Illinois General Assembly - Full Text of SB0647
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Full Text of SB0647  103rd General Assembly


Sen. Julie A. Morrison

Filed: 4/20/2023





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2    AMENDMENT NO. ______. Amend Senate Bill 647 by replacing
3everything after the enacting clause with the following:
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 comprehensive
9medical benefits in all medical assistance programs or other
10health benefit programs administered by the Department,
11including the Children's Health Insurance Program Act and the
12Covering ALL KIDS Health Insurance Act, shall be enrolled in a
13care coordination program by no later than January 1, 2015.
14For purposes of this Section, "coordinated care" or "care
15coordination" means delivery systems where recipients will
16receive their care from providers who participate under



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1contract in integrated delivery systems that are responsible
2for providing or arranging the majority of care, including
3primary care physician services, referrals from primary care
4physicians, diagnostic and treatment services, behavioral
5health services, in-patient and outpatient hospital services,
6dental services, and rehabilitation and long-term care
7services. The Department shall designate or contract for such
8integrated delivery systems (i) to ensure enrollees have a
9choice of systems and of primary care providers within such
10systems; (ii) to ensure that enrollees receive quality care in
11a culturally and linguistically appropriate manner; and (iii)
12to ensure that coordinated care programs meet the diverse
13needs of enrollees with developmental, mental health,
14physical, and age-related disabilities.
15    (b) Payment for such coordinated care shall be based on
16arrangements where the State pays for performance related to
17health care outcomes, the use of evidence-based practices, the
18use of primary care delivered through comprehensive medical
19homes, the use of electronic medical records, and the
20appropriate exchange of health information electronically made
21either on a capitated basis in which a fixed monthly premium
22per recipient is paid and full financial risk is assumed for
23the delivery of services, or through other risk-based payment
25    (c) To qualify for compliance with this Section, the 50%
26goal shall be achieved by enrolling medical assistance



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1enrollees from each medical assistance enrollment category,
2including parents, children, seniors, and people with
3disabilities to the extent that current State Medicaid payment
4laws would not limit federal matching funds for recipients in
5care coordination programs. In addition, services must be more
6comprehensively defined and more risk shall be assumed than in
7the Department's primary care case management program as of
8January 25, 2011 (the effective date of Public Act 96-1501).
9    (d) The Department shall report to the General Assembly in
10a separate part of its annual medical assistance program
11report, beginning April, 2012 until April, 2016, on the
12progress and implementation of the care coordination program
13initiatives established by the provisions of Public Act
1496-1501. The Department shall include in its April 2011 report
15a full analysis of federal laws or regulations regarding upper
16payment limitations to providers and the necessary revisions
17or adjustments in rate methodologies and payments to providers
18under this Code that would be necessary to implement
19coordinated care with full financial risk by a party other
20than the Department.
21    (e) Integrated Care Program for individuals with chronic
22mental health conditions.
23        (1) The Integrated Care Program shall encompass
24    services administered to recipients of medical assistance
25    under this Article to prevent exacerbations and
26    complications using cost-effective, evidence-based



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



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1    implementation of this subsection (e) prior to and during
2    the implementation to best facilitate the goals and
3    objectives of this subsection (e).
4    (f) A hospital that is located in a county of the State in
5which the Department mandates some or all of the beneficiaries
6of the Medical Assistance Program residing in the county to
7enroll in a Care Coordination Program, as set forth in Section
85-30 of this Code, shall not be eligible for any non-claims
9based payments not mandated by Article V-A of this Code for
10which it would otherwise be qualified to receive, unless the
11hospital is a Coordinated Care Participating Hospital no later
12than 60 days after June 14, 2012 (the effective date of Public
13Act 97-689) or 60 days after the first mandatory enrollment of
14a beneficiary in a Coordinated Care program. For purposes of
15this subsection, "Coordinated Care Participating Hospital"
16means a hospital that meets one of the following criteria:
17        (1) The hospital has entered into a contract to
18    provide hospital services with one or more MCOs to
19    enrollees of the care coordination program.
20        (2) The hospital has not been offered a contract by a
21    care coordination plan that the Department has determined
22    to be a good faith offer and that pays at least as much as
23    the Department would pay, on a fee-for-service basis, not
24    including disproportionate share hospital adjustment
25    payments or any other supplemental adjustment or add-on
26    payment to the base fee-for-service rate, except to the



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



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



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1        (7) In months 19 through 36 of operation, unless the
2    ACE selects a shorter period, an ACE shall be paid on a
3    pre-paid capitation basis for all medical assistance
4    covered services, under contract terms similar to Managed
5    Care Organizations (MCO), with the Department sharing the
6    risk through either stop-loss insurance for extremely high
7    cost individuals or corridors of shared risk based on the
8    overall cost of the total enrollment in the ACE. The ACE
9    shall be responsible for claims processing, encounter data
10    submission, utilization control, and quality assurance.
11        (8) In the fourth and subsequent years of operation,
12    an ACE shall convert to a Managed Care Community Network
13    (MCCN), as defined in this Article, or Health Maintenance
14    Organization pursuant to the Illinois Insurance Code,
15    accepting full-risk capitation payments.
16    The Department shall allow potential ACE entities 5 months
17from the date of the posting of the solicitation to submit
18proposals. After the solicitation is released, in addition to
19the MCO rate development data available on the Department's
20website, subject to federal and State confidentiality and
21privacy laws and regulations, the Department shall provide 2
22years of de-identified summary service data on the targeted
23population, split between children and adults, showing the
24historical type and volume of services received and the cost
25of those services to those potential bidders that sign a data
26use agreement. The Department may add up to 2 non-state



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



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1risk shall be measured utilizing the same quality metrics. The
2quality metrics may be population specific. Any contracted
3entity serving at least 5,000 seniors or people with
4disabilities or 15,000 individuals in other populations
5covered by the Medical Assistance Program that has been
6receiving full-risk capitation for a year shall be accredited
7by a national accreditation organization authorized by the
8Department within 2 years after the date it is eligible to
9become accredited. The requirements of this subsection shall
10apply to contracts with MCOs entered into or renewed or
11extended after June 1, 2013.
12    (h-5) The Department shall monitor and enforce compliance
13by MCOs with agreements they have entered into with providers
14on issues that include, but are not limited to, timeliness of
15payment, payment rates, and processes for obtaining prior
16approval. The Department may impose sanctions on MCOs for
17violating provisions of those agreements that include, but are
18not limited to, financial penalties, suspension of enrollment
19of new enrollees, and termination of the MCO's contract with
20the Department. As used in this subsection (h-5), "MCO" has
21the meaning ascribed to that term in Section 5-30.1 of this
23    (i) Unless otherwise required by federal law, Medicaid
24Managed Care Entities and their respective business associates
25shall not disclose, directly or indirectly, including by
26sending a bill or explanation of benefits, information



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1concerning the sensitive health services received by enrollees
2of the Medicaid Managed Care Entity to any person other than
3covered entities and business associates, which may receive,
4use, and further disclose such information solely for the
5purposes permitted under applicable federal and State laws and
6regulations if such use and further disclosure satisfies all
7applicable requirements of such laws and regulations. The
8Medicaid Managed Care Entity or its respective business
9associates may disclose information concerning the sensitive
10health services if the enrollee who received the sensitive
11health services requests the information from the Medicaid
12Managed Care Entity or its respective business associates and
13authorized the sending of a bill or explanation of benefits.
14Communications including, but not limited to, statements of
15care received or appointment reminders either directly or
16indirectly to the enrollee from the health care provider,
17health care professional, and care coordinators, remain
18permissible. Medicaid Managed Care Entities or their
19respective business associates may communicate directly with
20their enrollees regarding care coordination activities for
21those enrollees.
22    For the purposes of this subsection, the term "Medicaid
23Managed Care Entity" includes Care Coordination Entities,
24Accountable Care Entities, Managed Care Organizations, and
25Managed Care Community Networks.
26    For purposes of this subsection, the term "sensitive



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1health services" means mental health services, substance abuse
2treatment services, reproductive health services, family
3planning services, services for sexually transmitted
4infections and sexually transmitted diseases, and services for
5sexual assault or domestic abuse. Services include prevention,
6screening, consultation, examination, treatment, or follow-up.
7    For purposes of this subsection, "business associate",
8"covered entity", "disclosure", and "use" have the meanings
9ascribed to those terms in 45 CFR 160.103.
10    Nothing in this subsection shall be construed to relieve a
11Medicaid Managed Care Entity or the Department of any duty to
12report incidents of sexually transmitted infections to the
13Department of Public Health or to the local board of health in
14accordance with regulations adopted under a statute or
15ordinance or to report incidents of sexually transmitted
16infections as necessary to comply with the requirements under
17Section 5 of the Abused and Neglected Child Reporting Act or as
18otherwise required by State or federal law.
19    The Department shall create policy in order to implement
20the requirements in this subsection.
21    (j) Managed Care Entities (MCEs), including MCOs and all
22other care coordination organizations, shall develop and
23maintain a written language access policy that sets forth the
24standards, guidelines, and operational plan to ensure language
25appropriate services and that is consistent with the standard
26of meaningful access for populations with limited English



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1proficiency. The language access policy shall describe how the
2MCEs will provide all of the following required services:
3        (1) Translation (the written replacement of text from
4    one language into another) of all vital documents and
5    forms as identified by the Department.
6        (2) Qualified interpreter services (the oral
7    communication of a message from one language into another
8    by a qualified interpreter).
9        (3) Staff training on the language access policy,
10    including how to identify language needs, access and
11    provide language assistance services, work with
12    interpreters, request translations, and track the use of
13    language assistance services.
14        (4) Data tracking that identifies the language need.
15        (5) Notification to participants on the availability
16    of language access services and on how to access such
17    services.
18    (k) The Department shall actively monitor the contractual
19relationship between Managed Care Organizations (MCOs) and any
20dental administrator contracted by an MCO to provide dental
21services. The Department shall adopt appropriate dental
22Healthcare Effectiveness Data and Information Set (HEDIS)
23measures and shall include the Annual Dental Visit (ADV) HEDIS
24measure in its Health Plan Comparison Tool and Illinois
25Medicaid Plan Report Card that is available on the
26Department's website for enrolled individuals.



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1    The Department shall collect from each MCO specific
2information about the types of contracted, broad-based care
3coordination occurring between the MCO and any dental
4administrator, including, but not limited to, pregnant women
5and diabetic patients in need of oral care.
6    (l) Notwithstanding any other provision of this Code, the
7Department may not impose and a dental provider shall not be
8required to pay any assessment, tax, or fee, the proceeds of
9which will fund any coordinated care program authorized by
10this Section.
11(Source: P.A. 99-106, eff. 1-1-16; 99-181, eff. 7-29-15;
1299-566, eff. 1-1-17; 99-642, eff. 7-28-16; 100-587, eff.