Sen. Omar Aquino

Filed: 4/20/2017

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 622

2    AMENDMENT NO. ______. Amend Senate Bill 622, AS AMENDED,
3with reference to page and line numbers of Senate Amendment No.
42 as follows:
 
5on page 1, line 5, by replacing "Section 5-5" with "Sections
65-5 and 5-30"; and
 
7on page 29, immediately below line 18, by inserting the
8following:
 
9    "(305 ILCS 5/5-30)
10    Sec. 5-30. Care coordination.
11    (a) At least 50% of recipients eligible for comprehensive
12medical benefits in all medical assistance programs or other
13health benefit programs administered by the Department,
14including the Children's Health Insurance Program Act and the
15Covering ALL KIDS Health Insurance Act, shall be enrolled in a

 

 

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1care coordination program by no later than January 1, 2015. For
2purposes of this Section, "coordinated care" or "care
3coordination" means delivery systems where recipients will
4receive their care from providers who participate under
5contract in integrated delivery systems that are responsible
6for providing or arranging the majority of care, including
7primary care physician services, referrals from primary care
8physicians, diagnostic and treatment services, behavioral
9health services, in-patient and outpatient hospital services,
10dental services, and rehabilitation and long-term care
11services. The Department shall designate or contract for such
12integrated delivery systems (i) to ensure enrollees have a
13choice of systems and of primary care providers within such
14systems; (ii) to ensure that enrollees receive quality care in
15a culturally and linguistically appropriate manner; and (iii)
16to ensure that coordinated care programs meet the diverse needs
17of enrollees with developmental, mental health, physical, and
18age-related disabilities.
19    (b) Payment for such coordinated care shall be based on
20arrangements where the State pays for performance related to
21health care outcomes, the use of evidence-based practices, the
22use of primary care delivered through comprehensive medical
23homes, the use of electronic medical records, and the
24appropriate exchange of health information electronically made
25either on a capitated basis in which a fixed monthly premium
26per recipient is paid and full financial risk is assumed for

 

 

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1the delivery of services, or through other risk-based payment
2arrangements.
3    (c) To qualify for compliance with this Section, the 50%
4goal shall be achieved by enrolling medical assistance
5enrollees from each medical assistance enrollment category,
6including parents, children, seniors, and people with
7disabilities to the extent that current State Medicaid payment
8laws would not limit federal matching funds for recipients in
9care coordination programs. In addition, services must be more
10comprehensively defined and more risk shall be assumed than in
11the Department's primary care case management program as of
12January 25, 2011 (the effective date of Public Act 96-1501).
13    (d) The Department shall report to the General Assembly in
14a separate part of its annual medical assistance program
15report, beginning April, 2012 until April, 2016, on the
16progress and implementation of the care coordination program
17initiatives established by the provisions of Public Act
1896-1501. The Department shall include in its April 2011 report
19a full analysis of federal laws or regulations regarding upper
20payment limitations to providers and the necessary revisions or
21adjustments in rate methodologies and payments to providers
22under this Code that would be necessary to implement
23coordinated care with full financial risk by a party other than
24the Department.
25    (e) Integrated Care Program for individuals with chronic
26mental health conditions.

 

 

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1        (1) The Integrated Care Program shall encompass
2    services administered to recipients of medical assistance
3    under this Article to prevent exacerbations and
4    complications using cost-effective, evidence-based
5    practice guidelines and mental health management
6    strategies.
7        (2) The Department may utilize and expand upon existing
8    contractual arrangements with integrated care plans under
9    the Integrated Care Program for providing the coordinated
10    care provisions of this Section.
11        (3) Payment for such coordinated care shall be based on
12    arrangements where the State pays for performance related
13    to mental health outcomes on a capitated basis in which a
14    fixed monthly premium per recipient is paid and full
15    financial risk is assumed for the delivery of services, or
16    through other risk-based payment arrangements such as
17    provider-based care coordination.
18        (4) The Department shall examine whether chronic
19    mental health management programs and services for
20    recipients with specific chronic mental health conditions
21    do any or all of the following:
22            (A) Improve the patient's overall mental health in
23        a more expeditious and cost-effective manner.
24            (B) Lower costs in other aspects of the medical
25        assistance program, such as hospital admissions,
26        emergency room visits, or more frequent and

 

 

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1        inappropriate psychotropic drug use.
2        (5) The Department shall work with the facilities and
3    any integrated care plan participating in the program to
4    identify and correct barriers to the successful
5    implementation of this subsection (e) prior to and during
6    the implementation to best facilitate the goals and
7    objectives of this subsection (e).
8    (f) A hospital that is located in a county of the State in
9which the Department mandates some or all of the beneficiaries
10of the Medical Assistance Program residing in the county to
11enroll in a Care Coordination Program, as set forth in Section
125-30 of this Code, shall not be eligible for any non-claims
13based payments not mandated by Article V-A of this Code for
14which it would otherwise be qualified to receive, unless the
15hospital is a Coordinated Care Participating Hospital no later
16than 60 days after June 14, 2012 (the effective date of Public
17Act 97-689) or 60 days after the first mandatory enrollment of
18a beneficiary in a Coordinated Care program. For purposes of
19this subsection, "Coordinated Care Participating Hospital"
20means a hospital that meets one of the following criteria:
21        (1) The hospital has entered into a contract to provide
22    hospital services with one or more MCOs to enrollees of the
23    care coordination program.
24        (2) The hospital has not been offered a contract by a
25    care coordination plan that the Department has determined
26    to be a good faith offer and that pays at least as much as

 

 

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1    the Department would pay, on a fee-for-service basis, not
2    including disproportionate share hospital adjustment
3    payments or any other supplemental adjustment or add-on
4    payment to the base fee-for-service rate, except to the
5    extent such adjustments or add-on payments are
6    incorporated into the development of the applicable MCO
7    capitated rates.
8    As used in this subsection (f), "MCO" means any entity
9which contracts with the Department to provide services where
10payment for medical services is made on a capitated basis.
11    (g) No later than August 1, 2013, the Department shall
12issue a purchase of care solicitation for Accountable Care
13Entities (ACE) to serve any children and parents or caretaker
14relatives of children eligible for medical assistance under
15this Article. An ACE may be a single corporate structure or a
16network of providers organized through contractual
17relationships with a single corporate entity. The solicitation
18shall require that:
19        (1) An ACE operating in Cook County be capable of
20    serving at least 40,000 eligible individuals in that
21    county; an ACE operating in Lake, Kane, DuPage, or Will
22    Counties be capable of serving at least 20,000 eligible
23    individuals in those counties and an ACE operating in other
24    regions of the State be capable of serving at least 10,000
25    eligible individuals in the region in which it operates.
26    During initial periods of mandatory enrollment, the

 

 

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1    Department shall require its enrollment services
2    contractor to use a default assignment algorithm that
3    ensures if possible an ACE reaches the minimum enrollment
4    levels set forth in this paragraph.
5        (2) An ACE must include at a minimum the following
6    types of providers: primary care, specialty care,
7    hospitals, and behavioral healthcare.
8        (3) An ACE shall have a governance structure that
9    includes the major components of the health care delivery
10    system, including one representative from each of the
11    groups listed in paragraph (2).
12        (4) An ACE must be an integrated delivery system,
13    including a network able to provide the full range of
14    services needed by Medicaid beneficiaries and system
15    capacity to securely pass clinical information across
16    participating entities and to aggregate and analyze that
17    data in order to coordinate care.
18        (5) An ACE must be capable of providing both care
19    coordination and complex case management, as necessary, to
20    beneficiaries. To be responsive to the solicitation, a
21    potential ACE must outline its care coordination and
22    complex case management model and plan to reduce the cost
23    of care.
24        (6) In the first 18 months of operation, unless the ACE
25    selects a shorter period, an ACE shall be paid care
26    coordination fees on a per member per month basis that are

 

 

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1    projected to be cost neutral to the State during the term
2    of their payment and, subject to federal approval, be
3    eligible to share in additional savings generated by their
4    care coordination.
5        (7) In months 19 through 36 of operation, unless the
6    ACE selects a shorter period, an ACE shall be paid on a
7    pre-paid capitation basis for all medical assistance
8    covered services, under contract terms similar to Managed
9    Care Organizations (MCO), with the Department sharing the
10    risk through either stop-loss insurance for extremely high
11    cost individuals or corridors of shared risk based on the
12    overall cost of the total enrollment in the ACE. The ACE
13    shall be responsible for claims processing, encounter data
14    submission, utilization control, and quality assurance.
15        (8) In the fourth and subsequent years of operation, an
16    ACE shall convert to a Managed Care Community Network
17    (MCCN), as defined in this Article, or Health Maintenance
18    Organization pursuant to the Illinois Insurance Code,
19    accepting full-risk capitation payments.
20    The Department shall allow potential ACE entities 5 months
21from the date of the posting of the solicitation to submit
22proposals. After the solicitation is released, in addition to
23the MCO rate development data available on the Department's
24website, subject to federal and State confidentiality and
25privacy laws and regulations, the Department shall provide 2
26years of de-identified summary service data on the targeted

 

 

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1population, split between children and adults, showing the
2historical type and volume of services received and the cost of
3those services to those potential bidders that sign a data use
4agreement. The Department may add up to 2 non-state government
5employees with expertise in creating integrated delivery
6systems to its review team for the purchase of care
7solicitation described in this subsection. Any such
8individuals must sign a no-conflict disclosure and
9confidentiality agreement and agree to act in accordance with
10all applicable State laws.
11    During the first 2 years of an ACE's operation, the
12Department shall provide claims data to the ACE on its
13enrollees on a periodic basis no less frequently than monthly.
14    Nothing in this subsection shall be construed to limit the
15Department's mandate to enroll 50% of its beneficiaries into
16care coordination systems by January 1, 2015, using all
17available care coordination delivery systems, including Care
18Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
19to affect the current CCEs, MCCNs, and MCOs selected to serve
20seniors and persons with disabilities prior to that date.
21    Nothing in this subsection precludes the Department from
22considering future proposals for new ACEs or expansion of
23existing ACEs at the discretion of the Department.
24    (h) Department contracts with MCOs and other entities
25reimbursed by risk based capitation shall have a minimum
26medical loss ratio of 85%, shall require the entity to

 

 

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1establish an appeals and grievances process for consumers and
2providers, and shall require the entity to provide a quality
3assurance and utilization review program. Entities contracted
4with the Department to coordinate healthcare regardless of risk
5shall be measured utilizing the same quality metrics. The
6quality metrics may be population specific. Any contracted
7entity serving at least 5,000 seniors or people with
8disabilities or 15,000 individuals in other populations
9covered by the Medical Assistance Program that has been
10receiving full-risk capitation for a year shall be accredited
11by a national accreditation organization authorized by the
12Department within 2 years after the date it is eligible to
13become accredited. The requirements of this subsection shall
14apply to contracts with MCOs entered into or renewed or
15extended after June 1, 2013.
16    (h-5) The Department shall monitor and enforce compliance
17by MCOs with agreements they have entered into with providers
18on issues that include, but are not limited to, timeliness of
19payment, payment rates, and processes for obtaining prior
20approval. The Department may impose sanctions on MCOs for
21violating provisions of those agreements that include, but are
22not limited to, financial penalties, suspension of enrollment
23of new enrollees, and termination of the MCO's contract with
24the Department. As used in this subsection (h-5), "MCO" has the
25meaning ascribed to that term in Section 5-30.1 of this Code.
26    (i) Unless otherwise required by federal law, Medicaid

 

 

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1Managed Care Entities and their respective business associates
2shall not disclose, directly or indirectly, including by
3sending a bill or explanation of benefits, information
4concerning the sensitive health services received by enrollees
5of the Medicaid Managed Care Entity to any person other than
6covered entities and business associates, which may receive,
7use, and further disclose such information solely for the
8purposes permitted under applicable federal and State laws and
9regulations if such use and further disclosure satisfies all
10applicable requirements of such laws and regulations. The
11Medicaid Managed Care Entity or its respective business
12associates may disclose information concerning the sensitive
13health services if the enrollee who received the sensitive
14health services requests the information from the Medicaid
15Managed Care Entity or its respective business associates and
16authorized the sending of a bill or explanation of benefits.
17Communications including, but not limited to, statements of
18care received or appointment reminders either directly or
19indirectly to the enrollee from the health care provider,
20health care professional, and care coordinators, remain
21permissible. Medicaid Managed Care Entities or their
22respective business associates may communicate directly with
23their enrollees regarding care coordination activities for
24those enrollees.
25    For the purposes of this subsection, the term "Medicaid
26Managed Care Entity" includes Care Coordination Entities,

 

 

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1Accountable Care Entities, Managed Care Organizations, and
2Managed Care Community Networks.
3    For purposes of this subsection, the term "sensitive health
4services" means mental health services, substance abuse
5treatment services, reproductive health services, family
6planning services, services for sexually transmitted
7infections and sexually transmitted diseases, and services for
8sexual assault or domestic abuse. Services include prevention,
9screening, consultation, examination, treatment, or follow-up.
10    For purposes of this subsection, "business associate",
11"covered entity", "disclosure", and "use" have the meanings
12ascribed to those terms in 45 CFR 160.103.
13    Nothing in this subsection shall be construed to relieve a
14Medicaid Managed Care Entity or the Department of any duty to
15report incidents of sexually transmitted infections to the
16Department of Public Health or to the local board of health in
17accordance with regulations adopted under a statute or
18ordinance or to report incidents of sexually transmitted
19infections as necessary to comply with the requirements under
20Section 5 of the Abused and Neglected Child Reporting Act or as
21otherwise required by State or federal law.
22    The Department shall create policy in order to implement
23the requirements in this subsection.
24    (j) Managed Care Entities (MCEs), including MCOs and all
25other care coordination organizations, shall develop and
26maintain a written language access policy that sets forth the

 

 

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1standards, guidelines, and operational plan to ensure language
2appropriate services and that is consistent with the standard
3of meaningful access for populations with limited English
4proficiency. The language access policy shall describe how the
5MCEs will provide all of the following required services:
6        (1) Translation (the written replacement of text from
7    one language into another) of all vital documents and forms
8    as identified by the Department.
9        (2) Qualified interpreter services (the oral
10    communication of a message from one language into another
11    by a qualified interpreter).
12        (3) Staff training on the language access policy,
13    including how to identify language needs, access and
14    provide language assistance services, work with
15    interpreters, request translations, and track the use of
16    language assistance services.
17        (4) Data tracking that identifies the language need.
18        (5) Notification to participants on the availability
19    of language access services and on how to access such
20    services.
21    (k) The Department shall actively monitor the contractual
22relationship between Managed Care Organizations (MCOs) and any
23dental administrator contracted by an MCO to provide dental
24services. The Department shall adopt appropriate dental
25Healthcare Effectiveness Data and Information Set measures or
26other dental quality performance measures as part of its

 

 

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1monitoring and shall include additional specific dental
2performance measurers in its Health Plan Comparison Tool and
3Illinois Medicaid Plan Report Card that is available on the
4Department's website for enrolled individuals.
5    The Department shall collect from each MCO specific
6information about the types of contracted, broad-based, care
7coordination occurring between the MCO and any dental
8administrator, including, but not limited to, pregnant women
9and diabetic patients in need of oral care.
10(Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14;
1199-106, eff. 1-1-16; 99-181, eff. 7-29-15; 99-566, eff. 1-1-17;
1299-642, eff. 7-28-16.)".