3 this Section.
4 (o) Notwithstanding any other provision of law or
5 contractual agreement to the contrary, providers shall not be
6 required to accept from any other third party payer the rates
7 determined or paid under this Code by the Illinois
8 Department, managed health care entity, or other health care
9 delivery system for services provided to recipients.
10 (p) The Illinois Department may seek and obtain any
11 necessary authorization provided under federal law to
12 implement the program, including the waiver of any federal
13 statutes or regulations. The Illinois Department may seek a
14 waiver of the federal requirement that the combined
15 membership of Medicare and Medicaid enrollees in a managed
16 care community network may not exceed 75% of the managed care
17 community network's total enrollment. The Illinois
18 Department shall not seek a waiver of this requirement for
19 any other category of managed health care entity. The
20 Illinois Department shall not seek a waiver of the inpatient
21 hospital reimbursement methodology in Section 1902(a)(13)(A)
22 of Title XIX of the Social Security Act even if the federal
23 agency responsible for administering Title XIX determines
24 that Section 1902(a)(13)(A) applies to managed health care
25 systems.
26 Notwithstanding any other provisions of this Code to the
27 contrary, the Illinois Department shall seek a waiver of
28 applicable federal law in order to impose a co-payment system
29 consistent with this subsection on recipients of medical
30 services under Title XIX of the Social Security Act who are
31 not enrolled in a managed health care entity. The waiver
32 request submitted by the Illinois Department shall provide
33 for co-payments of up to $0.50 for prescribed drugs and up to
34 $0.50 for x-ray services and shall provide for co-payments of
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1 up to $10 for non-emergency services provided in a hospital
2 emergency room and up to $10 for non-emergency ambulance
3 services. The purpose of the co-payments shall be to deter
4 those recipients from seeking unnecessary medical care.
5 Co-payments may not be used to deter recipients from seeking
6 necessary medical care. No recipient shall be required to
7 pay more than a total of $150 per year in co-payments under
8 the waiver request required by this subsection. A recipient
9 may not be required to pay more than $15 of any amount due
10 under this subsection in any one month.
11 Co-payments authorized under this subsection may not be
12 imposed when the care was necessitated by a true medical
13 emergency. Co-payments may not be imposed for any of the
14 following classifications of services:
15 (1) Services furnished to person under 18 years of
16 age.
17 (2) Services furnished to pregnant women.
18 (3) Services furnished to any individual who is an
19 inpatient in a hospital, nursing facility, intermediate
20 care facility, or other medical institution, if that
21 person is required to spend for costs of medical care all
22 but a minimal amount of his or her income required for
23 personal needs.
24 (4) Services furnished to a person who is receiving
25 hospice care.
26 Co-payments authorized under this subsection shall not be
27 deducted from or reduce in any way payments for medical
28 services from the Illinois Department to providers. No
29 provider may deny those services to an individual eligible
30 for services based on the individual's inability to pay the
31 co-payment.
32 Recipients who are subject to co-payments shall be
33 provided notice, in plain and clear language, of the amount
34 of the co-payments, the circumstances under which co-payments
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1 are exempted, the circumstances under which co-payments may
2 be assessed, and their manner of collection.
3 The Illinois Department shall establish a Medicaid
4 Co-Payment Council to assist in the development of co-payment
5 policies for the medical assistance program. The Medicaid
6 Co-Payment Council shall also have jurisdiction to develop a
7 program to provide financial or non-financial incentives to
8 Medicaid recipients in order to encourage recipients to seek
9 necessary health care. The Council shall be chaired by the
10 Director of the Illinois Department, and shall have 6
11 additional members. Two of the 6 additional members shall be
12 appointed by the Governor, and one each shall be appointed by
13 the President of the Senate, the Minority Leader of the
14 Senate, the Speaker of the House of Representatives, and the
15 Minority Leader of the House of Representatives. The Council
16 may be convened and make recommendations upon the appointment
17 of a majority of its members. The Council shall be appointed
18 and convened no later than September 1, 1994 and shall report
19 its recommendations to the Director of the Illinois
20 Department and the General Assembly no later than October 1,
21 1994. The chairperson of the Council shall be allowed to
22 vote only in the case of a tie vote among the appointed
23 members of the Council.
24 The Council shall be guided by the following principles
25 as it considers recommendations to be developed to implement
26 any approved waivers that the Illinois Department must seek
27 pursuant to this subsection:
28 (1) Co-payments should not be used to deter access
29 to adequate medical care.
30 (2) Co-payments should be used to reduce fraud.
31 (3) Co-payment policies should be examined in
32 consideration of other states' experience, and the
33 ability of successful co-payment plans to control
34 unnecessary or inappropriate utilization of services
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1 should be promoted.
2 (4) All participants, both recipients and
3 providers, in the medical assistance program have
4 responsibilities to both the State and the program.
5 (5) Co-payments are primarily a tool to educate the
6 participants in the responsible use of health care
7 resources.
8 (6) Co-payments should not be used to penalize
9 providers.
10 (7) A successful medical program requires the
11 elimination of improper utilization of medical resources.
12 The integrated health care program, or any part of that
13 program, established under this Section may not be
14 implemented if matching federal funds under Title XIX of the
15 Social Security Act are not available for administering the
16 program.
17 The Illinois Department shall submit for publication in
18 the Illinois Register the name, address, and telephone number
19 of the individual to whom a request may be directed for a
20 copy of the request for a waiver of provisions of Title XIX
21 of the Social Security Act that the Illinois Department
22 intends to submit to the Health Care Financing Administration
23 in order to implement this Section. The Illinois Department
24 shall mail a copy of that request for waiver to all
25 requestors at least 16 days before filing that request for
26 waiver with the Health Care Financing Administration.
27 (q) After the effective date of this Section, the
28 Illinois Department may take all planning and preparatory
29 action necessary to implement this Section, including, but
30 not limited to, seeking requests for proposals relating to
31 the integrated health care program created under this
32 Section. This planning and preparatory action shall include
33 the establishment of a Managed Care Roundtable, the members
34 of which shall be appointed following the guidelines set
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1 forth in Section 12-4.20. The purposes of the Roundtable are
2 (i) to provide a forum for discussion about the immediate and
3 long-term challenges presented by implementation of the
4 system for integrated health care services pursuant to this
5 Section and (ii) to provide State government with practical
6 input from those most directly involved in implementing the
7 system for integrated health care services and those most
8 directly affected by that implementation. The Roundtable
9 shall endeavor to recommend reasonable, no-cost or low-cost
10 solutions to the current operational concerns of health care
11 providers, which, in turn, impact the delivery of quality
12 health care to patients.
13 (r) In order to (i) accelerate and facilitate the
14 development of integrated health care in contracting areas
15 outside counties with populations in excess of 3,000,000 and
16 counties adjacent to those counties and (ii) maintain and
17 sustain the high quality of education and residency programs
18 coordinated and associated with local area hospitals, the
19 Illinois Department may develop and implement a demonstration
20 program for managed care community networks owned, operated,
21 or governed by State-funded medical schools. The Illinois
22 Department shall prescribe by rule the criteria, standards,
23 and procedures for effecting this demonstration program.
24 (s) (Blank).
25 (s-5) The Illinois Department may impose penalties or
26 sanctions permitted by law or contract for violations of
27 this Section.
28 (t) On April 1, 1995 and every 6 months thereafter, the
29 Illinois Department shall report to the Governor and General
30 Assembly on the progress of the integrated health care
31 program in enrolling clients into managed health care
32 entities. The report shall indicate the capacities of the
33 managed health care entities with which the State contracts,
34 the number of clients enrolled by each contractor, the areas
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1 of the State in which managed care options do not exist, and
2 the progress toward meeting the enrollment goals of the
3 integrated health care program.
4 (u) The Illinois Department may implement this Section
5 through the use of emergency rules in accordance with Section
6 5-45 of the Illinois Administrative Procedure Act. For
7 purposes of that Act, the adoption of rules to implement this
8 Section is deemed an emergency and necessary for the public
9 interest, safety, and welfare.
10 (v) The Auditor General shall conduct an annual
11 performance audit of the integrated health care program
12 created under this Section and the Illinois Department's
13 implementation of this Section. The initial audit shall
14 cover the fiscal year ending June 30, 1998, and subsequent
15 audits shall cover each fiscal year thereafter. The Auditor
16 General shall issue reports of the audits on or before
17 December 31 of 1998 and each year thereafter.
18 (Source: P.A. 89-21, eff. 7-1-95; 89-507, eff. 7-1-97;
19 89-673, eff. 8-14-96; 90-14, eff. 7-1-97; 90-254, eff.
20 1-1-98; 90-538, eff. 12-1-97; revised 12-3-97.)
21 (305 ILCS 5/5-16.12 new)
22 Sec. 5-16.12. Administration of managed care program.
23 (a) The Illinois Department shall, by rule, establish
24 guidelines for its administration of a managed care program
25 requiring each managed care organization participating in the
26 program to provide education programs for providers
27 participating within the managed care organization's network
28 and for persons eligible for medical assistance under Article
29 V, VI, or XII who are enrolled with the managed care
30 organization.
31 (b) A provider education program must include
32 information on:
33 (1) Medicaid policies, procedures, eligibility
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1 standards, and benefits;
2 (2) the specific problems and needs of Medicaid
3 clients; and
4 (3) the rights and responsibilities of Medicaid
5 clients prescribed by this Section.
6 (c) A client education program must present information
7 in a manner that is easy to understand. A program must
8 include information on:
9 (1) the rights and responsibilities prescribed by
10 this Section;
11 (2) how to access health care services;
12 (3) how to access complaint procedures and the
13 client's rights to bypass the managed care organization's
14 internal complaint system and use the notice and appeal
15 procedures otherwise required by the Medicaid program;
16 (4) Medicaid policies, procedures, eligibility
17 standards, and benefits;
18 (5) the policies and procedures of the managed care
19 organization; and
20 (6) the importance of prevention, early
21 intervention, and appropriate use of services.
22 (d) The Department or its designee shall inform each
23 person enrolled in the Medicaid program of the person's
24 rights and responsibilities under that program. The
25 information must address the client's right to:
26 (1) respect, dignity, privacy, confidentiality, and
27 nondiscrimination;
28 (2) a reasonable opportunity to choose a health
29 care plan and primary care provider and to change to
30 another plan or provider in a reasonable manner;
31 (3) consent to or refuse treatment and actively
32 participate in treatment decisions;
33 (4) ask questions and receive complete information
34 relating to the client's medical condition and treatment
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1 options, including specialty care;
2 (5) access each available complaint process,
3 receive a timely response to a complaint, and receive a
4 fair hearing; and
5 (6) timely access to care that does not have any
6 communication or physical access barriers.
7 (e) The information must address a client's
8 responsibility to:
9 (1) learn and understand each right the client has
10 under the Medicaid program;
11 (2) abide by the health plan and Medicaid policies
12 and procedures;
13 (3) share information relating to the client's
14 health status with the primary care provider and become
15 fully informed about service and treatment options; and
16 (4) actively participate in decisions relating to
17 service and treatment options, make personal choices and
18 take action to maintain the client's health.
19 (f) The Department shall provide support and information
20 services to a person enrolled in the program or applying for
21 Medicaid coverage who experiences barriers to receiving
22 health care services. The Department may contract for the
23 provision of support and information services. As a part of
24 the support and information services required by this
25 subsection, the Department or organization shall:
26 (1) operate a statewide toll-free assistance
27 telephone number that includes TDD lines and assistance
28 for persons who speak Spanish;
29 (2) intervene promptly with the managed care
30 organizations and providers and any other appropriate
31 entity on behalf of a person who has an urgent need for
32 medical services;
33 (3) assist a person who is experiencing barriers in
34 the Medicaid application and enrollment process and refer
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1 the person for further assistance if appropriate;
2 (4) educate persons so that they:
3 (A) understand the concept of managed care;
4 (B) understand their rights under the Medicaid
5 program, including grievance and appeal procedures;
6 and
7 (C) are able to advocate for themselves; and
8 (5) collect and maintain statistical information on
9 a regional basis regarding calls received by the
10 assistance lines and publish quarterly reports that:
11 (A) list the number of calls received by
12 region;
13 (B) identify trends in delivery and access
14 problems;
15 (C) identify recurring barriers in the
16 Medicaid system; and
17 (D) indicate other problems identified with
18 Medicaid managed care; and
19 (6) assist the managed care organizations and
20 providers in identifying and correcting problems,
21 including site visits to affected regions if necessary.
22 (g) If a managed care organization is accredited by a
23 private national organization that performs quality assurance
24 surveys of health maintenance organizations or related
25 organizations, the Illinois Department may take the
26 accreditation into consideration when selecting managed care
27 organizations for participation in the managed care program.
28 The medical director of a managed care organization must be a
29 physician licensed in the State to practice medicine in all
30 its branches.
31 (h) As a condition of participation in the managed care
32 program, a managed care organization shall authorize an
33 investigation to determine whether the organization, any
34 person holding an ownership interest in the organization, or
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1 any person employed by the organization in a managerial
2 capacity (i) has ever been sanctioned under Section 12-4.25
3 of this Code, (ii) has ever had a sanction (such as
4 revocation, suspension, or refusal to renew) imposed against
5 a professional or other license held by the organization or
6 person, or (iii) has ever been charged with a crime and, if
7 so, the disposition of those charges. Upon this
8 authorization, the Illinois Department shall request and
9 receive information and assistance from any federal, State,
10 or local governmental law enforcement or other agency as part
11 of the authorized investigation. The Department of State
12 Police shall provide information concerning any criminal
13 charges, and their disposition, currently or subsequently
14 filed against an organization or person described in this
15 subsection upon the request of the Illinois Department when
16 the request is made in the form and manner required by the
17 Department of State Police. The Illinois Department may
18 contract with a law enforcement agency for the performance of
19 investigations authorized under this subsection.
20 Information concerning convictions of an organization or
21 person investigated under this subsection, including the
22 source of the information and any conclusions or
23 recommendations derived from the information, shall be
24 provided, upon request, to the organization or person before
25 final action by the Illinois Department on the request to
26 participate in the managed care program. Any information
27 concerning criminal charges and the disposition of those
28 charges obtained by the Illinois Department shall be
29 confidential and may not be transmitted outside the Illinois
30 Department, except as required in this subsection, and may
31 not be transmitted to anyone within the Illinois Department
32 except as needed for the purpose of evaluating a request to
33 participate in the managed care program. Only information
34 and standards that bear a reasonable and rational relation to
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1 the performance of a managed care organization may be used by
2 the Illinois Department in taking action on a request to
3 participate in the managed care program. Any employee of the
4 Illinois Department, Department of State Police, or a managed
5 care organization receiving confidential information under
6 this subsection who gives or causes to be given any
7 confidential information concerning any criminal convictions
8 of an organization or person described in this subsection is
9 guilty of a Class A misdemeanor unless release of the
10 information is authorized by this subsection.
11 (i) A managed care organization may not participate in
12 the managed care program if the organization's license to
13 operate as a managed care organization has been revoked or is
14 currently under suspension by the Department of Insurance or
15 if the Department of Insurance is currently refusing to renew
16 the organization's license.
17 If any of the following circumstances exist with respect
18 to a managed care organization, the Illinois Department may
19 consider these circumstances, as they relate to the
20 organization's ability to perform its obligations under the
21 managed care program, and other criteria in determining
22 whether to initially select the organization for
23 participation in the program and whether to renew the
24 organization's participation in the program for another
25 contract term:
26 (1) An owner or officer of the organization is the
27 subject of a professional licensure disciplinary
28 proceeding.
29 (2) An owner or officer of the organization is the
30 subject of a proceeding by the Illinois Department to
31 impose any sanction authorized under this Code.
32 (j) A managed care organization that contracts with the
33 Illinois Department for the provision of services shall,
34 solely for purposes of the managed care program, provide
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1 orientation to the caretaker relative or payee of a medical
2 assistance unit that has an enrollee as a member. The
3 managed care organization must exercise good faith efforts to
4 provide all caretaker relatives or payees with the
5 orientation. The managed care organization shall inform the
6 Illinois Department of the caretaker relatives or payees who
7 have completed the orientation. This paragraph applies to
8 every caretaker relative or payee in a managed care
9 organization's system regardless of whether the caretaker
10 relative or payee has chosen the system or has been assigned
11 to the system as provided in this Code.
12 (k) The Illinois Department must include performance
13 standards in contracts with organizations participating in
14 the managed care program to require contractors to make a
15 good faith effort to have enrollees evaluated by a physician
16 within a reasonable period of time after enrollment, as
17 determined by the Illinois Department.
18 (l) A managed care organization that contracts with the
19 Illinois Department for the provision of services shall,
20 solely for purposes of the managed care program, ensure that
21 no payment is made to a physician or other provider of
22 services for withholding from an enrollee any covered
23 services because of the cost of those services. This
24 requirement shall not be construed to prevent managed care
25 organizations from offering, nor providers from accepting,
26 full or partial capitation.
27 (m) After December 31 of each year and before March 1 of
28 the succeeding year, every managed care organization that
29 participates in the managed care program shall file a report
30 with the Illinois Department. The report shall be in the
31 form specified by the Illinois Department. The Illinois
32 Department may specify that the report include, without
33 limitation, all salaries, wages, reimbursements, benefits,
34 and other consideration paid to the organization's owners,
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1 officers, employees, and agents during the calendar year just
2 ended.
3 If a physician providing or proposing to provide medical
4 services to a managed care organization's enrollees makes a
5 report to the Department of Professional Regulation required
6 under paragraph 34, 35, or 36 of Section 22 of the Medical
7 Practice Act of 1987, the managed care organization shall
8 cause a copy of the report to be submitted to the Illinois
9 Department.
10 Every managed care organization required to report under
11 this subsection shall keep records and books that will permit
12 verification of the information required to be reported under
13 this subsection. All such books and records shall be kept in
14 the English language and shall, at all times during business
15 hours of the day, be subject to inspection by the Illinois
16 Department or its authorized agents and employees.
17 In order to prevent profiteering by a managed care
18 organization as a result of the organization's participation
19 in the managed care program, the Illinois Department may, by
20 rule, establish limits on the amounts a managed care
21 organization may pay to its owners, officers, employees, and
22 agents.
23 On or before April 1 of each year, the Illinois
24 Department shall report the following to the General
25 Assembly:
26 (1) Amounts reported paid to managed care
27 organization owners, officers, employees, and agents, if
28 required to be reported by managed care organizations
29 under this subsection, for the preceding calendar year.
30 (2) Any limitations on amounts paid by managed care
31 organizations imposed by the Illinois Department under
32 this subsection.
33 (n) The Managed Care Roundtable established under
34 subsection (q) of Section 5-16.3 to perform certain functions
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1 with respect to the integrated health care program
2 established under that Section shall perform the same
3 functions with respect to any managed care program subject to
4 this Section.
5 (o) The Illinois Department may impose penalties or
6 sanctions permitted by law or contract for violations of
7 this Section.
8 (p) The Auditor General shall conduct an annual
9 performance audit of each managed care program subject to
10 this Section and the Illinois Department's implementation of
11 this Section. The initial audit shall cover the fiscal year
12 ending June 30, 1998, and subsequent audits shall cover each
13 fiscal year thereafter. The Auditor General shall issue
14 reports of the audits on or before December 31 of 1998 and
15 each year thereafter.
16 (305 ILCS 5/12-13.1)
17 Sec. 12-13.1. Inspector General.
18 (a) The Governor shall appoint, and the Senate shall
19 confirm, an Inspector General who shall function within the
20 Illinois Department of Public Aid and report to the Governor.
21 The term of the Inspector General shall expire on the third
22 Monday of January, 1997 and every 4 years thereafter.
23 (b) In order to prevent, detect, and eliminate fraud,
24 waste, abuse, mismanagement, and misconduct, the Inspector
25 General shall oversee the Illinois Department of Public Aid's
26 integrity functions, which include, but are not limited to,
27 the following:
28 (1) Investigation of misconduct by employees,
29 vendors, contractors and medical providers.
30 (2) Audits of medical providers related to ensuring
31 that appropriate payments are made for services rendered
32 and to the recovery of overpayments.
33 (3) Monitoring of quality assurance programs
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1 generally related to the medical assistance program and
2 specifically related to any managed care program.
3 (4) Quality control measurements of the programs
4 administered by the Illinois Department of Public Aid.
5 (5) Investigations of fraud or intentional program
6 violations committed by clients of the Illinois
7 Department of Public Aid.
8 (6) Actions initiated against contractors or
9 medical providers for any of the following reasons:
10 (A) Violations of the medical assistance
11 program.
12 (B) Sanctions against providers brought in
13 conjunction with the Department of Public Health or
14 the Department of Human Services (as successor to
15 the Department of Mental Health and Developmental
16 Disabilities).
17 (C) Recoveries of assessments against
18 hospitals and long-term care facilities.
19 (D) Sanctions mandated by the United States
20 Department of Health and Human Services against
21 medical providers.
22 (E) Violations of contracts related to any
23 managed care programs.
24 (7) Representation of the Illinois Department of
25 Public Aid at hearings with the Illinois Department of
26 Professional Regulation in actions taken against
27 professional licenses held by persons who are in
28 violation of orders for child support payments.
29 (b-5) At the request of the Secretary of Human Services,
30 the Inspector General shall, in relation to any function
31 performed by the Department of Human Services as successor to
32 the Department of Public Aid, exercise one or more of the
33 powers provided under this Section as if those powers related
34 to the Department of Human Services; in such matters, the
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1 Inspector General shall report his or her findings to the
2 Secretary of Human Services.
3 (b-7) The Inspector General may establish within that
4 Office a special administrative subdivision to monitor
5 managed health care entities or managed care organizations
6 participating in the integrated health care program
7 established under Section 5-16.3 of this Code or in any other
8 managed care program administered by the Illinois Department
9 to ensure that the entities or organizations comply with the
10 requirements of that Section and Section 5-16.12. This
11 special administrative subdivision may receive and
12 investigate complaints made by persons enrolled in a managed
13 health care entity's or managed care organization's health
14 care delivery system. If the Inspector General investigates
15 a complaint, the Inspector General shall determine whether a
16 managed health care entity or managed care organization has
17 complied with the requirements of Section 5-16.3 or 5-16.12
18 and the rules implementing those Sections to the extent that
19 those issues are raised by the complaint.
20 The Inspector General may also monitor the Enrolled
21 Managed Care Provider program to ensure that appropriate
22 management of patient care occurs and that services provided
23 are medically necessary. The special administrative
24 subdivision authorized under this subsection may receive and
25 investigate complaints made by persons receiving services
26 under Section 5-16.3 or under any other managed care program
27 administered by the Illinois Department.
28 (c) The Inspector General shall have access to all
29 information, personnel and facilities of the Illinois
30 Department of Public Aid and the Department of Human Services
31 (as successor to the Department of Public Aid), their
32 employees, vendors, contractors and medical providers and any
33 federal, State or local governmental agency that are
34 necessary to perform the duties of the Office as directly
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1 related to public assistance programs administered by those
2 departments. No medical provider shall be compelled,
3 however, to provide individual medical records of patients
4 who are not clients of the Medical Assistance Program. State
5 and local governmental agencies are authorized and directed
6 to provide the requested information, assistance or
7 cooperation.
8 (d) The Inspector General shall serve as the Illinois
9 Department of Public Aid's primary liaison with law
10 enforcement, investigatory and prosecutorial agencies,
11 including but not limited to the following:
12 (1) The Department of State Police.
13 (2) The Federal Bureau of Investigation and other
14 federal law enforcement agencies.
15 (3) The various Inspectors General of federal
16 agencies overseeing the programs administered by the
17 Illinois Department of Public Aid.
18 (4) The various Inspectors General of any other
19 State agencies with responsibilities for portions of
20 programs primarily administered by the Illinois
21 Department of Public Aid.
22 (5) The Offices of the several United States
23 Attorneys in Illinois.
24 (6) The several State's Attorneys.
25 The Inspector General shall meet on a regular basis with
26 these entities to share information regarding possible
27 misconduct by any persons or entities involved with the
28 public aid programs administered by the Illinois Department
29 of Public Aid.
30 (e) All investigations conducted by the Inspector
31 General shall be conducted in a manner that ensures the
32 preservation of evidence for use in criminal prosecutions.
33 If the Inspector General determines that a possible criminal
34 act relating to fraud in the provision or administration of
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1 the medical assistance program has been committed, the
2 Inspector General shall immediately notify the Medicaid Fraud
3 Control Unit. If the Inspector General determines that a
4 possible criminal act has been committed within the
5 jurisdiction of the Office, the Inspector General may request
6 the special expertise of the Department of State Police. The
7 Inspector General may present for prosecution the findings of
8 any criminal investigation to the Office of the Attorney
9 General, the Offices of the several United State Attorneys in
10 Illinois or the several State's Attorneys.
11 (f) To carry out his or her duties as described in this
12 Section, the Inspector General and his or her designees shall
13 have the power to compel by subpoena the attendance and
14 testimony of witnesses and the production of books,
15 electronic records and papers as directly related to public
16 assistance programs administered by the Illinois Department
17 of Public Aid or the Department of Human Services (as
18 successor to the Department of Public Aid). No medical
19 provider shall be compelled, however, to provide individual
20 medical records of patients who are not clients of the
21 Medical Assistance Program.
22 (g) The Inspector General shall report all convictions,
23 terminations, and suspensions taken against vendors,
24 contractors and medical providers to the Illinois Department
25 of Public Aid and to any agency responsible for licensing or
26 regulating those persons or entities.
27 (h) The Inspector General shall make quarterly reports,
28 findings, and recommendations regarding the Office's
29 investigations into reports of fraud, waste, abuse,
30 mismanagement, or misconduct relating to any public aid
31 programs administered by the Illinois Department of Public
32 Aid or the Department of Human Services (as successor to the
33 Department of Public Aid) to the General Assembly and the
34 Governor. These reports shall include, but not be limited
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1 to, the following information:
2 (1) Aggregate provider billing and payment
3 information, including the number of providers at various
4 Medicaid earning levels.
5 (2) The number of audits of the medical assistance
6 program and the dollar savings resulting from those
7 audits.
8 (3) The number of prescriptions rejected annually
9 under the Illinois Department of Public Aid's Refill Too
10 Soon program and the dollar savings resulting from that
11 program.
12 (4) Provider sanctions, in the aggregate, including
13 terminations and suspensions.
14 (5) A detailed summary of the investigations
15 undertaken in the previous fiscal year. These summaries
16 shall comply with all laws and rules regarding
17 maintaining confidentiality in the public aid programs.
18 (i) Nothing in this Section shall limit investigations
19 by the Illinois Department of Public Aid or the Department of
20 Human Services that may otherwise be required by law or that
21 may be necessary in their capacity as the central
22 administrative authorities responsible for administration of
23 public aid programs in this State.
24 (Source: P.A. 88-554, eff. 7-26-94; 89-507, eff. 7-1-97.)
25 Section 99. Effective date. This Act takes effect upon
26 becoming law.