State of Illinois
92nd General Assembly
Legislation

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[ Introduced ][ Enrolled ][ House Amendment 001 ]


92_SB0873eng

 
SB873 Engrossed                                LRB9201523DJgc

 1        AN ACT in relation to public aid.

 2        Be it enacted by the People of  the  State  of  Illinois,
 3    represented in the General Assembly:

 4        Section  5.  The  Illinois  Public Aid Code is amended by
 5    changing Section 5-11 as follows:

 6        (305 ILCS 5/5-11) (from Ch. 23, par. 5-11)
 7        Sec.  5-11.  Co-operative  arrangements;  contracts  with
 8    other  State  agencies,  health   care   and   rehabilitation
 9    organizations, and fiscal intermediaries.
10        (a)  The  Illinois Department may enter into co-operative
11    arrangements   with   State    agencies    responsible    for
12    administering  or  supervising  the  administration of health
13    services and vocational rehabilitation services  to  the  end
14    that there may be maximum utilization of such services in the
15    provision of medical assistance.
16        The  Illinois  Department  shall, not later than June 30,
17    1993, enter into one or more co-operative  arrangements  with
18    the   Department   of   Mental   Health   and   Developmental
19    Disabilities  providing  that the Department of Mental Health
20    and  Developmental  Disabilities  will  be  responsible   for
21    administering  or  supervising  all  programs for services to
22    persons  in  community  care  facilities  for  persons   with
23    developmental  disabilities,  including  but  not  limited to
24    intermediate care facilities, that  are  supported  by  State
25    funds  or  by  funding  under Title XIX of the federal Social
26    Security Act.  The  responsibilities  of  the  Department  of
27    Mental  Health  and  Developmental  Disabilities  under these
28    agreements  are  transferred  to  the  Department  of   Human
29    Services as provided in the Department of Human Services Act.
30        The  Department  may also contract with such State health
31    and rehabilitation  agencies  and  other  public  or  private
 
SB873 Engrossed             -2-                LRB9201523DJgc
 1    health care and rehabilitation organizations to act for it in
 2    supplying  designated  medical  services  to persons eligible
 3    therefor  under  this  Article.  Any  contracts  with  health
 4    services  or  health  maintenance  organizations   shall   be
 5    restricted  to  organizations  which  have  been certified as
 6    being in compliance with standards  promulgated  pursuant  to
 7    the  laws  of  this  State  governing  the  establishment and
 8    operation  of   health   services   or   health   maintenance
 9    organizations.   The   Department   may  also  contract  with
10    insurance companies or other corporate  entities  serving  as
11    fiscal   intermediaries   in   this  State  for  the  Federal
12    Government in respect to Medicare payments under Title  XVIII
13    of  the Federal Social Security Act to act for the Department
14    in paying medical care suppliers.  The provisions of  Section
15    9 of "An Act in relation to State finance", approved June 10,
16    1919,  as amended, notwithstanding, such contracts with State
17    agencies, other health care and rehabilitation organizations,
18    or fiscal intermediaries may provide for advance payments.
19        (b)  For purposes of this subsection (b),  "managed  care
20    community  network"  means  an  entity,  other  than a health
21    maintenance  organization,  that  is  owned,   operated,   or
22    governed  by  providers  of  health care services within this
23    State and that provides or arranges primary,  secondary,  and
24    tertiary managed health care services under contract with the
25    Illinois  Department  exclusively to persons participating in
26    programs administered by the Illinois Department.
27        The  Illinois  Department  may   certify   managed   care
28    community networks, including managed care community networks
29    owned, operated, managed, or governed by State-funded medical
30    schools,  as  risk-bearing entities eligible to contract with
31    the   Illinois   Department   as   Medicaid   managed    care
32    organizations.   The  Illinois  Department  may contract with
33    those managed care community networks to furnish health  care
34    services   to  or  arrange  those  services  for  individuals
 
SB873 Engrossed             -3-                LRB9201523DJgc
 1    participating  in  programs  administered  by  the   Illinois
 2    Department.    The   rates   for   those   provider-sponsored
 3    organizations  may  be  determined  on  a  prepaid, capitated
 4    basis.  A  managed  care  community  network  may  choose  to
 5    contract   with  the  Illinois  Department  to  provide  only
 6    pediatric health care services. The Illinois Department shall
 7    by rule adopt the  criteria,  standards,  and  procedures  by
 8    which  a  managed  care community network may be permitted to
 9    contract with the Illinois Department and shall consult  with
10    the Department of Insurance in adopting these rules.
11        A county provider as defined in Section 15-1 of this Code
12    may contract with the Illinois Department to provide primary,
13    secondary,  or  tertiary  managed  health  care services as a
14    managed care community network without the need to  establish
15    a  separate  entity  and  shall  be  deemed  a  managed  care
16    community  network  for  purposes  of  this  Code only to the
17    extent it provides services to participating individuals.   A
18    county  provider  is  entitled  to contract with the Illinois
19    Department with respect to any contracting region located  in
20    whole or in part within the county.  A county provider is not
21    required  to  accept  enrollees  who do not reside within the
22    county.
23        In order to (i) accelerate and facilitate the development
24    of  integrated  health  care  in  contracting  areas  outside
25    counties with populations in excess of 3,000,000 and counties
26    adjacent to those counties and (ii) maintain and sustain  the
27    high  quality of education and residency programs coordinated
28    and  associated  with  local  area  hospitals,  the  Illinois
29    Department may develop and implement a demonstration  program
30    from   managed   care  community  networks  owned,  operated,
31    managed, or governed by State-funded  medical  schools.   The
32    Illinois  Department  shall  prescribe  by rule the criteria,
33    standards, and procedures for  effecting  this  demonstration
34    program.
 
SB873 Engrossed             -4-                LRB9201523DJgc
 1        A  managed care community network that contracts with the
 2    Illinois Department to furnish health  care  services  to  or
 3    arrange   those   services  for  enrollees  participating  in
 4    programs administered by the Illinois Department shall do all
 5    of the following:
 6             (1)  Provide that any provider affiliated  with  the
 7        managed  care community network may also provide services
 8        on a fee-for-service basis to Illinois Department clients
 9        not enrolled in such managed care entities.
10             (2)  Provide client education services as determined
11        and approved by the Illinois  Department,  including  but
12        not   limited  to  (i)  education  regarding  appropriate
13        utilization of health care services  in  a  managed  care
14        system, (ii) written disclosure of treatment policies and
15        restrictions   or   limitations   on   health   services,
16        including,   but   not  limited  to,  physical  services,
17        clinical  laboratory   tests,   hospital   and   surgical
18        procedures,   prescription   drugs   and  biologics,  and
19        radiological examinations, and (iii) written notice  that
20        the  enrollee  may  receive  from  another provider those
21        covered services that are not  provided  by  the  managed
22        care community network.
23             (3)  Provide  that  enrollees  within the system may
24        choose the site for provision of services and  the  panel
25        of health care providers.
26             (4)  Not discriminate in enrollment or disenrollment
27        practices   among   recipients  of  medical  services  or
28        enrollees based on health status.
29             (5)  Provide a  quality  assurance  and  utilization
30        review program that meets the requirements established by
31        the  Illinois  Department in rules that incorporate those
32        standards   set   forth   in   the   Health   Maintenance
33        Organization Act.
34             (6)  Issue  a   managed   care   community   network
 
SB873 Engrossed             -5-                LRB9201523DJgc
 1        identification  card  to  each  enrollee upon enrollment.
 2        The card must contain all of the following:
 3                  (A)  The enrollee's health plan.
 4                  (B)  The  name  and  telephone  number  of  the
 5             enrollee's primary care physician or  the  site  for
 6             receiving primary care services.
 7                  (C)  A  telephone  number to be used to confirm
 8             eligibility  for  benefits  and  authorization   for
 9             services  that is available 24 hours per day, 7 days
10             per week.
11             (7)  Ensure that every primary  care  physician  and
12        pharmacy  in the managed care community network meets the
13        standards established  by  the  Illinois  Department  for
14        accessibility   and   quality  of  care.    The  Illinois
15        Department shall arrange for and oversee an evaluation of
16        the standards established under this  paragraph  (7)  and
17        may recommend any necessary changes to these standards.
18             (8)  Provide  a  procedure  for  handling complaints
19        that meets the requirements established by  the  Illinois
20        Department  in rules that incorporate those standards set
21        forth in the Health Maintenance Organization Act.
22             (9)  Maintain, retain, and  make  available  to  the
23        Illinois  Department records, data, and information, in a
24        uniform manner determined  by  the  Illinois  Department,
25        sufficient   for   the  Illinois  Department  to  monitor
26        utilization, accessibility, and quality of care.
27             (10)  Provide that the pharmacy  formulary  used  by
28        the  managed  care  community  network  and  its contract
29        providers  be  no  more  restrictive  than  the  Illinois
30        Department's pharmaceutical program on the effective date
31        of this amendatory Act of 1998 and as amended after  that
32        date.
33        The  Illinois Department shall contract with an entity or
34    entities to provide  external  peer-based  quality  assurance
 
SB873 Engrossed             -6-                LRB9201523DJgc
 1    review  for  the managed health care programs administered by
 2    the Illinois Department.  The entity shall be  representative
 3    of  Illinois  physicians licensed to practice medicine in all
 4    its branches and have statewide geographic representation  in
 5    all specialities of medical care that are provided in managed
 6    health care programs administered by the Illinois Department.
 7    The  entity may not be a third party payer and shall maintain
 8    offices in locations around the State  in  order  to  provide
 9    service   and   continuing  medical  education  to  physician
10    participants  within  those  managed  health  care   programs
11    administered  by the Illinois Department.  The review process
12    shall be  developed  and  conducted  by  Illinois  physicians
13    licensed  to  practice  medicine  in  all  its  branches.  In
14    consultation with the entity,  the  Illinois  Department  may
15    contract  with  other  entities  for  professional peer-based
16    quality assurance review of individual categories of services
17    other than services provided, supervised, or  coordinated  by
18    physicians licensed to practice medicine in all its branches.
19    The Illinois Department shall establish, by rule, criteria to
20    avoid  conflicts  of  interest  in  the  conduct  of  quality
21    assurance activities consistent with professional peer-review
22    standards.    All   quality  assurance  activities  shall  be
23    coordinated by the Illinois Department.
24        Each managed care community network must demonstrate  its
25    ability  to  bear  the  financial risk of serving individuals
26    under this program. The Illinois  Department  shall  by  rule
27    adopt  standards  for  assessing  the  solvency and financial
28    soundness  of  each  managed  care  community  network.   Any
29    solvency  and  financial  standards  adopted for managed care
30    community networks shall be  no  more  restrictive  than  the
31    solvency   and  financial  standards  adopted  under  Section
32    1856(a) of the Social  Security  Act  for  provider-sponsored
33    organizations  under  Part  C  of  Title  XVIII of the Social
34    Security Act.
 
SB873 Engrossed             -7-                LRB9201523DJgc
 1        The Illinois  Department  may  implement  the  amendatory
 2    changes  to  this  Code  made  by this amendatory Act of 1998
 3    through the use of emergency rules in accordance with Section
 4    5-45 of  the  Illinois  Administrative  Procedure  Act.   For
 5    purposes  of  that  Act,  the  adoption of rules to implement
 6    these changes is deemed an emergency and  necessary  for  the
 7    public interest, safety, and welfare.
 8        (c)  Not   later   than   June  30,  1996,  the  Illinois
 9    Department  shall  enter  into  one   or   more   cooperative
10    arrangements  with  the  Department  of Public Health for the
11    purpose of developing a single survey for nursing facilities,
12    including but not limited to facilities  funded  under  Title
13    XVIII  or  Title  XIX  of  the federal Social Security Act or
14    both, which shall be administered and conducted solely by the
15    Department of Public Health. The Departments shall  test  the
16    single  survey  process  on  a  pilot  basis,  with  both the
17    Departments of Public Aid and Public  Health  represented  on
18    the consolidated survey team.  The pilot will sunset June 30,
19    1997.   After  June  30, 1997, unless otherwise determined by
20    the Governor, a single survey shall  be  implemented  by  the
21    Department  of  Public  Health which would not preclude staff
22    from the Department of  Public  Aid  from  going  on-site  to
23    nursing  facilities  to  perform necessary audits and reviews
24    which shall not replicate  the  single  State  agency  survey
25    required  by  this  Act.   This  Section  shall  not apply to
26    community or intermediate care facilities  for  persons  with
27    developmental disabilities.
28        (d)  Nothing  in this Code in any way limits or otherwise
29    impairs the authority or power of the Illinois Department  to
30    enter  into  a  negotiated  contract pursuant to this Section
31    with a managed health care entity (including, but not limited
32    to, a health  maintenance  organization)  that  provides  for
33    termination or nonrenewal of the contract without cause, upon
34    notice as provided in the contract, and without a hearing.
 
SB873 Engrossed             -8-                LRB9201523DJgc
 1    (Source: P.A.  89-415,  eff.  1-1-96;  89-507,  eff.  7-1-97;
 2    90-618, eff. 7-10-98.)

 3        (305 ILCS 5/5-16.3 rep.)
 4        Section  6.  The  Illinois  Public Aid Code is amended by
 5    repealing Section 5-16.3.

 6        Section 99.  Effective date.  This Act takes effect  upon
 7    becoming law.

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