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(305 ILCS 65/10)
Medicaid pilot program for opioid and other
(a) Legislative findings. The General Assembly finds as follows:
(1) Illinois continues to face a serious and ongoing
(2) Opioid-related overdose deaths rose 76% between
(3) Opioid and other drug addictions are life-long
diseases that require a disease management approach and not just episodic treatment.
(4) There is an urgent need to create a treatment
approach that proactively engages and encourages individuals with opioid and other drug addictions into treatment to help prevent chronic use and a worsening addiction and to significantly curb the rate of overdose deaths.
(b) With the goal of early initial engagement of individuals who have an opioid or other drug addiction in addiction treatment and for keeping individuals engaged in treatment following detoxification, a residential treatment stay, or hospitalization to prevent chronic recurrent drug use, the Department of Healthcare and Family Services, in partnership with the Department of Human Services' Division of Substance Use Prevention and Recovery and with meaningful input from stakeholders, shall develop an Assertive Engagement and Community-Based Clinical Treatment Pilot Program for early treatment of an opioid or other drug addiction. The pilot program shall be implemented across a broad spectrum of geographic regions across the State.
(c) Assertive engagement and community-based clinical treatment services. All services included in the pilot program established under this Section shall be evidence-based or evidence-informed as applicable and the services shall be flexibly provided in-office, in-home, and in-community with an emphasis on in-home and in-community services. The model shall take into consideration area workforce, community uniqueness, and cultural diversity. The model shall, at a minimum, allow for and include each of the following:
(1) Assertive community outreach, engagement, and
continuing care strategies to encourage participation and retention in addiction treatment services for both initial engagement into addiction treatment services, and for post-hospitalization, post-detoxification, and post-residential treatment.
(2) Case management for purposes of linking
individuals to treatment, ongoing monitoring, problem solving, and assisting individuals in organizing their treatment and goals. Case management shall be covered for individuals not yet engaged in treatment for purposes of reaching such individuals early on in their addiction and for individuals in treatment.
(3) Clinical treatment that is delivered in an
individual's natural environment, including in-home or in-community treatment, to better equip the individual with coping mechanisms that may trigger re-use.
(4) Coverage of provider transportation costs in
delivering in-home and in-community services in both rural and urban settings. For rural communities, the model shall take into account the wider geographic areas providers are required to travel for in-home and in-community pilot services for purposes of reimbursement.
(5) Recovery support services.
(6) For individuals who receive services through the
pilot program but disengage for a short duration (a period of no longer than 9 months), allow seamless treatment re-engagement in the pilot program.
(7) Supported education and employment.
(8) Working with the individual's family, school, and
other community support systems.
(9) Service flexibility to enable recovery and
positive health outcomes.
(d) Federal waiver or State Plan amendment; implementation timeline. The Department shall follow the timeline for application for federal approval and implementation outlined in subsection (c) of Section 5. The pilot program contemplated in this Section shall be implemented only to the extent that federal financial participation is available.
(e) Pay-for-performance payment model. The Department of Healthcare and Family Services, in partnership with the Department of Human Services' Division of Substance Use Prevention and Recovery and with meaningful input from stakeholders, shall develop a pay-for-performance payment model aimed at achieving high-quality treatment and overall health and quality of life outcomes, rather than a fee-for-service payment model. The payment model shall allow for service flexibility to achieve such outcomes, shall cover actual provider costs of delivering the pilot program services to enable sustainability, and shall include all provider costs associated with the data collection for purposes of the analytics and outcomes reporting required in subsection (g). The Department shall ensure that the payment model works as intended by this Section within managed care.
(f) Rulemaking. The Department of Healthcare and Family Services, in partnership with the Department of Human Services' Division of Substance Use Prevention and Recovery and with meaningful input from stakeholders, shall develop rules for purposes of implementation of the pilot program within 6 months after federal approval of the pilot program. If the Department determines federal approval is not required for implementation, the Department shall develop rules with meaningful stakeholder input no later than December 31, 2019.
(g) Pilot program analytics and outcomes reports. The Department of Healthcare and Family Services shall engage a third party partner with expertise in program evaluation, analysis, and research at the end of 5 years of implementation to review the outcomes of the pilot program in treating addiction and preventing periods of symptom exacerbation and recurrence. For purposes of evaluating the outcomes of the pilot program, the Department shall require providers of the pilot program services to track all of the following annual data:
(1) Length of engagement and retention in pilot
(2) Recurrence of drug use.
(3) Symptom management (the ability or inability to
(4) Days of hospitalizations related to substance use
or residential treatment stays.
(5) Periods of homelessness and periods of housing
(6) Periods of criminal justice involvement.
(7) Educational and employment attainment during
following pilot program services.
(8) Enrollee satisfaction with his or her quality of
life and level of social connectedness, pre-pilot and post-pilot services.
(h) The Department of Healthcare and Family Services shall deliver a final report to the General Assembly on the outcomes of the pilot program within one year after 4 years of full implementation, and after 7 years of full implementation, compared to typical treatment available to other youth with significant mental health conditions, as well as the cost savings associated with the pilot program taking into account all public systems used when an individual with a significant mental health condition does not have access to the right treatment and supports in the early stages of his or her illness.
The reports to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.
Post-pilot program discharge outcomes shall be collected for all service recipients who exit the pilot program for up to 3 years after exit. This includes youth who exit the program with planned or unplanned discharges. The post-exit data collected shall include the annual data listed in paragraphs (1) through (8) of subsection (g). Data collection shall be done in a manner that does not violate individual privacy laws. Outcomes for enrollees in the pilot and post-exit outcomes shall be included in the final report to the General Assembly under this subsection (h) within one year of 4 full years of implementation, and in an additional report within one year of 7 full years of implementation in order to provide more information about post-exit outcomes on a greater number of youth who enroll in pilot program services in the final years of the pilot program.
(Source: P.A. 100-1016, eff. 8-21-18; 101-81, eff. 7-12-19.)