[ Search ] [ Legislation ] [ Bill Summary ]
[ Home ] [ Back ] [ Bottom ]
| [ Introduced ] | [ House Amendment 002 ] |
90_HB0781eng
305 ILCS 5/5-16.3
Amends the Medicaid Article of the Public Aid Code. In
the Section concerning the integrated health care program,
provides that if a managed health care entity is accredited
by a national organization, the Department of Public Aid may
give preference to that managed health care entity in
selecting participants for the program. Requires that the
medical director of a managed health care entity be
physician. Effective immediately.
LRB9000971DJcd
HB0781 Engrossed LRB9000971DJcd
1 AN ACT to amend the Illinois Public Aid Code by changing
2 Sections 5-16.3 and 12-13.1 and adding Section 5-16.8.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Illinois Public Aid Code is amended by
6 changing Sections 5-16.3 and 12-13.1 and adding Section
7 5-16.8 as follows:
8 (305 ILCS 5/5-16.3)
9 (Text of Section before amendment by P.A. 89-507)
10 Sec. 5-16.3. System for integrated health care services.
11 (a) It shall be the public policy of the State to adopt,
12 to the extent practicable, a health care program that
13 encourages the integration of health care services and
14 manages the health care of program enrollees while preserving
15 reasonable choice within a competitive and cost-efficient
16 environment. In furtherance of this public policy, the
17 Illinois Department shall develop and implement an integrated
18 health care program consistent with the provisions of this
19 Section. The provisions of this Section apply only to the
20 integrated health care program created under this Section.
21 Persons enrolled in the integrated health care program, as
22 determined by the Illinois Department by rule, shall be
23 afforded a choice among health care delivery systems, which
24 shall include, but are not limited to, (i) fee for service
25 care managed by a primary care physician licensed to practice
26 medicine in all its branches, (ii) managed health care
27 entities, and (iii) federally qualified health centers
28 (reimbursed according to a prospective cost-reimbursement
29 methodology) and rural health clinics (reimbursed according
30 to the Medicare methodology), where available. Persons
31 enrolled in the integrated health care program also may be
HB0781 Engrossed -2- LRB9000971DJcd
1 offered indemnity insurance plans, subject to availability.
2 For purposes of this Section, a "managed health care
3 entity" means a health maintenance organization or a managed
4 care community network as defined in this Section. A "health
5 maintenance organization" means a health maintenance
6 organization as defined in the Health Maintenance
7 Organization Act. A "managed care community network" means
8 an entity, other than a health maintenance organization, that
9 is owned, operated, or governed by providers of health care
10 services within this State and that provides or arranges
11 primary, secondary, and tertiary managed health care services
12 under contract with the Illinois Department exclusively to
13 enrollees of the integrated health care program. A managed
14 care community network may contract with the Illinois
15 Department to provide only pediatric health care services. A
16 county provider as defined in Section 15-1 of this Code may
17 contract with the Illinois Department to provide services to
18 enrollees of the integrated health care program as a managed
19 care community network without the need to establish a
20 separate entity that provides services exclusively to
21 enrollees of the integrated health care program and shall be
22 deemed a managed care community network for purposes of this
23 Code only to the extent of the provision of services to those
24 enrollees in conjunction with the integrated health care
25 program. A county provider shall be entitled to contract
26 with the Illinois Department with respect to any contracting
27 region located in whole or in part within the county. A
28 county provider shall not be required to accept enrollees who
29 do not reside within the county.
30 If a managed health care entity is accredited by a
31 private national organization that performs quality assurance
32 surveys of health maintenance organizations or related
33 organizations, the Illinois Department may take the
34 accreditation into consideration when selecting managed
HB0781 Engrossed -3- LRB9000971DJcd
1 health care entities for participation in the integrated
2 health care program. The medical director of a managed
3 health care entity must be a physician licensed in the State
4 to practice medicine in all its branches.
5 Each managed care community network must demonstrate its
6 ability to bear the financial risk of serving enrollees under
7 this program. The Illinois Department shall by rule adopt
8 criteria for assessing the financial soundness of each
9 managed care community network. These rules shall consider
10 the extent to which a managed care community network is
11 comprised of providers who directly render health care and
12 are located within the community in which they seek to
13 contract rather than solely arrange or finance the delivery
14 of health care. These rules shall further consider a variety
15 of risk-bearing and management techniques, including the
16 sufficiency of quality assurance and utilization management
17 programs and whether a managed care community network has
18 sufficiently demonstrated its financial solvency and net
19 worth. The Illinois Department's criteria must be based on
20 sound actuarial, financial, and accounting principles. In
21 adopting these rules, the Illinois Department shall consult
22 with the Illinois Department of Insurance. The Illinois
23 Department is responsible for monitoring compliance with
24 these rules.
25 This Section may not be implemented before the effective
26 date of these rules, the approval of any necessary federal
27 waivers, and the completion of the review of an application
28 submitted, at least 60 days before the effective date of
29 rules adopted under this Section, to the Illinois Department
30 by a managed care community network.
31 All health care delivery systems that contract with the
32 Illinois Department under the integrated health care program
33 shall clearly recognize a health care provider's right of
34 conscience under the Right of Conscience Act. In addition to
HB0781 Engrossed -4- LRB9000971DJcd
1 the provisions of that Act, no health care delivery system
2 that contracts with the Illinois Department under the
3 integrated health care program shall be required to provide,
4 arrange for, or pay for any health care or medical service,
5 procedure, or product if that health care delivery system is
6 owned, controlled, or sponsored by or affiliated with a
7 religious institution or religious organization that finds
8 that health care or medical service, procedure, or product to
9 violate its religious and moral teachings and beliefs.
10 (b) The Illinois Department may, by rule, provide for
11 different benefit packages for different categories of
12 persons enrolled in the program. Mental health services,
13 alcohol and substance abuse services, services related to
14 children with chronic or acute conditions requiring
15 longer-term treatment and follow-up, and rehabilitation care
16 provided by a free-standing rehabilitation hospital or a
17 hospital rehabilitation unit may be excluded from a benefit
18 package if the State ensures that those services are made
19 available through a separate delivery system. An exclusion
20 does not prohibit the Illinois Department from developing and
21 implementing demonstration projects for categories of persons
22 or services. Benefit packages for persons eligible for
23 medical assistance under Articles V, VI, and XII shall be
24 based on the requirements of those Articles and shall be
25 consistent with the Title XIX of the Social Security Act.
26 Nothing in this Act shall be construed to apply to services
27 purchased by the Department of Children and Family Services
28 and the Department of Mental Health and Developmental
29 Disabilities under the provisions of Title 59 of the Illinois
30 Administrative Code, Part 132 ("Medicaid Community Mental
31 Health Services Program").
32 (c) The program established by this Section may be
33 implemented by the Illinois Department in various contracting
34 areas at various times. The health care delivery systems and
HB0781 Engrossed -5- LRB9000971DJcd
1 providers available under the program may vary throughout the
2 State. For purposes of contracting with managed health care
3 entities and providers, the Illinois Department shall
4 establish contracting areas similar to the geographic areas
5 designated by the Illinois Department for contracting
6 purposes under the Illinois Competitive Access and
7 Reimbursement Equity Program (ICARE) under the authority of
8 Section 3-4 of the Illinois Health Finance Reform Act or
9 similarly-sized or smaller geographic areas established by
10 the Illinois Department by rule. A managed health care entity
11 shall be permitted to contract in any geographic areas for
12 which it has a sufficient provider network and otherwise
13 meets the contracting terms of the State. The Illinois
14 Department is not prohibited from entering into a contract
15 with a managed health care entity at any time.
16 (d) A managed health care entity that contracts with the
17 Illinois Department for the provision of services under the
18 program shall do all of the following, solely for purposes of
19 the integrated health care program:
20 (1) Provide that any individual physician licensed
21 to practice medicine in all its branches, any pharmacy,
22 any federally qualified health center, and any
23 podiatrist, that consistently meets the reasonable terms
24 and conditions established by the managed health care
25 entity, including but not limited to credentialing
26 standards, quality assurance program requirements,
27 utilization management requirements, financial
28 responsibility standards, contracting process
29 requirements, and provider network size and accessibility
30 requirements, must be accepted by the managed health care
31 entity for purposes of the Illinois integrated health
32 care program. Any individual who is either terminated
33 from or denied inclusion in the panel of physicians of
34 the managed health care entity shall be given, within 10
HB0781 Engrossed -6- LRB9000971DJcd
1 business days after that determination, a written
2 explanation of the reasons for his or her exclusion or
3 termination from the panel. This paragraph (1) does not
4 apply to the following:
5 (A) A managed health care entity that
6 certifies to the Illinois Department that:
7 (i) it employs on a full-time basis 125
8 or more Illinois physicians licensed to
9 practice medicine in all of its branches; and
10 (ii) it will provide medical services
11 through its employees to more than 80% of the
12 recipients enrolled with the entity in the
13 integrated health care program; or
14 (B) A domestic stock insurance company
15 licensed under clause (b) of class 1 of Section 4 of
16 the Illinois Insurance Code if (i) at least 66% of
17 the stock of the insurance company is owned by a
18 professional corporation organized under the
19 Professional Service Corporation Act that has 125 or
20 more shareholders who are Illinois physicians
21 licensed to practice medicine in all of its branches
22 and (ii) the insurance company certifies to the
23 Illinois Department that at least 80% of those
24 physician shareholders will provide services to
25 recipients enrolled with the company in the
26 integrated health care program.
27 (2) Provide for reimbursement for providers for
28 emergency care, as defined by the Illinois Department by
29 rule, that must be provided to its enrollees, including
30 an emergency room screening fee, and urgent care that it
31 authorizes for its enrollees, regardless of the
32 provider's affiliation with the managed health care
33 entity. Providers shall be reimbursed for emergency care
34 at an amount equal to the Illinois Department's
HB0781 Engrossed -7- LRB9000971DJcd
1 fee-for-service rates for those medical services rendered
2 by providers not under contract with the managed health
3 care entity to enrollees of the entity.
4 (3) Provide that any provider affiliated with a
5 managed health care entity may also provide services on a
6 fee-for-service basis to Illinois Department clients not
7 enrolled in a managed health care entity.
8 (4) Provide client education services as determined
9 and approved by the Illinois Department, including but
10 not limited to (i) education regarding appropriate
11 utilization of health care services in a managed care
12 system, (ii) written disclosure of treatment policies and
13 any restrictions or limitations on health services,
14 including, but not limited to, physical services,
15 clinical laboratory tests, hospital and surgical
16 procedures, prescription drugs and biologics, and
17 radiological examinations, and (iii) written notice that
18 the enrollee may receive from another provider those
19 services covered under this program that are not provided
20 by the managed health care entity.
21 (4.5) Provide orientation to the caretaker relative
22 or payee of a medical assistance unit that has an
23 enrollee as a member. The managed health care entity
24 must exercise good faith efforts to provide all caretaker
25 relatives or payees with the orientation. The managed
26 health care entity shall inform the Illinois Department
27 of the caretaker relatives or payees who have completed
28 the orientation. This paragraph applies to every
29 caretaker relative or payee in a managed health care
30 entity's system regardless of whether the caretaker
31 relative or payee has chosen the system or has been
32 assigned to the system as provided in subsection (e).
33 (5) Provide that enrollees within its system may
34 choose the site for provision of services and the panel
HB0781 Engrossed -8- LRB9000971DJcd
1 of health care providers.
2 (6) Not discriminate in its enrollment or
3 disenrollment practices among recipients of medical
4 services or program enrollees based on health status.
5 (7) Provide a quality assurance and utilization
6 review program that (i) for health maintenance
7 organizations meets the requirements of the Health
8 Maintenance Organization Act and (ii) for managed care
9 community networks meets the requirements established by
10 the Illinois Department in rules that incorporate those
11 standards set forth in the Health Maintenance
12 Organization Act.
13 (8) Issue a managed health care entity
14 identification card to each enrollee upon enrollment.
15 The card must contain all of the following:
16 (A) The enrollee's signature.
17 (B) The enrollee's health plan.
18 (C) The name and telephone number of the
19 enrollee's primary care physician.
20 (D) A telephone number to be used for
21 emergency service 24 hours per day, 7 days per week.
22 The telephone number required to be maintained
23 pursuant to this subparagraph by each managed health
24 care entity shall, at minimum, be staffed by
25 medically trained personnel and be provided
26 directly, or under arrangement, at an office or
27 offices in locations maintained solely within the
28 State of Illinois. For purposes of this
29 subparagraph, "medically trained personnel" means
30 licensed practical nurses or registered nurses
31 located in the State of Illinois who are licensed
32 pursuant to the Illinois Nursing Act of 1987.
33 (8.5) The Illinois Department must include
34 performance standards in contracts with entities
HB0781 Engrossed -9- LRB9000971DJcd
1 participating in the integrated health care program to
2 require contractors to make a good faith effort to have
3 enrollees evaluated by a physician within a reasonable
4 period of time after enrollment, as determined by the
5 Illinois Department.
6 (9) Ensure that every primary care physician and
7 pharmacy in the managed health care entity meets the
8 standards established by the Illinois Department for
9 accessibility and quality of care. The Illinois
10 Department shall arrange for and oversee an evaluation of
11 the standards established under this paragraph (9) and
12 may recommend any necessary changes to these standards.
13 The Illinois Department shall submit an annual report to
14 the Governor and the General Assembly by April 1 of each
15 year regarding the effect of the standards on ensuring
16 access and quality of care to enrollees.
17 (10) Provide a procedure for handling complaints
18 that (i) for health maintenance organizations meets the
19 requirements of the Health Maintenance Organization Act
20 and (ii) for managed care community networks meets the
21 requirements established by the Illinois Department in
22 rules that incorporate those standards set forth in the
23 Health Maintenance Organization Act.
24 (11) Maintain, retain, and make available to the
25 Illinois Department records, data, and information, in a
26 uniform manner determined by the Illinois Department,
27 sufficient for the Illinois Department to monitor
28 utilization, accessibility, and quality of care.
29 (12) Except for providers who are prepaid, pay all
30 approved claims for covered services that are completed
31 and submitted to the managed health care entity within 30
32 days after receipt of the claim or receipt of the
33 appropriate capitation payment or payments by the managed
34 health care entity from the State for the month in which
HB0781 Engrossed -10- LRB9000971DJcd
1 the services included on the claim were rendered,
2 whichever is later. If payment is not made or mailed to
3 the provider by the managed health care entity by the due
4 date under this subsection, an interest penalty of 1% of
5 any amount unpaid shall be added for each month or
6 fraction of a month after the due date, until final
7 payment is made. Nothing in this Section shall prohibit
8 managed health care entities and providers from mutually
9 agreeing to terms that require more timely payment.
10 (12.5) Ensure that no payment is made to a
11 physician or other provider of services for withholding
12 from an enrollee any covered services because of the cost
13 of those services. This requirement shall not be
14 construed to prevent managed health care entities from
15 offering, nor providers from accepting, full or partial
16 capitation.
17 (13) Provide integration with community-based
18 programs provided by certified local health departments
19 such as Women, Infants, and Children Supplemental Food
20 Program (WIC), childhood immunization programs, health
21 education programs, case management programs, and health
22 screening programs.
23 (14) Provide that the pharmacy formulary used by a
24 managed health care entity and its contract providers be
25 no more restrictive than the Illinois Department's
26 pharmaceutical program on the effective date of this
27 amendatory Act of 1994 and as amended after that date.
28 (15) Provide integration with community-based
29 organizations, including, but not limited to, any
30 organization that has operated within a Medicaid
31 Partnership as defined by this Code or by rule of the
32 Illinois Department, that may continue to operate under a
33 contract with the Illinois Department or a managed health
34 care entity under this Section to provide case management
HB0781 Engrossed -11- LRB9000971DJcd
1 services to Medicaid clients in designated high-need
2 areas.
3 The Illinois Department may, by rule, determine
4 methodologies to limit financial liability for managed health
5 care entities resulting from payment for services to
6 enrollees provided under the Illinois Department's integrated
7 health care program. Any methodology so determined may be
8 considered or implemented by the Illinois Department through
9 a contract with a managed health care entity under this
10 integrated health care program.
11 The Illinois Department shall contract with an entity or
12 entities to provide external peer-based quality assurance
13 review for the integrated health care program. The entity
14 shall be representative of Illinois physicians licensed to
15 practice medicine in all its branches and have statewide
16 geographic representation in all specialties of medical care
17 that are provided within the integrated health care program.
18 The entity may not be a third party payer and shall maintain
19 offices in locations around the State in order to provide
20 service and continuing medical education to physician
21 participants within the integrated health care program. The
22 review process shall be developed and conducted by Illinois
23 physicians licensed to practice medicine in all its branches.
24 In consultation with the entity, the Illinois Department may
25 contract with other entities for professional peer-based
26 quality assurance review of individual categories of services
27 other than services provided, supervised, or coordinated by
28 physicians licensed to practice medicine in all its branches.
29 The Illinois Department shall establish, by rule, criteria to
30 avoid conflicts of interest in the conduct of quality
31 assurance activities consistent with professional peer-review
32 standards. All quality assurance activities shall be
33 coordinated by the Illinois Department.
34 (e) All persons enrolled in the program shall be
HB0781 Engrossed -12- LRB9000971DJcd
1 provided with a full written explanation of all
2 fee-for-service and managed health care plan options and a
3 reasonable opportunity to choose among the options as
4 provided by rule. The Illinois Department shall provide to
5 enrollees, upon enrollment in the integrated health care
6 program and at least annually thereafter, notice of the
7 process for requesting an appeal under the Illinois
8 Department's administrative appeal procedures.
9 Notwithstanding any other Section of this Code, the Illinois
10 Department may provide by rule for the Illinois Department to
11 assign a person enrolled in the program to a specific
12 provider of medical services or to a specific health care
13 delivery system if an enrollee has failed to exercise choice
14 in a timely manner. An enrollee assigned by the Illinois
15 Department shall be afforded the opportunity to disenroll and
16 to select a specific provider of medical services or a
17 specific health care delivery system within the first 30 days
18 after the assignment. An enrollee who has failed to exercise
19 choice in a timely manner may be assigned only if there are 3
20 or more managed health care entities contracting with the
21 Illinois Department within the contracting area, except that,
22 outside the City of Chicago, this requirement may be waived
23 for an area by rules adopted by the Illinois Department after
24 consultation with all hospitals within the contracting area.
25 The Illinois Department shall establish by rule the procedure
26 for random assignment of enrollees who fail to exercise
27 choice in a timely manner to a specific managed health care
28 entity in proportion to the available capacity of that
29 managed health care entity. Assignment to a specific provider
30 of medical services or to a specific managed health care
31 entity may not exceed that provider's or entity's capacity as
32 determined by the Illinois Department. Any person who has
33 chosen a specific provider of medical services or a specific
34 managed health care entity, or any person who has been
HB0781 Engrossed -13- LRB9000971DJcd
1 assigned under this subsection, shall be given the
2 opportunity to change that choice or assignment at least once
3 every 12 months, as determined by the Illinois Department by
4 rule. The Illinois Department shall maintain a toll-free
5 telephone number for program enrollees' use in reporting
6 problems with managed health care entities.
7 (f) If a person becomes eligible for participation in
8 the integrated health care program while he or she is
9 hospitalized, the Illinois Department may not enroll that
10 person in the program until after he or she has been
11 discharged from the hospital. This subsection does not apply
12 to newborn infants whose mothers are enrolled in the
13 integrated health care program.
14 (g) The Illinois Department shall, by rule, establish
15 for managed health care entities rates that (i) are certified
16 to be actuarially sound, as determined by an actuary who is
17 an associate or a fellow of the Society of Actuaries or a
18 member of the American Academy of Actuaries and who has
19 expertise and experience in medical insurance and benefit
20 programs, in accordance with the Illinois Department's
21 current fee-for-service payment system, and (ii) take into
22 account any difference of cost to provide health care to
23 different populations based on gender, age, location, and
24 eligibility category. The rates for managed health care
25 entities shall be determined on a capitated basis.
26 The Illinois Department by rule shall establish a method
27 to adjust its payments to managed health care entities in a
28 manner intended to avoid providing any financial incentive to
29 a managed health care entity to refer patients to a county
30 provider, in an Illinois county having a population greater
31 than 3,000,000, that is paid directly by the Illinois
32 Department. The Illinois Department shall by April 1, 1997,
33 and annually thereafter, review the method to adjust
34 payments. Payments by the Illinois Department to the county
HB0781 Engrossed -14- LRB9000971DJcd
1 provider, for persons not enrolled in a managed care
2 community network owned or operated by a county provider,
3 shall be paid on a fee-for-service basis under Article XV of
4 this Code.
5 The Illinois Department by rule shall establish a method
6 to reduce its payments to managed health care entities to
7 take into consideration (i) any adjustment payments paid to
8 hospitals under subsection (h) of this Section to the extent
9 those payments, or any part of those payments, have been
10 taken into account in establishing capitated rates under this
11 subsection (g) and (ii) the implementation of methodologies
12 to limit financial liability for managed health care entities
13 under subsection (d) of this Section.
14 (h) For hospital services provided by a hospital that
15 contracts with a managed health care entity, adjustment
16 payments shall be paid directly to the hospital by the
17 Illinois Department. Adjustment payments may include but
18 need not be limited to adjustment payments to:
19 disproportionate share hospitals under Section 5-5.02 of this
20 Code; primary care access health care education payments (89
21 Ill. Adm. Code 149.140); payments for capital, direct medical
22 education, indirect medical education, certified registered
23 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
24 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
25 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
26 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
27 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
28 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
29 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
30 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
31 148.290(h)); and outpatient indigent volume adjustments (89
32 Ill. Adm. Code 148.140(b)(5)).
33 (i) For any hospital eligible for the adjustment
34 payments described in subsection (h), the Illinois Department
HB0781 Engrossed -15- LRB9000971DJcd
1 shall maintain, through the period ending June 30, 1995,
2 reimbursement levels in accordance with statutes and rules in
3 effect on April 1, 1994.
4 (j) Nothing contained in this Code in any way limits or
5 otherwise impairs the authority or power of the Illinois
6 Department to enter into a negotiated contract pursuant to
7 this Section with a managed health care entity, including,
8 but not limited to, a health maintenance organization, that
9 provides for termination or nonrenewal of the contract
10 without cause upon notice as provided in the contract and
11 without a hearing.
12 (k) Section 5-5.15 does not apply to the program
13 developed and implemented pursuant to this Section.
14 (l) The Illinois Department shall, by rule, define those
15 chronic or acute medical conditions of childhood that require
16 longer-term treatment and follow-up care. The Illinois
17 Department shall ensure that services required to treat these
18 conditions are available through a separate delivery system.
19 A managed health care entity that contracts with the
20 Illinois Department may refer a child with medical conditions
21 described in the rules adopted under this subsection directly
22 to a children's hospital or to a hospital, other than a
23 children's hospital, that is qualified to provide inpatient
24 and outpatient services to treat those conditions. The
25 Illinois Department shall provide fee-for-service
26 reimbursement directly to a children's hospital for those
27 services pursuant to Title 89 of the Illinois Administrative
28 Code, Section 148.280(a), at a rate at least equal to the
29 rate in effect on March 31, 1994. For hospitals, other than
30 children's hospitals, that are qualified to provide inpatient
31 and outpatient services to treat those conditions, the
32 Illinois Department shall provide reimbursement for those
33 services on a fee-for-service basis, at a rate at least equal
34 to the rate in effect for those other hospitals on March 31,
HB0781 Engrossed -16- LRB9000971DJcd
1 1994.
2 A children's hospital shall be directly reimbursed for
3 all services provided at the children's hospital on a
4 fee-for-service basis pursuant to Title 89 of the Illinois
5 Administrative Code, Section 148.280(a), at a rate at least
6 equal to the rate in effect on March 31, 1994, until the
7 later of (i) implementation of the integrated health care
8 program under this Section and development of actuarially
9 sound capitation rates for services other than those chronic
10 or acute medical conditions of childhood that require
11 longer-term treatment and follow-up care as defined by the
12 Illinois Department in the rules adopted under this
13 subsection or (ii) March 31, 1996.
14 Notwithstanding anything in this subsection to the
15 contrary, a managed health care entity shall not consider
16 sources or methods of payment in determining the referral of
17 a child. The Illinois Department shall adopt rules to
18 establish criteria for those referrals. The Illinois
19 Department by rule shall establish a method to adjust its
20 payments to managed health care entities in a manner intended
21 to avoid providing any financial incentive to a managed
22 health care entity to refer patients to a provider who is
23 paid directly by the Illinois Department.
24 (m) Behavioral health services provided or funded by the
25 Department of Mental Health and Developmental Disabilities,
26 the Department of Alcoholism and Substance Abuse, the
27 Department of Children and Family Services, and the Illinois
28 Department shall be excluded from a benefit package.
29 Conditions of an organic or physical origin or nature,
30 including medical detoxification, however, may not be
31 excluded. In this subsection, "behavioral health services"
32 means mental health services and subacute alcohol and
33 substance abuse treatment services, as defined in the
34 Illinois Alcoholism and Other Drug Dependency Act. In this
HB0781 Engrossed -17- LRB9000971DJcd
1 subsection, "mental health services" includes, at a minimum,
2 the following services funded by the Illinois Department, the
3 Department of Mental Health and Developmental Disabilities,
4 or the Department of Children and Family Services: (i)
5 inpatient hospital services, including related physician
6 services, related psychiatric interventions, and
7 pharmaceutical services provided to an eligible recipient
8 hospitalized with a primary diagnosis of psychiatric
9 disorder; (ii) outpatient mental health services as defined
10 and specified in Title 59 of the Illinois Administrative
11 Code, Part 132; (iii) any other outpatient mental health
12 services funded by the Illinois Department pursuant to the
13 State of Illinois Medicaid Plan; (iv) partial
14 hospitalization; and (v) follow-up stabilization related to
15 any of those services. Additional behavioral health services
16 may be excluded under this subsection as mutually agreed in
17 writing by the Illinois Department and the affected State
18 agency or agencies. The exclusion of any service does not
19 prohibit the Illinois Department from developing and
20 implementing demonstration projects for categories of persons
21 or services. The Department of Mental Health and
22 Developmental Disabilities, the Department of Children and
23 Family Services, and the Department of Alcoholism and
24 Substance Abuse shall each adopt rules governing the
25 integration of managed care in the provision of behavioral
26 health services. The State shall integrate managed care
27 community networks and affiliated providers, to the extent
28 practicable, in any separate delivery system for mental
29 health services.
30 (n) The Illinois Department shall adopt rules to
31 establish reserve requirements for managed care community
32 networks, as required by subsection (a), and health
33 maintenance organizations to protect against liabilities in
34 the event that a managed health care entity is declared
HB0781 Engrossed -18- LRB9000971DJcd
1 insolvent or bankrupt. If a managed health care entity other
2 than a county provider is declared insolvent or bankrupt,
3 after liquidation and application of any available assets,
4 resources, and reserves, the Illinois Department shall pay a
5 portion of the amounts owed by the managed health care entity
6 to providers for services rendered to enrollees under the
7 integrated health care program under this Section based on
8 the following schedule: (i) from April 1, 1995 through June
9 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
10 through June 30, 2001, 80% of the amounts owed; and (iii)
11 from July 1, 2001 through June 30, 2005, 75% of the amounts
12 owed. The amounts paid under this subsection shall be
13 calculated based on the total amount owed by the managed
14 health care entity to providers before application of any
15 available assets, resources, and reserves. After June 30,
16 2005, the Illinois Department may not pay any amounts owed to
17 providers as a result of an insolvency or bankruptcy of a
18 managed health care entity occurring after that date. The
19 Illinois Department is not obligated, however, to pay amounts
20 owed to a provider that has an ownership or other governing
21 interest in the managed health care entity. This subsection
22 applies only to managed health care entities and the services
23 they provide under the integrated health care program under
24 this Section.
25 (o) Notwithstanding any other provision of law or
26 contractual agreement to the contrary, providers shall not be
27 required to accept from any other third party payer the rates
28 determined or paid under this Code by the Illinois
29 Department, managed health care entity, or other health care
30 delivery system for services provided to recipients.
31 (p) The Illinois Department may seek and obtain any
32 necessary authorization provided under federal law to
33 implement the program, including the waiver of any federal
34 statutes or regulations. The Illinois Department may seek a
HB0781 Engrossed -19- LRB9000971DJcd
1 waiver of the federal requirement that the combined
2 membership of Medicare and Medicaid enrollees in a managed
3 care community network may not exceed 75% of the managed care
4 community network's total enrollment. The Illinois
5 Department shall not seek a waiver of this requirement for
6 any other category of managed health care entity. The
7 Illinois Department shall not seek a waiver of the inpatient
8 hospital reimbursement methodology in Section 1902(a)(13)(A)
9 of Title XIX of the Social Security Act even if the federal
10 agency responsible for administering Title XIX determines
11 that Section 1902(a)(13)(A) applies to managed health care
12 systems.
13 Notwithstanding any other provisions of this Code to the
14 contrary, the Illinois Department shall seek a waiver of
15 applicable federal law in order to impose a co-payment system
16 consistent with this subsection on recipients of medical
17 services under Title XIX of the Social Security Act who are
18 not enrolled in a managed health care entity. The waiver
19 request submitted by the Illinois Department shall provide
20 for co-payments of up to $0.50 for prescribed drugs and up to
21 $0.50 for x-ray services and shall provide for co-payments of
22 up to $10 for non-emergency services provided in a hospital
23 emergency room and up to $10 for non-emergency ambulance
24 services. The purpose of the co-payments shall be to deter
25 those recipients from seeking unnecessary medical care.
26 Co-payments may not be used to deter recipients from seeking
27 necessary medical care. No recipient shall be required to
28 pay more than a total of $150 per year in co-payments under
29 the waiver request required by this subsection. A recipient
30 may not be required to pay more than $15 of any amount due
31 under this subsection in any one month.
32 Co-payments authorized under this subsection may not be
33 imposed when the care was necessitated by a true medical
34 emergency. Co-payments may not be imposed for any of the
HB0781 Engrossed -20- LRB9000971DJcd
1 following classifications of services:
2 (1) Services furnished to person under 18 years of
3 age.
4 (2) Services furnished to pregnant women.
5 (3) Services furnished to any individual who is an
6 inpatient in a hospital, nursing facility, intermediate
7 care facility, or other medical institution, if that
8 person is required to spend for costs of medical care all
9 but a minimal amount of his or her income required for
10 personal needs.
11 (4) Services furnished to a person who is receiving
12 hospice care.
13 Co-payments authorized under this subsection shall not be
14 deducted from or reduce in any way payments for medical
15 services from the Illinois Department to providers. No
16 provider may deny those services to an individual eligible
17 for services based on the individual's inability to pay the
18 co-payment.
19 Recipients who are subject to co-payments shall be
20 provided notice, in plain and clear language, of the amount
21 of the co-payments, the circumstances under which co-payments
22 are exempted, the circumstances under which co-payments may
23 be assessed, and their manner of collection.
24 The Illinois Department shall establish a Medicaid
25 Co-Payment Council to assist in the development of co-payment
26 policies for the medical assistance program. The Medicaid
27 Co-Payment Council shall also have jurisdiction to develop a
28 program to provide financial or non-financial incentives to
29 Medicaid recipients in order to encourage recipients to seek
30 necessary health care. The Council shall be chaired by the
31 Director of the Illinois Department, and shall have 6
32 additional members. Two of the 6 additional members shall be
33 appointed by the Governor, and one each shall be appointed by
34 the President of the Senate, the Minority Leader of the
HB0781 Engrossed -21- LRB9000971DJcd
1 Senate, the Speaker of the House of Representatives, and the
2 Minority Leader of the House of Representatives. The Council
3 may be convened and make recommendations upon the appointment
4 of a majority of its members. The Council shall be appointed
5 and convened no later than September 1, 1994 and shall report
6 its recommendations to the Director of the Illinois
7 Department and the General Assembly no later than October 1,
8 1994. The chairperson of the Council shall be allowed to
9 vote only in the case of a tie vote among the appointed
10 members of the Council.
11 The Council shall be guided by the following principles
12 as it considers recommendations to be developed to implement
13 any approved waivers that the Illinois Department must seek
14 pursuant to this subsection:
15 (1) Co-payments should not be used to deter access
16 to adequate medical care.
17 (2) Co-payments should be used to reduce fraud.
18 (3) Co-payment policies should be examined in
19 consideration of other states' experience, and the
20 ability of successful co-payment plans to control
21 unnecessary or inappropriate utilization of services
22 should be promoted.
23 (4) All participants, both recipients and
24 providers, in the medical assistance program have
25 responsibilities to both the State and the program.
26 (5) Co-payments are primarily a tool to educate the
27 participants in the responsible use of health care
28 resources.
29 (6) Co-payments should not be used to penalize
30 providers.
31 (7) A successful medical program requires the
32 elimination of improper utilization of medical resources.
33 The integrated health care program, or any part of that
34 program, established under this Section may not be
HB0781 Engrossed -22- LRB9000971DJcd
1 implemented if matching federal funds under Title XIX of the
2 Social Security Act are not available for administering the
3 program.
4 The Illinois Department shall submit for publication in
5 the Illinois Register the name, address, and telephone number
6 of the individual to whom a request may be directed for a
7 copy of the request for a waiver of provisions of Title XIX
8 of the Social Security Act that the Illinois Department
9 intends to submit to the Health Care Financing Administration
10 in order to implement this Section. The Illinois Department
11 shall mail a copy of that request for waiver to all
12 requestors at least 16 days before filing that request for
13 waiver with the Health Care Financing Administration.
14 (q) After the effective date of this Section, the
15 Illinois Department may take all planning and preparatory
16 action necessary to implement this Section, including, but
17 not limited to, seeking requests for proposals relating to
18 the integrated health care program created under this
19 Section.
20 (r) In order to (i) accelerate and facilitate the
21 development of integrated health care in contracting areas
22 outside counties with populations in excess of 3,000,000 and
23 counties adjacent to those counties and (ii) maintain and
24 sustain the high quality of education and residency programs
25 coordinated and associated with local area hospitals, the
26 Illinois Department may develop and implement a demonstration
27 program for managed care community networks owned, operated,
28 or governed by State-funded medical schools. The Illinois
29 Department shall prescribe by rule the criteria, standards,
30 and procedures for effecting this demonstration program.
31 (s) (Blank).
32 (s-5) The Illinois Department may impose penalties or
33 sanctions permitted by law or contract for violations of
34 this Section.
HB0781 Engrossed -23- LRB9000971DJcd
1 (t) On April 1, 1995 and every 6 months thereafter, the
2 Illinois Department shall report to the Governor and General
3 Assembly on the progress of the integrated health care
4 program in enrolling clients into managed health care
5 entities. The report shall indicate the capacities of the
6 managed health care entities with which the State contracts,
7 the number of clients enrolled by each contractor, the areas
8 of the State in which managed care options do not exist, and
9 the progress toward meeting the enrollment goals of the
10 integrated health care program.
11 (u) The Illinois Department may implement this Section
12 through the use of emergency rules in accordance with Section
13 5-45 of the Illinois Administrative Procedure Act. For
14 purposes of that Act, the adoption of rules to implement this
15 Section is deemed an emergency and necessary for the public
16 interest, safety, and welfare.
17 (v) The Auditor General shall conduct an annual
18 performance audit of the integrated health care program
19 created under this Section and the Illinois Department's
20 implementation of this Section. The initial audit shall
21 cover the fiscal year ending June 30, 1997, and subsequent
22 audits shall cover each fiscal year thereafter. The Auditor
23 General shall issue reports of the audits on or before
24 December 31 of 1997 and each year thereafter.
25 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
26 89-673, eff. 8-14-96; revised 8-26-96.)
27 (Text of Section after amendment by P.A. 89-507)
28 Sec. 5-16.3. System for integrated health care services.
29 (a) It shall be the public policy of the State to adopt,
30 to the extent practicable, a health care program that
31 encourages the integration of health care services and
32 manages the health care of program enrollees while preserving
33 reasonable choice within a competitive and cost-efficient
34 environment. In furtherance of this public policy, the
HB0781 Engrossed -24- LRB9000971DJcd
1 Illinois Department shall develop and implement an integrated
2 health care program consistent with the provisions of this
3 Section. The provisions of this Section apply only to the
4 integrated health care program created under this Section.
5 Persons enrolled in the integrated health care program, as
6 determined by the Illinois Department by rule, shall be
7 afforded a choice among health care delivery systems, which
8 shall include, but are not limited to, (i) fee for service
9 care managed by a primary care physician licensed to practice
10 medicine in all its branches, (ii) managed health care
11 entities, and (iii) federally qualified health centers
12 (reimbursed according to a prospective cost-reimbursement
13 methodology) and rural health clinics (reimbursed according
14 to the Medicare methodology), where available. Persons
15 enrolled in the integrated health care program also may be
16 offered indemnity insurance plans, subject to availability.
17 For purposes of this Section, a "managed health care
18 entity" means a health maintenance organization or a managed
19 care community network as defined in this Section. A "health
20 maintenance organization" means a health maintenance
21 organization as defined in the Health Maintenance
22 Organization Act. A "managed care community network" means
23 an entity, other than a health maintenance organization, that
24 is owned, operated, or governed by providers of health care
25 services within this State and that provides or arranges
26 primary, secondary, and tertiary managed health care services
27 under contract with the Illinois Department exclusively to
28 enrollees of the integrated health care program. A managed
29 care community network may contract with the Illinois
30 Department to provide only pediatric health care services. A
31 county provider as defined in Section 15-1 of this Code may
32 contract with the Illinois Department to provide services to
33 enrollees of the integrated health care program as a managed
34 care community network without the need to establish a
HB0781 Engrossed -25- LRB9000971DJcd
1 separate entity that provides services exclusively to
2 enrollees of the integrated health care program and shall be
3 deemed a managed care community network for purposes of this
4 Code only to the extent of the provision of services to those
5 enrollees in conjunction with the integrated health care
6 program. A county provider shall be entitled to contract
7 with the Illinois Department with respect to any contracting
8 region located in whole or in part within the county. A
9 county provider shall not be required to accept enrollees who
10 do not reside within the county.
11 If a managed health care entity is accredited by a
12 private national organization that performs quality assurance
13 surveys of health maintenance organizations or related
14 organizations, the Illinois Department may take the
15 accreditation into consideration when selecting managed
16 health care entities for participation in the integrated
17 health care program. The medical director of a managed
18 health care entity must be a physician licensed in the State
19 to practice medicine in all its branches.
20 Each managed care community network must demonstrate its
21 ability to bear the financial risk of serving enrollees under
22 this program. The Illinois Department shall by rule adopt
23 criteria for assessing the financial soundness of each
24 managed care community network. These rules shall consider
25 the extent to which a managed care community network is
26 comprised of providers who directly render health care and
27 are located within the community in which they seek to
28 contract rather than solely arrange or finance the delivery
29 of health care. These rules shall further consider a variety
30 of risk-bearing and management techniques, including the
31 sufficiency of quality assurance and utilization management
32 programs and whether a managed care community network has
33 sufficiently demonstrated its financial solvency and net
34 worth. The Illinois Department's criteria must be based on
HB0781 Engrossed -26- LRB9000971DJcd
1 sound actuarial, financial, and accounting principles. In
2 adopting these rules, the Illinois Department shall consult
3 with the Illinois Department of Insurance. The Illinois
4 Department is responsible for monitoring compliance with
5 these rules.
6 This Section may not be implemented before the effective
7 date of these rules, the approval of any necessary federal
8 waivers, and the completion of the review of an application
9 submitted, at least 60 days before the effective date of
10 rules adopted under this Section, to the Illinois Department
11 by a managed care community network.
12 All health care delivery systems that contract with the
13 Illinois Department under the integrated health care program
14 shall clearly recognize a health care provider's right of
15 conscience under the Right of Conscience Act. In addition to
16 the provisions of that Act, no health care delivery system
17 that contracts with the Illinois Department under the
18 integrated health care program shall be required to provide,
19 arrange for, or pay for any health care or medical service,
20 procedure, or product if that health care delivery system is
21 owned, controlled, or sponsored by or affiliated with a
22 religious institution or religious organization that finds
23 that health care or medical service, procedure, or product to
24 violate its religious and moral teachings and beliefs.
25 (b) The Illinois Department may, by rule, provide for
26 different benefit packages for different categories of
27 persons enrolled in the program. Mental health services,
28 alcohol and substance abuse services, services related to
29 children with chronic or acute conditions requiring
30 longer-term treatment and follow-up, and rehabilitation care
31 provided by a free-standing rehabilitation hospital or a
32 hospital rehabilitation unit may be excluded from a benefit
33 package if the State ensures that those services are made
34 available through a separate delivery system. An exclusion
HB0781 Engrossed -27- LRB9000971DJcd
1 does not prohibit the Illinois Department from developing and
2 implementing demonstration projects for categories of persons
3 or services. Benefit packages for persons eligible for
4 medical assistance under Articles V, VI, and XII shall be
5 based on the requirements of those Articles and shall be
6 consistent with the Title XIX of the Social Security Act.
7 Nothing in this Act shall be construed to apply to services
8 purchased by the Department of Children and Family Services
9 and the Department of Human Services (as successor to the
10 Department of Mental Health and Developmental Disabilities)
11 under the provisions of Title 59 of the Illinois
12 Administrative Code, Part 132 ("Medicaid Community Mental
13 Health Services Program").
14 (c) The program established by this Section may be
15 implemented by the Illinois Department in various contracting
16 areas at various times. The health care delivery systems and
17 providers available under the program may vary throughout the
18 State. For purposes of contracting with managed health care
19 entities and providers, the Illinois Department shall
20 establish contracting areas similar to the geographic areas
21 designated by the Illinois Department for contracting
22 purposes under the Illinois Competitive Access and
23 Reimbursement Equity Program (ICARE) under the authority of
24 Section 3-4 of the Illinois Health Finance Reform Act or
25 similarly-sized or smaller geographic areas established by
26 the Illinois Department by rule. A managed health care entity
27 shall be permitted to contract in any geographic areas for
28 which it has a sufficient provider network and otherwise
29 meets the contracting terms of the State. The Illinois
30 Department is not prohibited from entering into a contract
31 with a managed health care entity at any time.
32 (d) A managed health care entity that contracts with the
33 Illinois Department for the provision of services under the
34 program shall do all of the following, solely for purposes of
HB0781 Engrossed -28- LRB9000971DJcd
1 the integrated health care program:
2 (1) Provide that any individual physician licensed
3 to practice medicine in all its branches, any pharmacy,
4 any federally qualified health center, and any
5 podiatrist, that consistently meets the reasonable terms
6 and conditions established by the managed health care
7 entity, including but not limited to credentialing
8 standards, quality assurance program requirements,
9 utilization management requirements, financial
10 responsibility standards, contracting process
11 requirements, and provider network size and accessibility
12 requirements, must be accepted by the managed health care
13 entity for purposes of the Illinois integrated health
14 care program. Any individual who is either terminated
15 from or denied inclusion in the panel of physicians of
16 the managed health care entity shall be given, within 10
17 business days after that determination, a written
18 explanation of the reasons for his or her exclusion or
19 termination from the panel. This paragraph (1) does not
20 apply to the following:
21 (A) A managed health care entity that
22 certifies to the Illinois Department that:
23 (i) it employs on a full-time basis 125
24 or more Illinois physicians licensed to
25 practice medicine in all of its branches; and
26 (ii) it will provide medical services
27 through its employees to more than 80% of the
28 recipients enrolled with the entity in the
29 integrated health care program; or
30 (B) A domestic stock insurance company
31 licensed under clause (b) of class 1 of Section 4 of
32 the Illinois Insurance Code if (i) at least 66% of
33 the stock of the insurance company is owned by a
34 professional corporation organized under the
HB0781 Engrossed -29- LRB9000971DJcd
1 Professional Service Corporation Act that has 125 or
2 more shareholders who are Illinois physicians
3 licensed to practice medicine in all of its branches
4 and (ii) the insurance company certifies to the
5 Illinois Department that at least 80% of those
6 physician shareholders will provide services to
7 recipients enrolled with the company in the
8 integrated health care program.
9 (2) Provide for reimbursement for providers for
10 emergency care, as defined by the Illinois Department by
11 rule, that must be provided to its enrollees, including
12 an emergency room screening fee, and urgent care that it
13 authorizes for its enrollees, regardless of the
14 provider's affiliation with the managed health care
15 entity. Providers shall be reimbursed for emergency care
16 at an amount equal to the Illinois Department's
17 fee-for-service rates for those medical services rendered
18 by providers not under contract with the managed health
19 care entity to enrollees of the entity.
20 (3) Provide that any provider affiliated with a
21 managed health care entity may also provide services on a
22 fee-for-service basis to Illinois Department clients not
23 enrolled in a managed health care entity.
24 (4) Provide client education services as determined
25 and approved by the Illinois Department, including but
26 not limited to (i) education regarding appropriate
27 utilization of health care services in a managed care
28 system, (ii) written disclosure of treatment policies and
29 any restrictions or limitations on health services,
30 including, but not limited to, physical services,
31 clinical laboratory tests, hospital and surgical
32 procedures, prescription drugs and biologics, and
33 radiological examinations, and (iii) written notice that
34 the enrollee may receive from another provider those
HB0781 Engrossed -30- LRB9000971DJcd
1 services covered under this program that are not provided
2 by the managed health care entity.
3 (4.5) Provide orientation to the caretaker relative
4 or payee of a medical assistance unit that has an
5 enrollee as a member. The managed health care entity
6 must exercise good faith efforts to provide all caretaker
7 relatives or payees with the orientation. The managed
8 health care entity shall inform the Illinois Department
9 of the caretaker relatives or payees who have completed
10 the orientation. This paragraph applies to every
11 caretaker relative or payee in a managed health care
12 entity's system regardless of whether the caretaker
13 relative or payee has chosen the system or has been
14 assigned to the system as provided in subsection (e).
15 (5) Provide that enrollees within its system may
16 choose the site for provision of services and the panel
17 of health care providers.
18 (6) Not discriminate in its enrollment or
19 disenrollment practices among recipients of medical
20 services or program enrollees based on health status.
21 (7) Provide a quality assurance and utilization
22 review program that (i) for health maintenance
23 organizations meets the requirements of the Health
24 Maintenance Organization Act and (ii) for managed care
25 community networks meets the requirements established by
26 the Illinois Department in rules that incorporate those
27 standards set forth in the Health Maintenance
28 Organization Act.
29 (8) Issue a managed health care entity
30 identification card to each enrollee upon enrollment.
31 The card must contain all of the following:
32 (A) The enrollee's signature.
33 (B) The enrollee's health plan.
34 (C) The name and telephone number of the
HB0781 Engrossed -31- LRB9000971DJcd
1 enrollee's primary care physician.
2 (D) A telephone number to be used for
3 emergency service 24 hours per day, 7 days per week.
4 The telephone number required to be maintained
5 pursuant to this subparagraph by each managed health
6 care entity shall, at minimum, be staffed by
7 medically trained personnel and be provided
8 directly, or under arrangement, at an office or
9 offices in locations maintained solely within the
10 State of Illinois. For purposes of this
11 subparagraph, "medically trained personnel" means
12 licensed practical nurses or registered nurses
13 located in the State of Illinois who are licensed
14 pursuant to the Illinois Nursing Act of 1987.
15 (8.5) The Illinois Department must include
16 performance standards in contracts with entities
17 participating in the integrated health care program to
18 require contractors to make a good faith effort to have
19 enrollees evaluated by a physician within a reasonable
20 period of time after enrollment, as determined by the
21 Illinois Department.
22 (9) Ensure that every primary care physician and
23 pharmacy in the managed health care entity meets the
24 standards established by the Illinois Department for
25 accessibility and quality of care. The Illinois
26 Department shall arrange for and oversee an evaluation of
27 the standards established under this paragraph (9) and
28 may recommend any necessary changes to these standards.
29 The Illinois Department shall submit an annual report to
30 the Governor and the General Assembly by April 1 of each
31 year regarding the effect of the standards on ensuring
32 access and quality of care to enrollees.
33 (10) Provide a procedure for handling complaints
34 that (i) for health maintenance organizations meets the
HB0781 Engrossed -32- LRB9000971DJcd
1 requirements of the Health Maintenance Organization Act
2 and (ii) for managed care community networks meets the
3 requirements established by the Illinois Department in
4 rules that incorporate those standards set forth in the
5 Health Maintenance Organization Act.
6 (11) Maintain, retain, and make available to the
7 Illinois Department records, data, and information, in a
8 uniform manner determined by the Illinois Department,
9 sufficient for the Illinois Department to monitor
10 utilization, accessibility, and quality of care.
11 (12) Except for providers who are prepaid, pay all
12 approved claims for covered services that are completed
13 and submitted to the managed health care entity within 30
14 days after receipt of the claim or receipt of the
15 appropriate capitation payment or payments by the managed
16 health care entity from the State for the month in which
17 the services included on the claim were rendered,
18 whichever is later. If payment is not made or mailed to
19 the provider by the managed health care entity by the due
20 date under this subsection, an interest penalty of 1% of
21 any amount unpaid shall be added for each month or
22 fraction of a month after the due date, until final
23 payment is made. Nothing in this Section shall prohibit
24 managed health care entities and providers from mutually
25 agreeing to terms that require more timely payment.
26 (12.5) Ensure that no payment is made to a
27 physician or other provider of services for withholding
28 from an enrollee any covered services because of the cost
29 of those services. This requirement shall not be
30 construed to prevent managed health care entities from
31 offering, nor providers from accepting, full or partial
32 capitation.
33 (13) Provide integration with community-based
34 programs provided by certified local health departments
HB0781 Engrossed -33- LRB9000971DJcd
1 such as Women, Infants, and Children Supplemental Food
2 Program (WIC), childhood immunization programs, health
3 education programs, case management programs, and health
4 screening programs.
5 (14) Provide that the pharmacy formulary used by a
6 managed health care entity and its contract providers be
7 no more restrictive than the Illinois Department's
8 pharmaceutical program on the effective date of this
9 amendatory Act of 1994 and as amended after that date.
10 (15) Provide integration with community-based
11 organizations, including, but not limited to, any
12 organization that has operated within a Medicaid
13 Partnership as defined by this Code or by rule of the
14 Illinois Department, that may continue to operate under a
15 contract with the Illinois Department or a managed health
16 care entity under this Section to provide case management
17 services to Medicaid clients in designated high-need
18 areas.
19 The Illinois Department may, by rule, determine
20 methodologies to limit financial liability for managed health
21 care entities resulting from payment for services to
22 enrollees provided under the Illinois Department's integrated
23 health care program. Any methodology so determined may be
24 considered or implemented by the Illinois Department through
25 a contract with a managed health care entity under this
26 integrated health care program.
27 The Illinois Department shall contract with an entity or
28 entities to provide external peer-based quality assurance
29 review for the integrated health care program. The entity
30 shall be representative of Illinois physicians licensed to
31 practice medicine in all its branches and have statewide
32 geographic representation in all specialties of medical care
33 that are provided within the integrated health care program.
34 The entity may not be a third party payer and shall maintain
HB0781 Engrossed -34- LRB9000971DJcd
1 offices in locations around the State in order to provide
2 service and continuing medical education to physician
3 participants within the integrated health care program. The
4 review process shall be developed and conducted by Illinois
5 physicians licensed to practice medicine in all its branches.
6 In consultation with the entity, the Illinois Department may
7 contract with other entities for professional peer-based
8 quality assurance review of individual categories of services
9 other than services provided, supervised, or coordinated by
10 physicians licensed to practice medicine in all its branches.
11 The Illinois Department shall establish, by rule, criteria to
12 avoid conflicts of interest in the conduct of quality
13 assurance activities consistent with professional peer-review
14 standards. All quality assurance activities shall be
15 coordinated by the Illinois Department.
16 (e) All persons enrolled in the program shall be
17 provided with a full written explanation of all
18 fee-for-service and managed health care plan options and a
19 reasonable opportunity to choose among the options as
20 provided by rule. The Illinois Department shall provide to
21 enrollees, upon enrollment in the integrated health care
22 program and at least annually thereafter, notice of the
23 process for requesting an appeal under the Illinois
24 Department's administrative appeal procedures.
25 Notwithstanding any other Section of this Code, the Illinois
26 Department may provide by rule for the Illinois Department to
27 assign a person enrolled in the program to a specific
28 provider of medical services or to a specific health care
29 delivery system if an enrollee has failed to exercise choice
30 in a timely manner. An enrollee assigned by the Illinois
31 Department shall be afforded the opportunity to disenroll and
32 to select a specific provider of medical services or a
33 specific health care delivery system within the first 30 days
34 after the assignment. An enrollee who has failed to exercise
HB0781 Engrossed -35- LRB9000971DJcd
1 choice in a timely manner may be assigned only if there are 3
2 or more managed health care entities contracting with the
3 Illinois Department within the contracting area, except that,
4 outside the City of Chicago, this requirement may be waived
5 for an area by rules adopted by the Illinois Department after
6 consultation with all hospitals within the contracting area.
7 The Illinois Department shall establish by rule the procedure
8 for random assignment of enrollees who fail to exercise
9 choice in a timely manner to a specific managed health care
10 entity in proportion to the available capacity of that
11 managed health care entity. Assignment to a specific provider
12 of medical services or to a specific managed health care
13 entity may not exceed that provider's or entity's capacity as
14 determined by the Illinois Department. Any person who has
15 chosen a specific provider of medical services or a specific
16 managed health care entity, or any person who has been
17 assigned under this subsection, shall be given the
18 opportunity to change that choice or assignment at least once
19 every 12 months, as determined by the Illinois Department by
20 rule. The Illinois Department shall maintain a toll-free
21 telephone number for program enrollees' use in reporting
22 problems with managed health care entities.
23 (f) If a person becomes eligible for participation in
24 the integrated health care program while he or she is
25 hospitalized, the Illinois Department may not enroll that
26 person in the program until after he or she has been
27 discharged from the hospital. This subsection does not apply
28 to newborn infants whose mothers are enrolled in the
29 integrated health care program.
30 (g) The Illinois Department shall, by rule, establish
31 for managed health care entities rates that (i) are certified
32 to be actuarially sound, as determined by an actuary who is
33 an associate or a fellow of the Society of Actuaries or a
34 member of the American Academy of Actuaries and who has
HB0781 Engrossed -36- LRB9000971DJcd
1 expertise and experience in medical insurance and benefit
2 programs, in accordance with the Illinois Department's
3 current fee-for-service payment system, and (ii) take into
4 account any difference of cost to provide health care to
5 different populations based on gender, age, location, and
6 eligibility category. The rates for managed health care
7 entities shall be determined on a capitated basis.
8 The Illinois Department by rule shall establish a method
9 to adjust its payments to managed health care entities in a
10 manner intended to avoid providing any financial incentive to
11 a managed health care entity to refer patients to a county
12 provider, in an Illinois county having a population greater
13 than 3,000,000, that is paid directly by the Illinois
14 Department. The Illinois Department shall by April 1, 1997,
15 and annually thereafter, review the method to adjust
16 payments. Payments by the Illinois Department to the county
17 provider, for persons not enrolled in a managed care
18 community network owned or operated by a county provider,
19 shall be paid on a fee-for-service basis under Article XV of
20 this Code.
21 The Illinois Department by rule shall establish a method
22 to reduce its payments to managed health care entities to
23 take into consideration (i) any adjustment payments paid to
24 hospitals under subsection (h) of this Section to the extent
25 those payments, or any part of those payments, have been
26 taken into account in establishing capitated rates under this
27 subsection (g) and (ii) the implementation of methodologies
28 to limit financial liability for managed health care entities
29 under subsection (d) of this Section.
30 (h) For hospital services provided by a hospital that
31 contracts with a managed health care entity, adjustment
32 payments shall be paid directly to the hospital by the
33 Illinois Department. Adjustment payments may include but
34 need not be limited to adjustment payments to:
HB0781 Engrossed -37- LRB9000971DJcd
1 disproportionate share hospitals under Section 5-5.02 of this
2 Code; primary care access health care education payments (89
3 Ill. Adm. Code 149.140); payments for capital, direct medical
4 education, indirect medical education, certified registered
5 nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
6 Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
7 Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
8 148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
9 Code 148.290(d)); perinatal center payments (89 Ill. Adm.
10 Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
11 Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
12 148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
13 148.290(h)); and outpatient indigent volume adjustments (89
14 Ill. Adm. Code 148.140(b)(5)).
15 (i) For any hospital eligible for the adjustment
16 payments described in subsection (h), the Illinois Department
17 shall maintain, through the period ending June 30, 1995,
18 reimbursement levels in accordance with statutes and rules in
19 effect on April 1, 1994.
20 (j) Nothing contained in this Code in any way limits or
21 otherwise impairs the authority or power of the Illinois
22 Department to enter into a negotiated contract pursuant to
23 this Section with a managed health care entity, including,
24 but not limited to, a health maintenance organization, that
25 provides for termination or nonrenewal of the contract
26 without cause upon notice as provided in the contract and
27 without a hearing.
28 (k) Section 5-5.15 does not apply to the program
29 developed and implemented pursuant to this Section.
30 (l) The Illinois Department shall, by rule, define those
31 chronic or acute medical conditions of childhood that require
32 longer-term treatment and follow-up care. The Illinois
33 Department shall ensure that services required to treat these
34 conditions are available through a separate delivery system.
HB0781 Engrossed -38- LRB9000971DJcd
1 A managed health care entity that contracts with the
2 Illinois Department may refer a child with medical conditions
3 described in the rules adopted under this subsection directly
4 to a children's hospital or to a hospital, other than a
5 children's hospital, that is qualified to provide inpatient
6 and outpatient services to treat those conditions. The
7 Illinois Department shall provide fee-for-service
8 reimbursement directly to a children's hospital for those
9 services pursuant to Title 89 of the Illinois Administrative
10 Code, Section 148.280(a), at a rate at least equal to the
11 rate in effect on March 31, 1994. For hospitals, other than
12 children's hospitals, that are qualified to provide inpatient
13 and outpatient services to treat those conditions, the
14 Illinois Department shall provide reimbursement for those
15 services on a fee-for-service basis, at a rate at least equal
16 to the rate in effect for those other hospitals on March 31,
17 1994.
18 A children's hospital shall be directly reimbursed for
19 all services provided at the children's hospital on a
20 fee-for-service basis pursuant to Title 89 of the Illinois
21 Administrative Code, Section 148.280(a), at a rate at least
22 equal to the rate in effect on March 31, 1994, until the
23 later of (i) implementation of the integrated health care
24 program under this Section and development of actuarially
25 sound capitation rates for services other than those chronic
26 or acute medical conditions of childhood that require
27 longer-term treatment and follow-up care as defined by the
28 Illinois Department in the rules adopted under this
29 subsection or (ii) March 31, 1996.
30 Notwithstanding anything in this subsection to the
31 contrary, a managed health care entity shall not consider
32 sources or methods of payment in determining the referral of
33 a child. The Illinois Department shall adopt rules to
34 establish criteria for those referrals. The Illinois
HB0781 Engrossed -39- LRB9000971DJcd
1 Department by rule shall establish a method to adjust its
2 payments to managed health care entities in a manner intended
3 to avoid providing any financial incentive to a managed
4 health care entity to refer patients to a provider who is
5 paid directly by the Illinois Department.
6 (m) Behavioral health services provided or funded by the
7 Department of Human Services, the Department of Children and
8 Family Services, and the Illinois Department shall be
9 excluded from a benefit package. Conditions of an organic or
10 physical origin or nature, including medical detoxification,
11 however, may not be excluded. In this subsection,
12 "behavioral health services" means mental health services and
13 subacute alcohol and substance abuse treatment services, as
14 defined in the Illinois Alcoholism and Other Drug Dependency
15 Act. In this subsection, "mental health services" includes,
16 at a minimum, the following services funded by the Illinois
17 Department, the Department of Human Services (as successor to
18 the Department of Mental Health and Developmental
19 Disabilities), or the Department of Children and Family
20 Services: (i) inpatient hospital services, including related
21 physician services, related psychiatric interventions, and
22 pharmaceutical services provided to an eligible recipient
23 hospitalized with a primary diagnosis of psychiatric
24 disorder; (ii) outpatient mental health services as defined
25 and specified in Title 59 of the Illinois Administrative
26 Code, Part 132; (iii) any other outpatient mental health
27 services funded by the Illinois Department pursuant to the
28 State of Illinois Medicaid Plan; (iv) partial
29 hospitalization; and (v) follow-up stabilization related to
30 any of those services. Additional behavioral health services
31 may be excluded under this subsection as mutually agreed in
32 writing by the Illinois Department and the affected State
33 agency or agencies. The exclusion of any service does not
34 prohibit the Illinois Department from developing and
HB0781 Engrossed -40- LRB9000971DJcd
1 implementing demonstration projects for categories of persons
2 or services. The Department of Children and Family Services
3 and the Department of Human Services shall each adopt rules
4 governing the integration of managed care in the provision of
5 behavioral health services. The State shall integrate managed
6 care community networks and affiliated providers, to the
7 extent practicable, in any separate delivery system for
8 mental health services.
9 (n) The Illinois Department shall adopt rules to
10 establish reserve requirements for managed care community
11 networks, as required by subsection (a), and health
12 maintenance organizations to protect against liabilities in
13 the event that a managed health care entity is declared
14 insolvent or bankrupt. If a managed health care entity other
15 than a county provider is declared insolvent or bankrupt,
16 after liquidation and application of any available assets,
17 resources, and reserves, the Illinois Department shall pay a
18 portion of the amounts owed by the managed health care entity
19 to providers for services rendered to enrollees under the
20 integrated health care program under this Section based on
21 the following schedule: (i) from April 1, 1995 through June
22 30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
23 through June 30, 2001, 80% of the amounts owed; and (iii)
24 from July 1, 2001 through June 30, 2005, 75% of the amounts
25 owed. The amounts paid under this subsection shall be
26 calculated based on the total amount owed by the managed
27 health care entity to providers before application of any
28 available assets, resources, and reserves. After June 30,
29 2005, the Illinois Department may not pay any amounts owed to
30 providers as a result of an insolvency or bankruptcy of a
31 managed health care entity occurring after that date. The
32 Illinois Department is not obligated, however, to pay amounts
33 owed to a provider that has an ownership or other governing
34 interest in the managed health care entity. This subsection
HB0781 Engrossed -41- LRB9000971DJcd
1 applies only to managed health care entities and the services
2 they provide under the integrated health care program under
3 this Section.
4 (o) Notwithstanding any other provision of law or
5 contractual agreement to the contrary, providers shall not be
6 required to accept from any other third party payer the rates
7 determined or paid under this Code by the Illinois
8 Department, managed health care entity, or other health care
9 delivery system for services provided to recipients.
10 (p) The Illinois Department may seek and obtain any
11 necessary authorization provided under federal law to
12 implement the program, including the waiver of any federal
13 statutes or regulations. The Illinois Department may seek a
14 waiver of the federal requirement that the combined
15 membership of Medicare and Medicaid enrollees in a managed
16 care community network may not exceed 75% of the managed care
17 community network's total enrollment. The Illinois
18 Department shall not seek a waiver of this requirement for
19 any other category of managed health care entity. The
20 Illinois Department shall not seek a waiver of the inpatient
21 hospital reimbursement methodology in Section 1902(a)(13)(A)
22 of Title XIX of the Social Security Act even if the federal
23 agency responsible for administering Title XIX determines
24 that Section 1902(a)(13)(A) applies to managed health care
25 systems.
26 Notwithstanding any other provisions of this Code to the
27 contrary, the Illinois Department shall seek a waiver of
28 applicable federal law in order to impose a co-payment system
29 consistent with this subsection on recipients of medical
30 services under Title XIX of the Social Security Act who are
31 not enrolled in a managed health care entity. The waiver
32 request submitted by the Illinois Department shall provide
33 for co-payments of up to $0.50 for prescribed drugs and up to
34 $0.50 for x-ray services and shall provide for co-payments of
HB0781 Engrossed -42- LRB9000971DJcd
1 up to $10 for non-emergency services provided in a hospital
2 emergency room and up to $10 for non-emergency ambulance
3 services. The purpose of the co-payments shall be to deter
4 those recipients from seeking unnecessary medical care.
5 Co-payments may not be used to deter recipients from seeking
6 necessary medical care. No recipient shall be required to
7 pay more than a total of $150 per year in co-payments under
8 the waiver request required by this subsection. A recipient
9 may not be required to pay more than $15 of any amount due
10 under this subsection in any one month.
11 Co-payments authorized under this subsection may not be
12 imposed when the care was necessitated by a true medical
13 emergency. Co-payments may not be imposed for any of the
14 following classifications of services:
15 (1) Services furnished to person under 18 years of
16 age.
17 (2) Services furnished to pregnant women.
18 (3) Services furnished to any individual who is an
19 inpatient in a hospital, nursing facility, intermediate
20 care facility, or other medical institution, if that
21 person is required to spend for costs of medical care all
22 but a minimal amount of his or her income required for
23 personal needs.
24 (4) Services furnished to a person who is receiving
25 hospice care.
26 Co-payments authorized under this subsection shall not be
27 deducted from or reduce in any way payments for medical
28 services from the Illinois Department to providers. No
29 provider may deny those services to an individual eligible
30 for services based on the individual's inability to pay the
31 co-payment.
32 Recipients who are subject to co-payments shall be
33 provided notice, in plain and clear language, of the amount
34 of the co-payments, the circumstances under which co-payments
HB0781 Engrossed -43- LRB9000971DJcd
1 are exempted, the circumstances under which co-payments may
2 be assessed, and their manner of collection.
3 The Illinois Department shall establish a Medicaid
4 Co-Payment Council to assist in the development of co-payment
5 policies for the medical assistance program. The Medicaid
6 Co-Payment Council shall also have jurisdiction to develop a
7 program to provide financial or non-financial incentives to
8 Medicaid recipients in order to encourage recipients to seek
9 necessary health care. The Council shall be chaired by the
10 Director of the Illinois Department, and shall have 6
11 additional members. Two of the 6 additional members shall be
12 appointed by the Governor, and one each shall be appointed by
13 the President of the Senate, the Minority Leader of the
14 Senate, the Speaker of the House of Representatives, and the
15 Minority Leader of the House of Representatives. The Council
16 may be convened and make recommendations upon the appointment
17 of a majority of its members. The Council shall be appointed
18 and convened no later than September 1, 1994 and shall report
19 its recommendations to the Director of the Illinois
20 Department and the General Assembly no later than October 1,
21 1994. The chairperson of the Council shall be allowed to
22 vote only in the case of a tie vote among the appointed
23 members of the Council.
24 The Council shall be guided by the following principles
25 as it considers recommendations to be developed to implement
26 any approved waivers that the Illinois Department must seek
27 pursuant to this subsection:
28 (1) Co-payments should not be used to deter access
29 to adequate medical care.
30 (2) Co-payments should be used to reduce fraud.
31 (3) Co-payment policies should be examined in
32 consideration of other states' experience, and the
33 ability of successful co-payment plans to control
34 unnecessary or inappropriate utilization of services
HB0781 Engrossed -44- LRB9000971DJcd
1 should be promoted.
2 (4) All participants, both recipients and
3 providers, in the medical assistance program have
4 responsibilities to both the State and the program.
5 (5) Co-payments are primarily a tool to educate the
6 participants in the responsible use of health care
7 resources.
8 (6) Co-payments should not be used to penalize
9 providers.
10 (7) A successful medical program requires the
11 elimination of improper utilization of medical resources.
12 The integrated health care program, or any part of that
13 program, established under this Section may not be
14 implemented if matching federal funds under Title XIX of the
15 Social Security Act are not available for administering the
16 program.
17 The Illinois Department shall submit for publication in
18 the Illinois Register the name, address, and telephone number
19 of the individual to whom a request may be directed for a
20 copy of the request for a waiver of provisions of Title XIX
21 of the Social Security Act that the Illinois Department
22 intends to submit to the Health Care Financing Administration
23 in order to implement this Section. The Illinois Department
24 shall mail a copy of that request for waiver to all
25 requestors at least 16 days before filing that request for
26 waiver with the Health Care Financing Administration.
27 (q) After the effective date of this Section, the
28 Illinois Department may take all planning and preparatory
29 action necessary to implement this Section, including, but
30 not limited to, seeking requests for proposals relating to
31 the integrated health care program created under this
32 Section.
33 (r) In order to (i) accelerate and facilitate the
34 development of integrated health care in contracting areas
HB0781 Engrossed -45- LRB9000971DJcd
1 outside counties with populations in excess of 3,000,000 and
2 counties adjacent to those counties and (ii) maintain and
3 sustain the high quality of education and residency programs
4 coordinated and associated with local area hospitals, the
5 Illinois Department may develop and implement a demonstration
6 program for managed care community networks owned, operated,
7 or governed by State-funded medical schools. The Illinois
8 Department shall prescribe by rule the criteria, standards,
9 and procedures for effecting this demonstration program.
10 (s) (Blank).
11 (s-5) The Illinois Department may impose penalties or
12 sanctions permitted by law or contract for violations of
13 this Section.
14 (t) On April 1, 1995 and every 6 months thereafter, the
15 Illinois Department shall report to the Governor and General
16 Assembly on the progress of the integrated health care
17 program in enrolling clients into managed health care
18 entities. The report shall indicate the capacities of the
19 managed health care entities with which the State contracts,
20 the number of clients enrolled by each contractor, the areas
21 of the State in which managed care options do not exist, and
22 the progress toward meeting the enrollment goals of the
23 integrated health care program.
24 (u) The Illinois Department may implement this Section
25 through the use of emergency rules in accordance with Section
26 5-45 of the Illinois Administrative Procedure Act. For
27 purposes of that Act, the adoption of rules to implement this
28 Section is deemed an emergency and necessary for the public
29 interest, safety, and welfare.
30 (v) The Auditor General shall conduct an annual
31 performance audit of the integrated health care program
32 created under this Section and the Illinois Department's
33 implementation of this Section. The initial audit shall
34 cover the fiscal year ending June 30, 1997, and subsequent
HB0781 Engrossed -46- LRB9000971DJcd
1 audits shall cover each fiscal year thereafter. The Auditor
2 General shall issue reports of the audits on or before
3 December 31 of 1997 and each year thereafter.
4 (Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
5 89-507, eff. 7-1-97; 89-673, eff. 8-14-96; revised 8-26-96.)
6 (305 ILCS 5/5-16.8 new)
7 Sec. 5-16.8. Administration of managed care program.
8 (a) The Illinois Department shall, by rule, establish
9 guidelines for its administration of a managed care program
10 requiring each managed care organization participating in the
11 program to provide education programs for providers
12 participating within the managed care organization's network
13 and for persons eligible for medical assistance under Article
14 V, VI, or XII who are enrolled with the managed care
15 organization.
16 (b) A provider education program must include
17 information on:
18 (1) Medicaid policies, procedures, eligibility
19 standards, and benefits;
20 (2) the specific problems and needs of Medicaid
21 clients; and
22 (3) the rights and responsibilities of Medicaid
23 clients prescribed by this Section.
24 (c) A client education program must present information
25 in a manner that is easy to understand. A program must
26 include information on:
27 (1) the rights and responsibilities prescribed by
28 this Section;
29 (2) how to access health care services;
30 (3) how to access complaint procedures and the
31 client's rights to bypass the managed care organization's
32 internal complaint system and use the notice and appeal
33 procedures otherwise required by the Medicaid program;
HB0781 Engrossed -47- LRB9000971DJcd
1 (4) Medicaid policies, procedures, eligibility
2 standards, and benefits;
3 (5) the policies and procedures of the managed care
4 organization; and
5 (6) the importance of prevention, early
6 intervention, and appropriate use of services.
7 (d) The Department or its designee shall inform each
8 person enrolled in the Medicaid program of the person's
9 rights and responsibilities under that program. The
10 information must address the client's right to:
11 (1) respect, dignity, privacy, confidentiality, and
12 nondiscrimination;
13 (2) a reasonable opportunity to choose a health
14 care plan and primary care provider and to change to
15 another plan or provider in a reasonable manner;
16 (3) consent to or refuse treatment and actively
17 participate in treatment decisions;
18 (4) ask questions and receive complete information
19 relating to the client's medical condition and treatment
20 options, including specialty care;
21 (5) access each available complaint process,
22 receive a timely response to a complaint, and receive a
23 fair hearing; and
24 (6) timely access to care that does not have any
25 communication or physical access barriers.
26 (e) The information must address a client's
27 responsibility to:
28 (1) learn and understand each right the client has
29 under the Medicaid program;
30 (2) abide by the health plan and Medicaid policies
31 and procedures;
32 (3) share information relating to the client's
33 health status with the primary care provider and become
34 fully informed about service and treatment options; and
HB0781 Engrossed -48- LRB9000971DJcd
1 (4) actively participate in decisions relating to
2 service and treatment options, make personal choices and
3 take action to maintain the client's health.
4 (f) The Department shall provide support and information
5 services to a person enrolled in the program or applying for
6 Medicaid coverage who experiences barriers to receiving
7 health care services. The Department may contract for the
8 provision of support and information services. As a part of
9 the support and information services required by this
10 subsection, the Department or organization shall:
11 (1) operate a statewide toll-free assistance
12 telephone number that includes TDD lines and assistance
13 for persons who speak Spanish;
14 (2) intervene promptly with the managed care
15 organizations and providers and any other appropriate
16 entity on behalf of a person who has an urgent need for
17 medical services;
18 (3) assist a person who is experiencing barriers in
19 the Medicaid application and enrollment process and refer
20 the person for further assistance if appropriate;
21 (4) educate persons so that they:
22 (A) understand the concept of managed care;
23 (B) understand their rights under the Medicaid
24 program, including grievance and appeal procedures;
25 and
26 (C) are able to advocate for themselves; and
27 (5) collect and maintain statistical information on
28 a regional basis regarding calls received by the
29 assistance lines and publish quarterly reports that:
30 (A) list the number of calls received by
31 region;
32 (B) identify trends in delivery and access
33 problems;
34 (C) identify recurring barriers in the
HB0781 Engrossed -49- LRB9000971DJcd
1 Medicaid system; and
2 (D) indicate other problems identified with
3 Medicaid managed care; and
4 (6) assist the managed care organizations and
5 providers in identifying and correcting problems,
6 including site visits to affected regions if necessary.
7 (305 ILCS 5/12-13.1)
8 (Text of Section before amendment by P.A. 89-507)
9 Sec. 12-13.1. Inspector General.
10 (a) The Governor shall appoint, and the Senate shall
11 confirm, an Inspector General who shall function within the
12 Illinois Department and report to the Governor. The term of
13 the Inspector General shall expire on the third Monday of
14 January, 1997 and every 4 years thereafter.
15 (b) In order to prevent, detect, and eliminate fraud,
16 waste, abuse, mismanagement, and misconduct, the Inspector
17 General shall oversee the Illinois Department's integrity
18 functions, which include, but are not limited to, the
19 following:
20 (1) Investigation of misconduct by employees,
21 vendors, contractors and medical providers.
22 (2) Audits of medical providers related to ensuring
23 that appropriate payments are made for services rendered
24 and to the recovery of overpayments.
25 (3) Monitoring of quality assurance programs
26 generally related to the medical assistance program and
27 specifically related to any managed care program.
28 (4) Quality control measurements of the programs
29 administered by the Illinois Department.
30 (5) Investigations of fraud or intentional program
31 violations committed by clients of the Illinois
32 Department.
33 (6) Actions initiated against contractors or
HB0781 Engrossed -50- LRB9000971DJcd
1 medical providers for any of the following reasons:
2 (A) Violations of the medical assistance
3 program.
4 (B) Sanctions against providers brought in
5 conjunction with the Department of Public Health or
6 the Department of Mental Health and Developmental
7 Disabilities.
8 (C) Recoveries of assessments against
9 hospitals and long-term care facilities.
10 (D) Sanctions mandated by the United States
11 Department of Health and Human Services against
12 medical providers.
13 (E) Violations of contracts related to any
14 managed care programs.
15 (7) Representation of the Illinois Department at
16 hearings with the Illinois Department of Professional
17 Regulation in actions taken against professional licenses
18 held by persons who are in violation of orders for child
19 support payments.
20 (b-7) The Inspector General may establish within that
21 Office a special administrative subdivision to monitor
22 managed health care entities participating in the integrated
23 health care program established under Section 5-16.3 of this
24 Code to ensure that the entities comply with the requirements
25 of that Section. This special administrative subdivision may
26 receive and investigate complaints made by persons enrolled
27 in a managed health care entity's health care delivery
28 system. If the Inspector General investigates a complaint,
29 the Inspector General shall determine whether a managed
30 health care entity has complied with the requirements of
31 Section 5-16.3 and the rules implementing that Section to the
32 extent that those issues are raised by the complaint.
33 The Inspector General may also monitor the Enrolled
34 Managed Care Provider program to ensure that appropriate
HB0781 Engrossed -51- LRB9000971DJcd
1 management of patient care occurs and that services provided
2 are medically necessary. The special administrative
3 subdivision authorized under this subsection may receive and
4 investigate complaints made by persons receiving services
5 under Section 5-16.3.
6 (c) The Inspector General shall have access to all
7 information, personnel and facilities of the Illinois
8 Department, its employees, vendors, contractors and medical
9 providers and any federal, State or local governmental agency
10 that are necessary to perform the duties of the Office as
11 directly related to public assistance programs administered
12 by the Illinois Department. No medical provider shall be
13 compelled, however, to provide individual medical records of
14 patients who are not clients of the Medical Assistance
15 Program. State and local governmental agencies are
16 authorized and directed to provide the requested information,
17 assistance or cooperation.
18 (d) The Inspector General shall serve as the Illinois
19 Department's primary liaison with law enforcement,
20 investigatory and prosecutorial agencies, including but not
21 limited to the following:
22 (1) The Department of State Police.
23 (2) The Federal Bureau of Investigation and other
24 federal law enforcement agencies.
25 (3) The various Inspectors General of federal
26 agencies overseeing the programs administered by the
27 Illinois Department.
28 (4) The various Inspectors General of any other
29 State agencies with responsibilities for portions of
30 programs primarily administered by the Illinois
31 Department.
32 (5) The Offices of the several United States
33 Attorneys in Illinois.
34 (6) The several State's Attorneys.
HB0781 Engrossed -52- LRB9000971DJcd
1 The Inspector General shall meet on a regular basis with
2 these entities to share information regarding possible
3 misconduct by any persons or entities involved with the
4 public aid programs administered by the Illinois Department.
5 (e) All investigations conducted by the Inspector
6 General shall be conducted in a manner that ensures the
7 preservation of evidence for use in criminal prosecutions.
8 If the Inspector General determines that a possible criminal
9 act relating to fraud in the provision or administration of
10 the medical assistance program has been committed, the
11 Inspector General shall immediately notify the Medicaid Fraud
12 Control Unit. If the Inspector General determines that a
13 possible criminal act has been committed within the
14 jurisdiction of the Office, the Inspector General may request
15 the special expertise of the Department of State Police. The
16 Inspector General may present for prosecution the findings of
17 any criminal investigation to the Office of the Attorney
18 General, the Offices of the several United State Attorneys in
19 Illinois or the several State's Attorneys.
20 (f) To carry out his or her duties as described in this
21 Section, the Inspector General and his or her designees shall
22 have the power to compel by subpoena the attendance and
23 testimony of witnesses and the production of books,
24 electronic records and papers as directly related to public
25 assistance programs administered by the Illinois Department.
26 No medical provider shall be compelled, however, to provide
27 individual medical records of patients who are not clients of
28 the Medical Assistance Program.
29 (g) The Inspector General shall report all convictions,
30 terminations, and suspensions taken against vendors,
31 contractors and medical providers to the Illinois Department
32 and to any agency responsible for licensing or regulating
33 those persons or entities.
34 (h) The Inspector General shall make quarterly reports,
HB0781 Engrossed -53- LRB9000971DJcd
1 findings, and recommendations regarding the Office's
2 investigations into reports of fraud, waste, abuse,
3 mismanagement, or misconduct relating to any public aid
4 programs administered by the Illinois Department to the
5 General Assembly and the Governor. These reports shall
6 include, but not be limited to, the following information:
7 (1) Aggregate provider billing and payment
8 information, including the number of providers at various
9 Medicaid earning levels.
10 (2) The number of audits of the medical assistance
11 program and the dollar savings resulting from those
12 audits.
13 (3) The number of prescriptions rejected annually
14 under the Illinois Department's Refill Too Soon program
15 and the dollar savings resulting from that program.
16 (4) Provider sanctions, in the aggregate, including
17 terminations and suspensions.
18 (5) A detailed summary of the investigations
19 undertaken in the previous fiscal year. These summaries
20 shall comply with all laws and rules regarding
21 maintaining confidentiality in the public aid programs.
22 (i) Nothing in this Section shall limit investigations
23 by the Illinois Department that may otherwise be required by
24 law or that may be necessary in the Illinois Department's
25 capacity as the central administrative authority responsible
26 for administration of public aid programs in this State.
27 (Source: P.A. 88-554, eff. 7-26-94.)
28 (Text of Section after amendment by P.A. 89-507)
29 Sec. 12-13.1. Inspector General.
30 (a) The Governor shall appoint, and the Senate shall
31 confirm, an Inspector General who shall function within the
32 Illinois Department of Public Aid and report to the Governor.
33 The term of the Inspector General shall expire on the third
34 Monday of January, 1997 and every 4 years thereafter.
HB0781 Engrossed -54- LRB9000971DJcd
1 (b) In order to prevent, detect, and eliminate fraud,
2 waste, abuse, mismanagement, and misconduct, the Inspector
3 General shall oversee the Illinois Department of Public Aid's
4 integrity functions, which include, but are not limited to,
5 the following:
6 (1) Investigation of misconduct by employees,
7 vendors, contractors and medical providers.
8 (2) Audits of medical providers related to ensuring
9 that appropriate payments are made for services rendered
10 and to the recovery of overpayments.
11 (3) Monitoring of quality assurance programs
12 generally related to the medical assistance program and
13 specifically related to any managed care program.
14 (4) Quality control measurements of the programs
15 administered by the Illinois Department of Public Aid.
16 (5) Investigations of fraud or intentional program
17 violations committed by clients of the Illinois
18 Department of Public Aid.
19 (6) Actions initiated against contractors or
20 medical providers for any of the following reasons:
21 (A) Violations of the medical assistance
22 program.
23 (B) Sanctions against providers brought in
24 conjunction with the Department of Public Health or
25 the Department of Human Services (as successor to
26 the Department of Mental Health and Developmental
27 Disabilities).
28 (C) Recoveries of assessments against
29 hospitals and long-term care facilities.
30 (D) Sanctions mandated by the United States
31 Department of Health and Human Services against
32 medical providers.
33 (E) Violations of contracts related to any
34 managed care programs.
HB0781 Engrossed -55- LRB9000971DJcd
1 (7) Representation of the Illinois Department of
2 Public Aid at hearings with the Illinois Department of
3 Professional Regulation in actions taken against
4 professional licenses held by persons who are in
5 violation of orders for child support payments.
6 (b-5) At the request of the Secretary of Human Services,
7 the Inspector General shall, in relation to any function
8 performed by the Department of Human Services as successor to
9 the Department of Public Aid, exercise one or more of the
10 powers provided under this Section as if those powers related
11 to the Department of Human Services; in such matters, the
12 Inspector General shall report his or her findings to the
13 Secretary of Human Services.
14 (b-7) The Inspector General may establish within that
15 Office a special administrative subdivision to monitor
16 managed health care entities participating in the integrated
17 health care program established under Section 5-16.3 of this
18 Code to ensure that the entities comply with the requirements
19 of that Section. This special administrative subdivision may
20 receive and investigate complaints made by persons enrolled
21 in a managed health care entity's health care delivery
22 system. If the Inspector General investigates a complaint,
23 the Inspector General shall determine whether a managed
24 health care entity has complied with the requirements of
25 Section 5-16.3 and the rules implementing that Section to the
26 extent that those issues are raised by the complaint.
27 The Inspector General may also monitor the Enrolled
28 Managed Care Provider program to ensure that appropriate
29 management of patient care occurs and that services provided
30 are medically necessary. The special administrative
31 subdivision authorized under this subsection may receive and
32 investigate complaints made by persons receiving services
33 under Section 5-16.3.
34 (c) The Inspector General shall have access to all
HB0781 Engrossed -56- LRB9000971DJcd
1 information, personnel and facilities of the Illinois
2 Department of Public Aid and the Department of Human Services
3 (as successor to the Department of Public Aid), their
4 employees, vendors, contractors and medical providers and any
5 federal, State or local governmental agency that are
6 necessary to perform the duties of the Office as directly
7 related to public assistance programs administered by those
8 departments. No medical provider shall be compelled,
9 however, to provide individual medical records of patients
10 who are not clients of the Medical Assistance Program. State
11 and local governmental agencies are authorized and directed
12 to provide the requested information, assistance or
13 cooperation.
14 (d) The Inspector General shall serve as the Illinois
15 Department of Public Aid's primary liaison with law
16 enforcement, investigatory and prosecutorial agencies,
17 including but not limited to the following:
18 (1) The Department of State Police.
19 (2) The Federal Bureau of Investigation and other
20 federal law enforcement agencies.
21 (3) The various Inspectors General of federal
22 agencies overseeing the programs administered by the
23 Illinois Department of Public Aid.
24 (4) The various Inspectors General of any other
25 State agencies with responsibilities for portions of
26 programs primarily administered by the Illinois
27 Department of Public Aid.
28 (5) The Offices of the several United States
29 Attorneys in Illinois.
30 (6) The several State's Attorneys.
31 The Inspector General shall meet on a regular basis with
32 these entities to share information regarding possible
33 misconduct by any persons or entities involved with the
34 public aid programs administered by the Illinois Department
HB0781 Engrossed -57- LRB9000971DJcd
1 of Public Aid.
2 (e) All investigations conducted by the Inspector
3 General shall be conducted in a manner that ensures the
4 preservation of evidence for use in criminal prosecutions.
5 If the Inspector General determines that a possible criminal
6 act relating to fraud in the provision or administration of
7 the medical assistance program has been committed, the
8 Inspector General shall immediately notify the Medicaid Fraud
9 Control Unit. If the Inspector General determines that a
10 possible criminal act has been committed within the
11 jurisdiction of the Office, the Inspector General may request
12 the special expertise of the Department of State Police. The
13 Inspector General may present for prosecution the findings of
14 any criminal investigation to the Office of the Attorney
15 General, the Offices of the several United State Attorneys in
16 Illinois or the several State's Attorneys.
17 (f) To carry out his or her duties as described in this
18 Section, the Inspector General and his or her designees shall
19 have the power to compel by subpoena the attendance and
20 testimony of witnesses and the production of books,
21 electronic records and papers as directly related to public
22 assistance programs administered by the Illinois Department
23 of Public Aid or the Department of Human Services (as
24 successor to the Department of Public Aid). No medical
25 provider shall be compelled, however, to provide individual
26 medical records of patients who are not clients of the
27 Medical Assistance Program.
28 (g) The Inspector General shall report all convictions,
29 terminations, and suspensions taken against vendors,
30 contractors and medical providers to the Illinois Department
31 of Public Aid and to any agency responsible for licensing or
32 regulating those persons or entities.
33 (h) The Inspector General shall make quarterly reports,
34 findings, and recommendations regarding the Office's
HB0781 Engrossed -58- LRB9000971DJcd
1 investigations into reports of fraud, waste, abuse,
2 mismanagement, or misconduct relating to any public aid
3 programs administered by the Illinois Department of Public
4 Aid or the Department of Human Services (as successor to the
5 Department of Public Aid) to the General Assembly and the
6 Governor. These reports shall include, but not be limited
7 to, the following information:
8 (1) Aggregate provider billing and payment
9 information, including the number of providers at various
10 Medicaid earning levels.
11 (2) The number of audits of the medical assistance
12 program and the dollar savings resulting from those
13 audits.
14 (3) The number of prescriptions rejected annually
15 under the Illinois Department of Public Aid's Refill Too
16 Soon program and the dollar savings resulting from that
17 program.
18 (4) Provider sanctions, in the aggregate, including
19 terminations and suspensions.
20 (5) A detailed summary of the investigations
21 undertaken in the previous fiscal year. These summaries
22 shall comply with all laws and rules regarding
23 maintaining confidentiality in the public aid programs.
24 (i) Nothing in this Section shall limit investigations
25 by the Illinois Department of Public Aid or the Department of
26 Human Services that may otherwise be required by law or that
27 may be necessary in their capacity as the central
28 administrative authorities responsible for administration of
29 public aid programs in this State.
30 (Source: P.A. 88-554, eff. 7-26-94; 89-507, eff. 7-1-97.)
31 Section 95. No acceleration or delay. Where this Act
32 makes changes in a statute that is represented in this Act by
33 text that is not yet or no longer in effect (for example, a
HB0781 Engrossed -59- LRB9000971DJcd
1 Section represented by multiple versions), the use of that
2 text does not accelerate or delay the taking effect of (i)
3 the changes made by this Act or (ii) provisions derived from
4 any other Public Act.
5 Section 99. Effective date. This Act takes effect upon
6 becoming law.