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92_SB0873eng SB873 Engrossed LRB9201523DJgc 1 AN ACT in relation to public aid. 2 Be it enacted by the People of the State of Illinois, 3 represented in the General Assembly: 4 Section 5. The Illinois Public Aid Code is amended by 5 changing Section 5-11 as follows: 6 (305 ILCS 5/5-11) (from Ch. 23, par. 5-11) 7 Sec. 5-11. Co-operative arrangements; contracts with 8 other State agencies, health care and rehabilitation 9 organizations, and fiscal intermediaries. 10 (a) The Illinois Department may enter into co-operative 11 arrangements with State agencies responsible for 12 administering or supervising the administration of health 13 services and vocational rehabilitation services to the end 14 that there may be maximum utilization of such services in the 15 provision of medical assistance. 16 The Illinois Department shall, not later than June 30, 17 1993, enter into one or more co-operative arrangements with 18 the Department of Mental Health and Developmental 19 Disabilities providing that the Department of Mental Health 20 and Developmental Disabilities will be responsible for 21 administering or supervising all programs for services to 22 persons in community care facilities for persons with 23 developmental disabilities, including but not limited to 24 intermediate care facilities, that are supported by State 25 funds or by funding under Title XIX of the federal Social 26 Security Act. The responsibilities of the Department of 27 Mental Health and Developmental Disabilities under these 28 agreements are transferred to the Department of Human 29 Services as provided in the Department of Human Services Act. 30 The Department may also contract with such State health 31 and rehabilitation agencies and other public or private SB873 Engrossed -2- LRB9201523DJgc 1 health care and rehabilitation organizations to act for it in 2 supplying designated medical services to persons eligible 3 therefor under this Article. Any contracts with health 4 services or health maintenance organizations shall be 5 restricted to organizations which have been certified as 6 being in compliance with standards promulgated pursuant to 7 the laws of this State governing the establishment and 8 operation of health services or health maintenance 9 organizations. The Department may also contract with 10 insurance companies or other corporate entities serving as 11 fiscal intermediaries in this State for the Federal 12 Government in respect to Medicare payments under Title XVIII 13 of the Federal Social Security Act to act for the Department 14 in paying medical care suppliers. The provisions of Section 15 9 of "An Act in relation to State finance", approved June 10, 16 1919, as amended, notwithstanding, such contracts with State 17 agencies, other health care and rehabilitation organizations, 18 or fiscal intermediaries may provide for advance payments. 19 (b) For purposes of this subsection (b), "managed care 20 community network" means an entity, other than a health 21 maintenance organization, that is owned, operated, or 22 governed by providers of health care services within this 23 State and that provides or arranges primary, secondary, and 24 tertiary managed health care services under contract with the 25 Illinois Department exclusively to persons participating in 26 programs administered by the Illinois Department. 27 The Illinois Department may certify managed care 28 community networks, including managed care community networks 29 owned, operated, managed, or governed by State-funded medical 30 schools, as risk-bearing entities eligible to contract with 31 the Illinois Department as Medicaid managed care 32 organizations. The Illinois Department may contract with 33 those managed care community networks to furnish health care 34 services to or arrange those services for individuals SB873 Engrossed -3- LRB9201523DJgc 1 participating in programs administered by the Illinois 2 Department. The rates for those provider-sponsored 3 organizations may be determined on a prepaid, capitated 4 basis. A managed care community network may choose to 5 contract with the Illinois Department to provide only 6 pediatric health care services. The Illinois Department shall 7 by rule adopt the criteria, standards, and procedures by 8 which a managed care community network may be permitted to 9 contract with the Illinois Department and shall consult with 10 the Department of Insurance in adopting these rules. 11 A county provider as defined in Section 15-1 of this Code 12 may contract with the Illinois Department to provide primary, 13 secondary, or tertiary managed health care services as a 14 managed care community network without the need to establish 15 a separate entity and shall be deemed a managed care 16 community network for purposes of this Code only to the 17 extent it provides services to participating individuals. A 18 county provider is entitled to contract with the Illinois 19 Department with respect to any contracting region located in 20 whole or in part within the county. A county provider is not 21 required to accept enrollees who do not reside within the 22 county. 23 In order to (i) accelerate and facilitate the development 24 of integrated health care in contracting areas outside 25 counties with populations in excess of 3,000,000 and counties 26 adjacent to those counties and (ii) maintain and sustain the 27 high quality of education and residency programs coordinated 28 and associated with local area hospitals, the Illinois 29 Department may develop and implement a demonstration program 30 from managed care community networks owned, operated, 31 managed, or governed by State-funded medical schools. The 32 Illinois Department shall prescribe by rule the criteria, 33 standards, and procedures for effecting this demonstration 34 program. SB873 Engrossed -4- LRB9201523DJgc 1 A managed care community network that contracts with the 2 Illinois Department to furnish health care services to or 3 arrange those services for enrollees participating in 4 programs administered by the Illinois Department shall do all 5 of the following: 6 (1) Provide that any provider affiliated with the 7 managed care community network may also provide services 8 on a fee-for-service basis to Illinois Department clients 9 not enrolled in such managed care entities. 10 (2) Provide client education services as determined 11 and approved by the Illinois Department, including but 12 not limited to (i) education regarding appropriate 13 utilization of health care services in a managed care 14 system, (ii) written disclosure of treatment policies and 15 restrictions or limitations on health services, 16 including, but not limited to, physical services, 17 clinical laboratory tests, hospital and surgical 18 procedures, prescription drugs and biologics, and 19 radiological examinations, and (iii) written notice that 20 the enrollee may receive from another provider those 21 covered services that are not provided by the managed 22 care community network. 23 (3) Provide that enrollees within the system may 24 choose the site for provision of services and the panel 25 of health care providers. 26 (4) Not discriminate in enrollment or disenrollment 27 practices among recipients of medical services or 28 enrollees based on health status. 29 (5) Provide a quality assurance and utilization 30 review program that meets the requirements established by 31 the Illinois Department in rules that incorporate those 32 standards set forth in the Health Maintenance 33 Organization Act. 34 (6) Issue a managed care community network SB873 Engrossed -5- LRB9201523DJgc 1 identification card to each enrollee upon enrollment. 2 The card must contain all of the following: 3 (A) The enrollee's health plan. 4 (B) The name and telephone number of the 5 enrollee's primary care physician or the site for 6 receiving primary care services. 7 (C) A telephone number to be used to confirm 8 eligibility for benefits and authorization for 9 services that is available 24 hours per day, 7 days 10 per week. 11 (7) Ensure that every primary care physician and 12 pharmacy in the managed care community network meets the 13 standards established by the Illinois Department for 14 accessibility and quality of care. The Illinois 15 Department shall arrange for and oversee an evaluation of 16 the standards established under this paragraph (7) and 17 may recommend any necessary changes to these standards. 18 (8) Provide a procedure for handling complaints 19 that meets the requirements established by the Illinois 20 Department in rules that incorporate those standards set 21 forth in the Health Maintenance Organization Act. 22 (9) Maintain, retain, and make available to the 23 Illinois Department records, data, and information, in a 24 uniform manner determined by the Illinois Department, 25 sufficient for the Illinois Department to monitor 26 utilization, accessibility, and quality of care. 27 (10) Provide that the pharmacy formulary used by 28 the managed care community network and its contract 29 providers be no more restrictive than the Illinois 30 Department's pharmaceutical program on the effective date 31 of this amendatory Act of 1998 and as amended after that 32 date. 33 The Illinois Department shall contract with an entity or 34 entities to provide external peer-based quality assurance SB873 Engrossed -6- LRB9201523DJgc 1 review for the managed health care programs administered by 2 the Illinois Department. The entity shall be representative 3 of Illinois physicians licensed to practice medicine in all 4 its branches and have statewide geographic representation in 5 all specialities of medical care that are provided in managed 6 health care programs administered by the Illinois Department. 7 The entity may not be a third party payer and shall maintain 8 offices in locations around the State in order to provide 9 service and continuing medical education to physician 10 participants within those managed health care programs 11 administered by the Illinois Department. The review process 12 shall be developed and conducted by Illinois physicians 13 licensed to practice medicine in all its branches. In 14 consultation with the entity, the Illinois Department may 15 contract with other entities for professional peer-based 16 quality assurance review of individual categories of services 17 other than services provided, supervised, or coordinated by 18 physicians licensed to practice medicine in all its branches. 19 The Illinois Department shall establish, by rule, criteria to 20 avoid conflicts of interest in the conduct of quality 21 assurance activities consistent with professional peer-review 22 standards. All quality assurance activities shall be 23 coordinated by the Illinois Department. 24 Each managed care community network must demonstrate its 25 ability to bear the financial risk of serving individuals 26 under this program. The Illinois Department shall by rule 27 adopt standards for assessing the solvency and financial 28 soundness of each managed care community network. Any 29 solvency and financial standards adopted for managed care 30 community networks shall be no more restrictive than the 31 solvency and financial standards adopted under Section 32 1856(a) of the Social Security Act for provider-sponsored 33 organizations under Part C of Title XVIII of the Social 34 Security Act. SB873 Engrossed -7- LRB9201523DJgc 1 The Illinois Department may implement the amendatory 2 changes to this Code made by this amendatory Act of 1998 3 through the use of emergency rules in accordance with Section 4 5-45 of the Illinois Administrative Procedure Act. For 5 purposes of that Act, the adoption of rules to implement 6 these changes is deemed an emergency and necessary for the 7 public interest, safety, and welfare. 8 (c) Not later than June 30, 1996, the Illinois 9 Department shall enter into one or more cooperative 10 arrangements with the Department of Public Health for the 11 purpose of developing a single survey for nursing facilities, 12 including but not limited to facilities funded under Title 13 XVIII or Title XIX of the federal Social Security Act or 14 both, which shall be administered and conducted solely by the 15 Department of Public Health. The Departments shall test the 16 single survey process on a pilot basis, with both the 17 Departments of Public Aid and Public Health represented on 18 the consolidated survey team. The pilot will sunset June 30, 19 1997. After June 30, 1997, unless otherwise determined by 20 the Governor, a single survey shall be implemented by the 21 Department of Public Health which would not preclude staff 22 from the Department of Public Aid from going on-site to 23 nursing facilities to perform necessary audits and reviews 24 which shall not replicate the single State agency survey 25 required by this Act. This Section shall not apply to 26 community or intermediate care facilities for persons with 27 developmental disabilities. 28 (d) Nothing in this Code in any way limits or otherwise 29 impairs the authority or power of the Illinois Department to 30 enter into a negotiated contract pursuant to this Section 31 with a managed health care entity (including, but not limited 32 to, a health maintenance organization) that provides for 33 termination or nonrenewal of the contract without cause, upon 34 notice as provided in the contract, and without a hearing. SB873 Engrossed -8- LRB9201523DJgc 1 (Source: P.A. 89-415, eff. 1-1-96; 89-507, eff. 7-1-97; 2 90-618, eff. 7-10-98.) 3 (305 ILCS 5/5-16.3 rep.) 4 Section 6. The Illinois Public Aid Code is amended by 5 repealing Section 5-16.3. 6 Section 99. Effective date. This Act takes effect upon 7 becoming law.