Full Text of SB3266 98th General Assembly
SB3266 98TH GENERAL ASSEMBLY |
| | 98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014 SB3266 Introduced 2/14/2014, by Sen. William R. Haine SYNOPSIS AS INTRODUCED: |
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Amends the Illinois Public Aid Code. In provisions concerning the Department of Healthcare and Family Services' care coordination program, provides that such provisions shall not be construed (1) to prevent a local health department from receiving fee-for-service reimbursement for providing services covered by the State's medical assistance program to eligible recipients of medical assistance regardless of their enrollment in a managed care plan or care coordination program, or (2) to prevent certified local health departments from receiving matching funds for expenditures of local tax revenues incurred in the efficient and effective administration of the State's medical assistance program.
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| | | FISCAL NOTE ACT MAY APPLY | |
| | A BILL FOR |
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| 1 | | AN ACT concerning public aid.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 1. Findings. The Illinois General Assembly finds | 5 | | that: | 6 | | (a) Local health departments and school-based health | 7 | | centers have been providing essential prevention, health | 8 | | promotion, primary care, oral health, and behavioral health | 9 | | services to low-income, Medicaid eligible families and | 10 | | individuals for many years in Illinois. | 11 | | (b) School-based and school-linked health centers provide | 12 | | essential behavioral health, health promotion, oral health, | 13 | | and primary care services to elementary, middle, and high | 14 | | school students in many parts of Illinois, providing unique | 15 | | access to services that increase students' ability to be in | 16 | | class healthy and learning. | 17 | | (c) Family planning agencies provide access to | 18 | | reproductive health and women's health care services for many | 19 | | low-income women and men, allowing them to choose the number | 20 | | and spacing of their children. | 21 | | (d) Including these established safety-net providers will | 22 | | increase the health care system's capacity to serve everyone | 23 | | eligible for medical assistance. | 24 | | (e) Since these agencies have been providing health |
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| 1 | | services to eligible recipients of medical assistance for many | 2 | | years and have unique access to vulnerable populations, | 3 | | excluding local health departments, school-based health | 4 | | centers, and family planning providers from participation in | 5 | | managed care and care coordination programs for eligible | 6 | | recipients of medical assistance will be detrimental to the | 7 | | public's health and hamper the State's efforts to reduce infant | 8 | | mortality, promote healthy child development, prevent and | 9 | | reduce overweight and obesity, discourage teen pregnancy, and | 10 | | prevent and control chronic diseases. | 11 | | Section 5. The Illinois Public Aid Code is amended by | 12 | | changing Section 5-30 as follows: | 13 | | (305 ILCS 5/5-30) | 14 | | Sec. 5-30. Care coordination. | 15 | | (a) At least 50% of recipients eligible for comprehensive | 16 | | medical benefits in all medical assistance programs or other | 17 | | health benefit programs administered by the Department, | 18 | | including the Children's Health Insurance Program Act and the | 19 | | Covering ALL KIDS Health Insurance Act, shall be enrolled in a | 20 | | care coordination program by no later than January 1, 2015. For | 21 | | purposes of this Section, "coordinated care" or "care | 22 | | coordination" means delivery systems where recipients will | 23 | | receive their care from providers who participate under | 24 | | contract in integrated delivery systems that are responsible |
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| 1 | | for providing or arranging the majority of care, including | 2 | | primary care physician services, referrals from primary care | 3 | | physicians, diagnostic and treatment services, behavioral | 4 | | health services, in-patient and outpatient hospital services, | 5 | | dental services, and rehabilitation and long-term care | 6 | | services. The Department shall designate or contract for such | 7 | | integrated delivery systems (i) to ensure enrollees have a | 8 | | choice of systems and of primary care providers within such | 9 | | systems; (ii) to ensure that enrollees receive quality care in | 10 | | a culturally and linguistically appropriate manner; and (iii) | 11 | | to ensure that coordinated care programs meet the diverse needs | 12 | | of enrollees with developmental, mental health, physical, and | 13 | | age-related disabilities. | 14 | | (b) Payment for such coordinated care shall be based on | 15 | | arrangements where the State pays for performance related to | 16 | | health care outcomes, the use of evidence-based practices, the | 17 | | use of primary care delivered through comprehensive medical | 18 | | homes, the use of electronic medical records, and the | 19 | | appropriate exchange of health information electronically made | 20 | | either on a capitated basis in which a fixed monthly premium | 21 | | per recipient is paid and full financial risk is assumed for | 22 | | the delivery of services, or through other risk-based payment | 23 | | arrangements. | 24 | | (c) To qualify for compliance with this Section, the 50% | 25 | | goal shall be achieved by enrolling medical assistance | 26 | | enrollees from each medical assistance enrollment category, |
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| 1 | | including parents, children, seniors, and people with | 2 | | disabilities to the extent that current State Medicaid payment | 3 | | laws would not limit federal matching funds for recipients in | 4 | | care coordination programs. In addition, services must be more | 5 | | comprehensively defined and more risk shall be assumed than in | 6 | | the Department's primary care case management program as of the | 7 | | effective date of this amendatory Act of the 96th General | 8 | | Assembly. | 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 this amendatory | 14 | | Act of the 96th General Assembly. The Department shall include | 15 | | in its April 2011 report a full analysis of federal laws or | 16 | | regulations regarding upper payment limitations to providers | 17 | | and the necessary revisions or adjustments in rate | 18 | | methodologies and payments to providers under this Code that | 19 | | would be necessary to implement coordinated care with full | 20 | | financial risk by a party other 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 existing | 4 | | contractual arrangements with integrated care plans under | 5 | | the Integrated Care Program for providing the coordinated | 6 | | care provisions of this Section. | 7 | | (3) Payment for such coordinated care shall be based on | 8 | | arrangements where the State pays for performance related | 9 | | to mental health outcomes on a capitated basis in which a | 10 | | fixed monthly premium per recipient is paid and full | 11 | | financial risk is assumed for the delivery of services, or | 12 | | through other risk-based payment arrangements such as | 13 | | 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 the effective date of this amendatory Act of | 13 | | the 97th General Assembly or 60 days after the first mandatory | 14 | | enrollment of a beneficiary in a Coordinated Care program. For | 15 | | purposes of this subsection, "Coordinated Care Participating | 16 | | Hospital" means a hospital that meets one of the following | 17 | | criteria: | 18 | | (1) The hospital has entered into a contract to provide | 19 | | hospital services to enrollees of the care coordination | 20 | | program. | 21 | | (2) The hospital has not been offered a contract by a | 22 | | care coordination plan that pays at least as much as the | 23 | | 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. |
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| 1 | | (g) No later than August 1, 2013, the Department shall | 2 | | issue a purchase of care solicitation for Accountable Care | 3 | | Entities (ACE) to serve any children and parents or caretaker | 4 | | relatives of children eligible for medical assistance under | 5 | | this Article. An ACE may be a single corporate structure or a | 6 | | network of providers organized through contractual | 7 | | relationships with a single corporate entity. The solicitation | 8 | | shall require that: | 9 | | (1) An ACE operating in Cook County be capable of | 10 | | serving at least 40,000 eligible individuals in that | 11 | | county; an ACE operating in Lake, Kane, DuPage, or Will | 12 | | Counties be capable of serving at least 20,000 eligible | 13 | | individuals in those counties and an ACE operating in other | 14 | | regions of the State be capable of serving at least 10,000 | 15 | | eligible individuals in the region in which it operates. | 16 | | During initial periods of mandatory enrollment, the | 17 | | Department shall require its enrollment services | 18 | | contractor to use a default assignment algorithm that | 19 | | ensures if possible an ACE reaches the minimum enrollment | 20 | | levels set forth in this paragraph. | 21 | | (2) An ACE must include at a minimum the following | 22 | | types of providers: primary care, specialty care, | 23 | | hospitals, and behavioral healthcare. | 24 | | (3) An ACE shall have a governance structure that | 25 | | includes the major components of the health care delivery | 26 | | system, including one representative from each of the |
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| 1 | | groups listed in paragraph (2). | 2 | | (4) An ACE must be an integrated delivery system, | 3 | | including a network able to provide the full range of | 4 | | services needed by Medicaid beneficiaries and system | 5 | | capacity to securely pass clinical information across | 6 | | participating entities and to aggregate and analyze that | 7 | | data in order to coordinate care. | 8 | | (5) An ACE must be capable of providing both care | 9 | | coordination and complex case management, as necessary, to | 10 | | beneficiaries. To be responsive to the solicitation, a | 11 | | potential ACE must outline its care coordination and | 12 | | complex case management model and plan to reduce the cost | 13 | | of care. | 14 | | (6) In the first 18 months of operation, unless the ACE | 15 | | selects a shorter period, an ACE shall be paid care | 16 | | coordination fees on a per member per month basis that are | 17 | | projected to be cost neutral to the State during the term | 18 | | of their payment and, subject to federal approval, be | 19 | | eligible to share in additional savings generated by their | 20 | | care coordination. | 21 | | (7) In months 19 through 36 of operation, unless the | 22 | | ACE selects a shorter period, an ACE shall be paid on a | 23 | | pre-paid capitation basis for all medical assistance | 24 | | covered services, under contract terms similar to Managed | 25 | | Care Organizations (MCO), with the Department sharing the | 26 | | risk through either stop-loss insurance for extremely high |
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| 1 | | cost individuals or corridors of shared risk based on the | 2 | | overall cost of the total enrollment in the ACE. The ACE | 3 | | shall be responsible for claims processing, encounter data | 4 | | submission, utilization control, and quality assurance. | 5 | | (8) In the fourth and subsequent years of operation, an | 6 | | ACE shall convert to a Managed Care Community Network | 7 | | (MCCN), as defined in this Article, or Health Maintenance | 8 | | Organization pursuant to the Illinois Insurance Code, | 9 | | accepting full-risk capitation payments. | 10 | | The Department shall allow potential ACE entities 5 months | 11 | | from the date of the posting of the solicitation to submit | 12 | | proposals. After the solicitation is released, in addition to | 13 | | the MCO rate development data available on the Department's | 14 | | website, subject to federal and State confidentiality and | 15 | | privacy laws and regulations, the Department shall provide 2 | 16 | | years of de-identified summary service data on the targeted | 17 | | population, split between children and adults, showing the | 18 | | historical type and volume of services received and the cost of | 19 | | those services to those potential bidders that sign a data use | 20 | | agreement. The Department may add up to 2 non-state government | 21 | | employees with expertise in creating integrated delivery | 22 | | systems to its review team for the purchase of care | 23 | | solicitation described in this subsection. Any such | 24 | | individuals must sign a no-conflict disclosure and | 25 | | confidentiality agreement and agree to act in accordance with | 26 | | all applicable State laws. |
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| 1 | | During the first 2 years of an ACE's operation, the | 2 | | Department shall provide claims data to the ACE on its | 3 | | enrollees on a periodic basis no less frequently than monthly. | 4 | | Nothing in this subsection shall be construed to limit the | 5 | | Department's mandate to enroll 50% of its beneficiaries into | 6 | | care coordination systems by January 1, 2015, using all | 7 | | available care coordination delivery systems, including Care | 8 | | Coordination Entities (CCE), MCCNs, or MCOs, nor be construed | 9 | | to affect the current CCEs, MCCNs, and MCOs selected to serve | 10 | | seniors and persons with disabilities prior to that date. | 11 | | (h) Department contracts with MCOs and other entities | 12 | | reimbursed by risk based capitation shall have a minimum | 13 | | medical loss ratio of 85%, shall require the MCO or other | 14 | | entity to pay claims within 30 days of receiving a bill that | 15 | | contains all the essential information needed to adjudicate the | 16 | | bill, and shall require the entity to pay a penalty that is at | 17 | | least equal to the penalty imposed under the Illinois Insurance | 18 | | Code for any claims not paid within this time period. The | 19 | | requirements of this subsection shall apply to contracts with | 20 | | MCOs entered into or renewed or extended after June 1, 2013. | 21 | | (i) Nothing in this Section shall be construed (1) to | 22 | | prevent a local health department from receiving | 23 | | fee-for-service reimbursement for providing services covered | 24 | | by the State's medical assistance program to eligible | 25 | | recipients of medical assistance regardless of their | 26 | | enrollment in a managed care plan or care coordination program, |
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| 1 | | or (2) to prevent certified local health departments from | 2 | | receiving matching funds for expenditures of local tax revenues | 3 | | incurred in the efficient and effective administration of the | 4 | | State's medical assistance program. | 5 | | (Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)
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