State of Illinois
90th General Assembly
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[ Re-enrolled ][ Senate Amendment 001 ][ Conference Committee Report 001 ]

90_SB0317ham001

                                             LRB9001503SMksam
 1                    AMENDMENT TO SENATE BILL 317
 2        AMENDMENT NO.     .  Amend Senate Bill 317, on page 1, by
 3    replacing line 2  with the following:
 4    "Sections 4-19 and 5-16.3."; and
 5    on page 1, by replacing line 6 with the following:
 6    "changing Sections 4-19 and 5-16.3 as follows:"; and
 7    on page 1, below line 24, by inserting the following:
 8        "(305 ILCS 5/5-16.3)
 9        (Text of Section before amendment by P.A. 89-507)
10        Sec. 5-16.3.  System for integrated health care services.
11        (a)  It shall be the public policy of the State to adopt,
12    to  the  extent  practicable,  a  health  care  program  that
13    encourages  the  integration  of  health  care  services  and
14    manages the health care of program enrollees while preserving
15    reasonable choice within  a  competitive  and  cost-efficient
16    environment.   In  furtherance  of  this  public  policy, the
17    Illinois Department shall develop and implement an integrated
18    health care program consistent with the  provisions  of  this
19    Section.   The  provisions  of this Section apply only to the
20    integrated health care program created  under  this  Section.
21    Persons  enrolled  in  the integrated health care program, as
22    determined by the  Illinois  Department  by  rule,  shall  be
                            -2-              LRB9001503SMksam
 1    afforded  a  choice among health care delivery systems, which
 2    shall include, but are not limited to, (i)  fee  for  service
 3    care managed by a primary care physician licensed to practice
 4    medicine  in  all  its  branches,  (ii)  managed  health care
 5    entities,  and  (iii)  federally  qualified  health   centers
 6    (reimbursed  according  to  a  prospective cost-reimbursement
 7    methodology) and rural health clinics  (reimbursed  according
 8    to  the  Medicare  methodology),  where  available.   Persons
 9    enrolled  in  the  integrated health care program also may be
10    offered indemnity insurance plans, subject to availability.
11        For purposes of this  Section,  a  "managed  health  care
12    entity"  means a health maintenance organization or a managed
13    care community network as defined in this Section.  A "health
14    maintenance  organization"   means   a   health   maintenance
15    organization   as   defined   in   the   Health   Maintenance
16    Organization  Act.   A "managed care community network" means
17    an entity, other than a health maintenance organization, that
18    is owned, operated, or governed by providers of  health  care
19    services  within  this  State  and  that provides or arranges
20    primary, secondary, and tertiary managed health care services
21    under contract with the Illinois  Department  exclusively  to
22    enrollees  of  the  integrated health care program. A managed
23    care  community  network  may  contract  with  the   Illinois
24    Department  to provide only pediatric health care services. A
25    county provider as defined in Section 15-1 of this  Code  may
26    contract  with the Illinois Department to provide services to
27    enrollees of the integrated health care program as a  managed
28    care  community  network  without  the  need  to  establish a
29    separate  entity  that  provides  services   exclusively   to
30    enrollees  of the integrated health care program and shall be
31    deemed a managed care community network for purposes of  this
32    Code only to the extent of the provision of services to those
33    enrollees  in  conjunction  with  the  integrated health care
34    program.  A county provider shall  be  entitled  to  contract
                            -3-              LRB9001503SMksam
 1    with  the Illinois Department with respect to any contracting
 2    region located in whole or in  part  within  the  county.   A
 3    county provider shall not be required to accept enrollees who
 4    do not reside within the county.
 5        Each  managed care community network must demonstrate its
 6    ability to bear the financial risk of serving enrollees under
 7    this program.  The Illinois Department shall  by  rule  adopt
 8    criteria  for  assessing  the  financial  soundness  of  each
 9    managed  care  community  network. These rules shall consider
10    the extent to which  a  managed  care  community  network  is
11    comprised  of  providers  who directly render health care and
12    are located within  the  community  in  which  they  seek  to
13    contract  rather  than solely arrange or finance the delivery
14    of health care.  These rules shall further consider a variety
15    of risk-bearing  and  management  techniques,  including  the
16    sufficiency  of  quality assurance and utilization management
17    programs and whether a managed  care  community  network  has
18    sufficiently  demonstrated  its  financial  solvency  and net
19    worth. The Illinois Department's criteria must  be  based  on
20    sound  actuarial,  financial,  and accounting principles.  In
21    adopting these rules, the Illinois Department  shall  consult
22    with  the  Illinois  Department  of  Insurance.  The Illinois
23    Department is  responsible  for  monitoring  compliance  with
24    these rules.
25        This  Section may not be implemented before the effective
26    date of these rules, the approval of  any  necessary  federal
27    waivers,  and  the completion of the review of an application
28    submitted, at least 60 days  before  the  effective  date  of
29    rules  adopted under this Section, to the Illinois Department
30    by a managed care community network.
31        All health care delivery systems that contract  with  the
32    Illinois  Department under the integrated health care program
33    shall clearly recognize a health  care  provider's  right  of
34    conscience under the Right of Conscience Act.  In addition to
                            -4-              LRB9001503SMksam
 1    the  provisions  of  that Act, no health care delivery system
 2    that  contracts  with  the  Illinois  Department  under   the
 3    integrated  health care program shall be required to provide,
 4    arrange for, or pay for any health care or  medical  service,
 5    procedure,  or product if that health care delivery system is
 6    owned, controlled, or  sponsored  by  or  affiliated  with  a
 7    religious  institution  or  religious organization that finds
 8    that health care or medical service, procedure, or product to
 9    violate its religious and moral teachings and beliefs.
10        (b)  The Illinois Department may, by  rule,  provide  for
11    different   benefit  packages  for  different  categories  of
12    persons enrolled in the  program.   Mental  health  services,
13    alcohol  and  substance  abuse  services, services related to
14    children  with  chronic   or   acute   conditions   requiring
15    longer-term  treatment and follow-up, and rehabilitation care
16    provided by a  free-standing  rehabilitation  hospital  or  a
17    hospital  rehabilitation  unit may be excluded from a benefit
18    package if the State ensures that  those  services  are  made
19    available  through  a separate delivery system.  An exclusion
20    does not prohibit the Illinois Department from developing and
21    implementing demonstration projects for categories of persons
22    or services.   Benefit  packages  for  persons  eligible  for
23    medical  assistance  under  Articles  V, VI, and XII shall be
24    based on the requirements of  those  Articles  and  shall  be
25    consistent  with  the  Title  XIX of the Social Security Act.
26    Nothing in this Act shall be construed to apply  to  services
27    purchased  by  the Department of Children and Family Services
28    and  the  Department  of  Mental  Health  and   Developmental
29    Disabilities under the provisions of Title 59 of the Illinois
30    Administrative  Code,  Part  132  ("Medicaid Community Mental
31    Health Services Program").
32        (c)  The program  established  by  this  Section  may  be
33    implemented by the Illinois Department in various contracting
34    areas at various times.  The health care delivery systems and
                            -5-              LRB9001503SMksam
 1    providers available under the program may vary throughout the
 2    State.   For purposes of contracting with managed health care
 3    entities  and  providers,  the  Illinois   Department   shall
 4    establish  contracting  areas similar to the geographic areas
 5    designated  by  the  Illinois  Department   for   contracting
 6    purposes   under   the   Illinois   Competitive   Access  and
 7    Reimbursement Equity Program (ICARE) under the  authority  of
 8    Section  3-4  of  the  Illinois  Health Finance Reform Act or
 9    similarly-sized or smaller geographic  areas  established  by
10    the Illinois Department by rule. A managed health care entity
11    shall  be  permitted  to contract in any geographic areas for
12    which it has a  sufficient  provider  network  and  otherwise
13    meets  the  contracting  terms  of  the  State.  The Illinois
14    Department is not prohibited from entering  into  a  contract
15    with a managed health care entity at any time.
16        (d)  A managed health care entity that contracts with the
17    Illinois  Department  for the provision of services under the
18    program shall do all of the following, solely for purposes of
19    the integrated health care program:
20             (1)  Provide that any individual physician  licensed
21        under  the  Medical  Practice  Act  of  1987  to practice
22        medicine in all its branches, any pharmacy, any federally
23        qualified  health  center,  and  any   podiatrist,   that
24        consistently  meets  the  reasonable terms and conditions
25        established by the managed health care entity,  including
26        but  not  limited  to  credentialing  standards,  quality
27        assurance  program  requirements,  utilization management
28        requirements,   financial    responsibility    standards,
29        contracting  process  requirements,  and provider network
30        size and accessibility requirements, must be accepted  by
31        the  managed  health  care  entity  for  purposes  of the
32        Illinois integrated health care program.  Any  individual
33        who  is either terminated from or denied inclusion in the
34        panel of physicians of the  managed  health  care  entity
                            -6-              LRB9001503SMksam
 1        shall  be  given,  within  10  business  days  after that
 2        determination, a written explanation of the  reasons  for
 3        his  or her exclusion or termination from the panel. This
 4        paragraph (1) does not apply to the following:
 5                  (A)  A  managed   health   care   entity   that
 6             certifies to the Illinois Department that:
 7                       (i)  it  employs  on a full-time basis 125
 8                  or  more  Illinois   physicians   licensed   to
 9                  practice medicine in all of its branches; and
10                       (ii)  it  will  provide  medical  services
11                  through  its  employees to more than 80% of the
12                  recipients enrolled  with  the  entity  in  the
13                  integrated health care program; or
14                  (B)  A   domestic   stock   insurance   company
15             licensed under clause (b) of class 1 of Section 4 of
16             the  Illinois  Insurance Code if (i) at least 66% of
17             the stock of the insurance company  is  owned  by  a
18             professional   corporation   organized   under   the
19             Professional Service Corporation Act that has 125 or
20             more   shareholders   who  are  Illinois  physicians
21             licensed to practice medicine in all of its branches
22             and (ii) the  insurance  company  certifies  to  the
23             Illinois  Department  that  at  least  80%  of those
24             physician  shareholders  will  provide  services  to
25             recipients  enrolled  with  the   company   in   the
26             integrated health care program.
27             (2)  Provide  for  reimbursement  for  providers for
28        emergency care, as defined by the Illinois Department  by
29        rule,  that  must be provided to its enrollees, including
30        an emergency room screening fee, and urgent care that  it
31        authorizes   for   its   enrollees,   regardless  of  the
32        provider's  affiliation  with  the  managed  health  care
33        entity. Providers shall be reimbursed for emergency  care
34        at   an   amount   equal  to  the  Illinois  Department's
                            -7-              LRB9001503SMksam
 1        fee-for-service rates for those medical services rendered
 2        by providers not under contract with the  managed  health
 3        care entity to enrollees of the entity.
 4             (3)  Provide  that  any  provider  affiliated with a
 5        managed health care entity may also provide services on a
 6        fee-for-service basis to Illinois Department clients  not
 7        enrolled in a managed health care entity.
 8             (4)  Provide client education services as determined
 9        and  approved  by  the Illinois Department, including but
10        not  limited  to  (i)  education  regarding   appropriate
11        utilization  of  health  care  services in a managed care
12        system, (ii) written disclosure of treatment policies and
13        any  restrictions  or  limitations  on  health  services,
14        including,  but  not  limited  to,   physical   services,
15        clinical   laboratory   tests,   hospital   and  surgical
16        procedures,  prescription  drugs   and   biologics,   and
17        radiological  examinations, and (iii) written notice that
18        the enrollee may  receive  from  another  provider  those
19        services covered under this program that are not provided
20        by the managed health care entity.
21             (5)  Provide  that  enrollees  within its system may
22        choose the site for provision of services and  the  panel
23        of health care providers.
24             (6)  Not   discriminate   in   its   enrollment   or
25        disenrollment   practices  among  recipients  of  medical
26        services or program enrollees based on health status.
27             (7)  Provide a  quality  assurance  and  utilization
28        review   program   that   (i)   for   health  maintenance
29        organizations  meets  the  requirements  of  the   Health
30        Maintenance  Organization  Act  and (ii) for managed care
31        community networks meets the requirements established  by
32        the  Illinois  Department in rules that incorporate those
33        standards   set   forth   in   the   Health   Maintenance
34        Organization Act.
                            -8-              LRB9001503SMksam
 1             (8)  Issue   a   managed    health    care    entity
 2        identification  card  to  each  enrollee upon enrollment.
 3        The card must contain all of the following:
 4                  (A)  The enrollee's signature.
 5                  (B)  The enrollee's health plan.
 6                  (C)  The  name  and  telephone  number  of  the
 7             enrollee's primary care physician.
 8                  (D)  A  telephone  number  to   be   used   for
 9             emergency service 24 hours per day, 7 days per week.
10             The  telephone  number  required  to  be  maintained
11             pursuant to this subparagraph by each managed health
12             care   entity  shall,  at  minimum,  be  staffed  by
13             medically  trained   personnel   and   be   provided
14             directly,  or  under  arrangement,  at  an office or
15             offices in  locations maintained solely  within  the
16             State    of   Illinois.   For   purposes   of   this
17             subparagraph, "medically  trained  personnel"  means
18             licensed   practical  nurses  or  registered  nurses
19             located in the State of Illinois  who  are  licensed
20             pursuant to the Illinois Nursing Act of 1987.
21             (9)  Ensure  that  every  primary care physician and
22        pharmacy in the managed  health  care  entity  meets  the
23        standards  established  by  the  Illinois  Department for
24        accessibility  and  quality   of   care.   The   Illinois
25        Department shall arrange for and oversee an evaluation of
26        the  standards  established  under this paragraph (9) and
27        may recommend any necessary changes to  these  standards.
28        The  Illinois Department shall submit an annual report to
29        the Governor and the General Assembly by April 1 of  each
30        year  regarding  the  effect of the standards on ensuring
31        access and quality of care to enrollees.
32             (10)  Provide a procedure  for  handling  complaints
33        that  (i)  for health maintenance organizations meets the
34        requirements of the Health Maintenance  Organization  Act
                            -9-              LRB9001503SMksam
 1        and  (ii)  for  managed care community networks meets the
 2        requirements established by the  Illinois  Department  in
 3        rules  that  incorporate those standards set forth in the
 4        Health Maintenance Organization Act.
 5             (11)  Maintain, retain, and make  available  to  the
 6        Illinois  Department records, data, and information, in a
 7        uniform manner determined  by  the  Illinois  Department,
 8        sufficient   for   the  Illinois  Department  to  monitor
 9        utilization, accessibility, and quality of care.
10             (12)  Except for providers who are prepaid, pay  all
11        approved  claims  for covered services that are completed
12        and submitted to the managed health care entity within 30
13        days after  receipt  of  the  claim  or  receipt  of  the
14        appropriate capitation payment or payments by the managed
15        health  care entity from the State for the month in which
16        the  services  included  on  the  claim  were   rendered,
17        whichever  is  later. If payment is not made or mailed to
18        the provider by the managed health care entity by the due
19        date under this subsection, an interest penalty of 1%  of
20        any  amount  unpaid  shall  be  added  for  each month or
21        fraction of a month  after  the  due  date,  until  final
22        payment  is  made. Nothing in this Section shall prohibit
23        managed health care entities and providers from  mutually
24        agreeing to terms that require more timely payment.
25             (13)  Provide   integration   with   community-based
26        programs  provided  by certified local health departments
27        such as Women, Infants, and  Children  Supplemental  Food
28        Program  (WIC),  childhood  immunization programs, health
29        education programs, case management programs, and  health
30        screening programs.
31             (14)  Provide  that the pharmacy formulary used by a
32        managed health care entity and its contract providers  be
33        no   more  restrictive  than  the  Illinois  Department's
34        pharmaceutical program on  the  effective  date  of  this
                            -10-             LRB9001503SMksam
 1        amendatory Act of 1994 and as amended after that date.
 2             (15)  Provide   integration   with   community-based
 3        organizations,   including,   but  not  limited  to,  any
 4        organization  that  has  operated   within   a   Medicaid
 5        Partnership  as  defined  by  this Code or by rule of the
 6        Illinois Department, that may continue to operate under a
 7        contract with the Illinois Department or a managed health
 8        care entity under this Section to provide case management
 9        services to  Medicaid  clients  in  designated  high-need
10        areas.
11        The   Illinois   Department   may,   by  rule,  determine
12    methodologies to limit financial liability for managed health
13    care  entities  resulting  from  payment  for   services   to
14    enrollees provided under the Illinois Department's integrated
15    health  care  program.  Any  methodology so determined may be
16    considered or implemented by the Illinois Department  through
17    a  contract  with  a  managed  health  care entity under this
18    integrated health care program.
19        The Illinois Department shall contract with an entity  or
20    entities  to  provide  external  peer-based quality assurance
21    review for the integrated health  care  program.  The  entity
22    shall  be  representative  of Illinois physicians licensed to
23    practice medicine in all  its  branches  and  have  statewide
24    geographic  representation in all specialties of medical care
25    that are provided within the integrated health care  program.
26    The  entity may not be a third party payer and shall maintain
27    offices in locations around the State  in  order  to  provide
28    service   and   continuing  medical  education  to  physician
29    participants within the integrated health care program.   The
30    review  process  shall be developed and conducted by Illinois
31    physicians licensed to practice medicine in all its branches.
32    In consultation with the entity, the Illinois Department  may
33    contract  with  other  entities  for  professional peer-based
34    quality assurance review of individual categories of services
                            -11-             LRB9001503SMksam
 1    other than services provided, supervised, or  coordinated  by
 2    physicians licensed to practice medicine in all its branches.
 3    The Illinois Department shall establish, by rule, criteria to
 4    avoid  conflicts  of  interest  in  the  conduct  of  quality
 5    assurance activities consistent with professional peer-review
 6    standards.   All   quality   assurance  activities  shall  be
 7    coordinated by the Illinois Department.
 8        (e)  All  persons  enrolled  in  the  program  shall   be
 9    provided   with   a   full   written   explanation   of   all
10    fee-for-service  and  managed  health care plan options and a
11    reasonable  opportunity  to  choose  among  the  options   as
12    provided  by  rule.  The Illinois Department shall provide to
13    enrollees, upon enrollment  in  the  integrated  health  care
14    program  and  at  least  annually  thereafter,  notice of the
15    process  for  requesting  an  appeal   under   the   Illinois
16    Department's      administrative      appeal      procedures.
17    Notwithstanding  any other Section of this Code, the Illinois
18    Department may provide by rule for the Illinois Department to
19    assign a  person  enrolled  in  the  program  to  a  specific
20    provider  of  medical  services  or to a specific health care
21    delivery system if an enrollee has failed to exercise  choice
22    in  a  timely  manner.  An  enrollee assigned by the Illinois
23    Department shall be afforded the opportunity to disenroll and
24    to select a  specific  provider  of  medical  services  or  a
25    specific health care delivery system within the first 30 days
26    after  the assignment. An enrollee who has failed to exercise
27    choice in a timely manner may be assigned only if there are 3
28    or more managed health care  entities  contracting  with  the
29    Illinois Department within the contracting area, except that,
30    outside  the  City of Chicago, this requirement may be waived
31    for an area by rules adopted by the Illinois Department after
32    consultation with all hospitals within the contracting  area.
33    The Illinois Department shall establish by rule the procedure
34    for  random  assignment  of  enrollees  who  fail to exercise
                            -12-             LRB9001503SMksam
 1    choice in a timely manner to a specific managed  health  care
 2    entity  in  proportion  to  the  available  capacity  of that
 3    managed health care entity. Assignment to a specific provider
 4    of medical services or to  a  specific  managed  health  care
 5    entity may not exceed that provider's or entity's capacity as
 6    determined  by  the  Illinois Department.  Any person who has
 7    chosen a specific provider of medical services or a  specific
 8    managed  health  care  entity,  or  any  person  who has been
 9    assigned  under  this  subsection,   shall   be   given   the
10    opportunity to change that choice or assignment at least once
11    every  12 months, as determined by the Illinois Department by
12    rule. The Illinois  Department  shall  maintain  a  toll-free
13    telephone  number  for  program  enrollees'  use in reporting
14    problems with managed health care entities.
15        (f)  If a person becomes eligible  for  participation  in
16    the  integrated  health  care  program  while  he  or  she is
17    hospitalized, the Illinois Department  may  not  enroll  that
18    person  in  the  program  until  after  he  or  she  has been
19    discharged from the hospital.  This subsection does not apply
20    to  newborn  infants  whose  mothers  are  enrolled  in   the
21    integrated health care program.
22        (g)  The  Illinois  Department  shall, by rule, establish
23    for managed health care entities rates that (i) are certified
24    to be actuarially sound, as determined by an actuary  who  is
25    an  associate  or  a  fellow of the Society of Actuaries or a
26    member of the American  Academy  of  Actuaries  and  who  has
27    expertise  and  experience  in  medical insurance and benefit
28    programs,  in  accordance  with  the  Illinois   Department's
29    current  fee-for-service  payment  system, and (ii) take into
30    account any difference of cost  to  provide  health  care  to
31    different  populations  based  on  gender, age, location, and
32    eligibility category.  The  rates  for  managed  health  care
33    entities shall be determined on a capitated basis.
34        The  Illinois Department by rule shall establish a method
                            -13-             LRB9001503SMksam
 1    to adjust its payments to managed health care entities  in  a
 2    manner intended to avoid providing any financial incentive to
 3    a  managed  health  care entity to refer patients to a county
 4    provider, in an Illinois county having a  population  greater
 5    than  3,000,000,  that  is  paid  directly  by  the  Illinois
 6    Department.   The Illinois Department shall by April 1, 1997,
 7    and  annually  thereafter,  review  the  method   to   adjust
 8    payments.  Payments  by the Illinois Department to the county
 9    provider,  for  persons  not  enrolled  in  a  managed   care
10    community  network  owned  or  operated by a county provider,
11    shall be paid on a fee-for-service basis under Article XV  of
12    this Code.
13        The  Illinois Department by rule shall establish a method
14    to reduce its payments to managed  health  care  entities  to
15    take  into  consideration (i) any adjustment payments paid to
16    hospitals under subsection (h) of this Section to the  extent
17    those  payments,  or  any  part  of those payments, have been
18    taken into account in establishing capitated rates under this
19    subsection (g) and (ii) the implementation  of  methodologies
20    to limit financial liability for managed health care entities
21    under subsection (d) of this Section.
22        (h)  For  hospital  services  provided by a hospital that
23    contracts with  a  managed  health  care  entity,  adjustment
24    payments  shall  be  paid  directly  to  the  hospital by the
25    Illinois Department.  Adjustment  payments  may  include  but
26    need    not   be   limited   to   adjustment   payments   to:
27    disproportionate share hospitals under Section 5-5.02 of this
28    Code; primary care access health care education payments  (89
29    Ill. Adm. Code 149.140); payments for capital, direct medical
30    education,  indirect  medical education, certified registered
31    nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
32    Code 149.150(c)); uncompensated care payments (89  Ill.  Adm.
33    Code  148.150(h));  trauma center payments (89 Ill. Adm. Code
34    148.290(c)); rehabilitation hospital payments (89  Ill.  Adm.
                            -14-             LRB9001503SMksam
 1    Code  148.290(d));  perinatal  center  payments (89 Ill. Adm.
 2    Code 148.290(e)); obstetrical care  payments  (89  Ill.  Adm.
 3    Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
 4    148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
 5    148.290(h));  and  outpatient indigent volume adjustments (89
 6    Ill. Adm. Code 148.140(b)(5)).
 7        (i)  For  any  hospital  eligible  for   the   adjustment
 8    payments described in subsection (h), the Illinois Department
 9    shall  maintain,  through  the  period  ending June 30, 1995,
10    reimbursement levels in accordance with statutes and rules in
11    effect on April 1, 1994.
12        (j)  Nothing contained in this Code in any way limits  or
13    otherwise  impairs  the  authority  or  power of the Illinois
14    Department to enter into a negotiated  contract  pursuant  to
15    this  Section  with  a managed health care entity, including,
16    but not limited to, a health maintenance  organization,  that
17    provides  for  termination  or  nonrenewal  of  the  contract
18    without  cause  upon  notice  as provided in the contract and
19    without a hearing.
20        (k)  Section  5-5.15  does  not  apply  to  the   program
21    developed and implemented pursuant to this Section.
22        (l)  The Illinois Department shall, by rule, define those
23    chronic or acute medical conditions of childhood that require
24    longer-term  treatment  and  follow-up  care.   The  Illinois
25    Department shall ensure that services required to treat these
26    conditions are available through a separate delivery system.
27        A  managed  health  care  entity  that contracts with the
28    Illinois Department may refer a child with medical conditions
29    described in the rules adopted under this subsection directly
30    to a children's hospital or  to  a  hospital,  other  than  a
31    children's  hospital,  that is qualified to provide inpatient
32    and outpatient  services  to  treat  those  conditions.   The
33    Illinois    Department    shall    provide    fee-for-service
34    reimbursement  directly  to  a  children's hospital for those
                            -15-             LRB9001503SMksam
 1    services pursuant to Title 89 of the Illinois  Administrative
 2    Code,  Section  148.280(a),  at  a rate at least equal to the
 3    rate in effect on March 31, 1994. For hospitals,  other  than
 4    children's hospitals, that are qualified to provide inpatient
 5    and  outpatient  services  to  treat  those  conditions,  the
 6    Illinois  Department  shall  provide  reimbursement for those
 7    services on a fee-for-service basis, at a rate at least equal
 8    to the rate in effect for those other hospitals on March  31,
 9    1994.
10        A  children's  hospital  shall be directly reimbursed for
11    all  services  provided  at  the  children's  hospital  on  a
12    fee-for-service basis pursuant to Title 89  of  the  Illinois
13    Administrative  Code,  Section 148.280(a), at a rate at least
14    equal to the rate in effect on  March  31,  1994,  until  the
15    later  of  (i)  implementation  of the integrated health care
16    program under this Section  and  development  of  actuarially
17    sound  capitation rates for services other than those chronic
18    or  acute  medical  conditions  of  childhood  that   require
19    longer-term  treatment  and  follow-up care as defined by the
20    Illinois  Department  in  the  rules   adopted   under   this
21    subsection or (ii) March 31, 1996.
22        Notwithstanding   anything  in  this  subsection  to  the
23    contrary, a managed health care  entity  shall  not  consider
24    sources  or methods of payment in determining the referral of
25    a child.   The  Illinois  Department  shall  adopt  rules  to
26    establish   criteria   for  those  referrals.   The  Illinois
27    Department by rule shall establish a  method  to  adjust  its
28    payments to managed health care entities in a manner intended
29    to  avoid  providing  any  financial  incentive  to a managed
30    health care entity to refer patients to  a  provider  who  is
31    paid directly by the Illinois Department.
32        (m)  Behavioral health services provided or funded by the
33    Department  of  Mental Health and Developmental Disabilities,
34    the  Department  of  Alcoholism  and  Substance  Abuse,   the
                            -16-             LRB9001503SMksam
 1    Department  of Children and Family Services, and the Illinois
 2    Department  shall  be  excluded  from  a   benefit   package.
 3    Conditions  of  an  organic  or  physical  origin  or nature,
 4    including  medical  detoxification,  however,  may   not   be
 5    excluded.   In  this subsection, "behavioral health services"
 6    means  mental  health  services  and  subacute  alcohol   and
 7    substance   abuse  treatment  services,  as  defined  in  the
 8    Illinois Alcoholism and Other Drug Dependency Act.   In  this
 9    subsection,  "mental health services" includes, at a minimum,
10    the following services funded by the Illinois Department, the
11    Department of Mental Health and  Developmental  Disabilities,
12    or  the  Department  of  Children  and  Family  Services: (i)
13    inpatient  hospital  services,  including  related  physician
14    services,    related    psychiatric    interventions,     and
15    pharmaceutical  services  provided  to  an eligible recipient
16    hospitalized  with  a  primary   diagnosis   of   psychiatric
17    disorder;  (ii)  outpatient mental health services as defined
18    and specified in Title  59  of  the  Illinois  Administrative
19    Code,  Part  132;  (iii)  any  other outpatient mental health
20    services funded by the Illinois Department  pursuant  to  the
21    State    of    Illinois    Medicaid    Plan;   (iv)   partial
22    hospitalization; and (v) follow-up stabilization  related  to
23    any of those services.  Additional behavioral health services
24    may  be  excluded under this subsection as mutually agreed in
25    writing by the Illinois Department  and  the  affected  State
26    agency  or  agencies.   The exclusion of any service does not
27    prohibit  the  Illinois  Department   from   developing   and
28    implementing demonstration projects for categories of persons
29    or   services.    The   Department   of   Mental  Health  and
30    Developmental Disabilities, the Department  of  Children  and
31    Family   Services,  and  the  Department  of  Alcoholism  and
32    Substance  Abuse  shall  each  adopt  rules   governing   the
33    integration  of  managed  care in the provision of behavioral
34    health services.  The  State  shall  integrate  managed  care
                            -17-             LRB9001503SMksam
 1    community  networks  and  affiliated providers, to the extent
 2    practicable, in  any  separate  delivery  system  for  mental
 3    health services.
 4        (n)  The   Illinois   Department  shall  adopt  rules  to
 5    establish reserve requirements  for  managed  care  community
 6    networks,   as   required   by  subsection  (a),  and  health
 7    maintenance organizations to protect against  liabilities  in
 8    the  event  that  a  managed  health  care entity is declared
 9    insolvent or bankrupt.  If a managed health care entity other
10    than a county provider is  declared  insolvent  or  bankrupt,
11    after  liquidation  and  application of any available assets,
12    resources, and reserves, the Illinois Department shall pay  a
13    portion of the amounts owed by the managed health care entity
14    to  providers  for  services  rendered to enrollees under the
15    integrated health care program under this  Section  based  on
16    the  following  schedule: (i) from April 1, 1995 through June
17    30, 1998, 90% of the amounts owed; (ii)  from  July  1,  1998
18    through  June  30,  2001,  80% of the amounts owed; and (iii)
19    from July 1, 2001 through June 30, 2005, 75% of  the  amounts
20    owed.   The  amounts  paid  under  this  subsection  shall be
21    calculated based on the total  amount  owed  by  the  managed
22    health  care  entity  to  providers before application of any
23    available assets, resources, and reserves.   After  June  30,
24    2005, the Illinois Department may not pay any amounts owed to
25    providers  as  a  result  of an insolvency or bankruptcy of a
26    managed health care entity occurring after that  date.    The
27    Illinois Department is not obligated, however, to pay amounts
28    owed  to  a provider that has an ownership or other governing
29    interest in the managed health care entity.  This  subsection
30    applies only to managed health care entities and the services
31    they  provide  under the integrated health care program under
32    this Section.
33        (o)  Notwithstanding  any  other  provision  of  law   or
34    contractual agreement to the contrary, providers shall not be
                            -18-             LRB9001503SMksam
 1    required to accept from any other third party payer the rates
 2    determined   or   paid   under  this  Code  by  the  Illinois
 3    Department, managed health care entity, or other health  care
 4    delivery system for services provided to recipients.
 5        (p)  The  Illinois  Department  may  seek  and obtain any
 6    necessary  authorization  provided  under  federal   law   to
 7    implement  the  program,  including the waiver of any federal
 8    statutes or regulations. The Illinois Department may  seek  a
 9    waiver   of   the   federal  requirement  that  the  combined
10    membership of Medicare and Medicaid enrollees  in  a  managed
11    care community network may not exceed 75% of the managed care
12    community   network's   total   enrollment.    The   Illinois
13    Department  shall  not  seek a waiver of this requirement for
14    any other  category  of  managed  health  care  entity.   The
15    Illinois  Department shall not seek a waiver of the inpatient
16    hospital reimbursement methodology in Section  1902(a)(13)(A)
17    of  Title  XIX of the Social Security Act even if the federal
18    agency responsible for  administering  Title  XIX  determines
19    that  Section  1902(a)(13)(A)  applies to managed health care
20    systems.
21        Notwithstanding any other provisions of this Code to  the
22    contrary,  the  Illinois  Department  shall  seek a waiver of
23    applicable federal law in order to impose a co-payment system
24    consistent with this  subsection  on  recipients  of  medical
25    services  under  Title XIX of the Social Security Act who are
26    not enrolled in a managed health  care  entity.   The  waiver
27    request  submitted  by  the Illinois Department shall provide
28    for co-payments of up to $0.50 for prescribed drugs and up to
29    $0.50 for x-ray services and shall provide for co-payments of
30    up to $10 for non-emergency services provided in  a  hospital
31    emergency  room  and  up  to  $10 for non-emergency ambulance
32    services.  The purpose of the co-payments shall be  to  deter
33    those  recipients  from  seeking  unnecessary  medical  care.
34    Co-payments  may not be used to deter recipients from seeking
                            -19-             LRB9001503SMksam
 1    necessary medical care.  No recipient shall  be  required  to
 2    pay  more  than a total of $150 per year in co-payments under
 3    the waiver request required by this subsection.  A  recipient
 4    may  not  be  required to pay more than $15 of any amount due
 5    under this subsection in any one month.
 6        Co-payments authorized under this subsection may  not  be
 7    imposed  when  the  care  was  necessitated by a true medical
 8    emergency.  Co-payments may not be imposed  for  any  of  the
 9    following classifications of services:
10             (1)  Services  furnished to person under 18 years of
11        age.
12             (2)  Services furnished to pregnant women.
13             (3)  Services furnished to any individual who is  an
14        inpatient  in  a hospital, nursing facility, intermediate
15        care facility, or  other  medical  institution,  if  that
16        person is required to spend for costs of medical care all
17        but  a  minimal  amount of his or her income required for
18        personal needs.
19             (4)  Services furnished to a person who is receiving
20        hospice care.
21        Co-payments authorized under this subsection shall not be
22    deducted from or reduce  in  any  way  payments  for  medical
23    services  from  the  Illinois  Department  to  providers.  No
24    provider may deny those services to  an  individual  eligible
25    for  services  based on the individual's inability to pay the
26    co-payment.
27        Recipients  who  are  subject  to  co-payments  shall  be
28    provided notice, in plain and clear language, of  the  amount
29    of the co-payments, the circumstances under which co-payments
30    are  exempted,  the circumstances under which co-payments may
31    be assessed, and their manner of collection.
32        The  Illinois  Department  shall  establish  a   Medicaid
33    Co-Payment Council to assist in the development of co-payment
34    policies  for  the  medical assistance program.  The Medicaid
                            -20-             LRB9001503SMksam
 1    Co-Payment Council shall also have jurisdiction to develop  a
 2    program  to  provide financial or non-financial incentives to
 3    Medicaid recipients in order to encourage recipients to  seek
 4    necessary  health  care.  The Council shall be chaired by the
 5    Director  of  the  Illinois  Department,  and  shall  have  6
 6    additional members.  Two of the 6 additional members shall be
 7    appointed by the Governor, and one each shall be appointed by
 8    the President of the  Senate,  the  Minority  Leader  of  the
 9    Senate,  the Speaker of the House of Representatives, and the
10    Minority Leader of the House of Representatives.  The Council
11    may be convened and make recommendations upon the appointment
12    of a majority of its members.  The Council shall be appointed
13    and convened no later than September 1, 1994 and shall report
14    its  recommendations  to  the  Director   of   the   Illinois
15    Department  and the General Assembly no later than October 1,
16    1994.  The chairperson of the Council  shall  be  allowed  to
17    vote  only  in  the  case  of  a tie vote among the appointed
18    members of the Council.
19        The Council shall be guided by the  following  principles
20    as  it considers recommendations to be developed to implement
21    any approved waivers that the Illinois Department  must  seek
22    pursuant to this subsection:
23             (1)  Co-payments  should not be used to deter access
24        to adequate medical care.
25             (2)  Co-payments should be used to reduce fraud.
26             (3)  Co-payment  policies  should  be  examined   in
27        consideration   of  other  states'  experience,  and  the
28        ability  of  successful  co-payment  plans   to   control
29        unnecessary  or  inappropriate  utilization  of  services
30        should be promoted.
31             (4)  All    participants,    both   recipients   and
32        providers,  in  the  medical  assistance   program   have
33        responsibilities to both the State and the program.
34             (5)  Co-payments are primarily a tool to educate the
                            -21-             LRB9001503SMksam
 1        participants  in  the  responsible  use  of  health  care
 2        resources.
 3             (6)  Co-payments  should  not  be  used  to penalize
 4        providers.
 5             (7)  A  successful  medical  program  requires   the
 6        elimination of improper utilization of medical resources.
 7        The  integrated  health care program, or any part of that
 8    program,  established  under  this   Section   may   not   be
 9    implemented  if matching federal funds under Title XIX of the
10    Social Security Act are not available for  administering  the
11    program.
12        The  Illinois  Department shall submit for publication in
13    the Illinois Register the name, address, and telephone number
14    of the individual to whom a request may  be  directed  for  a
15    copy  of  the request for a waiver of provisions of Title XIX
16    of the Social  Security  Act  that  the  Illinois  Department
17    intends to submit to the Health Care Financing Administration
18    in  order to implement this Section.  The Illinois Department
19    shall  mail  a  copy  of  that  request  for  waiver  to  all
20    requestors at least 16 days before filing  that  request  for
21    waiver with the Health Care Financing Administration.
22        (q)  After  the  effective  date  of  this  Section,  the
23    Illinois  Department  may  take  all planning and preparatory
24    action necessary to implement this  Section,  including,  but
25    not  limited  to,  seeking requests for proposals relating to
26    the  integrated  health  care  program  created  under   this
27    Section.
28        (r)  In  order  to  (i)  accelerate  and  facilitate  the
29    development  of  integrated  health care in contracting areas
30    outside counties with populations in excess of 3,000,000  and
31    counties  adjacent  to  those  counties and (ii) maintain and
32    sustain the high quality of education and residency  programs
33    coordinated  and  associated  with  local area hospitals, the
34    Illinois Department may develop and implement a demonstration
                            -22-             LRB9001503SMksam
 1    program for managed care community networks owned,  operated,
 2    or  governed  by  State-funded medical schools.  The Illinois
 3    Department shall prescribe by rule the  criteria,  standards,
 4    and procedures for effecting this demonstration program.
 5        (s)  (Blank).
 6        (t)  On  April 1, 1995 and every 6 months thereafter, the
 7    Illinois Department shall report to the Governor and  General
 8    Assembly  on  the  progress  of  the  integrated  health care
 9    program  in  enrolling  clients  into  managed  health   care
10    entities.   The  report  shall indicate the capacities of the
11    managed health care entities with which the State  contracts,
12    the  number of clients enrolled by each contractor, the areas
13    of the State in which managed care options do not exist,  and
14    the  progress  toward  meeting  the  enrollment  goals of the
15    integrated health care program.
16        (u)  The Illinois Department may implement  this  Section
17    through the use of emergency rules in accordance with Section
18    5-45  of  the  Illinois  Administrative  Procedure  Act.  For
19    purposes of that Act, the adoption of rules to implement this
20    Section is deemed an emergency and necessary for  the  public
21    interest, safety, and welfare.
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
                            -23-             LRB9001503SMksam
 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
                            -24-             LRB9001503SMksam
 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
                            -25-             LRB9001503SMksam
 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
                            -26-             LRB9001503SMksam
 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        under  the  Medical  Practice  Act  of  1987  to practice
26        medicine in all its branches, any pharmacy, any federally
27        qualified  health  center,  and  any   podiatrist,   that
28        consistently  meets  the  reasonable terms and conditions
29        established by the managed health care entity,  including
30        but  not  limited  to  credentialing  standards,  quality
31        assurance  program  requirements,  utilization management
32        requirements,   financial    responsibility    standards,
33        contracting  process  requirements,  and provider network
34        size and accessibility requirements, must be accepted  by
                            -27-             LRB9001503SMksam
 1        the  managed  health  care  entity  for  purposes  of the
 2        Illinois integrated health care program.  Any  individual
 3        who  is either terminated from or denied inclusion in the
 4        panel of physicians of the  managed  health  care  entity
 5        shall  be  given,  within  10  business  days  after that
 6        determination, a written explanation of the  reasons  for
 7        his  or her exclusion or termination from the panel. This
 8        paragraph (1) does not 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
                            -28-             LRB9001503SMksam
 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
                            -29-             LRB9001503SMksam
 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
                            -30-             LRB9001503SMksam
 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.
                            -31-             LRB9001503SMksam
 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
                            -32-             LRB9001503SMksam
 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
                            -33-             LRB9001503SMksam
 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
                            -34-             LRB9001503SMksam
 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
                            -35-             LRB9001503SMksam
 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
                            -36-             LRB9001503SMksam
 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
                            -37-             LRB9001503SMksam
 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
                            -38-             LRB9001503SMksam
 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
                            -39-             LRB9001503SMksam
 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.
                            -40-             LRB9001503SMksam
 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
                            -41-             LRB9001503SMksam
 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.
                            -42-             LRB9001503SMksam
 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
                            -43-             LRB9001503SMksam
 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    (Source: P.A.  88-554,  eff.  7-26-94;  89-21,  eff.  7-1-95;
24    89-507,   eff.   7-1-97;   89-673,   eff.   8-14-96;  revised
25    8-26-96.)".

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