Bill Text: IL SB1724 | 2017-2018 | 100th General Assembly | Introduced


Bill Title: Amends the Illinois Public Aid Code. Requires managed care organizations (MCOs) to participate in the Non-Emergency Transportation Services Prior Approval Program (NETSPAP) established under the Code beginning 90 days after the effective date of the amendatory Act. Requires each MCO to submit through NETSPAP for adjudication every unpaid non-emergency transportation claim incurred since January 1, 2012; and requires a NETSPAP contractor to adjudicate such claims without regard to any deadlines for submission or processing that are otherwise applicable. Provides that all non-emergency ambulance service providers seeking reimbursement for prior claims must submit documentation of the transport no later than 150 days after the effective date of the amendatory Act. Provides that upon receipt of approval from the NETSPAP contractor, each MCO shall process and pay all approved claims within 30 days, without requiring any further action by the non-emergency transportation services provider; and that any denial of reimbursement by the NETSPAP contractor may be appealed. Provides that any costs incurred in connection with the review of claims by the NETSPAP contractor shall be the sole responsibility of the MCO. Provides that MCOs shall not unreasonably refuse to contract with ground ambulance services providers and medi-car services providers, shall not unreasonably restrict access to and the availability of ground ambulance services and medi-car services, and shall ensure that recipients of benefits provided under the Department of Healthcare and Family Services' programs shall not be liable for ground ambulance services and medi-car services expenses consistent with federal law and specified provisions of the Illinois Insurance Code and the Illinois Administrative Code. Effective immediately.

Spectrum: Slight Partisan Bill (Democrat 11-4)

Status: (Introduced) 2017-05-05 - Rule 3-9(a) / Re-referred to Assignments [SB1724 Detail]

Download: Illinois-2017-SB1724-Introduced.html


100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
SB1724

Introduced 2/9/2017, by Sen. Antonio Muņoz

SYNOPSIS AS INTRODUCED:
305 ILCS 5/5-30

Amends the Illinois Public Aid Code. Requires managed care organizations (MCOs) to participate in the Non-Emergency Transportation Services Prior Approval Program (NETSPAP) established under the Code beginning 90 days after the effective date of the amendatory Act. Requires each MCO to submit through NETSPAP for adjudication every unpaid non-emergency transportation claim incurred since January 1, 2012; and requires a NETSPAP contractor to adjudicate such claims without regard to any deadlines for submission or processing that are otherwise applicable. Provides that all non-emergency ambulance service providers seeking reimbursement for prior claims must submit documentation of the transport no later than 150 days after the effective date of the amendatory Act. Provides that upon receipt of approval from the NETSPAP contractor, each MCO shall process and pay all approved claims within 30 days, without requiring any further action by the non-emergency transportation services provider; and that any denial of reimbursement by the NETSPAP contractor may be appealed. Provides that any costs incurred in connection with the review of claims by the NETSPAP contractor shall be the sole responsibility of the MCO. Provides that MCOs shall not unreasonably refuse to contract with ground ambulance services providers and medi-car services providers, shall not unreasonably restrict access to and the availability of ground ambulance services and medi-car services, and shall ensure that recipients of benefits provided under the Department of Healthcare and Family Services' programs shall not be liable for ground ambulance services and medi-car services expenses consistent with federal law and specified provisions of the Illinois Insurance Code and the Illinois Administrative Code. Effective immediately.
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FISCAL NOTE ACT MAY APPLY

A BILL FOR

SB1724LRB100 11237 KTG 21567 b
1 AN ACT concerning public aid.
2 Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4 Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-30 as follows:
6 (305 ILCS 5/5-30)
7 Sec. 5-30. Care coordination.
8 (a) At least 50% of recipients eligible for comprehensive
9medical benefits in all medical assistance programs or other
10health benefit programs administered by the Department,
11including the Children's Health Insurance Program Act and the
12Covering ALL KIDS Health Insurance Act, shall be enrolled in a
13care coordination program by no later than January 1, 2015. For
14purposes of this Section, "coordinated care" or "care
15coordination" means delivery systems where recipients will
16receive their care from providers who participate under
17contract in integrated delivery systems that are responsible
18for providing or arranging the majority of care, including
19primary care physician services, referrals from primary care
20physicians, diagnostic and treatment services, behavioral
21health services, in-patient and outpatient hospital services,
22dental services, and rehabilitation and long-term care
23services. The Department shall designate or contract for such

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1integrated delivery systems (i) to ensure enrollees have a
2choice of systems and of primary care providers within such
3systems; (ii) to ensure that enrollees receive quality care in
4a culturally and linguistically appropriate manner; and (iii)
5to ensure that coordinated care programs meet the diverse needs
6of enrollees with developmental, mental health, physical, and
7age-related disabilities.
8 (b) Payment for such coordinated care shall be based on
9arrangements where the State pays for performance related to
10health care outcomes, the use of evidence-based practices, the
11use of primary care delivered through comprehensive medical
12homes, the use of electronic medical records, and the
13appropriate exchange of health information electronically made
14either on a capitated basis in which a fixed monthly premium
15per recipient is paid and full financial risk is assumed for
16the delivery of services, or through other risk-based payment
17arrangements.
18 (c) To qualify for compliance with this Section, the 50%
19goal shall be achieved by enrolling medical assistance
20enrollees from each medical assistance enrollment category,
21including parents, children, seniors, and people with
22disabilities to the extent that current State Medicaid payment
23laws would not limit federal matching funds for recipients in
24care coordination programs. In addition, services must be more
25comprehensively defined and more risk shall be assumed than in
26the Department's primary care case management program as of

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1January 25, 2011 (the effective date of Public Act 96-1501).
2 (d) The Department shall report to the General Assembly in
3a separate part of its annual medical assistance program
4report, beginning April, 2012 until April, 2016, on the
5progress and implementation of the care coordination program
6initiatives established by the provisions of Public Act
796-1501. The Department shall include in its April 2011 report
8a full analysis of federal laws or regulations regarding upper
9payment limitations to providers and the necessary revisions or
10adjustments in rate methodologies and payments to providers
11under this Code that would be necessary to implement
12coordinated care with full financial risk by a party other than
13the Department.
14 (e) Integrated Care Program for individuals with chronic
15mental health conditions.
16 (1) The Integrated Care Program shall encompass
17 services administered to recipients of medical assistance
18 under this Article to prevent exacerbations and
19 complications using cost-effective, evidence-based
20 practice guidelines and mental health management
21 strategies.
22 (2) The Department may utilize and expand upon existing
23 contractual arrangements with integrated care plans under
24 the Integrated Care Program for providing the coordinated
25 care provisions of this Section.
26 (3) Payment for such coordinated care shall be based on

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1 arrangements where the State pays for performance related
2 to mental health outcomes on a capitated basis in which a
3 fixed monthly premium per recipient is paid and full
4 financial risk is assumed for the delivery of services, or
5 through other risk-based payment arrangements such as
6 provider-based care coordination.
7 (4) The Department shall examine whether chronic
8 mental health management programs and services for
9 recipients with specific chronic mental health conditions
10 do any or all of the following:
11 (A) Improve the patient's overall mental health in
12 a more expeditious and cost-effective manner.
13 (B) Lower costs in other aspects of the medical
14 assistance program, such as hospital admissions,
15 emergency room visits, or more frequent and
16 inappropriate psychotropic drug use.
17 (5) The Department shall work with the facilities and
18 any integrated care plan participating in the program to
19 identify and correct barriers to the successful
20 implementation of this subsection (e) prior to and during
21 the implementation to best facilitate the goals and
22 objectives of this subsection (e).
23 (f) A hospital that is located in a county of the State in
24which the Department mandates some or all of the beneficiaries
25of the Medical Assistance Program residing in the county to
26enroll in a Care Coordination Program, as set forth in Section

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15-30 of this Code, shall not be eligible for any non-claims
2based payments not mandated by Article V-A of this Code for
3which it would otherwise be qualified to receive, unless the
4hospital is a Coordinated Care Participating Hospital no later
5than 60 days after June 14, 2012 (the effective date of Public
6Act 97-689) or 60 days after the first mandatory enrollment of
7a beneficiary in a Coordinated Care program. For purposes of
8this subsection, "Coordinated Care Participating Hospital"
9means a hospital that meets one of the following criteria:
10 (1) The hospital has entered into a contract to provide
11 hospital services with one or more MCOs to enrollees of the
12 care coordination program.
13 (2) The hospital has not been offered a contract by a
14 care coordination plan that the Department has determined
15 to be a good faith offer and that pays at least as much as
16 the Department would pay, on a fee-for-service basis, not
17 including disproportionate share hospital adjustment
18 payments or any other supplemental adjustment or add-on
19 payment to the base fee-for-service rate, except to the
20 extent such adjustments or add-on payments are
21 incorporated into the development of the applicable MCO
22 capitated rates.
23 As used in this subsection (f), "MCO" means any entity
24which contracts with the Department to provide services where
25payment for medical services is made on a capitated basis.
26 (g) No later than August 1, 2013, the Department shall

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1issue a purchase of care solicitation for Accountable Care
2Entities (ACE) to serve any children and parents or caretaker
3relatives of children eligible for medical assistance under
4this Article. An ACE may be a single corporate structure or a
5network of providers organized through contractual
6relationships with a single corporate entity. The solicitation
7shall require that:
8 (1) An ACE operating in Cook County be capable of
9 serving at least 40,000 eligible individuals in that
10 county; an ACE operating in Lake, Kane, DuPage, or Will
11 Counties be capable of serving at least 20,000 eligible
12 individuals in those counties and an ACE operating in other
13 regions of the State be capable of serving at least 10,000
14 eligible individuals in the region in which it operates.
15 During initial periods of mandatory enrollment, the
16 Department shall require its enrollment services
17 contractor to use a default assignment algorithm that
18 ensures if possible an ACE reaches the minimum enrollment
19 levels set forth in this paragraph.
20 (2) An ACE must include at a minimum the following
21 types of providers: primary care, specialty care,
22 hospitals, and behavioral healthcare.
23 (3) An ACE shall have a governance structure that
24 includes the major components of the health care delivery
25 system, including one representative from each of the
26 groups listed in paragraph (2).

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1 (4) An ACE must be an integrated delivery system,
2 including a network able to provide the full range of
3 services needed by Medicaid beneficiaries and system
4 capacity to securely pass clinical information across
5 participating entities and to aggregate and analyze that
6 data in order to coordinate care.
7 (5) An ACE must be capable of providing both care
8 coordination and complex case management, as necessary, to
9 beneficiaries. To be responsive to the solicitation, a
10 potential ACE must outline its care coordination and
11 complex case management model and plan to reduce the cost
12 of care.
13 (6) In the first 18 months of operation, unless the ACE
14 selects a shorter period, an ACE shall be paid care
15 coordination fees on a per member per month basis that are
16 projected to be cost neutral to the State during the term
17 of their payment and, subject to federal approval, be
18 eligible to share in additional savings generated by their
19 care coordination.
20 (7) In months 19 through 36 of operation, unless the
21 ACE selects a shorter period, an ACE shall be paid on a
22 pre-paid capitation basis for all medical assistance
23 covered services, under contract terms similar to Managed
24 Care Organizations (MCO), with the Department sharing the
25 risk through either stop-loss insurance for extremely high
26 cost individuals or corridors of shared risk based on the

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1 overall cost of the total enrollment in the ACE. The ACE
2 shall be responsible for claims processing, encounter data
3 submission, utilization control, and quality assurance.
4 (8) In the fourth and subsequent years of operation, an
5 ACE shall convert to a Managed Care Community Network
6 (MCCN), as defined in this Article, or Health Maintenance
7 Organization pursuant to the Illinois Insurance Code,
8 accepting full-risk capitation payments.
9 The Department shall allow potential ACE entities 5 months
10from the date of the posting of the solicitation to submit
11proposals. After the solicitation is released, in addition to
12the MCO rate development data available on the Department's
13website, subject to federal and State confidentiality and
14privacy laws and regulations, the Department shall provide 2
15years of de-identified summary service data on the targeted
16population, split between children and adults, showing the
17historical type and volume of services received and the cost of
18those services to those potential bidders that sign a data use
19agreement. The Department may add up to 2 non-state government
20employees with expertise in creating integrated delivery
21systems to its review team for the purchase of care
22solicitation described in this subsection. Any such
23individuals must sign a no-conflict disclosure and
24confidentiality agreement and agree to act in accordance with
25all applicable State laws.
26 During the first 2 years of an ACE's operation, the

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1Department shall provide claims data to the ACE on its
2enrollees on a periodic basis no less frequently than monthly.
3 Nothing in this subsection shall be construed to limit the
4Department's mandate to enroll 50% of its beneficiaries into
5care coordination systems by January 1, 2015, using all
6available care coordination delivery systems, including Care
7Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
8to affect the current CCEs, MCCNs, and MCOs selected to serve
9seniors and persons with disabilities prior to that date.
10 Nothing in this subsection precludes the Department from
11considering future proposals for new ACEs or expansion of
12existing ACEs at the discretion of the Department.
13 (h) Department contracts with MCOs and other entities
14reimbursed by risk based capitation shall have a minimum
15medical loss ratio of 85%, shall require the entity to
16establish an appeals and grievances process for consumers and
17providers, and shall require the entity to provide a quality
18assurance and utilization review program. Entities contracted
19with the Department to coordinate healthcare regardless of risk
20shall be measured utilizing the same quality metrics. The
21quality metrics may be population specific. Any contracted
22entity serving at least 5,000 seniors or people with
23disabilities or 15,000 individuals in other populations
24covered by the Medical Assistance Program that has been
25receiving full-risk capitation for a year shall be accredited
26by a national accreditation organization authorized by the

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1Department within 2 years after the date it is eligible to
2become accredited. The requirements of this subsection shall
3apply to contracts with MCOs entered into or renewed or
4extended after June 1, 2013.
5 (h-5) The Department shall monitor and enforce compliance
6by MCOs with agreements they have entered into with providers
7on issues that include, but are not limited to, timeliness of
8payment, payment rates, and processes for obtaining prior
9approval. The Department may impose sanctions on MCOs for
10violating provisions of those agreements that include, but are
11not limited to, financial penalties, suspension of enrollment
12of new enrollees, and termination of the MCO's contract with
13the Department. As used in this subsection (h-5), "MCO" has the
14meaning ascribed to that term in Section 5-30.1 of this Code.
15 (i) Unless otherwise required by federal law, Medicaid
16Managed Care Entities and their respective business associates
17shall not disclose, directly or indirectly, including by
18sending a bill or explanation of benefits, information
19concerning the sensitive health services received by enrollees
20of the Medicaid Managed Care Entity to any person other than
21covered entities and business associates, which may receive,
22use, and further disclose such information solely for the
23purposes permitted under applicable federal and State laws and
24regulations if such use and further disclosure satisfies all
25applicable requirements of such laws and regulations. The
26Medicaid Managed Care Entity or its respective business

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1associates may disclose information concerning the sensitive
2health services if the enrollee who received the sensitive
3health services requests the information from the Medicaid
4Managed Care Entity or its respective business associates and
5authorized the sending of a bill or explanation of benefits.
6Communications including, but not limited to, statements of
7care received or appointment reminders either directly or
8indirectly to the enrollee from the health care provider,
9health care professional, and care coordinators, remain
10permissible. Medicaid Managed Care Entities or their
11respective business associates may communicate directly with
12their enrollees regarding care coordination activities for
13those enrollees.
14 For the purposes of this subsection, the term "Medicaid
15Managed Care Entity" includes Care Coordination Entities,
16Accountable Care Entities, Managed Care Organizations, and
17Managed Care Community Networks.
18 For purposes of this subsection, the term "sensitive health
19services" means mental health services, substance abuse
20treatment services, reproductive health services, family
21planning services, services for sexually transmitted
22infections and sexually transmitted diseases, and services for
23sexual assault or domestic abuse. Services include prevention,
24screening, consultation, examination, treatment, or follow-up.
25 For purposes of this subsection, "business associate",
26"covered entity", "disclosure", and "use" have the meanings

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1ascribed to those terms in 45 CFR 160.103.
2 Nothing in this subsection shall be construed to relieve a
3Medicaid Managed Care Entity or the Department of any duty to
4report incidents of sexually transmitted infections to the
5Department of Public Health or to the local board of health in
6accordance with regulations adopted under a statute or
7ordinance or to report incidents of sexually transmitted
8infections as necessary to comply with the requirements under
9Section 5 of the Abused and Neglected Child Reporting Act or as
10otherwise required by State or federal law.
11 The Department shall create policy in order to implement
12the requirements in this subsection.
13 (j) Managed Care Entities (MCEs), including MCOs and all
14other care coordination organizations, shall develop and
15maintain a written language access policy that sets forth the
16standards, guidelines, and operational plan to ensure language
17appropriate services and that is consistent with the standard
18of meaningful access for populations with limited English
19proficiency. The language access policy shall describe how the
20MCEs will provide all of the following required services:
21 (1) Translation (the written replacement of text from
22 one language into another) of all vital documents and forms
23 as identified by the Department.
24 (2) Qualified interpreter services (the oral
25 communication of a message from one language into another
26 by a qualified interpreter).

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1 (3) Staff training on the language access policy,
2 including how to identify language needs, access and
3 provide language assistance services, work with
4 interpreters, request translations, and track the use of
5 language assistance services.
6 (4) Data tracking that identifies the language need.
7 (5) Notification to participants on the availability
8 of language access services and on how to access such
9 services.
10 (k) Beginning 90 days after the effective date of this
11amendatory Act of the 100th General Assembly, MCOs, as defined
12in Section 5-30.1 of this Code, including managed care
13community networks, as defined in Section 5-11 of this Code,
14shall participate in the Non-Emergency Transportation Services
15Prior Approval Program (NETSPAP) established pursuant to
16Section 5-4.2 of this Code. Each MCO shall submit through
17NETSPAP for adjudication every unpaid non-emergency
18transportation claim incurred since January 1, 2012. The
19NETSPAP contractor shall adjudicate all claims received
20without regard to any deadlines for submission or processing
21that are otherwise applicable to such claims. In reviewing
22claims under this subsection, the NETSPAP contractor may accept
23a certification of medical necessity, a medical certification
24for ambulance services, a physician certification statement,
25or such other documentation of medical necessity as would be
26accepted by the Department in an appeal brought pursuant to

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1Section 5-4.2 of this Code.
2 All non-emergency ambulance service providers seeking
3reimbursement for prior claims under this subsection must
4submit documentation of the transport no later than 150 days
5after the effective date of this amendatory Act of the 100th
6General Assembly.
7 Upon receipt of approval from the NETSPAP contractor, each
8MCO shall process and pay all approved claims within 30 days,
9without requiring any further action by the non-emergency
10transportation services provider.
11 Any denial of reimbursement by the NETSPAP contractor may
12be appealed under the process established in Section 5-4.2 of
13this Code.
14 Any costs incurred in connection with the review of claims
15by the NETSPAP contractor shall be the sole responsibility of
16the MCO.
17 (l) Beginning on the effective date of this amendatory Act
18of the 100th General Assembly, MCOs shall not unreasonably
19refuse to contract with ground ambulance services providers as
20defined in Section 5-4.2 of this Code and medi-car services
21providers as defined in Section 5-4.2 of this Code, shall not
22unreasonably restrict access to and the availability of ground
23ambulance services and medi-car services, and shall ensure that
24recipients of benefits provided under the Department's
25programs shall not be liable for ground ambulance services and
26medi-car services expenses consistent with federal law,

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1Sections 370h and 370i of the Illinois Insurance Code, and any
2amendments, regulations, policies, and guidelines thereto,
3including, but not limited to, 50 Ill. Admin. Code 2051.280(b)
4and any amendments thereto.
5(Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14;
699-106, eff. 1-1-16; 99-181, eff. 7-29-15; 99-566, eff. 1-1-17;
799-642, eff. 7-28-16.)
8 Section 99. Effective date. This Act takes effect upon
9becoming law.
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