98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
HB5405

 

Introduced , by Rep. Greg Harris

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 134/10
305 ILCS 5/5-30

    Amends the Managed Care Reform and Patient Rights Act. Expands the definition of "health care plan" to include Health Maintenance Organizations, Managed Care Community Networks, Care Coordination Entities, and Accountable Care Entities. Amends the Medical Assistance Article of the Illinois Public Aid Code. In provisions concerning the Department of Healthcare and Family Services' contracts with Managed Care Organizations and other entities reimbursed by risk based capitation, provides that such contracts shall require the entity to (i) be accredited by the National Committee for Quality Assurance, (ii) establish an appeals and grievances process for consumers and providers, and (iii) provide a quality assurance and utilization review program that meets the requirements established by the Department in rules that incorporate those standards set forth in the Health Maintenance Organization Act.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB5405LRB098 18640 KTG 53783 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 5. The Managed Care Reform and Patient Rights Act
5is amended by changing Section 10 as follows:
 
6    (215 ILCS 134/10)
7    Sec. 10. Definitions:
8    "Adverse determination" means a determination by a health
9care plan under Section 45 or by a utilization review program
10under Section 85 that a health care service is not medically
11necessary.
12    "Clinical peer" means a health care professional who is in
13the same profession and the same or similar specialty as the
14health care provider who typically manages the medical
15condition, procedures, or treatment under review.
16    "Department" means the Department of Insurance.
17    "Emergency medical condition" means a medical condition
18manifesting itself by acute symptoms of sufficient severity
19(including, but not limited to, severe pain) such that a
20prudent layperson, who possesses an average knowledge of health
21and medicine, could reasonably expect the absence of immediate
22medical attention to result in:
23        (1) placing the health of the individual (or, with

 

 

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1    respect to a pregnant woman, the health of the woman or her
2    unborn child) in serious jeopardy;
3        (2) serious impairment to bodily functions; or
4        (3) serious dysfunction of any bodily organ or part.
5    "Emergency medical screening examination" means a medical
6screening examination and evaluation by a physician licensed to
7practice medicine in all its branches, or to the extent
8permitted by applicable laws, by other appropriately licensed
9personnel under the supervision of or in collaboration with a
10physician licensed to practice medicine in all its branches to
11determine whether the need for emergency services exists.
12    "Emergency services" means, with respect to an enrollee of
13a health care plan, transportation services, including but not
14limited to ambulance services, and covered inpatient and
15outpatient hospital services furnished by a provider qualified
16to furnish those services that are needed to evaluate or
17stabilize an emergency medical condition. "Emergency services"
18does not refer to post-stabilization medical services.
19    "Enrollee" means any person and his or her dependents
20enrolled in or covered by a health care plan.
21    "Health care plan" means a plan, including, but not limited
22to, a Health Maintenance Organization, Managed Care Community
23Network as defined in the Illinois Public Aid Code, Care
24Coordination Entity as defined in the Illinois Public Aid Code,
25and Accountable Care Entity as defined in the Illinois Public
26Aid Code, that establishes, operates, or maintains a network of

 

 

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1health care providers that has entered into an agreement with
2the plan to provide health care services to enrollees to whom
3the plan has the ultimate obligation to arrange for the
4provision of or payment for services through organizational
5arrangements for ongoing quality assurance, utilization review
6programs, or dispute resolution. Nothing in this definition
7shall be construed to mean that an independent practice
8association or a physician hospital organization that
9subcontracts with a health care plan is, for purposes of that
10subcontract, a health care plan.
11    For purposes of this definition, "health care plan" shall
12not include the following:
13        (1) indemnity health insurance policies including
14    those using a contracted provider network;
15        (2) health care plans that offer only dental or only
16    vision coverage;
17        (3) preferred provider administrators, as defined in
18    Section 370g(g) of the Illinois Insurance Code;
19        (4) employee or employer self-insured health benefit
20    plans under the federal Employee Retirement Income
21    Security Act of 1974;
22        (5) health care provided pursuant to the Workers'
23    Compensation Act or the Workers' Occupational Diseases
24    Act; and
25        (6) not-for-profit voluntary health services plans
26    with health maintenance organization authority in

 

 

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1    existence as of January 1, 1999 that are affiliated with a
2    union and that only extend coverage to union members and
3    their dependents.
4    "Health care professional" means a physician, a registered
5professional nurse, or other individual appropriately licensed
6or registered to provide health care services.
7    "Health care provider" means any physician, hospital
8facility, or other person that is licensed or otherwise
9authorized to deliver health care services. Nothing in this Act
10shall be construed to define Independent Practice Associations
11or Physician-Hospital Organizations as health care providers.
12    "Health care services" means any services included in the
13furnishing to any individual of medical care, or the
14hospitalization incident to the furnishing of such care, as
15well as the furnishing to any person of any and all other
16services for the purpose of preventing, alleviating, curing, or
17healing human illness or injury including home health and
18pharmaceutical services and products.
19    "Medical director" means a physician licensed in any state
20to practice medicine in all its branches appointed by a health
21care plan.
22    "Person" means a corporation, association, partnership,
23limited liability company, sole proprietorship, or any other
24legal entity.
25    "Physician" means a person licensed under the Medical
26Practice Act of 1987.

 

 

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1    "Post-stabilization medical services" means health care
2services provided to an enrollee that are furnished in a
3licensed hospital by a provider that is qualified to furnish
4such services, and determined to be medically necessary and
5directly related to the emergency medical condition following
6stabilization.
7    "Stabilization" means, with respect to an emergency
8medical condition, to provide such medical treatment of the
9condition as may be necessary to assure, within reasonable
10medical probability, that no material deterioration of the
11condition is likely to result.
12    "Utilization review" means the evaluation of the medical
13necessity, appropriateness, and efficiency of the use of health
14care services, procedures, and facilities.
15    "Utilization review program" means a program established
16by a person to perform utilization review.
17(Source: P.A. 91-617, eff. 1-1-00.)
 
18    Section 10. The Illinois Public Aid Code is amended by
19changing Section 5-30 as follows:
 
20    (305 ILCS 5/5-30)
21    Sec. 5-30. Care coordination.
22    (a) At least 50% of recipients eligible for comprehensive
23medical benefits in all medical assistance programs or other
24health benefit programs administered by the Department,

 

 

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1including the Children's Health Insurance Program Act and the
2Covering ALL KIDS Health Insurance Act, shall be enrolled in a
3care coordination program by no later than January 1, 2015. For
4purposes of this Section, "coordinated care" or "care
5coordination" means delivery systems where recipients will
6receive their care from providers who participate under
7contract in integrated delivery systems that are responsible
8for providing or arranging the majority of care, including
9primary care physician services, referrals from primary care
10physicians, diagnostic and treatment services, behavioral
11health services, in-patient and outpatient hospital services,
12dental services, and rehabilitation and long-term care
13services. The Department shall designate or contract for such
14integrated delivery systems (i) to ensure enrollees have a
15choice of systems and of primary care providers within such
16systems; (ii) to ensure that enrollees receive quality care in
17a culturally and linguistically appropriate manner; and (iii)
18to ensure that coordinated care programs meet the diverse needs
19of enrollees with developmental, mental health, physical, and
20age-related disabilities.
21    (b) Payment for such coordinated care shall be based on
22arrangements where the State pays for performance related to
23health care outcomes, the use of evidence-based practices, the
24use of primary care delivered through comprehensive medical
25homes, the use of electronic medical records, and the
26appropriate exchange of health information electronically made

 

 

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1either on a capitated basis in which a fixed monthly premium
2per recipient is paid and full financial risk is assumed for
3the delivery of services, or through other risk-based payment
4arrangements.
5    (c) To qualify for compliance with this Section, the 50%
6goal shall be achieved by enrolling medical assistance
7enrollees from each medical assistance enrollment category,
8including parents, children, seniors, and people with
9disabilities to the extent that current State Medicaid payment
10laws would not limit federal matching funds for recipients in
11care coordination programs. In addition, services must be more
12comprehensively defined and more risk shall be assumed than in
13the Department's primary care case management program as of the
14effective date of this amendatory Act of the 96th General
15Assembly.
16    (d) The Department shall report to the General Assembly in
17a separate part of its annual medical assistance program
18report, beginning April, 2012 until April, 2016, on the
19progress and implementation of the care coordination program
20initiatives established by the provisions of this amendatory
21Act of the 96th General Assembly. The Department shall include
22in its April 2011 report a full analysis of federal laws or
23regulations regarding upper payment limitations to providers
24and the necessary revisions or adjustments in rate
25methodologies and payments to providers under this Code that
26would be necessary to implement coordinated care with full

 

 

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1financial risk by a party other than the Department.
2    (e) Integrated Care Program for individuals with chronic
3mental health conditions.
4        (1) The Integrated Care Program shall encompass
5    services administered to recipients of medical assistance
6    under this Article to prevent exacerbations and
7    complications using cost-effective, evidence-based
8    practice guidelines and mental health management
9    strategies.
10        (2) The Department may utilize and expand upon existing
11    contractual arrangements with integrated care plans under
12    the Integrated Care Program for providing the coordinated
13    care provisions of this Section.
14        (3) Payment for such coordinated care shall be based on
15    arrangements where the State pays for performance related
16    to mental health outcomes on a capitated basis in which a
17    fixed monthly premium per recipient is paid and full
18    financial risk is assumed for the delivery of services, or
19    through other risk-based payment arrangements such as
20    provider-based care coordination.
21        (4) The Department shall examine whether chronic
22    mental health management programs and services for
23    recipients with specific chronic mental health conditions
24    do any or all of the following:
25            (A) Improve the patient's overall mental health in
26        a more expeditious and cost-effective manner.

 

 

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1            (B) Lower costs in other aspects of the medical
2        assistance program, such as hospital admissions,
3        emergency room visits, or more frequent and
4        inappropriate psychotropic drug use.
5        (5) The Department shall work with the facilities and
6    any integrated care plan participating in the program to
7    identify and correct barriers to the successful
8    implementation of this subsection (e) prior to and during
9    the implementation to best facilitate the goals and
10    objectives of this subsection (e).
11    (f) A hospital that is located in a county of the State in
12which the Department mandates some or all of the beneficiaries
13of the Medical Assistance Program residing in the county to
14enroll in a Care Coordination Program, as set forth in Section
155-30 of this Code, shall not be eligible for any non-claims
16based payments not mandated by Article V-A of this Code for
17which it would otherwise be qualified to receive, unless the
18hospital is a Coordinated Care Participating Hospital no later
19than 60 days after the effective date of this amendatory Act of
20the 97th General Assembly or 60 days after the first mandatory
21enrollment of a beneficiary in a Coordinated Care program. For
22purposes of this subsection, "Coordinated Care Participating
23Hospital" means a hospital that meets one of the following
24criteria:
25        (1) The hospital has entered into a contract to provide
26    hospital services to enrollees of the care coordination

 

 

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1    program.
2        (2) The hospital has not been offered a contract by a
3    care coordination plan that pays at least as much as the
4    Department would pay, on a fee-for-service basis, not
5    including disproportionate share hospital adjustment
6    payments or any other supplemental adjustment or add-on
7    payment to the base fee-for-service rate.
8    (g) No later than August 1, 2013, the Department shall
9issue a purchase of care solicitation for Accountable Care
10Entities (ACE) to serve any children and parents or caretaker
11relatives of children eligible for medical assistance under
12this Article. An ACE may be a single corporate structure or a
13network of providers organized through contractual
14relationships with a single corporate entity. The solicitation
15shall require that:
16        (1) An ACE operating in Cook County be capable of
17    serving at least 40,000 eligible individuals in that
18    county; an ACE operating in Lake, Kane, DuPage, or Will
19    Counties be capable of serving at least 20,000 eligible
20    individuals in those counties and an ACE operating in other
21    regions of the State be capable of serving at least 10,000
22    eligible individuals in the region in which it operates.
23    During initial periods of mandatory enrollment, the
24    Department shall require its enrollment services
25    contractor to use a default assignment algorithm that
26    ensures if possible an ACE reaches the minimum enrollment

 

 

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1    levels set forth in this paragraph.
2        (2) An ACE must include at a minimum the following
3    types of providers: primary care, specialty care,
4    hospitals, and behavioral healthcare.
5        (3) An ACE shall have a governance structure that
6    includes the major components of the health care delivery
7    system, including one representative from each of the
8    groups listed in paragraph (2).
9        (4) An ACE must be an integrated delivery system,
10    including a network able to provide the full range of
11    services needed by Medicaid beneficiaries and system
12    capacity to securely pass clinical information across
13    participating entities and to aggregate and analyze that
14    data in order to coordinate care.
15        (5) An ACE must be capable of providing both care
16    coordination and complex case management, as necessary, to
17    beneficiaries. To be responsive to the solicitation, a
18    potential ACE must outline its care coordination and
19    complex case management model and plan to reduce the cost
20    of care.
21        (6) In the first 18 months of operation, unless the ACE
22    selects a shorter period, an ACE shall be paid care
23    coordination fees on a per member per month basis that are
24    projected to be cost neutral to the State during the term
25    of their payment and, subject to federal approval, be
26    eligible to share in additional savings generated by their

 

 

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1    care coordination.
2        (7) In months 19 through 36 of operation, unless the
3    ACE selects a shorter period, an ACE shall be paid on a
4    pre-paid capitation basis for all medical assistance
5    covered services, under contract terms similar to Managed
6    Care Organizations (MCO), with the Department sharing the
7    risk through either stop-loss insurance for extremely high
8    cost individuals or corridors of shared risk based on the
9    overall cost of the total enrollment in the ACE. The ACE
10    shall be responsible for claims processing, encounter data
11    submission, utilization control, and quality assurance.
12        (8) In the fourth and subsequent years of operation, an
13    ACE shall convert to a Managed Care Community Network
14    (MCCN), as defined in this Article, or Health Maintenance
15    Organization pursuant to the Illinois Insurance Code,
16    accepting full-risk capitation payments.
17    The Department shall allow potential ACE entities 5 months
18from the date of the posting of the solicitation to submit
19proposals. After the solicitation is released, in addition to
20the MCO rate development data available on the Department's
21website, subject to federal and State confidentiality and
22privacy laws and regulations, the Department shall provide 2
23years of de-identified summary service data on the targeted
24population, split between children and adults, showing the
25historical type and volume of services received and the cost of
26those services to those potential bidders that sign a data use

 

 

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1agreement. The Department may add up to 2 non-state government
2employees with expertise in creating integrated delivery
3systems to its review team for the purchase of care
4solicitation described in this subsection. Any such
5individuals must sign a no-conflict disclosure and
6confidentiality agreement and agree to act in accordance with
7all applicable State laws.
8    During the first 2 years of an ACE's operation, the
9Department shall provide claims data to the ACE on its
10enrollees on a periodic basis no less frequently than monthly.
11    Nothing in this subsection shall be construed to limit the
12Department's mandate to enroll 50% of its beneficiaries into
13care coordination systems by January 1, 2015, using all
14available care coordination delivery systems, including Care
15Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
16to affect the current CCEs, MCCNs, and MCOs selected to serve
17seniors and persons with disabilities prior to that date.
18    (h) Department contracts with MCOs and other entities
19reimbursed by risk based capitation shall have a minimum
20medical loss ratio of 85%, shall require the MCO or other
21entity to pay claims within 30 days of receiving a bill that
22contains all the essential information needed to adjudicate the
23bill, and shall require the entity to pay a penalty that is at
24least equal to the penalty imposed under the Illinois Insurance
25Code for any claims not paid within this time period, shall
26require the entity to be accredited by the National Committee

 

 

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1for Quality Assurance, shall require the entity to establish an
2appeals and grievances process for consumers and providers, and
3shall require the entity to provide a quality assurance and
4utilization review program that meets the requirements
5established by the Department in rules that incorporate those
6standards set forth in the Health Maintenance Organization Act.
7The requirements of this subsection shall apply to contracts
8with MCOs entered into or renewed or extended after June 1,
92013.
10(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)