Public Act 099-0181

HB2812 Enrolled LRB099 10944 KTG 31288 b

AN ACT concerning public aid.

Be it enacted by the People of the State of Illinois,

represented in the General Assembly:

Section 5. The Illinois Public Aid Code is amended by

changing Section 5-30 as follows:

(305 ILCS 5/5-30)

Sec. 5-30. Care coordination.

(a) At least 50% of recipients eligible for comprehensive

medical benefits in all medical assistance programs or other

health benefit programs administered by the Department,

including the Children's Health Insurance Program Act and the

Covering ALL KIDS Health Insurance Act, shall be enrolled in a

care coordination program by no later than January 1, 2015. For

purposes of this Section, "coordinated care" or "care

coordination" means delivery systems where recipients will

receive their care from providers who participate under

contract in integrated delivery systems that are responsible

for providing or arranging the majority of care, including

primary care physician services, referrals from primary care

physicians, diagnostic and treatment services, behavioral

health services, in-patient and outpatient hospital services,

dental services, and rehabilitation and long-term care

services. The Department shall designate or contract for such

integrated delivery systems (i) to ensure enrollees have a

choice of systems and of primary care providers within such

systems; (ii) to ensure that enrollees receive quality care in

a culturally and linguistically appropriate manner; and (iii)

to ensure that coordinated care programs meet the diverse needs

of enrollees with developmental, mental health, physical, and

age-related disabilities.

(b) Payment for such coordinated care shall be based on

arrangements where the State pays for performance related to

health care outcomes, the use of evidence-based practices, the

use of primary care delivered through comprehensive medical

homes, the use of electronic medical records, and the

appropriate exchange of health information electronically made

either on a capitated basis in which a fixed monthly premium

per recipient is paid and full financial risk is assumed for

the delivery of services, or through other risk-based payment

arrangements.

(c) To qualify for compliance with this Section, the 50%

goal shall be achieved by enrolling medical assistance

enrollees from each medical assistance enrollment category,

including parents, children, seniors, and people with

disabilities to the extent that current State Medicaid payment

laws would not limit federal matching funds for recipients in

care coordination programs. In addition, services must be more

comprehensively defined and more risk shall be assumed than in

the Department's primary care case management program as of the

effective date of this amendatory Act of the 96th General

Assembly.

(d) The Department shall report to the General Assembly in

a separate part of its annual medical assistance program

report, beginning April, 2012 until April, 2016, on the

progress and implementation of the care coordination program

initiatives established by the provisions of this amendatory

Act of the 96th General Assembly. The Department shall include

in its April 2011 report a full analysis of federal laws or

regulations regarding upper payment limitations to providers

and the necessary revisions or adjustments in rate

methodologies and payments to providers under this Code that

would be necessary to implement coordinated care with full

financial risk by a party other than the Department.

(e) Integrated Care Program for individuals with chronic

mental health conditions.

(1) The Integrated Care Program shall encompass

services administered to recipients of medical assistance

under this Article to prevent exacerbations and

complications using cost-effective, evidence-based

practice guidelines and mental health management

strategies.

(2) The Department may utilize and expand upon existing

contractual arrangements with integrated care plans under

the Integrated Care Program for providing the coordinated

care provisions of this Section.

(3) Payment for such coordinated care shall be based on

arrangements where the State pays for performance related

to mental health outcomes on a capitated basis in which a

fixed monthly premium per recipient is paid and full

financial risk is assumed for the delivery of services, or

through other risk-based payment arrangements such as

provider-based care coordination.

(4) The Department shall examine whether chronic

mental health management programs and services for

recipients with specific chronic mental health conditions

do any or all of the following:

(A) Improve the patient's overall mental health in

a more expeditious and cost-effective manner.

(B) Lower costs in other aspects of the medical

assistance program, such as hospital admissions,

emergency room visits, or more frequent and

inappropriate psychotropic drug use.

(5) The Department shall work with the facilities and

any integrated care plan participating in the program to

identify and correct barriers to the successful

implementation of this subsection (e) prior to and during

the implementation to best facilitate the goals and

objectives of this subsection (e).

(f) A hospital that is located in a county of the State in

which the Department mandates some or all of the beneficiaries

of the Medical Assistance Program residing in the county to

enroll in a Care Coordination Program, as set forth in Section

5-30 of this Code, shall not be eligible for any non-claims

based payments not mandated by Article V-A of this Code for

which it would otherwise be qualified to receive, unless the

hospital is a Coordinated Care Participating Hospital no later

than 60 days after the effective date of this amendatory Act of

the 97th General Assembly or 60 days after the first mandatory

enrollment of a beneficiary in a Coordinated Care program. For

purposes of this subsection, "Coordinated Care Participating

Hospital" means a hospital that meets one of the following

criteria:

(1) The hospital has entered into a contract to provide

hospital services with one or more MCOs to enrollees of the

care coordination program.

(2) The hospital has not been offered a contract by a

care coordination plan that the Department has determined

to be a good faith offer and that pays at least as much as

the Department would pay, on a fee-for-service basis, not

including disproportionate share hospital adjustment

payments or any other supplemental adjustment or add-on

payment to the base fee-for-service rate, except to the

extent such adjustments or add-on payments are

incorporated into the development of the applicable MCO

capitated rates.

As used in this subsection (f), "MCO" means any entity

which contracts with the Department to provide services where

payment for medical services is made on a capitated basis.

(g) No later than August 1, 2013, the Department shall

issue a purchase of care solicitation for Accountable Care

Entities (ACE) to serve any children and parents or caretaker

relatives of children eligible for medical assistance under

this Article. An ACE may be a single corporate structure or a

network of providers organized through contractual

relationships with a single corporate entity. The solicitation

shall require that:

(1) An ACE operating in Cook County be capable of

serving at least 40,000 eligible individuals in that

county; an ACE operating in Lake, Kane, DuPage, or Will

Counties be capable of serving at least 20,000 eligible

individuals in those counties and an ACE operating in other

regions of the State be capable of serving at least 10,000

eligible individuals in the region in which it operates.

During initial periods of mandatory enrollment, the

Department shall require its enrollment services

contractor to use a default assignment algorithm that

ensures if possible an ACE reaches the minimum enrollment

levels set forth in this paragraph.

(2) An ACE must include at a minimum the following

types of providers: primary care, specialty care,

hospitals, and behavioral healthcare.

(3) An ACE shall have a governance structure that

includes the major components of the health care delivery

system, including one representative from each of the

groups listed in paragraph (2).

(4) An ACE must be an integrated delivery system,

including a network able to provide the full range of

services needed by Medicaid beneficiaries and system

capacity to securely pass clinical information across

participating entities and to aggregate and analyze that

data in order to coordinate care.

(5) An ACE must be capable of providing both care

coordination and complex case management, as necessary, to

beneficiaries. To be responsive to the solicitation, a

potential ACE must outline its care coordination and

complex case management model and plan to reduce the cost

of care.

(6) In the first 18 months of operation, unless the ACE

selects a shorter period, an ACE shall be paid care

coordination fees on a per member per month basis that are

projected to be cost neutral to the State during the term

of their payment and, subject to federal approval, be

eligible to share in additional savings generated by their

care coordination.

(7) In months 19 through 36 of operation, unless the

ACE selects a shorter period, an ACE shall be paid on a

pre-paid capitation basis for all medical assistance

covered services, under contract terms similar to Managed

Care Organizations (MCO), with the Department sharing the

risk through either stop-loss insurance for extremely high

cost individuals or corridors of shared risk based on the

overall cost of the total enrollment in the ACE. The ACE

shall be responsible for claims processing, encounter data

submission, utilization control, and quality assurance.

(8) In the fourth and subsequent years of operation, an

ACE shall convert to a Managed Care Community Network

(MCCN), as defined in this Article, or Health Maintenance

Organization pursuant to the Illinois Insurance Code,

accepting full-risk capitation payments.

The Department shall allow potential ACE entities 5 months

from the date of the posting of the solicitation to submit

proposals. After the solicitation is released, in addition to

the MCO rate development data available on the Department's

website, subject to federal and State confidentiality and

privacy laws and regulations, the Department shall provide 2

years of de-identified summary service data on the targeted

population, split between children and adults, showing the

historical type and volume of services received and the cost of

those services to those potential bidders that sign a data use

agreement. The Department may add up to 2 non-state government

employees with expertise in creating integrated delivery

systems to its review team for the purchase of care

solicitation described in this subsection. Any such

individuals must sign a no-conflict disclosure and

confidentiality agreement and agree to act in accordance with

all applicable State laws.

During the first 2 years of an ACE's operation, the

Department shall provide claims data to the ACE on its

enrollees on a periodic basis no less frequently than monthly.

Nothing in this subsection shall be construed to limit the

Department's mandate to enroll 50% of its beneficiaries into

care coordination systems by January 1, 2015, using all

available care coordination delivery systems, including Care

Coordination Entities (CCE), MCCNs, or MCOs, nor be construed

to affect the current CCEs, MCCNs, and MCOs selected to serve

seniors and persons with disabilities prior to that date.

Nothing in this subsection precludes the Department from

considering future proposals for new ACEs or expansion of

existing ACEs at the discretion of the Department.

(h) Department contracts with MCOs and other entities

reimbursed by risk based capitation shall have a minimum

medical loss ratio of 85%, shall require the entity to

establish an appeals and grievances process for consumers and

providers, and shall require the entity to provide a quality

assurance and utilization review program. Entities contracted

with the Department to coordinate healthcare regardless of risk

shall be measured utilizing the same quality metrics. The

quality metrics may be population specific. Any contracted

entity serving at least 5,000 seniors or people with

disabilities or 15,000 individuals in other populations

covered by the Medical Assistance Program that has been

receiving full-risk capitation for a year shall be accredited

by a national accreditation organization authorized by the

Department within 2 years after the date it is eligible to

become accredited. The requirements of this subsection shall

apply to contracts with MCOs entered into or renewed or

extended after June 1, 2013.

(h-5) The Department shall monitor and enforce compliance

by MCOs with agreements they have entered into with providers

on issues that include, but are not limited to, timeliness of

payment, payment rates, and processes for obtaining prior

approval. The Department may impose sanctions on MCOs for

violating provisions of those agreements that include, but are

not limited to, financial penalties, suspension of enrollment

of new enrollees, and termination of the MCO's contract with

the Department. As used in this subsection (h-5), "MCO" has the

meaning ascribed to that term in Section 5-30.1 of this Code.

(i) Unless otherwise required by federal law, Medicaid

Managed Care Entities shall not divulge, directly or

indirectly, including by sending a bill or explanation of

benefits, information concerning the sensitive health services

received by enrollees of the Medicaid Managed Care Entity to

any person other than providers and care coordinators caring

for the enrollee and employees of the entity in the course of

the entity's internal operations. The Medicaid Managed Care

Entity may divulge information concerning the sensitive health

services if the enrollee who received the sensitive health

services requests the information from the Medicaid Managed

Care Entity and authorized the sending of a bill or explanation

of benefits. Communications including, but not limited to,

statements of care received or appointment reminders either

directly or indirectly to the enrollee from the health care

provider, health care professional, and care coordinators,

remain permissible.

For the purposes of this subsection, the term "Medicaid

Managed Care Entity" includes Care Coordination Entities,

Accountable Care Entities, Managed Care Organizations, and

Managed Care Community Networks.

For purposes of this subsection, the term "sensitive health

services" means mental health services, substance abuse

treatment services, reproductive health services, family

planning services, services for sexually transmitted

infections and sexually transmitted diseases, and services for

sexual assault or domestic abuse. Services include prevention,

screening, consultation, examination, treatment, or follow-up.

Nothing in this subsection shall be construed to relieve a

Medicaid Managed Care Entity or the Department of any duty to

report incidents of sexually transmitted infections to the

Department of Public Health or to the local board of health in

accordance with regulations adopted under a statute or

ordinance or to report incidents of sexually transmitted

infections as necessary to comply with the requirements under

Section 5 of the Abused and Neglected Child Reporting Act or as

otherwise required by State or federal law.

The Department shall create policy in order to implement

the requirements in this subsection.

(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13;

98-651, eff. 6-16-14.)

Section 99. Effective date. This Act takes effect upon

becoming law.