Illinois General Assembly - Full Text of HB5433
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Full Text of HB5433  100th General Assembly




State of Illinois
2017 and 2018


Introduced , by Rep. Fred Crespo


305 ILCS 5/5-30

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to calculate the payout ratios reported by managed care organizations no less frequently than annually and to post these calculations on its website. Provides that the minimum payout ratio shall be 85% and that a managed care organization not meeting the 85% threshold must refund to the State, for each coverage year, an amount equal to the difference between the calculated payout ratio and 85% multiplied by coverage year revenue for that managed care organization. Defines "payment ratio". Requires the Department to exclusively use paid claims data submitted by managed care organizations in establishing managed care capitation rates. Provides that managed care organizations shall not be reimbursed by the State for any costs associated with health insurance fees.

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HB5433LRB100 19504 KTG 34770 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 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



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1January 25, 2011 (the effective date of Public Act 96-1501).
2    (d) The Department shall report to the General Assembly in
3a separate part of its annual medical assistance program
4report, beginning April, 2012 until April, 2016, on the
5progress and implementation of the care coordination program
6initiatives established by the provisions of Public Act
796-1501. The Department shall include in its April 2011 report
8a full analysis of federal laws or regulations regarding upper
9payment limitations to providers and the necessary revisions or
10adjustments in rate methodologies and payments to providers
11under this Code that would be necessary to implement
12coordinated care with full financial risk by a party other than
13the Department.
14    (e) Integrated Care Program for individuals with chronic
15mental health conditions.
16        (1) The Integrated Care Program shall encompass
17    services administered to recipients of medical assistance
18    under this Article to prevent exacerbations and
19    complications using cost-effective, evidence-based
20    practice guidelines and mental health management
21    strategies.
22        (2) The Department may utilize and expand upon existing
23    contractual arrangements with integrated care plans under
24    the Integrated Care Program for providing the coordinated
25    care provisions of this Section.
26        (3) Payment for such coordinated care shall be based on



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



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15-30 of this Code, shall not be eligible for any non-claims
2based payments not mandated by Article V-A of this Code for
3which it would otherwise be qualified to receive, unless the
4hospital is a Coordinated Care Participating Hospital no later
5than 60 days after June 14, 2012 (the effective date of Public
6Act 97-689) or 60 days after the first mandatory enrollment of
7a beneficiary in a Coordinated Care program. For purposes of
8this subsection, "Coordinated Care Participating Hospital"
9means a hospital that meets one of the following criteria:
10        (1) The hospital has entered into a contract to provide
11    hospital services with one or more MCOs to enrollees of the
12    care coordination program.
13        (2) The hospital has not been offered a contract by a
14    care coordination plan that the Department has determined
15    to be a good faith offer and that pays at least as much as
16    the Department would pay, on a fee-for-service basis, not
17    including disproportionate share hospital adjustment
18    payments or any other supplemental adjustment or add-on
19    payment to the base fee-for-service rate, except to the
20    extent such adjustments or add-on payments are
21    incorporated into the development of the applicable MCO
22    capitated rates.
23    As used in this subsection (f), "MCO" means any entity
24which contracts with the Department to provide services where
25payment for medical services is made on a capitated basis.
26    (g) No later than August 1, 2013, the Department shall



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1issue a purchase of care solicitation for Accountable Care
2Entities (ACE) to serve any children and parents or caretaker
3relatives of children eligible for medical assistance under
4this Article. An ACE may be a single corporate structure or a
5network of providers organized through contractual
6relationships with a single corporate entity. The solicitation
7shall require that:
8        (1) An ACE operating in Cook County be capable of
9    serving at least 40,000 eligible individuals in that
10    county; an ACE operating in Lake, Kane, DuPage, or Will
11    Counties be capable of serving at least 20,000 eligible
12    individuals in those counties and an ACE operating in other
13    regions of the State be capable of serving at least 10,000
14    eligible individuals in the region in which it operates.
15    During initial periods of mandatory enrollment, the
16    Department shall require its enrollment services
17    contractor to use a default assignment algorithm that
18    ensures if possible an ACE reaches the minimum enrollment
19    levels set forth in this paragraph.
20        (2) An ACE must include at a minimum the following
21    types of providers: primary care, specialty care,
22    hospitals, and behavioral healthcare.
23        (3) An ACE shall have a governance structure that
24    includes the major components of the health care delivery
25    system, including one representative from each of the
26    groups listed in paragraph (2).



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



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



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



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1Department within 2 years after the date it is eligible to
2become accredited. The requirements of this subsection shall
3apply to contracts with MCOs entered into or renewed or
4extended after June 1, 2013.
5    (h-2) The Department must calculate the payout ratios
6reported by MCOs no less frequently than annually and post
7these calculations on its website. The minimum payout ratio
8shall be 85%. For an MCO not meeting the 85% threshold, the MCO
9must refund to the State, for each coverage year, an amount
10equal to the difference between the calculated payout ratio and
1185% multiplied by coverage year revenue for that MCO. As used
12in this subsection, "payout ratio" means the total amount of
13paid claims to medical providers by an MCO as reported to the
14Department divided by total capitation payments made by the
15Department to the MCO for any given period of time.
16    (h-3) Beginning with capitation rates for calendar year
172019, the Department must exclusively use paid claims data
18submitted by MCOs in establishing managed care capitation
20    (h-4) MCOs shall not be reimbursed by the State for any
21costs associated with health insurance fees.
22    (h-5) The Department shall monitor and enforce compliance
23by MCOs with agreements they have entered into with providers
24on issues that include, but are not limited to, timeliness of
25payment, payment rates, and processes for obtaining prior
26approval. The Department may impose sanctions on MCOs for



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1violating provisions of those agreements that include, but are
2not limited to, financial penalties, suspension of enrollment
3of new enrollees, and termination of the MCO's contract with
4the Department. As used in this subsection (h-5), "MCO" has the
5meaning ascribed to that term in Section 5-30.1 of this Code.
6    (i) Unless otherwise required by federal law, Medicaid
7Managed Care Entities and their respective business associates
8shall not disclose, directly or indirectly, including by
9sending a bill or explanation of benefits, information
10concerning the sensitive health services received by enrollees
11of the Medicaid Managed Care Entity to any person other than
12covered entities and business associates, which may receive,
13use, and further disclose such information solely for the
14purposes permitted under applicable federal and State laws and
15regulations if such use and further disclosure satisfies all
16applicable requirements of such laws and regulations. The
17Medicaid Managed Care Entity or its respective business
18associates may disclose information concerning the sensitive
19health services if the enrollee who received the sensitive
20health services requests the information from the Medicaid
21Managed Care Entity or its respective business associates and
22authorized the sending of a bill or explanation of benefits.
23Communications including, but not limited to, statements of
24care received or appointment reminders either directly or
25indirectly to the enrollee from the health care provider,
26health care professional, and care coordinators, remain



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1permissible. Medicaid Managed Care Entities or their
2respective business associates may communicate directly with
3their enrollees regarding care coordination activities for
4those enrollees.
5    For the purposes of this subsection, the term "Medicaid
6Managed Care Entity" includes Care Coordination Entities,
7Accountable Care Entities, Managed Care Organizations, and
8Managed Care Community Networks.
9    For purposes of this subsection, the term "sensitive health
10services" means mental health services, substance abuse
11treatment services, reproductive health services, family
12planning services, services for sexually transmitted
13infections and sexually transmitted diseases, and services for
14sexual assault or domestic abuse. Services include prevention,
15screening, consultation, examination, treatment, or follow-up.
16    For purposes of this subsection, "business associate",
17"covered entity", "disclosure", and "use" have the meanings
18ascribed to those terms in 45 CFR 160.103.
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    (j) Managed Care Entities (MCEs), including MCOs and all
5other care coordination organizations, shall develop and
6maintain a written language access policy that sets forth the
7standards, guidelines, and operational plan to ensure language
8appropriate services and that is consistent with the standard
9of meaningful access for populations with limited English
10proficiency. The language access policy shall describe how the
11MCEs will provide all of the following required services:
12        (1) Translation (the written replacement of text from
13    one language into another) of all vital documents and forms
14    as identified by the Department.
15        (2) Qualified interpreter services (the oral
16    communication of a message from one language into another
17    by a qualified interpreter).
18        (3) Staff training on the language access policy,
19    including how to identify language needs, access and
20    provide language assistance services, work with
21    interpreters, request translations, and track the use of
22    language assistance services.
23        (4) Data tracking that identifies the language need.
24        (5) Notification to participants on the availability
25    of language access services and on how to access such
26    services.



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1(Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14;
299-106, eff. 1-1-16; 99-181, eff. 7-29-15; 99-566, eff. 1-1-17;
399-642, eff. 7-28-16.)