[ Search ] [ Legislation ] [ Bill Summary ]
[ Home ] [ Back ] [ Bottom ]
| [ Introduced ] | [ Engrossed ] | [ Enrolled ] |
| [ House Amendment 003 ] | [ House Amendment 004 ] | [ House Amendment 005 ] |
| [ House Amendment 006 ] | [ Senate Amendment 001 ] | [ Conference Committee Report 001 ] |
90_SB0320ham002
LRB9001689SMdvam03
1 AMENDMENT TO SENATE BILL 320
2 AMENDMENT NO. . Amend Senate Bill 320 by replacing
3 the title with the following:
4 "AN ACT to amend the Illinois Public Aid Code by changing
5 Sections 5-16.3 and 12-13.1, and by adding Sections 5-16.8
6 and 5-16.10."; and
7 by replacing everything after the enacting clause with the
8 following:
9 "Section 5. The Illinois Public Aid Code is amended by
10 changing Sections 5-16.3 and 12-13.1, and by adding Sections
11 5-16.8 and 5-16.10 as follows:
12 (305 ILCS 5/5-16.3)
13 (Text of Section before amendment by P.A. 89-507)
14 Sec. 5-16.3. System for integrated health care services.
15 (a) It shall be the public policy of the State to adopt,
16 to the extent practicable, a health care program that
17 encourages the integration of health care services and
18 manages the health care of program enrollees while preserving
19 reasonable choice within a competitive and cost-efficient
20 environment. In furtherance of this public policy, the
21 Illinois Department shall develop and implement an integrated
-2- LRB9001689SMdvam03
1 health care program consistent with the provisions of this
2 Section. The provisions of this Section apply only to the
3 integrated health care program created under this Section.
4 Persons enrolled in the integrated health care program, as
5 determined by the Illinois Department by rule, shall be
6 afforded a choice among health care delivery systems, which
7 shall include, but are not limited to, (i) fee for service
8 care managed by a primary care physician licensed to practice
9 medicine in all its branches, (ii) managed health care
10 entities, and (iii) federally qualified health centers
11 (reimbursed according to a prospective cost-reimbursement
12 methodology) and rural health clinics (reimbursed according
13 to the Medicare methodology), where available. Persons
14 enrolled in the integrated health care program also may be
15 offered indemnity insurance plans, subject to availability.
16 For purposes of this Section, a "managed health care
17 entity" means a health maintenance organization or a managed
18 care community network as defined in this Section. A "health
19 maintenance organization" means a health maintenance
20 organization as defined in the Health Maintenance
21 Organization Act. A "managed care community network" means
22 an entity, other than a health maintenance organization, that
23 is owned, operated, or governed by providers of health care
24 services within this State and that provides or arranges
25 primary, secondary, and tertiary managed health care services
26 under contract with the Illinois Department exclusively to
27 enrollees of the integrated health care program. A managed
28 care community network may contract with the Illinois
29 Department to provide only pediatric health care services. A
30 county provider as defined in Section 15-1 of this Code may
31 contract with the Illinois Department to provide services to
32 enrollees of the integrated health care program as a managed
33 care community network without the need to establish a
34 separate entity that provides services exclusively to
-3- LRB9001689SMdvam03
1 enrollees of the integrated health care program and shall be
2 deemed a managed care community network for purposes of this
3 Code only to the extent of the provision of services to those
4 enrollees in conjunction with the integrated health care
5 program. A county provider shall be entitled to contract
6 with the Illinois Department with respect to any contracting
7 region located in whole or in part within the county. A
8 county provider shall not be required to accept enrollees who
9 do not reside within the county.
10 If a managed health care entity is accredited by a
11 private national organization that performs quality assurance
12 surveys of health maintenance organizations or related
13 organizations, the Illinois Department may take the
14 accreditation into consideration when selecting managed
15 health care entities for participation in the integrated
16 health care program. The medical director of a managed
17 health care entity must be a physician licensed in the State
18 to practice medicine in all its branches.
19 Each managed care community network must demonstrate its
20 ability to bear the financial risk of serving enrollees under
21 this program. The Illinois Department shall by rule adopt
22 criteria for assessing the financial soundness of each
23 managed care community network. These rules shall consider
24 the extent to which a managed care community network is
25 comprised of providers who directly render health care and
26 are located within the community in which they seek to
27 contract rather than solely arrange or finance the delivery
28 of health care. These rules shall further consider a variety
29 of risk-bearing and management techniques, including the
30 sufficiency of quality assurance and utilization management
31 programs and whether a managed care community network has
32 sufficiently demonstrated its financial solvency and net
33 worth. The Illinois Department's criteria must be based on
34 sound actuarial, financial, and accounting principles. In
-4- LRB9001689SMdvam03
1 adopting these rules, the Illinois Department shall consult
2 with the Illinois Department of Insurance. The Illinois
3 Department is responsible for monitoring compliance with
4 these rules.
5 This Section may not be implemented before the effective
6 date of these rules, the approval of any necessary federal
7 waivers, and the completion of the review of an application
8 submitted, at least 60 days before the effective date of
9 rules adopted under this Section, to the Illinois Department
10 by a managed care community network.
11 All health care delivery systems that contract with the
12 Illinois Department under the integrated health care program
13 shall clearly recognize a health care provider's right of
14 conscience under the Right of Conscience Act. In addition to
15 the provisions of that Act, no health care delivery system
16 that contracts with the Illinois Department under the
17 integrated health care program shall be required to provide,
18 arrange for, or pay for any health care or medical service,
19 procedure, or product if that health care delivery system is
20 owned, controlled, or sponsored by or affiliated with a
21 religious institution or religious organization that finds
22 that health care or medical service, procedure, or product to
23 violate its religious and moral teachings and beliefs.
24 (b) The Illinois Department may, by rule, provide for
25 different benefit packages for different categories of
26 persons enrolled in the program. Mental health services,
27 alcohol and substance abuse services, services related to
28 children with chronic or acute conditions requiring
29 longer-term treatment and follow-up, and rehabilitation care
30 provided by a free-standing rehabilitation hospital or a
31 hospital rehabilitation unit may be excluded from a benefit
32 package if the State ensures that those services are made
33 available through a separate delivery system. An exclusion
34 does not prohibit the Illinois Department from developing and
-5- LRB9001689SMdvam03
1 implementing demonstration projects for categories of persons
2 or services. Benefit packages for persons eligible for
3 medical assistance under Articles V, VI, and XII shall be
4 based on the requirements of those Articles and shall be
5 consistent with the Title XIX of the Social Security Act.
6 Nothing in this Act shall be construed to apply to services
7 purchased by the Department of Children and Family Services
8 and the Department of Mental Health and Developmental
9 Disabilities under the provisions of Title 59 of the Illinois
10 Administrative Code, Part 132 ("Medicaid Community Mental
11 Health Services Program").
12 (c) The program established by this Section may be
13 implemented by the Illinois Department in various contracting
14 areas at various times. The health care delivery systems and
15 providers available under the program may vary throughout the
16 State. For purposes of contracting with managed health care
17 entities and providers, the Illinois Department shall
18 establish contracting areas similar to the geographic areas
19 designated by the Illinois Department for contracting
20 purposes under the Illinois Competitive Access and
21 Reimbursement Equity Program (ICARE) under the authority of
22 Section 3-4 of the Illinois Health Finance Reform Act or
23 similarly-sized or smaller geographic areas established by
24 the Illinois Department by rule. A managed health care entity
25 shall be permitted to contract in any geographic areas for
26 which it has a sufficient provider network and otherwise
27 meets the contracting terms of the State. The Illinois
28 Department is not prohibited from entering into a contract
29 with a managed health care entity at any time.
30 (c-5) A managed health care entity may not engage in
31 door-to-door marketing activities or marketing activities at
32 an office of the Illinois Department or a county department
33 in order to enroll in the entity's health care delivery
34 system persons who are enrolled in the integrated health care
-6- LRB9001689SMdvam03
1 program established under this Section. The Illinois
2 Department shall adopt rules defining "marketing activities"
3 prohibited by this subsection (c-5).
4 Before a managed health care entity may market its health
5 care delivery system to persons enrolled in the integrated
6 health care program established under this Section, the
7 Illinois Department must approve a marketing plan submitted
8 by the entity to the Illinois Department. The Illinois
9 Department shall adopt guidelines for approving marketing
10 plans submitted by managed health care entities under this
11 subsection. Besides prohibiting door-to-door marketing
12 activities and marketing activities at public aid offices,
13 the guidelines shall include at least the following:
14 (1) A managed health care entity may not offer or
15 provide any gift, favor, or other inducement in marketing
16 its health care delivery system to integrated health care
17 program enrollees. A managed health care entity may
18 provide health care related items that are of nominal
19 value and pre-approved by the Illinois Department to
20 prospective enrollees. A managed health care entity may
21 also provide to enrollees health care related items that
22 have been pre-approved by the Illinois Department as an
23 incentive to manage their health care appropriately.
24 (2) All persons employed or otherwise engaged by a
25 managed health care entity to market the entity's health
26 care delivery system to integrated health care program
27 enrollees or to supervise that marketing shall register
28 with the Illinois Department.
29 The Inspector General appointed under Section 12-13.1 may
30 conduct investigations to determine whether the marketing
31 practices of managed health care entities participating in
32 the integrated health care program comply with the
33 guidelines.
34 (d) A managed health care entity that contracts with the
-7- LRB9001689SMdvam03
1 Illinois Department for the provision of services under the
2 program shall do all of the following, solely for purposes of
3 the integrated health care program:
4 (1) Provide that any individual physician licensed
5 to practice medicine in all its branches, any pharmacy,
6 any federally qualified health center, and any
7 podiatrist, that consistently meets the reasonable terms
8 and conditions established by the managed health care
9 entity, including but not limited to credentialing
10 standards, quality assurance program requirements,
11 utilization management requirements, financial
12 responsibility standards, contracting process
13 requirements, and provider network size and accessibility
14 requirements, must be accepted by the managed health care
15 entity for purposes of the Illinois integrated health
16 care program. Any individual who is either terminated
17 from or denied inclusion in the panel of physicians of
18 the managed health care entity shall be given, within 10
19 business days after that determination, a written
20 explanation of the reasons for his or her exclusion or
21 termination from the panel. This paragraph (1) does not
22 apply to the following:
23 (A) A managed health care entity that
24 certifies to the Illinois Department that:
25 (i) it employs on a full-time basis 125
26 or more Illinois physicians licensed to
27 practice medicine in all of its branches; and
28 (ii) it will provide medical services
29 through its employees to more than 80% of the
30 recipients enrolled with the entity in the
31 integrated health care program; or
32 (B) A domestic stock insurance company
33 licensed under clause (b) of class 1 of Section 4 of
34 the Illinois Insurance Code if (i) at least 66% of
-8- LRB9001689SMdvam03
1 the stock of the insurance company is owned by a
2 professional corporation organized under the
3 Professional Service Corporation Act that has 125 or
4 more shareholders who are Illinois physicians
5 licensed to practice medicine in all of its branches
6 and (ii) the insurance company certifies to the
7 Illinois Department that at least 80% of those
8 physician shareholders will provide services to
9 recipients enrolled with the company in the
10 integrated health care program.
11 (2) Provide for reimbursement for providers for
12 emergency care, as defined by the Illinois Department by
13 rule, that must be provided to its enrollees, including
14 an emergency room screening fee, and urgent care that it
15 authorizes for its enrollees, regardless of the
16 provider's affiliation with the managed health care
17 entity. Providers shall be reimbursed for emergency care
18 at an amount equal to the Illinois Department's
19 fee-for-service rates for those medical services rendered
20 by providers not under contract with the managed health
21 care entity to enrollees of the entity.
22 (3) Provide that any provider affiliated with a
23 managed health care entity may also provide services on a
24 fee-for-service basis to Illinois Department clients not
25 enrolled in a managed health care entity.
26 (4) Provide client education services as determined
27 and approved by the Illinois Department, including but
28 not limited to (i) education regarding appropriate
29 utilization of health care services in a managed care
30 system, (ii) written disclosure of treatment policies and
31 any restrictions or limitations on health services,
32 including, but not limited to, physical services,
33 clinical laboratory tests, hospital and surgical
34 procedures, prescription drugs and biologics, and
-9- LRB9001689SMdvam03
1 radiological examinations, and (iii) written notice that
2 the enrollee may receive from another provider those
3 services covered under this program that are not provided
4 by the managed health care entity.
5 (4.5) Provide orientation to the caretaker relative
6 or payee of a medical assistance unit that has an
7 enrollee as a member. The managed health care entity
8 must exercise good faith efforts to provide all caretaker
9 relatives or payees with the orientation. The managed
10 health care entity shall inform the Illinois Department
11 of the caretaker relatives or payees who have completed
12 the orientation. This paragraph applies to every
13 caretaker relative or payee in a managed health care
14 entity's system regardless of whether the caretaker
15 relative or payee has chosen the system or has been
16 assigned to the system as provided in subsection (e).
17 (5) Provide that enrollees within its system may
18 choose the site for provision of services and the panel
19 of health care providers.
20 (6) Not discriminate in its enrollment or
21 disenrollment practices among recipients of medical
22 services or program enrollees based on health status.
23 (7) Provide a quality assurance and utilization
24 review program that (i) for health maintenance
25 organizations meets the requirements of the Health
26 Maintenance Organization Act and (ii) for managed care
27 community networks meets the requirements established by
28 the Illinois Department in rules that incorporate those
29 standards set forth in the Health Maintenance
30 Organization Act.
31 (8) Issue a managed health care entity
32 identification card to each enrollee upon enrollment.
33 The card must contain all of the following:
34 (A) The enrollee's signature.
-10- LRB9001689SMdvam03
1 (B) The enrollee's health plan.
2 (C) The name and telephone number of the
3 enrollee's primary care physician.
4 (D) A telephone number to be used for
5 emergency service 24 hours per day, 7 days per week.
6 The telephone number required to be maintained
7 pursuant to this subparagraph by each managed health
8 care entity shall, at minimum, be staffed by
9 medically trained personnel and be provided
10 directly, or under arrangement, at an office or
11 offices in locations maintained solely within the
12 State of Illinois. For purposes of this
13 subparagraph, "medically trained personnel" means
14 licensed practical nurses or registered nurses
15 located in the State of Illinois who are licensed
16 pursuant to the Illinois Nursing Act of 1987.
17 (8.5) The Illinois Department must include
18 performance standards in contracts with entities
19 participating in the integrated health care program to
20 require contractors to make a good faith effort to have
21 enrollees evaluated by a physician within a reasonable
22 period of time after enrollment, as determined by the
23 Illinois Department.
24 (9) Ensure that every primary care physician and
25 pharmacy in the managed health care entity meets the
26 standards established by the Illinois Department for
27 accessibility and quality of care. The Illinois
28 Department shall arrange for and oversee an evaluation of
29 the standards established under this paragraph (9) and
30 may recommend any necessary changes to these standards.
31 The Illinois Department shall submit an annual report to
32 the Governor and the General Assembly by April 1 of each
33 year regarding the effect of the standards on ensuring
34 access and quality of care to enrollees.
-11- LRB9001689SMdvam03
1 (10) Provide a procedure for handling complaints
2 that (i) for health maintenance organizations meets the
3 requirements of the Health Maintenance Organization Act
4 and (ii) for managed care community networks meets the
5 requirements established by the Illinois Department in
6 rules that incorporate those standards set forth in the
7 Health Maintenance Organization Act.
8 (11) Maintain, retain, and make available to the
9 Illinois Department records, data, and information, in a
10 uniform manner determined by the Illinois Department,
11 sufficient for the Illinois Department to monitor
12 utilization, accessibility, and quality of care.
13 (12) Except for providers who are prepaid, pay all
14 approved claims for covered services that are completed
15 and submitted to the managed health care entity within 30
16 days after receipt of the claim or receipt of the
17 appropriate capitation payment or payments by the managed
18 health care entity from the State for the month in which
19 the services included on the claim were rendered,
20 whichever is later. If payment is not made or mailed to
21 the provider by the managed health care entity by the due
22 date under this subsection, an interest penalty of 1% of
23 any amount unpaid shall be added for each month or
24 fraction of a month after the due date, until final
25 payment is made. Nothing in this Section shall prohibit
26 managed health care entities and providers from mutually
27 agreeing to terms that require more timely payment.
28 (12.5) Ensure that no payment is made to a
29 physician or other provider of services for withholding
30 from an enrollee any covered services because of the cost
31 of those services. This requirement shall not be
32 construed to prevent managed health care entities from
33 offering, nor providers from accepting, full or partial
34 capitation.
-12- LRB9001689SMdvam03
1 (13) Provide integration with community-based
2 programs provided by certified local health departments
3 such as Women, Infants, and Children Supplemental Food
4 Program (WIC), childhood immunization programs, health
5 education programs, case management programs, and health
6 screening programs.
7 (14) Provide that the pharmacy formulary used by a
8 managed health care entity and its contract providers be
9 no more restrictive than the Illinois Department's
10 pharmaceutical program on the effective date of this
11 amendatory Act of 1994 and as amended after that date.
12 (15) Provide integration with community-based
13 organizations, including, but not limited to, any
14 organization that has operated within a Medicaid
15 Partnership as defined by this Code or by rule of the
16 Illinois Department, that may continue to operate under a
17 contract with the Illinois Department or a managed health
18 care entity under this Section to provide case management
19 services to Medicaid clients in designated high-need
20 areas.
21 The Illinois Department may, by rule, determine
22 methodologies to limit financial liability for managed health
23 care entities resulting from payment for services to
24 enrollees provided under the Illinois Department's integrated
25 health care program. Any methodology so determined may be
26 considered or implemented by the Illinois Department through
27 a contract with a managed health care entity under this
28 integrated health care program.
29 The Illinois Department shall contract with an entity or
30 entities to provide external peer-based quality assurance
31 review for the integrated health care program. The entity
32 shall be representative of Illinois physicians licensed to
33 practice medicine in all its branches and have statewide
34 geographic representation in all specialties of medical care
-13- LRB9001689SMdvam03
1 that are provided within the integrated health care program.
2 The entity may not be a third party payer and shall maintain
3 offices in locations around the State in order to provide
4 service and continuing medical education to physician
5 participants within the integrated health care program. The
6 review process shall be developed and conducted by Illinois
7 physicians licensed to practice medicine in all its branches.
8 In consultation with the entity, the Illinois Department may
9 contract with other entities for professional peer-based
10 quality assurance review of individual categories of services
11 other than services provided, supervised, or coordinated by
12 physicians licensed to practice medicine in all its branches.
13 The Illinois Department shall establish, by rule, criteria to
14 avoid conflicts of interest in the conduct of quality
15 assurance activities consistent with professional peer-review
16 standards. All quality assurance activities shall be
17 coordinated by the Illinois Department.
18 (e) All persons enrolled in the program shall be
19 provided with a full written explanation of all
20 fee-for-service and managed health care plan options and a
21 reasonable opportunity to choose among the options as
22 provided by rule. The Illinois Department shall provide to
23 enrollees, upon enrollment in the integrated health care
24 program and at least annually thereafter, notice of the
25 process for requesting an appeal under the Illinois
26 Department's administrative appeal procedures.
27 Notwithstanding any other Section of this Code, the Illinois
28 Department may provide by rule for the Illinois Department to
29 assign a person enrolled in the program to a specific
30 provider of medical services or to a specific health care
31 delivery system if an enrollee has failed to exercise choice
32 in a timely manner. An enrollee assigned by the Illinois
33 Department shall be afforded the opportunity to disenroll and
34 to select a specific provider of medical services or a
-14- LRB9001689SMdvam03
1 specific health care delivery system within the first 30 days
2 after the assignment. An enrollee who has failed to exercise
3 choice in a timely manner may be assigned only if there are 3
4 or more managed health care entities contracting with the
5 Illinois Department within the contracting area, except that,
6 outside the City of Chicago, this requirement may be waived
7 for an area by rules adopted by the Illinois Department after
8 consultation with all hospitals within the contracting area.
9 The Illinois Department shall establish by rule the procedure
10 for random assignment of enrollees who fail to exercise
11 choice in a timely manner to a specific managed health care
12 entity in proportion to the available capacity of that
13 managed health care entity. Assignment to a specific provider
14 of medical services or to a specific managed health care
15 entity may not exceed that provider's or entity's capacity as
16 determined by the Illinois Department. Any person who has
17 chosen a specific provider of medical services or a specific
18 managed health care entity, or any person who has been
19 assigned under this subsection, shall be given the
20 opportunity to change that choice or assignment at least once
21 every 12 months, as determined by the Illinois Department by
22 rule. The Illinois Department shall maintain a toll-free
23 telephone number for program enrollees' use in reporting
24 problems with managed health care entities.
25 (f) If a person becomes eligible for participation in
26 the integrated health care program while he or she is
27 hospitalized, the Illinois Department may not enroll that
28 person in the program until after he or she has been
29 discharged from the hospital. This subsection does not apply
30 to newborn infants whose mothers are enrolled in the
31 integrated health care program.
32 (g) The Illinois Department shall, by rule, establish
33 for managed health care entities rates that (i) are certified
34 to be actuarially sound, as determined by an actuary who is
-15- LRB9001689SMdvam03
1 an associate or a fellow of the Society of Actuaries or a
2 member of the American Academy of Actuaries and who has
3 expertise and experience in medical insurance and benefit
4 programs, in accordance with the Illinois Department's
5 current fee-for-service payment system, and (ii) take into
6 account any difference of cost to provide health care to
7 different populations based on gender, age, location, and
8 eligibility category. The rates for managed health care
9 entities shall be determined on a capitated basis.
10 The Illinois Department by rule shall establish a method
11 to adjust its payments to managed health care entities in a
12 manner intended to avoid providing any financial incentive to
13 a managed health care entity to refer patients to a county
14 provider, in an Illinois county having a population greater
15 than 3,000,000, that is paid directly by the Illinois
16 Department. The Illinois Department shall by April 1, 1997,
17 and annually thereafter, review the method to adjust
18 payments. Payments by the Illinois Department to the county
19 provider, for persons not enrolled in a managed care
20 community network owned or operated by a county provider,
21 shall be paid on a fee-for-service basis under Article XV of
22 this Code.
23 The Illinois Department by rule shall establish a method
24 to reduce its payments to managed health care entities to
25 take into consideration (i) any adjustment payments paid to
26 hospitals under subsection (h) of this Section to the extent
27 those payments, or any part of those payments, have been
28 taken into account in establishing capitated rates under this
29 subsection (g) and (ii) the implementation of methodologies
30 to limit financial liability for managed health care entities
31 under subsection (d) of this Section.
32 (h) For hospital services provided by a hospital that
33 contracts with a managed health care entity, adjustment
34 payments shall be paid directly to the hospital by the
-16- LRB9001689SMdvam03
1 Illinois Department. Adjustment payments may include but
2 need not be limited to adjustment payments to:
3 disproportionate share hospitals under Section 5-5.02 of this
4 Code; primary care access health care education payments (89
5 Ill. Adm. Code 149.140); payments for capital, direct medical
6 education, indirect medical education, certified registered
7 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
8 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
9 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
10 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
11 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
12 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
13 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
14 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
15 148.290(h)); and outpatient indigent volume adjustments (89
16 Ill. Adm. Code 148.140(b)(5)).
17 (i) For any hospital eligible for the adjustment
18 payments described in subsection (h), the Illinois Department
19 shall maintain, through the period ending June 30, 1995,
20 reimbursement levels in accordance with statutes and rules in
21 effect on April 1, 1994.
22 (j) Nothing contained in this Code in any way limits or
23 otherwise impairs the authority or power of the Illinois
24 Department to enter into a negotiated contract pursuant to
25 this Section with a managed health care entity, including,
26 but not limited to, a health maintenance organization, that
27 provides for termination or nonrenewal of the contract
28 without cause upon notice as provided in the contract and
29 without a hearing.
30 (k) Section 5-5.15 does not apply to the program
31 developed and implemented pursuant to this Section.
32 (l) The Illinois Department shall, by rule, define those
33 chronic or acute medical conditions of childhood that require
34 longer-term treatment and follow-up care. The Illinois
-17- LRB9001689SMdvam03
1 Department shall ensure that services required to treat these
2 conditions are available through a separate delivery system.
3 A managed health care entity that contracts with the
4 Illinois Department may refer a child with medical conditions
5 described in the rules adopted under this subsection directly
6 to a children's hospital or to a hospital, other than a
7 children's hospital, that is qualified to provide inpatient
8 and outpatient services to treat those conditions. The
9 Illinois Department shall provide fee-for-service
10 reimbursement directly to a children's hospital for those
11 services pursuant to Title 89 of the Illinois Administrative
12 Code, Section 148.280(a), at a rate at least equal to the
13 rate in effect on March 31, 1994. For hospitals, other than
14 children's hospitals, that are qualified to provide inpatient
15 and outpatient services to treat those conditions, the
16 Illinois Department shall provide reimbursement for those
17 services on a fee-for-service basis, at a rate at least equal
18 to the rate in effect for those other hospitals on March 31,
19 1994.
20 A children's hospital shall be directly reimbursed for
21 all services provided at the children's hospital on a
22 fee-for-service basis pursuant to Title 89 of the Illinois
23 Administrative Code, Section 148.280(a), at a rate at least
24 equal to the rate in effect on March 31, 1994, until the
25 later of (i) implementation of the integrated health care
26 program under this Section and development of actuarially
27 sound capitation rates for services other than those chronic
28 or acute medical conditions of childhood that require
29 longer-term treatment and follow-up care as defined by the
30 Illinois Department in the rules adopted under this
31 subsection or (ii) March 31, 1996.
32 Notwithstanding anything in this subsection to the
33 contrary, a managed health care entity shall not consider
34 sources or methods of payment in determining the referral of
-18- LRB9001689SMdvam03
1 a child. The Illinois Department shall adopt rules to
2 establish criteria for those referrals. The Illinois
3 Department by rule shall establish a method to adjust its
4 payments to managed health care entities in a manner intended
5 to avoid providing any financial incentive to a managed
6 health care entity to refer patients to a provider who is
7 paid directly by the Illinois Department.
8 (m) Behavioral health services provided or funded by the
9 Department of Mental Health and Developmental Disabilities,
10 the Department of Alcoholism and Substance Abuse, the
11 Department of Children and Family Services, and the Illinois
12 Department shall be excluded from a benefit package.
13 Conditions of an organic or physical origin or nature,
14 including medical detoxification, however, may not be
15 excluded. In this subsection, "behavioral health services"
16 means mental health services and subacute alcohol and
17 substance abuse treatment services, as defined in the
18 Illinois Alcoholism and Other Drug Dependency Act. In this
19 subsection, "mental health services" includes, at a minimum,
20 the following services funded by the Illinois Department, the
21 Department of Mental Health and Developmental Disabilities,
22 or the Department of Children and Family Services: (i)
23 inpatient hospital services, including related physician
24 services, related psychiatric interventions, and
25 pharmaceutical services provided to an eligible recipient
26 hospitalized with a primary diagnosis of psychiatric
27 disorder; (ii) outpatient mental health services as defined
28 and specified in Title 59 of the Illinois Administrative
29 Code, Part 132; (iii) any other outpatient mental health
30 services funded by the Illinois Department pursuant to the
31 State of Illinois Medicaid Plan; (iv) partial
32 hospitalization; and (v) follow-up stabilization related to
33 any of those services. Additional behavioral health services
34 may be excluded under this subsection as mutually agreed in
-19- LRB9001689SMdvam03
1 writing by the Illinois Department and the affected State
2 agency or agencies. The exclusion of any service does not
3 prohibit the Illinois Department from developing and
4 implementing demonstration projects for categories of persons
5 or services. The Department of Mental Health and
6 Developmental Disabilities, the Department of Children and
7 Family Services, and the Department of Alcoholism and
8 Substance Abuse shall each adopt rules governing the
9 integration of managed care in the provision of behavioral
10 health services. The State shall integrate managed care
11 community networks and affiliated providers, to the extent
12 practicable, in any separate delivery system for mental
13 health services.
14 (n) The Illinois Department shall adopt rules to
15 establish reserve requirements for managed care community
16 networks, as required by subsection (a), and health
17 maintenance organizations to protect against liabilities in
18 the event that a managed health care entity is declared
19 insolvent or bankrupt. If a managed health care entity other
20 than a county provider is declared insolvent or bankrupt,
21 after liquidation and application of any available assets,
22 resources, and reserves, the Illinois Department shall pay a
23 portion of the amounts owed by the managed health care entity
24 to providers for services rendered to enrollees under the
25 integrated health care program under this Section based on
26 the following schedule: (i) from April 1, 1995 through June
27 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
28 through June 30, 2001, 80% of the amounts owed; and (iii)
29 from July 1, 2001 through June 30, 2005, 75% of the amounts
30 owed. The amounts paid under this subsection shall be
31 calculated based on the total amount owed by the managed
32 health care entity to providers before application of any
33 available assets, resources, and reserves. After June 30,
34 2005, the Illinois Department may not pay any amounts owed to
-20- LRB9001689SMdvam03
1 providers as a result of an insolvency or bankruptcy of a
2 managed health care entity occurring after that date. The
3 Illinois Department is not obligated, however, to pay amounts
4 owed to a provider that has an ownership or other governing
5 interest in the managed health care entity. This subsection
6 applies only to managed health care entities and the services
7 they provide under the integrated health care program under
8 this Section.
9 (o) Notwithstanding any other provision of law or
10 contractual agreement to the contrary, providers shall not be
11 required to accept from any other third party payer the rates
12 determined or paid under this Code by the Illinois
13 Department, managed health care entity, or other health care
14 delivery system for services provided to recipients.
15 (p) The Illinois Department may seek and obtain any
16 necessary authorization provided under federal law to
17 implement the program, including the waiver of any federal
18 statutes or regulations. The Illinois Department may seek a
19 waiver of the federal requirement that the combined
20 membership of Medicare and Medicaid enrollees in a managed
21 care community network may not exceed 75% of the managed care
22 community network's total enrollment. The Illinois
23 Department shall not seek a waiver of this requirement for
24 any other category of managed health care entity. The
25 Illinois Department shall not seek a waiver of the inpatient
26 hospital reimbursement methodology in Section 1902(a)(13)(A)
27 of Title XIX of the Social Security Act even if the federal
28 agency responsible for administering Title XIX determines
29 that Section 1902(a)(13)(A) applies to managed health care
30 systems.
31 Notwithstanding any other provisions of this Code to the
32 contrary, the Illinois Department shall seek a waiver of
33 applicable federal law in order to impose a co-payment system
34 consistent with this subsection on recipients of medical
-21- LRB9001689SMdvam03
1 services under Title XIX of the Social Security Act who are
2 not enrolled in a managed health care entity. The waiver
3 request submitted by the Illinois Department shall provide
4 for co-payments of up to $0.50 for prescribed drugs and up to
5 $0.50 for x-ray services and shall provide for co-payments of
6 up to $10 for non-emergency services provided in a hospital
7 emergency room and up to $10 for non-emergency ambulance
8 services. The purpose of the co-payments shall be to deter
9 those recipients from seeking unnecessary medical care.
10 Co-payments may not be used to deter recipients from seeking
11 necessary medical care. No recipient shall be required to
12 pay more than a total of $150 per year in co-payments under
13 the waiver request required by this subsection. A recipient
14 may not be required to pay more than $15 of any amount due
15 under this subsection in any one month.
16 Co-payments authorized under this subsection may not be
17 imposed when the care was necessitated by a true medical
18 emergency. Co-payments may not be imposed for any of the
19 following classifications of services:
20 (1) Services furnished to person under 18 years of
21 age.
22 (2) Services furnished to pregnant women.
23 (3) Services furnished to any individual who is an
24 inpatient in a hospital, nursing facility, intermediate
25 care facility, or other medical institution, if that
26 person is required to spend for costs of medical care all
27 but a minimal amount of his or her income required for
28 personal needs.
29 (4) Services furnished to a person who is receiving
30 hospice care.
31 Co-payments authorized under this subsection shall not be
32 deducted from or reduce in any way payments for medical
33 services from the Illinois Department to providers. No
34 provider may deny those services to an individual eligible
-22- LRB9001689SMdvam03
1 for services based on the individual's inability to pay the
2 co-payment.
3 Recipients who are subject to co-payments shall be
4 provided notice, in plain and clear language, of the amount
5 of the co-payments, the circumstances under which co-payments
6 are exempted, the circumstances under which co-payments may
7 be assessed, and their manner of collection.
8 The Illinois Department shall establish a Medicaid
9 Co-Payment Council to assist in the development of co-payment
10 policies for the medical assistance program. The Medicaid
11 Co-Payment Council shall also have jurisdiction to develop a
12 program to provide financial or non-financial incentives to
13 Medicaid recipients in order to encourage recipients to seek
14 necessary health care. The Council shall be chaired by the
15 Director of the Illinois Department, and shall have 6
16 additional members. Two of the 6 additional members shall be
17 appointed by the Governor, and one each shall be appointed by
18 the President of the Senate, the Minority Leader of the
19 Senate, the Speaker of the House of Representatives, and the
20 Minority Leader of the House of Representatives. The Council
21 may be convened and make recommendations upon the appointment
22 of a majority of its members. The Council shall be appointed
23 and convened no later than September 1, 1994 and shall report
24 its recommendations to the Director of the Illinois
25 Department and the General Assembly no later than October 1,
26 1994. The chairperson of the Council shall be allowed to
27 vote only in the case of a tie vote among the appointed
28 members of the Council.
29 The Council shall be guided by the following principles
30 as it considers recommendations to be developed to implement
31 any approved waivers that the Illinois Department must seek
32 pursuant to this subsection:
33 (1) Co-payments should not be used to deter access
34 to adequate medical care.
-23- LRB9001689SMdvam03
1 (2) Co-payments should be used to reduce fraud.
2 (3) Co-payment policies should be examined in
3 consideration of other states' experience, and the
4 ability of successful co-payment plans to control
5 unnecessary or inappropriate utilization of services
6 should be promoted.
7 (4) All participants, both recipients and
8 providers, in the medical assistance program have
9 responsibilities to both the State and the program.
10 (5) Co-payments are primarily a tool to educate the
11 participants in the responsible use of health care
12 resources.
13 (6) Co-payments should not be used to penalize
14 providers.
15 (7) A successful medical program requires the
16 elimination of improper utilization of medical resources.
17 The integrated health care program, or any part of that
18 program, established under this Section may not be
19 implemented if matching federal funds under Title XIX of the
20 Social Security Act are not available for administering the
21 program.
22 The Illinois Department shall submit for publication in
23 the Illinois Register the name, address, and telephone number
24 of the individual to whom a request may be directed for a
25 copy of the request for a waiver of provisions of Title XIX
26 of the Social Security Act that the Illinois Department
27 intends to submit to the Health Care Financing Administration
28 in order to implement this Section. The Illinois Department
29 shall mail a copy of that request for waiver to all
30 requestors at least 16 days before filing that request for
31 waiver with the Health Care Financing Administration.
32 (q) After the effective date of this Section, the
33 Illinois Department may take all planning and preparatory
34 action necessary to implement this Section, including, but
-24- LRB9001689SMdvam03
1 not limited to, seeking requests for proposals relating to
2 the integrated health care program created under this
3 Section.
4 (r) In order to (i) accelerate and facilitate the
5 development of integrated health care in contracting areas
6 outside counties with populations in excess of 3,000,000 and
7 counties adjacent to those counties and (ii) maintain and
8 sustain the high quality of education and residency programs
9 coordinated and associated with local area hospitals, the
10 Illinois Department may develop and implement a demonstration
11 program for managed care community networks owned, operated,
12 or governed by State-funded medical schools. The Illinois
13 Department shall prescribe by rule the criteria, standards,
14 and procedures for effecting this demonstration program.
15 (s) (Blank).
16 (s-5) The Illinois Department may impose penalties or
17 sanctions permitted by law or contract for violations of
18 this Section.
19 (t) On April 1, 1995 and every 6 months thereafter, the
20 Illinois Department shall report to the Governor and General
21 Assembly on the progress of the integrated health care
22 program in enrolling clients into managed health care
23 entities. The report shall indicate the capacities of the
24 managed health care entities with which the State contracts,
25 the number of clients enrolled by each contractor, the areas
26 of the State in which managed care options do not exist, and
27 the progress toward meeting the enrollment goals of the
28 integrated health care program.
29 (u) The Illinois Department may implement this Section
30 through the use of emergency rules in accordance with Section
31 5-45 of the Illinois Administrative Procedure Act. For
32 purposes of that Act, the adoption of rules to implement this
33 Section is deemed an emergency and necessary for the public
34 interest, safety, and welfare.
-25- LRB9001689SMdvam03
1 (v) The Auditor General shall conduct an annual
2 performance audit of the integrated health care program
3 created under this Section and the Illinois Department's
4 implementation of this Section. The initial audit shall
5 cover the fiscal year ending June 30, 1997, and subsequent
6 audits shall cover each fiscal year thereafter. The Auditor
7 General shall issue reports of the audits on or before
8 December 31 of 1997 and each year thereafter.
9 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
10 89-673, eff. 8-14-96; revised 8-26-96.)
11 (Text of Section after amendment by P.A. 89-507)
12 Sec. 5-16.3. System for integrated health care services.
13 (a) It shall be the public policy of the State to adopt,
14 to the extent practicable, a health care program that
15 encourages the integration of health care services and
16 manages the health care of program enrollees while preserving
17 reasonable choice within a competitive and cost-efficient
18 environment. In furtherance of this public policy, the
19 Illinois Department shall develop and implement an integrated
20 health care program consistent with the provisions of this
21 Section. The provisions of this Section apply only to the
22 integrated health care program created under this Section.
23 Persons enrolled in the integrated health care program, as
24 determined by the Illinois Department by rule, shall be
25 afforded a choice among health care delivery systems, which
26 shall include, but are not limited to, (i) fee for service
27 care managed by a primary care physician licensed to practice
28 medicine in all its branches, (ii) managed health care
29 entities, and (iii) federally qualified health centers
30 (reimbursed according to a prospective cost-reimbursement
31 methodology) and rural health clinics (reimbursed according
32 to the Medicare methodology), where available. Persons
33 enrolled in the integrated health care program also may be
34 offered indemnity insurance plans, subject to availability.
-26- LRB9001689SMdvam03
1 For purposes of this Section, a "managed health care
2 entity" means a health maintenance organization or a managed
3 care community network as defined in this Section. A "health
4 maintenance organization" means a health maintenance
5 organization as defined in the Health Maintenance
6 Organization Act. A "managed care community network" means
7 an entity, other than a health maintenance organization, that
8 is owned, operated, or governed by providers of health care
9 services within this State and that provides or arranges
10 primary, secondary, and tertiary managed health care services
11 under contract with the Illinois Department exclusively to
12 enrollees of the integrated health care program. A managed
13 care community network may contract with the Illinois
14 Department to provide only pediatric health care services. A
15 county provider as defined in Section 15-1 of this Code may
16 contract with the Illinois Department to provide services to
17 enrollees of the integrated health care program as a managed
18 care community network without the need to establish a
19 separate entity that provides services exclusively to
20 enrollees of the integrated health care program and shall be
21 deemed a managed care community network for purposes of this
22 Code only to the extent of the provision of services to those
23 enrollees in conjunction with the integrated health care
24 program. A county provider shall be entitled to contract
25 with the Illinois Department with respect to any contracting
26 region located in whole or in part within the county. A
27 county provider shall not be required to accept enrollees who
28 do not reside within the county.
29 If a managed health care entity is accredited by a
30 private national organization that performs quality assurance
31 surveys of health maintenance organizations or related
32 organizations, the Illinois Department may take the
33 accreditation into consideration when selecting managed
34 health care entities for participation in the integrated
-27- LRB9001689SMdvam03
1 health care program. The medical director of a managed
2 health care entity must be a physician licensed in the State
3 to practice medicine in all its branches.
4 Each managed care community network must demonstrate its
5 ability to bear the financial risk of serving enrollees under
6 this program. The Illinois Department shall by rule adopt
7 criteria for assessing the financial soundness of each
8 managed care community network. These rules shall consider
9 the extent to which a managed care community network is
10 comprised of providers who directly render health care and
11 are located within the community in which they seek to
12 contract rather than solely arrange or finance the delivery
13 of health care. These rules shall further consider a variety
14 of risk-bearing and management techniques, including the
15 sufficiency of quality assurance and utilization management
16 programs and whether a managed care community network has
17 sufficiently demonstrated its financial solvency and net
18 worth. The Illinois Department's criteria must be based on
19 sound actuarial, financial, and accounting principles. In
20 adopting these rules, the Illinois Department shall consult
21 with the Illinois Department of Insurance. The Illinois
22 Department is responsible for monitoring compliance with
23 these rules.
24 This Section may not be implemented before the effective
25 date of these rules, the approval of any necessary federal
26 waivers, and the completion of the review of an application
27 submitted, at least 60 days before the effective date of
28 rules adopted under this Section, to the Illinois Department
29 by a managed care community network.
30 All health care delivery systems that contract with the
31 Illinois Department under the integrated health care program
32 shall clearly recognize a health care provider's right of
33 conscience under the Right of Conscience Act. In addition to
34 the provisions of that Act, no health care delivery system
-28- LRB9001689SMdvam03
1 that contracts with the Illinois Department under the
2 integrated health care program shall be required to provide,
3 arrange for, or pay for any health care or medical service,
4 procedure, or product if that health care delivery system is
5 owned, controlled, or sponsored by or affiliated with a
6 religious institution or religious organization that finds
7 that health care or medical service, procedure, or product to
8 violate its religious and moral teachings and beliefs.
9 (b) The Illinois Department may, by rule, provide for
10 different benefit packages for different categories of
11 persons enrolled in the program. Mental health services,
12 alcohol and substance abuse services, services related to
13 children with chronic or acute conditions requiring
14 longer-term treatment and follow-up, and rehabilitation care
15 provided by a free-standing rehabilitation hospital or a
16 hospital rehabilitation unit may be excluded from a benefit
17 package if the State ensures that those services are made
18 available through a separate delivery system. An exclusion
19 does not prohibit the Illinois Department from developing and
20 implementing demonstration projects for categories of persons
21 or services. Benefit packages for persons eligible for
22 medical assistance under Articles V, VI, and XII shall be
23 based on the requirements of those Articles and shall be
24 consistent with the Title XIX of the Social Security Act.
25 Nothing in this Act shall be construed to apply to services
26 purchased by the Department of Children and Family Services
27 and the Department of Human Services (as successor to the
28 Department of Mental Health and Developmental Disabilities)
29 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
-29- LRB9001689SMdvam03
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 (c-5) A managed health care entity may not engage in
17 door-to-door marketing activities or marketing activities at
18 an office of the Illinois Department or a county department
19 in order to enroll in the entity's health care delivery
20 system persons who are enrolled in the integrated health care
21 program established under this Section. The Illinois
22 Department shall adopt rules defining "marketing activities"
23 prohibited by this subsection (c-5).
24 Before a managed health care entity may market its health
25 care delivery system to persons enrolled in the integrated
26 health care program established under this Section, the
27 Illinois Department must approve a marketing plan submitted
28 by the entity to the Illinois Department. The Illinois
29 Department shall adopt guidelines for approving marketing
30 plans submitted by managed health care entities under this
31 subsection. Besides prohibiting door-to-door marketing
32 activities and marketing activities at public aid offices,
33 the guidelines shall include at least the following:
34 (1) A managed health care entity may not offer or
-30- LRB9001689SMdvam03
1 provide any gift, favor, or other inducement in marketing
2 its health care delivery system to integrated health care
3 program enrollees. A managed health care entity may
4 provide health care related items that are of nominal
5 value and pre-approved by the Illinois Department to
6 prospective enrollees. A managed health care entity may
7 also provide to enrollees health care related items that
8 have been pre-approved by the Illinois Department as an
9 incentive to manage their health care appropriately.
10 (2) All persons employed or otherwise engaged by a
11 managed health care entity to market the entity's health
12 care delivery system to integrated health care program
13 enrollees or to supervise that marketing shall register
14 with the Illinois Department.
15 The Inspector General appointed under Section 12-13.1 may
16 conduct investigations to determine whether the marketing
17 practices of managed health care entities participating in
18 the integrated health care program comply with the
19 guidelines.
20 (d) A managed health care entity that contracts with the
21 Illinois Department for the provision of services under the
22 program shall do all of the following, solely for purposes of
23 the integrated health care program:
24 (1) Provide that any individual physician licensed
25 to practice medicine in all its branches, any pharmacy,
26 any federally qualified health center, and any
27 podiatrist, that consistently meets the reasonable terms
28 and conditions established by the managed health care
29 entity, including but not limited to credentialing
30 standards, quality assurance program requirements,
31 utilization management requirements, financial
32 responsibility standards, contracting process
33 requirements, and provider network size and accessibility
34 requirements, must be accepted by the managed health care
-31- LRB9001689SMdvam03
1 entity for purposes of the Illinois integrated health
2 care program. Any individual who is either terminated
3 from or denied inclusion in the panel of physicians of
4 the managed health care entity shall be given, within 10
5 business days after that determination, a written
6 explanation of the reasons for his or her exclusion or
7 termination from the panel. This paragraph (1) does not
8 apply to the following:
9 (A) A managed health care entity that
10 certifies to the Illinois Department that:
11 (i) it employs on a full-time basis 125
12 or more Illinois physicians licensed to
13 practice medicine in all of its branches; and
14 (ii) it will provide medical services
15 through its employees to more than 80% of the
16 recipients enrolled with the entity in the
17 integrated health care program; or
18 (B) A domestic stock insurance company
19 licensed under clause (b) of class 1 of Section 4 of
20 the Illinois Insurance Code if (i) at least 66% of
21 the stock of the insurance company is owned by a
22 professional corporation organized under the
23 Professional Service Corporation Act that has 125 or
24 more shareholders who are Illinois physicians
25 licensed to practice medicine in all of its branches
26 and (ii) the insurance company certifies to the
27 Illinois Department that at least 80% of those
28 physician shareholders will provide services to
29 recipients enrolled with the company in the
30 integrated health care program.
31 (2) Provide for reimbursement for providers for
32 emergency care, as defined by the Illinois Department by
33 rule, that must be provided to its enrollees, including
34 an emergency room screening fee, and urgent care that it
-32- LRB9001689SMdvam03
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 (4.5) Provide orientation to the caretaker relative
26 or payee of a medical assistance unit that has an
27 enrollee as a member. The managed health care entity
28 must exercise good faith efforts to provide all caretaker
29 relatives or payees with the orientation. The managed
30 health care entity shall inform the Illinois Department
31 of the caretaker relatives or payees who have completed
32 the orientation. This paragraph applies to every
33 caretaker relative or payee in a managed health care
34 entity's system regardless of whether the caretaker
-33- LRB9001689SMdvam03
1 relative or payee has chosen the system or has been
2 assigned to the system as provided in subsection (e).
3 (5) Provide that enrollees within its system may
4 choose the site for provision of services and the panel
5 of health care providers.
6 (6) Not discriminate in its enrollment or
7 disenrollment practices among recipients of medical
8 services or program enrollees based on health status.
9 (7) Provide a quality assurance and utilization
10 review program that (i) for health maintenance
11 organizations meets the requirements of the Health
12 Maintenance Organization Act and (ii) for managed care
13 community networks meets the requirements established by
14 the Illinois Department in rules that incorporate those
15 standards set forth in the Health Maintenance
16 Organization Act.
17 (8) Issue a managed health care entity
18 identification card to each enrollee upon enrollment.
19 The card must contain all of the following:
20 (A) The enrollee's signature.
21 (B) The enrollee's health plan.
22 (C) The name and telephone number of the
23 enrollee's primary care physician.
24 (D) A telephone number to be used for
25 emergency service 24 hours per day, 7 days per week.
26 The telephone number required to be maintained
27 pursuant to this subparagraph by each managed health
28 care entity shall, at minimum, be staffed by
29 medically trained personnel and be provided
30 directly, or under arrangement, at an office or
31 offices in locations maintained solely within the
32 State of Illinois. For purposes of this
33 subparagraph, "medically trained personnel" means
34 licensed practical nurses or registered nurses
-34- LRB9001689SMdvam03
1 located in the State of Illinois who are licensed
2 pursuant to the Illinois Nursing Act of 1987.
3 (8.5) The Illinois Department must include
4 performance standards in contracts with entities
5 participating in the integrated health care program to
6 require contractors to make a good faith effort to have
7 enrollees evaluated by a physician within a reasonable
8 period of time after enrollment, as determined by the
9 Illinois Department.
10 (9) Ensure that every primary care physician and
11 pharmacy in the managed health care entity meets the
12 standards established by the Illinois Department for
13 accessibility and quality of care. The Illinois
14 Department shall arrange for and oversee an evaluation of
15 the standards established under this paragraph (9) and
16 may recommend any necessary changes to these standards.
17 The Illinois Department shall submit an annual report to
18 the Governor and the General Assembly by April 1 of each
19 year regarding the effect of the standards on ensuring
20 access and quality of care to enrollees.
21 (10) Provide a procedure for handling complaints
22 that (i) for health maintenance organizations meets the
23 requirements of the Health Maintenance Organization Act
24 and (ii) for managed care community networks meets the
25 requirements established by the Illinois Department in
26 rules that incorporate those standards set forth in the
27 Health Maintenance Organization Act.
28 (11) Maintain, retain, and make available to the
29 Illinois Department records, data, and information, in a
30 uniform manner determined by the Illinois Department,
31 sufficient for the Illinois Department to monitor
32 utilization, accessibility, and quality of care.
33 (12) Except for providers who are prepaid, pay all
34 approved claims for covered services that are completed
-35- LRB9001689SMdvam03
1 and submitted to the managed health care entity within 30
2 days after receipt of the claim or receipt of the
3 appropriate capitation payment or payments by the managed
4 health care entity from the State for the month in which
5 the services included on the claim were rendered,
6 whichever is later. If payment is not made or mailed to
7 the provider by the managed health care entity by the due
8 date under this subsection, an interest penalty of 1% of
9 any amount unpaid shall be added for each month or
10 fraction of a month after the due date, until final
11 payment is made. Nothing in this Section shall prohibit
12 managed health care entities and providers from mutually
13 agreeing to terms that require more timely payment.
14 (12.5) Ensure that no payment is made to a
15 physician or other provider of services for withholding
16 from an enrollee any covered services because of the cost
17 of those services. This requirement shall not be
18 construed to prevent managed health care entities from
19 offering, nor providers from accepting, full or partial
20 capitation.
21 (13) Provide integration with community-based
22 programs provided by certified local health departments
23 such as Women, Infants, and Children Supplemental Food
24 Program (WIC), childhood immunization programs, health
25 education programs, case management programs, and health
26 screening programs.
27 (14) Provide that the pharmacy formulary used by a
28 managed health care entity and its contract providers be
29 no more restrictive than the Illinois Department's
30 pharmaceutical program on the effective date of this
31 amendatory Act of 1994 and as amended after that date.
32 (15) Provide integration with community-based
33 organizations, including, but not limited to, any
34 organization that has operated within a Medicaid
-36- LRB9001689SMdvam03
1 Partnership as defined by this Code or by rule of the
2 Illinois Department, that may continue to operate under a
3 contract with the Illinois Department or a managed health
4 care entity under this Section to provide case management
5 services to Medicaid clients in designated high-need
6 areas.
7 The Illinois Department may, by rule, determine
8 methodologies to limit financial liability for managed health
9 care entities resulting from payment for services to
10 enrollees provided under the Illinois Department's integrated
11 health care program. Any methodology so determined may be
12 considered or implemented by the Illinois Department through
13 a contract with a managed health care entity under this
14 integrated health care program.
15 The Illinois Department shall contract with an entity or
16 entities to provide external peer-based quality assurance
17 review for the integrated health care program. The entity
18 shall be representative of Illinois physicians licensed to
19 practice medicine in all its branches and have statewide
20 geographic representation in all specialties of medical care
21 that are provided within the integrated health care program.
22 The entity may not be a third party payer and shall maintain
23 offices in locations around the State in order to provide
24 service and continuing medical education to physician
25 participants within the integrated health care program. The
26 review process shall be developed and conducted by Illinois
27 physicians licensed to practice medicine in all its branches.
28 In consultation with the entity, the Illinois Department may
29 contract with other entities for professional peer-based
30 quality assurance review of individual categories of services
31 other than services provided, supervised, or coordinated by
32 physicians licensed to practice medicine in all its branches.
33 The Illinois Department shall establish, by rule, criteria to
34 avoid conflicts of interest in the conduct of quality
-37- LRB9001689SMdvam03
1 assurance activities consistent with professional peer-review
2 standards. All quality assurance activities shall be
3 coordinated by the Illinois Department.
4 (e) All persons enrolled in the program shall be
5 provided with a full written explanation of all
6 fee-for-service and managed health care plan options and a
7 reasonable opportunity to choose among the options as
8 provided by rule. The Illinois Department shall provide to
9 enrollees, upon enrollment in the integrated health care
10 program and at least annually thereafter, notice of the
11 process for requesting an appeal under the Illinois
12 Department's administrative appeal procedures.
13 Notwithstanding any other Section of this Code, the Illinois
14 Department may provide by rule for the Illinois Department to
15 assign a person enrolled in the program to a specific
16 provider of medical services or to a specific health care
17 delivery system if an enrollee has failed to exercise choice
18 in a timely manner. An enrollee assigned by the Illinois
19 Department shall be afforded the opportunity to disenroll and
20 to select a specific provider of medical services or a
21 specific health care delivery system within the first 30 days
22 after the assignment. An enrollee who has failed to exercise
23 choice in a timely manner may be assigned only if there are 3
24 or more managed health care entities contracting with the
25 Illinois Department within the contracting area, except that,
26 outside the City of Chicago, this requirement may be waived
27 for an area by rules adopted by the Illinois Department after
28 consultation with all hospitals within the contracting area.
29 The Illinois Department shall establish by rule the procedure
30 for random assignment of enrollees who fail to exercise
31 choice in a timely manner to a specific managed health care
32 entity in proportion to the available capacity of that
33 managed health care entity. Assignment to a specific provider
34 of medical services or to a specific managed health care
-38- LRB9001689SMdvam03
1 entity may not exceed that provider's or entity's capacity as
2 determined by the Illinois Department. Any person who has
3 chosen a specific provider of medical services or a specific
4 managed health care entity, or any person who has been
5 assigned under this subsection, shall be given the
6 opportunity to change that choice or assignment at least once
7 every 12 months, as determined by the Illinois Department by
8 rule. The Illinois Department shall maintain a toll-free
9 telephone number for program enrollees' use in reporting
10 problems with managed health care entities.
11 (f) If a person becomes eligible for participation in
12 the integrated health care program while he or she is
13 hospitalized, the Illinois Department may not enroll that
14 person in the program until after he or she has been
15 discharged from the hospital. This subsection does not apply
16 to newborn infants whose mothers are enrolled in the
17 integrated health care program.
18 (g) The Illinois Department shall, by rule, establish
19 for managed health care entities rates that (i) are certified
20 to be actuarially sound, as determined by an actuary who is
21 an associate or a fellow of the Society of Actuaries or a
22 member of the American Academy of Actuaries and who has
23 expertise and experience in medical insurance and benefit
24 programs, in accordance with the Illinois Department's
25 current fee-for-service payment system, and (ii) take into
26 account any difference of cost to provide health care to
27 different populations based on gender, age, location, and
28 eligibility category. The rates for managed health care
29 entities shall be determined on a capitated basis.
30 The Illinois Department by rule shall establish a method
31 to adjust its payments to managed health care entities in a
32 manner intended to avoid providing any financial incentive to
33 a managed health care entity to refer patients to a county
34 provider, in an Illinois county having a population greater
-39- LRB9001689SMdvam03
1 than 3,000,000, that is paid directly by the Illinois
2 Department. The Illinois Department shall by April 1, 1997,
3 and annually thereafter, review the method to adjust
4 payments. Payments by the Illinois Department to the county
5 provider, for persons not enrolled in a managed care
6 community network owned or operated by a county provider,
7 shall be paid on a fee-for-service basis under Article XV of
8 this Code.
9 The Illinois Department by rule shall establish a method
10 to reduce its payments to managed health care entities to
11 take into consideration (i) any adjustment payments paid to
12 hospitals under subsection (h) of this Section to the extent
13 those payments, or any part of those payments, have been
14 taken into account in establishing capitated rates under this
15 subsection (g) and (ii) the implementation of methodologies
16 to limit financial liability for managed health care entities
17 under subsection (d) of this Section.
18 (h) For hospital services provided by a hospital that
19 contracts with a managed health care entity, adjustment
20 payments shall be paid directly to the hospital by the
21 Illinois Department. Adjustment payments may include but
22 need not be limited to adjustment payments to:
23 disproportionate share hospitals under Section 5-5.02 of this
24 Code; primary care access health care education payments (89
25 Ill. Adm. Code 149.140); payments for capital, direct medical
26 education, indirect medical education, certified registered
27 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
28 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
29 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
30 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
31 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
32 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
33 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
34 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
-40- LRB9001689SMdvam03
1 148.290(h)); and outpatient indigent volume adjustments (89
2 Ill. Adm. Code 148.140(b)(5)).
3 (i) For any hospital eligible for the adjustment
4 payments described in subsection (h), the Illinois Department
5 shall maintain, through the period ending June 30, 1995,
6 reimbursement levels in accordance with statutes and rules in
7 effect on April 1, 1994.
8 (j) Nothing contained in this Code in any way limits or
9 otherwise impairs the authority or power of the Illinois
10 Department to enter into a negotiated contract pursuant to
11 this Section with a managed health care entity, including,
12 but not limited to, a health maintenance organization, that
13 provides for termination or nonrenewal of the contract
14 without cause upon notice as provided in the contract and
15 without a hearing.
16 (k) Section 5-5.15 does not apply to the program
17 developed and implemented pursuant to this Section.
18 (l) The Illinois Department shall, by rule, define those
19 chronic or acute medical conditions of childhood that require
20 longer-term treatment and follow-up care. The Illinois
21 Department shall ensure that services required to treat these
22 conditions are available through a separate delivery system.
23 A managed health care entity that contracts with the
24 Illinois Department may refer a child with medical conditions
25 described in the rules adopted under this subsection directly
26 to a children's hospital or to a hospital, other than a
27 children's hospital, that is qualified to provide inpatient
28 and outpatient services to treat those conditions. The
29 Illinois Department shall provide fee-for-service
30 reimbursement directly to a children's hospital for those
31 services pursuant to Title 89 of the Illinois Administrative
32 Code, Section 148.280(a), at a rate at least equal to the
33 rate in effect on March 31, 1994. For hospitals, other than
34 children's hospitals, that are qualified to provide inpatient
-41- LRB9001689SMdvam03
1 and outpatient services to treat those conditions, the
2 Illinois Department shall provide reimbursement for those
3 services on a fee-for-service basis, at a rate at least equal
4 to the rate in effect for those other hospitals on March 31,
5 1994.
6 A children's hospital shall be directly reimbursed for
7 all services provided at the children's hospital on a
8 fee-for-service basis pursuant to Title 89 of the Illinois
9 Administrative Code, Section 148.280(a), at a rate at least
10 equal to the rate in effect on March 31, 1994, until the
11 later of (i) implementation of the integrated health care
12 program under this Section and development of actuarially
13 sound capitation rates for services other than those chronic
14 or acute medical conditions of childhood that require
15 longer-term treatment and follow-up care as defined by the
16 Illinois Department in the rules adopted under this
17 subsection or (ii) March 31, 1996.
18 Notwithstanding anything in this subsection to the
19 contrary, a managed health care entity shall not consider
20 sources or methods of payment in determining the referral of
21 a child. The Illinois Department shall adopt rules to
22 establish criteria for those referrals. The Illinois
23 Department by rule shall establish a method to adjust its
24 payments to managed health care entities in a manner intended
25 to avoid providing any financial incentive to a managed
26 health care entity to refer patients to a provider who is
27 paid directly by the Illinois Department.
28 (m) Behavioral health services provided or funded by the
29 Department of Human Services, the Department of Children and
30 Family Services, and the Illinois Department shall be
31 excluded from a benefit package. Conditions of an organic or
32 physical origin or nature, including medical detoxification,
33 however, may not be excluded. In this subsection,
34 "behavioral health services" means mental health services and
-42- LRB9001689SMdvam03
1 subacute alcohol and substance abuse treatment services, as
2 defined in the Illinois Alcoholism and Other Drug Dependency
3 Act. In this subsection, "mental health services" includes,
4 at a minimum, the following services funded by the Illinois
5 Department, the Department of Human Services (as successor to
6 the Department of Mental Health and Developmental
7 Disabilities), or the Department of Children and Family
8 Services: (i) inpatient hospital services, including related
9 physician services, related psychiatric interventions, and
10 pharmaceutical services provided to an eligible recipient
11 hospitalized with a primary diagnosis of psychiatric
12 disorder; (ii) outpatient mental health services as defined
13 and specified in Title 59 of the Illinois Administrative
14 Code, Part 132; (iii) any other outpatient mental health
15 services funded by the Illinois Department pursuant to the
16 State of Illinois Medicaid Plan; (iv) partial
17 hospitalization; and (v) follow-up stabilization related to
18 any of those services. Additional behavioral health services
19 may be excluded under this subsection as mutually agreed in
20 writing by the Illinois Department and the affected State
21 agency or agencies. The exclusion of any service does not
22 prohibit the Illinois Department from developing and
23 implementing demonstration projects for categories of persons
24 or services. The Department of Children and Family Services
25 and the Department of Human Services shall each adopt rules
26 governing the integration of managed care in the provision of
27 behavioral health services. The State shall integrate managed
28 care community networks and affiliated providers, to the
29 extent practicable, in any separate delivery system for
30 mental health services.
31 (n) The Illinois Department shall adopt rules to
32 establish reserve requirements for managed care community
33 networks, as required by subsection (a), and health
34 maintenance organizations to protect against liabilities in
-43- LRB9001689SMdvam03
1 the event that a managed health care entity is declared
2 insolvent or bankrupt. If a managed health care entity other
3 than a county provider is declared insolvent or bankrupt,
4 after liquidation and application of any available assets,
5 resources, and reserves, the Illinois Department shall pay a
6 portion of the amounts owed by the managed health care entity
7 to providers for services rendered to enrollees under the
8 integrated health care program under this Section based on
9 the following schedule: (i) from April 1, 1995 through June
10 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
11 through June 30, 2001, 80% of the amounts owed; and (iii)
12 from July 1, 2001 through June 30, 2005, 75% of the amounts
13 owed. The amounts paid under this subsection shall be
14 calculated based on the total amount owed by the managed
15 health care entity to providers before application of any
16 available assets, resources, and reserves. After June 30,
17 2005, the Illinois Department may not pay any amounts owed to
18 providers as a result of an insolvency or bankruptcy of a
19 managed health care entity occurring after that date. The
20 Illinois Department is not obligated, however, to pay amounts
21 owed to a provider that has an ownership or other governing
22 interest in the managed health care entity. This subsection
23 applies only to managed health care entities and the services
24 they provide under the integrated health care program under
25 this Section.
26 (o) Notwithstanding any other provision of law or
27 contractual agreement to the contrary, providers shall not be
28 required to accept from any other third party payer the rates
29 determined or paid under this Code by the Illinois
30 Department, managed health care entity, or other health care
31 delivery system for services provided to recipients.
32 (p) The Illinois Department may seek and obtain any
33 necessary authorization provided under federal law to
34 implement the program, including the waiver of any federal
-44- LRB9001689SMdvam03
1 statutes or regulations. The Illinois Department may seek a
2 waiver of the federal requirement that the combined
3 membership of Medicare and Medicaid enrollees in a managed
4 care community network may not exceed 75% of the managed care
5 community network's total enrollment. The Illinois
6 Department shall not seek a waiver of this requirement for
7 any other category of managed health care entity. The
8 Illinois Department shall not seek a waiver of the inpatient
9 hospital reimbursement methodology in Section 1902(a)(13)(A)
10 of Title XIX of the Social Security Act even if the federal
11 agency responsible for administering Title XIX determines
12 that Section 1902(a)(13)(A) applies to managed health care
13 systems.
14 Notwithstanding any other provisions of this Code to the
15 contrary, the Illinois Department shall seek a waiver of
16 applicable federal law in order to impose a co-payment system
17 consistent with this subsection on recipients of medical
18 services under Title XIX of the Social Security Act who are
19 not enrolled in a managed health care entity. The waiver
20 request submitted by the Illinois Department shall provide
21 for co-payments of up to $0.50 for prescribed drugs and up to
22 $0.50 for x-ray services and shall provide for co-payments of
23 up to $10 for non-emergency services provided in a hospital
24 emergency room and up to $10 for non-emergency ambulance
25 services. The purpose of the co-payments shall be to deter
26 those recipients from seeking unnecessary medical care.
27 Co-payments may not be used to deter recipients from seeking
28 necessary medical care. No recipient shall be required to
29 pay more than a total of $150 per year in co-payments under
30 the waiver request required by this subsection. A recipient
31 may not be required to pay more than $15 of any amount due
32 under this subsection in any one month.
33 Co-payments authorized under this subsection may not be
34 imposed when the care was necessitated by a true medical
-45- LRB9001689SMdvam03
1 emergency. Co-payments may not be imposed for any of the
2 following classifications of services:
3 (1) Services furnished to person under 18 years of
4 age.
5 (2) Services furnished to pregnant women.
6 (3) Services furnished to any individual who is an
7 inpatient in a hospital, nursing facility, intermediate
8 care facility, or other medical institution, if that
9 person is required to spend for costs of medical care all
10 but a minimal amount of his or her income required for
11 personal needs.
12 (4) Services furnished to a person who is receiving
13 hospice care.
14 Co-payments authorized under this subsection shall not be
15 deducted from or reduce in any way payments for medical
16 services from the Illinois Department to providers. No
17 provider may deny those services to an individual eligible
18 for services based on the individual's inability to pay the
19 co-payment.
20 Recipients who are subject to co-payments shall be
21 provided notice, in plain and clear language, of the amount
22 of the co-payments, the circumstances under which co-payments
23 are exempted, the circumstances under which co-payments may
24 be assessed, and their manner of collection.
25 The Illinois Department shall establish a Medicaid
26 Co-Payment Council to assist in the development of co-payment
27 policies for the medical assistance program. The Medicaid
28 Co-Payment Council shall also have jurisdiction to develop a
29 program to provide financial or non-financial incentives to
30 Medicaid recipients in order to encourage recipients to seek
31 necessary health care. The Council shall be chaired by the
32 Director of the Illinois Department, and shall have 6
33 additional members. Two of the 6 additional members shall be
34 appointed by the Governor, and one each shall be appointed by
-46- LRB9001689SMdvam03
1 the President of the Senate, the Minority Leader of the
2 Senate, the Speaker of the House of Representatives, and the
3 Minority Leader of the House of Representatives. The Council
4 may be convened and make recommendations upon the appointment
5 of a majority of its members. The Council shall be appointed
6 and convened no later than September 1, 1994 and shall report
7 its recommendations to the Director of the Illinois
8 Department and the General Assembly no later than October 1,
9 1994. The chairperson of the Council shall be allowed to
10 vote only in the case of a tie vote among the appointed
11 members of the Council.
12 The Council shall be guided by the following principles
13 as it considers recommendations to be developed to implement
14 any approved waivers that the Illinois Department must seek
15 pursuant to this subsection:
16 (1) Co-payments should not be used to deter access
17 to adequate medical care.
18 (2) Co-payments should be used to reduce fraud.
19 (3) Co-payment policies should be examined in
20 consideration of other states' experience, and the
21 ability of successful co-payment plans to control
22 unnecessary or inappropriate utilization of services
23 should be promoted.
24 (4) All participants, both recipients and
25 providers, in the medical assistance program have
26 responsibilities to both the State and the program.
27 (5) Co-payments are primarily a tool to educate the
28 participants in the responsible use of health care
29 resources.
30 (6) Co-payments should not be used to penalize
31 providers.
32 (7) A successful medical program requires the
33 elimination of improper utilization of medical resources.
34 The integrated health care program, or any part of that
-47- LRB9001689SMdvam03
1 program, established under this Section may not be
2 implemented if matching federal funds under Title XIX of the
3 Social Security Act are not available for administering the
4 program.
5 The Illinois Department shall submit for publication in
6 the Illinois Register the name, address, and telephone number
7 of the individual to whom a request may be directed for a
8 copy of the request for a waiver of provisions of Title XIX
9 of the Social Security Act that the Illinois Department
10 intends to submit to the Health Care Financing Administration
11 in order to implement this Section. The Illinois Department
12 shall mail a copy of that request for waiver to all
13 requestors at least 16 days before filing that request for
14 waiver with the Health Care Financing Administration.
15 (q) After the effective date of this Section, the
16 Illinois Department may take all planning and preparatory
17 action necessary to implement this Section, including, but
18 not limited to, seeking requests for proposals relating to
19 the integrated health care program created under this
20 Section.
21 (r) In order to (i) accelerate and facilitate the
22 development of integrated health care in contracting areas
23 outside counties with populations in excess of 3,000,000 and
24 counties adjacent to those counties and (ii) maintain and
25 sustain the high quality of education and residency programs
26 coordinated and associated with local area hospitals, the
27 Illinois Department may develop and implement a demonstration
28 program for managed care community networks owned, operated,
29 or governed by State-funded medical schools. The Illinois
30 Department shall prescribe by rule the criteria, standards,
31 and procedures for effecting this demonstration program.
32 (s) (Blank).
33 (s-5) The Illinois Department may impose penalties or
34 sanctions permitted by law or contract for violations of
-48- LRB9001689SMdvam03
1 this Section.
2 (t) On April 1, 1995 and every 6 months thereafter, the
3 Illinois Department shall report to the Governor and General
4 Assembly on the progress of the integrated health care
5 program in enrolling clients into managed health care
6 entities. The report shall indicate the capacities of the
7 managed health care entities with which the State contracts,
8 the number of clients enrolled by each contractor, the areas
9 of the State in which managed care options do not exist, and
10 the progress toward meeting the enrollment goals of the
11 integrated health care program.
12 (u) The Illinois Department may implement this Section
13 through the use of emergency rules in accordance with Section
14 5-45 of the Illinois Administrative Procedure Act. For
15 purposes of that Act, the adoption of rules to implement this
16 Section is deemed an emergency and necessary for the public
17 interest, safety, and welfare.
18 (v) The Auditor General shall conduct an annual
19 performance audit of the integrated health care program
20 created under this Section and the Illinois Department's
21 implementation of this Section. The initial audit shall
22 cover the fiscal year ending June 30, 1997, and subsequent
23 audits shall cover each fiscal year thereafter. The Auditor
24 General shall issue reports of the audits on or before
25 December 31 of 1997 and each year thereafter.
26 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
27 89-507, eff. 7-1-97; 89-673, eff. 8-14-96; revised 8-26-96.)
28 (305 ILCS 5/5-16.8 new)
29 Sec. 5-16.8. Administration of managed care program.
30 (a) The Illinois Department shall, by rule, establish
31 guidelines for its administration of a managed care program
32 requiring each managed care organization participating in the
33 program to provide education programs for providers
-49- LRB9001689SMdvam03
1 participating within the managed care organization's network
2 and for persons eligible for medical assistance under Article
3 V, VI, or XII who are enrolled with the managed care
4 organization.
5 (b) A provider education program must include
6 information on:
7 (1) Medicaid policies, procedures, eligibility
8 standards, and benefits;
9 (2) the specific problems and needs of Medicaid
10 clients; and
11 (3) the rights and responsibilities of Medicaid
12 clients prescribed by this Section.
13 (c) A client education program must present information
14 in a manner that is easy to understand. A program must
15 include information on:
16 (1) the rights and responsibilities prescribed by
17 this Section;
18 (2) how to access health care services;
19 (3) how to access complaint procedures and the
20 client's rights to bypass the managed care organization's
21 internal complaint system and use the notice and appeal
22 procedures otherwise required by the Medicaid program;
23 (4) Medicaid policies, procedures, eligibility
24 standards, and benefits;
25 (5) the policies and procedures of the managed care
26 organization; and
27 (6) the importance of prevention, early
28 intervention, and appropriate use of services.
29 (d) The Department or its designee shall inform each
30 person enrolled in the Medicaid program of the person's
31 rights and responsibilities under that program. The
32 information must address the client's right to:
33 (1) respect, dignity, privacy, confidentiality, and
34 nondiscrimination;
-50- LRB9001689SMdvam03
1 (2) a reasonable opportunity to choose a health
2 care plan and primary care provider and to change to
3 another plan or provider in a reasonable manner;
4 (3) consent to or refuse treatment and actively
5 participate in treatment decisions;
6 (4) ask questions and receive complete information
7 relating to the client's medical condition and treatment
8 options, including specialty care;
9 (5) access each available complaint process,
10 receive a timely response to a complaint, and receive a
11 fair hearing; and
12 (6) timely access to care that does not have any
13 communication or physical access barriers.
14 (e) The information must address a client's
15 responsibility to:
16 (1) learn and understand each right the client has
17 under the Medicaid program;
18 (2) abide by the health plan and Medicaid policies
19 and procedures;
20 (3) share information relating to the client's
21 health status with the primary care provider and become
22 fully informed about service and treatment options; and
23 (4) actively participate in decisions relating to
24 service and treatment options, make personal choices and
25 take action to maintain the client's health.
26 (f) The Department shall provide support and information
27 services to a person enrolled in the program or applying for
28 Medicaid coverage who experiences barriers to receiving
29 health care services. The Department may contract for the
30 provision of support and information services. As a part of
31 the support and information services required by this
32 subsection, the Department or organization shall:
33 (1) operate a statewide toll-free assistance
34 telephone number that includes TDD lines and assistance
-51- LRB9001689SMdvam03
1 for persons who speak Spanish;
2 (2) intervene promptly with the managed care
3 organizations and providers and any other appropriate
4 entity on behalf of a person who has an urgent need for
5 medical services;
6 (3) assist a person who is experiencing barriers in
7 the Medicaid application and enrollment process and refer
8 the person for further assistance if appropriate;
9 (4) educate persons so that they:
10 (A) understand the concept of managed care;
11 (B) understand their rights under the Medicaid
12 program, including grievance and appeal procedures;
13 and
14 (C) are able to advocate for themselves; and
15 (5) collect and maintain statistical information on
16 a regional basis regarding calls received by the
17 assistance lines and publish quarterly reports that:
18 (A) list the number of calls received by
19 region;
20 (B) identify trends in delivery and access
21 problems;
22 (C) identify recurring barriers in the
23 Medicaid system; and
24 (D) indicate other problems identified with
25 Medicaid managed care; and
26 (6) assist the managed care organizations and
27 providers in identifying and correcting problems,
28 including site visits to affected regions if necessary.
29 (305 ILCS 5/5-16.10 new)
30 Sec. 5-16.10. Managed care entities; marketing. A
31 managed health care entity providing services under this
32 Article V may not engage in door-to-door marketing activities
33 or marketing activities at an office of the Illinois
-52- LRB9001689SMdvam03
1 Department or a county department in order to enroll
2 recipients in the entity's health care delivery system. The
3 Department shall adopt rules defining "marketing activities"
4 prohibited by this Section.
5 Before a managed health care entity providing services
6 under this Article V may market its health care delivery
7 system to recipients, the Illinois Department must approve a
8 marketing plan submitted by the entity to the Illinois
9 Department. The Illinois Department shall adopt guidelines
10 for approving marketing plans submitted by managed health
11 care entities under this Section. Besides prohibiting
12 door-to-door marketing activities and marketing activities at
13 public aid offices, the guidelines shall include at least the
14 following:
15 (1) A managed health care entity may not offer or
16 provide any gift, favor, or other inducement in marketing
17 its health care delivery system to integrated health care
18 program enrollees. A managed health care entity may
19 provide health care related items that are of nominal
20 value and pre-approved by the Department to prospective
21 enrollees. A managed health care entity may also
22 provide to enrollees health care related items that have
23 been pre-approved by the Department as an incentive to
24 manage their health care appropriately.
25 (2) All persons employed or otherwise engaged by a
26 managed health care entity to market the entity's health
27 care delivery system to recipients or to supervise that
28 marketing shall register with the Illinois Department.
29 The Inspector General appointed under Section 12-13.1 may
30 conduct investigations to determine whether the marketing
31 practices of managed health care entities providing services
32 under this Article V comply with the guidelines.
33 (305 ILCS 5/12-13.1)
-53- LRB9001689SMdvam03
1 (Text of Section before amendment by P.A. 89-507)
2 Sec. 12-13.1. Inspector General.
3 (a) The Governor shall appoint, and the Senate shall
4 confirm, an Inspector General who shall function within the
5 Illinois Department and report to the Governor. The term of
6 the Inspector General shall expire on the third Monday of
7 January, 1997 and every 4 years thereafter.
8 (b) In order to prevent, detect, and eliminate fraud,
9 waste, abuse, mismanagement, and misconduct, the Inspector
10 General shall oversee the Illinois Department's integrity
11 functions, which include, but are not limited to, the
12 following:
13 (1) Investigation of misconduct by employees,
14 vendors, contractors and medical providers.
15 (2) Audits of medical providers related to ensuring
16 that appropriate payments are made for services rendered
17 and to the recovery of overpayments.
18 (3) Monitoring of quality assurance programs
19 generally related to the medical assistance program and
20 specifically related to any managed care program.
21 (4) Quality control measurements of the programs
22 administered by the Illinois Department.
23 (5) Investigations of fraud or intentional program
24 violations committed by clients of the Illinois
25 Department.
26 (6) Actions initiated against contractors or
27 medical providers for any of the following reasons:
28 (A) Violations of the medical assistance
29 program.
30 (B) Sanctions against providers brought in
31 conjunction with the Department of Public Health or
32 the Department of Mental Health and Developmental
33 Disabilities.
34 (C) Recoveries of assessments against
-54- LRB9001689SMdvam03
1 hospitals and long-term care facilities.
2 (D) Sanctions mandated by the United States
3 Department of Health and Human Services against
4 medical providers.
5 (E) Violations of contracts related to any
6 managed care programs.
7 (7) Representation of the Illinois Department at
8 hearings with the Illinois Department of Professional
9 Regulation in actions taken against professional licenses
10 held by persons who are in violation of orders for child
11 support payments.
12 (b-7) The Inspector General may establish within that
13 Office a special administrative subdivision to monitor
14 managed health care entities participating in the integrated
15 health care program established under Section 5-16.3 of this
16 Code to ensure that the entities comply with the requirements
17 of that Section. This special administrative subdivision may
18 receive and investigate complaints made by persons enrolled
19 in a managed health care entity's health care delivery
20 system. If the Inspector General investigates a complaint,
21 the Inspector General shall determine whether a managed
22 health care entity has complied with the requirements of
23 Section 5-16.3 and the rules implementing that Section to the
24 extent that those issues are raised by the complaint.
25 The Inspector General may also monitor the Enrolled
26 Managed Care Provider program to ensure that appropriate
27 management of patient care occurs and that services provided
28 are medically necessary. The special administrative
29 subdivision authorized under this subsection may receive and
30 investigate complaints made by persons receiving services
31 under Section 5-16.3.
32 (c) The Inspector General shall have access to all
33 information, personnel and facilities of the Illinois
34 Department, its employees, vendors, contractors and medical
-55- LRB9001689SMdvam03
1 providers and any federal, State or local governmental agency
2 that are necessary to perform the duties of the Office as
3 directly related to public assistance programs administered
4 by the Illinois Department. No medical provider shall be
5 compelled, however, to provide individual medical records of
6 patients who are not clients of the Medical Assistance
7 Program. State and local governmental agencies are
8 authorized and directed to provide the requested information,
9 assistance or cooperation.
10 (d) The Inspector General shall serve as the Illinois
11 Department's primary liaison with law enforcement,
12 investigatory and prosecutorial agencies, including but not
13 limited to the following:
14 (1) The Department of State Police.
15 (2) The Federal Bureau of Investigation and other
16 federal law enforcement agencies.
17 (3) The various Inspectors General of federal
18 agencies overseeing the programs administered by the
19 Illinois Department.
20 (4) The various Inspectors General of any other
21 State agencies with responsibilities for portions of
22 programs primarily administered by the Illinois
23 Department.
24 (5) The Offices of the several United States
25 Attorneys in Illinois.
26 (6) The several State's Attorneys.
27 The Inspector General shall meet on a regular basis with
28 these entities to share information regarding possible
29 misconduct by any persons or entities involved with the
30 public aid programs administered by the Illinois Department.
31 (e) All investigations conducted by the Inspector
32 General shall be conducted in a manner that ensures the
33 preservation of evidence for use in criminal prosecutions.
34 If the Inspector General determines that a possible criminal
-56- LRB9001689SMdvam03
1 act relating to fraud in the provision or administration of
2 the medical assistance program has been committed, the
3 Inspector General shall immediately notify the Medicaid Fraud
4 Control Unit. If the Inspector General determines that a
5 possible criminal act has been committed within the
6 jurisdiction of the Office, the Inspector General may request
7 the special expertise of the Department of State Police. The
8 Inspector General may present for prosecution the findings of
9 any criminal investigation to the Office of the Attorney
10 General, the Offices of the several United State Attorneys in
11 Illinois or the several State's Attorneys.
12 (f) To carry out his or her duties as described in this
13 Section, the Inspector General and his or her designees shall
14 have the power to compel by subpoena the attendance and
15 testimony of witnesses and the production of books,
16 electronic records and papers as directly related to public
17 assistance programs administered by the Illinois Department.
18 No medical provider shall be compelled, however, to provide
19 individual medical records of patients who are not clients of
20 the Medical Assistance Program.
21 (g) The Inspector General shall report all convictions,
22 terminations, and suspensions taken against vendors,
23 contractors and medical providers to the Illinois Department
24 and to any agency responsible for licensing or regulating
25 those persons or entities.
26 (h) The Inspector General shall make quarterly reports,
27 findings, and recommendations regarding the Office's
28 investigations into reports of fraud, waste, abuse,
29 mismanagement, or misconduct relating to any public aid
30 programs administered by the Illinois Department to the
31 General Assembly and the Governor. These reports shall
32 include, but not be limited to, the following information:
33 (1) Aggregate provider billing and payment
34 information, including the number of providers at various
-57- LRB9001689SMdvam03
1 Medicaid earning levels.
2 (2) The number of audits of the medical assistance
3 program and the dollar savings resulting from those
4 audits.
5 (3) The number of prescriptions rejected annually
6 under the Illinois Department's Refill Too Soon program
7 and the dollar savings resulting from that program.
8 (4) Provider sanctions, in the aggregate, including
9 terminations and suspensions.
10 (5) A detailed summary of the investigations
11 undertaken in the previous fiscal year. These summaries
12 shall comply with all laws and rules regarding
13 maintaining confidentiality in the public aid programs.
14 (i) Nothing in this Section shall limit investigations
15 by the Illinois Department that may otherwise be required by
16 law or that may be necessary in the Illinois Department's
17 capacity as the central administrative authority responsible
18 for administration of public aid programs in this State.
19 (Source: P.A. 88-554, eff. 7-26-94.)
20 (Text of Section after amendment by P.A. 89-507)
21 Sec. 12-13.1. Inspector General.
22 (a) The Governor shall appoint, and the Senate shall
23 confirm, an Inspector General who shall function within the
24 Illinois Department of Public Aid and report to the Governor.
25 The term of the Inspector General shall expire on the third
26 Monday of January, 1997 and every 4 years thereafter.
27 (b) In order to prevent, detect, and eliminate fraud,
28 waste, abuse, mismanagement, and misconduct, the Inspector
29 General shall oversee the Illinois Department of Public Aid's
30 integrity functions, which include, but are not limited to,
31 the following:
32 (1) Investigation of misconduct by employees,
33 vendors, contractors and medical providers.
34 (2) Audits of medical providers related to ensuring
-58- LRB9001689SMdvam03
1 that appropriate payments are made for services rendered
2 and to the recovery of overpayments.
3 (3) Monitoring of quality assurance programs
4 generally related to the medical assistance program and
5 specifically related to any managed care program.
6 (4) Quality control measurements of the programs
7 administered by the Illinois Department of Public Aid.
8 (5) Investigations of fraud or intentional program
9 violations committed by clients of the Illinois
10 Department of Public Aid.
11 (6) Actions initiated against contractors or
12 medical providers for any of the following reasons:
13 (A) Violations of the medical assistance
14 program.
15 (B) Sanctions against providers brought in
16 conjunction with the Department of Public Health or
17 the Department of Human Services (as successor to
18 the Department of Mental Health and Developmental
19 Disabilities).
20 (C) Recoveries of assessments against
21 hospitals and long-term care facilities.
22 (D) Sanctions mandated by the United States
23 Department of Health and Human Services against
24 medical providers.
25 (E) Violations of contracts related to any
26 managed care programs.
27 (7) Representation of the Illinois Department of
28 Public Aid at hearings with the Illinois Department of
29 Professional Regulation in actions taken against
30 professional licenses held by persons who are in
31 violation of orders for child support payments.
32 (b-5) At the request of the Secretary of Human Services,
33 the Inspector General shall, in relation to any function
34 performed by the Department of Human Services as successor to
-59- LRB9001689SMdvam03
1 the Department of Public Aid, exercise one or more of the
2 powers provided under this Section as if those powers related
3 to the Department of Human Services; in such matters, the
4 Inspector General shall report his or her findings to the
5 Secretary of Human Services.
6 (b-7) The Inspector General may establish within that
7 Office a special administrative subdivision to monitor
8 managed health care entities participating in the integrated
9 health care program established under Section 5-16.3 of this
10 Code to ensure that the entities comply with the requirements
11 of that Section. This special administrative subdivision may
12 receive and investigate complaints made by persons enrolled
13 in a managed health care entity's health care delivery
14 system. If the Inspector General investigates a complaint,
15 the Inspector General shall determine whether a managed
16 health care entity has complied with the requirements of
17 Section 5-16.3 and the rules implementing that Section to the
18 extent that those issues are raised by the complaint.
19 The Inspector General may also monitor the Enrolled
20 Managed Care Provider program to ensure that appropriate
21 management of patient care occurs and that services provided
22 are medically necessary. The special administrative
23 subdivision authorized under this subsection may receive and
24 investigate complaints made by persons receiving services
25 under Section 5-16.3.
26 (c) The Inspector General shall have access to all
27 information, personnel and facilities of the Illinois
28 Department of Public Aid and the Department of Human Services
29 (as successor to the Department of Public Aid), their
30 employees, vendors, contractors and medical providers and any
31 federal, State or local governmental agency that are
32 necessary to perform the duties of the Office as directly
33 related to public assistance programs administered by those
34 departments. No medical provider shall be compelled,
-60- LRB9001689SMdvam03
1 however, to provide individual medical records of patients
2 who are not clients of the Medical Assistance Program. State
3 and local governmental agencies are authorized and directed
4 to provide the requested information, assistance or
5 cooperation.
6 (d) The Inspector General shall serve as the Illinois
7 Department of Public Aid's primary liaison with law
8 enforcement, investigatory and prosecutorial agencies,
9 including but not limited to the following:
10 (1) The Department of State Police.
11 (2) The Federal Bureau of Investigation and other
12 federal law enforcement agencies.
13 (3) The various Inspectors General of federal
14 agencies overseeing the programs administered by the
15 Illinois Department of Public Aid.
16 (4) The various Inspectors General of any other
17 State agencies with responsibilities for portions of
18 programs primarily administered by the Illinois
19 Department of Public Aid.
20 (5) The Offices of the several United States
21 Attorneys in Illinois.
22 (6) The several State's Attorneys.
23 The Inspector General shall meet on a regular basis with
24 these entities to share information regarding possible
25 misconduct by any persons or entities involved with the
26 public aid programs administered by the Illinois Department
27 of Public Aid.
28 (e) All investigations conducted by the Inspector
29 General shall be conducted in a manner that ensures the
30 preservation of evidence for use in criminal prosecutions.
31 If the Inspector General determines that a possible criminal
32 act relating to fraud in the provision or administration of
33 the medical assistance program has been committed, the
34 Inspector General shall immediately notify the Medicaid Fraud
-61- LRB9001689SMdvam03
1 Control Unit. If the Inspector General determines that a
2 possible criminal act has been committed within the
3 jurisdiction of the Office, the Inspector General may request
4 the special expertise of the Department of State Police. The
5 Inspector General may present for prosecution the findings of
6 any criminal investigation to the Office of the Attorney
7 General, the Offices of the several United State Attorneys in
8 Illinois or the several State's Attorneys.
9 (f) To carry out his or her duties as described in this
10 Section, the Inspector General and his or her designees shall
11 have the power to compel by subpoena the attendance and
12 testimony of witnesses and the production of books,
13 electronic records and papers as directly related to public
14 assistance programs administered by the Illinois Department
15 of Public Aid or the Department of Human Services (as
16 successor to the Department of Public Aid). No medical
17 provider shall be compelled, however, to provide individual
18 medical records of patients who are not clients of the
19 Medical Assistance Program.
20 (g) The Inspector General shall report all convictions,
21 terminations, and suspensions taken against vendors,
22 contractors and medical providers to the Illinois Department
23 of Public Aid and to any agency responsible for licensing or
24 regulating those persons or entities.
25 (h) The Inspector General shall make quarterly reports,
26 findings, and recommendations regarding the Office's
27 investigations into reports of fraud, waste, abuse,
28 mismanagement, or misconduct relating to any public aid
29 programs administered by the Illinois Department of Public
30 Aid or the Department of Human Services (as successor to the
31 Department of Public Aid) to the General Assembly and the
32 Governor. These reports shall include, but not be limited
33 to, the following information:
34 (1) Aggregate provider billing and payment
-62- LRB9001689SMdvam03
1 information, including the number of providers at various
2 Medicaid earning levels.
3 (2) The number of audits of the medical assistance
4 program and the dollar savings resulting from those
5 audits.
6 (3) The number of prescriptions rejected annually
7 under the Illinois Department of Public Aid's Refill Too
8 Soon program and the dollar savings resulting from that
9 program.
10 (4) Provider sanctions, in the aggregate, including
11 terminations and suspensions.
12 (5) A detailed summary of the investigations
13 undertaken in the previous fiscal year. These summaries
14 shall comply with all laws and rules regarding
15 maintaining confidentiality in the public aid programs.
16 (i) Nothing in this Section shall limit investigations
17 by the Illinois Department of Public Aid or the Department of
18 Human Services that may otherwise be required by law or that
19 may be necessary in their capacity as the central
20 administrative authorities responsible for administration of
21 public aid programs in this State.
22 (Source: P.A. 88-554, eff. 7-26-94; 89-507, eff. 7-1-97.)
23 Section 95. No acceleration or delay. Where this Act
24 makes changes in a statute that is represented in this Act by
25 text that is not yet or no longer in effect (for example, a
26 Section represented by multiple versions), the use of that
27 text does not accelerate or delay the taking effect of (i)
28 the changes made by this Act or (ii) provisions derived from
29 any other Public Act.
30 Section 99. Effective date. This Act takes effect upon
31 becoming law.".