(320 ILCS 40/15) (from Ch. 23, par. 6915)

Sec. 15. Program implementation.

(a) The Department of Healthcare and Family Services must prepare and submit a PACE State Plan amendment no later than December 31, 2022 to the federal Centers for Medicare and Medicaid Services to establish the Program of All-Inclusive Care for the Elderly (PACE program) to provide community-based, risk-based, and capitated long-term care services as optional services under the Illinois Title XIX State Plan and under contracts entered into between the federal Centers for Medicare and Medicaid Services, the Department of Healthcare and Family Services, and PACE organizations, meeting the requirements of the Balanced Budget Act of 1997 (Public Law 105-33) and any other applicable law or regulation.

(b) The Department of Healthcare and Family Services shall facilitate the PACE organization application process no later than December 31, 2023.

(c) All PACE organizations selected shall begin operations no later than June 30, 2024.

(d) Using a risk-based financing model, the organizations contracted to implement the PACE program shall assume responsibility for all costs generated by the PACE program participants, and shall create and maintain a risk reserve fund that will cover any cost overages for any participant. The PACE program is responsible for the entire range of services in the consolidated service model, including hospital and nursing home care, according to participant need as determined by a multidisciplinary team. The contracted organizations are responsible for the full financial risk. Specific arrangements of the risk-based financing model shall be adopted and negotiated by the federal Centers for Medicare and Medicaid Services, the organizations contracted to implement the PACE program, and the Department of Healthcare and Family Services.

(e) The requirements of the PACE model, as provided for under Section 1894 (42 U.S.C. Sec. 1395eee) and Section 1934 (42 U.S.C. Sec. 1396u-4) of the federal Social Security Act, shall not be waived or modified. The requirements that shall not be waived or modified include all of the following:

(1) The focus on frail elderly qualifying individuals who require the level of care provided in a nursing facility.

(2) The delivery of comprehensive, integrated acute and long-term care services.

(3) The interdisciplinary team approach to care management and service delivery.

(4) Capitated, integrated financing that allows the provider to pool payments received from public and private programs and individuals.

(5) The assumption by the provider of full financial risk.

(6) The provision of a PACE benefit package for all participants, regardless of source of payment, that shall include all of the following:

(A) All Medicare-covered items and services.

(B) All Medicaid-covered items and services, as specified in the Illinois Title XIX State Plan.

(C) Other services determined necessary by the interdisciplinary team to improve and maintain the participant's overall health status.

(f) The provisions under Sections 1-7 and 5-4 of the Illinois Public Aid Code and under 80 Ill. Adm. Code 120.379, 120.380, and 120.385 shall apply when determining the eligibility for medical assistance of a person receiving PACE services from an organization providing services under this Act.

(g) Provisions governing the treatment of income and resources of a married couple, for the purposes of determining the eligibility of a nursing-facility certifiable or institutionalized spouse, shall be established so as to qualify for federal financial participation.

(h) Notwithstanding subsection (e), and only to the extent federal financial participation is available, the Department of Healthcare and Family Services, in consultation with PACE organizations, may seek increased federal regulatory flexibility from the federal Centers for Medicare and Medicaid Services to modernize the PACE program, which may include, but is not limited to, addressing all of the following:

(A) Composition of PACE interdisciplinary teams.

(B) Use of community-based physicians.

(C) Marketing practices.

(D) Development of a streamlined PACE waiver process.

This subsection shall be operative upon federal approval of a capitation rate methodology as provided under Section 16.

(i) Each PACE organization shall provide the Department with required reporting documents as set forth in 42 CFR 460.190 through 42 CFR 460.196.

(Source: P.A. 102-43, eff. 7-6-21.)