Bill Text: IL HB3189 | 2013-2014 | 98th General Assembly | Introduced

---

Bill Title: Creates the Patient-Centered Medicaid Reform Act. Provides that the Medicaid Managed Care Program is established as a statewide, integrated managed care program for all covered services, including long-term care services. Requires the Department of Healthcare and Family Services to apply for and implement appropriate amendments to the Illinois Title XIX State Plan and waivers of applicable federal laws and regulations necessary to implement the program and that before submitting the waiver or State Plan amendment, the Department shall provide public notice and the opportunity for public comment and shall include public feedback to the U.S. Department of Health and Human Services. Provides that services provided under the Medicaid Managed Care Program shall be provided by managed care plans that are capable of coordinating or delivering all covered services to enrollees. Requires the Department to select managed care plans to participate in the Medicaid Managed Care Program using invitations to negotiate. Contains provisions concerning the quality factor the Department must consider when selecting manage care plans; plan accountability; managed care payments; enrollment, choice counseling, and opt-out standards; mandatory, exempt, and voluntary populations standards; services covered by the managed plans; the implementation of a Medicaid Long-Term Care Managed Care Program; eligibility criteria for the Medicaid Long-Term Care Managed Care Program; and other matters. Effective immediately.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Failed) 2014-12-03 - Session Sine Die [HB3189 Detail]

Download: Illinois-2013-HB3189-Introduced.html

---

98TH GENERAL ASSEMBLY State of Illinois 2013 and 2014 HB3189 Introduced , by Rep. Patricia R. Bellock SYNOPSIS AS INTRODUCED:
New Act
Creates the Patient-Centered Medicaid Reform Act. Provides that the Medicaid Managed Care Program is established as a statewide, integrated managed care program for all covered services, including long-term care services. Requires the Department of Healthcare and Family Services to apply for and implement appropriate amendments to the Illinois Title XIX State Plan and waivers of applicable federal laws and regulations necessary to implement the program and that before submitting the waiver or State Plan amendment, the Department shall provide public notice and the opportunity for public comment and shall include public feedback to the U.S. Department of Health and Human Services. Provides that services provided under the Medicaid Managed Care Program shall be provided by managed care plans that are capable of coordinating or delivering all covered services to enrollees. Requires the Department to select managed care plans to participate in the Medicaid Managed Care Program using invitations to negotiate. Contains provisions concerning the quality factor the Department must consider when selecting manage care plans; plan accountability; managed care payments; enrollment, choice counseling, and opt-out standards; mandatory, exempt, and voluntary populations standards; services covered by the managed plans; the implementation of a Medicaid Long-Term Care Managed Care Program; eligibility criteria for the Medicaid Long-Term Care Managed Care Program; and other matters. Effective immediately.
LRB098 08448 KTG 38555 b
FISCAL NOTE ACT MAY APPLY
A BILL FOR
HB3189 LRB098 08448 KTG 38555 b
AN ACT concerning public aid.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 1. Short title. This Act may be cited as the
Patient-Centered Medicaid Reform Act.
Section 5. Definitions. As used in this Act:
(a) "Department" means the Department of Healthcare and
Family Services or any State department which may administer in
the future the Medicaid Managed Care Program established under
this Act.
(b) "Managed care plan" means a health insurer, a specialty
plan, a health maintenance organization authorized under the
Illinois Insurance Code, or a Medicaid-authorized provider
service network under contract with the Department to provide
services to clients eligible for medical assistance under the
State's Medical Assistance Program established under Article V
of the Illinois Public Aid Code.
(c) "Medicaid" means the medical assistance program
authorized by Title XIX of the Social Security Act, and
regulations thereunder, as administered in this State by the
Department of Healthcare and Family Services.
(d) "Medicaid recipient" or "recipient" means an
individual who receives medical assistance as provided under

HB3189 - 2 - LRB098 08448 KTG 38555 b
Article V of the Illinois Public Aid Code.
(e) "Prepaid plan" means a managed care plan that is
licensed or certified as a risk-bearing entity or is an
approved provider service network, and is paid a prospective
per-member, per-month payment by the Department.
(f) "Provider service network" means a Department-approved
entity, a controlling interest of which is owned by a health
care provider, or by a group of affiliated providers, or by a
public agency or entity that delivers health services. Health
care providers include State-licensed health care
professionals or licensed health care facilities, federally
qualified health care centers, and home health care agencies.
(g) "Specialty plan" means a managed care plan that serves
Medicaid recipients who meet specified criteria based on age,
medical condition, or diagnosis.
(h) "Comprehensive long-term care plan" means a managed
care plan, provider-sponsored organization, health maintenance
organization, or coordinated care plan that provides long-term
care services as outlined in this Act.
(i) "Long-term care plan" means a managed care plan that
provides the services described in Section 60 of this Act for
the Medicaid Long-Term Care Managed Care Program established
under this Act.
(j) "Long-term care provider service network" means a
provider service network, a controlling interest of which is
owned by one or more licensed nursing homes, assisted living

HB3189 - 3 - LRB098 08448 KTG 38555 b
facilities with 17 or more beds, home health agencies,
community care for the elderly lead agencies, or hospices.
Section 10. Authorization for Medicaid waiver or amendment
to the Medicaid State Plan. The Medicaid Managed Care Program
is established as a statewide, integrated managed care program
for all covered services, including long-term care services.
The Department shall apply for and implement appropriate
amendments to the Illinois Title XIX State Plan and waivers of
applicable federal laws and regulations necessary to implement
the program. Before submitting the waiver or State Plan
amendment, the Department shall provide public notice and the
opportunity for public comment and shall include public
feedback to the U.S. Department of Health and Human Services.
Section 15. Criteria for managed care plans.
(a) Services provided under the Medicaid Managed Care
Program shall be provided by managed care plans that are
capable of coordinating or delivering all covered services to
enrollees.
(b) The Department shall select managed care plans to
participate in the Medicaid Managed Care Program using
invitations to negotiate. The procurement method must give the
State the most flexibility and broadest power to negotiate
value and must provide potential bidders the most room to
innovate. Separate and simultaneous procurements shall be

HB3189 - 4 - LRB098 08448 KTG 38555 b
conducted in regions to be determined by the Department.
(c) The Department shall consider quality factors in the
selection of managed care plans, including all of the
following:
(1) Accreditation by a nationally recognized
accrediting body.
(2) Documentation of policies and procedures for
preventing fraud and abuse.
(3) Experience serving and achieving quality standards
for similar populations.
(4) The availability or accessibility of primary and
specialty care physicians in the network.
(5) The provision of additional benefits, particularly
dental care and disease management, and other initiatives
that improve health outcomes.
(d) After negotiations are conducted, the Department shall
select the managed care plans that are determined to be
responsive and provide the best value to the State. Preference
shall be given to plans that have signed contracts with primary
and specialty physicians in sufficient numbers to meet the
specific standards established pursuant to this Act.
(e) To ensure managed care plan participation in all
regions, the Department shall award an additional contract in a
more populous region to each plan with a contract award in a
more rural region. If a plan terminates its contract in a more
rural region, the additional contract in the more populous

HB3189 - 5 - LRB098 08448 KTG 38555 b
region shall be automatically terminated within 180 days. The
plan must also reimburse the Department for the cost of
enrollment changes and other transition activities.
(f) The Department may not execute contracts with managed
care plans at payment rates not supported by appropriations
made to the Department for these purposes.
Section 20. Selection of managed care plans.
(a) The Department shall select managed care plans through
the procurement process described in this Act. The Department
shall notice invitations to negotiate no later than June 30,
2014. The Department shall procure at least 3 plans and no more
than 11 plans for each region. At least one plan in each region
must be a provider service network.
(b) Participation by specialty plans shall be subject to
the procurement requirements in this Act. The enrollment of a
specialty plan in a region may not exceed 10% of the total
number of enrollees of that region. However, a specialty plan
whose target population includes no more than 10% of the
enrollees of that region shall not be subject to the regional
plan number limits under this Section.
(c) Participation by a Medicare Advantage Preferred
Provider Organization, a Medicare Advantage Provider-Sponsored
Organization, a Medicare Advantage Health Maintenance
Organization, a Medicare Advantage Coordinated Care Plan, or a
Medicare Advantage Special Needs Plan shall not be subject to

HB3189 - 6 - LRB098 08448 KTG 38555 b
the procurement requirements under this Section if the plan's
Medicaid enrollees consist exclusively of dually eligible
recipients who are enrolled in the plan in order to receive
Medicare benefits.
Section 25. Plan accountability.
(a) The Department shall establish a 5-year contract with
each managed care plan selected through the procurement process
described in this Act. A plan contract may not be renewed.
However, the Department may extend the term of a plan contract
to cover any delays during the transition to a new plan.
(b) The Department shall establish such contract
requirements as are necessary for the operation of the
statewide Medicaid Managed Care Program. In addition to any
other provisions the Department may deem necessary, the
contract must require all of the following:
(1) Physician compensation: Managed care plans are
expected to coordinate care, manage chronic disease, and
prevent the need for more costly services. Effective care
management should enable plans to redirect available
resources and increase compensation for physicians.
(2) Hospital compensation: Managed care plans and
hospitals shall negotiate mutually acceptable rates,
methods, and terms of payment. Payment rates may be updated
periodically.
(3) Access:

HB3189 - 7 - LRB098 08448 KTG 38555 b
(A) The Department shall establish specific,
population-based standards for the number, type, and
regional distribution of providers in managed care
plan networks to ensure access to care for both adults
and children. Consistent with standards established by
the Department, provider networks may include
providers located outside the region. Plans may limit
the providers in their networks based on credentials,
quality indicators, and price.
(B) Each plan shall establish and maintain an
accurate and complete electronic database of
contracted providers, including information about
licensure or registration, locations and hours of
operation, or specialty credentials and other
certifications. The database must be available online
to both the Department and the public and have the
capability to compare the availability of providers to
network adequacy standards and to accept and display
feedback from each provider's patients.
(C) Each managed care plan must publish any
prescribed drug formulary or preferred drug list on the
plan's website in a manner that is accessible to and
searchable by enrollees and providers. The plan must
update the list within 24 hours after making a change.
Each plan must ensure that the prior authorization
process for prescribed drugs is readily accessible to

HB3189 - 8 - LRB098 08448 KTG 38555 b
health care providers, including posting appropriate
contact information on its website and providing
timely responses to providers.
(4) Encounter data: The Department shall maintain and
operate a Medicaid encounter data system to collect,
process, store, and report on covered services provided to
all Medicaid recipients enrolled in prepaid plans. The
Department shall make encounter data available to those
plans accepting enrollees who are assigned to them from
other plans leaving a region.
(5) Continuous improvement: The Department shall
establish specific performance standards and expected
milestones or timelines for improving performance over the
term of the contract.
(A) Each managed care plan shall establish an
internal health care quality improvement system,
including enrollee satisfaction and disenrollment
surveys. The quality improvement system must include
incentives and disincentives for network providers.
(B) Each plan must collect and report Health Plan
Employer Data and Information Set (HEDIS) measures, as
specified by the Department. These measures must be
published on the plan's website in a manner that allows
recipients to reliably compare the performance of
plans. The Department shall use the HEDIS measures as a
tool to monitor plan performance.

HB3189 - 9 - LRB098 08448 KTG 38555 b
(C) Each managed care plan must be accredited by
the National Committee for Quality Assurance, the
Joint Commission, or another nationally recognized
accrediting body, or have initiated the accreditation
process, within one year after the contract is
executed.
(6) Program integrity: Each managed care plan shall
establish program integrity functions and activities to
reduce the incidence of fraud and abuse, including, at a
minimum, all of the following:
(A) A provider credentialing system and ongoing
provider monitoring.
(B) Procedures for reporting instances of fraud
and abuse.
(C) Designation of a program integrity compliance
officer.
(7) Grievance resolution: Consistent with federal law,
each managed care plan shall establish and the Department
shall approve an internal process for reviewing and
responding to grievances from enrollees. Each plan shall
submit quarterly reports on the number, description, and
outcome of grievances filed by enrollees.
(8) Penalties: Managed care plans shall incur
penalties for withdrawal and enrollment reductions;
failure to comply with encounter data reporting
requirements; or termination of a regional contract due to

HB3189 - 10 - LRB098 08448 KTG 38555 b
noncompliance.
(9) Prompt payment: Managed care plans shall comply
with the prompt payment requirements of the Illinois
Insurance Code.
(10) Electronic claims: Managed care plans, and their
fiscal agents or intermediaries, shall accept electronic
claims in compliance with federal standards.
(11) Itemized payment: Any claims payment to a provider
by a managed care plan or by a fiscal agent or intermediary
of the plan must be accompanied by an itemized accounting
of the individual claims included in the payment,
including, but not limited to, the enrollee's name, the
date of service, the procedure code, the amount of
reimbursement, and the identification of the plan on whose
behalf the payment is made.
(c) The Department shall be responsible for verifying the
achieved savings rebate for all Medicaid prepaid plans. The
achieved savings rebate shall be established by determining
pretax income as a percentage of revenues and applying the
following income-sharing ratios:
(1) 100% of income, up to and including 5% of revenue,
shall be retained by the plan.
(2) 50% of income above 5% and up to and including 10%
of revenue shall be retained by the plan, and the other 50%
refunded to the State.
(3) 100% of income above 10% of revenue shall be

HB3189 - 11 - LRB098 08448 KTG 38555 b
refunded to the State.
(d) Each managed care plan must accept any medically needy
recipient eligible for medical assistance under paragraph 2 of
Section 5-2 of the Illinois Public Aid Code who selects or is
assigned to the plan and must provide that medically needy
recipient with continuous enrollment for 12 months. After the
first month of qualifying as a medically needy recipient and
enrolling in a plan, and contingent upon federal approval, the
medically needy recipient shall pay the plan a portion of the
monthly premium equal to the medically needy recipient's share
of the cost as determined by the Department. The Department
shall pay any remaining portion of the monthly premium. A plan
is not obligated to pay claims for medically needy recipients
for services provided before enrollment in the plan. Medically
needy recipients are responsible for payment of incurred claims
that are used to determine eligibility. A plan must provide a
grace period of at least 90 days before disenrolling medically
needy recipients who fail to pay their shares of the premium.
Section 30. Managed care payments.
(a) Prepaid plans shall receive per-member, per-month
payments negotiated pursuant to the procurements described in
this Act. Payments shall be risk-adjusted rates based on
historical utilization and spending data, and shall be
projected forward and adjusted to reflect the eligibility
category, geographic area, and clinical risk profile of the

HB3189 - 12 - LRB098 08448 KTG 38555 b
recipients. In negotiating rates with the plans, the Department
shall consider any adjustments necessary to encourage plans to
use the most cost-effective modalities for treatment of chronic
disease.
(b) Provider service networks may be prepaid plans and
receive per-member, per-month payments. The fee-for-service
option shall be available to a provider service network only
for the first 2 years of its operation.
(c) The Department may not approve any plan request for a
rate increase unless sufficient funds to support the increase
have been authorized by appropriations made to the Department
for the purposes of this Act.
Section 35. Enrollment, choice counseling, and opt-out.
(a) All Medicaid recipients shall be enrolled in a managed
care plan unless specifically exempted under this Act. Each
recipient shall have a choice of plans and may select any
available plan unless that plan is restricted by contract to a
specific population that does not include the recipient.
Recipients shall have 30 days in which to make a choice of
plans.
(b) The Department shall implement a choice counseling
system to ensure that recipients have timely access to accurate
information on the available plans. The counseling system shall
include plan-to-plan comparative information on benefits,
provider networks, drug formularies, quality measures, and

HB3189 - 13 - LRB098 08448 KTG 38555 b
other data points as determined by the Department. Choice
counseling must be made available through face-to-face
interaction, through the Internet, by telephone, in writing,
and through other forms of relevant media. Materials must be
provided in a culturally relevant manner, consistent with
federal requirements. The Department shall contract for any or
all choice counseling functions.
(c) After a recipient has enrolled in a managed care plan,
the recipient shall have 90 days to voluntarily disenroll and
select another plan. After 90 days, no further changes may be
made except for good cause.
(d) The Department shall automatically enroll into a
managed care plan those Medicaid recipients who do not
voluntarily choose a plan. Except as otherwise outlined in this
Act, the Department may not engage in practices that are
designed to favor one managed care plan over another.
(1) The Department shall automatically enroll
recipients in plans that meet or exceed the performance or
quality standards established in this Act, and may not
automatically enroll recipients in a plan that is deficient
in those performance or quality standards.
(2) If a specialty plan is available to accommodate a
specific condition or diagnosis of a recipient, the
Department shall assign the recipient to that plan.
(3) In the first year of the first contract term only,
if a recipient was previously enrolled in a plan that is

HB3189 - 14 - LRB098 08448 KTG 38555 b
still available in the region, the Department shall
automatically enroll the recipient in that plan unless an
applicable specialty plan is available.
(4) A newborn of a mother enrolled in a plan at the
time of the child's birth shall be enrolled in the mother's
plan. Upon birth, such a newborn is deemed enrolled in the
managed care plan, regardless of the administrative
enrollment procedures, and the managed care plan is
responsible for providing services to the newborn. The
mother may choose another plan for the newborn within 90
days after the child's birth.
(5) Otherwise, the Department shall automatically
enroll recipients based on the following criteria:
(A) Whether the plan has sufficient network
capacity to meet the needs of the recipient.
(B) Whether the recipient has previously received
services from one of the plan's primary care providers.
(C) Whether primary care providers in one plan are
more geographically accessible to the recipient's
residence than those in other plans.
(e) A recipient with access to private health care coverage
shall opt out of all managed care plans and use Medicaid
financial assistance to pay for his or her share of the cost in
such coverage. The amount of financial assistance provided for
each recipient may not exceed the amount of the Medicaid
premium that would have been paid to a managed care plan for

HB3189 - 15 - LRB098 08448 KTG 38555 b
that recipient. The Department shall seek federal approval to
require Medicaid recipients with access to employer-sponsored
health care coverage to enroll in that coverage and use
Medicaid financial assistance to pay for the recipient's share
of the cost for such coverage. The amount of financial
assistance provided for each recipient may not exceed the
amount of the Medicaid premium that would have been paid to a
managed care plan for that recipient.
Section 40. Mandatory, exempt, and voluntary populations.
(a) All Medicaid recipients shall receive covered services
through the Medicaid Managed Care Program. The following
Medicaid recipients are exempt from participation in the
Medicaid Managed Care program:
(1) Recipients who are eligible for both Medicaid and
Medicare and who reside in a facility licensed under the
Nursing Home Care Act.
(2) Medicaid recipients residing in a facility
licensed under the ID/DD Community Care Act.
(3) Medicaid recipients enrolled in a home and
community-based waiver services program administered by
the Department of Healthcare and Family Services.
(4) SSI-eligible or other children with special needs.
(5) Children in foster care or subsidized adoption.
(6) Populations who receive only limited services,
including women eligible only for family planning services

HB3189 - 16 - LRB098 08448 KTG 38555 b
and women who are eligible only for breast and cervical
cancer services.
(b) The following persons eligible for Medicaid are exempt
from mandatory managed care enrollment required by this Act,
and may voluntarily choose to participate in the managed
medical assistance program:
(1) Recipients who are eligible for both Medicaid and
Medicare.
(2) Medicaid recipients residing in residential
commitment facilities operated by the Department of
Juvenile Justice or residing in State-owned or
State-operated residential mental health treatment
facilities.
(3) Persons eligible for refugee assistance.
(4) Medicaid recipients who are residents of a State
developmental disability center.
(5) Medicaid recipients enrolled in the State's Home
and Community-Based Services Waiver Program for persons
with disabilities.
(c) Medically needy recipients eligible for medical
assistance under paragraph 2 of Section 5-2 of the Illinois
Public Aid Code shall enroll in managed care plans. Such
recipients shall meet their share of the cost by paying the
plan premium, up to the share of the cost amount.
Section 45. Benefits.

HB3189 - 17 - LRB098 08448 KTG 38555 b
(a) Managed care plans shall cover, at a minimum, those
mandatory and optional services provided under the State's
medical assistance program pursuant to Article V of the
Illinois Public Aid Code.
(b) Managed care plans may customize benefit packages for
non-pregnant adults, vary cost-sharing provisions, and provide
coverage for additional services. The Department shall
evaluate the proposed benefit packages to ensure that services
are sufficient to meet the needs of the plan's enrollees and to
verify actuarial equivalence.
(c) Each plan operating in the Medicaid Managed Care
Program shall establish a program to encourage and reward
healthy behaviors. At a minimum, each plan must establish a
medically approved smoking cessation program, a medically
directed weight loss program, and a medically approved alcohol
or substance abuse recovery program. Each plan must identify
enrollees who smoke, who are morbidly obese, or who are
diagnosed with alcohol or substance abuse in order to establish
written agreements to secure the enrollees' commitment to
participation in these programs.
Section 50. Medicaid Long-Term Care Managed Care Program.
(a) The Department shall make payments for long-term care
home and community-based and residential services, and for
primary and acute medical assistance and related services for
recipients eligible for long-term care, using a managed care

HB3189 - 18 - LRB098 08448 KTG 38555 b
model. By June 30, 2014, the Department shall begin
implementation of the Medicaid Long-Term Care Managed Care
Program, with full implementation in all regions by June 30,
2015.
(b) The Department on Aging shall: (i) assist the
Department in developing specifications for the invitation to
negotiate and the model contract; (ii) determine clinical
eligibility for enrollment in managed long-term care plans;
(iii) monitor plan performance and measure quality of service
delivery; (iv) assist clients and families to address
complaints with the plans; (v) facilitate working
relationships between plans and providers serving elders and
disabled adults; and (vi) perform other functions specified in
a memorandum of agreement.
Section 55. Eligibility criteria for the Medicaid
Long-Term Care Managed Care Program.
(a) Medicaid recipients who meet all of the following
criteria are eligible to receive long-term care services and
must receive long-term care services by participating in the
Medicaid Long-Term Care Managed Care Program. The recipient
must be:
(1) 65 years of age or older, or age 18 or older and
eligible for Medicaid by reason of a disability; or
(2) determined to require nursing facility care.
(b) Medicaid recipients who, on the date long-term care

HB3189 - 19 - LRB098 08448 KTG 38555 b
managed care plans become available in their region, reside in
a facility licensed under the Nursing Home Care Act or the
ID/DD Community Care Act or who are enrolled in an existing
State long-term care Medicaid waiver program are eligible to
participate in the Medicaid Long-Term Care Managed Care Program
for up to 12 months without being reevaluated for their need
for nursing facility care.
(c) The Department shall make offers for enrollment to
eligible individuals based on a wait-list prioritization and
subject to the availability of funds. Before enrollment offers,
the Department shall determine that sufficient funds exist to
support additional enrollment into plans.
Section 60. Long-Term Care Plan Benefits. Long-term care
managed care plans shall, at a minimum, cover those mandatory
and optional services provided under the State's medical
assistance program pursuant to Article V of the Illinois Public
Aid Code.
Section 65. Selection of long-term care managed care plans.
(a) Provider service networks must be long-term care
provider service networks. Other eligible plans may be
long-term care plans or comprehensive long-term care plans.
(b) The Department shall select managed care plans through
the procurement process described in this Act. The Department
shall notice invitations to negotiate no later than June 30,

HB3189 - 20 - LRB098 08448 KTG 38555 b
2014. The Department shall procure at least 3 plans and no more
than 11 plans for each region. At least one plan in each region
must be a provider service network.
(c) In addition to the criteria established in this Act,
the Department shall consider all of the following factors in
the selection of long-term care managed care plans:
(1) Evidence of the employment of executive managers
with expertise and experience in serving aged and disabled
persons who require long-term care.
(2) Whether a plan has established a network of service
providers dispersed throughout the region and in
sufficient numbers to meet specific service standards
established by the Department for specialty services for
persons receiving home and community-based care.
(3) Whether a plan is proposing to establish a
comprehensive long-term care plan and whether the plan has
a contract to provide managed medical assistance services
in the same region.
(4) Whether a plan offers consumer-directed care
services to enrollees.
(5) Whether a plan is proposing to provide home and
community-based services in addition to the minimum
benefits required by this Act.
(d) Participation by a Medicare Advantage Special Needs
Plan is not subject to the procurement requirements if the
plan's Medicaid enrollees consist exclusively of recipients

HB3189 - 21 - LRB098 08448 KTG 38555 b
eligible for both Medicaid and Medicare services who are
enrolled in the plan in order to receive Medicare services.
Section 70. Long-term care managed care plan
accountability. In addition to the requirements enumerated
elsewhere in this Act, managed care plans and providers
participating in the Medicaid Long-Term Care Managed Care
Program must comply with the requirements of this Section.
(a) Managed care plans may limit the providers in their
networks based on credentials, quality indicators, and price.
For the period between June 30, 2014 and June 30, 2015, each
selected plan must offer a network contract to all the
following providers in the region:
(1) Nursing homes.
(2) Hospices.
(3) Aging network service providers that have
previously participated in the State's home and
community-based waiver programs serving seniors, or that
have previously participated in community-service programs
administered by the Department on Aging.
(b) Except as provided in this Section, providers may limit
the managed care plans they join. Nursing homes and hospices
that are enrolled Medicaid providers must participate in all
managed care plans selected by the Department in the region in
which the provider is located.
(c) Each managed care plan shall monitor the quality and

HB3189 - 22 - LRB098 08448 KTG 38555 b
performance of each participating provider using measures
adopted by and collected by the Department and any additional
measures mutually agreed upon by the provider and the plan.
(d) The Department shall establish, and each managed care
plan must comply with, specific standards for the number, type,
and regional distribution of providers in the plan's network.
(e) Managed care plans and providers shall negotiate
mutually acceptable rates, methods, and terms of payment. Plans
shall pay nursing homes an amount equal to the nursing
facility-specific payment rates set by the Department.
However, mutually acceptable higher rates may be negotiated for
medically complex care. Plans must ensure that electronic
nursing home and hospice claims that contain sufficient
information for processing are paid within 10 business days
after receipt.
Section 75. Long-term care managed care plan payment. In
addition to the payment provisions enumerated elsewhere in this
Act, the Department shall provide payment to plans in the
Medicaid Long-Term Care Managed Care Program pursuant to this
Section.
(a) Payment rates to plans shall be blended for some
long-term care services.
(b) Payment rates for plans must reflect historic
utilization and spending for covered services projected
forward and adjusted to reflect the level of care profile for

HB3189 - 23 - LRB098 08448 KTG 38555 b
enrollees in each plan. The Department shall periodically
adjust payment rates to account for changes in the level of
care profile for each managed care plan based on encounter
data.
(1) Level 1 Care consists of recipients residing in or
who must be placed in a nursing home.
(2) Level 2 Care consists of recipients at imminent
risk of nursing home placement, as evidenced by the need
for the constant availability of routine medical and
nursing treatment and care, and require extensive
health-related care and services because of mental or
physical incapacitation.
(3) Level 3 Care consists of recipients at imminent
risk of nursing home placement, as evidenced by the need
for the constant availability of routine medical and
nursing treatment and care, who have a limited need for
health-related care and services and are mildly,
medically, or physically incapacitated.
(c) The Department shall make an incentive adjustment in
payment rates to encourage the increased utilization of home
and community-based services and a commensurate reduction of
institutional placement. The incentive adjustment shall
continue until no more than 35% of the plan's enrollees are
placed in institutional settings. The Department shall
annually report to the General Assembly the actual change in
the utilization mix of home and community-based services

HB3189 - 24 - LRB098 08448 KTG 38555 b
compared to institutional placements and provide a
recommendation for utilization mix requirements for future
contracts.
Section 80. Enrollment in a long-term care managed care
plan.
(a) The Department shall automatically enroll into a
long-term care managed care plan those Medicaid recipients who
do not voluntarily choose a plan. Except as otherwise provided
in this Act, the Department may not engage in practices
designed to favor one managed care plan over another.
(b) The Department shall automatically enroll Medicaid
recipients in plans that meet or exceed the performance or
quality standards established in this Act, or by the Department
through contract, and may not automatically enroll recipients
in a plan that is deficient in those performance or quality
standards.
(1) If a Medicaid recipient is deemed eligible for both
Medicaid and Medicare services and is currently receiving
Medicare services from a Medicare Advantage Preferred
Provider Organization, a Medicare Advantage
Provider-Sponsored Organization, or a Medicare Advantage
Special Needs Plan, the Department shall automatically
enroll the recipient in such plan for Medicaid services if
the plan is currently participating in the Medicaid
Long-Term Care Managed Care Program.

HB3189 - 25 - LRB098 08448 KTG 38555 b
(2) Otherwise, the Department shall automatically
enroll Medicaid recipients based on all of the following
criteria:
(a) Whether the plan has sufficient network
capacity to meet the needs of the recipient.
(b) Whether the recipient has previously received
services from one of the plan's home and
community-based service providers.
(c) Whether the home and community-based providers
in one plan are more geographically accessible to the
recipient's residence than those in other plans.
(c) If a recipient is referred for hospice services, the
recipient has 30 days during which the recipient may select to
enroll in another managed care plan to access the hospice
provider of the recipient's choice.
(d) If a recipient is referred for placement in a nursing
home or assisted living facility, the plan must inform the
recipient of any facilities within the plan that have specific
cultural or religious affiliations and, if requested by the
recipient, make a reasonable effort to place the recipient in
the facility of the recipient's choice.
Section 97. Severability. The provisions of this Act are
severable under Section 1.31 of the Statute on Statutes.
Section 999. Effective date. This Act takes effect upon
becoming law.