Full Text of SB3486 103rd General Assembly
SB3486 103RD GENERAL ASSEMBLY | | | 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. |
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| | 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 5-11 as follows: | 6 | | (305 ILCS 5/5-11) (from Ch. 23, par. 5-11) | 7 | | Sec. 5-11. Co-operative arrangements; contracts with other | 8 | | State agencies, health care and rehabilitation organizations, | 9 | | and fiscal intermediaries. | 10 | | (a) The Illinois Department may enter into co-operative | 11 | | arrangements with State agencies responsible for administering | 12 | | or supervising the administration of health services and | 13 | | vocational rehabilitation services to the end that there may | 14 | | be maximum utilization of such services in the provision of | 15 | | medical assistance. | 16 | | The Illinois Department shall, not later than June 30, | 17 | | 1993, enter into one or more co-operative arrangements with | 18 | | the Department of Mental Health and Developmental Disabilities | 19 | | providing that the Department of Mental Health and | 20 | | Developmental Disabilities will be responsible for | 21 | | administering or supervising all programs for services to | 22 | | persons in community care facilities for persons with | 23 | | developmental disabilities, including but not limited to |
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| 1 | | intermediate care facilities, that are supported by State | 2 | | funds or by funding under Title XIX of the federal Social | 3 | | Security Act. The responsibilities of the Department of Mental | 4 | | Health and Developmental Disabilities under these agreements | 5 | | are transferred to the Department of Human Services as | 6 | | provided in the Department of Human Services Act. | 7 | | The Department may also contract with such State health | 8 | | and rehabilitation agencies and other public or private health | 9 | | care and rehabilitation organizations to act for it in | 10 | | supplying designated medical services to persons eligible | 11 | | therefor under this Article. Any contracts with health | 12 | | services or health maintenance organizations shall be | 13 | | restricted to organizations which have been certified as being | 14 | | in compliance with standards promulgated pursuant to the laws | 15 | | of this State governing the establishment and operation of | 16 | | health services or health maintenance organizations. The | 17 | | Department shall renegotiate the contracts with health | 18 | | maintenance organizations and managed care community networks | 19 | | that took effect August 1, 2003, so as to produce $70,000,000 | 20 | | savings to the Department net of resulting increases to the | 21 | | fee-for-service program for State fiscal year 2006. The | 22 | | Department may also contract with insurance companies or other | 23 | | corporate entities serving as fiscal intermediaries in this | 24 | | State for the Federal Government in respect to Medicare | 25 | | payments under Title XVIII of the Federal Social Security Act | 26 | | to act for the Department in paying medical care suppliers. |
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| 1 | | The provisions of Section 9 of "An Act in relation to State | 2 | | finance", approved June 10, 1919, as amended, notwithstanding, | 3 | | such contracts with State agencies, other health care and | 4 | | rehabilitation organizations, or fiscal intermediaries may | 5 | | provide for advance payments. | 6 | | (b) For purposes of this subsection (b), "managed care | 7 | | community network" means an entity, other than a health | 8 | | maintenance organization, that is owned, operated, or governed | 9 | | by providers of health care services within this State and | 10 | | that provides or arranges primary, secondary, and tertiary | 11 | | managed health care services under contract with the Illinois | 12 | | Department exclusively to persons participating in programs | 13 | | administered by the Illinois Department. | 14 | | The Illinois Department may certify managed care community | 15 | | networks, including managed care community networks owned, | 16 | | operated, managed, or governed by State-funded medical | 17 | | schools, as risk-bearing entities eligible to contract with | 18 | | the Illinois Department as Medicaid managed care | 19 | | organizations. The Illinois Department may contract with those | 20 | | managed care community networks to furnish health care | 21 | | services to or arrange those services for individuals | 22 | | participating in programs administered by the Illinois | 23 | | Department. The rates for those provider-sponsored | 24 | | organizations may be determined on a prepaid, capitated basis. | 25 | | A managed care community network may choose to contract with | 26 | | the Illinois Department to provide only pediatric health care |
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| 1 | | services. The Illinois Department shall by rule adopt the | 2 | | criteria, standards, and procedures by which a managed care | 3 | | community network may be permitted to contract with the | 4 | | Illinois Department and shall consult with the Department of | 5 | | Insurance in adopting these rules. | 6 | | A county provider as defined in Section 15-1 of this Code | 7 | | may contract with the Illinois Department to provide primary, | 8 | | secondary, or tertiary managed health care services as a | 9 | | managed care community network without the need to establish a | 10 | | separate entity and shall be deemed a managed care community | 11 | | network for purposes of this Code only to the extent it | 12 | | provides services to participating individuals. A county | 13 | | provider is entitled to contract with the Illinois Department | 14 | | with respect to any contracting region located in whole or in | 15 | | part within the county. A county provider is not required to | 16 | | accept enrollees who do not reside within the county. | 17 | | The Illinois Department shall enter into one or more | 18 | | cooperative arrangements with safety-net providers to provide | 19 | | primary, secondary, or tertiary managed health care services | 20 | | as a managed care community network with a monthly total | 21 | | capitation amount not to exceed $100,000,000. As used in this | 22 | | paragraph, "safety-net provider" means a non-government owned | 23 | | managed care community network operating and located in Cook | 24 | | County with at least 80% ownership by one or more safety-net | 25 | | hospitals, as that term is defined in Section 5-5e.1 of this | 26 | | Code. A safety-net provider shall be deemed a managed care |
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| 1 | | community network for purposes of this Code only to the extent | 2 | | that it provides services to participating individuals. A | 3 | | safety-net provider is entitled to contract with the Illinois | 4 | | Department with respect to Cook County only. A safety-net | 5 | | provider is not required to accept enrollees who do not reside | 6 | | within Cook County. | 7 | | In order to (i) accelerate and facilitate the development | 8 | | of integrated health care in contracting areas outside | 9 | | counties with populations in excess of 3,000,000 and counties | 10 | | adjacent to those counties and (ii) maintain and sustain the | 11 | | high quality of education and residency programs coordinated | 12 | | and associated with local area hospitals, the Illinois | 13 | | Department may develop and implement a demonstration program | 14 | | from managed care community networks owned, operated, managed, | 15 | | or governed by State-funded medical schools. The Illinois | 16 | | Department shall prescribe by rule the criteria, standards, | 17 | | and procedures for effecting this demonstration program. | 18 | | A managed care community network that contracts with the | 19 | | Illinois Department to furnish health care services to or | 20 | | arrange those services for enrollees participating in programs | 21 | | administered by the Illinois Department shall do all of the | 22 | | following: | 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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| 1 | | entities to provide external peer-based quality assurance | 2 | | review for the managed health care programs administered by | 3 | | the Illinois Department. The entity shall meet all federal | 4 | | requirements for an external quality review organization. | 5 | | Each managed care community network must demonstrate its | 6 | | ability to bear the financial risk of serving individuals | 7 | | under this program. The Illinois Department shall by rule | 8 | | adopt standards for assessing the solvency and financial | 9 | | soundness of each managed care community network. Any solvency | 10 | | and financial standards adopted for managed care community | 11 | | networks shall be no more restrictive than the solvency and | 12 | | financial standards adopted under Section 1856(a) of the | 13 | | Social Security Act for provider-sponsored organizations under | 14 | | Part C of Title XVIII of the Social Security Act. | 15 | | The Illinois Department may implement the amendatory | 16 | | changes to this Code made by this amendatory Act of 1998 | 17 | | through the use of emergency rules in accordance with Section | 18 | | 5-45 of the Illinois Administrative Procedure Act. For | 19 | | purposes of that Act, the adoption of rules to implement these | 20 | | changes is deemed an emergency and necessary for the public | 21 | | interest, safety, and welfare. | 22 | | (c) Not later than June 30, 1996, the Illinois Department | 23 | | shall enter into one or more cooperative arrangements with the | 24 | | Department of Public Health for the purpose of developing a | 25 | | single survey for nursing facilities, including but not | 26 | | limited to facilities funded under Title XVIII or Title XIX of |
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| 1 | | the federal Social Security Act or both, which shall be | 2 | | administered and conducted solely by the Department of Public | 3 | | Health. The Departments shall test the single survey process | 4 | | on a pilot basis, with both the Departments of Public Aid and | 5 | | Public Health represented on the consolidated survey team. The | 6 | | pilot will sunset June 30, 1997. After June 30, 1997, unless | 7 | | otherwise determined by the Governor, a single survey shall be | 8 | | implemented by the Department of Public Health which would not | 9 | | preclude staff from the Department of Healthcare and Family | 10 | | Services (formerly Department of Public Aid) from going | 11 | | on-site to nursing facilities to perform necessary audits and | 12 | | reviews which shall not replicate the single State agency | 13 | | survey required by this Act. This Section shall not apply to | 14 | | community or intermediate care facilities for persons with | 15 | | developmental disabilities. | 16 | | (d) Nothing in this Code in any way limits or otherwise | 17 | | impairs the authority or power of the Illinois Department to | 18 | | enter into a negotiated contract pursuant to this Section with | 19 | | a managed care community network or a health maintenance | 20 | | organization, as defined in the Health Maintenance | 21 | | Organization Act, that provides for termination or nonrenewal | 22 | | of the contract without cause, upon notice as provided in the | 23 | | contract, and without a hearing. | 24 | | (Source: P.A. 95-331, eff. 8-21-07; 96-1501, eff. 1-25-11.) |
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