Full Text of SB0343 99th General Assembly
SB0343sam001 99TH GENERAL ASSEMBLY | Sen. Heather A. Steans Filed: 3/19/2015
| | 09900SB0343sam001 | | LRB099 03285 KTG 32439 a |
|
| 1 | | AMENDMENT TO SENATE BILL 343
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 343 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Illinois Public Aid Code is amended by | 5 | | changing 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 | 9 | | medical benefits in all medical assistance programs or other | 10 | | health benefit programs administered by the Department, | 11 | | including the Children's Health Insurance Program Act and the | 12 | | Covering ALL KIDS Health Insurance Act, shall be enrolled in a | 13 | | care coordination program by no later than January 1, 2015. For | 14 | | purposes of this Section, "coordinated care" or "care | 15 | | coordination" means delivery systems where recipients will | 16 | | receive their care from providers who participate under |
| | | 09900SB0343sam001 | - 2 - | LRB099 03285 KTG 32439 a |
|
| 1 | | contract in integrated delivery systems that are responsible | 2 | | for providing or arranging the majority of care, including | 3 | | primary care physician services, referrals from primary care | 4 | | physicians, diagnostic and treatment services, behavioral | 5 | | health services, in-patient and outpatient hospital services, | 6 | | dental services, and rehabilitation and long-term care | 7 | | services. The Department shall designate or contract for such | 8 | | integrated delivery systems (i) to ensure enrollees have a | 9 | | choice of systems and of primary care providers within such | 10 | | systems; (ii) to ensure that enrollees receive quality care in | 11 | | a culturally and linguistically appropriate manner; and (iii) | 12 | | to ensure that coordinated care programs meet the diverse needs | 13 | | of enrollees with developmental, mental health, physical, and | 14 | | age-related disabilities. | 15 | | (b) Payment for such coordinated care shall be based on | 16 | | arrangements where the State pays for performance related to | 17 | | health care outcomes, the use of evidence-based practices, the | 18 | | use of primary care delivered through comprehensive medical | 19 | | homes, the use of electronic medical records, and the | 20 | | appropriate exchange of health information electronically made | 21 | | either on a capitated basis in which a fixed monthly premium | 22 | | per recipient is paid and full financial risk is assumed for | 23 | | the delivery of services, or through other risk-based payment | 24 | | arrangements. | 25 | | (c) To qualify for compliance with this Section, the 50% | 26 | | goal shall be achieved by enrolling medical assistance |
| | | 09900SB0343sam001 | - 3 - | LRB099 03285 KTG 32439 a |
|
| 1 | | enrollees from each medical assistance enrollment category, | 2 | | including parents, children, seniors, and people with | 3 | | disabilities to the extent that current State Medicaid payment | 4 | | laws would not limit federal matching funds for recipients in | 5 | | care coordination programs. In addition, services must be more | 6 | | comprehensively defined and more risk shall be assumed than in | 7 | | the Department's primary care case management program as of the | 8 | | effective date of this amendatory Act of the 96th General | 9 | | Assembly. | 10 | | (d) The Department shall report to the General Assembly in | 11 | | a separate part of its annual medical assistance program | 12 | | report, beginning April, 2012 until April, 2016, on the | 13 | | progress and implementation of the care coordination program | 14 | | initiatives established by the provisions of this amendatory | 15 | | Act of the 96th General Assembly. The Department shall include | 16 | | in its April 2011 report a full analysis of federal laws or | 17 | | regulations regarding upper payment limitations to providers | 18 | | and the necessary revisions or adjustments in rate | 19 | | methodologies and payments to providers under this Code that | 20 | | would be necessary to implement coordinated care with full | 21 | | financial risk by a party other than the Department.
| 22 | | (e) Integrated Care Program for individuals with chronic | 23 | | mental health conditions. | 24 | | (1) The Integrated Care Program shall encompass | 25 | | services administered to recipients of medical assistance | 26 | | under this Article to prevent exacerbations and |
| | | 09900SB0343sam001 | - 4 - | LRB099 03285 KTG 32439 a |
|
| 1 | | complications using cost-effective, evidence-based | 2 | | practice guidelines and mental health management | 3 | | strategies. | 4 | | (2) The Department may utilize and expand upon existing | 5 | | contractual arrangements with integrated care plans under | 6 | | the Integrated Care Program for providing the coordinated | 7 | | care provisions of this Section. | 8 | | (3) Payment for such coordinated care shall be based on | 9 | | arrangements where the State pays for performance related | 10 | | to mental health outcomes on a capitated basis in which a | 11 | | fixed monthly premium per recipient is paid and full | 12 | | financial risk is assumed for the delivery of services, or | 13 | | through other risk-based payment arrangements such as | 14 | | provider-based care coordination. | 15 | | (4) The Department shall examine whether chronic | 16 | | mental health management programs and services for | 17 | | recipients with specific chronic mental health conditions | 18 | | do any or all of the following: | 19 | | (A) Improve the patient's overall mental health in | 20 | | a more expeditious and cost-effective manner. | 21 | | (B) Lower costs in other aspects of the medical | 22 | | assistance program, such as hospital admissions, | 23 | | emergency room visits, or more frequent and | 24 | | inappropriate psychotropic drug use. | 25 | | (5) The Department shall work with the facilities and | 26 | | any integrated care plan participating in the program to |
| | | 09900SB0343sam001 | - 5 - | LRB099 03285 KTG 32439 a |
|
| 1 | | identify and correct barriers to the successful | 2 | | implementation of this subsection (e) prior to and during | 3 | | the implementation to best facilitate the goals and | 4 | | objectives of this subsection (e). | 5 | | (f) A hospital that is located in a county of the State in | 6 | | which the Department mandates some or all of the beneficiaries | 7 | | of the Medical Assistance Program residing in the county to | 8 | | enroll in a Care Coordination Program, as set forth in Section | 9 | | 5-30 of this Code, shall not be eligible for any non-claims | 10 | | based payments not mandated by Article V-A of this Code for | 11 | | which it would otherwise be qualified to receive, unless the | 12 | | hospital is a Coordinated Care Participating Hospital no later | 13 | | than 60 days after the effective date of this amendatory Act of | 14 | | the 97th General Assembly or 60 days after the first mandatory | 15 | | enrollment of a beneficiary in a Coordinated Care program. For | 16 | | purposes of this subsection, "Coordinated Care Participating | 17 | | Hospital" means a hospital that meets one of the following | 18 | | criteria: | 19 | | (1) The hospital has entered into a contract to provide | 20 | | hospital services with one or more MCOs to enrollees of the | 21 | | care coordination program. | 22 | | (2) The hospital has not been offered a contract by a | 23 | | care coordination plan that the Department has determined | 24 | | to be a good faith offer and that pays at least as much as | 25 | | the Department would pay, on a fee-for-service basis, not | 26 | | including disproportionate share hospital adjustment |
| | | 09900SB0343sam001 | - 6 - | LRB099 03285 KTG 32439 a |
|
| 1 | | payments or any other supplemental adjustment or add-on | 2 | | payment to the base fee-for-service rate, except to the | 3 | | extent such adjustments or add-on payments are | 4 | | incorporated into the development of the applicable MCO | 5 | | capitated rates. | 6 | | As used in this subsection (f), "MCO" means any entity | 7 | | which contracts with the Department to provide services where | 8 | | payment for medical services is made on a capitated basis. | 9 | | (g) No later than August 1, 2013, the Department shall | 10 | | issue a purchase of care solicitation for Accountable Care | 11 | | Entities (ACE) to serve any children and parents or caretaker | 12 | | relatives of children eligible for medical assistance under | 13 | | this Article. An ACE may be a single corporate structure or a | 14 | | network of providers organized through contractual | 15 | | relationships with a single corporate entity. The solicitation | 16 | | shall require that: | 17 | | (1) An ACE operating in Cook County be capable of | 18 | | serving at least 40,000 eligible individuals in that | 19 | | county; an ACE operating in Lake, Kane, DuPage, or Will | 20 | | Counties be capable of serving at least 20,000 eligible | 21 | | individuals in those counties and an ACE operating in other | 22 | | regions of the State be capable of serving at least 10,000 | 23 | | eligible individuals in the region in which it operates. | 24 | | During initial periods of mandatory enrollment, the | 25 | | Department shall require its enrollment services | 26 | | contractor to use a default assignment algorithm that |
| | | 09900SB0343sam001 | - 7 - | LRB099 03285 KTG 32439 a |
|
| 1 | | ensures if possible an ACE reaches the minimum enrollment | 2 | | levels set forth in this paragraph. | 3 | | (2) An ACE must include at a minimum the following | 4 | | types of providers: primary care, specialty care, | 5 | | hospitals, and behavioral healthcare. | 6 | | (3) An ACE shall have a governance structure that | 7 | | includes the major components of the health care delivery | 8 | | system, including one representative from each of the | 9 | | groups listed in paragraph (2). | 10 | | (4) An ACE must be an integrated delivery system, | 11 | | including a network able to provide the full range of | 12 | | services needed by Medicaid beneficiaries and system | 13 | | capacity to securely pass clinical information across | 14 | | participating entities and to aggregate and analyze that | 15 | | data in order to coordinate care. | 16 | | (5) An ACE must be capable of providing both care | 17 | | coordination and complex case management, as necessary, to | 18 | | beneficiaries. To be responsive to the solicitation, a | 19 | | potential ACE must outline its care coordination and | 20 | | complex case management model and plan to reduce the cost | 21 | | of care. | 22 | | (6) In the first 18 months of operation, unless the ACE | 23 | | selects a shorter period, an ACE shall be paid care | 24 | | coordination fees on a per member per month basis that are | 25 | | projected to be cost neutral to the State during the term | 26 | | of their payment and, subject to federal approval, be |
| | | 09900SB0343sam001 | - 8 - | LRB099 03285 KTG 32439 a |
|
| 1 | | eligible to share in additional savings generated by their | 2 | | care coordination. | 3 | | (7) In months 19 through 36 of operation, unless the | 4 | | ACE selects a shorter period, an ACE shall be paid on a | 5 | | pre-paid capitation basis for all medical assistance | 6 | | covered services, under contract terms similar to Managed | 7 | | Care Organizations (MCO), with the Department sharing the | 8 | | risk through either stop-loss insurance for extremely high | 9 | | cost individuals or corridors of shared risk based on the | 10 | | overall cost of the total enrollment in the ACE. The ACE | 11 | | shall be responsible for claims processing, encounter data | 12 | | submission, utilization control, and quality assurance. | 13 | | (8) In the fourth and subsequent years of operation, an | 14 | | ACE shall convert to a Managed Care Community Network | 15 | | (MCCN), as defined in this Article, or Health Maintenance | 16 | | Organization pursuant to the Illinois Insurance Code, | 17 | | accepting full-risk capitation payments. | 18 | | The Department shall allow potential ACE entities 5 months | 19 | | from the date of the posting of the solicitation to submit | 20 | | proposals. After the solicitation is released, in addition to | 21 | | the MCO rate development data available on the Department's | 22 | | website, subject to federal and State confidentiality and | 23 | | privacy laws and regulations, the Department shall provide 2 | 24 | | years of de-identified summary service data on the targeted | 25 | | population, split between children and adults, showing the | 26 | | historical type and volume of services received and the cost of |
| | | 09900SB0343sam001 | - 9 - | LRB099 03285 KTG 32439 a |
|
| 1 | | those services to those potential bidders that sign a data use | 2 | | agreement. The Department may add up to 2 non-state government | 3 | | employees with expertise in creating integrated delivery | 4 | | systems to its review team for the purchase of care | 5 | | solicitation described in this subsection. Any such | 6 | | individuals must sign a no-conflict disclosure and | 7 | | confidentiality agreement and agree to act in accordance with | 8 | | all applicable State laws. | 9 | | During the first 2 years of an ACE's operation, the | 10 | | Department shall provide claims data to the ACE on its | 11 | | enrollees on a periodic basis no less frequently than monthly. | 12 | | Nothing in this subsection shall be construed to limit the | 13 | | Department's mandate to enroll 50% of its beneficiaries into | 14 | | care coordination systems by January 1, 2015, using all | 15 | | available care coordination delivery systems, including Care | 16 | | Coordination Entities (CCE), MCCNs, or MCOs, nor be construed | 17 | | to affect the current CCEs, MCCNs, and MCOs selected to serve | 18 | | seniors and persons with disabilities prior to that date. | 19 | | Nothing in this subsection precludes the Department from | 20 | | considering future proposals for new ACEs or expansion of | 21 | | existing ACEs at the discretion of the Department. | 22 | | (h) Department contracts with MCOs and other entities | 23 | | reimbursed by risk based capitation shall have a minimum | 24 | | medical loss ratio of 85%, shall require the entity to | 25 | | establish an appeals and grievances process for consumers and | 26 | | providers, and shall require the entity to provide a quality |
| | | 09900SB0343sam001 | - 10 - | LRB099 03285 KTG 32439 a |
|
| 1 | | assurance and utilization review program. Entities contracted | 2 | | with the Department to coordinate healthcare regardless of risk | 3 | | shall be measured utilizing the same quality metrics. The | 4 | | quality metrics may be population specific. Any contracted | 5 | | entity serving at least 5,000 seniors or people with | 6 | | disabilities or 15,000 individuals in other populations | 7 | | covered by the Medical Assistance Program that has been | 8 | | receiving full-risk capitation for a year shall be accredited | 9 | | by a national accreditation organization authorized by the | 10 | | Department within 2 years after the date it is eligible to | 11 | | become accredited. The requirements of this subsection shall | 12 | | apply to contracts with MCOs entered into or renewed or | 13 | | extended after June 1, 2013. | 14 | | (h-5) The Department shall monitor and enforce compliance | 15 | | by MCOs with agreements they have entered into with providers | 16 | | on issues that include, but are not limited to, timeliness of | 17 | | payment, payment rates, and processes for obtaining prior | 18 | | approval. The Department may impose sanctions on MCOs for | 19 | | violating provisions of those agreements that include, but are | 20 | | not limited to, financial penalties, suspension of enrollment | 21 | | of new enrollees, and termination of the MCO's contract with | 22 | | the Department. As used in this subsection (h-5), "MCO" has the | 23 | | meaning ascribed to that term in Section 5-30.1 of this Code. | 24 | | (i) As used in this subsection: | 25 | | "Care coordination entity" means a collaboration of | 26 | | providers and community agencies, governed by a lead entity, |
| | | 09900SB0343sam001 | - 11 - | LRB099 03285 KTG 32439 a |
|
| 1 | | which receives a care coordination payment with a portion of | 2 | | the payment at risk for meeting quality outcome targets, in | 3 | | order to provide care coordination services for its enrollees. | 4 | | "Children with complex medical needs" means persons under | 5 | | 21 years of age who are clients of medical assistance programs | 6 | | or other health benefit programs administered by the Department | 7 | | through the use of the 3M TM Clinical Risk Grouping Software | 8 | | (CRG) as Status 6.1 and above, through a clinical screening | 9 | | tool, or those who do not have sufficient claims data in order | 10 | | to be identified by the Department through the CRG software. | 11 | | The Department shall offer children with complex medical | 12 | | needs the choice of enrollment in a coordinated care entity | 13 | | (CCE) to provide services to the children, where available. | 14 | | This choice shall be in addition to otherwise available health | 15 | | maintenance organizations (HMOs), managed care community | 16 | | networks (MCCNs), and accountable care entities (ACEs). | 17 | | Children with complex medical needs under 18 years of age | 18 | | shall be eligible to enroll in the CCE as long as such children | 19 | | continue to maintain eligibility for medical assistance | 20 | | programs or other health benefit programs administered by the | 21 | | Department. The Department may choose to extend enrollment to | 22 | | individuals under 21 years of age for initial enrollment. | 23 | | Individuals may also be excluded if they are: | 24 | | (1) enrolled in the Medically Fragile Technology | 25 | | Dependent Waiver; | 26 | | (2) receiving private duty nursing; |
| | | 09900SB0343sam001 | - 12 - | LRB099 03285 KTG 32439 a |
|
| 1 | | (3) eligible for high third party liability coverage as | 2 | | defined by the Department; | 3 | | (4) residing in institutions including pediatric | 4 | | skilled nursing facilities; | 5 | | (5) enrolled in the DSCC Core Program; or | 6 | | (6) placed in foster care with the Department of | 7 | | Children and Family Services. | 8 | | The Department shall ensure that the parents of all | 9 | | eligible enrollees that are children with complex medical needs | 10 | | shall receive notification of their eligibility and an | 11 | | explanation of how to elect the CCE option. The Department | 12 | | shall ensure that any third party enrollment broker is briefed | 13 | | on such CCE option and that the broker shall ensure that all | 14 | | enrollment options are presented to the parents of children | 15 | | with complex medical needs. | 16 | | (Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13; | 17 | | 98-651, eff. 6-16-14.)
| 18 | | Section 99. Effective date. This Act takes effect upon | 19 | | becoming law.".
|
|