94TH GENERAL ASSEMBLY
State of Illinois
2005 and 2006
SB3025

 

Introduced 1/20/2006, by Sen. Dale A. Righter - Christine Radogno

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 106/27 new
305 ILCS 5/5-16.14 new

    Amends the Children's Health Insurance Program Act and the Illinois Public Aid Code. Under the Children's Health Insurance Program Act, provides that on and after July 1, 2006, the Department of Healthcare and Family Services shall implement the following: (1) a capitated managed care system for selected populations of persons in certain counties surrounding Cook County and in certain counties in southern Illinois, under which the State pays a fixed amount per individual per month to a third-party entity to manage the program of health care benefits and assume the risk associated with the payment of medical bills without regard to the actual medical claims incurred; (2) a primary care case management (PCCM) system for selected populations of persons in the remaining counties of the State other than Cook County, under which each participant has one health care provider who is responsible for managing all aspects of the participant's medical care; and (3) a PCCM system for selected populations of persons in Cook County. Requires the Department to file a report describing a mechanism for achieving a transition to a capitated managed care system for persons in Cook County by July 1, 2007. Requires that the populations selected for participation in the various systems must include, at a minimum, all persons eligible for benefits under the Children's Health Insurance Program Act. Provides that the Department may implement similar capitated managed care systems and primary care case management systems for Medicaid recipients under the Illinois Public Aid Code. Effective immediately.


LRB094 18981 DRJ 54449 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

SB3025 LRB094 18981 DRJ 54449 b

1     AN ACT concerning health.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Children's Health Insurance Program Act is
5 amended by adding Section 27 as follows:
 
6     (215 ILCS 106/27 new)
7     Sec. 27. Transition to capitated managed care or primary
8 care case management systems.
9     (a) Designated counties. On and after July 1, 2006, in
10 counties determined by the Department of Healthcare and Family
11 Services by rule, the Department shall implement a capitated
12 managed care system for selected populations of persons. Under
13 the capitated managed care system, the State shall pay a fixed
14 amount per individual per month to a third-party entity to
15 manage the program of health care benefits and assume the risk
16 associated with the payment of medical bills without regard to
17 the actual medical claims incurred. At a minimum, the counties
18 in which the Department implements the capitated managed care
19 system must include the following:
20         (1) The counties of Winnebago, Boone, McHenry, Lake,
21     DeKalb, Kane, DuPage, Kendall, Grundy, Will, and Kankakee.
22         (2) The counties of Madison, St. Clair, Monroe,
23     Randolph, Perry, Franklin, Jackson, and Williamson.
24     In counties of the State in which the Department implements
25 the capitated managed care system under this subsection, the
26 Department may provide for the payment of capitated payments
27 within a time period that is consistent with the time period
28 within which payments are made to fee-for-service providers in
29 counties in which the Department uses a primary care case
30 management system.
31     The Department shall adopt rules establishing the
32 populations in the designated counties that must participate in

 

 

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1 the capitated managed care system. At a minimum, those
2 populations must include all persons eligible for benefits
3 under Sections 25 and 40. The Department shall adopt rules
4 providing for the implementation and continued oversight of the
5 capitated managed care system.
6     (b) Remaining counties, other than Cook. On and after July
7 1, 2006, in the counties of the State other than Cook County
8 and other than the counties designated under subsection (a),
9 the Department of Healthcare and Family Services shall
10 implement a primary care case management system for selected
11 populations of persons. Under the primary care case management
12 system, each individual enrolled in the system shall have one
13 health care provider who is responsible for managing all
14 aspects of the individual's medical care.
15     An individual who is required to participate in the primary
16 care case management system must select a primary care provider
17 from a panel of primary care physicians designated by the
18 Department. An individual may change his or her primary care
19 provider when the provider selected by the individual becomes
20 unavailable, as provided by the Department in rules, or in
21 other situations as provided by the Department in rules. At a
22 minimum, an individual must be given an opportunity to change
23 his or her primary care provider at least once during each
24 State fiscal year.
25     The Department shall adopt rules establishing the
26 populations in these counties that must participate in the
27 primary care case management system. At a minimum, those
28 populations must include all persons eligible for benefits
29 under Sections 25 and 40.
30     A health care provider serving as a primary care physician
31 in the primary care case management system is entitled to a
32 care coordination fee, as determined by the Department, for
33 managing each patient's medical care. The fee may be contingent
34 on performance measures as determined by the Department in
35 rules. In addition, a health care provider is entitled to
36 reimbursement for specific services rendered to a patient.

 

 

SB3025 - 3 - LRB094 18981 DRJ 54449 b

1     The Department shall adopt rules providing for the
2 implementation and continued oversight of the primary care case
3 management system.
4     (c) Cook County. On and after July 1, 2006, in Cook County,
5 the Department of Healthcare and Family Services shall
6 implement a primary care case management system for selected
7 populations of persons. The Department shall implement the
8 primary care case management system in Cook County in a manner
9 consistent with the implementation of a primary care case
10 management system in other counties under subsection (b).
11     The Department shall adopt rules establishing the
12 populations in Cook County that must participate in the primary
13 care case management system. At a minimum, those populations
14 must include all persons eligible for benefits under Sections
15 25 and 40.
16     The Department shall adopt rules providing for the
17 implementation and continued oversight of the primary care case
18 management system.
19     No later than January 1, 2007, the Department shall file
20 with the General Assembly a report setting forth a proposed
21 means of transferring the individuals participating in the
22 primary care case management system to a capitated managed care
23 system by July 1, 20007.
24     (d) Waivers. The Department of Healthcare and Family
25 Services shall promptly apply for all waivers of federal law
26 and regulations that are necessary to allow the full
27 implementation of this Section.
 
28     Section 10. The Illinois Public Aid Code is amended by
29 adding Section 5-16.14 as follows:
 
30     (305 ILCS 5/5-16.14 new)
31     Sec. 5-16.14. Transition to capitated managed care or
32 primary care case management systems.
33     (a) Designated counties. On and after July 1, 2006, in
34 counties determined by the Department of Healthcare and Family

 

 

SB3025 - 4 - LRB094 18981 DRJ 54449 b

1 Services by rule, the Department may implement a capitated
2 managed care system for selected populations of recipients of
3 medical assistance under this Article. Under the capitated
4 system, the State shall pay a fixed amount per member per month
5 to a third-party entity to manage the program of medical
6 assistance benefits and assume the risk associated with the
7 payment of medical bills without regard to the actual medical
8 claims incurred. If the Department implements a capitated
9 managed care system as provided in this subsection, the
10 counties in which the Department implements the system must be
11 the same as the counties in which the Department implements a
12 capitated managed care system under subsection (a) of Section
13 27 of the Children's Health Insurance Program Act and must
14 include, at a minimum, the following:
15         (1) The counties of Winnebago, Boone, McHenry, Lake,
16     DeKalb, Kane, DuPage, Kendall, Grundy, Will, and Kankakee.
17         (2) The counties of Madison, St. Clair, Monroe,
18     Randolph, Perry, Franklin, Jackson, and Williamson.
19     In the counties in which the Department implements a
20 capitated managed care system under this subsection, the
21 Department may provide for the payment of capitated payments
22 within a time period that is consistent with the time period
23 within which payments are made to fee-for-service providers in
24 areas where the Department uses a primary care case management
25 system.
26     The Department shall adopt rules establishing the medical
27 assistance recipient populations in the designated counties
28 that must participate in the capitated managed care system. The
29 Department shall adopt rules providing for the implementation
30 and continued oversight of the capitated managed care system.
31 The rules shall provide for the implementation of the system in
32 a manner consistent with the Department's implementation of a
33 capitated managed care system under subsection (a) of Section
34 27 of the Children's Health Insurance Program Act.
35     (b) Remaining counties, other than Cook. On and after July
36 1, 2006, in the counties of the State other than Cook County

 

 

SB3025 - 5 - LRB094 18981 DRJ 54449 b

1 and other than the counties designated under subsection (a),
2 the Department of Healthcare and Family Services may implement
3 a primary care case management system for selected populations
4 of recipients of medical assistance under this Article. Under
5 the primary care case management system, each individual
6 enrolled in the system shall have one health care provider who
7 is responsible for managing all aspects of the individual's
8 medical care.
9     An individual who is required to participate in the primary
10 care case management system must select a primary care provider
11 from a panel of primary care physicians designated by the
12 Department. An individual may change his or her primary care
13 provider when the provider selected by the individual becomes
14 unavailable, as provided by the Department in rules, or in
15 other situations as provided by the Department in rules. At a
16 minimum, an individual must be given an opportunity to change
17 his or her primary care provider at least once during each
18 State fiscal year.
19     The Department shall adopt rules establishing the medical
20 assistance recipient populations in these counties that must
21 participate in the primary care case management system.
22     A health care provider serving as a primary care physician
23 in the primary care case management system is entitled to a
24 care coordination fee, as determined by the Department, for
25 managing each patient's medical care. The fee may be contingent
26 on performance measures as determined by the Department in
27 rules. In addition, a health care provider is entitled to
28 reimbursement for specific services rendered to a patient.
29     The Department shall adopt rules providing for the
30 implementation and continued oversight of the primary care case
31 management system. The rules shall provide for the
32 implementation of the system in a manner consistent with the
33 Department's implementation of a primary care casse management
34 system under subsection (b) of Section 27 of the Children's
35 Health Insurance Program Act.
36     (c) Cook County. On and after July 1, 2006, in Cook County,

 

 

SB3025 - 6 - LRB094 18981 DRJ 54449 b

1 the Department of Healthcare and Family Services may implement
2 a primary care case management system for selected populations
3 of recipients of medical assistance under this Article. The
4 Department shall implement the primary care case management
5 system in Cook County in a manner consistent with (i) the
6 implementation of a primary care case management system in
7 other counties under subsection (b) and (ii) the implementation
8 of a primary care case management system in under subsection
9 (c) of Section 27 of the Children's Health Insurance Program
10 Act.
11     The Department shall adopt rules establishing the
12 populations in Cook County that must participate in the primary
13 care case management system.
14     The Department shall adopt rules providing for the
15 implementation and continued oversight of the primary care case
16 management system. The rules shall provide for the
17 implementation of the system in a manner consistent with the
18 Department's implementation of a primary care case management
19 system under subsection (c) of Section 27 of the Children's
20 Health Insurance Program Act.
21     (d) Waivers. If the Department of Healthcare and Family
22 Services implements any of the health care benefit systems
23 authorized under this Section for recipients of medical
24 assistance, the Department shall promptly apply for all waivers
25 of federal law and regulations that are necessary to allow the
26 full implementation of those provisions.
 
27     Section 99. Effective date. This Act takes effect upon
28 becoming law.