State of Illinois
91st General Assembly
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91_SB0054

 
                                               LRB9101284SMdv

 1        AN ACT to amend the Illinois Public Aid Code by  changing
 2    Section 5-16.3.

 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 Section 5-16.3 as follows:

 7        (305 ILCS 5/5-16.3)
 8        Sec. 5-16.3.  System for integrated health care services.
 9        (a)  It shall be the public policy of the State to adopt,
10    to  the  extent  practicable,  a  health  care  program  that
11    encourages  the  integration  of  health  care  services  and
12    manages the health care of program enrollees while preserving
13    reasonable  choice  within  a  competitive and cost-efficient
14    environment.  In  furtherance  of  this  public  policy,  the
15    Illinois Department shall develop and implement an integrated
16    health  care  program  consistent with the provisions of this
17    Section.  The provisions of this Section apply  only  to  the
18    integrated  health  care  program created under this Section.
19    Persons enrolled in the integrated health  care  program,  as
20    determined  by  the  Illinois  Department  by  rule, shall be
21    afforded a choice among health care delivery  systems,  which
22    shall  include,  but  are not limited to, (i) fee for service
23    care managed by a primary care physician licensed to practice
24    medicine in  all  its  branches,  (ii)  managed  health  care
25    entities,   and  (iii)  federally  qualified  health  centers
26    (reimbursed according  to  a  prospective  cost-reimbursement
27    methodology)  and  rural health clinics (reimbursed according
28    to  the  Medicare  methodology),  where  available.   Persons
29    enrolled in the integrated health care program  also  may  be
30    offered indemnity insurance plans, subject to availability.
31        For  purposes  of  this  Section,  a "managed health care
 
                            -2-                LRB9101284SMdv
 1    entity" means a health maintenance organization or a  managed
 2    care community network as defined in this Section.  A "health
 3    maintenance   organization"   means   a   health  maintenance
 4    organization   as   defined   in   the   Health   Maintenance
 5    Organization Act.  A "managed care community  network"  means
 6    an entity, other than a health maintenance organization, that
 7    is  owned,  operated, or governed by providers of health care
 8    services within this State  and  that  provides  or  arranges
 9    primary, secondary, and tertiary managed health care services
10    under  contract  with  the Illinois Department exclusively to
11    enrollees of the integrated health care  program.  A  managed
12    care   community  network  may  contract  with  the  Illinois
13    Department to provide only pediatric health care services.  A
14    county  provider  as defined in Section 15-1 of this Code may
15    contract with the Illinois Department to provide services  to
16    enrollees  of the integrated health care program as a managed
17    care community  network  without  the  need  to  establish  a
18    separate   entity   that  provides  services  exclusively  to
19    enrollees of the integrated health care program and shall  be
20    deemed  a managed care community network for purposes of this
21    Code only to the extent of the provision of services to those
22    enrollees in conjunction  with  the  integrated  health  care
23    program.   A  county  provider  shall be entitled to contract
24    with the Illinois Department with respect to any  contracting
25    region  located  in  whole  or  in part within the county.  A
26    county provider shall not be required to accept enrollees who
27    do not reside within the county.
28        Each managed care community network must demonstrate  its
29    ability to bear the financial risk of serving enrollees under
30    this  program.   The  Illinois Department shall by rule adopt
31    criteria  for  assessing  the  financial  soundness  of  each
32    managed care community network. These  rules  shall  consider
33    the  extent  to  which  a  managed  care community network is
34    comprised of providers who directly render  health  care  and
 
                            -3-                LRB9101284SMdv
 1    are  located  within  the  community  in  which  they seek to
 2    contract rather than solely arrange or finance  the  delivery
 3    of health care.  These rules shall further consider a variety
 4    of  risk-bearing  and  management  techniques,  including the
 5    sufficiency of quality assurance and  utilization  management
 6    programs  and  whether  a  managed care community network has
 7    sufficiently demonstrated  its  financial  solvency  and  net
 8    worth.  The  Illinois  Department's criteria must be based on
 9    sound actuarial, financial, and  accounting  principles.   In
10    adopting  these  rules, the Illinois Department shall consult
11    with the  Illinois  Department  of  Insurance.  The  Illinois
12    Department  is  responsible  for  monitoring  compliance with
13    these rules.
14        This Section may not be implemented before the  effective
15    date  of  these  rules, the approval of any necessary federal
16    waivers, and the completion of the review of  an  application
17    submitted,  at  least  60  days  before the effective date of
18    rules adopted under this Section, to the Illinois  Department
19    by a managed care community network.
20        All  health  care delivery systems that contract with the
21    Illinois Department under the integrated health care  program
22    shall  clearly  recognize  a  health care provider's right of
23    conscience under the Health Care Right of Conscience Act.  In
24    addition to the  provisions  of  that  Act,  no  health  care
25    delivery  system  that contracts with the Illinois Department
26    under the integrated health care program shall be required to
27    provide, arrange for, or pay for any health care  or  medical
28    service,  procedure,  or product if that health care delivery
29    system is owned, controlled, or sponsored  by  or  affiliated
30    with  a  religious institution or religious organization that
31    finds that health care  or  medical  service,  procedure,  or
32    product  to  violate  its  religious  and moral teachings and
33    beliefs.
34        (b)  The Illinois Department may, by  rule,  provide  for
 
                            -4-                LRB9101284SMdv
 1    different   benefit  packages  for  different  categories  of
 2    persons enrolled in the  program.   Mental  health  services,
 3    alcohol  and  substance  abuse  services, services related to
 4    children  with  chronic   or   acute   conditions   requiring
 5    longer-term  treatment and follow-up, and rehabilitation care
 6    provided by a  free-standing  rehabilitation  hospital  or  a
 7    hospital  rehabilitation  unit may be excluded from a benefit
 8    package if the State ensures that  those  services  are  made
 9    available  through  a separate delivery system.  An exclusion
10    does not prohibit the Illinois Department from developing and
11    implementing demonstration projects for categories of persons
12    or services.   Benefit  packages  for  persons  eligible  for
13    medical  assistance  under  Articles  V, VI, and XII shall be
14    based on the requirements of  those  Articles  and  shall  be
15    consistent  with  the  Title  XIX of the Social Security Act.
16    Nothing in this Act shall be construed to apply  to  services
17    purchased  by  the Department of Children and Family Services
18    and the Department of Human Services  (as  successor  to  the
19    Department  of  Mental Health and Developmental Disabilities)
20    under  the  provisions  of   Title   59   of   the   Illinois
21    Administrative  Code,  Part  132  ("Medicaid Community Mental
22    Health Services Program").
23        (c)  The program  established  by  this  Section  may  be
24    implemented by the Illinois Department in various contracting
25    areas at various times.  The health care delivery systems and
26    providers available under the program may vary throughout the
27    State.   For purposes of contracting with managed health care
28    entities  and  providers,  the  Illinois   Department   shall
29    establish  contracting  areas similar to the geographic areas
30    designated  by  the  Illinois  Department   for   contracting
31    purposes   under   the   Illinois   Competitive   Access  and
32    Reimbursement Equity Program (ICARE) under the  authority  of
33    Section  3-4  of  the  Illinois  Health Finance Reform Act or
34    similarly-sized or smaller geographic  areas  established  by
 
                            -5-                LRB9101284SMdv
 1    the Illinois Department by rule. A managed health care entity
 2    shall  be  permitted  to contract in any geographic areas for
 3    which it has a  sufficient  provider  network  and  otherwise
 4    meets  the  contracting  terms  of  the  State.  The Illinois
 5    Department is not prohibited from entering  into  a  contract
 6    with a managed health care entity at any time.
 7        (c-5)  A  managed  health  care  entity may not engage in
 8    door-to-door marketing activities or marketing activities  at
 9    an  office  of the Illinois Department or a county department
10    in order to enroll  in  the  entity's  health  care  delivery
11    system persons who are enrolled in the integrated health care
12    program   established   under  this  Section.   The  Illinois
13    Department shall adopt rules defining "marketing  activities"
14    prohibited by this subsection (c-5).
15        Before a managed health care entity may market its health
16    care  delivery  system  to persons enrolled in the integrated
17    health care  program  established  under  this  Section,  the
18    Illinois  Department  must approve a marketing plan submitted
19    by the  entity  to  the  Illinois  Department.  The  Illinois
20    Department  shall  adopt  guidelines  for approving marketing
21    plans submitted by managed health care  entities  under  this
22    subsection.   Besides   prohibiting   door-to-door  marketing
23    activities and marketing activities at  public  aid  offices,
24    the guidelines shall include at least the following:
25             (1)  A  managed  health care entity may not offer or
26        provide any gift, favor, or other inducement in marketing
27        its health care delivery system to integrated health care
28        program enrollees.  A  managed  health  care  entity  may
29        provide  health  care  related  items that are of nominal
30        value and pre-approved  by  the  Illinois  Department  to
31        prospective  enrollees.  A managed health care entity may
32        also provide to enrollees health care related items  that
33        have  been  pre-approved by the Illinois Department as an
34        incentive to manage their health care appropriately.
 
                            -6-                LRB9101284SMdv
 1             (2)  All persons employed or otherwise engaged by  a
 2        managed  health care entity to market the entity's health
 3        care delivery system to integrated  health  care  program
 4        enrollees  or to supervise  that marketing shall register
 5        with the Illinois Department.
 6        The Inspector General appointed under Section 12-13.1 may
 7    conduct investigations to  determine  whether  the  marketing
 8    practices  of  managed  health care entities participating in
 9    the  integrated  health  care   program   comply   with   the
10    guidelines.
11        (d)  A managed health care entity that contracts with the
12    Illinois  Department  for the provision of services under the
13    program shall do all of the following, solely for purposes of
14    the integrated health care program:
15             (1)  Provide that any individual physician  licensed
16        under the Medical Practice Act of 1987, any pharmacy, any
17        federally  qualified  health  center, any therapeutically
18        certified   optometrist,   and   any   podiatrist,   that
19        consistently meets the reasonable  terms  and  conditions
20        established  by the managed health care entity, including
21        but  not  limited  to  credentialing  standards,  quality
22        assurance program  requirements,  utilization  management
23        requirements,    financial    responsibility   standards,
24        contracting process requirements,  and  provider  network
25        size  and accessibility requirements, must be accepted by
26        the managed  health  care  entity  for  purposes  of  the
27        Illinois  integrated health care program. Notwithstanding
28        the preceding sentence,  only  a  physician  licensed  to
29        practice  medicine  in  all  its  branches shall act as a
30        primary care  physician  within  a  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
 
                            -7-                LRB9101284SMdv
 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
 
                            -8-                LRB9101284SMdv
 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             (5)  Provide  that  enrollees  within its system may
22        choose the site for provision of services and  the  panel
23        of health care providers.
24             (6)  Not   discriminate   in   its   enrollment   or
25        disenrollment   practices  among  recipients  of  medical
26        services or program enrollees based on health status.
27             (7)  Provide a  quality  assurance  and  utilization
28        review   program   that   (i)   for   health  maintenance
29        organizations  meets  the  requirements  of  the   Health
30        Maintenance  Organization  Act  and (ii) for managed care
31        community networks meets the requirements established  by
32        the  Illinois  Department in rules that incorporate those
33        standards   set   forth   in   the   Health   Maintenance
34        Organization Act.
 
                            -9-                LRB9101284SMdv
 1             (8)  Issue   a   managed    health    care    entity
 2        identification  card  to  each  enrollee upon enrollment.
 3        The card must contain all of the following:
 4                  (A)  The enrollee's signature.
 5                  (B)  The enrollee's health plan.
 6                  (C)  The  name  and  telephone  number  of  the
 7             enrollee's primary care physician.
 8                  (D)  A  telephone  number  to   be   used   for
 9             emergency service 24 hours per day, 7 days per week.
10             The  telephone  number  required  to  be  maintained
11             pursuant to this subparagraph by each managed health
12             care   entity  shall,  at  minimum,  be  staffed  by
13             medically  trained   personnel   and   be   provided
14             directly,  or  under  arrangement,  at  an office or
15             offices in  locations maintained solely  within  the
16             State    of   Illinois.   For   purposes   of   this
17             subparagraph, "medically  trained  personnel"  means
18             licensed   practical  nurses  or  registered  nurses
19             located in the State of Illinois  who  are  licensed
20             pursuant   to  the  Nursing  and  Advanced  Practice
21             Nursing Act.
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
 
                            -10-               LRB9101284SMdv
 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             (13)  Provide   integration   with   community-based
27        programs provided by certified local  health  departments
28        such  as  Women,  Infants, and Children Supplemental Food
29        Program (WIC), childhood  immunization  programs,  health
30        education  programs, case management programs, and health
31        screening programs.
32             (14)  Provide that the pharmacy formulary used by  a
33        managed  health care entity and its contract providers be
34        no  more  restrictive  than  the  Illinois   Department's
 
                            -11-               LRB9101284SMdv
 1        pharmaceutical  program  on  the  effective  date of this
 2        amendatory Act of 1994 and as amended after that date.
 3             (15)  Provide   integration   with   community-based
 4        organizations,  including,  but  not  limited   to,   any
 5        organization   that   has   operated  within  a  Medicaid
 6        Partnership as defined by this Code or  by  rule  of  the
 7        Illinois Department, that may continue to operate under a
 8        contract with the Illinois Department or a managed health
 9        care entity under this Section to provide case management
10        services  to  Medicaid  clients  in  designated high-need
11        areas.
12        The  Illinois  Department   may,   by   rule,   determine
13    methodologies to limit financial liability for managed health
14    care   entities   resulting  from  payment  for  services  to
15    enrollees provided under the Illinois Department's integrated
16    health care program. Any methodology  so  determined  may  be
17    considered  or implemented by the Illinois Department through
18    a contract with a  managed  health  care  entity  under  this
19    integrated health care program.
20        The  Illinois Department shall contract with an entity or
21    entities to provide  external  peer-based  quality  assurance
22    review  for  the  integrated  health care program. The entity
23    shall be representative of Illinois  physicians  licensed  to
24    practice  medicine  in  all  its  branches and have statewide
25    geographic representation in all specialties of medical  care
26    that  are provided within the integrated health care program.
27    The entity may not be a third party payer and shall  maintain
28    offices  in  locations  around  the State in order to provide
29    service  and  continuing  medical  education   to   physician
30    participants  within the integrated health care program.  The
31    review process shall be developed and conducted  by  Illinois
32    physicians licensed to practice medicine in all its branches.
33    In  consultation with the entity, the Illinois Department may
34    contract with  other  entities  for  professional  peer-based
 
                            -12-               LRB9101284SMdv
 1    quality assurance review of individual categories of services
 2    other  than  services provided, supervised, or coordinated by
 3    physicians licensed to practice medicine in all its branches.
 4    The Illinois Department shall establish, by rule, criteria to
 5    avoid  conflicts  of  interest  in  the  conduct  of  quality
 6    assurance activities consistent with professional peer-review
 7    standards.  All  quality  assurance   activities   shall   be
 8    coordinated by the Illinois Department.
 9        (e)  All   persons  enrolled  in  the  program  shall  be
10    provided   with   a   full   written   explanation   of   all
11    fee-for-service and managed health care plan  options  and  a
12    reasonable   opportunity  to  choose  among  the  options  as
13    provided by rule.  The Illinois Department shall  provide  to
14    enrollees,  upon  enrollment  in  the  integrated health care
15    program and at  least  annually  thereafter,  notice  of  the
16    process   for   requesting   an  appeal  under  the  Illinois
17    Department's      administrative      appeal      procedures.
18    Notwithstanding any other Section of this Code, the  Illinois
19    Department may provide by rule for the Illinois Department to
20    assign  a  person  enrolled  in  the  program  to  a specific
21    provider of medical services or to  a  specific  health  care
22    delivery  system if an enrollee has failed to exercise choice
23    in a timely manner. An  enrollee  assigned  by  the  Illinois
24    Department shall be afforded the opportunity to disenroll and
25    to  select  a  specific  provider  of  medical  services or a
26    specific health care delivery system within the first 30 days
27    after the assignment. An enrollee who has failed to  exercise
28    choice in a timely manner may be assigned only if there are 3
29    or  more  managed  health  care entities contracting with the
30    Illinois Department within the contracting area, except that,
31    outside the City of Chicago, this requirement may  be  waived
32    for an area by rules adopted by the Illinois Department after
33    consultation  with all hospitals within the contracting area.
34    The Illinois Department shall establish by rule the procedure
 
                            -13-               LRB9101284SMdv
 1    for random assignment  of  enrollees  who  fail  to  exercise
 2    choice  in  a timely manner to a specific managed health care
 3    entity in  proportion  to  the  available  capacity  of  that
 4    managed health care entity. Assignment to a specific provider
 5    of  medical  services  or  to  a specific managed health care
 6    entity may not exceed that provider's or entity's capacity as
 7    determined by the Illinois Department.  Any  person  who  has
 8    chosen  a specific provider of medical services or a specific
 9    managed health care  entity,  or  any  person  who  has  been
10    assigned   under   this   subsection,   shall  be  given  the
11    opportunity to change that choice or assignment at least once
12    every 12 months, as determined by the Illinois Department  by
13    rule.  The  Illinois  Department  shall  maintain a toll-free
14    telephone number for  program  enrollees'  use  in  reporting
15    problems with managed health care entities.
16        (f)  If  a  person  becomes eligible for participation in
17    the integrated  health  care  program  while  he  or  she  is
18    hospitalized,  the  Illinois  Department  may not enroll that
19    person in  the  program  until  after  he  or  she  has  been
20    discharged from the hospital.  This subsection does not apply
21    to   newborn  infants  whose  mothers  are  enrolled  in  the
22    integrated health care program.
23        (g)  The Illinois Department shall,  by  rule,  establish
24    for managed health care entities rates that (i) are certified
25    to  be  actuarially sound, as determined by an actuary who is
26    an associate or a fellow of the Society  of  Actuaries  or  a
27    member  of  the  American  Academy  of  Actuaries and who has
28    expertise and experience in  medical  insurance  and  benefit
29    programs,   in  accordance  with  the  Illinois  Department's
30    current fee-for-service payment system, and  (ii)  take  into
31    account  any  difference  of  cost  to provide health care to
32    different populations based on  gender,  age,  location,  and
33    eligibility  category.   The  rates  for  managed health care
34    entities shall be determined on a capitated basis.
 
                            -14-               LRB9101284SMdv
 1        The Illinois Department by rule shall establish a  method
 2    to  adjust  its payments to managed health care entities in a
 3    manner intended to avoid providing any financial incentive to
 4    a managed health care entity to refer patients  to  a  county
 5    provider,  in  an Illinois county having a population greater
 6    than  3,000,000,  that  is  paid  directly  by  the  Illinois
 7    Department.  The Illinois Department shall by April 1,  1997,
 8    and   annually   thereafter,  review  the  method  to  adjust
 9    payments. Payments by the Illinois Department to  the  county
10    provider,   for  persons  not  enrolled  in  a  managed  care
11    community network owned or operated  by  a  county  provider,
12    shall  be paid on a fee-for-service basis under Article XV of
13    this Code.
14        The Illinois Department by rule shall establish a  method
15    to  reduce  its  payments  to managed health care entities to
16    take into consideration (i) any adjustment payments  paid  to
17    hospitals  under subsection (h) of this Section to the extent
18    those payments, or any part  of  those  payments,  have  been
19    taken into account in establishing capitated rates under this
20    subsection  (g)  and (ii) the implementation of methodologies
21    to limit financial liability for managed health care entities
22    under subsection (d) of this Section.
23        (h)  For hospital services provided by  a  hospital  that
24    contracts  with  a  managed  health  care  entity, adjustment
25    payments shall be  paid  directly  to  the  hospital  by  the
26    Illinois  Department.   Adjustment  payments  may include but
27    need   not   be   limited   to   adjustment   payments    to:
28    disproportionate share hospitals under Section 5-5.02 of this
29    Code;  primary care access health care education payments (89
30    Ill. Adm. Code 149.140); payments for capital, direct medical
31    education, indirect medical education,  certified  registered
32    nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
33    Code  149.150(c));  uncompensated care payments (89 Ill. Adm.
34    Code 148.150(h)); trauma center payments (89 Ill.  Adm.  Code
 
                            -15-               LRB9101284SMdv
 1    148.290(c));  rehabilitation  hospital payments (89 Ill. Adm.
 2    Code 148.290(d)); perinatal center  payments  (89  Ill.  Adm.
 3    Code  148.290(e));  obstetrical  care  payments (89 Ill. Adm.
 4    Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
 5    148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
 6    148.290(h)); and outpatient indigent volume  adjustments  (89
 7    Ill. Adm. Code 148.140(b)(5)).
 8        (i)  For   any   hospital  eligible  for  the  adjustment
 9    payments described in subsection (h), the Illinois Department
10    shall maintain, through the  period  ending  June  30,  1995,
11    reimbursement levels in accordance with statutes and rules in
12    effect on April 1, 1994.
13        (j)  Nothing  contained in this Code in any way limits or
14    otherwise impairs the authority  or  power  of  the  Illinois
15    Department  to  enter  into a negotiated contract pursuant to
16    this Section with a managed health  care  entity,  including,
17    but  not  limited to, a health maintenance organization, that
18    provides  for  termination  or  nonrenewal  of  the  contract
19    without cause upon notice as provided  in  the  contract  and
20    without a hearing.
21        (k)  Section   5-5.15  does  not  apply  to  the  program
22    developed and implemented pursuant to this Section.
23        (l)  The Illinois Department shall, by rule, define those
24    chronic or acute medical conditions of childhood that require
25    longer-term  treatment  and  follow-up  care.   The  Illinois
26    Department shall ensure that services required to treat these
27    conditions are available through a separate delivery system.
28        A managed health care  entity  that  contracts  with  the
29    Illinois Department may refer a child with medical conditions
30    described in the rules adopted under this subsection directly
31    to  a  children's  hospital  or  to  a hospital, other than a
32    children's hospital, that is qualified to  provide  inpatient
33    and  outpatient  services  to  treat  those  conditions.  The
34    Illinois    Department    shall    provide    fee-for-service
 
                            -16-               LRB9101284SMdv
 1    reimbursement directly to a  children's  hospital  for  those
 2    services  pursuant to Title 89 of the Illinois Administrative
 3    Code, Section 148.280(a), at a rate at  least  equal  to  the
 4    rate  in  effect on March 31, 1994. For hospitals, other than
 5    children's hospitals, that are qualified to provide inpatient
 6    and  outpatient  services  to  treat  those  conditions,  the
 7    Illinois Department shall  provide  reimbursement  for  those
 8    services on a fee-for-service basis, at a rate at least equal
 9    to  the rate in effect for those other hospitals on March 31,
10    1994.
11        A children's hospital shall be  directly  reimbursed  for
12    all  services  provided  at  the  children's  hospital  on  a
13    fee-for-service  basis  pursuant  to Title 89 of the Illinois
14    Administrative Code, Section 148.280(a), at a rate  at  least
15    equal  to  the  rate  in  effect on March 31, 1994, until the
16    later of (i) implementation of  the  integrated  health  care
17    program  under  this  Section  and development of actuarially
18    sound capitation rates for services other than those  chronic
19    or   acute  medical  conditions  of  childhood  that  require
20    longer-term treatment and follow-up care as  defined  by  the
21    Illinois   Department   in   the  rules  adopted  under  this
22    subsection or (ii) March 31, 1996.
23        Notwithstanding  anything  in  this  subsection  to   the
24    contrary,  a  managed  health  care entity shall not consider
25    sources or methods of payment in determining the referral  of
26    a  child.   The  Illinois  Department  shall  adopt  rules to
27    establish  criteria  for  those  referrals.    The   Illinois
28    Department  by  rule  shall  establish a method to adjust its
29    payments to managed health care entities in a manner intended
30    to avoid providing  any  financial  incentive  to  a  managed
31    health  care  entity  to  refer patients to a provider who is
32    paid directly by the Illinois Department.
33        (m)  Behavioral health services provided or funded by the
34    Department of Human Services, the Department of Children  and
 
                            -17-               LRB9101284SMdv
 1    Family   Services,  and  the  Illinois  Department  shall  be
 2    excluded from a benefit package.  Conditions of an organic or
 3    physical origin or nature, including medical  detoxification,
 4    however,   may   not   be   excluded.   In  this  subsection,
 5    "behavioral health services" means mental health services and
 6    subacute alcohol and substance abuse treatment  services,  as
 7    defined  in the Illinois Alcoholism and Other Drug Dependency
 8    Act.  In this subsection, "mental health services"  includes,
 9    at  a  minimum, the following services funded by the Illinois
10    Department, the Department of Human Services (as successor to
11    the   Department   of   Mental   Health   and   Developmental
12    Disabilities), or  the  Department  of  Children  and  Family
13    Services:  (i) inpatient hospital services, including related
14    physician services, related  psychiatric  interventions,  and
15    pharmaceutical  services  provided  to  an eligible recipient
16    hospitalized  with  a  primary   diagnosis   of   psychiatric
17    disorder;  (ii)  outpatient mental health services as defined
18    and specified in Title  59  of  the  Illinois  Administrative
19    Code,  Part  132;  (iii)  any  other outpatient mental health
20    services funded by the Illinois Department  pursuant  to  the
21    State    of    Illinois    Medicaid    Plan;   (iv)   partial
22    hospitalization; and (v) follow-up stabilization  related  to
23    any of those services.  Additional behavioral health services
24    may  be  excluded under this subsection as mutually agreed in
25    writing by the Illinois Department  and  the  affected  State
26    agency  or  agencies.   The exclusion of any service does not
27    prohibit  the  Illinois  Department   from   developing   and
28    implementing demonstration projects for categories of persons
29    or  services.  The Department of Children and Family Services
30    and the Department of Human Services shall each  adopt  rules
31    governing the integration of managed care in the provision of
32    behavioral health services. The State shall integrate managed
33    care  community  networks  and  affiliated  providers, to the
34    extent practicable,  in  any  separate  delivery  system  for
 
                            -18-               LRB9101284SMdv
 1    mental health services.
 2        (n)  The   Illinois   Department  shall  adopt  rules  to
 3    establish reserve requirements  for  managed  care  community
 4    networks,   as   required   by  subsection  (a),  and  health
 5    maintenance organizations to protect against  liabilities  in
 6    the  event  that  a  managed  health  care entity is declared
 7    insolvent or bankrupt.  If a managed health care entity other
 8    than a county provider is  declared  insolvent  or  bankrupt,
 9    after  liquidation  and  application of any available assets,
10    resources, and reserves, the Illinois Department shall pay  a
11    portion of the amounts owed by the managed health care entity
12    to  providers  for  services  rendered to enrollees under the
13    integrated health care program under this  Section  based  on
14    the  following  schedule: (i) from April 1, 1995 through June
15    30, 1998, 90% of the amounts owed; (ii)  from  July  1,  1998
16    through  June  30,  2001,  80% of the amounts owed; and (iii)
17    from July 1, 2001 through June 30, 2005, 75% of  the  amounts
18    owed.   The  amounts  paid  under  this  subsection  shall be
19    calculated based on the total  amount  owed  by  the  managed
20    health  care  entity  to  providers before application of any
21    available assets, resources, and reserves.   After  June  30,
22    2005, the Illinois Department may not pay any amounts owed to
23    providers  as  a  result  of an insolvency or bankruptcy of a
24    managed health care entity occurring after that  date.    The
25    Illinois Department is not obligated, however, to pay amounts
26    owed  to  a provider that has an ownership or other governing
27    interest in the managed health care entity.  This  subsection
28    applies only to managed health care entities and the services
29    they  provide  under the integrated health care program under
30    this Section.
31        (o)  Notwithstanding  any  other  provision  of  law   or
32    contractual agreement to the contrary, providers shall not be
33    required to accept from any other third party payer the rates
34    determined   or   paid   under  this  Code  by  the  Illinois
 
                            -19-               LRB9101284SMdv
 1    Department, managed health care entity, or other health  care
 2    delivery system for services provided to recipients.
 3        (p)  The  Illinois  Department  may  seek  and obtain any
 4    necessary  authorization  provided  under  federal   law   to
 5    implement  the  program,  including the waiver of any federal
 6    statutes or regulations. The Illinois Department may  seek  a
 7    waiver   of   the   federal  requirement  that  the  combined
 8    membership of Medicare and Medicaid enrollees  in  a  managed
 9    care community network may not exceed 75% of the managed care
10    community   network's   total   enrollment.    The   Illinois
11    Department  shall  not  seek a waiver of this requirement for
12    any other  category  of  managed  health  care  entity.   The
13    Illinois  Department shall not seek a waiver of the inpatient
14    hospital reimbursement methodology in Section  1902(a)(13)(A)
15    of  Title  XIX of the Social Security Act even if the federal
16    agency responsible for  administering  Title  XIX  determines
17    that  Section  1902(a)(13)(A)  applies to managed health care
18    systems.
19        Notwithstanding any other provisions of this Code to  the
20    contrary,  the  Illinois  Department  shall  seek a waiver of
21    applicable federal law in order to impose a co-payment system
22    consistent with this  subsection  on  recipients  of  medical
23    services  under  Title XIX of the Social Security Act who are
24    not enrolled in a managed health  care  entity.   The  waiver
25    request  submitted  by  the Illinois Department shall provide
26    for co-payments of up to $0.50 for prescribed drugs and up to
27    $0.50 for x-ray services and shall provide for co-payments of
28    up to $10 for non-emergency services provided in  a  hospital
29    emergency  room  and  up  to  $10 for non-emergency ambulance
30    services.  The purpose of the co-payments shall be  to  deter
31    those  recipients  from  seeking  unnecessary  medical  care.
32    Co-payments  may not be used to deter recipients from seeking
33    necessary medical care.  No recipient shall  be  required  to
34    pay  more  than a total of $150 per year in co-payments under
 
                            -20-               LRB9101284SMdv
 1    the waiver request required by this subsection.  A  recipient
 2    may  not  be  required to pay more than $15 of any amount due
 3    under this subsection in any one month.
 4        Co-payments authorized under this subsection may  not  be
 5    imposed  when  the  care  was  necessitated by a true medical
 6    emergency.  Co-payments may not be imposed  for  any  of  the
 7    following classifications of services:
 8             (1)  Services  furnished to person under 18 years of
 9        age.
10             (2)  Services furnished to pregnant women.
11             (3)  Services furnished to any individual who is  an
12        inpatient  in  a hospital, nursing facility, intermediate
13        care facility, or  other  medical  institution,  if  that
14        person is required to spend for costs of medical care all
15        but  a  minimal  amount of his or her income required for
16        personal needs.
17             (4)  Services furnished to a person who is receiving
18        hospice care.
19        Co-payments authorized under this subsection shall not be
20    deducted from or reduce  in  any  way  payments  for  medical
21    services  from  the  Illinois  Department  to  providers.  No
22    provider may deny those services to  an  individual  eligible
23    for  services  based on the individual's inability to pay the
24    co-payment.
25        Recipients  who  are  subject  to  co-payments  shall  be
26    provided notice, in plain and clear language, of  the  amount
27    of the co-payments, the circumstances under which co-payments
28    are  exempted,  the circumstances under which co-payments may
29    be assessed, and their manner of collection.
30        The  Illinois  Department  shall  establish  a   Medicaid
31    Co-Payment Council to assist in the development of co-payment
32    policies  for  the  medical assistance program.  The Medicaid
33    Co-Payment Council shall also have jurisdiction to develop  a
34    program  to  provide financial or non-financial incentives to
 
                            -21-               LRB9101284SMdv
 1    Medicaid recipients in order to encourage recipients to  seek
 2    necessary  health  care.  The Council shall be chaired by the
 3    Director  of  the  Illinois  Department,  and  shall  have  6
 4    additional members.  Two of the 6 additional members shall be
 5    appointed by the Governor, and one each shall be appointed by
 6    the President of the  Senate,  the  Minority  Leader  of  the
 7    Senate,  the Speaker of the House of Representatives, and the
 8    Minority Leader of the House of Representatives.  The Council
 9    may be convened and make recommendations upon the appointment
10    of a majority of its members.  The Council shall be appointed
11    and convened no later than September 1, 1994 and shall report
12    its  recommendations  to  the  Director   of   the   Illinois
13    Department  and the General Assembly no later than October 1,
14    1994.  The chairperson of the Council  shall  be  allowed  to
15    vote  only  in  the  case  of  a tie vote among the appointed
16    members of the Council.
17        The Council shall be guided by the  following  principles
18    as  it considers recommendations to be developed to implement
19    any approved waivers that the Illinois Department  must  seek
20    pursuant to this subsection:
21             (1)  Co-payments  should not be used to deter access
22        to adequate medical care.
23             (2)  Co-payments should be used to reduce fraud.
24             (3)  Co-payment  policies  should  be  examined   in
25        consideration   of  other  states'  experience,  and  the
26        ability  of  successful  co-payment  plans   to   control
27        unnecessary  or  inappropriate  utilization  of  services
28        should be promoted.
29             (4)  All    participants,    both   recipients   and
30        providers,  in  the  medical  assistance   program   have
31        responsibilities to both the State and the program.
32             (5)  Co-payments are primarily a tool to educate the
33        participants  in  the  responsible  use  of  health  care
34        resources.
 
                            -22-               LRB9101284SMdv
 1             (6)  Co-payments  should  not  be  used  to penalize
 2        providers.
 3             (7)  A  successful  medical  program  requires   the
 4        elimination of improper utilization of medical resources.
 5        The  integrated  health care program, or any part of that
 6    program,  established  under  this   Section   may   not   be
 7    implemented  if matching federal funds under Title XIX of the
 8    Social Security Act are not available for  administering  the
 9    program.
10        The  Illinois  Department shall submit for publication in
11    the Illinois Register the name, address, and telephone number
12    of the individual to whom a request may  be  directed  for  a
13    copy  of  the request for a waiver of provisions of Title XIX
14    of the Social  Security  Act  that  the  Illinois  Department
15    intends to submit to the Health Care Financing Administration
16    in  order to implement this Section.  The Illinois Department
17    shall  mail  a  copy  of  that  request  for  waiver  to  all
18    requestors at least 16 days before filing  that  request  for
19    waiver with the Health Care Financing Administration.
20        (q)  After  the  effective  date  of  this  Section,  the
21    Illinois  Department  may  take  all planning and preparatory
22    action necessary to implement this  Section,  including,  but
23    not  limited  to,  seeking requests for proposals relating to
24    the  integrated  health  care  program  created  under   this
25    Section.
26        (r)  In  order  to  (i)  accelerate  and  facilitate  the
27    development  of  integrated  health care in contracting areas
28    outside counties with populations in excess of 3,000,000  and
29    counties  adjacent  to  those  counties and (ii) maintain and
30    sustain the high quality of education and residency  programs
31    coordinated  and  associated  with  local area hospitals, the
32    Illinois Department may develop and implement a demonstration
33    program for managed care community networks owned,  operated,
34    or  governed  by  State-funded medical schools.  The Illinois
 
                            -23-               LRB9101284SMdv
 1    Department shall prescribe by rule the  criteria,  standards,
 2    and procedures for effecting this demonstration program.
 3        (s)  (Blank).
 4        (t)  On  April 1, 1995 and every 6 months thereafter, the
 5    Illinois Department shall report to the Governor and  General
 6    Assembly  on  the  progress  of  the  integrated  health care
 7    program  in  enrolling  clients  into  managed  health   care
 8    entities.   The  report  shall indicate the capacities of the
 9    managed health care entities with which the State  contracts,
10    the  number of clients enrolled by each contractor, the areas
11    of the State in which managed care options do not exist,  and
12    the  progress  toward  meeting  the  enrollment  goals of the
13    integrated health care program.
14        (u)  The Illinois Department may implement  this  Section
15    through the use of emergency rules in accordance with Section
16    5-45  of  the  Illinois  Administrative  Procedure  Act.  For
17    purposes of that Act, the adoption of rules to implement this
18    Section is deemed an emergency and necessary for  the  public
19    interest, safety, and welfare.
20    (Source:  P.A.  89-21,  eff.  7-1-95;  89-507,  eff.  7-1-97;
21    89-673,  eff.  8-14-96;  90-14,  eff.  7-1-97;  90-254,  eff.
22    1-1-98;  90-538,  eff. 12-1-97; 90-655, eff. 7-30-98; 90-742,
23    eff. 8-13-98.)

24        Section 99.  Effective date.  This Act takes effect  upon
25    becoming law.

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