99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
HB5524

 

Introduced , by Rep. Greg Harris

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-30

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that, beginning July 1, 2018, Accountable Care Entities, Managed Care Community Networks, and Managed Care Organizations shall report annually on HIV viral load suppression as a quality measure related to HIV/AIDS disease management. Requires implementation of reporting on the HIV quality measure to be done in consultation with the Department of Healthcare and Family Services, the Department of Public Health, health care providers and community-based organizations with expertise in HIV/AIDS care, impacted MCOs, and other interested parties and to be based on nationally-recognized quality measurement standards.


LRB099 18688 KTG 43071 b

 

 

A BILL FOR

 

HB5524LRB099 18688 KTG 43071 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

 

 

HB5524- 2 -LRB099 18688 KTG 43071 b

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

 

 

HB5524- 3 -LRB099 18688 KTG 43071 b

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

 

 

HB5524- 4 -LRB099 18688 KTG 43071 b

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

 

 

HB5524- 5 -LRB099 18688 KTG 43071 b

1of the Medical Assistance Program residing in the county to
2enroll in a Care Coordination Program, as set forth in Section
35-30 of this Code, shall not be eligible for any non-claims
4based payments not mandated by Article V-A of this Code for
5which it would otherwise be qualified to receive, unless the
6hospital is a Coordinated Care Participating Hospital no later
7than 60 days after June 14, 2012 (the effective date of Public
8Act 97-689) this amendatory Act of the 97th General Assembly or
960 days after the first mandatory enrollment of a beneficiary
10in a Coordinated Care program. For purposes of this subsection,
11"Coordinated Care Participating Hospital" means a hospital
12that meets one of the following criteria:
13        (1) The hospital has entered into a contract to provide
14    hospital services with one or more MCOs to enrollees of the
15    care coordination program.
16        (2) The hospital has not been offered a contract by a
17    care coordination plan that the Department has determined
18    to be a good faith offer and that pays at least as much as
19    the Department would pay, on a fee-for-service basis, not
20    including disproportionate share hospital adjustment
21    payments or any other supplemental adjustment or add-on
22    payment to the base fee-for-service rate, except to the
23    extent such adjustments or add-on payments are
24    incorporated into the development of the applicable MCO
25    capitated rates.
26    As used in this subsection (f), "MCO" means any entity

 

 

HB5524- 6 -LRB099 18688 KTG 43071 b

1which contracts with the Department to provide services where
2payment for medical services is made on a capitated basis.
3    (g) No later than August 1, 2013, the Department shall
4issue a purchase of care solicitation for Accountable Care
5Entities (ACE) to serve any children and parents or caretaker
6relatives of children eligible for medical assistance under
7this Article. An ACE may be a single corporate structure or a
8network of providers organized through contractual
9relationships with a single corporate entity. The solicitation
10shall require that:
11        (1) An ACE operating in Cook County be capable of
12    serving at least 40,000 eligible individuals in that
13    county; an ACE operating in Lake, Kane, DuPage, or Will
14    Counties be capable of serving at least 20,000 eligible
15    individuals in those counties and an ACE operating in other
16    regions of the State be capable of serving at least 10,000
17    eligible individuals in the region in which it operates.
18    During initial periods of mandatory enrollment, the
19    Department shall require its enrollment services
20    contractor to use a default assignment algorithm that
21    ensures if possible an ACE reaches the minimum enrollment
22    levels set forth in this paragraph.
23        (2) An ACE must include at a minimum the following
24    types of providers: primary care, specialty care,
25    hospitals, and behavioral healthcare.
26        (3) An ACE shall have a governance structure that

 

 

HB5524- 7 -LRB099 18688 KTG 43071 b

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

 

 

HB5524- 8 -LRB099 18688 KTG 43071 b

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

 

 

HB5524- 9 -LRB099 18688 KTG 43071 b

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

 

 

HB5524- 10 -LRB099 18688 KTG 43071 b

1covered by the Medical Assistance Program that has been
2receiving full-risk capitation for a year shall be accredited
3by a national accreditation organization authorized by the
4Department within 2 years after the date it is eligible to
5become accredited. The requirements of this subsection shall
6apply to contracts with MCOs entered into or renewed or
7extended after June 1, 2013.
8    (h-5) The Department shall monitor and enforce compliance
9by MCOs with agreements they have entered into with providers
10on issues that include, but are not limited to, timeliness of
11payment, payment rates, and processes for obtaining prior
12approval. The Department may impose sanctions on MCOs for
13violating provisions of those agreements that include, but are
14not limited to, financial penalties, suspension of enrollment
15of new enrollees, and termination of the MCO's contract with
16the Department. As used in this subsection (h-5), "MCO" has the
17meaning ascribed to that term in Section 5-30.1 of this Code.
18    (i) Unless otherwise required by federal law, Medicaid
19Managed Care Entities shall not divulge, directly or
20indirectly, including by sending a bill or explanation of
21benefits, information concerning the sensitive health services
22received by enrollees of the Medicaid Managed Care Entity to
23any person other than providers and care coordinators caring
24for the enrollee and employees of the entity in the course of
25the entity's internal operations. The Medicaid Managed Care
26Entity may divulge information concerning the sensitive health

 

 

HB5524- 11 -LRB099 18688 KTG 43071 b

1services if the enrollee who received the sensitive health
2services requests the information from the Medicaid Managed
3Care Entity and authorized the sending of a bill or explanation
4of benefits. Communications including, but not limited to,
5statements of care received or appointment reminders either
6directly or indirectly to the enrollee from the health care
7provider, health care professional, and care coordinators,
8remain permissible.
9    For the purposes of this subsection, the term "Medicaid
10Managed Care Entity" includes Care Coordination Entities,
11Accountable Care Entities, Managed Care Organizations, and
12Managed Care Community Networks.
13    For purposes of this subsection, the term "sensitive health
14services" means mental health services, substance abuse
15treatment services, reproductive health services, family
16planning services, services for sexually transmitted
17infections and sexually transmitted diseases, and services for
18sexual assault or domestic abuse. Services include prevention,
19screening, consultation, examination, treatment, or follow-up.
20    Nothing in this subsection shall be construed to relieve a
21Medicaid Managed Care Entity or the Department of any duty to
22report incidents of sexually transmitted infections to the
23Department of Public Health or to the local board of health in
24accordance with regulations adopted under a statute or
25ordinance or to report incidents of sexually transmitted
26infections as necessary to comply with the requirements under

 

 

HB5524- 12 -LRB099 18688 KTG 43071 b

1Section 5 of the Abused and Neglected Child Reporting Act or as
2otherwise required by State or federal law.
3    The Department shall create policy in order to implement
4the requirements in this subsection.
5    (j) (i) Managed Care Entities (MCEs), including MCOs and
6all other care coordination organizations, shall develop and
7maintain a written language access policy that sets forth the
8standards, guidelines, and operational plan to ensure language
9appropriate services and that is consistent with the standard
10of meaningful access for populations with limited English
11proficiency. The language access policy shall describe how the
12MCEs will provide all of the following required services:
13        (1) Translation (the written replacement of text from
14    one language into another) of all vital documents and forms
15    as identified by the Department.
16        (2) Qualified interpreter services (the oral
17    communication of a message from one language into another
18    by a qualified interpreter).
19        (3) Staff training on the language access policy,
20    including how to identify language needs, access and
21    provide language assistance services, work with
22    interpreters, request translations, and track the use of
23    language assistance services.
24        (4) Data tracking that identifies the language need.
25        (5) Notification to participants on the availability
26    of language access services and on how to access such

 

 

HB5524- 13 -LRB099 18688 KTG 43071 b

1    services.
2    (k) Beginning July 1, 2018, ACEs, MCCNs, and MCOs shall
3report annually on HIV viral load suppression as a quality
4measure related to HIV/AIDS disease management. Implementation
5of reporting on the HIV quality measure shall be done in
6consultation with the Department, the Department of Public
7Health, health care providers and community-based
8organizations with expertise in HIV/AIDS care, impacted MCOs,
9and other interested parties and shall be based on
10nationally-recognized quality measurement standards. As used
11in this subsection, "MCO" has the meaning ascribed to that term
12in Section 5-30.1 of this Code.
13(Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14;
1499-106, eff. 1-1-16; 99-181, eff. 7-29-15; revised 10-26-15.)