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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 the

 

 

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1effective date of this amendatory Act of the 96th General
2Assembly.
3    (d) The Department shall report to the General Assembly in
4a separate part of its annual medical assistance program
5report, beginning April, 2012 until April, 2016, on the
6progress and implementation of the care coordination program
7initiatives established by the provisions of this amendatory
8Act of the 96th General Assembly. The Department shall include
9in its April 2011 report a full analysis of federal laws or
10regulations regarding upper payment limitations to providers
11and the necessary revisions or adjustments in rate
12methodologies and payments to providers under this Code that
13would be necessary to implement coordinated care with full
14financial risk by a party other than the Department.
15    The progress reports required under this subsection shall
16include, but need not be limited to, the following data and
17information:
18        (1) The total number of individuals covered under the
19    medical assistance program.
20        (2) The total number of individuals enrolled in
21    coordinated care.
22        (3) A breakdown of the individuals enrolled in
23    coordinated care by medical assistance enrollment
24    category, including parents, adults eligible for medical
25    assistance pursuant to the Patient Protection and
26    Affordable Care Act, children, seniors, and people with

 

 

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1    disabilities.
2        (4) A breakdown of the number of individuals enrolled
3    in coordinated care by the type of coordinated care model,
4    including individuals enrolled in Care Coordination
5    Entities (CCEs), Managed Care Community Networks (MCCNs),
6    Managed Care Organizations (MCOs), and Accountable Care
7    Entities (ACEs).
8    (e) Integrated Care Program for individuals with chronic
9mental health conditions.
10        (1) The Integrated Care Program shall encompass
11    services administered to recipients of medical assistance
12    under this Article to prevent exacerbations and
13    complications using cost-effective, evidence-based
14    practice guidelines and mental health management
15    strategies.
16        (2) The Department may utilize and expand upon existing
17    contractual arrangements with integrated care plans under
18    the Integrated Care Program for providing the coordinated
19    care provisions of this Section.
20        (3) Payment for such coordinated care shall be based on
21    arrangements where the State pays for performance related
22    to mental health outcomes on a capitated basis in which a
23    fixed monthly premium per recipient is paid and full
24    financial risk is assumed for the delivery of services, or
25    through other risk-based payment arrangements such as
26    provider-based care coordination.

 

 

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1        (4) The Department shall examine whether chronic
2    mental health management programs and services for
3    recipients with specific chronic mental health conditions
4    do any or all of the following:
5            (A) Improve the patient's overall mental health in
6        a more expeditious and cost-effective manner.
7            (B) Lower costs in other aspects of the medical
8        assistance program, such as hospital admissions,
9        emergency room visits, or more frequent and
10        inappropriate psychotropic drug use.
11        (5) The Department shall work with the facilities and
12    any integrated care plan participating in the program to
13    identify and correct barriers to the successful
14    implementation of this subsection (e) prior to and during
15    the implementation to best facilitate the goals and
16    objectives of this subsection (e).
17    (f) A hospital that is located in a county of the State in
18which the Department mandates some or all of the beneficiaries
19of the Medical Assistance Program residing in the county to
20enroll in a Care Coordination Program, as set forth in Section
215-30 of this Code, shall not be eligible for any non-claims
22based payments not mandated by Article V-A of this Code for
23which it would otherwise be qualified to receive, unless the
24hospital is a Coordinated Care Participating Hospital no later
25than 60 days after the effective date of this amendatory Act of
26the 97th General Assembly or 60 days after the first mandatory

 

 

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1enrollment of a beneficiary in a Coordinated Care program. For
2purposes of this subsection, "Coordinated Care Participating
3Hospital" means a hospital that meets one of the following
4criteria:
5        (1) The hospital has entered into a contract to provide
6    hospital services with one or more MCOs to enrollees of the
7    care coordination program.
8        (2) The hospital has not been offered a contract by a
9    care coordination plan that the Department has determined
10    to be a good faith offer and that pays at least as much as
11    the Department would pay, on a fee-for-service basis, not
12    including disproportionate share hospital adjustment
13    payments or any other supplemental adjustment or add-on
14    payment to the base fee-for-service rate, except to the
15    extent such adjustments or add-on payments are
16    incorporated into the development of the applicable MCO
17    capitated rates.
18    As used in this subsection (f), "MCO" means any entity
19which contracts with the Department to provide services where
20payment for medical services is made on a capitated basis.
21    (g) No later than August 1, 2013, the Department shall
22issue a purchase of care solicitation for Accountable Care
23Entities (ACE) to serve any children and parents or caretaker
24relatives of children eligible for medical assistance under
25this Article. An ACE may be a single corporate structure or a
26network of providers organized through contractual

 

 

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1relationships with a single corporate entity. The solicitation
2shall require that:
3        (1) An ACE operating in Cook County be capable of
4    serving at least 40,000 eligible individuals in that
5    county; an ACE operating in Lake, Kane, DuPage, or Will
6    Counties be capable of serving at least 20,000 eligible
7    individuals in those counties and an ACE operating in other
8    regions of the State be capable of serving at least 10,000
9    eligible individuals in the region in which it operates.
10    During initial periods of mandatory enrollment, the
11    Department shall require its enrollment services
12    contractor to use a default assignment algorithm that
13    ensures if possible an ACE reaches the minimum enrollment
14    levels set forth in this paragraph.
15        (2) An ACE must include at a minimum the following
16    types of providers: primary care, specialty care,
17    hospitals, and behavioral healthcare.
18        (3) An ACE shall have a governance structure that
19    includes the major components of the health care delivery
20    system, including one representative from each of the
21    groups listed in paragraph (2).
22        (4) An ACE must be an integrated delivery system,
23    including a network able to provide the full range of
24    services needed by Medicaid beneficiaries and system
25    capacity to securely pass clinical information across
26    participating entities and to aggregate and analyze that

 

 

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1    data in order to coordinate care.
2        (5) An ACE must be capable of providing both care
3    coordination and complex case management, as necessary, to
4    beneficiaries. To be responsive to the solicitation, a
5    potential ACE must outline its care coordination and
6    complex case management model and plan to reduce the cost
7    of care.
8        (6) In the first 18 months of operation, unless the ACE
9    selects a shorter period, an ACE shall be paid care
10    coordination fees on a per member per month basis that are
11    projected to be cost neutral to the State during the term
12    of their payment and, subject to federal approval, be
13    eligible to share in additional savings generated by their
14    care coordination.
15        (7) In months 19 through 36 of operation, unless the
16    ACE selects a shorter period, an ACE shall be paid on a
17    pre-paid capitation basis for all medical assistance
18    covered services, under contract terms similar to Managed
19    Care Organizations (MCO), with the Department sharing the
20    risk through either stop-loss insurance for extremely high
21    cost individuals or corridors of shared risk based on the
22    overall cost of the total enrollment in the ACE. The ACE
23    shall be responsible for claims processing, encounter data
24    submission, utilization control, and quality assurance.
25        (8) In the fourth and subsequent years of operation, an
26    ACE shall convert to a Managed Care Community Network

 

 

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1    (MCCN), as defined in this Article, or Health Maintenance
2    Organization pursuant to the Illinois Insurance Code,
3    accepting full-risk capitation payments.
4    The Department shall allow potential ACE entities 5 months
5from the date of the posting of the solicitation to submit
6proposals. After the solicitation is released, in addition to
7the MCO rate development data available on the Department's
8website, subject to federal and State confidentiality and
9privacy laws and regulations, the Department shall provide 2
10years of de-identified summary service data on the targeted
11population, split between children and adults, showing the
12historical type and volume of services received and the cost of
13those services to those potential bidders that sign a data use
14agreement. The Department may add up to 2 non-state government
15employees with expertise in creating integrated delivery
16systems to its review team for the purchase of care
17solicitation described in this subsection. Any such
18individuals must sign a no-conflict disclosure and
19confidentiality agreement and agree to act in accordance with
20all applicable State laws.
21    During the first 2 years of an ACE's operation, the
22Department shall provide claims data to the ACE on its
23enrollees on a periodic basis no less frequently than monthly.
24    Nothing in this subsection shall be construed to limit the
25Department's mandate to enroll 50% of its beneficiaries into
26care coordination systems by January 1, 2015, using all

 

 

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1available care coordination delivery systems, including Care
2Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
3to affect the current CCEs, MCCNs, and MCOs selected to serve
4seniors and persons with disabilities prior to that date.
5    Nothing in this subsection precludes the Department from
6considering future proposals for new ACEs or expansion of
7existing ACEs at the discretion of the Department.
8    (h) Department contracts with MCOs and other entities
9reimbursed by risk based capitation shall have a minimum
10medical loss ratio of 85%, shall require the entity to
11establish an appeals and grievances process for consumers and
12providers, and shall require the entity to provide a quality
13assurance and utilization review program. Entities contracted
14with the Department to coordinate healthcare regardless of risk
15shall be measured utilizing the same quality metrics. The
16quality metrics may be population specific. Any contracted
17entity serving at least 5,000 seniors or people with
18disabilities or 15,000 individuals in other populations
19covered by the Medical Assistance Program that has been
20receiving full-risk capitation for a year shall be accredited
21by a national accreditation organization authorized by the
22Department within 2 years after the date it is eligible to
23become accredited. The requirements of this subsection shall
24apply to contracts with MCOs entered into or renewed or
25extended after June 1, 2013.
26    (h-5) The Department shall monitor and enforce compliance

 

 

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1by MCOs with agreements they have entered into with providers
2on issues that include, but are not limited to, timeliness of
3payment, payment rates, and processes for obtaining prior
4approval. The Department may impose sanctions on MCOs for
5violating provisions of those agreements that include, but are
6not limited to, financial penalties, suspension of enrollment
7of new enrollees, and termination of the MCO's contract with
8the Department. As used in this subsection (h-5), "MCO" has the
9meaning ascribed to that term in Section 5-30.1 of this Code.
10(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13;
1198-651, eff. 6-16-14.)