99TH GENERAL ASSEMBLY State of Illinois 2015 and 2016 HB3306

Introduced , by Rep. Jim Durkin - Patricia R. Bellock

SYNOPSIS AS INTRODUCED:

305 ILCS 5/5-30

Amends the Medical Assistance Article of the Illinois Public Aid Code. In a provision requiring the Department of Healthcare and Family Services to report to the General Assembly on the progress and implementation of the care coordination program initiatives established under the Code, provides that the Department shall submit such information beginning April, 2012 (rather than beginning April, 2012 until April, 2016). Provides that the progress reports shall include, but need not be limited to, certain data and information, including: (i) the total number of individuals covered under the medical assistance program; (ii) the total number of individuals enrolled in coordinated care; (iii) a breakdown of the individuals enrolled in coordinated care by medical assistance enrollment category; and (iv) a breakdown of the number of individuals enrolled in coordinated care by the type of coordinated care model.

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FISCAL NOTE ACT MAY APPLY

A BILL FOR

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1 AN ACT concerning public aid.

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

3 represented in the General Assembly:

4 Section 5. The Illinois Public Aid Code is amended by

5 changing Section 5-30 as follows:

6 (305 ILCS 5/5-30)

7 Sec. 5-30. Care coordination.

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

9 medical benefits in all medical assistance programs or other

10 health benefit programs administered by the Department,

11 including the Children's Health Insurance Program Act and the

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

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

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

15 coordination" means delivery systems where recipients will

16 receive their care from providers who participate under

17 contract in integrated delivery systems that are responsible

18 for providing or arranging the majority of care, including

19 primary care physician services, referrals from primary care

20 physicians, diagnostic and treatment services, behavioral

21 health services, in-patient and outpatient hospital services,

22 dental services, and rehabilitation and long-term care

23 services. The Department shall designate or contract for such

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1 integrated delivery systems (i) to ensure enrollees have a

2 choice of systems and of primary care providers within such

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

4 a culturally and linguistically appropriate manner; and (iii)

5 to ensure that coordinated care programs meet the diverse needs

6 of enrollees with developmental, mental health, physical, and

7 age-related disabilities.

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

9 arrangements where the State pays for performance related to

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

11 use of primary care delivered through comprehensive medical

12 homes, the use of electronic medical records, and the

13 appropriate exchange of health information electronically made

14 either on a capitated basis in which a fixed monthly premium

15 per recipient is paid and full financial risk is assumed for

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

17 arrangements.

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

19 goal shall be achieved by enrolling medical assistance

20 enrollees from each medical assistance enrollment category,

21 including parents, children, seniors, and people with

22 disabilities to the extent that current State Medicaid payment

23 laws would not limit federal matching funds for recipients in

24 care coordination programs. In addition, services must be more

25 comprehensively defined and more risk shall be assumed than in

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

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1 effective date of this amendatory Act of the 96th General

2 Assembly.

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

4 a separate part of its annual medical assistance program

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

6 progress and implementation of the care coordination program

7 initiatives established by the provisions of this amendatory

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

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

10 regulations regarding upper payment limitations to providers

11 and the necessary revisions or adjustments in rate

12 methodologies and payments to providers under this Code that

13 would be necessary to implement coordinated care with full

14 financial risk by a party other than the Department.

15 The progress reports required under this subsection shall

16 include, but need not be limited to, the following data and

17 information:

18 (1) The total number of individuals covered under the

19 medical assistance program.

20 (2) The total number of individuals enrolled in

21 coordinated care.

22 (3) A breakdown of the individuals enrolled in

23 coordinated care by medical assistance enrollment

24 category, including parents, adults eligible for medical

25 assistance pursuant to the Patient Protection and

26 Affordable Care Act, children, seniors, and people with

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1 disabilities.

2 (4) A breakdown of the number of individuals enrolled

3 in coordinated care by the type of coordinated care model,

4 including individuals enrolled in Care Coordination

5 Entities (CCEs), Managed Care Community Networks (MCCNs),

6 Managed Care Organizations (MCOs), and Accountable Care

7 Entities (ACEs).

8 (5) The number of individuals enrolled in coordinated

9 care who are enrolled under an entity that is paid through

10 a fully capitated payment arrangement.

11 (6) Information showing migratory behavior between

12 different coordinated care delivery systems and also

13 between the fee-for-service system and the coordinated

14 care delivery systems, including the extent to which

15 individuals auto-enrolled into a coordinated care delivery

16 system opt out of coverage through the assigned entity.

17 (e) Integrated Care Program for individuals with chronic

18 mental health conditions.

19 (1) The Integrated Care Program shall encompass

20 services administered to recipients of medical assistance

21 under this Article to prevent exacerbations and

22 complications using cost-effective, evidence-based

23 practice guidelines and mental health management

24 strategies.

25 (2) The Department may utilize and expand upon existing

26 contractual arrangements with integrated care plans under

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1 the Integrated Care Program for providing the coordinated

2 care provisions of this Section.

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

4 arrangements where the State pays for performance related

5 to mental health outcomes on a capitated basis in which a

6 fixed monthly premium per recipient is paid and full

7 financial risk is assumed for the delivery of services, or

8 through other risk-based payment arrangements such as

9 provider-based care coordination.

10 (4) The Department shall examine whether chronic

11 mental health management programs and services for

12 recipients with specific chronic mental health conditions

13 do any or all of the following:

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

15 a more expeditious and cost-effective manner.

16 (B) Lower costs in other aspects of the medical

17 assistance program, such as hospital admissions,

18 emergency room visits, or more frequent and

19 inappropriate psychotropic drug use.

20 (5) The Department shall work with the facilities and

21 any integrated care plan participating in the program to

22 identify and correct barriers to the successful

23 implementation of this subsection (e) prior to and during

24 the implementation to best facilitate the goals and

25 objectives of this subsection (e).

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

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1 which the Department mandates some or all of the beneficiaries

2 of the Medical Assistance Program residing in the county to

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

4 5-30 of this Code, shall not be eligible for any non-claims

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

6 which it would otherwise be qualified to receive, unless the

7 hospital is a Coordinated Care Participating Hospital no later

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

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

10 enrollment of a beneficiary in a Coordinated Care program. For

11 purposes of this subsection, "Coordinated Care Participating

12 Hospital" means a hospital that meets one of the following

13 criteria:

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

15 hospital services with one or more MCOs to enrollees of the

16 care coordination program.

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

18 care coordination plan that the Department has determined

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

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

21 including disproportionate share hospital adjustment

22 payments or any other supplemental adjustment or add-on

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

24 extent such adjustments or add-on payments are

25 incorporated into the development of the applicable MCO

26 capitated rates.

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

2 which contracts with the Department to provide services where

3 payment for medical services is made on a capitated basis.

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

5 issue a purchase of care solicitation for Accountable Care

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

7 relatives of children eligible for medical assistance under

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

9 network of providers organized through contractual

10 relationships with a single corporate entity. The solicitation

11 shall require that:

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

13 serving at least 40,000 eligible individuals in that

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

15 Counties be capable of serving at least 20,000 eligible

16 individuals in those counties and an ACE operating in other

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

18 eligible individuals in the region in which it operates.

19 During initial periods of mandatory enrollment, the

20 Department shall require its enrollment services

21 contractor to use a default assignment algorithm that

22 ensures if possible an ACE reaches the minimum enrollment

23 levels set forth in this paragraph.

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

25 types of providers: primary care, specialty care,

26 hospitals, and behavioral healthcare.

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1 (3) An ACE shall have a governance structure that

2 includes the major components of the health care delivery

3 system, including one representative from each of the

4 groups listed in paragraph (2).

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

6 including a network able to provide the full range of

7 services needed by Medicaid beneficiaries and system

8 capacity to securely pass clinical information across

9 participating entities and to aggregate and analyze that

10 data in order to coordinate care.

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

12 coordination and complex case management, as necessary, to

13 beneficiaries. To be responsive to the solicitation, a

14 potential ACE must outline its care coordination and

15 complex case management model and plan to reduce the cost

16 of care.

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

18 selects a shorter period, an ACE shall be paid care

19 coordination fees on a per member per month basis that are

20 projected to be cost neutral to the State during the term

21 of their payment and, subject to federal approval, be

22 eligible to share in additional savings generated by their

23 care coordination.

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

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

26 pre-paid capitation basis for all medical assistance

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1 covered services, under contract terms similar to Managed

2 Care Organizations (MCO), with the Department sharing the

3 risk through either stop-loss insurance for extremely high

4 cost individuals or corridors of shared risk based on the

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

6 shall be responsible for claims processing, encounter data

7 submission, utilization control, and quality assurance.

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

9 ACE shall convert to a Managed Care Community Network

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

11 Organization pursuant to the Illinois Insurance Code,

12 accepting full-risk capitation payments.

13 The Department shall allow potential ACE entities 5 months

14 from the date of the posting of the solicitation to submit

15 proposals. After the solicitation is released, in addition to

16 the MCO rate development data available on the Department's

17 website, subject to federal and State confidentiality and

18 privacy laws and regulations, the Department shall provide 2

19 years of de-identified summary service data on the targeted

20 population, split between children and adults, showing the

21 historical type and volume of services received and the cost of

22 those services to those potential bidders that sign a data use

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

24 employees with expertise in creating integrated delivery

25 systems to its review team for the purchase of care

26 solicitation described in this subsection. Any such

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1 individuals must sign a no-conflict disclosure and

2 confidentiality agreement and agree to act in accordance with

3 all applicable State laws.

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

5 Department shall provide claims data to the ACE on its

6 enrollees on a periodic basis no less frequently than monthly.

7 Nothing in this subsection shall be construed to limit the

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

9 care coordination systems by January 1, 2015, using all

10 available care coordination delivery systems, including Care

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

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

13 seniors and persons with disabilities prior to that date.

14 Nothing in this subsection precludes the Department from

15 considering future proposals for new ACEs or expansion of

16 existing ACEs at the discretion of the Department.

17 (h) Department contracts with MCOs and other entities

18 reimbursed by risk based capitation shall have a minimum

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

20 establish an appeals and grievances process for consumers and

21 providers, and shall require the entity to provide a quality

22 assurance and utilization review program. Entities contracted

23 with the Department to coordinate healthcare regardless of risk

24 shall be measured utilizing the same quality metrics. The

25 quality metrics may be population specific. Any contracted

26 entity serving at least 5,000 seniors or people with

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1 disabilities or 15,000 individuals in other populations

2 covered by the Medical Assistance Program that has been

3 receiving full-risk capitation for a year shall be accredited

4 by a national accreditation organization authorized by the

5 Department within 2 years after the date it is eligible to

6 become accredited. The requirements of this subsection shall

7 apply to contracts with MCOs entered into or renewed or

8 extended after June 1, 2013.

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

10 by MCOs with agreements they have entered into with providers

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

12 payment, payment rates, and processes for obtaining prior

13 approval. The Department may impose sanctions on MCOs for

14 violating provisions of those agreements that include, but are

15 not limited to, financial penalties, suspension of enrollment

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

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

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

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

20 98-651, eff. 6-16-14.)