Full Text of SB0647 103rd General Assembly
SB0647sam001 103RD GENERAL ASSEMBLY | Sen. Julie A. Morrison Filed: 4/20/2023
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| 1 | | AMENDMENT TO SENATE BILL 647
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 647 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Illinois Public Aid Code is amended by | 5 | | changing 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 | 9 | | medical benefits in all medical assistance programs or other | 10 | | health benefit programs administered by the Department, | 11 | | including the Children's Health Insurance Program Act and the | 12 | | Covering ALL KIDS Health Insurance Act, shall be enrolled in a | 13 | | care coordination program by no later than January 1, 2015. | 14 | | For purposes of this Section, "coordinated care" or "care | 15 | | coordination" means delivery systems where recipients will | 16 | | receive their care from providers who participate under |
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| 1 | | contract in integrated delivery systems that are responsible | 2 | | for providing or arranging the majority of care, including | 3 | | primary care physician services, referrals from primary care | 4 | | physicians, diagnostic and treatment services, behavioral | 5 | | health services, in-patient and outpatient hospital services, | 6 | | dental services, and rehabilitation and long-term care | 7 | | services. The Department shall designate or contract for such | 8 | | integrated delivery systems (i) to ensure enrollees have a | 9 | | choice of systems and of primary care providers within such | 10 | | systems; (ii) to ensure that enrollees receive quality care in | 11 | | a culturally and linguistically appropriate manner; and (iii) | 12 | | to ensure that coordinated care programs meet the diverse | 13 | | needs of enrollees with developmental, mental health, | 14 | | physical, and age-related disabilities. | 15 | | (b) Payment for such coordinated care shall be based on | 16 | | arrangements where the State pays for performance related to | 17 | | health care outcomes, the use of evidence-based practices, the | 18 | | use of primary care delivered through comprehensive medical | 19 | | homes, the use of electronic medical records, and the | 20 | | appropriate exchange of health information electronically made | 21 | | either on a capitated basis in which a fixed monthly premium | 22 | | per recipient is paid and full financial risk is assumed for | 23 | | the delivery of services, or through other risk-based payment | 24 | | arrangements. | 25 | | (c) To qualify for compliance with this Section, the 50% | 26 | | goal shall be achieved by enrolling medical assistance |
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| 1 | | enrollees from each medical assistance enrollment category, | 2 | | including parents, children, seniors, and people with | 3 | | disabilities to the extent that current State Medicaid payment | 4 | | laws would not limit federal matching funds for recipients in | 5 | | care coordination programs. In addition, services must be more | 6 | | comprehensively defined and more risk shall be assumed than in | 7 | | the Department's primary care case management program as of | 8 | | January 25, 2011 (the effective date of Public Act 96-1501). | 9 | | (d) The Department shall report to the General Assembly in | 10 | | a separate part of its annual medical assistance program | 11 | | report, beginning April, 2012 until April, 2016, on the | 12 | | progress and implementation of the care coordination program | 13 | | initiatives established by the provisions of Public Act | 14 | | 96-1501. The Department shall include in its April 2011 report | 15 | | a full analysis of federal laws or regulations regarding upper | 16 | | payment limitations to providers and the necessary revisions | 17 | | or adjustments in rate methodologies and payments to providers | 18 | | under this Code that would be necessary to implement | 19 | | coordinated care with full financial risk by a party other | 20 | | than the Department.
| 21 | | (e) Integrated Care Program for individuals with chronic | 22 | | mental health conditions. | 23 | | (1) The Integrated Care Program shall encompass | 24 | | services administered to recipients of medical assistance | 25 | | under this Article to prevent exacerbations and | 26 | | complications using cost-effective, evidence-based |
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| 1 | | practice guidelines and mental health management | 2 | | strategies. | 3 | | (2) The Department may utilize and expand upon | 4 | | existing contractual arrangements with integrated care | 5 | | plans under the Integrated Care Program for providing the | 6 | | coordinated care provisions of this Section. | 7 | | (3) Payment for such coordinated care shall be based | 8 | | on arrangements where the State pays for performance | 9 | | related to mental health outcomes on a capitated basis in | 10 | | which a fixed monthly premium per recipient is paid and | 11 | | full financial risk is assumed for the delivery of | 12 | | services, or through other risk-based payment arrangements | 13 | | such as provider-based care coordination. | 14 | | (4) The Department shall examine whether chronic | 15 | | mental health management programs and services for | 16 | | recipients with specific chronic mental health conditions | 17 | | do any or all of the following: | 18 | | (A) Improve the patient's overall mental health in | 19 | | a more expeditious and cost-effective manner. | 20 | | (B) Lower costs in other aspects of the medical | 21 | | assistance program, such as hospital admissions, | 22 | | emergency room visits, or more frequent and | 23 | | inappropriate psychotropic drug use. | 24 | | (5) The Department shall work with the facilities and | 25 | | any integrated care plan participating in the program to | 26 | | identify and correct barriers to the successful |
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| 1 | | implementation of this subsection (e) prior to and during | 2 | | the implementation to best facilitate the goals and | 3 | | objectives of this subsection (e). | 4 | | (f) A hospital that is located in a county of the State in | 5 | | which the Department mandates some or all of the beneficiaries | 6 | | of the Medical Assistance Program residing in the county to | 7 | | enroll in a Care Coordination Program, as set forth in Section | 8 | | 5-30 of this Code, shall not be eligible for any non-claims | 9 | | based payments not mandated by Article V-A of this Code for | 10 | | which it would otherwise be qualified to receive, unless the | 11 | | hospital is a Coordinated Care Participating Hospital no later | 12 | | than 60 days after June 14, 2012 (the effective date of Public | 13 | | Act 97-689) or 60 days after the first mandatory enrollment of | 14 | | a beneficiary in a Coordinated Care program. For purposes of | 15 | | this subsection, "Coordinated Care Participating Hospital" | 16 | | means a hospital that meets one of the following criteria: | 17 | | (1) The hospital has entered into a contract to | 18 | | provide hospital services with one or more MCOs to | 19 | | enrollees of the care coordination program. | 20 | | (2) The hospital has not been offered a contract by a | 21 | | care coordination plan that the Department has determined | 22 | | to be a good faith offer and that pays at least as much as | 23 | | the Department would pay, on a fee-for-service basis, not | 24 | | including disproportionate share hospital adjustment | 25 | | payments or any other supplemental adjustment or add-on | 26 | | payment to the base fee-for-service rate, except to the |
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| 1 | | extent such adjustments or add-on payments are | 2 | | incorporated into the development of the applicable MCO | 3 | | capitated rates. | 4 | | As used in this subsection (f), "MCO" means any entity | 5 | | which contracts with the Department to provide services where | 6 | | payment for medical services is made on a capitated basis. | 7 | | (g) No later than August 1, 2013, the Department shall | 8 | | issue a purchase of care solicitation for Accountable Care | 9 | | Entities (ACE) to serve any children and parents or caretaker | 10 | | relatives of children eligible for medical assistance under | 11 | | this Article. An ACE may be a single corporate structure or a | 12 | | network of providers organized through contractual | 13 | | relationships with a single corporate entity. The solicitation | 14 | | shall require that: | 15 | | (1) An ACE operating in Cook County be capable of | 16 | | serving at least 40,000 eligible individuals in that | 17 | | county; an ACE operating in Lake, Kane, DuPage, or Will | 18 | | Counties be capable of serving at least 20,000 eligible | 19 | | individuals in those counties and an ACE operating in | 20 | | other regions of the State be capable of serving at least | 21 | | 10,000 eligible individuals in the region in which it | 22 | | operates. During initial periods of mandatory enrollment, | 23 | | the Department shall require its enrollment services | 24 | | contractor to use a default assignment algorithm that | 25 | | ensures if possible an ACE reaches the minimum enrollment | 26 | | levels set forth in this paragraph. |
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| 1 | | (2) An ACE must include at a minimum the following | 2 | | types of providers: primary care, specialty care, | 3 | | hospitals, and behavioral healthcare. | 4 | | (3) An ACE shall have a governance structure that | 5 | | includes the major components of the health care delivery | 6 | | system, including one representative from each of the | 7 | | groups listed in paragraph (2). | 8 | | (4) An ACE must be an integrated delivery system, | 9 | | including a network able to provide the full range of | 10 | | services needed by Medicaid beneficiaries and system | 11 | | capacity to securely pass clinical information across | 12 | | participating entities and to aggregate and analyze that | 13 | | data in order to coordinate care. | 14 | | (5) An ACE must be capable of providing both care | 15 | | coordination and complex case management, as necessary, to | 16 | | beneficiaries. To be responsive to the solicitation, a | 17 | | potential ACE must outline its care coordination and | 18 | | complex case management model and plan to reduce the cost | 19 | | of care. | 20 | | (6) In the first 18 months of operation, unless the | 21 | | ACE selects a shorter period, an ACE shall be paid care | 22 | | coordination fees on a per member per month basis that are | 23 | | projected to be cost neutral to the State during the term | 24 | | of their payment and, subject to federal approval, be | 25 | | eligible to share in additional savings generated by their | 26 | | care coordination. |
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| 1 | | (7) In months 19 through 36 of operation, unless the | 2 | | ACE selects a shorter period, an ACE shall be paid on a | 3 | | pre-paid capitation basis for all medical assistance | 4 | | covered services, under contract terms similar to Managed | 5 | | Care Organizations (MCO), with the Department sharing the | 6 | | risk through either stop-loss insurance for extremely high | 7 | | cost individuals or corridors of shared risk based on the | 8 | | overall cost of the total enrollment in the ACE. The ACE | 9 | | shall be responsible for claims processing, encounter data | 10 | | submission, utilization control, and quality assurance. | 11 | | (8) In the fourth and subsequent years of operation, | 12 | | an ACE shall convert to a Managed Care Community Network | 13 | | (MCCN), as defined in this Article, or Health Maintenance | 14 | | Organization pursuant to the Illinois Insurance Code, | 15 | | accepting full-risk capitation payments. | 16 | | The Department shall allow potential ACE entities 5 months | 17 | | from the date of the posting of the solicitation to submit | 18 | | proposals. After the solicitation is released, in addition to | 19 | | the MCO rate development data available on the Department's | 20 | | website, subject to federal and State confidentiality and | 21 | | privacy laws and regulations, the Department shall provide 2 | 22 | | years of de-identified summary service data on the targeted | 23 | | population, split between children and adults, showing the | 24 | | historical type and volume of services received and the cost | 25 | | of those services to those potential bidders that sign a data | 26 | | use agreement. The Department may add up to 2 non-state |
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| 1 | | government employees with expertise in creating integrated | 2 | | delivery systems to its review team for the purchase of care | 3 | | solicitation described in this subsection. Any such | 4 | | individuals must sign a no-conflict disclosure and | 5 | | confidentiality agreement and agree to act in accordance with | 6 | | all applicable State laws. | 7 | | During the first 2 years of an ACE's operation, the | 8 | | Department shall provide claims data to the ACE on its | 9 | | enrollees on a periodic basis no less frequently than monthly. | 10 | | Nothing in this subsection shall be construed to limit the | 11 | | Department's mandate to enroll 50% of its beneficiaries into | 12 | | care coordination systems by January 1, 2015, using all | 13 | | available care coordination delivery systems, including Care | 14 | | Coordination Entities (CCE), MCCNs, or MCOs, nor be construed | 15 | | to affect the current CCEs, MCCNs, and MCOs selected to serve | 16 | | seniors and persons with disabilities prior to that date. | 17 | | Nothing in this subsection precludes the Department from | 18 | | considering future proposals for new ACEs or expansion of | 19 | | existing ACEs at the discretion of the Department. | 20 | | (h) Department contracts with MCOs and other entities | 21 | | reimbursed by risk based capitation shall have a minimum | 22 | | medical loss ratio of 85%, shall require the entity to | 23 | | establish an appeals and grievances process for consumers and | 24 | | providers, and shall require the entity to provide a quality | 25 | | assurance and utilization review program. Entities contracted | 26 | | with the Department to coordinate healthcare regardless of |
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| 1 | | risk shall be measured utilizing the same quality metrics. The | 2 | | quality metrics may be population specific. Any contracted | 3 | | entity serving at least 5,000 seniors or people with | 4 | | disabilities or 15,000 individuals in other populations | 5 | | covered by the Medical Assistance Program that has been | 6 | | receiving full-risk capitation for a year shall be accredited | 7 | | by a national accreditation organization authorized by the | 8 | | Department within 2 years after the date it is eligible to | 9 | | become accredited. The requirements of this subsection shall | 10 | | apply to contracts with MCOs entered into or renewed or | 11 | | extended after June 1, 2013. | 12 | | (h-5) The Department shall monitor and enforce compliance | 13 | | by MCOs with agreements they have entered into with providers | 14 | | on issues that include, but are not limited to, timeliness of | 15 | | payment, payment rates, and processes for obtaining prior | 16 | | approval. The Department may impose sanctions on MCOs for | 17 | | violating provisions of those agreements that include, but are | 18 | | not limited to, financial penalties, suspension of enrollment | 19 | | of new enrollees, and termination of the MCO's contract with | 20 | | the Department. As used in this subsection (h-5), "MCO" has | 21 | | the meaning ascribed to that term in Section 5-30.1 of this | 22 | | Code. | 23 | | (i) Unless otherwise required by federal law, Medicaid | 24 | | Managed Care Entities and their respective business associates | 25 | | shall not disclose, directly or indirectly, including by | 26 | | sending a bill or explanation of benefits, information |
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| 1 | | concerning the sensitive health services received by enrollees | 2 | | of the Medicaid Managed Care Entity to any person other than | 3 | | covered entities and business associates, which may receive, | 4 | | use, and further disclose such information solely for the | 5 | | purposes permitted under applicable federal and State laws and | 6 | | regulations if such use and further disclosure satisfies all | 7 | | applicable requirements of such laws and regulations. The | 8 | | Medicaid Managed Care Entity or its respective business | 9 | | associates may disclose information concerning the sensitive | 10 | | health services if the enrollee who received the sensitive | 11 | | health services requests the information from the Medicaid | 12 | | Managed Care Entity or its respective business associates and | 13 | | authorized the sending of a bill or explanation of benefits. | 14 | | Communications including, but not limited to, statements of | 15 | | care received or appointment reminders either directly or | 16 | | indirectly to the enrollee from the health care provider, | 17 | | health care professional, and care coordinators, remain | 18 | | permissible. Medicaid Managed Care Entities or their | 19 | | respective business associates may communicate directly with | 20 | | their enrollees regarding care coordination activities for | 21 | | those enrollees. | 22 | | For the purposes of this subsection, the term "Medicaid | 23 | | Managed Care Entity" includes Care Coordination Entities, | 24 | | Accountable Care Entities, Managed Care Organizations, and | 25 | | Managed Care Community Networks. | 26 | | For purposes of this subsection, the term "sensitive |
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| 1 | | health services" means mental health services, substance abuse | 2 | | treatment services, reproductive health services, family | 3 | | planning services, services for sexually transmitted | 4 | | infections and sexually transmitted diseases, and services for | 5 | | sexual assault or domestic abuse. Services include prevention, | 6 | | screening, consultation, examination, treatment, or follow-up. | 7 | | For purposes of this subsection, "business associate", | 8 | | "covered entity", "disclosure", and "use" have the meanings | 9 | | ascribed to those terms in 45 CFR 160.103. | 10 | | Nothing in this subsection shall be construed to relieve a | 11 | | Medicaid Managed Care Entity or the Department of any duty to | 12 | | report incidents of sexually transmitted infections to the | 13 | | Department of Public Health or to the local board of health in | 14 | | accordance with regulations adopted under a statute or | 15 | | ordinance or to report incidents of sexually transmitted | 16 | | infections as necessary to comply with the requirements under | 17 | | Section 5 of the Abused and Neglected Child Reporting Act or as | 18 | | otherwise required by State or federal law. | 19 | | The Department shall create policy in order to implement | 20 | | the requirements in this subsection. | 21 | | (j) Managed Care Entities (MCEs), including MCOs and all | 22 | | other care coordination organizations, shall develop and | 23 | | maintain a written language access policy that sets forth the | 24 | | standards, guidelines, and operational plan to ensure language | 25 | | appropriate services and that is consistent with the standard | 26 | | of meaningful access for populations with limited English |
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| 1 | | proficiency. The language access policy shall describe how the | 2 | | MCEs will provide all of the following required services: | 3 | | (1) Translation (the written replacement of text from | 4 | | one language into another) of all vital documents and | 5 | | forms as identified by the Department. | 6 | | (2) Qualified interpreter services (the oral | 7 | | communication of a message from one language into another | 8 | | by a qualified interpreter). | 9 | | (3) Staff training on the language access policy, | 10 | | including how to identify language needs, access and | 11 | | provide language assistance services, work with | 12 | | interpreters, request translations, and track the use of | 13 | | language assistance services. | 14 | | (4) Data tracking that identifies the language need. | 15 | | (5) Notification to participants on the availability | 16 | | of language access services and on how to access such | 17 | | services. | 18 | | (k) The Department shall actively monitor the contractual | 19 | | relationship between Managed Care Organizations (MCOs) and any | 20 | | dental administrator contracted by an MCO to provide dental | 21 | | services. The Department shall adopt appropriate dental | 22 | | Healthcare Effectiveness Data and Information Set (HEDIS) | 23 | | measures and shall include the Annual Dental Visit (ADV) HEDIS | 24 | | measure in its Health Plan Comparison Tool and Illinois | 25 | | Medicaid Plan Report Card that is available on the | 26 | | Department's website for enrolled individuals. |
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| 1 | | The Department shall collect from each MCO specific | 2 | | information about the types of contracted, broad-based care | 3 | | coordination occurring between the MCO and any dental | 4 | | administrator, including, but not limited to, pregnant women | 5 | | and diabetic patients in need of oral care. | 6 | | (l) Notwithstanding any other provision of this Code, the | 7 | | Department may not impose and a dental provider shall not be | 8 | | required to pay any assessment, tax, or fee, the proceeds of | 9 | | which will fund any coordinated care program authorized by | 10 | | this Section. | 11 | | (Source: P.A. 99-106, eff. 1-1-16; 99-181, eff. 7-29-15; | 12 | | 99-566, eff. 1-1-17; 99-642, eff. 7-28-16; 100-587, eff. | 13 | | 6-4-18.)".
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