320 ILCS 40/ Program of All-Inclusive Care for the Elderly Act.

(320 ILCS 40/1) (from Ch. 23, par. 6901)

Sec. 1. Short title. This Act may be cited as the Program of All-Inclusive Care for the Elderly Act.

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

(320 ILCS 40/5) (from Ch. 23, par. 6905)

Sec. 5. Legislative declaration. The General Assembly finds and declares that it is the intent of this Act to replicate the On Lok program in San Francisco, California, that has proven to be cost-effective at both the state and federal levels. The PACE program is part of a national replication project authorized in Section 9412(b)(2) of the federal Omnibus Reconciliation Act of 1986, which instructs the Secretary of the federal Department of Health and Human Services to grant Medicare and Medicaid waivers to permit not more than 10 public or nonprofit private community-based organizations in the country to provide comprehensive health care services on a capitated basis to frail elderly who are at risk of institutionalization. The General Assembly finds that by coordinating an extensive array of medical and nonmedical services, the needs of the participants will be met primarily in an outpatient environment in an adult day health center, in their homes, or in an institutional setting. The General Assembly finds that such a service delivery system will enhance the quality of life for the participant and offers the potential to reduce and cap costs to Illinois of the medical needs of the participants, including hospital and nursing home admissions.

The General Assembly declares that the purpose of this Act is to provide services that would foster the following goals:

To maintain eligible persons at home as an alternative to long-term institutionalization;

To provide optimum accessibility to various important social and health resources that are available to assist eligible persons in maintaining independent living;

To provide that eligible persons who are frail elderly but who have the capacity to remain in an independent living situation have access to the appropriate social and health services without which independent living would not be possible;

To coordinate, integrate, and link these social and health services by removing obstacles that impede or limit improvements in delivery of these services;

To provide the most efficient and effective use of capitated funds for the delivery of these social and health services;

To assure that capitation payments amount to no more than 95% of the amount paid under the Medicaid fee-for-service structure of an actuarially similar population.

(Source: P.A. 95-331, eff. 8-21-07.)

(320 ILCS 40/6)

Sec. 6. Definitions. As used in this Act:

"Department" means the Department of Healthcare and Family Services.

"PACE organization" means an entity as defined in 42 CFR 460.6.

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

(320 ILCS 40/10) (from Ch. 23, par. 6910)

Sec. 10. Services for eligible persons. Within the context of the PACE program established under this Act, the Department of Healthcare and Family Services may include any or all of the services in Article V of the Illinois Public Aid Code.

An eligible person may elect to receive services from the PACE program. If such an election is made, the eligible person shall not remain eligible for payment through the regular Medicare or Medicaid program. All services and programs provided through the PACE program shall be provided in accordance with this Act. An eligible person may elect to disenroll from the PACE program at any time.

For purposes of this Act, "eligible person" means a frail elderly individual who voluntarily enrolls in the PACE program, whose income and resources do not exceed limits established by the Department of Healthcare and Family Services and for whom a licensed physician certifies that such a program provides an appropriate alternative to institutionalized care. The term "frail elderly" means an individual who meets the age and functional eligibility requirements established by the Department of Healthcare and Family Services.

(Source: P.A. 94-48, eff. 7-1-05; 95-331, eff. 8-21-07.)

(320 ILCS 40/15) (from Ch. 23, par. 6915)

Sec. 15. Program implementation.

(a) The Department of Healthcare and Family Services must prepare and submit a PACE State Plan amendment no later than December 31, 2022 to the federal Centers for Medicare and Medicaid Services to establish the Program of All-Inclusive Care for the Elderly (PACE program) to provide community-based, risk-based, and capitated long-term care services as optional services under the Illinois Title XIX State Plan and under contracts entered into between the federal Centers for Medicare and Medicaid Services, the Department of Healthcare and Family Services, and PACE organizations, meeting the requirements of the Balanced Budget Act of 1997 (Public Law 105-33) and any other applicable law or regulation.

(b) The Department of Healthcare and Family Services shall facilitate the PACE organization application process no later than December 31, 2023.

(c) All PACE organizations selected shall begin operations no later than June 30, 2024.

(d) Using a risk-based financing model, the organizations contracted to implement the PACE program shall assume responsibility for all costs generated by the PACE program participants, and shall create and maintain a risk reserve fund that will cover any cost overages for any participant. The PACE program is responsible for the entire range of services in the consolidated service model, including hospital and nursing home care, according to participant need as determined by a multidisciplinary team. The contracted organizations are responsible for the full financial risk. Specific arrangements of the risk-based financing model shall be adopted and negotiated by the federal Centers for Medicare and Medicaid Services, the organizations contracted to implement the PACE program, and the Department of Healthcare and Family Services.

(e) The requirements of the PACE model, as provided for under Section 1894 (42 U.S.C. Sec. 1395eee) and Section 1934 (42 U.S.C. Sec. 1396u-4) of the federal Social Security Act, shall not be waived or modified. The requirements that shall not be waived or modified include all of the following:

(1) The focus on frail elderly qualifying individuals who require the level of care provided in a nursing facility.

(2) The delivery of comprehensive, integrated acute and long-term care services.

(3) The interdisciplinary team approach to care management and service delivery.

(4) Capitated, integrated financing that allows the provider to pool payments received from public and private programs and individuals.

(5) The assumption by the provider of full financial risk.

(6) The provision of a PACE benefit package for all participants, regardless of source of payment, that shall include all of the following:

(A) All Medicare-covered items and services.

(B) All Medicaid-covered items and services, as specified in the Illinois Title XIX State Plan.

(C) Other services determined necessary by the interdisciplinary team to improve and maintain the participant's overall health status.

(f) The provisions under Sections 1-7 and 5-4 of the Illinois Public Aid Code and under 80 Ill. Adm. Code 120.379, 120.380, and 120.385 shall apply when determining the eligibility for medical assistance of a person receiving PACE services from an organization providing services under this Act.

(g) Provisions governing the treatment of income and resources of a married couple, for the purposes of determining the eligibility of a nursing-facility certifiable or institutionalized spouse, shall be established so as to qualify for federal financial participation.

(h) Notwithstanding subsection (e), and only to the extent federal financial participation is available, the Department of Healthcare and Family Services, in consultation with PACE organizations, may seek increased federal regulatory flexibility from the federal Centers for Medicare and Medicaid Services to modernize the PACE program, which may include, but is not limited to, addressing all of the following:

(A) Composition of PACE interdisciplinary teams.

(B) Use of community-based physicians.

(C) Marketing practices.

(D) Development of a streamlined PACE waiver process.

This subsection shall be operative upon federal approval of a capitation rate methodology as provided under Section 16.

(i) Each PACE organization shall provide the Department with required reporting documents as set forth in 42 CFR 460.190 through 42 CFR 460.196.

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

(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.)

(320 ILCS 40/20) (from Ch. 23, par. 6920)

Sec. 20. Duties of the Department of Healthcare and Family Services.

(a) The Department of Healthcare and Family Services shall provide a system for reimbursement for services to the PACE program.

(b) The Department of Healthcare and Family Services shall develop and implement contracts with organizations as provided in subsection (d) of Section 15 that set forth contractual obligations for the PACE program, including, but not limited to, reporting and monitoring of utilization of costs of the program as required by the Illinois Department.

(c) The Department of Healthcare and Family Services shall acknowledge that it is participating in the national PACE project as initiated by Congress.

(d) The Department of Healthcare and Family Services or its designee shall be responsible for certifying the eligibility for services of all PACE program participants.

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

(320 ILCS 40/25) (from Ch. 23, par. 6925)

Sec. 25. Rules and regulations. The Department of Healthcare and Family Services shall promulgate rules and regulations necessary to implement this Act.

(Source: P.A. 95-331, eff. 8-21-07.)

(320 ILCS 40/30)

Sec. 30. (Repealed).

(Source: P.A. 95-331, eff. 8-21-07. Repealed by P.A. 102-43, eff. 7-6-21.)