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91_HB2713
LRB9103967SMpr
1 AN ACT regarding managed care.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Health Maintenance Organization Act is
5 amended by changing Section 5-7.1 as follows:
6 (215 ILCS 125/5-7.1) (from Ch. 111 1/2, par. 1415.1)
7 Sec. 5-7.1. No health care plan shall include any
8 provision which shall have the effect of denying coverage to
9 or on behalf of an enrollee under the such plan on the basis
10 of a failure by the enrollee to file a notice of claim within
11 the time period required by the plan, provided such failure
12 is caused solely by the physical inability or mental
13 incapacity of the enrollee to file such notice of claim
14 because of a period of emergency hospitalization.
15 (Source: P.A. 86-784.)
16 Section 10. The Illinois Public Aid Code is amended by
17 changing Section 5-16 as follows:
18 (305 ILCS 5/5-16) (from Ch. 23, par. 5-16)
19 Sec. 5-16. Managed Care. The Illinois Department may
20 develop and implement a Primary Care Sponsor System
21 consistent with the provisions of this Section. The purpose
22 of this managed care delivery system shall be to contain the
23 costs of providing medical care to Medicaid recipients by
24 having one provider responsible for managing all aspects of a
25 recipient's medical care. This managed care system shall
26 have the following characteristics:
27 (a) The Department, by rule, shall establish
28 criteria to determine which clients must participate in
29 this program;
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1 (b) Providers participating in the program may be
2 paid an amount per patient per month, to be set by the
3 Illinois Department, for managing each recipient's
4 medical care;
5 (c) Providers eligible to participate in the
6 program shall be physicians licensed to practice medicine
7 in all its branches, and the Illinois Department may
8 terminate a provider's participation if the provider is
9 determined to have failed to comply with any applicable
10 program standard or procedure established by the Illinois
11 Department;
12 (d) Each recipient required to participate in the
13 program must select from a panel of primary care
14 providers or networks established by the Department in
15 their communities;
16 (e) A recipient may change his designated primary
17 care provider:
18 (1) when the designated source becomes
19 unavailable, as the Illinois Department shall
20 determine by rule; or
21 (2) when the designated primary care provider
22 notifies the Illinois Department that it wishes to
23 withdraw from any obligation as primary care
24 provider; or
25 (3) in other situations, as the Illinois
26 Department shall provide by rule;
27 (f) The Illinois Department shall, by rule,
28 establish procedures for providing medical services when
29 the designated source becomes unavailable or wishes to
30 withdraw from any obligation as primary care provider
31 taking into consideration the need for emergency or
32 temporary medical assistance and ensuring that the
33 recipient has continuous and unrestricted access to
34 medical care from the date on which the such
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1 unavailability or withdrawal becomes effective until such
2 time as the recipient designates a primary care source;
3 (g) Only medical care services authorized by a
4 recipient's designated provider, except for emergency
5 services, services performed by a provider that is owned
6 or operated by a county and that provides non-emergency
7 services without regard to ability to pay and such other
8 services as provided by the Illinois Department, shall be
9 subject to payment by the Illinois Department. The
10 Illinois Department shall enter into an intergovernmental
11 agreement with each county that owns or operates such a
12 provider to develop and implement policies to minimize
13 the provision of medical care services provided by county
14 owned or operated providers pursuant to the foregoing
15 exception.
16 The Illinois Department shall seek and obtain necessary
17 authorization provided under federal law to implement such a
18 program including the waiver of any federal regulations.
19 The Illinois Department may implement the amendatory
20 changes to this Section made by this amendatory Act of 1991
21 through the use of emergency rules in accordance with the
22 provisions of Section 5.02 of the Illinois Administrative
23 Procedure Act. For purposes of the Illinois Administrative
24 Procedure Act, the adoption of rules to implement the
25 amendatory changes to this Section made by this amendatory
26 Act of 1991 shall be deemed an emergency and necessary for
27 the public interest, safety and welfare.
28 The Illinois Department may establish a managed care
29 system demonstration program, on a limited basis, as
30 described in this Section. The demonstration program shall
31 terminate on June 30, 1997. Within 30 days after the end of
32 each year of the demonstration program's operation, the
33 Illinois Department shall report to the Governor and the
34 General Assembly concerning the operation of the
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1 demonstration program.
2 (Source: P.A. 87-14; 88-490.)