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91_HB0253
LRB9101283SMdv
1 AN ACT to amend the Illinois Public Aid Code by changing
2 Section 5-16.3.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Illinois Public Aid Code is amended by
6 changing Section 5-16.3 as follows:
7 (305 ILCS 5/5-16.3)
8 Sec. 5-16.3. System for integrated health care services.
9 (a) It shall be the public policy of the State to adopt,
10 to the extent practicable, a health care program that
11 encourages the integration of health care services and
12 manages the health care of program enrollees while preserving
13 reasonable choice within a competitive and cost-efficient
14 environment. In furtherance of this public policy, the
15 Illinois Department shall develop and implement an integrated
16 health care program consistent with the provisions of this
17 Section. The provisions of this Section apply only to the
18 integrated health care program created under this Section.
19 Persons enrolled in the integrated health care program, as
20 determined by the Illinois Department by rule, shall be
21 afforded a choice among health care delivery systems, which
22 shall include, but are not limited to, (i) fee for service
23 care managed by a primary care physician licensed to practice
24 medicine in all its branches, (ii) managed health care
25 entities, and (iii) federally qualified health centers
26 (reimbursed according to a prospective cost-reimbursement
27 methodology) and rural health clinics (reimbursed according
28 to the Medicare methodology), where available. Persons
29 enrolled in the integrated health care program also may be
30 offered indemnity insurance plans, subject to availability.
31 For purposes of this Section, a "managed health care
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1 entity" means a health maintenance organization or a managed
2 care community network as defined in this Section. A "health
3 maintenance organization" means a health maintenance
4 organization as defined in the Health Maintenance
5 Organization Act. A "managed care community network" means
6 an entity, other than a health maintenance organization, that
7 is owned, operated, or governed by providers of health care
8 services within this State and that provides or arranges
9 primary, secondary, and tertiary managed health care services
10 under contract with the Illinois Department exclusively to
11 enrollees of the integrated health care program. A managed
12 care community network may contract with the Illinois
13 Department to provide only pediatric health care services. A
14 county provider as defined in Section 15-1 of this Code may
15 contract with the Illinois Department to provide services to
16 enrollees of the integrated health care program as a managed
17 care community network without the need to establish a
18 separate entity that provides services exclusively to
19 enrollees of the integrated health care program and shall be
20 deemed a managed care community network for purposes of this
21 Code only to the extent of the provision of services to those
22 enrollees in conjunction with the integrated health care
23 program. A county provider shall be entitled to contract
24 with the Illinois Department with respect to any contracting
25 region located in whole or in part within the county. A
26 county provider shall not be required to accept enrollees who
27 do not reside within the county.
28 Each managed care community network must demonstrate its
29 ability to bear the financial risk of serving enrollees under
30 this program. The Illinois Department shall by rule adopt
31 criteria for assessing the financial soundness of each
32 managed care community network. These rules shall consider
33 the extent to which a managed care community network is
34 comprised of providers who directly render health care and
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1 are located within the community in which they seek to
2 contract rather than solely arrange or finance the delivery
3 of health care. These rules shall further consider a variety
4 of risk-bearing and management techniques, including the
5 sufficiency of quality assurance and utilization management
6 programs and whether a managed care community network has
7 sufficiently demonstrated its financial solvency and net
8 worth. The Illinois Department's criteria must be based on
9 sound actuarial, financial, and accounting principles. In
10 adopting these rules, the Illinois Department shall consult
11 with the Illinois Department of Insurance. The Illinois
12 Department is responsible for monitoring compliance with
13 these rules.
14 This Section may not be implemented before the effective
15 date of these rules, the approval of any necessary federal
16 waivers, and the completion of the review of an application
17 submitted, at least 60 days before the effective date of
18 rules adopted under this Section, to the Illinois Department
19 by a managed care community network.
20 All health care delivery systems that contract with the
21 Illinois Department under the integrated health care program
22 shall clearly recognize a health care provider's right of
23 conscience under the Health Care Right of Conscience Act. In
24 addition to the provisions of that Act, no health care
25 delivery system that contracts with the Illinois Department
26 under the integrated health care program shall be required to
27 provide, arrange for, or pay for any health care or medical
28 service, procedure, or product if that health care delivery
29 system is owned, controlled, or sponsored by or affiliated
30 with a religious institution or religious organization that
31 finds that health care or medical service, procedure, or
32 product to violate its religious and moral teachings and
33 beliefs.
34 (b) The Illinois Department may, by rule, provide for
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1 different benefit packages for different categories of
2 persons enrolled in the program. Mental health services,
3 alcohol and substance abuse services, services related to
4 children with chronic or acute conditions requiring
5 longer-term treatment and follow-up, and rehabilitation care
6 provided by a free-standing rehabilitation hospital or a
7 hospital rehabilitation unit may be excluded from a benefit
8 package if the State ensures that those services are made
9 available through a separate delivery system. An exclusion
10 does not prohibit the Illinois Department from developing and
11 implementing demonstration projects for categories of persons
12 or services. Benefit packages for persons eligible for
13 medical assistance under Articles V, VI, and XII shall be
14 based on the requirements of those Articles and shall be
15 consistent with the Title XIX of the Social Security Act.
16 Nothing in this Act shall be construed to apply to services
17 purchased by the Department of Children and Family Services
18 and the Department of Human Services (as successor to the
19 Department of Mental Health and Developmental Disabilities)
20 under the provisions of Title 59 of the Illinois
21 Administrative Code, Part 132 ("Medicaid Community Mental
22 Health Services Program").
23 (c) The program established by this Section may be
24 implemented by the Illinois Department in various contracting
25 areas at various times. The health care delivery systems and
26 providers available under the program may vary throughout the
27 State. For purposes of contracting with managed health care
28 entities and providers, the Illinois Department shall
29 establish contracting areas similar to the geographic areas
30 designated by the Illinois Department for contracting
31 purposes under the Illinois Competitive Access and
32 Reimbursement Equity Program (ICARE) under the authority of
33 Section 3-4 of the Illinois Health Finance Reform Act or
34 similarly-sized or smaller geographic areas established by
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1 the Illinois Department by rule. A managed health care entity
2 shall be permitted to contract in any geographic areas for
3 which it has a sufficient provider network and otherwise
4 meets the contracting terms of the State. The Illinois
5 Department is not prohibited from entering into a contract
6 with a managed health care entity at any time.
7 (c-5) A managed health care entity may not engage in
8 door-to-door marketing activities or marketing activities at
9 an office of the Illinois Department or a county department
10 in order to enroll in the entity's health care delivery
11 system persons who are enrolled in the integrated health care
12 program established under this Section. The Illinois
13 Department shall adopt rules defining "marketing activities"
14 prohibited by this subsection (c-5).
15 Before a managed health care entity may market its health
16 care delivery system to persons enrolled in the integrated
17 health care program established under this Section, the
18 Illinois Department must approve a marketing plan submitted
19 by the entity to the Illinois Department. The Illinois
20 Department shall adopt guidelines for approving marketing
21 plans submitted by managed health care entities under this
22 subsection. Besides prohibiting door-to-door marketing
23 activities and marketing activities at public aid offices,
24 the guidelines shall include at least the following:
25 (1) A managed health care entity may not offer or
26 provide any gift, favor, or other inducement in marketing
27 its health care delivery system to integrated health care
28 program enrollees. A managed health care entity may
29 provide health care related items that are of nominal
30 value and pre-approved by the Illinois Department to
31 prospective enrollees. A managed health care entity may
32 also provide to enrollees health care related items that
33 have been pre-approved by the Illinois Department as an
34 incentive to manage their health care appropriately.
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1 (2) All persons employed or otherwise engaged by a
2 managed health care entity to market the entity's health
3 care delivery system to integrated health care program
4 enrollees or to supervise that marketing shall register
5 with the Illinois Department.
6 The Inspector General appointed under Section 12-13.1 may
7 conduct investigations to determine whether the marketing
8 practices of managed health care entities participating in
9 the integrated health care program comply with the
10 guidelines.
11 (d) A managed health care entity that contracts with the
12 Illinois Department for the provision of services under the
13 program shall do all of the following, solely for purposes of
14 the integrated health care program:
15 (1) Provide that any individual physician licensed
16 under the Medical Practice Act of 1987, any pharmacy, any
17 federally qualified health center, any therapeutically
18 certified optometrist, and any podiatrist, that
19 consistently meets the reasonable terms and conditions
20 established by the managed health care entity, including
21 but not limited to credentialing standards, quality
22 assurance program requirements, utilization management
23 requirements, financial responsibility standards,
24 contracting process requirements, and provider network
25 size and accessibility requirements, must be accepted by
26 the managed health care entity for purposes of the
27 Illinois integrated health care program. Notwithstanding
28 the preceding sentence, only a physician licensed to
29 practice medicine in all its branches shall act as a
30 primary care physician within a managed health care
31 entity for purposes of the Illinois integrated health
32 care program. Any individual who is either terminated
33 from or denied inclusion in the panel of physicians of
34 the managed health care entity shall be given, within 10
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1 business days after that determination, a written
2 explanation of the reasons for his or her exclusion or
3 termination from the panel. This paragraph (1) does not
4 apply to the following:
5 (A) A managed health care entity that
6 certifies to the Illinois Department that:
7 (i) it employs on a full-time basis 125
8 or more Illinois physicians licensed to
9 practice medicine in all of its branches; and
10 (ii) it will provide medical services
11 through its employees to more than 80% of the
12 recipients enrolled with the entity in the
13 integrated health care program; or
14 (B) A domestic stock insurance company
15 licensed under clause (b) of class 1 of Section 4 of
16 the Illinois Insurance Code if (i) at least 66% of
17 the stock of the insurance company is owned by a
18 professional corporation organized under the
19 Professional Service Corporation Act that has 125 or
20 more shareholders who are Illinois physicians
21 licensed to practice medicine in all of its branches
22 and (ii) the insurance company certifies to the
23 Illinois Department that at least 80% of those
24 physician shareholders will provide services to
25 recipients enrolled with the company in the
26 integrated health care program.
27 (2) Provide for reimbursement for providers for
28 emergency care, as defined by the Illinois Department by
29 rule, that must be provided to its enrollees, including
30 an emergency room screening fee, and urgent care that it
31 authorizes for its enrollees, regardless of the
32 provider's affiliation with the managed health care
33 entity. Providers shall be reimbursed for emergency care
34 at an amount equal to the Illinois Department's
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1 fee-for-service rates for those medical services rendered
2 by providers not under contract with the managed health
3 care entity to enrollees of the entity.
4 (3) Provide that any provider affiliated with a
5 managed health care entity may also provide services on a
6 fee-for-service basis to Illinois Department clients not
7 enrolled in a managed health care entity.
8 (4) Provide client education services as determined
9 and approved by the Illinois Department, including but
10 not limited to (i) education regarding appropriate
11 utilization of health care services in a managed care
12 system, (ii) written disclosure of treatment policies and
13 any restrictions or limitations on health services,
14 including, but not limited to, physical services,
15 clinical laboratory tests, hospital and surgical
16 procedures, prescription drugs and biologics, and
17 radiological examinations, and (iii) written notice that
18 the enrollee may receive from another provider those
19 services covered under this program that are not provided
20 by the managed health care entity.
21 (5) Provide that enrollees within its system may
22 choose the site for provision of services and the panel
23 of health care providers.
24 (6) Not discriminate in its enrollment or
25 disenrollment practices among recipients of medical
26 services or program enrollees based on health status.
27 (7) Provide a quality assurance and utilization
28 review program that (i) for health maintenance
29 organizations meets the requirements of the Health
30 Maintenance Organization Act and (ii) for managed care
31 community networks meets the requirements established by
32 the Illinois Department in rules that incorporate those
33 standards set forth in the Health Maintenance
34 Organization Act.
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1 (8) Issue a managed health care entity
2 identification card to each enrollee upon enrollment.
3 The card must contain all of the following:
4 (A) The enrollee's signature.
5 (B) The enrollee's health plan.
6 (C) The name and telephone number of the
7 enrollee's primary care physician.
8 (D) A telephone number to be used for
9 emergency service 24 hours per day, 7 days per week.
10 The telephone number required to be maintained
11 pursuant to this subparagraph by each managed health
12 care entity shall, at minimum, be staffed by
13 medically trained personnel and be provided
14 directly, or under arrangement, at an office or
15 offices in locations maintained solely within the
16 State of Illinois. For purposes of this
17 subparagraph, "medically trained personnel" means
18 licensed practical nurses or registered nurses
19 located in the State of Illinois who are licensed
20 pursuant to the Nursing and Advanced Practice
21 Nursing Act.
22 (9) Ensure that every primary care physician and
23 pharmacy in the managed health care entity meets the
24 standards established by the Illinois Department for
25 accessibility and quality of care. The Illinois
26 Department shall arrange for and oversee an evaluation of
27 the standards established under this paragraph (9) and
28 may recommend any necessary changes to these standards.
29 The Illinois Department shall submit an annual report to
30 the Governor and the General Assembly by April 1 of each
31 year regarding the effect of the standards on ensuring
32 access and quality of care to enrollees.
33 (10) Provide a procedure for handling complaints
34 that (i) for health maintenance organizations meets the
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1 requirements of the Health Maintenance Organization Act
2 and (ii) for managed care community networks meets the
3 requirements established by the Illinois Department in
4 rules that incorporate those standards set forth in the
5 Health Maintenance Organization Act.
6 (11) Maintain, retain, and make available to the
7 Illinois Department records, data, and information, in a
8 uniform manner determined by the Illinois Department,
9 sufficient for the Illinois Department to monitor
10 utilization, accessibility, and quality of care.
11 (12) Except for providers who are prepaid, pay all
12 approved claims for covered services that are completed
13 and submitted to the managed health care entity within 30
14 days after receipt of the claim or receipt of the
15 appropriate capitation payment or payments by the managed
16 health care entity from the State for the month in which
17 the services included on the claim were rendered,
18 whichever is later. If payment is not made or mailed to
19 the provider by the managed health care entity by the due
20 date under this subsection, an interest penalty of 1% of
21 any amount unpaid shall be added for each month or
22 fraction of a month after the due date, until final
23 payment is made. Nothing in this Section shall prohibit
24 managed health care entities and providers from mutually
25 agreeing to terms that require more timely payment.
26 (13) Provide integration with community-based
27 programs provided by certified local health departments
28 such as Women, Infants, and Children Supplemental Food
29 Program (WIC), childhood immunization programs, health
30 education programs, case management programs, and health
31 screening programs.
32 (14) Provide that the pharmacy formulary used by a
33 managed health care entity and its contract providers be
34 no more restrictive than the Illinois Department's
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1 pharmaceutical program on the effective date of this
2 amendatory Act of 1994 and as amended after that date.
3 (15) Provide integration with community-based
4 organizations, including, but not limited to, any
5 organization that has operated within a Medicaid
6 Partnership as defined by this Code or by rule of the
7 Illinois Department, that may continue to operate under a
8 contract with the Illinois Department or a managed health
9 care entity under this Section to provide case management
10 services to Medicaid clients in designated high-need
11 areas.
12 The Illinois Department may, by rule, determine
13 methodologies to limit financial liability for managed health
14 care entities resulting from payment for services to
15 enrollees provided under the Illinois Department's integrated
16 health care program. Any methodology so determined may be
17 considered or implemented by the Illinois Department through
18 a contract with a managed health care entity under this
19 integrated health care program.
20 The Illinois Department shall contract with an entity or
21 entities to provide external peer-based quality assurance
22 review for the integrated health care program. The entity
23 shall be representative of Illinois physicians licensed to
24 practice medicine in all its branches and have statewide
25 geographic representation in all specialties of medical care
26 that are provided within the integrated health care program.
27 The entity may not be a third party payer and shall maintain
28 offices in locations around the State in order to provide
29 service and continuing medical education to physician
30 participants within the integrated health care program. The
31 review process shall be developed and conducted by Illinois
32 physicians licensed to practice medicine in all its branches.
33 In consultation with the entity, the Illinois Department may
34 contract with other entities for professional peer-based
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1 quality assurance review of individual categories of services
2 other than services provided, supervised, or coordinated by
3 physicians licensed to practice medicine in all its branches.
4 The Illinois Department shall establish, by rule, criteria to
5 avoid conflicts of interest in the conduct of quality
6 assurance activities consistent with professional peer-review
7 standards. All quality assurance activities shall be
8 coordinated by the Illinois Department.
9 (e) All persons enrolled in the program shall be
10 provided with a full written explanation of all
11 fee-for-service and managed health care plan options and a
12 reasonable opportunity to choose among the options as
13 provided by rule. The Illinois Department shall provide to
14 enrollees, upon enrollment in the integrated health care
15 program and at least annually thereafter, notice of the
16 process for requesting an appeal under the Illinois
17 Department's administrative appeal procedures.
18 Notwithstanding any other Section of this Code, the Illinois
19 Department may provide by rule for the Illinois Department to
20 assign a person enrolled in the program to a specific
21 provider of medical services or to a specific health care
22 delivery system if an enrollee has failed to exercise choice
23 in a timely manner. An enrollee assigned by the Illinois
24 Department shall be afforded the opportunity to disenroll and
25 to select a specific provider of medical services or a
26 specific health care delivery system within the first 30 days
27 after the assignment. An enrollee who has failed to exercise
28 choice in a timely manner may be assigned only if there are 3
29 or more managed health care entities contracting with the
30 Illinois Department within the contracting area, except that,
31 outside the City of Chicago, this requirement may be waived
32 for an area by rules adopted by the Illinois Department after
33 consultation with all hospitals within the contracting area.
34 The Illinois Department shall establish by rule the procedure
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1 for random assignment of enrollees who fail to exercise
2 choice in a timely manner to a specific managed health care
3 entity in proportion to the available capacity of that
4 managed health care entity. Assignment to a specific provider
5 of medical services or to a specific managed health care
6 entity may not exceed that provider's or entity's capacity as
7 determined by the Illinois Department. Any person who has
8 chosen a specific provider of medical services or a specific
9 managed health care entity, or any person who has been
10 assigned under this subsection, shall be given the
11 opportunity to change that choice or assignment at least once
12 every 12 months, as determined by the Illinois Department by
13 rule. The Illinois Department shall maintain a toll-free
14 telephone number for program enrollees' use in reporting
15 problems with managed health care entities.
16 (f) If a person becomes eligible for participation in
17 the integrated health care program while he or she is
18 hospitalized, the Illinois Department may not enroll that
19 person in the program until after he or she has been
20 discharged from the hospital. This subsection does not apply
21 to newborn infants whose mothers are enrolled in the
22 integrated health care program.
23 (g) The Illinois Department shall, by rule, establish
24 for managed health care entities rates that (i) are certified
25 to be actuarially sound, as determined by an actuary who is
26 an associate or a fellow of the Society of Actuaries or a
27 member of the American Academy of Actuaries and who has
28 expertise and experience in medical insurance and benefit
29 programs, in accordance with the Illinois Department's
30 current fee-for-service payment system, and (ii) take into
31 account any difference of cost to provide health care to
32 different populations based on gender, age, location, and
33 eligibility category. The rates for managed health care
34 entities shall be determined on a capitated basis.
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1 The Illinois Department by rule shall establish a method
2 to adjust its payments to managed health care entities in a
3 manner intended to avoid providing any financial incentive to
4 a managed health care entity to refer patients to a county
5 provider, in an Illinois county having a population greater
6 than 3,000,000, that is paid directly by the Illinois
7 Department. The Illinois Department shall by April 1, 1997,
8 and annually thereafter, review the method to adjust
9 payments. Payments by the Illinois Department to the county
10 provider, for persons not enrolled in a managed care
11 community network owned or operated by a county provider,
12 shall be paid on a fee-for-service basis under Article XV of
13 this Code.
14 The Illinois Department by rule shall establish a method
15 to reduce its payments to managed health care entities to
16 take into consideration (i) any adjustment payments paid to
17 hospitals under subsection (h) of this Section to the extent
18 those payments, or any part of those payments, have been
19 taken into account in establishing capitated rates under this
20 subsection (g) and (ii) the implementation of methodologies
21 to limit financial liability for managed health care entities
22 under subsection (d) of this Section.
23 (h) For hospital services provided by a hospital that
24 contracts with a managed health care entity, adjustment
25 payments shall be paid directly to the hospital by the
26 Illinois Department. Adjustment payments may include but
27 need not be limited to adjustment payments to:
28 disproportionate share hospitals under Section 5-5.02 of this
29 Code; primary care access health care education payments (89
30 Ill. Adm. Code 149.140); payments for capital, direct medical
31 education, indirect medical education, certified registered
32 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
33 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
34 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
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1 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
2 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
3 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
4 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
5 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
6 148.290(h)); and outpatient indigent volume adjustments (89
7 Ill. Adm. Code 148.140(b)(5)).
8 (i) For any hospital eligible for the adjustment
9 payments described in subsection (h), the Illinois Department
10 shall maintain, through the period ending June 30, 1995,
11 reimbursement levels in accordance with statutes and rules in
12 effect on April 1, 1994.
13 (j) Nothing contained in this Code in any way limits or
14 otherwise impairs the authority or power of the Illinois
15 Department to enter into a negotiated contract pursuant to
16 this Section with a managed health care entity, including,
17 but not limited to, a health maintenance organization, that
18 provides for termination or nonrenewal of the contract
19 without cause upon notice as provided in the contract and
20 without a hearing.
21 (k) Section 5-5.15 does not apply to the program
22 developed and implemented pursuant to this Section.
23 (l) The Illinois Department shall, by rule, define those
24 chronic or acute medical conditions of childhood that require
25 longer-term treatment and follow-up care. The Illinois
26 Department shall ensure that services required to treat these
27 conditions are available through a separate delivery system.
28 A managed health care entity that contracts with the
29 Illinois Department may refer a child with medical conditions
30 described in the rules adopted under this subsection directly
31 to a children's hospital or to a hospital, other than a
32 children's hospital, that is qualified to provide inpatient
33 and outpatient services to treat those conditions. The
34 Illinois Department shall provide fee-for-service
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1 reimbursement directly to a children's hospital for those
2 services pursuant to Title 89 of the Illinois Administrative
3 Code, Section 148.280(a), at a rate at least equal to the
4 rate in effect on March 31, 1994. For hospitals, other than
5 children's hospitals, that are qualified to provide inpatient
6 and outpatient services to treat those conditions, the
7 Illinois Department shall provide reimbursement for those
8 services on a fee-for-service basis, at a rate at least equal
9 to the rate in effect for those other hospitals on March 31,
10 1994.
11 A children's hospital shall be directly reimbursed for
12 all services provided at the children's hospital on a
13 fee-for-service basis pursuant to Title 89 of the Illinois
14 Administrative Code, Section 148.280(a), at a rate at least
15 equal to the rate in effect on March 31, 1994, until the
16 later of (i) implementation of the integrated health care
17 program under this Section and development of actuarially
18 sound capitation rates for services other than those chronic
19 or acute medical conditions of childhood that require
20 longer-term treatment and follow-up care as defined by the
21 Illinois Department in the rules adopted under this
22 subsection or (ii) March 31, 1996.
23 Notwithstanding anything in this subsection to the
24 contrary, a managed health care entity shall not consider
25 sources or methods of payment in determining the referral of
26 a child. The Illinois Department shall adopt rules to
27 establish criteria for those referrals. The Illinois
28 Department by rule shall establish a method to adjust its
29 payments to managed health care entities in a manner intended
30 to avoid providing any financial incentive to a managed
31 health care entity to refer patients to a provider who is
32 paid directly by the Illinois Department.
33 (m) Behavioral health services provided or funded by the
34 Department of Human Services, the Department of Children and
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1 Family Services, and the Illinois Department shall be
2 excluded from a benefit package. Conditions of an organic or
3 physical origin or nature, including medical detoxification,
4 however, may not be excluded. In this subsection,
5 "behavioral health services" means mental health services and
6 subacute alcohol and substance abuse treatment services, as
7 defined in the Illinois Alcoholism and Other Drug Dependency
8 Act. In this subsection, "mental health services" includes,
9 at a minimum, the following services funded by the Illinois
10 Department, the Department of Human Services (as successor to
11 the Department of Mental Health and Developmental
12 Disabilities), or the Department of Children and Family
13 Services: (i) inpatient hospital services, including related
14 physician services, related psychiatric interventions, and
15 pharmaceutical services provided to an eligible recipient
16 hospitalized with a primary diagnosis of psychiatric
17 disorder; (ii) outpatient mental health services as defined
18 and specified in Title 59 of the Illinois Administrative
19 Code, Part 132; (iii) any other outpatient mental health
20 services funded by the Illinois Department pursuant to the
21 State of Illinois Medicaid Plan; (iv) partial
22 hospitalization; and (v) follow-up stabilization related to
23 any of those services. Additional behavioral health services
24 may be excluded under this subsection as mutually agreed in
25 writing by the Illinois Department and the affected State
26 agency or agencies. The exclusion of any service does not
27 prohibit the Illinois Department from developing and
28 implementing demonstration projects for categories of persons
29 or services. The Department of Children and Family Services
30 and the Department of Human Services shall each adopt rules
31 governing the integration of managed care in the provision of
32 behavioral health services. The State shall integrate managed
33 care community networks and affiliated providers, to the
34 extent practicable, in any separate delivery system for
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1 mental health services.
2 (n) The Illinois Department shall adopt rules to
3 establish reserve requirements for managed care community
4 networks, as required by subsection (a), and health
5 maintenance organizations to protect against liabilities in
6 the event that a managed health care entity is declared
7 insolvent or bankrupt. If a managed health care entity other
8 than a county provider is declared insolvent or bankrupt,
9 after liquidation and application of any available assets,
10 resources, and reserves, the Illinois Department shall pay a
11 portion of the amounts owed by the managed health care entity
12 to providers for services rendered to enrollees under the
13 integrated health care program under this Section based on
14 the following schedule: (i) from April 1, 1995 through June
15 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
16 through June 30, 2001, 80% of the amounts owed; and (iii)
17 from July 1, 2001 through June 30, 2005, 75% of the amounts
18 owed. The amounts paid under this subsection shall be
19 calculated based on the total amount owed by the managed
20 health care entity to providers before application of any
21 available assets, resources, and reserves. After June 30,
22 2005, the Illinois Department may not pay any amounts owed to
23 providers as a result of an insolvency or bankruptcy of a
24 managed health care entity occurring after that date. The
25 Illinois Department is not obligated, however, to pay amounts
26 owed to a provider that has an ownership or other governing
27 interest in the managed health care entity. This subsection
28 applies only to managed health care entities and the services
29 they provide under the integrated health care program under
30 this Section.
31 (o) Notwithstanding any other provision of law or
32 contractual agreement to the contrary, providers shall not be
33 required to accept from any other third party payer the rates
34 determined or paid under this Code by the Illinois
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1 Department, managed health care entity, or other health care
2 delivery system for services provided to recipients.
3 (p) The Illinois Department may seek and obtain any
4 necessary authorization provided under federal law to
5 implement the program, including the waiver of any federal
6 statutes or regulations. The Illinois Department may seek a
7 waiver of the federal requirement that the combined
8 membership of Medicare and Medicaid enrollees in a managed
9 care community network may not exceed 75% of the managed care
10 community network's total enrollment. The Illinois
11 Department shall not seek a waiver of this requirement for
12 any other category of managed health care entity. The
13 Illinois Department shall not seek a waiver of the inpatient
14 hospital reimbursement methodology in Section 1902(a)(13)(A)
15 of Title XIX of the Social Security Act even if the federal
16 agency responsible for administering Title XIX determines
17 that Section 1902(a)(13)(A) applies to managed health care
18 systems.
19 Notwithstanding any other provisions of this Code to the
20 contrary, the Illinois Department shall seek a waiver of
21 applicable federal law in order to impose a co-payment system
22 consistent with this subsection on recipients of medical
23 services under Title XIX of the Social Security Act who are
24 not enrolled in a managed health care entity. The waiver
25 request submitted by the Illinois Department shall provide
26 for co-payments of up to $0.50 for prescribed drugs and up to
27 $0.50 for x-ray services and shall provide for co-payments of
28 up to $10 for non-emergency services provided in a hospital
29 emergency room and up to $10 for non-emergency ambulance
30 services. The purpose of the co-payments shall be to deter
31 those recipients from seeking unnecessary medical care.
32 Co-payments may not be used to deter recipients from seeking
33 necessary medical care. No recipient shall be required to
34 pay more than a total of $150 per year in co-payments under
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1 the waiver request required by this subsection. A recipient
2 may not be required to pay more than $15 of any amount due
3 under this subsection in any one month.
4 Co-payments authorized under this subsection may not be
5 imposed when the care was necessitated by a true medical
6 emergency. Co-payments may not be imposed for any of the
7 following classifications of services:
8 (1) Services furnished to person under 18 years of
9 age.
10 (2) Services furnished to pregnant women.
11 (3) Services furnished to any individual who is an
12 inpatient in a hospital, nursing facility, intermediate
13 care facility, or other medical institution, if that
14 person is required to spend for costs of medical care all
15 but a minimal amount of his or her income required for
16 personal needs.
17 (4) Services furnished to a person who is receiving
18 hospice care.
19 Co-payments authorized under this subsection shall not be
20 deducted from or reduce in any way payments for medical
21 services from the Illinois Department to providers. No
22 provider may deny those services to an individual eligible
23 for services based on the individual's inability to pay the
24 co-payment.
25 Recipients who are subject to co-payments shall be
26 provided notice, in plain and clear language, of the amount
27 of the co-payments, the circumstances under which co-payments
28 are exempted, the circumstances under which co-payments may
29 be assessed, and their manner of collection.
30 The Illinois Department shall establish a Medicaid
31 Co-Payment Council to assist in the development of co-payment
32 policies for the medical assistance program. The Medicaid
33 Co-Payment Council shall also have jurisdiction to develop a
34 program to provide financial or non-financial incentives to
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1 Medicaid recipients in order to encourage recipients to seek
2 necessary health care. The Council shall be chaired by the
3 Director of the Illinois Department, and shall have 6
4 additional members. Two of the 6 additional members shall be
5 appointed by the Governor, and one each shall be appointed by
6 the President of the Senate, the Minority Leader of the
7 Senate, the Speaker of the House of Representatives, and the
8 Minority Leader of the House of Representatives. The Council
9 may be convened and make recommendations upon the appointment
10 of a majority of its members. The Council shall be appointed
11 and convened no later than September 1, 1994 and shall report
12 its recommendations to the Director of the Illinois
13 Department and the General Assembly no later than October 1,
14 1994. The chairperson of the Council shall be allowed to
15 vote only in the case of a tie vote among the appointed
16 members of the Council.
17 The Council shall be guided by the following principles
18 as it considers recommendations to be developed to implement
19 any approved waivers that the Illinois Department must seek
20 pursuant to this subsection:
21 (1) Co-payments should not be used to deter access
22 to adequate medical care.
23 (2) Co-payments should be used to reduce fraud.
24 (3) Co-payment policies should be examined in
25 consideration of other states' experience, and the
26 ability of successful co-payment plans to control
27 unnecessary or inappropriate utilization of services
28 should be promoted.
29 (4) All participants, both recipients and
30 providers, in the medical assistance program have
31 responsibilities to both the State and the program.
32 (5) Co-payments are primarily a tool to educate the
33 participants in the responsible use of health care
34 resources.
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1 (6) Co-payments should not be used to penalize
2 providers.
3 (7) A successful medical program requires the
4 elimination of improper utilization of medical resources.
5 The integrated health care program, or any part of that
6 program, established under this Section may not be
7 implemented if matching federal funds under Title XIX of the
8 Social Security Act are not available for administering the
9 program.
10 The Illinois Department shall submit for publication in
11 the Illinois Register the name, address, and telephone number
12 of the individual to whom a request may be directed for a
13 copy of the request for a waiver of provisions of Title XIX
14 of the Social Security Act that the Illinois Department
15 intends to submit to the Health Care Financing Administration
16 in order to implement this Section. The Illinois Department
17 shall mail a copy of that request for waiver to all
18 requestors at least 16 days before filing that request for
19 waiver with the Health Care Financing Administration.
20 (q) After the effective date of this Section, the
21 Illinois Department may take all planning and preparatory
22 action necessary to implement this Section, including, but
23 not limited to, seeking requests for proposals relating to
24 the integrated health care program created under this
25 Section.
26 (r) In order to (i) accelerate and facilitate the
27 development of integrated health care in contracting areas
28 outside counties with populations in excess of 3,000,000 and
29 counties adjacent to those counties and (ii) maintain and
30 sustain the high quality of education and residency programs
31 coordinated and associated with local area hospitals, the
32 Illinois Department may develop and implement a demonstration
33 program for managed care community networks owned, operated,
34 or governed by State-funded medical schools. The Illinois
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1 Department shall prescribe by rule the criteria, standards,
2 and procedures for effecting this demonstration program.
3 (s) (Blank).
4 (t) On April 1, 1995 and every 6 months thereafter, the
5 Illinois Department shall report to the Governor and General
6 Assembly on the progress of the integrated health care
7 program in enrolling clients into managed health care
8 entities. The report shall indicate the capacities of the
9 managed health care entities with which the State contracts,
10 the number of clients enrolled by each contractor, the areas
11 of the State in which managed care options do not exist, and
12 the progress toward meeting the enrollment goals of the
13 integrated health care program.
14 (u) The Illinois Department may implement this Section
15 through the use of emergency rules in accordance with Section
16 5-45 of the Illinois Administrative Procedure Act. For
17 purposes of that Act, the adoption of rules to implement this
18 Section is deemed an emergency and necessary for the public
19 interest, safety, and welfare.
20 (Source: P.A. 89-21, eff. 7-1-95; 89-507, eff. 7-1-97;
21 89-673, eff. 8-14-96; 90-14, eff. 7-1-97; 90-254, eff.
22 1-1-98; 90-538, eff. 12-1-97; 90-655, eff. 7-30-98; 90-742,
23 eff. 8-13-98.)
24 Section 99. Effective date. This Act takes effect upon
25 becoming law.