99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
SB2331

 

Introduced 1/27/2016, by Sen. Daniel Biss

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-30

    Amends the Illinois Public Aid Code. Makes a technical change in a Section concerning care coordination.


LRB099 19286 KTG 43678 b

 

 

A BILL FOR

 

SB2331LRB099 19286 KTG 43678 b

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 5-30 as follows:
 
6    (305 ILCS 5/5-30)
7    Sec. 5-30. Care coordination.
8    (a) At least 50% of recipients eligible for for
9comprehensive medical benefits in all medical assistance
10programs or other health benefit programs administered by the
11Department, including the Children's Health Insurance Program
12Act and the Covering ALL KIDS Health Insurance Act, shall be
13enrolled in a care coordination program by no later than
14January 1, 2015. For purposes of this Section, "coordinated
15care" or "care coordination" means delivery systems where
16recipients will receive their care from providers who
17participate under contract in integrated delivery systems that
18are responsible for providing or arranging the majority of
19care, including primary care physician services, referrals
20from primary care physicians, diagnostic and treatment
21services, behavioral health services, in-patient and
22outpatient hospital services, dental services, and
23rehabilitation and long-term care services. The Department

 

 

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1shall designate or contract for such integrated delivery
2systems (i) to ensure enrollees have a choice of systems and of
3primary care providers within such systems; (ii) to ensure that
4enrollees receive quality care in a culturally and
5linguistically appropriate manner; and (iii) to ensure that
6coordinated care programs meet the diverse needs of enrollees
7with developmental, mental health, physical, and age-related
8disabilities.
9    (b) Payment for such coordinated care shall be based on
10arrangements where the State pays for performance related to
11health care outcomes, the use of evidence-based practices, the
12use of primary care delivered through comprehensive medical
13homes, the use of electronic medical records, and the
14appropriate exchange of health information electronically made
15either on a capitated basis in which a fixed monthly premium
16per recipient is paid and full financial risk is assumed for
17the delivery of services, or through other risk-based payment
18arrangements.
19    (c) To qualify for compliance with this Section, the 50%
20goal shall be achieved by enrolling medical assistance
21enrollees from each medical assistance enrollment category,
22including parents, children, seniors, and people with
23disabilities to the extent that current State Medicaid payment
24laws would not limit federal matching funds for recipients in
25care coordination programs. In addition, services must be more
26comprehensively defined and more risk shall be assumed than in

 

 

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1the Department's primary care case management program as of
2January 25, 2011 (the effective date of Public Act 96-1501)
3this amendatory Act of the 96th General Assembly.
4    (d) The Department shall report to the General Assembly in
5a separate part of its annual medical assistance program
6report, beginning April, 2012 until April, 2016, on the
7progress and implementation of the care coordination program
8initiatives established by the provisions of Public Act 96-1501
9this amendatory Act of the 96th General Assembly. The
10Department shall include in its April 2011 report a full
11analysis of federal laws or regulations regarding upper payment
12limitations to providers and the necessary revisions or
13adjustments in rate methodologies and payments to providers
14under this Code that would be necessary to implement
15coordinated care with full financial risk by a party other than
16the Department.
17    (e) Integrated Care Program for individuals with chronic
18mental health conditions.
19        (1) The Integrated Care Program shall encompass
20    services administered to recipients of medical assistance
21    under this Article to prevent exacerbations and
22    complications using cost-effective, evidence-based
23    practice guidelines and mental health management
24    strategies.
25        (2) The Department may utilize and expand upon existing
26    contractual arrangements with integrated care plans under

 

 

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1    the Integrated Care Program for providing the coordinated
2    care provisions of this Section.
3        (3) Payment for such coordinated care shall be based on
4    arrangements where the State pays for performance related
5    to mental health outcomes on a capitated basis in which a
6    fixed monthly premium per recipient is paid and full
7    financial risk is assumed for the delivery of services, or
8    through other risk-based payment arrangements such as
9    provider-based care coordination.
10        (4) The Department shall examine whether chronic
11    mental health management programs and services for
12    recipients with specific chronic mental health conditions
13    do any or all of the following:
14            (A) Improve the patient's overall mental health in
15        a more expeditious and cost-effective manner.
16            (B) Lower costs in other aspects of the medical
17        assistance program, such as hospital admissions,
18        emergency room visits, or more frequent and
19        inappropriate psychotropic drug use.
20        (5) The Department shall work with the facilities and
21    any integrated care plan participating in the program to
22    identify and correct barriers to the successful
23    implementation of this subsection (e) prior to and during
24    the implementation to best facilitate the goals and
25    objectives of this subsection (e).
26    (f) A hospital that is located in a county of the State in

 

 

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1which the Department mandates some or all of the beneficiaries
2of the Medical Assistance Program residing in the county to
3enroll in a Care Coordination Program, as set forth in Section
45-30 of this Code, shall not be eligible for any non-claims
5based payments not mandated by Article V-A of this Code for
6which it would otherwise be qualified to receive, unless the
7hospital is a Coordinated Care Participating Hospital no later
8than 60 days after June 14, 2012 (the effective date of Public
9Act 97-689) this amendatory Act of the 97th General Assembly or
1060 days after the first mandatory enrollment of a beneficiary
11in a Coordinated Care program. For purposes of this subsection,
12"Coordinated Care Participating Hospital" means a hospital
13that meets one of the following criteria:
14        (1) The hospital has entered into a contract to provide
15    hospital services with one or more MCOs to enrollees of the
16    care coordination program.
17        (2) The hospital has not been offered a contract by a
18    care coordination plan that the Department has determined
19    to be a good faith offer and that pays at least as much as
20    the Department would pay, on a fee-for-service basis, not
21    including disproportionate share hospital adjustment
22    payments or any other supplemental adjustment or add-on
23    payment to the base fee-for-service rate, except to the
24    extent such adjustments or add-on payments are
25    incorporated into the development of the applicable MCO
26    capitated rates.

 

 

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1    As used in this subsection (f), "MCO" means any entity
2which contracts with the Department to provide services where
3payment for medical services is made on a capitated basis.
4    (g) No later than August 1, 2013, the Department shall
5issue a purchase of care solicitation for Accountable Care
6Entities (ACE) to serve any children and parents or caretaker
7relatives of children eligible for medical assistance under
8this Article. An ACE may be a single corporate structure or a
9network of providers organized through contractual
10relationships with a single corporate entity. The solicitation
11shall require that:
12        (1) An ACE operating in Cook County be capable of
13    serving at least 40,000 eligible individuals in that
14    county; an ACE operating in Lake, Kane, DuPage, or Will
15    Counties be capable of serving at least 20,000 eligible
16    individuals in those counties and an ACE operating in other
17    regions of the State be capable of serving at least 10,000
18    eligible individuals in the region in which it operates.
19    During initial periods of mandatory enrollment, the
20    Department shall require its enrollment services
21    contractor to use a default assignment algorithm that
22    ensures if possible an ACE reaches the minimum enrollment
23    levels set forth in this paragraph.
24        (2) An ACE must include at a minimum the following
25    types of providers: primary care, specialty care,
26    hospitals, and behavioral healthcare.

 

 

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1        (3) An ACE shall have a governance structure that
2    includes the major components of the health care delivery
3    system, including one representative from each of the
4    groups listed in paragraph (2).
5        (4) An ACE must be an integrated delivery system,
6    including a network able to provide the full range of
7    services needed by Medicaid beneficiaries and system
8    capacity to securely pass clinical information across
9    participating entities and to aggregate and analyze that
10    data in order to coordinate care.
11        (5) An ACE must be capable of providing both care
12    coordination and complex case management, as necessary, to
13    beneficiaries. To be responsive to the solicitation, a
14    potential ACE must outline its care coordination and
15    complex case management model and plan to reduce the cost
16    of care.
17        (6) In the first 18 months of operation, unless the ACE
18    selects a shorter period, an ACE shall be paid care
19    coordination fees on a per member per month basis that are
20    projected to be cost neutral to the State during the term
21    of their payment and, subject to federal approval, be
22    eligible to share in additional savings generated by their
23    care coordination.
24        (7) In months 19 through 36 of operation, unless the
25    ACE selects a shorter period, an ACE shall be paid on a
26    pre-paid capitation basis for all medical assistance

 

 

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1    covered services, under contract terms similar to Managed
2    Care Organizations (MCO), with the Department sharing the
3    risk through either stop-loss insurance for extremely high
4    cost individuals or corridors of shared risk based on the
5    overall cost of the total enrollment in the ACE. The ACE
6    shall be responsible for claims processing, encounter data
7    submission, utilization control, and quality assurance.
8        (8) In the fourth and subsequent years of operation, an
9    ACE shall convert to a Managed Care Community Network
10    (MCCN), as defined in this Article, or Health Maintenance
11    Organization pursuant to the Illinois Insurance Code,
12    accepting full-risk capitation payments.
13    The Department shall allow potential ACE entities 5 months
14from the date of the posting of the solicitation to submit
15proposals. After the solicitation is released, in addition to
16the MCO rate development data available on the Department's
17website, subject to federal and State confidentiality and
18privacy laws and regulations, the Department shall provide 2
19years of de-identified summary service data on the targeted
20population, split between children and adults, showing the
21historical type and volume of services received and the cost of
22those services to those potential bidders that sign a data use
23agreement. The Department may add up to 2 non-state government
24employees with expertise in creating integrated delivery
25systems to its review team for the purchase of care
26solicitation described in this subsection. Any such

 

 

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1individuals must sign a no-conflict disclosure and
2confidentiality agreement and agree to act in accordance with
3all applicable State laws.
4    During the first 2 years of an ACE's operation, the
5Department shall provide claims data to the ACE on its
6enrollees on a periodic basis no less frequently than monthly.
7    Nothing in this subsection shall be construed to limit the
8Department's mandate to enroll 50% of its beneficiaries into
9care coordination systems by January 1, 2015, using all
10available care coordination delivery systems, including Care
11Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
12to affect the current CCEs, MCCNs, and MCOs selected to serve
13seniors and persons with disabilities prior to that date.
14    Nothing in this subsection precludes the Department from
15considering future proposals for new ACEs or expansion of
16existing ACEs at the discretion of the Department.
17    (h) Department contracts with MCOs and other entities
18reimbursed by risk based capitation shall have a minimum
19medical loss ratio of 85%, shall require the entity to
20establish an appeals and grievances process for consumers and
21providers, and shall require the entity to provide a quality
22assurance and utilization review program. Entities contracted
23with the Department to coordinate healthcare regardless of risk
24shall be measured utilizing the same quality metrics. The
25quality metrics may be population specific. Any contracted
26entity serving at least 5,000 seniors or people with

 

 

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1disabilities or 15,000 individuals in other populations
2covered by the Medical Assistance Program that has been
3receiving full-risk capitation for a year shall be accredited
4by a national accreditation organization authorized by the
5Department within 2 years after the date it is eligible to
6become accredited. The requirements of this subsection shall
7apply to contracts with MCOs entered into or renewed or
8extended after June 1, 2013.
9    (h-5) The Department shall monitor and enforce compliance
10by MCOs with agreements they have entered into with providers
11on issues that include, but are not limited to, timeliness of
12payment, payment rates, and processes for obtaining prior
13approval. The Department may impose sanctions on MCOs for
14violating provisions of those agreements that include, but are
15not limited to, financial penalties, suspension of enrollment
16of new enrollees, and termination of the MCO's contract with
17the Department. As used in this subsection (h-5), "MCO" has the
18meaning ascribed to that term in Section 5-30.1 of this Code.
19    (i) Unless otherwise required by federal law, Medicaid
20Managed Care Entities shall not divulge, directly or
21indirectly, including by sending a bill or explanation of
22benefits, information concerning the sensitive health services
23received by enrollees of the Medicaid Managed Care Entity to
24any person other than providers and care coordinators caring
25for the enrollee and employees of the entity in the course of
26the entity's internal operations. The Medicaid Managed Care

 

 

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1Entity may divulge information concerning the sensitive health
2services if the enrollee who received the sensitive health
3services requests the information from the Medicaid Managed
4Care Entity and authorized the sending of a bill or explanation
5of benefits. Communications including, but not limited to,
6statements of care received or appointment reminders either
7directly or indirectly to the enrollee from the health care
8provider, health care professional, and care coordinators,
9remain permissible.
10    For the purposes of this subsection, the term "Medicaid
11Managed Care Entity" includes Care Coordination Entities,
12Accountable Care Entities, Managed Care Organizations, and
13Managed Care Community Networks.
14    For purposes of this subsection, the term "sensitive health
15services" means mental health services, substance abuse
16treatment services, reproductive health services, family
17planning services, services for sexually transmitted
18infections and sexually transmitted diseases, and services for
19sexual assault or domestic abuse. Services include prevention,
20screening, consultation, examination, treatment, or follow-up.
21    Nothing in this subsection shall be construed to relieve a
22Medicaid Managed Care Entity or the Department of any duty to
23report incidents of sexually transmitted infections to the
24Department of Public Health or to the local board of health in
25accordance with regulations adopted under a statute or
26ordinance or to report incidents of sexually transmitted

 

 

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1infections as necessary to comply with the requirements under
2Section 5 of the Abused and Neglected Child Reporting Act or as
3otherwise required by State or federal law.
4    The Department shall create policy in order to implement
5the requirements in this subsection.
6    (j) (i) Managed Care Entities (MCEs), including MCOs and
7all other care coordination organizations, shall develop and
8maintain a written language access policy that sets forth the
9standards, guidelines, and operational plan to ensure language
10appropriate services and that is consistent with the standard
11of meaningful access for populations with limited English
12proficiency. The language access policy shall describe how the
13MCEs will provide all of the following required services:
14        (1) Translation (the written replacement of text from
15    one language into another) of all vital documents and forms
16    as identified by the Department.
17        (2) Qualified interpreter services (the oral
18    communication of a message from one language into another
19    by a qualified interpreter).
20        (3) Staff training on the language access policy,
21    including how to identify language needs, access and
22    provide language assistance services, work with
23    interpreters, request translations, and track the use of
24    language assistance services.
25        (4) Data tracking that identifies the language need.
26        (5) Notification to participants on the availability

 

 

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1    of language access services and on how to access such
2    services.
3(Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14;
499-106, eff. 1-1-16; 99-181, eff. 7-29-15; revised 10-26-15.)