| |||||||||||||||||||||||||
| |||||||||||||||||||||||||
| |||||||||||||||||||||||||
| |||||||||||||||||||||||||
| |||||||||||||||||||||||||
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 1. Short title. This Act may be cited as the | ||||||||||||||||||||||||
5 | Patient-Centered Medicaid Reform Act. | ||||||||||||||||||||||||
6 | Section 5. Definitions. As used in this Act:
| ||||||||||||||||||||||||
7 | (a) "Department" means the Department of Healthcare and | ||||||||||||||||||||||||
8 | Family Services or any State department which may administer in | ||||||||||||||||||||||||
9 | the future the Medicaid Managed Care Program established under | ||||||||||||||||||||||||
10 | this Act. | ||||||||||||||||||||||||
11 | (b) "Managed care plan" means a health insurer, a specialty | ||||||||||||||||||||||||
12 | plan, a health maintenance organization authorized under the | ||||||||||||||||||||||||
13 | Illinois Insurance Code, or a Medicaid-authorized provider | ||||||||||||||||||||||||
14 | service network under contract with the Department to provide | ||||||||||||||||||||||||
15 | services to clients eligible for medical assistance under the | ||||||||||||||||||||||||
16 | State's Medical Assistance Program established under Article V | ||||||||||||||||||||||||
17 | of the Illinois Public Aid Code.
| ||||||||||||||||||||||||
18 | (c) "Medicaid" means the medical assistance program | ||||||||||||||||||||||||
19 | authorized by Title XIX of the Social Security Act, and | ||||||||||||||||||||||||
20 | regulations thereunder, as administered in this State by the | ||||||||||||||||||||||||
21 | Department of Healthcare and Family Services. | ||||||||||||||||||||||||
22 | (d) "Medicaid recipient" or "recipient" means an | ||||||||||||||||||||||||
23 | individual who receives medical assistance as provided under |
| |||||||
| |||||||
1 | Article V of the Illinois Public Aid Code. | ||||||
2 | (e) "Prepaid plan" means a managed care plan that is | ||||||
3 | licensed or certified as a risk-bearing entity or is an | ||||||
4 | approved provider service network, and is paid a prospective | ||||||
5 | per-member, per-month payment by the Department.
| ||||||
6 | (f) "Provider service network" means a Department-approved | ||||||
7 | entity, a controlling interest of which is owned by a health | ||||||
8 | care provider, or by a group of affiliated providers, or by a | ||||||
9 | public agency or entity that delivers health services. Health | ||||||
10 | care providers include State-licensed health care | ||||||
11 | professionals or licensed health care facilities, federally | ||||||
12 | qualified health care centers, and home health care agencies.
| ||||||
13 | (g) "Specialty plan" means a managed care plan that serves | ||||||
14 | Medicaid recipients who meet specified criteria based on age, | ||||||
15 | medical condition, or diagnosis.
| ||||||
16 | (h) "Comprehensive long-term care plan" means a managed | ||||||
17 | care plan, provider-sponsored organization, health maintenance | ||||||
18 | organization, or coordinated care plan that provides long-term | ||||||
19 | care services as outlined in this Act.
| ||||||
20 | (i) "Long-term care plan" means a managed care plan that | ||||||
21 | provides the services described in Section 60 of this Act for | ||||||
22 | the Medicaid Long-Term Care Managed Care Program established | ||||||
23 | under this Act. | ||||||
24 | (j) "Long-term care provider service network" means a | ||||||
25 | provider service network, a controlling interest of which is | ||||||
26 | owned by one or more licensed nursing homes, assisted living |
| |||||||
| |||||||
1 | facilities with 17 or more beds, home health agencies, | ||||||
2 | community care for the elderly lead agencies, or hospices.
| ||||||
3 | Section 10. Authorization for Medicaid waiver or amendment | ||||||
4 | to the Medicaid State Plan.
The Medicaid Managed Care Program | ||||||
5 | is established as a statewide, integrated managed care program | ||||||
6 | for all covered services, including long-term care services. | ||||||
7 | The Department shall apply for and implement appropriate | ||||||
8 | amendments to the Illinois Title XIX State Plan and waivers of | ||||||
9 | applicable federal laws and regulations necessary to implement | ||||||
10 | the program. Before submitting the waiver or State Plan | ||||||
11 | amendment, the Department shall provide public notice and the | ||||||
12 | opportunity for public comment and shall include public | ||||||
13 | feedback 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 | ||||||
16 | Program shall be provided by managed care plans that are | ||||||
17 | capable of coordinating or delivering all covered services to | ||||||
18 | enrollees.
| ||||||
19 | (b) The Department shall select managed care plans to | ||||||
20 | participate in the Medicaid Managed Care Program using | ||||||
21 | invitations to negotiate. The procurement method must give the | ||||||
22 | State the most flexibility and broadest power to negotiate | ||||||
23 | value and must provide potential bidders the most room to | ||||||
24 | innovate. Separate and simultaneous procurements shall be |
| |||||||
| |||||||
1 | conducted in regions to be determined by the Department. | ||||||
2 | (c) The Department shall consider quality factors in the | ||||||
3 | selection of managed care plans, including all of the | ||||||
4 | following:
| ||||||
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 | ||||||
17 | select the managed care plans that are determined to be | ||||||
18 | responsive and provide the best value to the State. Preference | ||||||
19 | shall be given to plans that have signed contracts with primary | ||||||
20 | and specialty physicians in sufficient numbers to meet the | ||||||
21 | specific standards established pursuant to this Act.
| ||||||
22 | (e) To ensure managed care plan participation in all | ||||||
23 | regions, the Department shall award an additional contract in a | ||||||
24 | more populous region to each plan with a contract award in a | ||||||
25 | more rural region. If a plan terminates its contract in a more | ||||||
26 | rural region, the additional contract in the more populous |
| |||||||
| |||||||
1 | region shall be automatically terminated within 180 days. The | ||||||
2 | plan must also reimburse the Department for the cost of | ||||||
3 | enrollment changes and other transition activities. | ||||||
4 | (f) The Department may not execute contracts with managed | ||||||
5 | care plans at payment rates not supported by appropriations | ||||||
6 | made to the Department for these purposes. | ||||||
7 | Section 20. Selection of managed care plans. | ||||||
8 | (a) The Department shall select managed care plans through | ||||||
9 | the procurement process described in this Act. The Department | ||||||
10 | shall notice invitations to negotiate no later than June 30, | ||||||
11 | 2014. The Department shall procure at least 3 plans and no more | ||||||
12 | than 11 plans for each region. At least one plan in each region | ||||||
13 | must be a provider service network.
| ||||||
14 | (b) Participation by specialty plans shall be subject to | ||||||
15 | the procurement requirements in this Act. The enrollment of a | ||||||
16 | specialty plan in a region may not exceed 10% of the total | ||||||
17 | number of enrollees of that region. However, a specialty plan | ||||||
18 | whose target population includes no more than 10% of the | ||||||
19 | enrollees of that region shall not be subject to the regional | ||||||
20 | plan number limits under this Section.
| ||||||
21 | (c) Participation by a Medicare Advantage Preferred | ||||||
22 | Provider Organization, a Medicare Advantage Provider-Sponsored | ||||||
23 | Organization, a Medicare Advantage Health Maintenance | ||||||
24 | Organization, a Medicare Advantage Coordinated Care Plan, or a | ||||||
25 | Medicare Advantage Special Needs Plan shall not be subject to |
| |||||||
| |||||||
1 | the procurement requirements under this Section if the plan's | ||||||
2 | Medicaid enrollees consist exclusively of dually eligible | ||||||
3 | recipients who are enrolled in the plan in order to receive | ||||||
4 | Medicare benefits.
| ||||||
5 | Section 25. Plan accountability.
| ||||||
6 | (a) The Department shall establish a 5-year contract with | ||||||
7 | each managed care plan selected through the procurement process | ||||||
8 | described in this Act. A plan contract may not be renewed. | ||||||
9 | However, the Department may extend the term of a plan contract | ||||||
10 | to cover any delays during the transition to a new plan.
| ||||||
11 | (b) The Department shall establish such contract | ||||||
12 | requirements as are necessary for the operation of the | ||||||
13 | statewide Medicaid Managed Care Program. In addition to any | ||||||
14 | other provisions the Department may deem necessary, the | ||||||
15 | contract 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:
|
| |||||||
| |||||||
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 |
| |||||||
| |||||||
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.
|
| |||||||
| |||||||
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 |
| |||||||
| |||||||
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 | ||||||
17 | achieved savings rebate for all Medicaid prepaid plans. The | ||||||
18 | achieved savings rebate shall be established by determining | ||||||
19 | pretax income as a percentage of revenues and applying the | ||||||
20 | following 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 |
| |||||||
| |||||||
1 | refunded to the State.
| ||||||
2 | (d) Each managed care plan must accept any medically needy | ||||||
3 | recipient eligible for medical assistance under paragraph 2 of | ||||||
4 | Section 5-2 of the Illinois Public Aid Code who selects or is | ||||||
5 | assigned to the plan and must provide that medically needy | ||||||
6 | recipient with continuous enrollment for 12 months. After the | ||||||
7 | first month of qualifying as a medically needy recipient and | ||||||
8 | enrolling in a plan, and contingent upon federal approval, the | ||||||
9 | medically needy recipient shall pay the plan a portion of the | ||||||
10 | monthly premium equal to the medically needy recipient's share | ||||||
11 | of the cost as determined by the Department. The Department | ||||||
12 | shall pay any remaining portion of the monthly premium. A plan | ||||||
13 | is not obligated to pay claims for medically needy recipients | ||||||
14 | for services provided before enrollment in the plan. Medically | ||||||
15 | needy recipients are responsible for payment of incurred claims | ||||||
16 | that are used to determine eligibility. A plan must provide a | ||||||
17 | grace period of at least 90 days before disenrolling medically | ||||||
18 | needy 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 | ||||||
21 | payments negotiated pursuant to the procurements described in | ||||||
22 | this Act. Payments shall be risk-adjusted rates based on | ||||||
23 | historical utilization and spending data, and shall be | ||||||
24 | projected forward and adjusted to reflect the eligibility | ||||||
25 | category, geographic area, and clinical risk profile of the |
| |||||||
| |||||||
1 | recipients. In negotiating rates with the plans, the Department | ||||||
2 | shall consider any adjustments necessary to encourage plans to | ||||||
3 | use the most cost-effective modalities for treatment of chronic | ||||||
4 | disease. | ||||||
5 | (b) Provider service networks may be prepaid plans and | ||||||
6 | receive per-member, per-month payments. The fee-for-service | ||||||
7 | option shall be available to a provider service network only | ||||||
8 | for the first 2 years of its operation.
| ||||||
9 | (c) The Department may not approve any plan request for a | ||||||
10 | rate increase unless sufficient funds to support the increase | ||||||
11 | have been authorized by appropriations made to the Department | ||||||
12 | for 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 | ||||||
15 | care plan unless specifically exempted under this Act. Each | ||||||
16 | recipient shall have a choice of plans and may select any | ||||||
17 | available plan unless that plan is restricted by contract to a | ||||||
18 | specific population that does not include the recipient. | ||||||
19 | Recipients shall have 30 days in which to make a choice of | ||||||
20 | plans. | ||||||
21 | (b) The Department shall implement a choice counseling | ||||||
22 | system to ensure that recipients have timely access to accurate | ||||||
23 | information on the available plans. The counseling system shall | ||||||
24 | include plan-to-plan comparative information on benefits, | ||||||
25 | provider networks, drug formularies, quality measures, and |
| |||||||
| |||||||
1 | other data points as determined by the Department. Choice | ||||||
2 | counseling must be made available through face-to-face | ||||||
3 | interaction, through the Internet, by telephone, in writing, | ||||||
4 | and through other forms of relevant media. Materials must be | ||||||
5 | provided in a culturally relevant manner, consistent with | ||||||
6 | federal requirements. The Department shall contract for any or | ||||||
7 | all choice counseling functions.
| ||||||
8 | (c) After a recipient has enrolled in a managed care plan, | ||||||
9 | the recipient shall have 90 days to voluntarily disenroll and | ||||||
10 | select another plan. After 90 days, no further changes may be | ||||||
11 | made except for good cause.
| ||||||
12 | (d) The Department shall automatically enroll into a | ||||||
13 | managed care plan those Medicaid recipients who do not | ||||||
14 | voluntarily choose a plan. Except as otherwise outlined in this | ||||||
15 | Act, the Department may not engage in practices that are | ||||||
16 | designed 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 |
| |||||||
| |||||||
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 | ||||||
22 | shall opt out of all managed care plans and use Medicaid | ||||||
23 | financial assistance to pay for his or her share of the cost in | ||||||
24 | such coverage. The amount of financial assistance provided for | ||||||
25 | each recipient may not exceed the amount of the Medicaid | ||||||
26 | premium that would have been paid to a managed care plan for |
| |||||||
| |||||||
1 | that recipient. The Department shall seek federal approval to | ||||||
2 | require Medicaid recipients with access to employer-sponsored | ||||||
3 | health care coverage to enroll in that coverage and use | ||||||
4 | Medicaid financial assistance to pay for the recipient's share | ||||||
5 | of the cost for such coverage. The amount of financial | ||||||
6 | assistance provided for each recipient may not exceed the | ||||||
7 | amount of the Medicaid premium that would have been paid to a | ||||||
8 | managed care plan for that recipient.
| ||||||
9 | Section 40. Mandatory, exempt, and voluntary populations.
| ||||||
10 | (a) All Medicaid recipients shall receive covered services | ||||||
11 | through the Medicaid Managed Care Program. The following | ||||||
12 | Medicaid recipients are exempt from participation in the | ||||||
13 | Medicaid 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 |
| |||||||
| |||||||
1 | and women who are eligible only for breast and cervical | ||||||
2 | cancer services. | ||||||
3 | (b) The following persons eligible for Medicaid are exempt | ||||||
4 | from mandatory managed care enrollment required by this Act, | ||||||
5 | and may voluntarily choose to participate in the managed | ||||||
6 | medical 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 | ||||||
21 | assistance under paragraph 2 of Section 5-2 of the Illinois | ||||||
22 | Public Aid Code shall enroll in managed care plans. Such | ||||||
23 | recipients shall meet their share of the cost by paying the | ||||||
24 | plan premium, up to the share of the cost amount.
| ||||||
25 | Section 45. Benefits.
|
| |||||||
| |||||||
1 | (a) Managed care plans shall cover, at a minimum, those | ||||||
2 | mandatory and optional services provided under the State's | ||||||
3 | medical assistance program pursuant to Article V of the | ||||||
4 | Illinois Public Aid Code.
| ||||||
5 | (b) Managed care plans may customize benefit packages for | ||||||
6 | non-pregnant adults, vary cost-sharing provisions, and provide | ||||||
7 | coverage for additional services. The Department shall | ||||||
8 | evaluate the proposed benefit packages to ensure that services | ||||||
9 | are sufficient to meet the needs of the plan's enrollees and to | ||||||
10 | verify actuarial equivalence.
| ||||||
11 | (c) Each plan operating in the Medicaid Managed Care | ||||||
12 | Program shall establish a program to encourage and reward | ||||||
13 | healthy behaviors. At a minimum, each plan must establish a | ||||||
14 | medically approved smoking cessation program, a medically | ||||||
15 | directed weight loss program, and a medically approved alcohol | ||||||
16 | or substance abuse recovery program. Each plan must identify | ||||||
17 | enrollees who smoke, who are morbidly obese, or who are | ||||||
18 | diagnosed with alcohol or substance abuse in order to establish | ||||||
19 | written agreements to secure the enrollees' commitment to | ||||||
20 | participation in these programs.
| ||||||
21 | Section 50. Medicaid Long-Term Care Managed Care Program. | ||||||
22 | (a) The Department shall make payments for long-term care | ||||||
23 | home and community-based and residential services, and for | ||||||
24 | primary and acute medical assistance and related services for | ||||||
25 | recipients eligible for long-term care, using a managed care |
| |||||||
| |||||||
1 | model. By June 30, 2014, the Department shall begin | ||||||
2 | implementation of the Medicaid Long-Term Care Managed Care | ||||||
3 | Program, with full implementation in all regions by June 30, | ||||||
4 | 2015.
| ||||||
5 | (b) The Department on Aging shall: (i) assist the | ||||||
6 | Department in developing specifications for the invitation to | ||||||
7 | negotiate and the model contract; (ii) determine clinical | ||||||
8 | eligibility for enrollment in managed long-term care plans; | ||||||
9 | (iii) monitor plan performance and measure quality of service | ||||||
10 | delivery; (iv) assist clients and families to address | ||||||
11 | complaints with the plans; (v) facilitate working | ||||||
12 | relationships between plans and providers serving elders and | ||||||
13 | disabled adults; and (vi) perform other functions specified in | ||||||
14 | a memorandum of agreement.
| ||||||
15 | Section 55. Eligibility criteria for the Medicaid | ||||||
16 | Long-Term Care Managed Care Program.
| ||||||
17 | (a) Medicaid recipients who meet all of the following | ||||||
18 | criteria are eligible to receive long-term care services and | ||||||
19 | must receive long-term care services by participating in the | ||||||
20 | Medicaid Long-Term Care Managed Care Program. The recipient | ||||||
21 | must 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 |
| |||||||
| |||||||
1 | managed care plans become available in their region, reside in | ||||||
2 | a facility licensed under the Nursing Home Care Act or the | ||||||
3 | ID/DD Community Care Act or who are enrolled in an existing | ||||||
4 | State long-term care Medicaid waiver program are eligible to | ||||||
5 | participate in the Medicaid Long-Term Care Managed Care Program | ||||||
6 | for up to 12 months without being reevaluated for their need | ||||||
7 | for nursing facility care.
| ||||||
8 | (c) The Department shall make offers for enrollment to | ||||||
9 | eligible individuals based on a wait-list prioritization and | ||||||
10 | subject to the availability of funds. Before enrollment offers, | ||||||
11 | the Department shall determine that sufficient funds exist to | ||||||
12 | support additional enrollment into plans.
| ||||||
13 | Section 60. Long-Term Care Plan Benefits.
Long-term care | ||||||
14 | managed care plans shall, at a minimum, cover those mandatory | ||||||
15 | and optional services provided under the State's medical | ||||||
16 | assistance program pursuant to Article V of the Illinois Public | ||||||
17 | Aid Code. | ||||||
18 | Section 65. Selection of long-term care managed care plans.
| ||||||
19 | (a) Provider service networks must be long-term care | ||||||
20 | provider service networks. Other eligible plans may be | ||||||
21 | long-term care plans or comprehensive long-term care plans.
| ||||||
22 | (b) The Department shall select managed care plans through | ||||||
23 | the procurement process described in this Act. The Department | ||||||
24 | shall notice invitations to negotiate no later than June 30, |
| |||||||
| |||||||
1 | 2014. The Department shall procure at least 3 plans and no more | ||||||
2 | than 11 plans for each region. At least one plan in each region | ||||||
3 | must be a provider service network. | ||||||
4 | (c) In addition to the criteria established in this Act, | ||||||
5 | the Department shall consider all of the following factors in | ||||||
6 | the 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 | ||||||
25 | Plan is not subject to the procurement requirements if the | ||||||
26 | plan's Medicaid enrollees consist exclusively of recipients |
| |||||||
| |||||||
1 | eligible for both Medicaid and Medicare services who are | ||||||
2 | enrolled in the plan in order to receive Medicare services.
| ||||||
3 | Section 70. Long-term care managed care plan | ||||||
4 | accountability. In addition to the requirements enumerated | ||||||
5 | elsewhere in this Act, managed care plans and providers | ||||||
6 | participating in the Medicaid Long-Term Care Managed Care | ||||||
7 | Program must comply with the requirements of this Section.
| ||||||
8 | (a) Managed care plans may limit the providers in their | ||||||
9 | networks based on credentials, quality indicators, and price. | ||||||
10 | For the period between June 30, 2014 and June 30, 2015, each | ||||||
11 | selected plan must offer a network contract to all the | ||||||
12 | following 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 | ||||||
21 | the managed care plans they join. Nursing homes and hospices | ||||||
22 | that are enrolled Medicaid providers must participate in all | ||||||
23 | managed care plans selected by the Department in the region in | ||||||
24 | which the provider is located. | ||||||
25 | (c) Each managed care plan shall monitor the quality and |
| |||||||
| |||||||
1 | performance of each participating provider using measures | ||||||
2 | adopted by and collected by the Department and any additional | ||||||
3 | measures mutually agreed upon by the provider and the plan. | ||||||
4 | (d) The Department shall establish, and each managed care | ||||||
5 | plan must comply with, specific standards for the number, type, | ||||||
6 | and regional distribution of providers in the plan's network.
| ||||||
7 | (e) Managed care plans and providers shall negotiate | ||||||
8 | mutually acceptable rates, methods, and terms of payment. Plans | ||||||
9 | shall pay nursing homes an amount equal to the nursing | ||||||
10 | facility-specific payment rates set by the Department. | ||||||
11 | However, mutually acceptable higher rates may be negotiated for | ||||||
12 | medically complex care. Plans must ensure that electronic | ||||||
13 | nursing home and hospice claims that contain sufficient | ||||||
14 | information for processing are paid within 10 business days | ||||||
15 | after receipt.
| ||||||
16 | Section 75. Long-term care managed care plan payment. In | ||||||
17 | addition to the payment provisions enumerated elsewhere in this | ||||||
18 | Act, the Department shall provide payment to plans in the | ||||||
19 | Medicaid Long-Term Care Managed Care Program pursuant to this | ||||||
20 | Section.
| ||||||
21 | (a) Payment rates to plans shall be blended for some | ||||||
22 | long-term care services.
| ||||||
23 | (b) Payment rates for plans must reflect historic | ||||||
24 | utilization and spending for covered services projected | ||||||
25 | forward and adjusted to reflect the level of care profile for |
| |||||||
| |||||||
1 | enrollees in each plan. The Department shall periodically | ||||||
2 | adjust payment rates to account for changes in the level of | ||||||
3 | care profile for each managed care plan based on encounter | ||||||
4 | data.
| ||||||
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 | ||||||
20 | payment rates to encourage the increased utilization of home | ||||||
21 | and community-based services and a commensurate reduction of | ||||||
22 | institutional placement. The incentive adjustment shall | ||||||
23 | continue until no more than 35% of the plan's enrollees are | ||||||
24 | placed in institutional settings. The Department shall | ||||||
25 | annually report to the General Assembly the actual change in | ||||||
26 | the utilization mix of home and community-based services |
| |||||||
| |||||||
1 | compared to institutional placements and provide a | ||||||
2 | recommendation for utilization mix requirements for future | ||||||
3 | contracts. | ||||||
4 | Section 80. Enrollment in a long-term care managed care | ||||||
5 | plan.
| ||||||
6 | (a) The Department shall automatically enroll into a | ||||||
7 | long-term care managed care plan those Medicaid recipients who | ||||||
8 | do not voluntarily choose a plan. Except as otherwise provided | ||||||
9 | in this Act, the Department may not engage in practices | ||||||
10 | designed to favor one managed care plan over another.
| ||||||
11 | (b) The Department shall automatically enroll Medicaid | ||||||
12 | recipients in plans that meet or exceed the performance or | ||||||
13 | quality standards established in this Act, or by the Department | ||||||
14 | through contract, and may not automatically enroll recipients | ||||||
15 | in a plan that is deficient in those performance or quality | ||||||
16 | standards.
| ||||||
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.
|
| |||||||
| |||||||
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 | ||||||
13 | recipient has 30 days during which the recipient may select to | ||||||
14 | enroll in another managed care plan to access the hospice | ||||||
15 | provider of the recipient's choice.
| ||||||
16 | (d) If a recipient is referred for placement in a nursing | ||||||
17 | home or assisted living facility, the plan must inform the | ||||||
18 | recipient of any facilities within the plan that have specific | ||||||
19 | cultural or religious affiliations and, if requested by the | ||||||
20 | recipient, make a reasonable effort to place the recipient in | ||||||
21 | the facility of the recipient's choice.
| ||||||
22 | Section 97. Severability. The provisions of this Act are | ||||||
23 | severable under Section 1.31 of the Statute on Statutes.
| ||||||
24 | Section 999. Effective date. This Act takes effect upon | ||||||
25 | becoming law.
|