Bill Amendment: IL SB0343 | 2015-2016 | 99th General Assembly

NOTE: For additional amemendments please see the Bill Drafting List

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Bill Title: MED ASSIST-COMPLEX MED NEEDS

Status: 2015-10-10 - Pursuant to Senate Rule 3-9(b) / Referred to Assignments [SB0343 Detail]

Download: Illinois-2015-SB0343-Senate_Amendment_002.html

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Sen. Heather A. Steans

Filed: 5/19/2015

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AMENDMENT TO SENATE BILL 343
AMENDMENT NO. ______. Amend Senate Bill 343, AS AMENDED, by
replacing everything after the enacting clause with the
following:
"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

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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%

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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.
(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

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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

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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

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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

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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

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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

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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

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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) As used in this subsection:
"Pediatric care coordination entity" means a collaboration

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of providers and community agencies, governed by a lead entity,
serving primarily persons under the age of 21 which receives a
care coordination payment with a portion of the payment at risk
for meeting quality outcome targets, in order to provide care
coordination services for its enrollees.
"Pediatric care coordination plan" means a pediatric care
coordination entity defined in this subsection or a pediatric
only managed care community network as defined in subsection
(b) of Section 5-11.
"Children with complex medical needs" means persons under
21 years of age who are clients of medical assistance programs
or other health benefit programs administered by the Department
through the use of the 3MTM Clinical Risk Grouping Software
(CRG) as Status 6.1 and above, through a clinical screening
tool, or those who do not have sufficient claims data in order
to be identified by the Department through the CRG software.
Beginning on the effective date of this amendatory Act of
the 99th General Assembly and until April 1, 2016, the
Department, where available, shall offer newly eligible
children with complex medical needs, and currently eligible
children with complex medical needs making their annual health
plan choice, the choice of enrollment in a pediatric care
coordination entity as defined in this subsection. At any time,
the Department may offer, where available, the choice of
enrollment in a pediatric only managed care community network
as defined in subsection (b) of Section 5-11. On and after

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April 1, 2016, the Department shall offer a pediatric care
coordination plan where available but may require the plan to
meet the requirements of subsection (b) of Section 5-11. This
choice shall be in addition to otherwise available health
maintenance organizations (HMOs), managed care community
networks (MCCNs), and accountable care entities (ACEs).
Children with complex medical needs under 18 years of age
shall be eligible to enroll in the pediatric care coordination
plan as long as such children continue to maintain eligibility
for medical assistance programs or other health benefit
programs administered by the Department. The Department may
choose to extend enrollment to individuals under 21 years of
age for initial enrollment. Individuals may also be excluded if
they are:
(1) enrolled in the Medically Fragile Technology
Dependent Waiver;
(2) receiving private duty nursing;
(3) eligible for high third party liability coverage as
defined by the Department;
(4) residing in institutions including pediatric
skilled nursing facilities;
(5) enrolled in the DSCC Core Program; or
(6) placed in foster care with the Department of
Children and Family Services.
The Department shall ensure that the parents of all
eligible enrollees that are children with complex medical needs

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shall receive notification of their eligibility and an
explanation of how to elect the pediatric care coordination
plan option. The Department shall ensure that any third party
enrollment broker is briefed on the pediatric care coordination
plan option and that the broker shall ensure that all
enrollment options are presented to the parents of children
with complex medical needs.
(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13;
98-651, eff. 6-16-14.)
Section 99. Effective date. This Act takes effect upon
becoming law.".