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90_SB0317ren
305 ILCS 5/4-0.5
Amends the Aid to Families with Dependent Children
Article of the Illinois Public Aid Code. Makes a technical
change in provisions regarding the termination of the AFDC
program on December 31, 1998.
LRB9001503SMdv
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1 AN ACT regarding health services, amending named Acts.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Public Aid Code is amended by
5 changing Sections 4-19, 5-16.3, and 8A-6, and by adding
6 Sections 5-16.10, 5-16.11, 8A-13, 8A-14, 8A-15, 8A-16, and
7 8A-17 as follows:
8 (305 ILCS 5/4-19)
9 Sec. 4-19. Demonstration project; treatment; AFDC. The
10 Department, in cooperation with the Department of Alcoholism
11 and Substance Abuse, is authorized to conduct a demonstration
12 project in which clients who are identified as having an
13 alcohol or substance abuse problem must, as a condition of
14 eligibility for assistance under this Article, participate in
15 an alcohol or substance abuse treatment program. The
16 Department shall, by rule, establish (i) the sites for the
17 demonstration program, (ii) the methods for determining
18 whether a client has an alcohol or substance abuse problem,
19 and (iii) the sanctions for failure to cooperate. The
20 demonstration program shall terminate on January 1, 2000. At
21 the end of the demonstration program, the program may be
22 extended expended, by rule, to other areas of the State or
23 the entire State. The Department shall apply for all
24 appropriate waivers of federal requirements necessary to
25 implement this Section.
26 (305 ILCS 5/5-16.3)
27 (Text of Section before amendment by P.A. 89-507)
28 Sec. 5-16.3. System for integrated health care services.
29 (a) It shall be the public policy of the State to adopt,
30 to the extent practicable, a health care program that
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1 encourages the integration of health care services and
2 manages the health care of program enrollees while preserving
3 reasonable choice within a competitive and cost-efficient
4 environment. In furtherance of this public policy, the
5 Illinois Department shall develop and implement an integrated
6 health care program consistent with the provisions of this
7 Section. The provisions of this Section apply only to the
8 integrated health care program created under this Section.
9 Persons enrolled in the integrated health care program, as
10 determined by the Illinois Department by rule, shall be
11 afforded a choice among health care delivery systems, which
12 shall include, but are not limited to, (i) fee for service
13 care managed by a primary care physician licensed to practice
14 medicine in all its branches, (ii) managed health care
15 entities, and (iii) federally qualified health centers
16 (reimbursed according to a prospective cost-reimbursement
17 methodology) and rural health clinics (reimbursed according
18 to the Medicare methodology), where available. Persons
19 enrolled in the integrated health care program also may be
20 offered indemnity insurance plans, subject to availability.
21 For purposes of this Section, a "managed health care
22 entity" means a health maintenance organization or a managed
23 care community network as defined in this Section. A "health
24 maintenance organization" means a health maintenance
25 organization as defined in the Health Maintenance
26 Organization Act. A "managed care community network" means
27 an entity, other than a health maintenance organization, that
28 is owned, operated, or governed by providers of health care
29 services within this State and that provides or arranges
30 primary, secondary, and tertiary managed health care services
31 under contract with the Illinois Department exclusively to
32 enrollees of the integrated health care program. A managed
33 care community network may contract with the Illinois
34 Department to provide only pediatric health care services. A
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1 county provider as defined in Section 15-1 of this Code may
2 contract with the Illinois Department to provide services to
3 enrollees of the integrated health care program as a managed
4 care community network without the need to establish a
5 separate entity that provides services exclusively to
6 enrollees of the integrated health care program and shall be
7 deemed a managed care community network for purposes of this
8 Code only to the extent of the provision of services to those
9 enrollees in conjunction with the integrated health care
10 program. A county provider shall be entitled to contract
11 with the Illinois Department with respect to any contracting
12 region located in whole or in part within the county. A
13 county provider shall not be required to accept enrollees who
14 do not reside within the county.
15 Each managed care community network must demonstrate its
16 ability to bear the financial risk of serving enrollees under
17 this program. The Illinois Department shall by rule adopt
18 criteria for assessing the financial soundness of each
19 managed care community network. These rules shall consider
20 the extent to which a managed care community network is
21 comprised of providers who directly render health care and
22 are located within the community in which they seek to
23 contract rather than solely arrange or finance the delivery
24 of health care. These rules shall further consider a variety
25 of risk-bearing and management techniques, including the
26 sufficiency of quality assurance and utilization management
27 programs and whether a managed care community network has
28 sufficiently demonstrated its financial solvency and net
29 worth. The Illinois Department's criteria must be based on
30 sound actuarial, financial, and accounting principles. In
31 adopting these rules, the Illinois Department shall consult
32 with the Illinois Department of Insurance. The Illinois
33 Department is responsible for monitoring compliance with
34 these rules.
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1 This Section may not be implemented before the effective
2 date of these rules, the approval of any necessary federal
3 waivers, and the completion of the review of an application
4 submitted, at least 60 days before the effective date of
5 rules adopted under this Section, to the Illinois Department
6 by a managed care community network.
7 All health care delivery systems that contract with the
8 Illinois Department under the integrated health care program
9 shall clearly recognize a health care provider's right of
10 conscience under the Right of Conscience Act. In addition to
11 the provisions of that Act, no health care delivery system
12 that contracts with the Illinois Department under the
13 integrated health care program shall be required to provide,
14 arrange for, or pay for any health care or medical service,
15 procedure, or product if that health care delivery system is
16 owned, controlled, or sponsored by or affiliated with a
17 religious institution or religious organization that finds
18 that health care or medical service, procedure, or product to
19 violate its religious and moral teachings and beliefs.
20 (b) The Illinois Department may, by rule, provide for
21 different benefit packages for different categories of
22 persons enrolled in the program. Mental health services,
23 alcohol and substance abuse services, services related to
24 children with chronic or acute conditions requiring
25 longer-term treatment and follow-up, and rehabilitation care
26 provided by a free-standing rehabilitation hospital or a
27 hospital rehabilitation unit may be excluded from a benefit
28 package if the State ensures that those services are made
29 available through a separate delivery system. An exclusion
30 does not prohibit the Illinois Department from developing and
31 implementing demonstration projects for categories of persons
32 or services. Benefit packages for persons eligible for
33 medical assistance under Articles V, VI, and XII shall be
34 based on the requirements of those Articles and shall be
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1 consistent with the Title XIX of the Social Security Act.
2 Nothing in this Act shall be construed to apply to services
3 purchased by the Department of Children and Family Services
4 and the Department of Mental Health and Developmental
5 Disabilities under the provisions of Title 59 of the Illinois
6 Administrative Code, Part 132 ("Medicaid Community Mental
7 Health Services Program").
8 (c) The program established by this Section may be
9 implemented by the Illinois Department in various contracting
10 areas at various times. The health care delivery systems and
11 providers available under the program may vary throughout the
12 State. For purposes of contracting with managed health care
13 entities and providers, the Illinois Department shall
14 establish contracting areas similar to the geographic areas
15 designated by the Illinois Department for contracting
16 purposes under the Illinois Competitive Access and
17 Reimbursement Equity Program (ICARE) under the authority of
18 Section 3-4 of the Illinois Health Finance Reform Act or
19 similarly-sized or smaller geographic areas established by
20 the Illinois Department by rule. A managed health care entity
21 shall be permitted to contract in any geographic areas for
22 which it has a sufficient provider network and otherwise
23 meets the contracting terms of the State. The Illinois
24 Department is not prohibited from entering into a contract
25 with a managed health care entity at any time.
26 (c-5) A managed health care entity may not engage in
27 door-to-door marketing activities or marketing activities at
28 an office of the Illinois Department or a county department
29 in order to enroll in the entity's health care delivery
30 system persons who are enrolled in the integrated health care
31 program established under this Section. The Illinois
32 Department shall adopt rules defining "marketing activities"
33 prohibited by this subsection (c-5).
34 Before a managed health care entity may market its health
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1 care delivery system to persons enrolled in the integrated
2 health care program established under this Section, the
3 Illinois Department must approve a marketing plan submitted
4 by the entity to the Illinois Department. The Illinois
5 Department shall adopt guidelines for approving marketing
6 plans submitted by managed health care entities under this
7 subsection. Besides prohibiting door-to-door marketing
8 activities and marketing activities at public aid offices,
9 the guidelines shall include at least the following:
10 (1) A managed health care entity may not offer or
11 provide any gift, favor, or other inducement in marketing
12 its health care delivery system to integrated health care
13 program enrollees. A managed health care entity may
14 provide health care related items that are of nominal
15 value and pre-approved by the Illinois Department to
16 prospective enrollees. A managed health care entity may
17 also provide to enrollees health care related items that
18 have been pre-approved by the Illinois Department as an
19 incentive to manage their health care appropriately.
20 (2) All persons employed or otherwise engaged by a
21 managed health care entity to market the entity's health
22 care delivery system to integrated health care program
23 enrollees or to supervise that marketing shall register
24 with the Illinois Department.
25 The Inspector General appointed under Section 12-13.1 may
26 conduct investigations to determine whether the marketing
27 practices of managed health care entities participating in
28 the integrated health care program comply with the
29 guidelines.
30 (d) A managed health care entity that contracts with the
31 Illinois Department for the provision of services under the
32 program shall do all of the following, solely for purposes of
33 the integrated health care program:
34 (1) Provide that any individual physician licensed
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1 under the Medical Practice Act of 1987 to practice
2 medicine in all its branches, any pharmacy, any federally
3 qualified health center, and any podiatrist, that
4 consistently meets the reasonable terms and conditions
5 established by the managed health care entity, including
6 but not limited to credentialing standards, quality
7 assurance program requirements, utilization management
8 requirements, financial responsibility standards,
9 contracting process requirements, and provider network
10 size and accessibility requirements, must be accepted by
11 the managed health care entity for purposes of the
12 Illinois integrated health care program. Notwithstanding
13 the preceding sentence, only a physician licensed to
14 practice medicine in all its branches shall act as a
15 primary care physician within a managed health care
16 entity for purposes of the Illinois integrated health
17 care program. Any individual who is either terminated
18 from or denied inclusion in the panel of physicians of
19 the managed health care entity shall be given, within 10
20 business days after that determination, a written
21 explanation of the reasons for his or her exclusion or
22 termination from the panel. This paragraph (1) does not
23 apply to the following:
24 (A) A managed health care entity that
25 certifies to the Illinois Department that:
26 (i) it employs on a full-time basis 125
27 or more Illinois physicians licensed to
28 practice medicine in all of its branches; and
29 (ii) it will provide medical services
30 through its employees to more than 80% of the
31 recipients enrolled with the entity in the
32 integrated health care program; or
33 (B) A domestic stock insurance company
34 licensed under clause (b) of class 1 of Section 4 of
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1 the Illinois Insurance Code if (i) at least 66% of
2 the stock of the insurance company is owned by a
3 professional corporation organized under the
4 Professional Service Corporation Act that has 125 or
5 more shareholders who are Illinois physicians
6 licensed to practice medicine in all of its branches
7 and (ii) the insurance company certifies to the
8 Illinois Department that at least 80% of those
9 physician shareholders will provide services to
10 recipients enrolled with the company in the
11 integrated health care program.
12 (2) Provide for reimbursement for providers for
13 emergency care, as defined by the Illinois Department by
14 rule, that must be provided to its enrollees, including
15 an emergency room screening fee, and urgent care that it
16 authorizes for its enrollees, regardless of the
17 provider's affiliation with the managed health care
18 entity. Providers shall be reimbursed for emergency care
19 at an amount equal to the Illinois Department's
20 fee-for-service rates for those medical services rendered
21 by providers not under contract with the managed health
22 care entity to enrollees of the entity.
23 (3) Provide that any provider affiliated with a
24 managed health care entity may also provide services on a
25 fee-for-service basis to Illinois Department clients not
26 enrolled in a managed health care entity.
27 (4) Provide client education services as determined
28 and approved by the Illinois Department, including but
29 not limited to (i) education regarding appropriate
30 utilization of health care services in a managed care
31 system, (ii) written disclosure of treatment policies and
32 any restrictions or limitations on health services,
33 including, but not limited to, physical services,
34 clinical laboratory tests, hospital and surgical
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1 procedures, prescription drugs and biologics, and
2 radiological examinations, and (iii) written notice that
3 the enrollee may receive from another provider those
4 services covered under this program that are not provided
5 by the managed health care entity.
6 (5) Provide that enrollees within its system may
7 choose the site for provision of services and the panel
8 of health care providers.
9 (6) Not discriminate in its enrollment or
10 disenrollment practices among recipients of medical
11 services or program enrollees based on health status.
12 (7) Provide a quality assurance and utilization
13 review program that (i) for health maintenance
14 organizations meets the requirements of the Health
15 Maintenance Organization Act and (ii) for managed care
16 community networks meets the requirements established by
17 the Illinois Department in rules that incorporate those
18 standards set forth in the Health Maintenance
19 Organization Act.
20 (8) Issue a managed health care entity
21 identification card to each enrollee upon enrollment.
22 The card must contain all of the following:
23 (A) The enrollee's signature.
24 (B) The enrollee's health plan.
25 (C) The name and telephone number of the
26 enrollee's primary care physician.
27 (D) A telephone number to be used for
28 emergency service 24 hours per day, 7 days per week.
29 The telephone number required to be maintained
30 pursuant to this subparagraph by each managed health
31 care entity shall, at minimum, be staffed by
32 medically trained personnel and be provided
33 directly, or under arrangement, at an office or
34 offices in locations maintained solely within the
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1 State of Illinois. For purposes of this
2 subparagraph, "medically trained personnel" means
3 licensed practical nurses or registered nurses
4 located in the State of Illinois who are licensed
5 pursuant to the Illinois Nursing Act of 1987.
6 (9) Ensure that every primary care physician and
7 pharmacy in the managed health care entity meets the
8 standards established by the Illinois Department for
9 accessibility and quality of care. The Illinois
10 Department shall arrange for and oversee an evaluation of
11 the standards established under this paragraph (9) and
12 may recommend any necessary changes to these standards.
13 The Illinois Department shall submit an annual report to
14 the Governor and the General Assembly by April 1 of each
15 year regarding the effect of the standards on ensuring
16 access and quality of care to enrollees.
17 (10) Provide a procedure for handling complaints
18 that (i) for health maintenance organizations meets the
19 requirements of the Health Maintenance Organization Act
20 and (ii) for managed care community networks meets the
21 requirements established by the Illinois Department in
22 rules that incorporate those standards set forth in the
23 Health Maintenance Organization Act.
24 (11) Maintain, retain, and make available to the
25 Illinois Department records, data, and information, in a
26 uniform manner determined by the Illinois Department,
27 sufficient for the Illinois Department to monitor
28 utilization, accessibility, and quality of care.
29 (12) Except for providers who are prepaid, pay all
30 approved claims for covered services that are completed
31 and submitted to the managed health care entity within 30
32 days after receipt of the claim or receipt of the
33 appropriate capitation payment or payments by the managed
34 health care entity from the State for the month in which
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1 the services included on the claim were rendered,
2 whichever is later. If payment is not made or mailed to
3 the provider by the managed health care entity by the due
4 date under this subsection, an interest penalty of 1% of
5 any amount unpaid shall be added for each month or
6 fraction of a month after the due date, until final
7 payment is made. Nothing in this Section shall prohibit
8 managed health care entities and providers from mutually
9 agreeing to terms that require more timely payment.
10 (13) Provide integration with community-based
11 programs provided by certified local health departments
12 such as Women, Infants, and Children Supplemental Food
13 Program (WIC), childhood immunization programs, health
14 education programs, case management programs, and health
15 screening programs.
16 (14) Provide that the pharmacy formulary used by a
17 managed health care entity and its contract providers be
18 no more restrictive than the Illinois Department's
19 pharmaceutical program on the effective date of this
20 amendatory Act of 1994 and as amended after that date.
21 (15) Provide integration with community-based
22 organizations, including, but not limited to, any
23 organization that has operated within a Medicaid
24 Partnership as defined by this Code or by rule of the
25 Illinois Department, that may continue to operate under a
26 contract with the Illinois Department or a managed health
27 care entity under this Section to provide case management
28 services to Medicaid clients in designated high-need
29 areas.
30 The Illinois Department may, by rule, determine
31 methodologies to limit financial liability for managed health
32 care entities resulting from payment for services to
33 enrollees provided under the Illinois Department's integrated
34 health care program. Any methodology so determined may be
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1 considered or implemented by the Illinois Department through
2 a contract with a managed health care entity under this
3 integrated health care program.
4 The Illinois Department shall contract with an entity or
5 entities to provide external peer-based quality assurance
6 review for the integrated health care program. The entity
7 shall be representative of Illinois physicians licensed to
8 practice medicine in all its branches and have statewide
9 geographic representation in all specialties of medical care
10 that are provided within the integrated health care program.
11 The entity may not be a third party payer and shall maintain
12 offices in locations around the State in order to provide
13 service and continuing medical education to physician
14 participants within the integrated health care program. The
15 review process shall be developed and conducted by Illinois
16 physicians licensed to practice medicine in all its branches.
17 In consultation with the entity, the Illinois Department may
18 contract with other entities for professional peer-based
19 quality assurance review of individual categories of services
20 other than services provided, supervised, or coordinated by
21 physicians licensed to practice medicine in all its branches.
22 The Illinois Department shall establish, by rule, criteria to
23 avoid conflicts of interest in the conduct of quality
24 assurance activities consistent with professional peer-review
25 standards. All quality assurance activities shall be
26 coordinated by the Illinois Department.
27 (e) All persons enrolled in the program shall be
28 provided with a full written explanation of all
29 fee-for-service and managed health care plan options and a
30 reasonable opportunity to choose among the options as
31 provided by rule. The Illinois Department shall provide to
32 enrollees, upon enrollment in the integrated health care
33 program and at least annually thereafter, notice of the
34 process for requesting an appeal under the Illinois
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1 Department's administrative appeal procedures.
2 Notwithstanding any other Section of this Code, the Illinois
3 Department may provide by rule for the Illinois Department to
4 assign a person enrolled in the program to a specific
5 provider of medical services or to a specific health care
6 delivery system if an enrollee has failed to exercise choice
7 in a timely manner. An enrollee assigned by the Illinois
8 Department shall be afforded the opportunity to disenroll and
9 to select a specific provider of medical services or a
10 specific health care delivery system within the first 30 days
11 after the assignment. An enrollee who has failed to exercise
12 choice in a timely manner may be assigned only if there are 3
13 or more managed health care entities contracting with the
14 Illinois Department within the contracting area, except that,
15 outside the City of Chicago, this requirement may be waived
16 for an area by rules adopted by the Illinois Department after
17 consultation with all hospitals within the contracting area.
18 The Illinois Department shall establish by rule the procedure
19 for random assignment of enrollees who fail to exercise
20 choice in a timely manner to a specific managed health care
21 entity in proportion to the available capacity of that
22 managed health care entity. Assignment to a specific provider
23 of medical services or to a specific managed health care
24 entity may not exceed that provider's or entity's capacity as
25 determined by the Illinois Department. Any person who has
26 chosen a specific provider of medical services or a specific
27 managed health care entity, or any person who has been
28 assigned under this subsection, shall be given the
29 opportunity to change that choice or assignment at least once
30 every 12 months, as determined by the Illinois Department by
31 rule. The Illinois Department shall maintain a toll-free
32 telephone number for program enrollees' use in reporting
33 problems with managed health care entities.
34 (f) If a person becomes eligible for participation in
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1 the integrated health care program while he or she is
2 hospitalized, the Illinois Department may not enroll that
3 person in the program until after he or she has been
4 discharged from the hospital. This subsection does not apply
5 to newborn infants whose mothers are enrolled in the
6 integrated health care program.
7 (g) The Illinois Department shall, by rule, establish
8 for managed health care entities rates that (i) are certified
9 to be actuarially sound, as determined by an actuary who is
10 an associate or a fellow of the Society of Actuaries or a
11 member of the American Academy of Actuaries and who has
12 expertise and experience in medical insurance and benefit
13 programs, in accordance with the Illinois Department's
14 current fee-for-service payment system, and (ii) take into
15 account any difference of cost to provide health care to
16 different populations based on gender, age, location, and
17 eligibility category. The rates for managed health care
18 entities shall be determined on a capitated basis.
19 The Illinois Department by rule shall establish a method
20 to adjust its payments to managed health care entities in a
21 manner intended to avoid providing any financial incentive to
22 a managed health care entity to refer patients to a county
23 provider, in an Illinois county having a population greater
24 than 3,000,000, that is paid directly by the Illinois
25 Department. The Illinois Department shall by April 1, 1997,
26 and annually thereafter, review the method to adjust
27 payments. Payments by the Illinois Department to the county
28 provider, for persons not enrolled in a managed care
29 community network owned or operated by a county provider,
30 shall be paid on a fee-for-service basis under Article XV of
31 this Code.
32 The Illinois Department by rule shall establish a method
33 to reduce its payments to managed health care entities to
34 take into consideration (i) any adjustment payments paid to
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1 hospitals under subsection (h) of this Section to the extent
2 those payments, or any part of those payments, have been
3 taken into account in establishing capitated rates under this
4 subsection (g) and (ii) the implementation of methodologies
5 to limit financial liability for managed health care entities
6 under subsection (d) of this Section.
7 (h) For hospital services provided by a hospital that
8 contracts with a managed health care entity, adjustment
9 payments shall be paid directly to the hospital by the
10 Illinois Department. Adjustment payments may include but
11 need not be limited to adjustment payments to:
12 disproportionate share hospitals under Section 5-5.02 of this
13 Code; primary care access health care education payments (89
14 Ill. Adm. Code 149.140); payments for capital, direct medical
15 education, indirect medical education, certified registered
16 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
17 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
18 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
19 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
20 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
21 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
22 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
23 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
24 148.290(h)); and outpatient indigent volume adjustments (89
25 Ill. Adm. Code 148.140(b)(5)).
26 (i) For any hospital eligible for the adjustment
27 payments described in subsection (h), the Illinois Department
28 shall maintain, through the period ending June 30, 1995,
29 reimbursement levels in accordance with statutes and rules in
30 effect on April 1, 1994.
31 (j) Nothing contained in this Code in any way limits or
32 otherwise impairs the authority or power of the Illinois
33 Department to enter into a negotiated contract pursuant to
34 this Section with a managed health care entity, including,
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1 but not limited to, a health maintenance organization, that
2 provides for termination or nonrenewal of the contract
3 without cause upon notice as provided in the contract and
4 without a hearing.
5 (k) Section 5-5.15 does not apply to the program
6 developed and implemented pursuant to this Section.
7 (l) The Illinois Department shall, by rule, define those
8 chronic or acute medical conditions of childhood that require
9 longer-term treatment and follow-up care. The Illinois
10 Department shall ensure that services required to treat these
11 conditions are available through a separate delivery system.
12 A managed health care entity that contracts with the
13 Illinois Department may refer a child with medical conditions
14 described in the rules adopted under this subsection directly
15 to a children's hospital or to a hospital, other than a
16 children's hospital, that is qualified to provide inpatient
17 and outpatient services to treat those conditions. The
18 Illinois Department shall provide fee-for-service
19 reimbursement directly to a children's hospital for those
20 services pursuant to Title 89 of the Illinois Administrative
21 Code, Section 148.280(a), at a rate at least equal to the
22 rate in effect on March 31, 1994. For hospitals, other than
23 children's hospitals, that are qualified to provide inpatient
24 and outpatient services to treat those conditions, the
25 Illinois Department shall provide reimbursement for those
26 services on a fee-for-service basis, at a rate at least equal
27 to the rate in effect for those other hospitals on March 31,
28 1994.
29 A children's hospital shall be directly reimbursed for
30 all services provided at the children's hospital on a
31 fee-for-service basis pursuant to Title 89 of the Illinois
32 Administrative Code, Section 148.280(a), at a rate at least
33 equal to the rate in effect on March 31, 1994, until the
34 later of (i) implementation of the integrated health care
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1 program under this Section and development of actuarially
2 sound capitation rates for services other than those chronic
3 or acute medical conditions of childhood that require
4 longer-term treatment and follow-up care as defined by the
5 Illinois Department in the rules adopted under this
6 subsection or (ii) March 31, 1996.
7 Notwithstanding anything in this subsection to the
8 contrary, a managed health care entity shall not consider
9 sources or methods of payment in determining the referral of
10 a child. The Illinois Department shall adopt rules to
11 establish criteria for those referrals. The Illinois
12 Department by rule shall establish a method to adjust its
13 payments to managed health care entities in a manner intended
14 to avoid providing any financial incentive to a managed
15 health care entity to refer patients to a provider who is
16 paid directly by the Illinois Department.
17 (m) Behavioral health services provided or funded by the
18 Department of Mental Health and Developmental Disabilities,
19 the Department of Alcoholism and Substance Abuse, the
20 Department of Children and Family Services, and the Illinois
21 Department shall be excluded from a benefit package.
22 Conditions of an organic or physical origin or nature,
23 including medical detoxification, however, may not be
24 excluded. In this subsection, "behavioral health services"
25 means mental health services and subacute alcohol and
26 substance abuse treatment services, as defined in the
27 Illinois Alcoholism and Other Drug Dependency Act. In this
28 subsection, "mental health services" includes, at a minimum,
29 the following services funded by the Illinois Department, the
30 Department of Mental Health and Developmental Disabilities,
31 or the Department of Children and Family Services: (i)
32 inpatient hospital services, including related physician
33 services, related psychiatric interventions, and
34 pharmaceutical services provided to an eligible recipient
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1 hospitalized with a primary diagnosis of psychiatric
2 disorder; (ii) outpatient mental health services as defined
3 and specified in Title 59 of the Illinois Administrative
4 Code, Part 132; (iii) any other outpatient mental health
5 services funded by the Illinois Department pursuant to the
6 State of Illinois Medicaid Plan; (iv) partial
7 hospitalization; and (v) follow-up stabilization related to
8 any of those services. Additional behavioral health services
9 may be excluded under this subsection as mutually agreed in
10 writing by the Illinois Department and the affected State
11 agency or agencies. The exclusion of any service does not
12 prohibit the Illinois Department from developing and
13 implementing demonstration projects for categories of persons
14 or services. The Department of Mental Health and
15 Developmental Disabilities, the Department of Children and
16 Family Services, and the Department of Alcoholism and
17 Substance Abuse shall each adopt rules governing the
18 integration of managed care in the provision of behavioral
19 health services. The State shall integrate managed care
20 community networks and affiliated providers, to the extent
21 practicable, in any separate delivery system for mental
22 health services.
23 (n) The Illinois Department shall adopt rules to
24 establish reserve requirements for managed care community
25 networks, as required by subsection (a), and health
26 maintenance organizations to protect against liabilities in
27 the event that a managed health care entity is declared
28 insolvent or bankrupt. If a managed health care entity other
29 than a county provider is declared insolvent or bankrupt,
30 after liquidation and application of any available assets,
31 resources, and reserves, the Illinois Department shall pay a
32 portion of the amounts owed by the managed health care entity
33 to providers for services rendered to enrollees under the
34 integrated health care program under this Section based on
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1 the following schedule: (i) from April 1, 1995 through June
2 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
3 through June 30, 2001, 80% of the amounts owed; and (iii)
4 from July 1, 2001 through June 30, 2005, 75% of the amounts
5 owed. The amounts paid under this subsection shall be
6 calculated based on the total amount owed by the managed
7 health care entity to providers before application of any
8 available assets, resources, and reserves. After June 30,
9 2005, the Illinois Department may not pay any amounts owed to
10 providers as a result of an insolvency or bankruptcy of a
11 managed health care entity occurring after that date. The
12 Illinois Department is not obligated, however, to pay amounts
13 owed to a provider that has an ownership or other governing
14 interest in the managed health care entity. This subsection
15 applies only to managed health care entities and the services
16 they provide under the integrated health care program under
17 this Section.
18 (o) Notwithstanding any other provision of law or
19 contractual agreement to the contrary, providers shall not be
20 required to accept from any other third party payer the rates
21 determined or paid under this Code by the Illinois
22 Department, managed health care entity, or other health care
23 delivery system for services provided to recipients.
24 (p) The Illinois Department may seek and obtain any
25 necessary authorization provided under federal law to
26 implement the program, including the waiver of any federal
27 statutes or regulations. The Illinois Department may seek a
28 waiver of the federal requirement that the combined
29 membership of Medicare and Medicaid enrollees in a managed
30 care community network may not exceed 75% of the managed care
31 community network's total enrollment. The Illinois
32 Department shall not seek a waiver of this requirement for
33 any other category of managed health care entity. The
34 Illinois Department shall not seek a waiver of the inpatient
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1 hospital reimbursement methodology in Section 1902(a)(13)(A)
2 of Title XIX of the Social Security Act even if the federal
3 agency responsible for administering Title XIX determines
4 that Section 1902(a)(13)(A) applies to managed health care
5 systems.
6 Notwithstanding any other provisions of this Code to the
7 contrary, the Illinois Department shall seek a waiver of
8 applicable federal law in order to impose a co-payment system
9 consistent with this subsection on recipients of medical
10 services under Title XIX of the Social Security Act who are
11 not enrolled in a managed health care entity. The waiver
12 request submitted by the Illinois Department shall provide
13 for co-payments of up to $0.50 for prescribed drugs and up to
14 $0.50 for x-ray services and shall provide for co-payments of
15 up to $10 for non-emergency services provided in a hospital
16 emergency room and up to $10 for non-emergency ambulance
17 services. The purpose of the co-payments shall be to deter
18 those recipients from seeking unnecessary medical care.
19 Co-payments may not be used to deter recipients from seeking
20 necessary medical care. No recipient shall be required to
21 pay more than a total of $150 per year in co-payments under
22 the waiver request required by this subsection. A recipient
23 may not be required to pay more than $15 of any amount due
24 under this subsection in any one month.
25 Co-payments authorized under this subsection may not be
26 imposed when the care was necessitated by a true medical
27 emergency. Co-payments may not be imposed for any of the
28 following classifications of services:
29 (1) Services furnished to person under 18 years of
30 age.
31 (2) Services furnished to pregnant women.
32 (3) Services furnished to any individual who is an
33 inpatient in a hospital, nursing facility, intermediate
34 care facility, or other medical institution, if that
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1 person is required to spend for costs of medical care all
2 but a minimal amount of his or her income required for
3 personal needs.
4 (4) Services furnished to a person who is receiving
5 hospice care.
6 Co-payments authorized under this subsection shall not be
7 deducted from or reduce in any way payments for medical
8 services from the Illinois Department to providers. No
9 provider may deny those services to an individual eligible
10 for services based on the individual's inability to pay the
11 co-payment.
12 Recipients who are subject to co-payments shall be
13 provided notice, in plain and clear language, of the amount
14 of the co-payments, the circumstances under which co-payments
15 are exempted, the circumstances under which co-payments may
16 be assessed, and their manner of collection.
17 The Illinois Department shall establish a Medicaid
18 Co-Payment Council to assist in the development of co-payment
19 policies for the medical assistance program. The Medicaid
20 Co-Payment Council shall also have jurisdiction to develop a
21 program to provide financial or non-financial incentives to
22 Medicaid recipients in order to encourage recipients to seek
23 necessary health care. The Council shall be chaired by the
24 Director of the Illinois Department, and shall have 6
25 additional members. Two of the 6 additional members shall be
26 appointed by the Governor, and one each shall be appointed by
27 the President of the Senate, the Minority Leader of the
28 Senate, the Speaker of the House of Representatives, and the
29 Minority Leader of the House of Representatives. The Council
30 may be convened and make recommendations upon the appointment
31 of a majority of its members. The Council shall be appointed
32 and convened no later than September 1, 1994 and shall report
33 its recommendations to the Director of the Illinois
34 Department and the General Assembly no later than October 1,
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1 1994. The chairperson of the Council shall be allowed to
2 vote only in the case of a tie vote among the appointed
3 members of the Council.
4 The Council shall be guided by the following principles
5 as it considers recommendations to be developed to implement
6 any approved waivers that the Illinois Department must seek
7 pursuant to this subsection:
8 (1) Co-payments should not be used to deter access
9 to adequate medical care.
10 (2) Co-payments should be used to reduce fraud.
11 (3) Co-payment policies should be examined in
12 consideration of other states' experience, and the
13 ability of successful co-payment plans to control
14 unnecessary or inappropriate utilization of services
15 should be promoted.
16 (4) All participants, both recipients and
17 providers, in the medical assistance program have
18 responsibilities to both the State and the program.
19 (5) Co-payments are primarily a tool to educate the
20 participants in the responsible use of health care
21 resources.
22 (6) Co-payments should not be used to penalize
23 providers.
24 (7) A successful medical program requires the
25 elimination of improper utilization of medical resources.
26 The integrated health care program, or any part of that
27 program, established under this Section may not be
28 implemented if matching federal funds under Title XIX of the
29 Social Security Act are not available for administering the
30 program.
31 The Illinois Department shall submit for publication in
32 the Illinois Register the name, address, and telephone number
33 of the individual to whom a request may be directed for a
34 copy of the request for a waiver of provisions of Title XIX
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1 of the Social Security Act that the Illinois Department
2 intends to submit to the Health Care Financing Administration
3 in order to implement this Section. The Illinois Department
4 shall mail a copy of that request for waiver to all
5 requestors at least 16 days before filing that request for
6 waiver with the Health Care Financing Administration.
7 (q) After the effective date of this Section, the
8 Illinois Department may take all planning and preparatory
9 action necessary to implement this Section, including, but
10 not limited to, seeking requests for proposals relating to
11 the integrated health care program created under this
12 Section.
13 (r) In order to (i) accelerate and facilitate the
14 development of integrated health care in contracting areas
15 outside counties with populations in excess of 3,000,000 and
16 counties adjacent to those counties and (ii) maintain and
17 sustain the high quality of education and residency programs
18 coordinated and associated with local area hospitals, the
19 Illinois Department may develop and implement a demonstration
20 program for managed care community networks owned, operated,
21 or governed by State-funded medical schools. The Illinois
22 Department shall prescribe by rule the criteria, standards,
23 and procedures for effecting this demonstration program.
24 (s) (Blank).
25 (t) On April 1, 1995 and every 6 months thereafter, the
26 Illinois Department shall report to the Governor and General
27 Assembly on the progress of the integrated health care
28 program in enrolling clients into managed health care
29 entities. The report shall indicate the capacities of the
30 managed health care entities with which the State contracts,
31 the number of clients enrolled by each contractor, the areas
32 of the State in which managed care options do not exist, and
33 the progress toward meeting the enrollment goals of the
34 integrated health care program.
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1 (u) The Illinois Department may implement this Section
2 through the use of emergency rules in accordance with Section
3 5-45 of the Illinois Administrative Procedure Act. For
4 purposes of that Act, the adoption of rules to implement this
5 Section is deemed an emergency and necessary for the public
6 interest, safety, and welfare.
7 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
8 89-673, eff. 8-14-96; revised 8-26-96.)
9 (Text of Section after amendment by P.A. 89-507)
10 Sec. 5-16.3. System for integrated health care services.
11 (a) It shall be the public policy of the State to adopt,
12 to the extent practicable, a health care program that
13 encourages the integration of health care services and
14 manages the health care of program enrollees while preserving
15 reasonable choice within a competitive and cost-efficient
16 environment. In furtherance of this public policy, the
17 Illinois Department shall develop and implement an integrated
18 health care program consistent with the provisions of this
19 Section. The provisions of this Section apply only to the
20 integrated health care program created under this Section.
21 Persons enrolled in the integrated health care program, as
22 determined by the Illinois Department by rule, shall be
23 afforded a choice among health care delivery systems, which
24 shall include, but are not limited to, (i) fee for service
25 care managed by a primary care physician licensed to practice
26 medicine in all its branches, (ii) managed health care
27 entities, and (iii) federally qualified health centers
28 (reimbursed according to a prospective cost-reimbursement
29 methodology) and rural health clinics (reimbursed according
30 to the Medicare methodology), where available. Persons
31 enrolled in the integrated health care program also may be
32 offered indemnity insurance plans, subject to availability.
33 For purposes of this Section, a "managed health care
34 entity" means a health maintenance organization or a managed
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1 care community network as defined in this Section. A "health
2 maintenance organization" means a health maintenance
3 organization as defined in the Health Maintenance
4 Organization Act. A "managed care community network" means
5 an entity, other than a health maintenance organization, that
6 is owned, operated, or governed by providers of health care
7 services within this State and that provides or arranges
8 primary, secondary, and tertiary managed health care services
9 under contract with the Illinois Department exclusively to
10 enrollees of the integrated health care program. A managed
11 care community network may contract with the Illinois
12 Department to provide only pediatric health care services. A
13 county provider as defined in Section 15-1 of this Code may
14 contract with the Illinois Department to provide services to
15 enrollees of the integrated health care program as a managed
16 care community network without the need to establish a
17 separate entity that provides services exclusively to
18 enrollees of the integrated health care program and shall be
19 deemed a managed care community network for purposes of this
20 Code only to the extent of the provision of services to those
21 enrollees in conjunction with the integrated health care
22 program. A county provider shall be entitled to contract
23 with the Illinois Department with respect to any contracting
24 region located in whole or in part within the county. A
25 county provider shall not be required to accept enrollees who
26 do not reside within the county.
27 Each managed care community network must demonstrate its
28 ability to bear the financial risk of serving enrollees under
29 this program. The Illinois Department shall by rule adopt
30 criteria for assessing the financial soundness of each
31 managed care community network. These rules shall consider
32 the extent to which a managed care community network is
33 comprised of providers who directly render health care and
34 are located within the community in which they seek to
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1 contract rather than solely arrange or finance the delivery
2 of health care. These rules shall further consider a variety
3 of risk-bearing and management techniques, including the
4 sufficiency of quality assurance and utilization management
5 programs and whether a managed care community network has
6 sufficiently demonstrated its financial solvency and net
7 worth. The Illinois Department's criteria must be based on
8 sound actuarial, financial, and accounting principles. In
9 adopting these rules, the Illinois Department shall consult
10 with the Illinois Department of Insurance. The Illinois
11 Department is responsible for monitoring compliance with
12 these rules.
13 This Section may not be implemented before the effective
14 date of these rules, the approval of any necessary federal
15 waivers, and the completion of the review of an application
16 submitted, at least 60 days before the effective date of
17 rules adopted under this Section, to the Illinois Department
18 by a managed care community network.
19 All health care delivery systems that contract with the
20 Illinois Department under the integrated health care program
21 shall clearly recognize a health care provider's right of
22 conscience under the Right of Conscience Act. In addition to
23 the provisions of that Act, no health care delivery system
24 that contracts with the Illinois Department under the
25 integrated health care program shall be required to provide,
26 arrange for, or pay for any health care or medical service,
27 procedure, or product if that health care delivery system is
28 owned, controlled, or sponsored by or affiliated with a
29 religious institution or religious organization that finds
30 that health care or medical service, procedure, or product to
31 violate its religious and moral teachings and beliefs.
32 (b) The Illinois Department may, by rule, provide for
33 different benefit packages for different categories of
34 persons enrolled in the program. Mental health services,
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1 alcohol and substance abuse services, services related to
2 children with chronic or acute conditions requiring
3 longer-term treatment and follow-up, and rehabilitation care
4 provided by a free-standing rehabilitation hospital or a
5 hospital rehabilitation unit may be excluded from a benefit
6 package if the State ensures that those services are made
7 available through a separate delivery system. An exclusion
8 does not prohibit the Illinois Department from developing and
9 implementing demonstration projects for categories of persons
10 or services. Benefit packages for persons eligible for
11 medical assistance under Articles V, VI, and XII shall be
12 based on the requirements of those Articles and shall be
13 consistent with the Title XIX of the Social Security Act.
14 Nothing in this Act shall be construed to apply to services
15 purchased by the Department of Children and Family Services
16 and the Department of Human Services (as successor to the
17 Department of Mental Health and Developmental Disabilities)
18 under the provisions of Title 59 of the Illinois
19 Administrative Code, Part 132 ("Medicaid Community Mental
20 Health Services Program").
21 (c) The program established by this Section may be
22 implemented by the Illinois Department in various contracting
23 areas at various times. The health care delivery systems and
24 providers available under the program may vary throughout the
25 State. For purposes of contracting with managed health care
26 entities and providers, the Illinois Department shall
27 establish contracting areas similar to the geographic areas
28 designated by the Illinois Department for contracting
29 purposes under the Illinois Competitive Access and
30 Reimbursement Equity Program (ICARE) under the authority of
31 Section 3-4 of the Illinois Health Finance Reform Act or
32 similarly-sized or smaller geographic areas established by
33 the Illinois Department by rule. A managed health care entity
34 shall be permitted to contract in any geographic areas for
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1 which it has a sufficient provider network and otherwise
2 meets the contracting terms of the State. The Illinois
3 Department is not prohibited from entering into a contract
4 with a managed health care entity at any time.
5 (c-5) A managed health care entity may not engage in
6 door-to-door marketing activities or marketing activities at
7 an office of the Illinois Department or a county department
8 in order to enroll in the entity's health care delivery
9 system persons who are enrolled in the integrated health care
10 program established under this Section. The Illinois
11 Department shall adopt rules defining "marketing activities"
12 prohibited by this subsection (c-5).
13 Before a managed health care entity may market its health
14 care delivery system to persons enrolled in the integrated
15 health care program established under this Section, the
16 Illinois Department must approve a marketing plan submitted
17 by the entity to the Illinois Department. The Illinois
18 Department shall adopt guidelines for approving marketing
19 plans submitted by managed health care entities under this
20 subsection. Besides prohibiting door-to-door marketing
21 activities and marketing activities at public aid offices,
22 the guidelines shall include at least the following:
23 (1) A managed health care entity may not offer or
24 provide any gift, favor, or other inducement in marketing
25 its health care delivery system to integrated health care
26 program enrollees. A managed health care entity may
27 provide health care related items that are of nominal
28 value and pre-approved by the Illinois Department to
29 prospective enrollees. A managed health care entity may
30 also provide to enrollees health care related items that
31 have been pre-approved by the Illinois Department as an
32 incentive to manage their health care appropriately.
33 (2) All persons employed or otherwise engaged by a
34 managed health care entity to market the entity's health
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1 care delivery system to integrated health care program
2 enrollees or to supervise that marketing shall register
3 with the Illinois Department.
4 The Inspector General appointed under Section 12-13.1 may
5 conduct investigations to determine whether the marketing
6 practices of managed health care entities participating in
7 the integrated health care program comply with the
8 guidelines.
9 (d) A managed health care entity that contracts with the
10 Illinois Department for the provision of services under the
11 program shall do all of the following, solely for purposes of
12 the integrated health care program:
13 (1) Provide that any individual physician licensed
14 under the Medical Practice Act of 1987 to practice
15 medicine in all its branches, any pharmacy, any federally
16 qualified health center, and any podiatrist, that
17 consistently meets the reasonable terms and conditions
18 established by the managed health care entity, including
19 but not limited to credentialing standards, quality
20 assurance program requirements, utilization management
21 requirements, financial responsibility standards,
22 contracting process requirements, and provider network
23 size and accessibility requirements, must be accepted by
24 the managed health care entity for purposes of the
25 Illinois integrated health care program. Notwithstanding
26 the preceding sentence, only a physician licensed to
27 practice medicine in all its branches shall act as a
28 primary care physician within a managed health care
29 entity for purposes of the Illinois integrated health
30 care program. Any individual who is either terminated
31 from or denied inclusion in the panel of physicians of
32 the managed health care entity shall be given, within 10
33 business days after that determination, a written
34 explanation of the reasons for his or her exclusion or
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1 termination from the panel. This paragraph (1) does not
2 apply to the following:
3 (A) A managed health care entity that
4 certifies to the Illinois Department that:
5 (i) it employs on a full-time basis 125
6 or more Illinois physicians licensed to
7 practice medicine in all of its branches; and
8 (ii) it will provide medical services
9 through its employees to more than 80% of the
10 recipients enrolled with the entity in the
11 integrated health care program; or
12 (B) A domestic stock insurance company
13 licensed under clause (b) of class 1 of Section 4 of
14 the Illinois Insurance Code if (i) at least 66% of
15 the stock of the insurance company is owned by a
16 professional corporation organized under the
17 Professional Service Corporation Act that has 125 or
18 more shareholders who are Illinois physicians
19 licensed to practice medicine in all of its branches
20 and (ii) the insurance company certifies to the
21 Illinois Department that at least 80% of those
22 physician shareholders will provide services to
23 recipients enrolled with the company in the
24 integrated health care program.
25 (2) Provide for reimbursement for providers for
26 emergency care, as defined by the Illinois Department by
27 rule, that must be provided to its enrollees, including
28 an emergency room screening fee, and urgent care that it
29 authorizes for its enrollees, regardless of the
30 provider's affiliation with the managed health care
31 entity. Providers shall be reimbursed for emergency care
32 at an amount equal to the Illinois Department's
33 fee-for-service rates for those medical services rendered
34 by providers not under contract with the managed health
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1 care entity to enrollees of the entity.
2 (3) Provide that any provider affiliated with a
3 managed health care entity may also provide services on a
4 fee-for-service basis to Illinois Department clients not
5 enrolled in a managed health care entity.
6 (4) Provide client education services as determined
7 and approved by the Illinois Department, including but
8 not limited to (i) education regarding appropriate
9 utilization of health care services in a managed care
10 system, (ii) written disclosure of treatment policies and
11 any restrictions or limitations on health services,
12 including, but not limited to, physical services,
13 clinical laboratory tests, hospital and surgical
14 procedures, prescription drugs and biologics, and
15 radiological examinations, and (iii) written notice that
16 the enrollee may receive from another provider those
17 services covered under this program that are not provided
18 by the managed health care entity.
19 (5) Provide that enrollees within its system may
20 choose the site for provision of services and the panel
21 of health care providers.
22 (6) Not discriminate in its enrollment or
23 disenrollment practices among recipients of medical
24 services or program enrollees based on health status.
25 (7) Provide a quality assurance and utilization
26 review program that (i) for health maintenance
27 organizations meets the requirements of the Health
28 Maintenance Organization Act and (ii) for managed care
29 community networks meets the requirements established by
30 the Illinois Department in rules that incorporate those
31 standards set forth in the Health Maintenance
32 Organization Act.
33 (8) Issue a managed health care entity
34 identification card to each enrollee upon enrollment.
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1 The card must contain all of the following:
2 (A) The enrollee's signature.
3 (B) The enrollee's health plan.
4 (C) The name and telephone number of the
5 enrollee's primary care physician.
6 (D) A telephone number to be used for
7 emergency service 24 hours per day, 7 days per week.
8 The telephone number required to be maintained
9 pursuant to this subparagraph by each managed health
10 care entity shall, at minimum, be staffed by
11 medically trained personnel and be provided
12 directly, or under arrangement, at an office or
13 offices in locations maintained solely within the
14 State of Illinois. For purposes of this
15 subparagraph, "medically trained personnel" means
16 licensed practical nurses or registered nurses
17 located in the State of Illinois who are licensed
18 pursuant to the Illinois Nursing Act of 1987.
19 (9) Ensure that every primary care physician and
20 pharmacy in the managed health care entity meets the
21 standards established by the Illinois Department for
22 accessibility and quality of care. The Illinois
23 Department shall arrange for and oversee an evaluation of
24 the standards established under this paragraph (9) and
25 may recommend any necessary changes to these standards.
26 The Illinois Department shall submit an annual report to
27 the Governor and the General Assembly by April 1 of each
28 year regarding the effect of the standards on ensuring
29 access and quality of care to enrollees.
30 (10) Provide a procedure for handling complaints
31 that (i) for health maintenance organizations meets the
32 requirements of the Health Maintenance Organization Act
33 and (ii) for managed care community networks meets the
34 requirements established by the Illinois Department in
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1 rules that incorporate those standards set forth in the
2 Health Maintenance Organization Act.
3 (11) Maintain, retain, and make available to the
4 Illinois Department records, data, and information, in a
5 uniform manner determined by the Illinois Department,
6 sufficient for the Illinois Department to monitor
7 utilization, accessibility, and quality of care.
8 (12) Except for providers who are prepaid, pay all
9 approved claims for covered services that are completed
10 and submitted to the managed health care entity within 30
11 days after receipt of the claim or receipt of the
12 appropriate capitation payment or payments by the managed
13 health care entity from the State for the month in which
14 the services included on the claim were rendered,
15 whichever is later. If payment is not made or mailed to
16 the provider by the managed health care entity by the due
17 date under this subsection, an interest penalty of 1% of
18 any amount unpaid shall be added for each month or
19 fraction of a month after the due date, until final
20 payment is made. Nothing in this Section shall prohibit
21 managed health care entities and providers from mutually
22 agreeing to terms that require more timely payment.
23 (13) Provide integration with community-based
24 programs provided by certified local health departments
25 such as Women, Infants, and Children Supplemental Food
26 Program (WIC), childhood immunization programs, health
27 education programs, case management programs, and health
28 screening programs.
29 (14) Provide that the pharmacy formulary used by a
30 managed health care entity and its contract providers be
31 no more restrictive than the Illinois Department's
32 pharmaceutical program on the effective date of this
33 amendatory Act of 1994 and as amended after that date.
34 (15) Provide integration with community-based
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1 organizations, including, but not limited to, any
2 organization that has operated within a Medicaid
3 Partnership as defined by this Code or by rule of the
4 Illinois Department, that may continue to operate under a
5 contract with the Illinois Department or a managed health
6 care entity under this Section to provide case management
7 services to Medicaid clients in designated high-need
8 areas.
9 The Illinois Department may, by rule, determine
10 methodologies to limit financial liability for managed health
11 care entities resulting from payment for services to
12 enrollees provided under the Illinois Department's integrated
13 health care program. Any methodology so determined may be
14 considered or implemented by the Illinois Department through
15 a contract with a managed health care entity under this
16 integrated health care program.
17 The Illinois Department shall contract with an entity or
18 entities to provide external peer-based quality assurance
19 review for the integrated health care program. The entity
20 shall be representative of Illinois physicians licensed to
21 practice medicine in all its branches and have statewide
22 geographic representation in all specialties of medical care
23 that are provided within the integrated health care program.
24 The entity may not be a third party payer and shall maintain
25 offices in locations around the State in order to provide
26 service and continuing medical education to physician
27 participants within the integrated health care program. The
28 review process shall be developed and conducted by Illinois
29 physicians licensed to practice medicine in all its branches.
30 In consultation with the entity, the Illinois Department may
31 contract with other entities for professional peer-based
32 quality assurance review of individual categories of services
33 other than services provided, supervised, or coordinated by
34 physicians licensed to practice medicine in all its branches.
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1 The Illinois Department shall establish, by rule, criteria to
2 avoid conflicts of interest in the conduct of quality
3 assurance activities consistent with professional peer-review
4 standards. All quality assurance activities shall be
5 coordinated by the Illinois Department.
6 (e) All persons enrolled in the program shall be
7 provided with a full written explanation of all
8 fee-for-service and managed health care plan options and a
9 reasonable opportunity to choose among the options as
10 provided by rule. The Illinois Department shall provide to
11 enrollees, upon enrollment in the integrated health care
12 program and at least annually thereafter, notice of the
13 process for requesting an appeal under the Illinois
14 Department's administrative appeal procedures.
15 Notwithstanding any other Section of this Code, the Illinois
16 Department may provide by rule for the Illinois Department to
17 assign a person enrolled in the program to a specific
18 provider of medical services or to a specific health care
19 delivery system if an enrollee has failed to exercise choice
20 in a timely manner. An enrollee assigned by the Illinois
21 Department shall be afforded the opportunity to disenroll and
22 to select a specific provider of medical services or a
23 specific health care delivery system within the first 30 days
24 after the assignment. An enrollee who has failed to exercise
25 choice in a timely manner may be assigned only if there are 3
26 or more managed health care entities contracting with the
27 Illinois Department within the contracting area, except that,
28 outside the City of Chicago, this requirement may be waived
29 for an area by rules adopted by the Illinois Department after
30 consultation with all hospitals within the contracting area.
31 The Illinois Department shall establish by rule the procedure
32 for random assignment of enrollees who fail to exercise
33 choice in a timely manner to a specific managed health care
34 entity in proportion to the available capacity of that
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1 managed health care entity. Assignment to a specific provider
2 of medical services or to a specific managed health care
3 entity may not exceed that provider's or entity's capacity as
4 determined by the Illinois Department. Any person who has
5 chosen a specific provider of medical services or a specific
6 managed health care entity, or any person who has been
7 assigned under this subsection, shall be given the
8 opportunity to change that choice or assignment at least once
9 every 12 months, as determined by the Illinois Department by
10 rule. The Illinois Department shall maintain a toll-free
11 telephone number for program enrollees' use in reporting
12 problems with managed health care entities.
13 (f) If a person becomes eligible for participation in
14 the integrated health care program while he or she is
15 hospitalized, the Illinois Department may not enroll that
16 person in the program until after he or she has been
17 discharged from the hospital. This subsection does not apply
18 to newborn infants whose mothers are enrolled in the
19 integrated health care program.
20 (g) The Illinois Department shall, by rule, establish
21 for managed health care entities rates that (i) are certified
22 to be actuarially sound, as determined by an actuary who is
23 an associate or a fellow of the Society of Actuaries or a
24 member of the American Academy of Actuaries and who has
25 expertise and experience in medical insurance and benefit
26 programs, in accordance with the Illinois Department's
27 current fee-for-service payment system, and (ii) take into
28 account any difference of cost to provide health care to
29 different populations based on gender, age, location, and
30 eligibility category. The rates for managed health care
31 entities shall be determined on a capitated basis.
32 The Illinois Department by rule shall establish a method
33 to adjust its payments to managed health care entities in a
34 manner intended to avoid providing any financial incentive to
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1 a managed health care entity to refer patients to a county
2 provider, in an Illinois county having a population greater
3 than 3,000,000, that is paid directly by the Illinois
4 Department. The Illinois Department shall by April 1, 1997,
5 and annually thereafter, review the method to adjust
6 payments. Payments by the Illinois Department to the county
7 provider, for persons not enrolled in a managed care
8 community network owned or operated by a county provider,
9 shall be paid on a fee-for-service basis under Article XV of
10 this Code.
11 The Illinois Department by rule shall establish a method
12 to reduce its payments to managed health care entities to
13 take into consideration (i) any adjustment payments paid to
14 hospitals under subsection (h) of this Section to the extent
15 those payments, or any part of those payments, have been
16 taken into account in establishing capitated rates under this
17 subsection (g) and (ii) the implementation of methodologies
18 to limit financial liability for managed health care entities
19 under subsection (d) of this Section.
20 (h) For hospital services provided by a hospital that
21 contracts with a managed health care entity, adjustment
22 payments shall be paid directly to the hospital by the
23 Illinois Department. Adjustment payments may include but
24 need not be limited to adjustment payments to:
25 disproportionate share hospitals under Section 5-5.02 of this
26 Code; primary care access health care education payments (89
27 Ill. Adm. Code 149.140); payments for capital, direct medical
28 education, indirect medical education, certified registered
29 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
30 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
31 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
32 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
33 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
34 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
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1 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
2 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
3 148.290(h)); and outpatient indigent volume adjustments (89
4 Ill. Adm. Code 148.140(b)(5)).
5 (i) For any hospital eligible for the adjustment
6 payments described in subsection (h), the Illinois Department
7 shall maintain, through the period ending June 30, 1995,
8 reimbursement levels in accordance with statutes and rules in
9 effect on April 1, 1994.
10 (j) Nothing contained in this Code in any way limits or
11 otherwise impairs the authority or power of the Illinois
12 Department to enter into a negotiated contract pursuant to
13 this Section with a managed health care entity, including,
14 but not limited to, a health maintenance organization, that
15 provides for termination or nonrenewal of the contract
16 without cause upon notice as provided in the contract and
17 without a hearing.
18 (k) Section 5-5.15 does not apply to the program
19 developed and implemented pursuant to this Section.
20 (l) The Illinois Department shall, by rule, define those
21 chronic or acute medical conditions of childhood that require
22 longer-term treatment and follow-up care. The Illinois
23 Department shall ensure that services required to treat these
24 conditions are available through a separate delivery system.
25 A managed health care entity that contracts with the
26 Illinois Department may refer a child with medical conditions
27 described in the rules adopted under this subsection directly
28 to a children's hospital or to a hospital, other than a
29 children's hospital, that is qualified to provide inpatient
30 and outpatient services to treat those conditions. The
31 Illinois Department shall provide fee-for-service
32 reimbursement directly to a children's hospital for those
33 services pursuant to Title 89 of the Illinois Administrative
34 Code, Section 148.280(a), at a rate at least equal to the
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1 rate in effect on March 31, 1994. For hospitals, other than
2 children's hospitals, that are qualified to provide inpatient
3 and outpatient services to treat those conditions, the
4 Illinois Department shall provide reimbursement for those
5 services on a fee-for-service basis, at a rate at least equal
6 to the rate in effect for those other hospitals on March 31,
7 1994.
8 A children's hospital shall be directly reimbursed for
9 all services provided at the children's hospital on a
10 fee-for-service basis pursuant to Title 89 of the Illinois
11 Administrative Code, Section 148.280(a), at a rate at least
12 equal to the rate in effect on March 31, 1994, until the
13 later of (i) implementation of the integrated health care
14 program under this Section and development of actuarially
15 sound capitation rates for services other than those chronic
16 or acute medical conditions of childhood that require
17 longer-term treatment and follow-up care as defined by the
18 Illinois Department in the rules adopted under this
19 subsection or (ii) March 31, 1996.
20 Notwithstanding anything in this subsection to the
21 contrary, a managed health care entity shall not consider
22 sources or methods of payment in determining the referral of
23 a child. The Illinois Department shall adopt rules to
24 establish criteria for those referrals. The Illinois
25 Department by rule shall establish a method to adjust its
26 payments to managed health care entities in a manner intended
27 to avoid providing any financial incentive to a managed
28 health care entity to refer patients to a provider who is
29 paid directly by the Illinois Department.
30 (m) Behavioral health services provided or funded by the
31 Department of Human Services, the Department of Children and
32 Family Services, and the Illinois Department shall be
33 excluded from a benefit package. Conditions of an organic or
34 physical origin or nature, including medical detoxification,
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1 however, may not be excluded. In this subsection,
2 "behavioral health services" means mental health services and
3 subacute alcohol and substance abuse treatment services, as
4 defined in the Illinois Alcoholism and Other Drug Dependency
5 Act. In this subsection, "mental health services" includes,
6 at a minimum, the following services funded by the Illinois
7 Department, the Department of Human Services (as successor to
8 the Department of Mental Health and Developmental
9 Disabilities), or the Department of Children and Family
10 Services: (i) inpatient hospital services, including related
11 physician services, related psychiatric interventions, and
12 pharmaceutical services provided to an eligible recipient
13 hospitalized with a primary diagnosis of psychiatric
14 disorder; (ii) outpatient mental health services as defined
15 and specified in Title 59 of the Illinois Administrative
16 Code, Part 132; (iii) any other outpatient mental health
17 services funded by the Illinois Department pursuant to the
18 State of Illinois Medicaid Plan; (iv) partial
19 hospitalization; and (v) follow-up stabilization related to
20 any of those services. Additional behavioral health services
21 may be excluded under this subsection as mutually agreed in
22 writing by the Illinois Department and the affected State
23 agency or agencies. The exclusion of any service does not
24 prohibit the Illinois Department from developing and
25 implementing demonstration projects for categories of persons
26 or services. The Department of Children and Family Services
27 and the Department of Human Services shall each adopt rules
28 governing the integration of managed care in the provision of
29 behavioral health services. The State shall integrate managed
30 care community networks and affiliated providers, to the
31 extent practicable, in any separate delivery system for
32 mental health services.
33 (n) The Illinois Department shall adopt rules to
34 establish reserve requirements for managed care community
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1 networks, as required by subsection (a), and health
2 maintenance organizations to protect against liabilities in
3 the event that a managed health care entity is declared
4 insolvent or bankrupt. If a managed health care entity other
5 than a county provider is declared insolvent or bankrupt,
6 after liquidation and application of any available assets,
7 resources, and reserves, the Illinois Department shall pay a
8 portion of the amounts owed by the managed health care entity
9 to providers for services rendered to enrollees under the
10 integrated health care program under this Section based on
11 the following schedule: (i) from April 1, 1995 through June
12 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
13 through June 30, 2001, 80% of the amounts owed; and (iii)
14 from July 1, 2001 through June 30, 2005, 75% of the amounts
15 owed. The amounts paid under this subsection shall be
16 calculated based on the total amount owed by the managed
17 health care entity to providers before application of any
18 available assets, resources, and reserves. After June 30,
19 2005, the Illinois Department may not pay any amounts owed to
20 providers as a result of an insolvency or bankruptcy of a
21 managed health care entity occurring after that date. The
22 Illinois Department is not obligated, however, to pay amounts
23 owed to a provider that has an ownership or other governing
24 interest in the managed health care entity. This subsection
25 applies only to managed health care entities and the services
26 they provide under the integrated health care program under
27 this Section.
28 (o) Notwithstanding any other provision of law or
29 contractual agreement to the contrary, providers shall not be
30 required to accept from any other third party payer the rates
31 determined or paid under this Code by the Illinois
32 Department, managed health care entity, or other health care
33 delivery system for services provided to recipients.
34 (p) The Illinois Department may seek and obtain any
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1 necessary authorization provided under federal law to
2 implement the program, including the waiver of any federal
3 statutes or regulations. The Illinois Department may seek a
4 waiver of the federal requirement that the combined
5 membership of Medicare and Medicaid enrollees in a managed
6 care community network may not exceed 75% of the managed care
7 community network's total enrollment. The Illinois
8 Department shall not seek a waiver of this requirement for
9 any other category of managed health care entity. The
10 Illinois Department shall not seek a waiver of the inpatient
11 hospital reimbursement methodology in Section 1902(a)(13)(A)
12 of Title XIX of the Social Security Act even if the federal
13 agency responsible for administering Title XIX determines
14 that Section 1902(a)(13)(A) applies to managed health care
15 systems.
16 Notwithstanding any other provisions of this Code to the
17 contrary, the Illinois Department shall seek a waiver of
18 applicable federal law in order to impose a co-payment system
19 consistent with this subsection on recipients of medical
20 services under Title XIX of the Social Security Act who are
21 not enrolled in a managed health care entity. The waiver
22 request submitted by the Illinois Department shall provide
23 for co-payments of up to $0.50 for prescribed drugs and up to
24 $0.50 for x-ray services and shall provide for co-payments of
25 up to $10 for non-emergency services provided in a hospital
26 emergency room and up to $10 for non-emergency ambulance
27 services. The purpose of the co-payments shall be to deter
28 those recipients from seeking unnecessary medical care.
29 Co-payments may not be used to deter recipients from seeking
30 necessary medical care. No recipient shall be required to
31 pay more than a total of $150 per year in co-payments under
32 the waiver request required by this subsection. A recipient
33 may not be required to pay more than $15 of any amount due
34 under this subsection in any one month.
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1 Co-payments authorized under this subsection may not be
2 imposed when the care was necessitated by a true medical
3 emergency. Co-payments may not be imposed for any of the
4 following classifications of services:
5 (1) Services furnished to person under 18 years of
6 age.
7 (2) Services furnished to pregnant women.
8 (3) Services furnished to any individual who is an
9 inpatient in a hospital, nursing facility, intermediate
10 care facility, or other medical institution, if that
11 person is required to spend for costs of medical care all
12 but a minimal amount of his or her income required for
13 personal needs.
14 (4) Services furnished to a person who is receiving
15 hospice care.
16 Co-payments authorized under this subsection shall not be
17 deducted from or reduce in any way payments for medical
18 services from the Illinois Department to providers. No
19 provider may deny those services to an individual eligible
20 for services based on the individual's inability to pay the
21 co-payment.
22 Recipients who are subject to co-payments shall be
23 provided notice, in plain and clear language, of the amount
24 of the co-payments, the circumstances under which co-payments
25 are exempted, the circumstances under which co-payments may
26 be assessed, and their manner of collection.
27 The Illinois Department shall establish a Medicaid
28 Co-Payment Council to assist in the development of co-payment
29 policies for the medical assistance program. The Medicaid
30 Co-Payment Council shall also have jurisdiction to develop a
31 program to provide financial or non-financial incentives to
32 Medicaid recipients in order to encourage recipients to seek
33 necessary health care. The Council shall be chaired by the
34 Director of the Illinois Department, and shall have 6
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1 additional members. Two of the 6 additional members shall be
2 appointed by the Governor, and one each shall be appointed by
3 the President of the Senate, the Minority Leader of the
4 Senate, the Speaker of the House of Representatives, and the
5 Minority Leader of the House of Representatives. The Council
6 may be convened and make recommendations upon the appointment
7 of a majority of its members. The Council shall be appointed
8 and convened no later than September 1, 1994 and shall report
9 its recommendations to the Director of the Illinois
10 Department and the General Assembly no later than October 1,
11 1994. The chairperson of the Council shall be allowed to
12 vote only in the case of a tie vote among the appointed
13 members of the Council.
14 The Council shall be guided by the following principles
15 as it considers recommendations to be developed to implement
16 any approved waivers that the Illinois Department must seek
17 pursuant to this subsection:
18 (1) Co-payments should not be used to deter access
19 to adequate medical care.
20 (2) Co-payments should be used to reduce fraud.
21 (3) Co-payment policies should be examined in
22 consideration of other states' experience, and the
23 ability of successful co-payment plans to control
24 unnecessary or inappropriate utilization of services
25 should be promoted.
26 (4) All participants, both recipients and
27 providers, in the medical assistance program have
28 responsibilities to both the State and the program.
29 (5) Co-payments are primarily a tool to educate the
30 participants in the responsible use of health care
31 resources.
32 (6) Co-payments should not be used to penalize
33 providers.
34 (7) A successful medical program requires the
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1 elimination of improper utilization of medical resources.
2 The integrated health care program, or any part of that
3 program, established under this Section may not be
4 implemented if matching federal funds under Title XIX of the
5 Social Security Act are not available for administering the
6 program.
7 The Illinois Department shall submit for publication in
8 the Illinois Register the name, address, and telephone number
9 of the individual to whom a request may be directed for a
10 copy of the request for a waiver of provisions of Title XIX
11 of the Social Security Act that the Illinois Department
12 intends to submit to the Health Care Financing Administration
13 in order to implement this Section. The Illinois Department
14 shall mail a copy of that request for waiver to all
15 requestors at least 16 days before filing that request for
16 waiver with the Health Care Financing Administration.
17 (q) After the effective date of this Section, the
18 Illinois Department may take all planning and preparatory
19 action necessary to implement this Section, including, but
20 not limited to, seeking requests for proposals relating to
21 the integrated health care program created under this
22 Section.
23 (r) In order to (i) accelerate and facilitate the
24 development of integrated health care in contracting areas
25 outside counties with populations in excess of 3,000,000 and
26 counties adjacent to those counties and (ii) maintain and
27 sustain the high quality of education and residency programs
28 coordinated and associated with local area hospitals, the
29 Illinois Department may develop and implement a demonstration
30 program for managed care community networks owned, operated,
31 or governed by State-funded medical schools. The Illinois
32 Department shall prescribe by rule the criteria, standards,
33 and procedures for effecting this demonstration program.
34 (s) (Blank).
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1 (t) On April 1, 1995 and every 6 months thereafter, the
2 Illinois Department shall report to the Governor and General
3 Assembly on the progress of the integrated health care
4 program in enrolling clients into managed health care
5 entities. The report shall indicate the capacities of the
6 managed health care entities with which the State contracts,
7 the number of clients enrolled by each contractor, the areas
8 of the State in which managed care options do not exist, and
9 the progress toward meeting the enrollment goals of the
10 integrated health care program.
11 (u) The Illinois Department may implement this Section
12 through the use of emergency rules in accordance with Section
13 5-45 of the Illinois Administrative Procedure Act. For
14 purposes of that Act, the adoption of rules to implement this
15 Section is deemed an emergency and necessary for the public
16 interest, safety, and welfare.
17 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
18 89-507, eff. 7-1-97; 89-673, eff. 8-14-96; revised 8-26-96.)
19 (305 ILCS 5/5-16.10 new)
20 Sec. 5-16.10. Managed care entities; marketing. A
21 managed health care entity providing services under this
22 Article V may not engage in door-to-door marketing activities
23 or marketing activities at an office of the Illinois
24 Department or a county department in order to enroll
25 recipients in the entity's health care delivery system. The
26 Department shall adopt rules defining "marketing activities"
27 prohibited by this Section.
28 Before a managed health care entity providing services
29 under this Article V may market its health care delivery
30 system to recipients, the Illinois Department must approve a
31 marketing plan submitted by the entity to the Illinois
32 Department. The Illinois Department shall adopt guidelines
33 for approving marketing plans submitted by managed health
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1 care entities under this Section. Besides prohibiting
2 door-to-door marketing activities and marketing activities at
3 public aid offices, the guidelines shall include at least the
4 following:
5 (1) A managed health care entity may not offer or
6 provide any gift, favor, or other inducement in marketing
7 its health care delivery system to integrated health care
8 program enrollees. A managed health care entity may
9 provide health care related items that are of nominal
10 value and pre-approved by the Department to prospective
11 enrollees. A managed health care entity may also
12 provide to enrollees health care related items that have
13 been pre-approved by the Department as an incentive to
14 manage their health care appropriately.
15 (2) All persons employed or otherwise engaged by a
16 managed health care entity to market the entity's health
17 care delivery system to recipients or to supervise that
18 marketing shall register with the Illinois Department.
19 The Inspector General appointed under Section 12-13.1 may
20 conduct investigations to determine whether the marketing
21 practices of managed health care entities providing services
22 under this Article V comply with the guidelines.
23 (305 ILCS 5/5-16.11 new)
24 Sec. 5-16.11. Uniform standards applied to managed care
25 entities. Any managed care entity providing services under
26 this Code shall comply with the criteria, standards, and
27 procedures imposed on managed care entities under paragraph
28 (14) of subsection (d) of Section 5-16.3 of this Code.
29 (305 ILCS 5/8A-6) (from Ch. 23, par. 8A-6)
30 Sec. 8A-6. Classification of violations.
31 (a) Any person, firm, corporation, association, agency,
32 institution or other legal entity that has been found by a
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1 court to have engaged in an act, practice or course of
2 conduct declared unlawful under Sections 8A-2 through 8A-5 or
3 Section 8A-13 or 8A-14 where:
4 (1) the total amount of money involved in the violation,
5 including the monetary value of federal food stamps and the
6 value of commodities, is less than $150, shall be guilty of a
7 Class A misdemeanor;
8 (2) the total amount of money involved in the violation,
9 including the monetary value of federal food stamps and the
10 value of commodities, is $150 or more but less than $1,000,
11 shall be guilty of a Class 4 felony;
12 (3) the total amount of money involved in the violation,
13 including the monetary value of federal food stamps and the
14 value of commodities, is $1,000 or more but less than $5,000,
15 shall be guilty of a Class 3 felony;
16 (4) the total amount of money involved in the violation,
17 including the monetary value of federal food stamps and the
18 value of commodities, is $5,000 or more but less than
19 $10,000, shall be guilty of a Class 2 felony; or
20 (5) the total amount of money involved in the violation,
21 including the monetary value of federal food stamps and the
22 value of commodities, is $10,000 or more, shall be guilty of
23 a Class 1 felony and, notwithstanding the provisions of
24 Section 8A-8 except for Subsection (c) of Section 8A-8, shall
25 be ineligible for financial aid under this Article for a
26 period of two years following conviction or until the total
27 amount of money, including the value of federal food stamps,
28 is repaid, whichever first occurs.
29 (b) Any person, firm, corporation, association, agency,
30 institution or other legal entity that commits a subsequent
31 violation of any of the provisions of Sections 8A-2 through
32 8A-5 and:
33 (1) the total amount of money involved in the subsequent
34 violation, including the monetary value of federal food
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1 stamps and the value of commodities, is less than $150, shall
2 be guilty of a Class 4 felony;
3 (2) the total amount of money involved in the subsequent
4 violation, including the monetary value of federal food
5 stamps and the value of commodities, is $150 or more but less
6 than $1,000, shall be guilty of a Class 3 felony;
7 (3) the total amount of money involved in the subsequent
8 violation, including the monetary value of federal food
9 stamps and the value of commodities, is $1,000 or more but
10 less than $5,000, shall be guilty of a Class 2 felony;
11 (4) the total amount of money involved in the subsequent
12 violation, including the monetary value of federal food
13 stamps and the value of commodities, is $5,000 or more but
14 less than $10,000, shall be guilty of a Class 1 felony.
15 (c) For purposes of determining the classification of
16 offense under this Section, all of the money received as a
17 result of the unlawful act, practice or course of conduct can
18 be accumulated.
19 (Source: P.A. 85-1209.)
20 (305 ILCS 5/8A-13 new)
21 Sec. 8A-13. Managed health care fraud.
22 (a) As used in this Section, "health plan" means any of
23 the following:
24 (1) Any health care reimbursement plan sponsored
25 wholly or partially by the State.
26 (2) Any private insurance carrier, health care
27 cooperative or alliance, health maintenance organization,
28 insurer, organization, entity, association, affiliation,
29 or person that contracts to provide or provides goods or
30 services that are reimbursed by or are a required benefit
31 of a health benefits program funded wholly or partially
32 by the State.
33 (3) Anyone who provides or contracts to provide
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1 goods and services to an entity described in paragraph
2 (1) or (2) of this subsection.
3 For purposes of item (2) in subsection (b),
4 "representation" and "statement" include, but are not limited
5 to, reports, claims, certifications, acknowledgments and
6 ratifications of financial information, enrollment claims,
7 demographic statistics, encounter data, health services
8 available or rendered, and the qualifications of person
9 rendering health care and ancillary services.
10 (b) Any person, firm, corporation, association, agency,
11 institution, or other legal entity that, with the intent to
12 obtain benefits or payments under this Code to which the
13 person or entity is not entitled or in a greater amount than
14 that to which the person or entity is entitled, knowingly
15 executes or conspires to execute a scheme or artifice
16 (1) to defraud any State or federally funded or
17 mandated health plan in connection with the delivery of
18 or payment for health care benefits, items, or services,
19 or
20 (2) to obtain by means of false or fraudulent
21 pretense, representation, statement, or promise money or
22 anything of value in connection with the delivery of or
23 payment for health care benefits, items, or services that
24 are in whole or in part paid for, reimbursed, or
25 subsidized by, or are a required benefit of, a State or
26 federally funded or mandated health plan
27 is guilty of a violation of this Article and shall be
28 punished as provided in Section 8A-6.
29 (305 ILCS 5/8A-14 new)
30 Sec. 8A-14. Bribery and graft in connection with health
31 care.
32 (a) As used in this Section:
33 "Health care official" means any of the following:
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1 (1) An administrator, officer, trustee, fiduciary,
2 custodian, counsel, agent, or employee of any health
3 plan.
4 (2) An officer, counsel, agent, or employee of an
5 organization that provides, proposes to provide, or
6 contracts to provide services to any health plan.
7 (3) An official, employee, or agent of a State or
8 federal agency having regulatory or administrative
9 authority over any health plan.
10 "Health plan" has the meaning attributed to that term in
11 Section 8A-13.
12 (b) Any person, firm, corporation, association, agency,
13 institution, or other legal entity that
14 (1) directly or indirectly gives, offers, or
15 promises anything of value to a health care official, or
16 offers or promises to a health care official to give
17 anything of value to another person, with the intent
18 (A) to influence or reward any act or decision
19 of any health care official exercising any authority
20 in any State or federally funded or mandated health
21 plan other than as specifically allowed by law, or
22 (B) to influence the official to commit, aid
23 in the commission of, or conspire to allow any fraud
24 in a State or federally funded or mandated health
25 plan, or
26 (C) to induce the official to engage in any
27 conduct in violation of the official's lawful duty,
28 or
29 (2) being a health care official, directly or
30 indirectly demands, solicits, receives, accepts, or
31 agrees to accept anything of value personally or for any
32 other person or entity, the giving of which would violate
33 paragraph (1) of this subsection,
34 is guilty of a violation of this Article and shall be
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1 punished as provided in Section 8A-6.
2 (305 ILCS 5/8A-15 new)
3 Sec. 8A-15. False statements relating to health care
4 delivery. Any person, firm, corporation, association,
5 agency, institution, or other legal entity that, in any
6 matter related to a State or federally funded or mandated
7 health plan, knowingly and wilfully falsifies, conceals, or
8 omits by any trick, scheme, artifice, or device a material
9 fact, or makes any false, fictitious, or fraudulent statement
10 or representation, or makes or uses any false writing or
11 document, knowing the same to contain any false, fictitious,
12 or fraudulent statement or entry in connection with the
13 provision of health care or related services, is guilty of a
14 Class A misdemeanor.
15 (305 ILCS 5/8A-16 new)
16 Sec. 8A-16. Unfair or deceptive marketing practices.
17 (a) As used in this Section, "health plan" has the
18 meaning attributed to that term in Section 8A-13.
19 (b) It is unlawful to knowingly and willfully engage in
20 any unfair or deceptive marketing practice in connection with
21 proposing, offering, selling, soliciting, or providing any
22 health care service or any health plan. Unfair or deceptive
23 marketing practices include the following:
24 (1) Making a false and misleading oral or written
25 statement, visual description, advertisement, or other
26 representation of any kind that has the capacity,
27 tendency, or effect of deceiving or misleading health
28 care consumers with respect to any health care service,
29 health plan, or health care provider.
30 (2) Making a representation that a health care plan
31 or a health care provider offers any service, benefit,
32 access to care, or choice that it does not in fact offer.
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1 (3) Making a representation that a health plan or
2 health care provider has any status, certification,
3 qualification, sponsorship, affiliation, or licensure
4 that it does not have.
5 (4) A failure to state a material fact if the
6 failure deceives or tends to deceive.
7 (5) Offering any kickback, bribe, reward, or
8 benefit to any person as an inducement to select or to
9 refrain from selecting any health care service, health
10 plan, or health care provider, unless the benefit offered
11 is medically necessary health care or is permitted by the
12 Illinois Department.
13 (6) The use of health care consumer or other
14 information that is confidential or privileged or that
15 cannot be disclosed to or obtained by the user without
16 violating a State or federal confidentiality law,
17 including:
18 (A) medical records information; and
19 (B) information that identifies the health
20 care consumer or any member of his or her group as a
21 recipient of any government sponsored or mandated
22 welfare program.
23 (7) The use of any device or artifice in
24 advertising a health plan or soliciting a health care
25 consumer that misrepresents the solicitor's profession,
26 status, affiliation, or mission.
27 (c) Any person who commits a first violation of this
28 Section is guilty of a Class A misdemeanor and is subject to
29 a fine of not more than $5,000. Any person who commits a
30 second or subsequent violation of this Section is guilty of a
31 Class 4 felony and is subject to a fine of not more than
32 $25,000.
33 (305 ILCS 5/8A-17 new)
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1 Sec. 8A-17. Penalties enhanced for persons other than
2 individuals. If a person who violates Section 8A-13, 8A-14,
3 8A-15, or 8A-16 is any person other than an individual, then
4 that person is subject to a fine of not more than $50,000 if
5 the violation is a misdemeanor and a fine of not more than
6 $250,000 if the violation is a felony.
7 Section 10. The Mental Health and Developmental
8 Disabilities Code is amended by changing Sections 2-102,
9 2-107, 2-107.1, 2-107.2, 2-110, and 3-800 and by adding
10 Sections 1-121.5, 2-110.1, and 3-601.2 as follows:
11 (405 ILCS 5/1-121.5 new)
12 Sec. 1-121.5. Authorized involuntary treatment.
13 "Authorized involuntary treatment" means psychotropic
14 medication or electro-convulsive therapy, including those
15 tests and related procedures that are essential for the safe
16 and effective administration of the treatment.
17 (405 ILCS 5/2-102) (from Ch. 91 1/2, par. 2-102)
18 Sec. 2-102. (a) A recipient of services shall be
19 provided with adequate and humane care and services in the
20 least restrictive environment, pursuant to an individual
21 services plan, which shall be formulated and periodically
22 reviewed with the participation of the recipient to the
23 extent feasible and, where appropriate, such recipient's
24 nearest of kin or guardian.
25 (a-5) If the services include the administration of
26 authorized involuntary treatment psychotropic medication, the
27 physician shall advise the recipient, in writing, of the side
28 effects and risks of the treatment and alternatives to the
29 proposed treatment, and the risks and benefits thereof,
30 medication to the extent such advice is consistent with the
31 nature and frequency of the side effects and the recipient's
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1 ability to understand the information communicated. The
2 physician shall determine in writing whether the recipient
3 has the capacity to make a reasoned decision about the
4 treatment. If the recipient lacks the capacity to make a
5 reasoned decision about the treatment, the treatment may be
6 administered only (i) pursuant to the provisions of Section
7 2-107 or 2-107.1 or (ii) pursuant to a power of attorney for
8 health care under the Powers of Attorney for Health Care Law
9 or a declaration for mental health treatment under the Mental
10 Health Treatment Preference Declaration Act. A surrogate
11 decision maker, other than a court appointed guardian, under
12 the Health Care Surrogate Act may not consent to the
13 administration of authorized involuntary treatment. A
14 surrogate may, however, petition for administration of
15 authorized involuntary treatment pursuant to this Act. If
16 the recipient is under guardianship and the guardian is
17 authorized to consent to the administration of authorized
18 involuntary treatment pursuant to subsection (c) of Section
19 2-107.1 of this Code, the physician shall advise the guardian
20 in writing of the side effects and risks of the treatment,
21 alternatives to the proposed treatment, and the risks and
22 benefits of the treatment. Any recipient who is a resident of
23 a mental health or developmental disabilities facility shall
24 be advised in writing of his right to refuse such services
25 pursuant to Section 2-107 of this Code. A qualified
26 professional shall be responsible for overseeing the
27 implementation of such plan. Such care and treatment shall
28 include the regular use of sign language for any hearing
29 impaired individual for whom sign language is a primary mode
30 of communication.
31 (b) A recipient of services who is an adherent or a
32 member of any well-recognized religious denomination, the
33 principles and tenets of which teach reliance upon services
34 by spiritual means through prayer alone for healing by a duly
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1 accredited practitioner thereof, shall have the right to
2 choose such services. The parent or guardian of a recipient
3 of services who is a minor, or a guardian of a recipient of
4 services who is not a minor, shall have the right to choose
5 services by spiritual means through prayer for the recipient
6 of services.
7 (Source: P.A. 86-1402.)
8 (405 ILCS 5/2-107) (from Ch. 91 1/2, par. 2-107)
9 Sec. 2-107. Refusal of services; informing of risks.
10 (a) An adult recipient of services, or, if the recipient
11 is under guardianship, the recipient's guardian, shall be
12 given the opportunity to refuse generally accepted mental
13 health or developmental disability services, including but
14 not limited to medication. If such services are refused,
15 they shall not be given unless such services are necessary to
16 prevent the recipient from causing serious and imminent
17 physical harm to himself or others. The facility director
18 shall inform a recipient or guardian who refuses such
19 services of alternate services available and the risks of
20 such alternate services, as well as the possible consequences
21 to the recipient of refusal of such services.
22 (b) Authorized involuntary treatment Psychotropic
23 medication may be given under this Section for up to 24 hours
24 only if the circumstances leading up to the need