Bill Text: IL SB3486 | 2023-2024 | 103rd General Assembly | Introduced

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Bill Title: Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to enter into one or more cooperative arrangements with safety-net providers to provide primary, secondary, or tertiary managed health care services as a managed care community network with a monthly total capitation amount not to exceed $100,000,000. Defines "safety-net provider" to mean a non-government owned managed care community network operating and located in Cook County with at least 80% ownership by one or more safety-net hospitals. Provides that a safety-net provider shall be deemed a managed care community network for purposes of the Code only to the extent that it provides services to participating individuals. Provides that a non-government owned safety-net provider is entitled to contract with the Department with respect to Cook County only. Provides that a safety-net provider is not required to accept enrollees who do not reside within Cook County.

Spectrum: Partisan Bill (Democrat 2-0)

Status: (Introduced) 2024-03-21 - Added as Co-Sponsor Sen. David Koehler [SB3486 Detail]

Download: Illinois-2023-SB3486-Introduced.html

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103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB3486 Introduced 2/9/2024, by Sen. Omar Aquino SYNOPSIS AS INTRODUCED:
305 ILCS 5/5-11 from Ch. 23, par. 5-11
Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to enter into one or more cooperative arrangements with safety-net providers to provide primary, secondary, or tertiary managed health care services as a managed care community network with a monthly total capitation amount not to exceed $100,000,000. Defines "safety-net provider" to mean a non-government owned managed care community network operating and located in Cook County with at least 80% ownership by one or more safety-net hospitals. Provides that a safety-net provider shall be deemed a managed care community network for purposes of the Code only to the extent that it provides services to participating individuals. Provides that a non-government owned safety-net provider is entitled to contract with the Department with respect to Cook County only. Provides that a safety-net provider is not required to accept enrollees who do not reside within Cook County.
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A BILL FOR
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AN ACT concerning public aid.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Public Aid Code is amended by
changing Section 5-11 as follows:
(305 ILCS 5/5-11) (from Ch. 23, par. 5-11)
Sec. 5-11. Co-operative arrangements; contracts with other
State agencies, health care and rehabilitation organizations,
and fiscal intermediaries.
(a) The Illinois Department may enter into co-operative
arrangements with State agencies responsible for administering
or supervising the administration of health services and
vocational rehabilitation services to the end that there may
be maximum utilization of such services in the provision of
medical assistance.
The Illinois Department shall, not later than June 30,
1993, enter into one or more co-operative arrangements with
the Department of Mental Health and Developmental Disabilities
providing that the Department of Mental Health and
Developmental Disabilities will be responsible for
administering or supervising all programs for services to
persons in community care facilities for persons with
developmental disabilities, including but not limited to

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intermediate care facilities, that are supported by State
funds or by funding under Title XIX of the federal Social
Security Act. The responsibilities of the Department of Mental
Health and Developmental Disabilities under these agreements
are transferred to the Department of Human Services as
provided in the Department of Human Services Act.
The Department may also contract with such State health
and rehabilitation agencies and other public or private health
care and rehabilitation organizations to act for it in
supplying designated medical services to persons eligible
therefor under this Article. Any contracts with health
services or health maintenance organizations shall be
restricted to organizations which have been certified as being
in compliance with standards promulgated pursuant to the laws
of this State governing the establishment and operation of
health services or health maintenance organizations. The
Department shall renegotiate the contracts with health
maintenance organizations and managed care community networks
that took effect August 1, 2003, so as to produce $70,000,000
savings to the Department net of resulting increases to the
fee-for-service program for State fiscal year 2006. The
Department may also contract with insurance companies or other
corporate entities serving as fiscal intermediaries in this
State for the Federal Government in respect to Medicare
payments under Title XVIII of the Federal Social Security Act
to act for the Department in paying medical care suppliers.

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The provisions of Section 9 of "An Act in relation to State
finance", approved June 10, 1919, as amended, notwithstanding,
such contracts with State agencies, other health care and
rehabilitation organizations, or fiscal intermediaries may
provide for advance payments.
(b) For purposes of this subsection (b), "managed care
community network" means an entity, other than a health
maintenance organization, that is owned, operated, or governed
by providers of health care services within this State and
that provides or arranges primary, secondary, and tertiary
managed health care services under contract with the Illinois
Department exclusively to persons participating in programs
administered by the Illinois Department.
The Illinois Department may certify managed care community
networks, including managed care community networks owned,
operated, managed, or governed by State-funded medical
schools, as risk-bearing entities eligible to contract with
the Illinois Department as Medicaid managed care
organizations. The Illinois Department may contract with those
managed care community networks to furnish health care
services to or arrange those services for individuals
participating in programs administered by the Illinois
Department. The rates for those provider-sponsored
organizations may be determined on a prepaid, capitated basis.
A managed care community network may choose to contract with
the Illinois Department to provide only pediatric health care

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services. The Illinois Department shall by rule adopt the
criteria, standards, and procedures by which a managed care
community network may be permitted to contract with the
Illinois Department and shall consult with the Department of
Insurance in adopting these rules.
A county provider as defined in Section 15-1 of this Code
may contract with the Illinois Department to provide primary,
secondary, or tertiary managed health care services as a
managed care community network without the need to establish a
separate entity and shall be deemed a managed care community
network for purposes of this Code only to the extent it
provides services to participating individuals. A county
provider is entitled to contract with the Illinois Department
with respect to any contracting region located in whole or in
part within the county. A county provider is not required to
accept enrollees who do not reside within the county.
The Illinois Department shall enter into one or more
cooperative arrangements with safety-net providers to provide
primary, secondary, or tertiary managed health care services
as a managed care community network with a monthly total
capitation amount not to exceed $100,000,000. As used in this
paragraph, "safety-net provider" means a non-government owned
managed care community network operating and located in Cook
County with at least 80% ownership by one or more safety-net
hospitals, as that term is defined in Section 5-5e.1 of this
Code. A safety-net provider shall be deemed a managed care

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community network for purposes of this Code only to the extent
that it provides services to participating individuals. A
safety-net provider is entitled to contract with the Illinois
Department with respect to Cook County only. A safety-net
provider is not required to accept enrollees who do not reside
within Cook County.
In order to (i) accelerate and facilitate the development
of integrated health care in contracting areas outside
counties with populations in excess of 3,000,000 and counties
adjacent to those counties and (ii) maintain and sustain the
high quality of education and residency programs coordinated
and associated with local area hospitals, the Illinois
Department may develop and implement a demonstration program
from managed care community networks owned, operated, managed,
or governed by State-funded medical schools. The Illinois
Department shall prescribe by rule the criteria, standards,
and procedures for effecting this demonstration program.
A managed care community network that contracts with the
Illinois Department to furnish health care services to or
arrange those services for enrollees participating in programs
administered by the Illinois Department shall do all of the
following:
(1) Provide that any provider affiliated with the
managed care community network may also provide services
on a fee-for-service basis to Illinois Department clients
not enrolled in such managed care entities.

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(2) Provide client education services as determined
and approved by the Illinois Department, including but not
limited to (i) education regarding appropriate utilization
of health care services in a managed care system, (ii)
written disclosure of treatment policies and restrictions
or limitations on health services, including, but not
limited to, physical services, clinical laboratory tests,
hospital and surgical procedures, prescription drugs and
biologics, and radiological examinations, and (iii)
written notice that the enrollee may receive from another
provider those covered services that are not provided by
the managed care community network.
(3) Provide that enrollees within the system may
choose the site for provision of services and the panel of
health care providers.
(4) Not discriminate in enrollment or disenrollment
practices among recipients of medical services or
enrollees based on health status.
(5) Provide a quality assurance and utilization review
program that meets the requirements established by the
Illinois Department in rules that incorporate those
standards set forth in the Health Maintenance Organization
Act.
(6) Issue a managed care community network
identification card to each enrollee upon enrollment. The
card must contain all of the following:

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(A) The enrollee's health plan.
(B) The name and telephone number of the
enrollee's primary care physician or the site for
receiving primary care services.
(C) A telephone number to be used to confirm
eligibility for benefits and authorization for
services that is available 24 hours per day, 7 days per
week.
(7) Ensure that every primary care physician and
pharmacy in the managed care community network meets the
standards established by the Illinois Department for
accessibility and quality of care. The Illinois Department
shall arrange for and oversee an evaluation of the
standards established under this paragraph (7) and may
recommend any necessary changes to these standards.
(8) Provide a procedure for handling complaints that
meets the requirements established by the Illinois
Department in rules that incorporate those standards set
forth in the Health Maintenance Organization Act.
(9) Maintain, retain, and make available to the
Illinois Department records, data, and information, in a
uniform manner determined by the Illinois Department,
sufficient for the Illinois Department to monitor
utilization, accessibility, and quality of care.
(10) (Blank).
The Illinois Department shall contract with an entity or

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entities to provide external peer-based quality assurance
review for the managed health care programs administered by
the Illinois Department. The entity shall meet all federal
requirements for an external quality review organization.
Each managed care community network must demonstrate its
ability to bear the financial risk of serving individuals
under this program. The Illinois Department shall by rule
adopt standards for assessing the solvency and financial
soundness of each managed care community network. Any solvency
and financial standards adopted for managed care community
networks shall be no more restrictive than the solvency and
financial standards adopted under Section 1856(a) of the
Social Security Act for provider-sponsored organizations under
Part C of Title XVIII of the Social Security Act.
The Illinois Department may implement the amendatory
changes to this Code made by this amendatory Act of 1998
through the use of emergency rules in accordance with Section
5-45 of the Illinois Administrative Procedure Act. For
purposes of that Act, the adoption of rules to implement these
changes is deemed an emergency and necessary for the public
interest, safety, and welfare.
(c) Not later than June 30, 1996, the Illinois Department
shall enter into one or more cooperative arrangements with the
Department of Public Health for the purpose of developing a
single survey for nursing facilities, including but not
limited to facilities funded under Title XVIII or Title XIX of

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