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1 | AN ACT concerning public aid.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 1. Findings. The Illinois General Assembly finds | ||||||||||||||||||||||||
5 | that: | ||||||||||||||||||||||||
6 | (a) Local health departments and school-based health | ||||||||||||||||||||||||
7 | centers have been providing essential prevention, health | ||||||||||||||||||||||||
8 | promotion, primary care, oral health, and behavioral health | ||||||||||||||||||||||||
9 | services to low-income, Medicaid eligible families and | ||||||||||||||||||||||||
10 | individuals for many years in Illinois. | ||||||||||||||||||||||||
11 | (b) School-based and school-linked health centers provide | ||||||||||||||||||||||||
12 | essential behavioral health, health promotion, oral health, | ||||||||||||||||||||||||
13 | and primary care services to elementary, middle, and high | ||||||||||||||||||||||||
14 | school students in many parts of Illinois, providing unique | ||||||||||||||||||||||||
15 | access to services that increase students' ability to be in | ||||||||||||||||||||||||
16 | class healthy and learning. | ||||||||||||||||||||||||
17 | (c) Family planning agencies provide access to | ||||||||||||||||||||||||
18 | reproductive health and women's health care services for many | ||||||||||||||||||||||||
19 | low-income women and men, allowing them to choose the number | ||||||||||||||||||||||||
20 | and spacing of their children. | ||||||||||||||||||||||||
21 | (d) Including these established safety-net providers will | ||||||||||||||||||||||||
22 | increase the health care system's capacity to serve everyone | ||||||||||||||||||||||||
23 | eligible for medical assistance. | ||||||||||||||||||||||||
24 | (e) Since these agencies have been providing health |
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1 | services to eligible recipients of medical assistance for many | ||||||
2 | years and have unique access to vulnerable populations, | ||||||
3 | excluding local health departments, school-based health | ||||||
4 | centers, and family planning providers from participation in | ||||||
5 | managed care and care coordination programs for eligible | ||||||
6 | recipients of medical assistance will be detrimental to the | ||||||
7 | public's health and hamper the State's efforts to reduce infant | ||||||
8 | mortality, promote healthy child development, prevent and | ||||||
9 | reduce overweight and obesity, discourage teen pregnancy, and | ||||||
10 | prevent and control chronic diseases.
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11 | Section 5. The Illinois Public Aid Code is amended by | ||||||
12 | changing Section 5-30 as follows:
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13 | (305 ILCS 5/5-30) | ||||||
14 | Sec. 5-30. Care coordination. | ||||||
15 | (a) At least 50% of recipients eligible for comprehensive | ||||||
16 | medical benefits in all medical assistance programs or other | ||||||
17 | health benefit programs administered by the Department, | ||||||
18 | including the Children's Health Insurance Program Act and the | ||||||
19 | Covering ALL KIDS Health Insurance Act, shall be enrolled in a | ||||||
20 | care coordination program by no later than January 1, 2015. For | ||||||
21 | purposes of this Section, "coordinated care" or "care | ||||||
22 | coordination" means delivery systems where recipients will | ||||||
23 | receive their care from providers who participate under | ||||||
24 | contract in integrated delivery systems that are responsible |
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1 | for providing or arranging the majority of care, including | ||||||
2 | primary care physician services, referrals from primary care | ||||||
3 | physicians, diagnostic and treatment services, behavioral | ||||||
4 | health services, in-patient and outpatient hospital services, | ||||||
5 | dental services, and rehabilitation and long-term care | ||||||
6 | services. The Department shall designate or contract for such | ||||||
7 | integrated delivery systems (i) to ensure enrollees have a | ||||||
8 | choice of systems and of primary care providers within such | ||||||
9 | systems; (ii) to ensure that enrollees receive quality care in | ||||||
10 | a culturally and linguistically appropriate manner; and (iii) | ||||||
11 | to ensure that coordinated care programs meet the diverse needs | ||||||
12 | of enrollees with developmental, mental health, physical, and | ||||||
13 | age-related disabilities. | ||||||
14 | (b) Payment for such coordinated care shall be based on | ||||||
15 | arrangements where the State pays for performance related to | ||||||
16 | health care outcomes, the use of evidence-based practices, the | ||||||
17 | use of primary care delivered through comprehensive medical | ||||||
18 | homes, the use of electronic medical records, and the | ||||||
19 | appropriate exchange of health information electronically made | ||||||
20 | either on a capitated basis in which a fixed monthly premium | ||||||
21 | per recipient is paid and full financial risk is assumed for | ||||||
22 | the delivery of services, or through other risk-based payment | ||||||
23 | arrangements. | ||||||
24 | (c) To qualify for compliance with this Section, the 50% | ||||||
25 | goal shall be achieved by enrolling medical assistance | ||||||
26 | enrollees from each medical assistance enrollment category, |
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1 | including parents, children, seniors, and people with | ||||||
2 | disabilities to the extent that current State Medicaid payment | ||||||
3 | laws would not limit federal matching funds for recipients in | ||||||
4 | care coordination programs. In addition, services must be more | ||||||
5 | comprehensively defined and more risk shall be assumed than in | ||||||
6 | the Department's primary care case management program as of the | ||||||
7 | effective date of this amendatory Act of the 96th General | ||||||
8 | Assembly. | ||||||
9 | (d) The Department shall report to the General Assembly in | ||||||
10 | a separate part of its annual medical assistance program | ||||||
11 | report, beginning April, 2012 until April, 2016, on the | ||||||
12 | progress and implementation of the care coordination program | ||||||
13 | initiatives established by the provisions of this amendatory | ||||||
14 | Act of the 96th General Assembly. The Department shall include | ||||||
15 | in its April 2011 report a full analysis of federal laws or | ||||||
16 | regulations regarding upper payment limitations to providers | ||||||
17 | and the necessary revisions or adjustments in rate | ||||||
18 | methodologies and payments to providers under this Code that | ||||||
19 | would be necessary to implement coordinated care with full | ||||||
20 | financial risk by a party other than the Department.
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21 | (e) Integrated Care Program for individuals with chronic | ||||||
22 | mental health conditions. | ||||||
23 | (1) The Integrated Care Program shall encompass | ||||||
24 | services administered to recipients of medical assistance | ||||||
25 | under this Article to prevent exacerbations and | ||||||
26 | complications using cost-effective, evidence-based |
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1 | practice guidelines and mental health management | ||||||
2 | strategies. | ||||||
3 | (2) The Department may utilize and expand upon existing | ||||||
4 | contractual arrangements with integrated care plans under | ||||||
5 | the Integrated Care Program for providing the coordinated | ||||||
6 | care provisions of this Section. | ||||||
7 | (3) Payment for such coordinated care shall be based on | ||||||
8 | arrangements where the State pays for performance related | ||||||
9 | to mental health outcomes on a capitated basis in which a | ||||||
10 | fixed monthly premium per recipient is paid and full | ||||||
11 | financial risk is assumed for the delivery of services, or | ||||||
12 | through other risk-based payment arrangements such as | ||||||
13 | provider-based care coordination. | ||||||
14 | (4) The Department shall examine whether chronic | ||||||
15 | mental health management programs and services for | ||||||
16 | recipients with specific chronic mental health conditions | ||||||
17 | do any or all of the following: | ||||||
18 | (A) Improve the patient's overall mental health in | ||||||
19 | a more expeditious and cost-effective manner. | ||||||
20 | (B) Lower costs in other aspects of the medical | ||||||
21 | assistance program, such as hospital admissions, | ||||||
22 | emergency room visits, or more frequent and | ||||||
23 | inappropriate psychotropic drug use. | ||||||
24 | (5) The Department shall work with the facilities and | ||||||
25 | any integrated care plan participating in the program to | ||||||
26 | identify and correct barriers to the successful |
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1 | implementation of this subsection (e) prior to and during | ||||||
2 | the implementation to best facilitate the goals and | ||||||
3 | objectives of this subsection (e). | ||||||
4 | (f) A hospital that is located in a county of the State in | ||||||
5 | which the Department mandates some or all of the beneficiaries | ||||||
6 | of the Medical Assistance Program residing in the county to | ||||||
7 | enroll in a Care Coordination Program, as set forth in Section | ||||||
8 | 5-30 of this Code, shall not be eligible for any non-claims | ||||||
9 | based payments not mandated by Article V-A of this Code for | ||||||
10 | which it would otherwise be qualified to receive, unless the | ||||||
11 | hospital is a Coordinated Care Participating Hospital no later | ||||||
12 | than 60 days after the effective date of this amendatory Act of | ||||||
13 | the 97th General Assembly or 60 days after the first mandatory | ||||||
14 | enrollment of a beneficiary in a Coordinated Care program. For | ||||||
15 | purposes of this subsection, "Coordinated Care Participating | ||||||
16 | Hospital" means a hospital that meets one of the following | ||||||
17 | criteria: | ||||||
18 | (1) The hospital has entered into a contract to provide | ||||||
19 | hospital services to enrollees of the care coordination | ||||||
20 | program. | ||||||
21 | (2) The hospital has not been offered a contract by a | ||||||
22 | care coordination plan that pays at least as much as the | ||||||
23 | Department would pay, on a fee-for-service basis, not | ||||||
24 | including disproportionate share hospital adjustment | ||||||
25 | payments or any other supplemental adjustment or add-on | ||||||
26 | payment to the base fee-for-service rate. |
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1 | (g) No later than August 1, 2013, the Department shall | ||||||
2 | issue a purchase of care solicitation for Accountable Care | ||||||
3 | Entities (ACE) to serve any children and parents or caretaker | ||||||
4 | relatives of children eligible for medical assistance under | ||||||
5 | this Article. An ACE may be a single corporate structure or a | ||||||
6 | network of providers organized through contractual | ||||||
7 | relationships with a single corporate entity. The solicitation | ||||||
8 | shall require that: | ||||||
9 | (1) An ACE operating in Cook County be capable of | ||||||
10 | serving at least 40,000 eligible individuals in that | ||||||
11 | county; an ACE operating in Lake, Kane, DuPage, or Will | ||||||
12 | Counties be capable of serving at least 20,000 eligible | ||||||
13 | individuals in those counties and an ACE operating in other | ||||||
14 | regions of the State be capable of serving at least 10,000 | ||||||
15 | eligible individuals in the region in which it operates. | ||||||
16 | During initial periods of mandatory enrollment, the | ||||||
17 | Department shall require its enrollment services | ||||||
18 | contractor to use a default assignment algorithm that | ||||||
19 | ensures if possible an ACE reaches the minimum enrollment | ||||||
20 | levels set forth in this paragraph. | ||||||
21 | (2) An ACE must include at a minimum the following | ||||||
22 | types of providers: primary care, specialty care, | ||||||
23 | hospitals, and behavioral healthcare. | ||||||
24 | (3) An ACE shall have a governance structure that | ||||||
25 | includes the major components of the health care delivery | ||||||
26 | system, including one representative from each of the |
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1 | groups listed in paragraph (2). | ||||||
2 | (4) An ACE must be an integrated delivery system, | ||||||
3 | including a network able to provide the full range of | ||||||
4 | services needed by Medicaid beneficiaries and system | ||||||
5 | capacity to securely pass clinical information across | ||||||
6 | participating entities and to aggregate and analyze that | ||||||
7 | data in order to coordinate care. | ||||||
8 | (5) An ACE must be capable of providing both care | ||||||
9 | coordination and complex case management, as necessary, to | ||||||
10 | beneficiaries. To be responsive to the solicitation, a | ||||||
11 | potential ACE must outline its care coordination and | ||||||
12 | complex case management model and plan to reduce the cost | ||||||
13 | of care. | ||||||
14 | (6) In the first 18 months of operation, unless the ACE | ||||||
15 | selects a shorter period, an ACE shall be paid care | ||||||
16 | coordination fees on a per member per month basis that are | ||||||
17 | projected to be cost neutral to the State during the term | ||||||
18 | of their payment and, subject to federal approval, be | ||||||
19 | eligible to share in additional savings generated by their | ||||||
20 | care coordination. | ||||||
21 | (7) In months 19 through 36 of operation, unless the | ||||||
22 | ACE selects a shorter period, an ACE shall be paid on a | ||||||
23 | pre-paid capitation basis for all medical assistance | ||||||
24 | covered services, under contract terms similar to Managed | ||||||
25 | Care Organizations (MCO), with the Department sharing the | ||||||
26 | risk through either stop-loss insurance for extremely high |
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1 | cost individuals or corridors of shared risk based on the | ||||||
2 | overall cost of the total enrollment in the ACE. The ACE | ||||||
3 | shall be responsible for claims processing, encounter data | ||||||
4 | submission, utilization control, and quality assurance. | ||||||
5 | (8) In the fourth and subsequent years of operation, an | ||||||
6 | ACE shall convert to a Managed Care Community Network | ||||||
7 | (MCCN), as defined in this Article, or Health Maintenance | ||||||
8 | Organization pursuant to the Illinois Insurance Code, | ||||||
9 | accepting full-risk capitation payments. | ||||||
10 | The Department shall allow potential ACE entities 5 months | ||||||
11 | from the date of the posting of the solicitation to submit | ||||||
12 | proposals. After the solicitation is released, in addition to | ||||||
13 | the MCO rate development data available on the Department's | ||||||
14 | website, subject to federal and State confidentiality and | ||||||
15 | privacy laws and regulations, the Department shall provide 2 | ||||||
16 | years of de-identified summary service data on the targeted | ||||||
17 | population, split between children and adults, showing the | ||||||
18 | historical type and volume of services received and the cost of | ||||||
19 | those services to those potential bidders that sign a data use | ||||||
20 | agreement. The Department may add up to 2 non-state government | ||||||
21 | employees with expertise in creating integrated delivery | ||||||
22 | systems to its review team for the purchase of care | ||||||
23 | solicitation described in this subsection. Any such | ||||||
24 | individuals must sign a no-conflict disclosure and | ||||||
25 | confidentiality agreement and agree to act in accordance with | ||||||
26 | all applicable State laws. |
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1 | During the first 2 years of an ACE's operation, the | ||||||
2 | Department shall provide claims data to the ACE on its | ||||||
3 | enrollees on a periodic basis no less frequently than monthly. | ||||||
4 | Nothing in this subsection shall be construed to limit the | ||||||
5 | Department's mandate to enroll 50% of its beneficiaries into | ||||||
6 | care coordination systems by January 1, 2015, using all | ||||||
7 | available care coordination delivery systems, including Care | ||||||
8 | Coordination Entities (CCE), MCCNs, or MCOs, nor be construed | ||||||
9 | to affect the current CCEs, MCCNs, and MCOs selected to serve | ||||||
10 | seniors and persons with disabilities prior to that date. | ||||||
11 | (h) Department contracts with MCOs and other entities | ||||||
12 | reimbursed by risk based capitation shall have a minimum | ||||||
13 | medical loss ratio of 85%, shall require the MCO or other | ||||||
14 | entity to pay claims within 30 days of receiving a bill that | ||||||
15 | contains all the essential information needed to adjudicate the | ||||||
16 | bill, and shall require the entity to pay a penalty that is at | ||||||
17 | least equal to the penalty imposed under the Illinois Insurance | ||||||
18 | Code for any claims not paid within this time period. The | ||||||
19 | requirements of this subsection shall apply to contracts with | ||||||
20 | MCOs entered into or renewed or extended after June 1, 2013. | ||||||
21 | (i) Nothing in this Section shall be construed (1) to | ||||||
22 | prevent a local health department from receiving | ||||||
23 | fee-for-service reimbursement for providing services covered | ||||||
24 | by the State's medical assistance program to eligible | ||||||
25 | recipients of medical assistance regardless of their | ||||||
26 | enrollment in a managed care plan or care coordination program, |
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1 | or (2) to prevent certified local health departments from | ||||||
2 | receiving matching funds for expenditures of local tax revenues | ||||||
3 | incurred in the efficient and effective administration of the | ||||||
4 | State's medical assistance program. | ||||||
5 | (Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)
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