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Public Act 099-0181 | ||||
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AN ACT concerning public aid.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Illinois Public Aid Code is amended by | ||||
changing Section 5-30 as follows: | ||||
(305 ILCS 5/5-30) | ||||
Sec. 5-30. Care coordination. | ||||
(a) At least 50% of recipients eligible for comprehensive | ||||
medical benefits in all medical assistance programs or other | ||||
health benefit programs administered by the Department, | ||||
including the Children's Health Insurance Program Act and the | ||||
Covering ALL KIDS Health Insurance Act, shall be enrolled in a | ||||
care coordination program by no later than January 1, 2015. For | ||||
purposes of this Section, "coordinated care" or "care | ||||
coordination" means delivery systems where recipients will | ||||
receive their care from providers who participate under | ||||
contract in integrated delivery systems that are responsible | ||||
for providing or arranging the majority of care, including | ||||
primary care physician services, referrals from primary care | ||||
physicians, diagnostic and treatment services, behavioral | ||||
health services, in-patient and outpatient hospital services, | ||||
dental services, and rehabilitation and long-term care | ||||
services. The Department shall designate or contract for such |
integrated delivery systems (i) to ensure enrollees have a | ||
choice of systems and of primary care providers within such | ||
systems; (ii) to ensure that enrollees receive quality care in | ||
a culturally and linguistically appropriate manner; and (iii) | ||
to ensure that coordinated care programs meet the diverse needs | ||
of enrollees with developmental, mental health, physical, and | ||
age-related disabilities. | ||
(b) Payment for such coordinated care shall be based on | ||
arrangements where the State pays for performance related to | ||
health care outcomes, the use of evidence-based practices, the | ||
use of primary care delivered through comprehensive medical | ||
homes, the use of electronic medical records, and the | ||
appropriate exchange of health information electronically made | ||
either on a capitated basis in which a fixed monthly premium | ||
per recipient is paid and full financial risk is assumed for | ||
the delivery of services, or through other risk-based payment | ||
arrangements. | ||
(c) To qualify for compliance with this Section, the 50% | ||
goal shall be achieved by enrolling medical assistance | ||
enrollees from each medical assistance enrollment category, | ||
including parents, children, seniors, and people with | ||
disabilities to the extent that current State Medicaid payment | ||
laws would not limit federal matching funds for recipients in | ||
care coordination programs. In addition, services must be more | ||
comprehensively defined and more risk shall be assumed than in | ||
the Department's primary care case management program as of the |
effective date of this amendatory Act of the 96th General | ||
Assembly. | ||
(d) The Department shall report to the General Assembly in | ||
a separate part of its annual medical assistance program | ||
report, beginning April, 2012 until April, 2016, on the | ||
progress and implementation of the care coordination program | ||
initiatives established by the provisions of this amendatory | ||
Act of the 96th General Assembly. The Department shall include | ||
in its April 2011 report a full analysis of federal laws or | ||
regulations regarding upper payment limitations to providers | ||
and the necessary revisions or adjustments in rate | ||
methodologies and payments to providers under this Code that | ||
would be necessary to implement coordinated care with full | ||
financial risk by a party other than the Department.
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(e) Integrated Care Program for individuals with chronic | ||
mental health conditions. | ||
(1) The Integrated Care Program shall encompass | ||
services administered to recipients of medical assistance | ||
under this Article to prevent exacerbations and | ||
complications using cost-effective, evidence-based | ||
practice guidelines and mental health management | ||
strategies. | ||
(2) The Department may utilize and expand upon existing | ||
contractual arrangements with integrated care plans under | ||
the Integrated Care Program for providing the coordinated | ||
care provisions of this Section. |
(3) Payment for such coordinated care shall be based on | ||
arrangements where the State pays for performance related | ||
to mental health outcomes on a capitated basis in which a | ||
fixed monthly premium per recipient is paid and full | ||
financial risk is assumed for the delivery of services, or | ||
through other risk-based payment arrangements such as | ||
provider-based care coordination. | ||
(4) The Department shall examine whether chronic | ||
mental health management programs and services for | ||
recipients with specific chronic mental health conditions | ||
do any or all of the following: | ||
(A) Improve the patient's overall mental health in | ||
a more expeditious and cost-effective manner. | ||
(B) Lower costs in other aspects of the medical | ||
assistance program, such as hospital admissions, | ||
emergency room visits, or more frequent and | ||
inappropriate psychotropic drug use. | ||
(5) The Department shall work with the facilities and | ||
any integrated care plan participating in the program to | ||
identify and correct barriers to the successful | ||
implementation of this subsection (e) prior to and during | ||
the implementation to best facilitate the goals and | ||
objectives of this subsection (e). | ||
(f) A hospital that is located in a county of the State in | ||
which the Department mandates some or all of the beneficiaries | ||
of the Medical Assistance Program residing in the county to |
enroll in a Care Coordination Program, as set forth in Section | ||
5-30 of this Code, shall not be eligible for any non-claims | ||
based payments not mandated by Article V-A of this Code for | ||
which it would otherwise be qualified to receive, unless the | ||
hospital is a Coordinated Care Participating Hospital no later | ||
than 60 days after the effective date of this amendatory Act of | ||
the 97th General Assembly or 60 days after the first mandatory | ||
enrollment of a beneficiary in a Coordinated Care program. For | ||
purposes of this subsection, "Coordinated Care Participating | ||
Hospital" means a hospital that meets one of the following | ||
criteria: | ||
(1) The hospital has entered into a contract to provide | ||
hospital services with one or more MCOs to enrollees of the | ||
care coordination program. | ||
(2) The hospital has not been offered a contract by a | ||
care coordination plan that the Department has determined | ||
to be a good faith offer and that pays at least as much as | ||
the Department would pay, on a fee-for-service basis, not | ||
including disproportionate share hospital adjustment | ||
payments or any other supplemental adjustment or add-on | ||
payment to the base fee-for-service rate, except to the | ||
extent such adjustments or add-on payments are | ||
incorporated into the development of the applicable MCO | ||
capitated rates. | ||
As used in this subsection (f), "MCO" means any entity | ||
which contracts with the Department to provide services where |
payment for medical services is made on a capitated basis. | ||
(g) No later than August 1, 2013, the Department shall | ||
issue a purchase of care solicitation for Accountable Care | ||
Entities (ACE) to serve any children and parents or caretaker | ||
relatives of children eligible for medical assistance under | ||
this Article. An ACE may be a single corporate structure or a | ||
network of providers organized through contractual | ||
relationships with a single corporate entity. The solicitation | ||
shall require that: | ||
(1) An ACE operating in Cook County be capable of | ||
serving at least 40,000 eligible individuals in that | ||
county; an ACE operating in Lake, Kane, DuPage, or Will | ||
Counties be capable of serving at least 20,000 eligible | ||
individuals in those counties and an ACE operating in other | ||
regions of the State be capable of serving at least 10,000 | ||
eligible individuals in the region in which it operates. | ||
During initial periods of mandatory enrollment, the | ||
Department shall require its enrollment services | ||
contractor to use a default assignment algorithm that | ||
ensures if possible an ACE reaches the minimum enrollment | ||
levels set forth in this paragraph. | ||
(2) An ACE must include at a minimum the following | ||
types of providers: primary care, specialty care, | ||
hospitals, and behavioral healthcare. | ||
(3) An ACE shall have a governance structure that | ||
includes the major components of the health care delivery |
system, including one representative from each of the | ||
groups listed in paragraph (2). | ||
(4) An ACE must be an integrated delivery system, | ||
including a network able to provide the full range of | ||
services needed by Medicaid beneficiaries and system | ||
capacity to securely pass clinical information across | ||
participating entities and to aggregate and analyze that | ||
data in order to coordinate care. | ||
(5) An ACE must be capable of providing both care | ||
coordination and complex case management, as necessary, to | ||
beneficiaries. To be responsive to the solicitation, a | ||
potential ACE must outline its care coordination and | ||
complex case management model and plan to reduce the cost | ||
of care. | ||
(6) In the first 18 months of operation, unless the ACE | ||
selects a shorter period, an ACE shall be paid care | ||
coordination fees on a per member per month basis that are | ||
projected to be cost neutral to the State during the term | ||
of their payment and, subject to federal approval, be | ||
eligible to share in additional savings generated by their | ||
care coordination. | ||
(7) In months 19 through 36 of operation, unless the | ||
ACE selects a shorter period, an ACE shall be paid on a | ||
pre-paid capitation basis for all medical assistance | ||
covered services, under contract terms similar to Managed | ||
Care Organizations (MCO), with the Department sharing the |
risk through either stop-loss insurance for extremely high | ||
cost individuals or corridors of shared risk based on the | ||
overall cost of the total enrollment in the ACE. The ACE | ||
shall be responsible for claims processing, encounter data | ||
submission, utilization control, and quality assurance. | ||
(8) In the fourth and subsequent years of operation, an | ||
ACE shall convert to a Managed Care Community Network | ||
(MCCN), as defined in this Article, or Health Maintenance | ||
Organization pursuant to the Illinois Insurance Code, | ||
accepting full-risk capitation payments. | ||
The Department shall allow potential ACE entities 5 months | ||
from the date of the posting of the solicitation to submit | ||
proposals. After the solicitation is released, in addition to | ||
the MCO rate development data available on the Department's | ||
website, subject to federal and State confidentiality and | ||
privacy laws and regulations, the Department shall provide 2 | ||
years of de-identified summary service data on the targeted | ||
population, split between children and adults, showing the | ||
historical type and volume of services received and the cost of | ||
those services to those potential bidders that sign a data use | ||
agreement. The Department may add up to 2 non-state government | ||
employees with expertise in creating integrated delivery | ||
systems to its review team for the purchase of care | ||
solicitation described in this subsection. Any such | ||
individuals must sign a no-conflict disclosure and | ||
confidentiality agreement and agree to act in accordance with |
all applicable State laws. | ||
During the first 2 years of an ACE's operation, the | ||
Department shall provide claims data to the ACE on its | ||
enrollees on a periodic basis no less frequently than monthly. | ||
Nothing in this subsection shall be construed to limit the | ||
Department's mandate to enroll 50% of its beneficiaries into | ||
care coordination systems by January 1, 2015, using all | ||
available care coordination delivery systems, including Care | ||
Coordination Entities (CCE), MCCNs, or MCOs, nor be construed | ||
to affect the current CCEs, MCCNs, and MCOs selected to serve | ||
seniors and persons with disabilities prior to that date. | ||
Nothing in this subsection precludes the Department from | ||
considering future proposals for new ACEs or expansion of | ||
existing ACEs at the discretion of the Department. | ||
(h) Department contracts with MCOs and other entities | ||
reimbursed by risk based capitation shall have a minimum | ||
medical loss ratio of 85%, shall require the entity to | ||
establish an appeals and grievances process for consumers and | ||
providers, and shall require the entity to provide a quality | ||
assurance and utilization review program. Entities contracted | ||
with the Department to coordinate healthcare regardless of risk | ||
shall be measured utilizing the same quality metrics. The | ||
quality metrics may be population specific. Any contracted | ||
entity serving at least 5,000 seniors or people with | ||
disabilities or 15,000 individuals in other populations | ||
covered by the Medical Assistance Program that has been |
receiving full-risk capitation for a year shall be accredited | ||
by a national accreditation organization authorized by the | ||
Department within 2 years after the date it is eligible to | ||
become accredited. The requirements of this subsection shall | ||
apply to contracts with MCOs entered into or renewed or | ||
extended after June 1, 2013. | ||
(h-5) The Department shall monitor and enforce compliance | ||
by MCOs with agreements they have entered into with providers | ||
on issues that include, but are not limited to, timeliness of | ||
payment, payment rates, and processes for obtaining prior | ||
approval. The Department may impose sanctions on MCOs for | ||
violating provisions of those agreements that include, but are | ||
not limited to, financial penalties, suspension of enrollment | ||
of new enrollees, and termination of the MCO's contract with | ||
the Department. As used in this subsection (h-5), "MCO" has the | ||
meaning ascribed to that term in Section 5-30.1 of this Code. | ||
(i) Unless otherwise required by federal law, Medicaid | ||
Managed Care Entities shall not divulge, directly or | ||
indirectly, including by sending a bill or explanation of | ||
benefits, information concerning the sensitive health services | ||
received by enrollees of the Medicaid Managed Care Entity to | ||
any person other than providers and care coordinators caring | ||
for the enrollee and employees of the entity in the course of | ||
the entity's internal operations. The Medicaid Managed Care | ||
Entity may divulge information concerning the sensitive health | ||
services if the enrollee who received the sensitive health |
services requests the information from the Medicaid Managed | ||
Care Entity and authorized the sending of a bill or explanation | ||
of benefits. Communications including, but not limited to, | ||
statements of care received or appointment reminders either | ||
directly or indirectly to the enrollee from the health care | ||
provider, health care professional, and care coordinators, | ||
remain permissible. | ||
For the purposes of this subsection, the term "Medicaid | ||
Managed Care Entity" includes Care Coordination Entities, | ||
Accountable Care Entities, Managed Care Organizations, and | ||
Managed Care Community Networks. | ||
For purposes of this subsection, the term "sensitive health | ||
services" means mental health services, substance abuse | ||
treatment services, reproductive health services, family | ||
planning services, services for sexually transmitted | ||
infections and sexually transmitted diseases, and services for | ||
sexual assault or domestic abuse. Services include prevention, | ||
screening, consultation, examination, treatment, or follow-up. | ||
Nothing in this subsection shall be construed to relieve a | ||
Medicaid Managed Care Entity or the Department of any duty to | ||
report incidents of sexually transmitted infections to the | ||
Department of Public Health or to the local board of health in | ||
accordance with regulations adopted under a statute or | ||
ordinance or to report incidents of sexually transmitted | ||
infections as necessary to comply with the requirements under | ||
Section 5 of the Abused and Neglected Child Reporting Act or as |
otherwise required by State or federal law. | ||
The Department shall create policy in order to implement | ||
the requirements in this subsection. | ||
(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13; | ||
98-651, eff. 6-16-14.)
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Section 99. Effective date. This Act takes effect upon | ||
becoming law.
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