98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
HB3189

 

Introduced , by Rep. Patricia R. Bellock

 

SYNOPSIS AS INTRODUCED:
 
New Act

    Creates the Patient-Centered Medicaid Reform Act. Provides that the Medicaid Managed Care Program is established as a statewide, integrated managed care program for all covered services, including long-term care services. Requires the Department of Healthcare and Family Services to apply for and implement appropriate amendments to the Illinois Title XIX State Plan and waivers of applicable federal laws and regulations necessary to implement the program and that before submitting the waiver or State Plan amendment, the Department shall provide public notice and the opportunity for public comment and shall include public feedback to the U.S. Department of Health and Human Services. Provides that services provided under the Medicaid Managed Care Program shall be provided by managed care plans that are capable of coordinating or delivering all covered services to enrollees. Requires the Department to select managed care plans to participate in the Medicaid Managed Care Program using invitations to negotiate. Contains provisions concerning the quality factor the Department must consider when selecting manage care plans; plan accountability; managed care payments; enrollment, choice counseling, and opt-out standards; mandatory, exempt, and voluntary populations standards; services covered by the managed plans; the implementation of a Medicaid Long-Term Care Managed Care Program; eligibility criteria for the Medicaid Long-Term Care Managed Care Program; and other matters. Effective immediately.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB3189LRB098 08448 KTG 38555 b

1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 1. Short title. This Act may be cited as the
5Patient-Centered Medicaid Reform Act.
 
6    Section 5. Definitions. As used in this Act:
7    (a) "Department" means the Department of Healthcare and
8Family Services or any State department which may administer in
9the future the Medicaid Managed Care Program established under
10this Act.
11    (b) "Managed care plan" means a health insurer, a specialty
12plan, a health maintenance organization authorized under the
13Illinois Insurance Code, or a Medicaid-authorized provider
14service network under contract with the Department to provide
15services to clients eligible for medical assistance under the
16State's Medical Assistance Program established under Article V
17of the Illinois Public Aid Code.
18    (c) "Medicaid" means the medical assistance program
19authorized by Title XIX of the Social Security Act, and
20regulations thereunder, as administered in this State by the
21Department of Healthcare and Family Services.
22    (d) "Medicaid recipient" or "recipient" means an
23individual who receives medical assistance as provided under

 

 

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1Article V of the Illinois Public Aid Code.
2    (e) "Prepaid plan" means a managed care plan that is
3licensed or certified as a risk-bearing entity or is an
4approved provider service network, and is paid a prospective
5per-member, per-month payment by the Department.
6    (f) "Provider service network" means a Department-approved
7entity, a controlling interest of which is owned by a health
8care provider, or by a group of affiliated providers, or by a
9public agency or entity that delivers health services. Health
10care providers include State-licensed health care
11professionals or licensed health care facilities, federally
12qualified health care centers, and home health care agencies.
13    (g) "Specialty plan" means a managed care plan that serves
14Medicaid recipients who meet specified criteria based on age,
15medical condition, or diagnosis.
16    (h) "Comprehensive long-term care plan" means a managed
17care plan, provider-sponsored organization, health maintenance
18organization, or coordinated care plan that provides long-term
19care services as outlined in this Act.
20    (i) "Long-term care plan" means a managed care plan that
21provides the services described in Section 60 of this Act for
22the Medicaid Long-Term Care Managed Care Program established
23under this Act.
24    (j) "Long-term care provider service network" means a
25provider service network, a controlling interest of which is
26owned by one or more licensed nursing homes, assisted living

 

 

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1facilities with 17 or more beds, home health agencies,
2community care for the elderly lead agencies, or hospices.
 
3    Section 10. Authorization for Medicaid waiver or amendment
4to the Medicaid State Plan. The Medicaid Managed Care Program
5is established as a statewide, integrated managed care program
6for all covered services, including long-term care services.
7The Department shall apply for and implement appropriate
8amendments to the Illinois Title XIX State Plan and waivers of
9applicable federal laws and regulations necessary to implement
10the program. Before submitting the waiver or State Plan
11amendment, the Department shall provide public notice and the
12opportunity for public comment and shall include public
13feedback to the U.S. Department of Health and Human Services.
 
14    Section 15. Criteria for managed care plans.
15    (a) Services provided under the Medicaid Managed Care
16Program shall be provided by managed care plans that are
17capable of coordinating or delivering all covered services to
18enrollees.
19    (b) The Department shall select managed care plans to
20participate in the Medicaid Managed Care Program using
21invitations to negotiate. The procurement method must give the
22State the most flexibility and broadest power to negotiate
23value and must provide potential bidders the most room to
24innovate. Separate and simultaneous procurements shall be

 

 

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1conducted in regions to be determined by the Department.
2    (c) The Department shall consider quality factors in the
3selection of managed care plans, including all of the
4following:
5        (1) Accreditation by a nationally recognized
6    accrediting body.
7        (2) Documentation of policies and procedures for
8    preventing fraud and abuse.
9        (3) Experience serving and achieving quality standards
10    for similar populations.
11        (4) The availability or accessibility of primary and
12    specialty care physicians in the network.
13        (5) The provision of additional benefits, particularly
14    dental care and disease management, and other initiatives
15    that improve health outcomes.
16    (d) After negotiations are conducted, the Department shall
17select the managed care plans that are determined to be
18responsive and provide the best value to the State. Preference
19shall be given to plans that have signed contracts with primary
20and specialty physicians in sufficient numbers to meet the
21specific standards established pursuant to this Act.
22    (e) To ensure managed care plan participation in all
23regions, the Department shall award an additional contract in a
24more populous region to each plan with a contract award in a
25more rural region. If a plan terminates its contract in a more
26rural region, the additional contract in the more populous

 

 

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1region shall be automatically terminated within 180 days. The
2plan must also reimburse the Department for the cost of
3enrollment changes and other transition activities.
4    (f) The Department may not execute contracts with managed
5care plans at payment rates not supported by appropriations
6made to the Department for these purposes.
 
7    Section 20. Selection of managed care plans.
8    (a) The Department shall select managed care plans through
9the procurement process described in this Act. The Department
10shall notice invitations to negotiate no later than June 30,
112014. The Department shall procure at least 3 plans and no more
12than 11 plans for each region. At least one plan in each region
13must be a provider service network.
14    (b) Participation by specialty plans shall be subject to
15the procurement requirements in this Act. The enrollment of a
16specialty plan in a region may not exceed 10% of the total
17number of enrollees of that region. However, a specialty plan
18whose target population includes no more than 10% of the
19enrollees of that region shall not be subject to the regional
20plan number limits under this Section.
21    (c) Participation by a Medicare Advantage Preferred
22Provider Organization, a Medicare Advantage Provider-Sponsored
23Organization, a Medicare Advantage Health Maintenance
24Organization, a Medicare Advantage Coordinated Care Plan, or a
25Medicare Advantage Special Needs Plan shall not be subject to

 

 

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1the procurement requirements under this Section if the plan's
2Medicaid enrollees consist exclusively of dually eligible
3recipients who are enrolled in the plan in order to receive
4Medicare benefits.
 
5    Section 25. Plan accountability.
6    (a) The Department shall establish a 5-year contract with
7each managed care plan selected through the procurement process
8described in this Act. A plan contract may not be renewed.
9However, the Department may extend the term of a plan contract
10to cover any delays during the transition to a new plan.
11    (b) The Department shall establish such contract
12requirements as are necessary for the operation of the
13statewide Medicaid Managed Care Program. In addition to any
14other provisions the Department may deem necessary, the
15contract must require all of the following:
16        (1) Physician compensation: Managed care plans are
17    expected to coordinate care, manage chronic disease, and
18    prevent the need for more costly services. Effective care
19    management should enable plans to redirect available
20    resources and increase compensation for physicians.
21        (2) Hospital compensation: Managed care plans and
22    hospitals shall negotiate mutually acceptable rates,
23    methods, and terms of payment. Payment rates may be updated
24    periodically.
25        (3) Access:

 

 

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1            (A) The Department shall establish specific,
2        population-based standards for the number, type, and
3        regional distribution of providers in managed care
4        plan networks to ensure access to care for both adults
5        and children. Consistent with standards established by
6        the Department, provider networks may include
7        providers located outside the region. Plans may limit
8        the providers in their networks based on credentials,
9        quality indicators, and price.
10            (B) Each plan shall establish and maintain an
11        accurate and complete electronic database of
12        contracted providers, including information about
13        licensure or registration, locations and hours of
14        operation, or specialty credentials and other
15        certifications. The database must be available online
16        to both the Department and the public and have the
17        capability to compare the availability of providers to
18        network adequacy standards and to accept and display
19        feedback from each provider's patients.
20            (C) Each managed care plan must publish any
21        prescribed drug formulary or preferred drug list on the
22        plan's website in a manner that is accessible to and
23        searchable by enrollees and providers. The plan must
24        update the list within 24 hours after making a change.
25        Each plan must ensure that the prior authorization
26        process for prescribed drugs is readily accessible to

 

 

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1        health care providers, including posting appropriate
2        contact information on its website and providing
3        timely responses to providers.
4        (4) Encounter data: The Department shall maintain and
5    operate a Medicaid encounter data system to collect,
6    process, store, and report on covered services provided to
7    all Medicaid recipients enrolled in prepaid plans. The
8    Department shall make encounter data available to those
9    plans accepting enrollees who are assigned to them from
10    other plans leaving a region.
11        (5) Continuous improvement: The Department shall
12    establish specific performance standards and expected
13    milestones or timelines for improving performance over the
14    term of the contract.
15            (A) Each managed care plan shall establish an
16        internal health care quality improvement system,
17        including enrollee satisfaction and disenrollment
18        surveys. The quality improvement system must include
19        incentives and disincentives for network providers.
20            (B) Each plan must collect and report Health Plan
21        Employer Data and Information Set (HEDIS) measures, as
22        specified by the Department. These measures must be
23        published on the plan's website in a manner that allows
24        recipients to reliably compare the performance of
25        plans. The Department shall use the HEDIS measures as a
26        tool to monitor plan performance.

 

 

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1            (C) Each managed care plan must be accredited by
2        the National Committee for Quality Assurance, the
3        Joint Commission, or another nationally recognized
4        accrediting body, or have initiated the accreditation
5        process, within one year after the contract is
6        executed.
7        (6) Program integrity: Each managed care plan shall
8    establish program integrity functions and activities to
9    reduce the incidence of fraud and abuse, including, at a
10    minimum, all of the following:
11            (A) A provider credentialing system and ongoing
12        provider monitoring.
13            (B) Procedures for reporting instances of fraud
14        and abuse.
15            (C) Designation of a program integrity compliance
16        officer.
17        (7) Grievance resolution: Consistent with federal law,
18    each managed care plan shall establish and the Department
19    shall approve an internal process for reviewing and
20    responding to grievances from enrollees. Each plan shall
21    submit quarterly reports on the number, description, and
22    outcome of grievances filed by enrollees.
23        (8) Penalties: Managed care plans shall incur
24    penalties for withdrawal and enrollment reductions;
25    failure to comply with encounter data reporting
26    requirements; or termination of a regional contract due to

 

 

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1    noncompliance.
2        (9) Prompt payment: Managed care plans shall comply
3    with the prompt payment requirements of the Illinois
4    Insurance Code.
5        (10) Electronic claims: Managed care plans, and their
6    fiscal agents or intermediaries, shall accept electronic
7    claims in compliance with federal standards.
8        (11) Itemized payment: Any claims payment to a provider
9    by a managed care plan or by a fiscal agent or intermediary
10    of the plan must be accompanied by an itemized accounting
11    of the individual claims included in the payment,
12    including, but not limited to, the enrollee's name, the
13    date of service, the procedure code, the amount of
14    reimbursement, and the identification of the plan on whose
15    behalf the payment is made.
16    (c) The Department shall be responsible for verifying the
17achieved savings rebate for all Medicaid prepaid plans. The
18achieved savings rebate shall be established by determining
19pretax income as a percentage of revenues and applying the
20following income-sharing ratios:
21        (1) 100% of income, up to and including 5% of revenue,
22    shall be retained by the plan.
23        (2) 50% of income above 5% and up to and including 10%
24    of revenue shall be retained by the plan, and the other 50%
25    refunded to the State.
26        (3) 100% of income above 10% of revenue shall be

 

 

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1    refunded to the State.
2    (d) Each managed care plan must accept any medically needy
3recipient eligible for medical assistance under paragraph 2 of
4Section 5-2 of the Illinois Public Aid Code who selects or is
5assigned to the plan and must provide that medically needy
6recipient with continuous enrollment for 12 months. After the
7first month of qualifying as a medically needy recipient and
8enrolling in a plan, and contingent upon federal approval, the
9medically needy recipient shall pay the plan a portion of the
10monthly premium equal to the medically needy recipient's share
11of the cost as determined by the Department. The Department
12shall pay any remaining portion of the monthly premium. A plan
13is not obligated to pay claims for medically needy recipients
14for services provided before enrollment in the plan. Medically
15needy recipients are responsible for payment of incurred claims
16that are used to determine eligibility. A plan must provide a
17grace period of at least 90 days before disenrolling medically
18needy recipients who fail to pay their shares of the premium.
 
19    Section 30. Managed care payments.
20    (a) Prepaid plans shall receive per-member, per-month
21payments negotiated pursuant to the procurements described in
22this Act. Payments shall be risk-adjusted rates based on
23historical utilization and spending data, and shall be
24projected forward and adjusted to reflect the eligibility
25category, geographic area, and clinical risk profile of the

 

 

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1recipients. In negotiating rates with the plans, the Department
2shall consider any adjustments necessary to encourage plans to
3use the most cost-effective modalities for treatment of chronic
4disease.
5    (b) Provider service networks may be prepaid plans and
6receive per-member, per-month payments. The fee-for-service
7option shall be available to a provider service network only
8for the first 2 years of its operation.
9    (c) The Department may not approve any plan request for a
10rate increase unless sufficient funds to support the increase
11have been authorized by appropriations made to the Department
12for the purposes of this Act.
 
13    Section 35. Enrollment, choice counseling, and opt-out.
14    (a) All Medicaid recipients shall be enrolled in a managed
15care plan unless specifically exempted under this Act. Each
16recipient shall have a choice of plans and may select any
17available plan unless that plan is restricted by contract to a
18specific population that does not include the recipient.
19Recipients shall have 30 days in which to make a choice of
20plans.
21    (b) The Department shall implement a choice counseling
22system to ensure that recipients have timely access to accurate
23information on the available plans. The counseling system shall
24include plan-to-plan comparative information on benefits,
25provider networks, drug formularies, quality measures, and

 

 

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1other data points as determined by the Department. Choice
2counseling must be made available through face-to-face
3interaction, through the Internet, by telephone, in writing,
4and through other forms of relevant media. Materials must be
5provided in a culturally relevant manner, consistent with
6federal requirements. The Department shall contract for any or
7all choice counseling functions.
8    (c) After a recipient has enrolled in a managed care plan,
9the recipient shall have 90 days to voluntarily disenroll and
10select another plan. After 90 days, no further changes may be
11made except for good cause.
12    (d) The Department shall automatically enroll into a
13managed care plan those Medicaid recipients who do not
14voluntarily choose a plan. Except as otherwise outlined in this
15Act, the Department may not engage in practices that are
16designed to favor one managed care plan over another.
17        (1) The Department shall automatically enroll
18    recipients in plans that meet or exceed the performance or
19    quality standards established in this Act, and may not
20    automatically enroll recipients in a plan that is deficient
21    in those performance or quality standards.
22        (2) If a specialty plan is available to accommodate a
23    specific condition or diagnosis of a recipient, the
24    Department shall assign the recipient to that plan.
25        (3) In the first year of the first contract term only,
26    if a recipient was previously enrolled in a plan that is

 

 

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1    still available in the region, the Department shall
2    automatically enroll the recipient in that plan unless an
3    applicable specialty plan is available.
4        (4) A newborn of a mother enrolled in a plan at the
5    time of the child's birth shall be enrolled in the mother's
6    plan. Upon birth, such a newborn is deemed enrolled in the
7    managed care plan, regardless of the administrative
8    enrollment procedures, and the managed care plan is
9    responsible for providing services to the newborn. The
10    mother may choose another plan for the newborn within 90
11    days after the child's birth.
12        (5) Otherwise, the Department shall automatically
13    enroll recipients based on the following criteria:
14            (A) Whether the plan has sufficient network
15        capacity to meet the needs of the recipient.
16            (B) Whether the recipient has previously received
17        services from one of the plan's primary care providers.
18            (C) Whether primary care providers in one plan are
19        more geographically accessible to the recipient's
20        residence than those in other plans.
21    (e) A recipient with access to private health care coverage
22shall opt out of all managed care plans and use Medicaid
23financial assistance to pay for his or her share of the cost in
24such coverage. The amount of financial assistance provided for
25each recipient may not exceed the amount of the Medicaid
26premium that would have been paid to a managed care plan for

 

 

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1that recipient. The Department shall seek federal approval to
2require Medicaid recipients with access to employer-sponsored
3health care coverage to enroll in that coverage and use
4Medicaid financial assistance to pay for the recipient's share
5of the cost for such coverage. The amount of financial
6assistance provided for each recipient may not exceed the
7amount of the Medicaid premium that would have been paid to a
8managed care plan for that recipient.
 
9    Section 40. Mandatory, exempt, and voluntary populations.
10    (a) All Medicaid recipients shall receive covered services
11through the Medicaid Managed Care Program. The following
12Medicaid recipients are exempt from participation in the
13Medicaid Managed Care program:
14        (1) Recipients who are eligible for both Medicaid and
15    Medicare and who reside in a facility licensed under the
16    Nursing Home Care Act.
17        (2) Medicaid recipients residing in a facility
18    licensed under the ID/DD Community Care Act.
19        (3) Medicaid recipients enrolled in a home and
20    community-based waiver services program administered by
21    the Department of Healthcare and Family Services.
22        (4) SSI-eligible or other children with special needs.
23        (5) Children in foster care or subsidized adoption.
24        (6) Populations who receive only limited services,
25    including women eligible only for family planning services

 

 

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1    and women who are eligible only for breast and cervical
2    cancer services.
3    (b) The following persons eligible for Medicaid are exempt
4from mandatory managed care enrollment required by this Act,
5and may voluntarily choose to participate in the managed
6medical assistance program:
7        (1) Recipients who are eligible for both Medicaid and
8    Medicare.
9        (2) Medicaid recipients residing in residential
10    commitment facilities operated by the Department of
11    Juvenile Justice or residing in State-owned or
12    State-operated residential mental health treatment
13    facilities.
14        (3) Persons eligible for refugee assistance.
15        (4) Medicaid recipients who are residents of a State
16    developmental disability center.
17        (5) Medicaid recipients enrolled in the State's Home
18    and Community-Based Services Waiver Program for persons
19    with disabilities.
20    (c) Medically needy recipients eligible for medical
21assistance under paragraph 2 of Section 5-2 of the Illinois
22Public Aid Code shall enroll in managed care plans. Such
23recipients shall meet their share of the cost by paying the
24plan premium, up to the share of the cost amount.
 
25    Section 45. Benefits.

 

 

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1    (a) Managed care plans shall cover, at a minimum, those
2mandatory and optional services provided under the State's
3medical assistance program pursuant to Article V of the
4Illinois Public Aid Code.
5    (b) Managed care plans may customize benefit packages for
6non-pregnant adults, vary cost-sharing provisions, and provide
7coverage for additional services. The Department shall
8evaluate the proposed benefit packages to ensure that services
9are sufficient to meet the needs of the plan's enrollees and to
10verify actuarial equivalence.
11    (c) Each plan operating in the Medicaid Managed Care
12Program shall establish a program to encourage and reward
13healthy behaviors. At a minimum, each plan must establish a
14medically approved smoking cessation program, a medically
15directed weight loss program, and a medically approved alcohol
16or substance abuse recovery program. Each plan must identify
17enrollees who smoke, who are morbidly obese, or who are
18diagnosed with alcohol or substance abuse in order to establish
19written agreements to secure the enrollees' commitment to
20participation in these programs.
 
21    Section 50. Medicaid Long-Term Care Managed Care Program.
22    (a) The Department shall make payments for long-term care
23home and community-based and residential services, and for
24primary and acute medical assistance and related services for
25recipients eligible for long-term care, using a managed care

 

 

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1model. By June 30, 2014, the Department shall begin
2implementation of the Medicaid Long-Term Care Managed Care
3Program, with full implementation in all regions by June 30,
42015.
5    (b) The Department on Aging shall: (i) assist the
6Department in developing specifications for the invitation to
7negotiate and the model contract; (ii) determine clinical
8eligibility for enrollment in managed long-term care plans;
9(iii) monitor plan performance and measure quality of service
10delivery; (iv) assist clients and families to address
11complaints with the plans; (v) facilitate working
12relationships between plans and providers serving elders and
13disabled adults; and (vi) perform other functions specified in
14a memorandum of agreement.
 
15    Section 55. Eligibility criteria for the Medicaid
16Long-Term Care Managed Care Program.
17    (a) Medicaid recipients who meet all of the following
18criteria are eligible to receive long-term care services and
19must receive long-term care services by participating in the
20Medicaid Long-Term Care Managed Care Program. The recipient
21must be:
22        (1) 65 years of age or older, or age 18 or older and
23    eligible for Medicaid by reason of a disability; or
24        (2) determined to require nursing facility care.
25    (b) Medicaid recipients who, on the date long-term care

 

 

HB3189- 19 -LRB098 08448 KTG 38555 b

1managed care plans become available in their region, reside in
2a facility licensed under the Nursing Home Care Act or the
3ID/DD Community Care Act or who are enrolled in an existing
4State long-term care Medicaid waiver program are eligible to
5participate in the Medicaid Long-Term Care Managed Care Program
6for up to 12 months without being reevaluated for their need
7for nursing facility care.
8    (c) The Department shall make offers for enrollment to
9eligible individuals based on a wait-list prioritization and
10subject to the availability of funds. Before enrollment offers,
11the Department shall determine that sufficient funds exist to
12support additional enrollment into plans.
 
13    Section 60. Long-Term Care Plan Benefits. Long-term care
14managed care plans shall, at a minimum, cover those mandatory
15and optional services provided under the State's medical
16assistance program pursuant to Article V of the Illinois Public
17Aid Code.
 
18    Section 65. Selection of long-term care managed care plans.
19    (a) Provider service networks must be long-term care
20provider service networks. Other eligible plans may be
21long-term care plans or comprehensive long-term care plans.
22    (b) The Department shall select managed care plans through
23the procurement process described in this Act. The Department
24shall notice invitations to negotiate no later than June 30,

 

 

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12014. The Department shall procure at least 3 plans and no more
2than 11 plans for each region. At least one plan in each region
3must be a provider service network.
4    (c) In addition to the criteria established in this Act,
5the Department shall consider all of the following factors in
6the selection of long-term care managed care plans:
7        (1) Evidence of the employment of executive managers
8    with expertise and experience in serving aged and disabled
9    persons who require long-term care.
10        (2) Whether a plan has established a network of service
11    providers dispersed throughout the region and in
12    sufficient numbers to meet specific service standards
13    established by the Department for specialty services for
14    persons receiving home and community-based care.
15        (3) Whether a plan is proposing to establish a
16    comprehensive long-term care plan and whether the plan has
17    a contract to provide managed medical assistance services
18    in the same region.
19        (4) Whether a plan offers consumer-directed care
20    services to enrollees.
21        (5) Whether a plan is proposing to provide home and
22    community-based services in addition to the minimum
23    benefits required by this Act.
24    (d) Participation by a Medicare Advantage Special Needs
25Plan is not subject to the procurement requirements if the
26plan's Medicaid enrollees consist exclusively of recipients

 

 

HB3189- 21 -LRB098 08448 KTG 38555 b

1eligible for both Medicaid and Medicare services who are
2enrolled in the plan in order to receive Medicare services.
 
3    Section 70. Long-term care managed care plan
4accountability. In addition to the requirements enumerated
5elsewhere in this Act, managed care plans and providers
6participating in the Medicaid Long-Term Care Managed Care
7Program must comply with the requirements of this Section.
8    (a) Managed care plans may limit the providers in their
9networks based on credentials, quality indicators, and price.
10For the period between June 30, 2014 and June 30, 2015, each
11selected plan must offer a network contract to all the
12following providers in the region:
13        (1) Nursing homes.
14        (2) Hospices.
15        (3) Aging network service providers that have
16    previously participated in the State's home and
17    community-based waiver programs serving seniors, or that
18    have previously participated in community-service programs
19    administered by the Department on Aging.
20    (b) Except as provided in this Section, providers may limit
21the managed care plans they join. Nursing homes and hospices
22that are enrolled Medicaid providers must participate in all
23managed care plans selected by the Department in the region in
24which the provider is located.
25    (c) Each managed care plan shall monitor the quality and

 

 

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1performance of each participating provider using measures
2adopted by and collected by the Department and any additional
3measures mutually agreed upon by the provider and the plan.
4    (d) The Department shall establish, and each managed care
5plan must comply with, specific standards for the number, type,
6and regional distribution of providers in the plan's network.
7    (e) Managed care plans and providers shall negotiate
8mutually acceptable rates, methods, and terms of payment. Plans
9shall pay nursing homes an amount equal to the nursing
10facility-specific payment rates set by the Department.
11However, mutually acceptable higher rates may be negotiated for
12medically complex care. Plans must ensure that electronic
13nursing home and hospice claims that contain sufficient
14information for processing are paid within 10 business days
15after receipt.
 
16    Section 75. Long-term care managed care plan payment. In
17addition to the payment provisions enumerated elsewhere in this
18Act, the Department shall provide payment to plans in the
19Medicaid Long-Term Care Managed Care Program pursuant to this
20Section.
21    (a) Payment rates to plans shall be blended for some
22long-term care services.
23    (b) Payment rates for plans must reflect historic
24utilization and spending for covered services projected
25forward and adjusted to reflect the level of care profile for

 

 

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1enrollees in each plan. The Department shall periodically
2adjust payment rates to account for changes in the level of
3care profile for each managed care plan based on encounter
4data.
5        (1) Level 1 Care consists of recipients residing in or
6    who must be placed in a nursing home.
7        (2) Level 2 Care consists of recipients at imminent
8    risk of nursing home placement, as evidenced by the need
9    for the constant availability of routine medical and
10    nursing treatment and care, and require extensive
11    health-related care and services because of mental or
12    physical incapacitation.
13        (3) Level 3 Care consists of recipients at imminent
14    risk of nursing home placement, as evidenced by the need
15    for the constant availability of routine medical and
16    nursing treatment and care, who have a limited need for
17    health-related care and services and are mildly,
18    medically, or physically incapacitated.
19    (c) The Department shall make an incentive adjustment in
20payment rates to encourage the increased utilization of home
21and community-based services and a commensurate reduction of
22institutional placement. The incentive adjustment shall
23continue until no more than 35% of the plan's enrollees are
24placed in institutional settings. The Department shall
25annually report to the General Assembly the actual change in
26the utilization mix of home and community-based services

 

 

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1compared to institutional placements and provide a
2recommendation for utilization mix requirements for future
3contracts.
 
4    Section 80. Enrollment in a long-term care managed care
5plan.
6    (a) The Department shall automatically enroll into a
7long-term care managed care plan those Medicaid recipients who
8do not voluntarily choose a plan. Except as otherwise provided
9in this Act, the Department may not engage in practices
10designed to favor one managed care plan over another.
11    (b) The Department shall automatically enroll Medicaid
12recipients in plans that meet or exceed the performance or
13quality standards established in this Act, or by the Department
14through contract, and may not automatically enroll recipients
15in a plan that is deficient in those performance or quality
16standards.
17        (1) If a Medicaid recipient is deemed eligible for both
18    Medicaid and Medicare services and is currently receiving
19    Medicare services from a Medicare Advantage Preferred
20    Provider Organization, a Medicare Advantage
21    Provider-Sponsored Organization, or a Medicare Advantage
22    Special Needs Plan, the Department shall automatically
23    enroll the recipient in such plan for Medicaid services if
24    the plan is currently participating in the Medicaid
25    Long-Term Care Managed Care Program.

 

 

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1        (2) Otherwise, the Department shall automatically
2    enroll Medicaid recipients based on all of the following
3    criteria:
4            (a) Whether the plan has sufficient network
5        capacity to meet the needs of the recipient.
6            (b) Whether the recipient has previously received
7        services from one of the plan's home and
8        community-based service providers.
9            (c) Whether the home and community-based providers
10        in one plan are more geographically accessible to the
11        recipient's residence than those in other plans.
12    (c) If a recipient is referred for hospice services, the
13recipient has 30 days during which the recipient may select to
14enroll in another managed care plan to access the hospice
15provider of the recipient's choice.
16    (d) If a recipient is referred for placement in a nursing
17home or assisted living facility, the plan must inform the
18recipient of any facilities within the plan that have specific
19cultural or religious affiliations and, if requested by the
20recipient, make a reasonable effort to place the recipient in
21the facility of the recipient's choice.
 
22    Section 97. Severability. The provisions of this Act are
23severable under Section 1.31 of the Statute on Statutes.
 
24    Section 999. Effective date. This Act takes effect upon
25becoming law.