94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006
SB3020

 

Introduced 1/20/2006, by Sen. Dale A. Righter - Christine Radogno - Larry K. Bomke - Gary G. Dahl - Cheryl Axley, et al.

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-16   from Ch. 23, par. 5-16

    Amends the Illinois Public Aid Code. Provides that in State fiscal year 2007, the Department of Healthcare and Family Services shall implement a pilot mandatory managed care program requiring recipients to enroll with a managed care organization under contract with the Department. Provides that the program shall be implemented in at least 4 contiguous counties determined suitable for a managed care organization-based managed care system using objective criteria. Sets forth features that the program must include, including criteria for evaluating potential managed care organization contractors. Effective immediately.


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FISCAL NOTE ACT MAY APPLY

 

 

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,
3 represented in the General Assembly:
 
4     Section 5. The Illinois Public Aid Code is amended by
5 changing Section 5-16 as follows:
 
6     (305 ILCS 5/5-16)  (from Ch. 23, par. 5-16)
7     Sec. 5-16. Managed Care. The Illinois Department may
8 develop and implement a Primary Care Sponsor System consistent
9 with the provisions of this Section. The purpose of this
10 managed care delivery system shall be to contain the costs of
11 providing medical care to Medicaid recipients by having one
12 provider responsible for managing all aspects of a recipient's
13 medical care. This managed care system shall have the following
14 characteristics:
15         (a) The Department, by rule, shall establish criteria
16     to determine which clients must participate in this
17     program;
18         (b) Providers participating in the program may be paid
19     an amount per patient per month, to be set by the Illinois
20     Department, for managing each recipient's medical care;
21         (c) Providers eligible to participate in the program
22     shall be physicians licensed to practice medicine in all
23     its branches, and the Illinois Department may terminate a
24     provider's participation if the provider is determined to
25     have failed to comply with any applicable program standard
26     or procedure established by the Illinois Department;
27         (d) Each recipient required to participate in the
28     program must select from a panel of primary care providers
29     or networks established by the Department in their
30     communities;
31         (e) A recipient may change his designated primary care
32     provider:

 

 

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1             (1) when the designated source becomes
2         unavailable, as the Illinois Department shall
3         determine by rule; or
4             (2) when the designated primary care provider
5         notifies the Illinois Department that it wishes to
6         withdraw from any obligation as primary care provider;
7         or
8             (3) in other situations, as the Illinois
9         Department shall provide by rule;
10         (f) The Illinois Department shall, by rule, establish
11     procedures for providing medical services when the
12     designated source becomes unavailable or wishes to
13     withdraw from any obligation as primary care provider
14     taking into consideration the need for emergency or
15     temporary medical assistance and ensuring that the
16     recipient has continuous and unrestricted access to
17     medical care from the date on which such unavailability or
18     withdrawal becomes effective until such time as the
19     recipient designates a primary care source;
20         (g) Only medical care services authorized by a
21     recipient's designated provider, except for emergency
22     services, services performed by a provider that is owned or
23     operated by a county and that provides non-emergency
24     services without regard to ability to pay and such other
25     services as provided by the Illinois Department, shall be
26     subject to payment by the Illinois Department. The Illinois
27     Department shall enter into an intergovernmental agreement
28     with each county that owns or operates such a provider to
29     develop and implement policies to minimize the provision of
30     medical care services provided by county owned or operated
31     providers pursuant to the foregoing exception.
32     The Illinois Department shall seek and obtain necessary
33 authorization provided under federal law to implement such a
34 program including the waiver of any federal regulations.
35     The Illinois Department may implement the amendatory
36 changes to this Section made by this amendatory Act of 1991

 

 

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1 through the use of emergency rules in accordance with the
2 provisions of Section 5.02 of the Illinois Administrative
3 Procedure Act. For purposes of the Illinois Administrative
4 Procedure Act, the adoption of rules to implement the
5 amendatory changes to this Section made by this amendatory Act
6 of 1991 shall be deemed an emergency and necessary for the
7 public interest, safety and welfare.
8     The Illinois Department may establish a managed care system
9 demonstration program, on a limited basis, as described in this
10 Section. The demonstration program shall terminate on June 30,
11 1997. Within 30 days after the end of each year of the
12 demonstration program's operation, the Illinois Department
13 shall report to the Governor and the General Assembly
14 concerning the operation of the demonstration program.
15     In order to determine the potential for savings and
16 improved quality of care in the Medicaid program, in State
17 fiscal year 2007, the Department shall implement a pilot
18 mandatory managed care program requiring recipients to enroll
19 with a managed care organization under contract with the
20 Department. The program shall be implemented in at least 4
21 contiguous counties determined suitable for a managed care
22 organization-based managed care system using objective
23 criteria. The program shall have the following features:
24         (A) All recipients in the selected counties who do not
25     have eligibility through the spend-down program and who are
26     not excluded from State-plan-based mandatory managed care
27     by the federal Balanced Budget Act of 1997 shall be
28     enrolled in the program.
29         (B) Only the following services shall be excluded from
30     the program and shall be delivered to eligible recipients
31     through the fee-for-service system: nursing home and
32     assisted living long-term care services and services
33     provided through waivers granted pursuant to Sections 1115
34     and 1915 of the Social Security Act.
35         (C) Three managed care organizations shall be selected
36     for the program following a competitive procurement. The

 

 

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1     competitive procurement shall evaluate potential managed
2     care organization contractors on the following criteria:
3     (i) network adequacy ensuring availability and access to
4     care, (ii) provider payment levels, (iii) quality
5     assurance plans, (iv) past performance on quality outcome
6     measures (for example, HEDIS), (v) plan for care
7     management, (vi) data system adequacy for member
8     enrollment and communication, and (vii) any other criteria
9     that the Department determines to be appropriate.
10         (D) The Department shall competitively procure the
11     services of an enrollment broker to facilitate enrollment
12     in the selected plans in a manner that maximizes consumer
13     choice and continuity of care. The Department shall develop
14     a default assignment algorithm for recipients in the
15     selected counties who do not choose a managed care
16     organization.
17 (Source: P.A. 87-14; 88-490.)
 
18     Section 99. Effective date. This Act takes effect upon
19 becoming law.