Illinois General Assembly - Full Text of HB2812
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Full Text of HB2812  99th General Assembly




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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 Illinois Public Aid Code is amended by
5changing Section 5-30 as follows:
6    (305 ILCS 5/5-30)
7    Sec. 5-30. Care coordination.
8    (a) At least 50% of recipients eligible for comprehensive
9medical benefits in all medical assistance programs or other
10health benefit programs administered by the Department,
11including the Children's Health Insurance Program Act and the
12Covering ALL KIDS Health Insurance Act, shall be enrolled in a
13care coordination program by no later than January 1, 2015. For
14purposes of this Section, "coordinated care" or "care
15coordination" means delivery systems where recipients will
16receive their care from providers who participate under
17contract in integrated delivery systems that are responsible
18for providing or arranging the majority of care, including
19primary care physician services, referrals from primary care
20physicians, diagnostic and treatment services, behavioral
21health services, in-patient and outpatient hospital services,
22dental services, and rehabilitation and long-term care
23services. The Department shall designate or contract for such



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1integrated delivery systems (i) to ensure enrollees have a
2choice of systems and of primary care providers within such
3systems; (ii) to ensure that enrollees receive quality care in
4a culturally and linguistically appropriate manner; and (iii)
5to ensure that coordinated care programs meet the diverse needs
6of enrollees with developmental, mental health, physical, and
7age-related disabilities.
8    (b) Payment for such coordinated care shall be based on
9arrangements where the State pays for performance related to
10health care outcomes, the use of evidence-based practices, the
11use of primary care delivered through comprehensive medical
12homes, the use of electronic medical records, and the
13appropriate exchange of health information electronically made
14either on a capitated basis in which a fixed monthly premium
15per recipient is paid and full financial risk is assumed for
16the delivery of services, or through other risk-based payment
18    (c) To qualify for compliance with this Section, the 50%
19goal shall be achieved by enrolling medical assistance
20enrollees from each medical assistance enrollment category,
21including parents, children, seniors, and people with
22disabilities to the extent that current State Medicaid payment
23laws would not limit federal matching funds for recipients in
24care coordination programs. In addition, services must be more
25comprehensively defined and more risk shall be assumed than in
26the Department's primary care case management program as of the



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1effective date of this amendatory Act of the 96th General
3    (d) The Department shall report to the General Assembly in
4a separate part of its annual medical assistance program
5report, beginning April, 2012 until April, 2016, on the
6progress and implementation of the care coordination program
7initiatives established by the provisions of this amendatory
8Act of the 96th General Assembly. The Department shall include
9in its April 2011 report a full analysis of federal laws or
10regulations regarding upper payment limitations to providers
11and the necessary revisions or adjustments in rate
12methodologies and payments to providers under this Code that
13would be necessary to implement coordinated care with full
14financial risk by a party other than the Department.
15    (e) Integrated Care Program for individuals with chronic
16mental health conditions.
17        (1) The Integrated Care Program shall encompass
18    services administered to recipients of medical assistance
19    under this Article to prevent exacerbations and
20    complications using cost-effective, evidence-based
21    practice guidelines and mental health management
22    strategies.
23        (2) The Department may utilize and expand upon existing
24    contractual arrangements with integrated care plans under
25    the Integrated Care Program for providing the coordinated
26    care provisions of this Section.



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1        (3) Payment for such coordinated care shall be based on
2    arrangements where the State pays for performance related
3    to mental health outcomes on a capitated basis in which a
4    fixed monthly premium per recipient is paid and full
5    financial risk is assumed for the delivery of services, or
6    through other risk-based payment arrangements such as
7    provider-based care coordination.
8        (4) The Department shall examine whether chronic
9    mental health management programs and services for
10    recipients with specific chronic mental health conditions
11    do any or all of the following:
12            (A) Improve the patient's overall mental health in
13        a more expeditious and cost-effective manner.
14            (B) Lower costs in other aspects of the medical
15        assistance program, such as hospital admissions,
16        emergency room visits, or more frequent and
17        inappropriate psychotropic drug use.
18        (5) The Department shall work with the facilities and
19    any integrated care plan participating in the program to
20    identify and correct barriers to the successful
21    implementation of this subsection (e) prior to and during
22    the implementation to best facilitate the goals and
23    objectives of this subsection (e).
24    (f) A hospital that is located in a county of the State in
25which the Department mandates some or all of the beneficiaries
26of the Medical Assistance Program residing in the county to



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1enroll in a Care Coordination Program, as set forth in Section
25-30 of this Code, shall not be eligible for any non-claims
3based payments not mandated by Article V-A of this Code for
4which it would otherwise be qualified to receive, unless the
5hospital is a Coordinated Care Participating Hospital no later
6than 60 days after the effective date of this amendatory Act of
7the 97th General Assembly or 60 days after the first mandatory
8enrollment of a beneficiary in a Coordinated Care program. For
9purposes of this subsection, "Coordinated Care Participating
10Hospital" means a hospital that meets one of the following
12        (1) The hospital has entered into a contract to provide
13    hospital services with one or more MCOs to enrollees of the
14    care coordination program.
15        (2) The hospital has not been offered a contract by a
16    care coordination plan that the Department has determined
17    to be a good faith offer and that pays at least as much as
18    the Department would pay, on a fee-for-service basis, not
19    including disproportionate share hospital adjustment
20    payments or any other supplemental adjustment or add-on
21    payment to the base fee-for-service rate, except to the
22    extent such adjustments or add-on payments are
23    incorporated into the development of the applicable MCO
24    capitated rates.
25    As used in this subsection (f), "MCO" means any entity
26which contracts with the Department to provide services where



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1payment for medical services is made on a capitated basis.
2    (g) No later than August 1, 2013, the Department shall
3issue a purchase of care solicitation for Accountable Care
4Entities (ACE) to serve any children and parents or caretaker
5relatives of children eligible for medical assistance under
6this Article. An ACE may be a single corporate structure or a
7network of providers organized through contractual
8relationships with a single corporate entity. The solicitation
9shall require that:
10        (1) An ACE operating in Cook County be capable of
11    serving at least 40,000 eligible individuals in that
12    county; an ACE operating in Lake, Kane, DuPage, or Will
13    Counties be capable of serving at least 20,000 eligible
14    individuals in those counties and an ACE operating in other
15    regions of the State be capable of serving at least 10,000
16    eligible individuals in the region in which it operates.
17    During initial periods of mandatory enrollment, the
18    Department shall require its enrollment services
19    contractor to use a default assignment algorithm that
20    ensures if possible an ACE reaches the minimum enrollment
21    levels set forth in this paragraph.
22        (2) An ACE must include at a minimum the following
23    types of providers: primary care, specialty care,
24    hospitals, and behavioral healthcare.
25        (3) An ACE shall have a governance structure that
26    includes the major components of the health care delivery



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1    system, including one representative from each of the
2    groups listed in paragraph (2).
3        (4) An ACE must be an integrated delivery system,
4    including a network able to provide the full range of
5    services needed by Medicaid beneficiaries and system
6    capacity to securely pass clinical information across
7    participating entities and to aggregate and analyze that
8    data in order to coordinate care.
9        (5) An ACE must be capable of providing both care
10    coordination and complex case management, as necessary, to
11    beneficiaries. To be responsive to the solicitation, a
12    potential ACE must outline its care coordination and
13    complex case management model and plan to reduce the cost
14    of care.
15        (6) In the first 18 months of operation, unless the ACE
16    selects a shorter period, an ACE shall be paid care
17    coordination fees on a per member per month basis that are
18    projected to be cost neutral to the State during the term
19    of their payment and, subject to federal approval, be
20    eligible to share in additional savings generated by their
21    care coordination.
22        (7) In months 19 through 36 of operation, unless the
23    ACE selects a shorter period, an ACE shall be paid on a
24    pre-paid capitation basis for all medical assistance
25    covered services, under contract terms similar to Managed
26    Care Organizations (MCO), with the Department sharing the



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1    risk through either stop-loss insurance for extremely high
2    cost individuals or corridors of shared risk based on the
3    overall cost of the total enrollment in the ACE. The ACE
4    shall be responsible for claims processing, encounter data
5    submission, utilization control, and quality assurance.
6        (8) In the fourth and subsequent years of operation, an
7    ACE shall convert to a Managed Care Community Network
8    (MCCN), as defined in this Article, or Health Maintenance
9    Organization pursuant to the Illinois Insurance Code,
10    accepting full-risk capitation payments.
11    The Department shall allow potential ACE entities 5 months
12from the date of the posting of the solicitation to submit
13proposals. After the solicitation is released, in addition to
14the MCO rate development data available on the Department's
15website, subject to federal and State confidentiality and
16privacy laws and regulations, the Department shall provide 2
17years of de-identified summary service data on the targeted
18population, split between children and adults, showing the
19historical type and volume of services received and the cost of
20those services to those potential bidders that sign a data use
21agreement. The Department may add up to 2 non-state government
22employees with expertise in creating integrated delivery
23systems to its review team for the purchase of care
24solicitation described in this subsection. Any such
25individuals must sign a no-conflict disclosure and
26confidentiality agreement and agree to act in accordance with



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1all applicable State laws.
2    During the first 2 years of an ACE's operation, the
3Department shall provide claims data to the ACE on its
4enrollees on a periodic basis no less frequently than monthly.
5    Nothing in this subsection shall be construed to limit the
6Department's mandate to enroll 50% of its beneficiaries into
7care coordination systems by January 1, 2015, using all
8available care coordination delivery systems, including Care
9Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
10to affect the current CCEs, MCCNs, and MCOs selected to serve
11seniors and persons with disabilities prior to that date.
12    Nothing in this subsection precludes the Department from
13considering future proposals for new ACEs or expansion of
14existing ACEs at the discretion of the Department.
15    (h) Department contracts with MCOs and other entities
16reimbursed by risk based capitation shall have a minimum
17medical loss ratio of 85%, shall require the entity to
18establish an appeals and grievances process for consumers and
19providers, and shall require the entity to provide a quality
20assurance and utilization review program. Entities contracted
21with the Department to coordinate healthcare regardless of risk
22shall be measured utilizing the same quality metrics. The
23quality metrics may be population specific. Any contracted
24entity serving at least 5,000 seniors or people with
25disabilities or 15,000 individuals in other populations
26covered by the Medical Assistance Program that has been



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1receiving full-risk capitation for a year shall be accredited
2by a national accreditation organization authorized by the
3Department within 2 years after the date it is eligible to
4become accredited. The requirements of this subsection shall
5apply to contracts with MCOs entered into or renewed or
6extended after June 1, 2013.
7    (h-5) The Department shall monitor and enforce compliance
8by MCOs with agreements they have entered into with providers
9on issues that include, but are not limited to, timeliness of
10payment, payment rates, and processes for obtaining prior
11approval. The Department may impose sanctions on MCOs for
12violating provisions of those agreements that include, but are
13not limited to, financial penalties, suspension of enrollment
14of new enrollees, and termination of the MCO's contract with
15the Department. As used in this subsection (h-5), "MCO" has the
16meaning ascribed to that term in Section 5-30.1 of this Code.
17    (i) Unless otherwise required by federal law, Medicaid
18Managed Care Entities shall not divulge, directly or
19indirectly, including by sending a bill or explanation of
20benefits, information concerning the sensitive health services
21received by enrollees of the Medicaid Managed Care Entity to
22any person other than providers and care coordinators caring
23for the enrollee and employees of the entity in the course of
24the entity's internal operations. The Medicaid Managed Care
25Entity may divulge information concerning the sensitive health
26services if the enrollee who received the sensitive health



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1services requests the information from the Medicaid Managed
2Care Entity and authorized the sending of a bill or explanation
3of benefits. Communications including, but not limited to,
4statements of care received or appointment reminders either
5directly or indirectly to the enrollee from the health care
6provider, health care professional, and care coordinators,
7remain permissible.
8    For the purposes of this subsection, the term "Medicaid
9Managed Care Entity" includes Care Coordination Entities,
10Accountable Care Entities, Managed Care Organizations, and
11Managed Care Community Networks.
12    For purposes of this subsection, the term "sensitive health
13services" means mental health services, substance abuse
14treatment services, reproductive health services, family
15planning services, services for sexually transmitted
16infections and sexually transmitted diseases, and services for
17sexual assault or domestic abuse. Services include prevention,
18screening, consultation, examination, treatment, or follow-up.
19    Nothing in this subsection shall be construed to relieve a
20Medicaid Managed Care Entity or the Department of any duty to
21report incidents of sexually transmitted infections to the
22Department of Public Health or to the local board of health in
23accordance with regulations adopted under a statute or
24ordinance or to report incidents of sexually transmitted
25infections as necessary to comply with the requirements under
26Section 5 of the Abused and Neglected Child Reporting Act or as



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1otherwise required by State or federal law.
2    The Department shall create policy in order to implement
3the requirements in this subsection.
4(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13;
598-651, eff. 6-16-14.)
6    Section 99. Effective date. This Act takes effect upon
7becoming law.