(320 ILCS 40/16)

Sec. 16. Rates of payment.

(a) The General Assembly shall make appropriations to the Department to fund services under this Act. The Department shall develop and pay capitation rates to organizations contracted to implement the PACE program as described in Section 15 using actuarial methods.

The Department may develop capitation rates using a standardized rate methodology across managed care plan models for comparable populations. The specific rate methodology applied to PACE organizations shall address features of PACE that distinguishes it from other managed care plan models.

The rate methodology shall be consistent with actuarial rate development principles and shall provide for all reasonable, appropriate, and attainable costs for each PACE organization within a region.

(b) The Department may develop statewide rates and apply geographic adjustments, using available data sources deemed appropriate by the Department. Consistent with actuarial methods, the primary source of data used to develop rates for each PACE organization shall be its cost and utilization data for the Medical Assistance Program or other data sources as deemed necessary by the Department. Rates developed under this Section shall reflect the level of care associated with the specific populations served under the contract.

(c) The rate methodology developed in accordance with this Section shall contain a mechanism to account for the costs of high-cost drugs and treatments. Rates developed shall be actuarially certified prior to implementation.

(d) Consistent with the requirements of federal law, the Department shall calculate an upper payment limit for payments to PACE organizations. In calculating the upper payment limit, the Department shall collect the applicable data as necessary and shall consider the risk of nursing home placement for the comparable population when estimating the level of care and risk of PACE participants.

(e) The Department shall pay organizations contracted to implement the PACE program at a rate within the certified actuarially sound rate range developed with respect to that entity as necessary to mitigate the impact to the entity of the methodology developed in accordance with this Section.

(f) This Section shall apply for rates established no earlier than July 1, 2022.

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