103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
SB3486

 

Introduced 2/9/2024, by Sen. Omar Aquino

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-11  from Ch. 23, par. 5-11

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to enter into one or more cooperative arrangements with safety-net providers to provide primary, secondary, or tertiary managed health care services as a managed care community network with a monthly total capitation amount not to exceed $100,000,000. Defines "safety-net provider" to mean a non-government owned managed care community network operating and located in Cook County with at least 80% ownership by one or more safety-net hospitals. Provides that a safety-net provider shall be deemed a managed care community network for purposes of the Code only to the extent that it provides services to participating individuals. Provides that a non-government owned safety-net provider is entitled to contract with the Department with respect to Cook County only. Provides that a safety-net provider is not required to accept enrollees who do not reside within Cook County.


LRB103 39341 KTG 69504 b

 

 

A BILL FOR

 

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1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-11 as follows:
 
6    (305 ILCS 5/5-11)  (from Ch. 23, par. 5-11)
7    Sec. 5-11. Co-operative arrangements; contracts with other
8State agencies, health care and rehabilitation organizations,
9and fiscal intermediaries.
10    (a) The Illinois Department may enter into co-operative
11arrangements with State agencies responsible for administering
12or supervising the administration of health services and
13vocational rehabilitation services to the end that there may
14be maximum utilization of such services in the provision of
15medical assistance.
16    The Illinois Department shall, not later than June 30,
171993, enter into one or more co-operative arrangements with
18the Department of Mental Health and Developmental Disabilities
19providing that the Department of Mental Health and
20Developmental Disabilities will be responsible for
21administering or supervising all programs for services to
22persons in community care facilities for persons with
23developmental disabilities, including but not limited to

 

 

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1intermediate care facilities, that are supported by State
2funds or by funding under Title XIX of the federal Social
3Security Act. The responsibilities of the Department of Mental
4Health and Developmental Disabilities under these agreements
5are transferred to the Department of Human Services as
6provided in the Department of Human Services Act.
7    The Department may also contract with such State health
8and rehabilitation agencies and other public or private health
9care and rehabilitation organizations to act for it in
10supplying designated medical services to persons eligible
11therefor under this Article. Any contracts with health
12services or health maintenance organizations shall be
13restricted to organizations which have been certified as being
14in compliance with standards promulgated pursuant to the laws
15of this State governing the establishment and operation of
16health services or health maintenance organizations. The
17Department shall renegotiate the contracts with health
18maintenance organizations and managed care community networks
19that took effect August 1, 2003, so as to produce $70,000,000
20savings to the Department net of resulting increases to the
21fee-for-service program for State fiscal year 2006. The
22Department may also contract with insurance companies or other
23corporate entities serving as fiscal intermediaries in this
24State for the Federal Government in respect to Medicare
25payments under Title XVIII of the Federal Social Security Act
26to act for the Department in paying medical care suppliers.

 

 

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1The provisions of Section 9 of "An Act in relation to State
2finance", approved June 10, 1919, as amended, notwithstanding,
3such contracts with State agencies, other health care and
4rehabilitation organizations, or fiscal intermediaries may
5provide for advance payments.
6    (b) For purposes of this subsection (b), "managed care
7community network" means an entity, other than a health
8maintenance organization, that is owned, operated, or governed
9by providers of health care services within this State and
10that provides or arranges primary, secondary, and tertiary
11managed health care services under contract with the Illinois
12Department exclusively to persons participating in programs
13administered by the Illinois Department.
14    The Illinois Department may certify managed care community
15networks, including managed care community networks owned,
16operated, managed, or governed by State-funded medical
17schools, as risk-bearing entities eligible to contract with
18the Illinois Department as Medicaid managed care
19organizations. The Illinois Department may contract with those
20managed care community networks to furnish health care
21services to or arrange those services for individuals
22participating in programs administered by the Illinois
23Department. The rates for those provider-sponsored
24organizations may be determined on a prepaid, capitated basis.
25A managed care community network may choose to contract with
26the Illinois Department to provide only pediatric health care

 

 

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1services. The Illinois Department shall by rule adopt the
2criteria, standards, and procedures by which a managed care
3community network may be permitted to contract with the
4Illinois Department and shall consult with the Department of
5Insurance in adopting these rules.
6    A county provider as defined in Section 15-1 of this Code
7may contract with the Illinois Department to provide primary,
8secondary, or tertiary managed health care services as a
9managed care community network without the need to establish a
10separate entity and shall be deemed a managed care community
11network for purposes of this Code only to the extent it
12provides services to participating individuals. A county
13provider is entitled to contract with the Illinois Department
14with respect to any contracting region located in whole or in
15part within the county. A county provider is not required to
16accept enrollees who do not reside within the county.
17    The Illinois Department shall enter into one or more
18cooperative arrangements with safety-net providers to provide
19primary, secondary, or tertiary managed health care services
20as a managed care community network with a monthly total
21capitation amount not to exceed $100,000,000. As used in this
22paragraph, "safety-net provider" means a non-government owned
23managed care community network operating and located in Cook
24County with at least 80% ownership by one or more safety-net
25hospitals, as that term is defined in Section 5-5e.1 of this
26Code. A safety-net provider shall be deemed a managed care

 

 

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1community network for purposes of this Code only to the extent
2that it provides services to participating individuals. A
3safety-net provider is entitled to contract with the Illinois
4Department with respect to Cook County only. A safety-net
5provider is not required to accept enrollees who do not reside
6within Cook County.
7    In order to (i) accelerate and facilitate the development
8of integrated health care in contracting areas outside
9counties with populations in excess of 3,000,000 and counties
10adjacent to those counties and (ii) maintain and sustain the
11high quality of education and residency programs coordinated
12and associated with local area hospitals, the Illinois
13Department may develop and implement a demonstration program
14from managed care community networks owned, operated, managed,
15or governed by State-funded medical schools. The Illinois
16Department shall prescribe by rule the criteria, standards,
17and procedures for effecting this demonstration program.
18    A managed care community network that contracts with the
19Illinois Department to furnish health care services to or
20arrange those services for enrollees participating in programs
21administered by the Illinois Department shall do all of the
22following:
23        (1) Provide that any provider affiliated with the
24    managed care community network may also provide services
25    on a fee-for-service basis to Illinois Department clients
26    not enrolled in such managed care entities.

 

 

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1        (2) Provide client education services as determined
2    and approved by the Illinois Department, including but not
3    limited to (i) education regarding appropriate utilization
4    of health care services in a managed care system, (ii)
5    written disclosure of treatment policies and restrictions
6    or limitations on health services, including, but not
7    limited to, physical services, clinical laboratory tests,
8    hospital and surgical procedures, prescription drugs and
9    biologics, and radiological examinations, and (iii)
10    written notice that the enrollee may receive from another
11    provider those covered services that are not provided by
12    the managed care community network.
13        (3) Provide that enrollees within the system may
14    choose the site for provision of services and the panel of
15    health care providers.
16        (4) Not discriminate in enrollment or disenrollment
17    practices among recipients of medical services or
18    enrollees based on health status.
19        (5) Provide a quality assurance and utilization review
20    program that meets the requirements established by the
21    Illinois Department in rules that incorporate those
22    standards set forth in the Health Maintenance Organization
23    Act.
24        (6) Issue a managed care community network
25    identification card to each enrollee upon enrollment. The
26    card must contain all of the following:

 

 

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1            (A) The enrollee's health plan.
2            (B) The name and telephone number of the
3        enrollee's primary care physician or the site for
4        receiving primary care services.
5            (C) A telephone number to be used to confirm
6        eligibility for benefits and authorization for
7        services that is available 24 hours per day, 7 days per
8        week.
9        (7) Ensure that every primary care physician and
10    pharmacy in the managed care community network meets the
11    standards established by the Illinois Department for
12    accessibility and quality of care. The Illinois Department
13    shall arrange for and oversee an evaluation of the
14    standards established under this paragraph (7) and may
15    recommend any necessary changes to these standards.
16        (8) Provide a procedure for handling complaints that
17    meets the requirements established by the Illinois
18    Department in rules that incorporate those standards set
19    forth in the Health Maintenance Organization Act.
20        (9) Maintain, retain, and make available to the
21    Illinois Department records, data, and information, in a
22    uniform manner determined by the Illinois Department,
23    sufficient for the Illinois Department to monitor
24    utilization, accessibility, and quality of care.
25        (10) (Blank).
26    The Illinois Department shall contract with an entity or

 

 

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1entities to provide external peer-based quality assurance
2review for the managed health care programs administered by
3the Illinois Department. The entity shall meet all federal
4requirements for an external quality review organization.
5    Each managed care community network must demonstrate its
6ability to bear the financial risk of serving individuals
7under this program. The Illinois Department shall by rule
8adopt standards for assessing the solvency and financial
9soundness of each managed care community network. Any solvency
10and financial standards adopted for managed care community
11networks shall be no more restrictive than the solvency and
12financial standards adopted under Section 1856(a) of the
13Social Security Act for provider-sponsored organizations under
14Part C of Title XVIII of the Social Security Act.
15    The Illinois Department may implement the amendatory
16changes to this Code made by this amendatory Act of 1998
17through the use of emergency rules in accordance with Section
185-45 of the Illinois Administrative Procedure Act. For
19purposes of that Act, the adoption of rules to implement these
20changes is deemed an emergency and necessary for the public
21interest, safety, and welfare.
22    (c) Not later than June 30, 1996, the Illinois Department
23shall enter into one or more cooperative arrangements with the
24Department of Public Health for the purpose of developing a
25single survey for nursing facilities, including but not
26limited to facilities funded under Title XVIII or Title XIX of

 

 

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1the federal Social Security Act or both, which shall be
2administered and conducted solely by the Department of Public
3Health. The Departments shall test the single survey process
4on a pilot basis, with both the Departments of Public Aid and
5Public Health represented on the consolidated survey team. The
6pilot will sunset June 30, 1997. After June 30, 1997, unless
7otherwise determined by the Governor, a single survey shall be
8implemented by the Department of Public Health which would not
9preclude staff from the Department of Healthcare and Family
10Services (formerly Department of Public Aid) from going
11on-site to nursing facilities to perform necessary audits and
12reviews which shall not replicate the single State agency
13survey required by this Act. This Section shall not apply to
14community or intermediate care facilities for persons with
15developmental disabilities.
16    (d) Nothing in this Code in any way limits or otherwise
17impairs the authority or power of the Illinois Department to
18enter into a negotiated contract pursuant to this Section with
19a managed care community network or a health maintenance
20organization, as defined in the Health Maintenance
21Organization Act, that provides for termination or nonrenewal
22of the contract without cause, upon notice as provided in the
23contract, and without a hearing.
24(Source: P.A. 95-331, eff. 8-21-07; 96-1501, eff. 1-25-11.)