Illinois General Assembly - Full Text of Public Act 099-0566
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Public Act 099-0566





Public Act 099-0566
SB2331 EnrolledLRB099 19286 KTG 43678 b

    AN ACT concerning public aid.
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
    Section 5. The Illinois Public Aid Code is amended by
changing Section 5-30 as follows:
    (305 ILCS 5/5-30)
    Sec. 5-30. Care coordination.
    (a) At least 50% of recipients eligible for comprehensive
medical benefits in all medical assistance programs or other
health benefit programs administered by the Department,
including the Children's Health Insurance Program Act and the
Covering ALL KIDS Health Insurance Act, shall be enrolled in a
care coordination program by no later than January 1, 2015. For
purposes of this Section, "coordinated care" or "care
coordination" means delivery systems where recipients will
receive their care from providers who participate under
contract in integrated delivery systems that are responsible
for providing or arranging the majority of care, including
primary care physician services, referrals from primary care
physicians, diagnostic and treatment services, behavioral
health services, in-patient and outpatient hospital services,
dental services, and rehabilitation and long-term care
services. The Department shall designate or contract for such
integrated delivery systems (i) to ensure enrollees have a
choice of systems and of primary care providers within such
systems; (ii) to ensure that enrollees receive quality care in
a culturally and linguistically appropriate manner; and (iii)
to ensure that coordinated care programs meet the diverse needs
of enrollees with developmental, mental health, physical, and
age-related disabilities.
    (b) Payment for such coordinated care shall be based on
arrangements where the State pays for performance related to
health care outcomes, the use of evidence-based practices, the
use of primary care delivered through comprehensive medical
homes, the use of electronic medical records, and the
appropriate exchange of health information electronically made
either on a capitated basis in which a fixed monthly premium
per recipient is paid and full financial risk is assumed for
the delivery of services, or through other risk-based payment
    (c) To qualify for compliance with this Section, the 50%
goal shall be achieved by enrolling medical assistance
enrollees from each medical assistance enrollment category,
including parents, children, seniors, and people with
disabilities to the extent that current State Medicaid payment
laws would not limit federal matching funds for recipients in
care coordination programs. In addition, services must be more
comprehensively defined and more risk shall be assumed than in
the Department's primary care case management program as of
January 25, 2011 (the effective date of Public Act 96-1501)
this amendatory Act of the 96th General Assembly.
    (d) The Department shall report to the General Assembly in
a separate part of its annual medical assistance program
report, beginning April, 2012 until April, 2016, on the
progress and implementation of the care coordination program
initiatives established by the provisions of Public Act 96-1501
this amendatory Act of the 96th General Assembly. The
Department shall include in its April 2011 report a full
analysis of federal laws or regulations regarding upper payment
limitations to providers and the necessary revisions or
adjustments in rate methodologies and payments to providers
under this Code that would be necessary to implement
coordinated care with full financial risk by a party other than
the Department.
    (e) Integrated Care Program for individuals with chronic
mental health conditions.
        (1) The Integrated Care Program shall encompass
    services administered to recipients of medical assistance
    under this Article to prevent exacerbations and
    complications using cost-effective, evidence-based
    practice guidelines and mental health management
        (2) The Department may utilize and expand upon existing
    contractual arrangements with integrated care plans under
    the Integrated Care Program for providing the coordinated
    care provisions of this Section.
        (3) Payment for such coordinated care shall be based on
    arrangements where the State pays for performance related
    to mental health outcomes on a capitated basis in which a
    fixed monthly premium per recipient is paid and full
    financial risk is assumed for the delivery of services, or
    through other risk-based payment arrangements such as
    provider-based care coordination.
        (4) The Department shall examine whether chronic
    mental health management programs and services for
    recipients with specific chronic mental health conditions
    do any or all of the following:
            (A) Improve the patient's overall mental health in
        a more expeditious and cost-effective manner.
            (B) Lower costs in other aspects of the medical
        assistance program, such as hospital admissions,
        emergency room visits, or more frequent and
        inappropriate psychotropic drug use.
        (5) The Department shall work with the facilities and
    any integrated care plan participating in the program to
    identify and correct barriers to the successful
    implementation of this subsection (e) prior to and during
    the implementation to best facilitate the goals and
    objectives of this subsection (e).
    (f) A hospital that is located in a county of the State in
which the Department mandates some or all of the beneficiaries
of the Medical Assistance Program residing in the county to
enroll in a Care Coordination Program, as set forth in Section
5-30 of this Code, shall not be eligible for any non-claims
based payments not mandated by Article V-A of this Code for
which it would otherwise be qualified to receive, unless the
hospital is a Coordinated Care Participating Hospital no later
than 60 days after June 14, 2012 (the effective date of Public
Act 97-689) this amendatory Act of the 97th General Assembly or
60 days after the first mandatory enrollment of a beneficiary
in a Coordinated Care program. For purposes of this subsection,
"Coordinated Care Participating Hospital" means a hospital
that meets one of the following criteria:
        (1) The hospital has entered into a contract to provide
    hospital services with one or more MCOs to enrollees of the
    care coordination program.
        (2) The hospital has not been offered a contract by a
    care coordination plan that the Department has determined
    to be a good faith offer and that pays at least as much as
    the Department would pay, on a fee-for-service basis, not
    including disproportionate share hospital adjustment
    payments or any other supplemental adjustment or add-on
    payment to the base fee-for-service rate, except to the
    extent such adjustments or add-on payments are
    incorporated into the development of the applicable MCO
    capitated rates.
    As used in this subsection (f), "MCO" means any entity
which contracts with the Department to provide services where
payment for medical services is made on a capitated basis.
    (g) No later than August 1, 2013, the Department shall
issue a purchase of care solicitation for Accountable Care
Entities (ACE) to serve any children and parents or caretaker
relatives of children eligible for medical assistance under
this Article. An ACE may be a single corporate structure or a
network of providers organized through contractual
relationships with a single corporate entity. The solicitation
shall require that:
        (1) An ACE operating in Cook County be capable of
    serving at least 40,000 eligible individuals in that
    county; an ACE operating in Lake, Kane, DuPage, or Will
    Counties be capable of serving at least 20,000 eligible
    individuals in those counties and an ACE operating in other
    regions of the State be capable of serving at least 10,000
    eligible individuals in the region in which it operates.
    During initial periods of mandatory enrollment, the
    Department shall require its enrollment services
    contractor to use a default assignment algorithm that
    ensures if possible an ACE reaches the minimum enrollment
    levels set forth in this paragraph.
        (2) An ACE must include at a minimum the following
    types of providers: primary care, specialty care,
    hospitals, and behavioral healthcare.
        (3) An ACE shall have a governance structure that
    includes the major components of the health care delivery
    system, including one representative from each of the
    groups listed in paragraph (2).
        (4) An ACE must be an integrated delivery system,
    including a network able to provide the full range of
    services needed by Medicaid beneficiaries and system
    capacity to securely pass clinical information across
    participating entities and to aggregate and analyze that
    data in order to coordinate care.
        (5) An ACE must be capable of providing both care
    coordination and complex case management, as necessary, to
    beneficiaries. To be responsive to the solicitation, a
    potential ACE must outline its care coordination and
    complex case management model and plan to reduce the cost
    of care.
        (6) In the first 18 months of operation, unless the ACE
    selects a shorter period, an ACE shall be paid care
    coordination fees on a per member per month basis that are
    projected to be cost neutral to the State during the term
    of their payment and, subject to federal approval, be
    eligible to share in additional savings generated by their
    care coordination.
        (7) In months 19 through 36 of operation, unless the
    ACE selects a shorter period, an ACE shall be paid on a
    pre-paid capitation basis for all medical assistance
    covered services, under contract terms similar to Managed
    Care Organizations (MCO), with the Department sharing the
    risk through either stop-loss insurance for extremely high
    cost individuals or corridors of shared risk based on the
    overall cost of the total enrollment in the ACE. The ACE
    shall be responsible for claims processing, encounter data
    submission, utilization control, and quality assurance.
        (8) In the fourth and subsequent years of operation, an
    ACE shall convert to a Managed Care Community Network
    (MCCN), as defined in this Article, or Health Maintenance
    Organization pursuant to the Illinois Insurance Code,
    accepting full-risk capitation payments.
    The Department shall allow potential ACE entities 5 months
from the date of the posting of the solicitation to submit
proposals. After the solicitation is released, in addition to
the MCO rate development data available on the Department's
website, subject to federal and State confidentiality and
privacy laws and regulations, the Department shall provide 2
years of de-identified summary service data on the targeted
population, split between children and adults, showing the
historical type and volume of services received and the cost of
those services to those potential bidders that sign a data use
agreement. The Department may add up to 2 non-state government
employees with expertise in creating integrated delivery
systems to its review team for the purchase of care
solicitation described in this subsection. Any such
individuals must sign a no-conflict disclosure and
confidentiality agreement and agree to act in accordance with
all applicable State laws.
    During the first 2 years of an ACE's operation, the
Department shall provide claims data to the ACE on its
enrollees on a periodic basis no less frequently than monthly.
    Nothing in this subsection shall be construed to limit the
Department's mandate to enroll 50% of its beneficiaries into
care coordination systems by January 1, 2015, using all
available care coordination delivery systems, including Care
Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
to affect the current CCEs, MCCNs, and MCOs selected to serve
seniors and persons with disabilities prior to that date.
    Nothing in this subsection precludes the Department from
considering future proposals for new ACEs or expansion of
existing ACEs at the discretion of the Department.
    (h) Department contracts with MCOs and other entities
reimbursed by risk based capitation shall have a minimum
medical loss ratio of 85%, shall require the entity to
establish an appeals and grievances process for consumers and
providers, and shall require the entity to provide a quality
assurance and utilization review program. Entities contracted
with the Department to coordinate healthcare regardless of risk
shall be measured utilizing the same quality metrics. The
quality metrics may be population specific. Any contracted
entity serving at least 5,000 seniors or people with
disabilities or 15,000 individuals in other populations
covered by the Medical Assistance Program that has been
receiving full-risk capitation for a year shall be accredited
by a national accreditation organization authorized by the
Department within 2 years after the date it is eligible to
become accredited. The requirements of this subsection shall
apply to contracts with MCOs entered into or renewed or
extended after June 1, 2013.
    (h-5) The Department shall monitor and enforce compliance
by MCOs with agreements they have entered into with providers
on issues that include, but are not limited to, timeliness of
payment, payment rates, and processes for obtaining prior
approval. The Department may impose sanctions on MCOs for
violating provisions of those agreements that include, but are
not limited to, financial penalties, suspension of enrollment
of new enrollees, and termination of the MCO's contract with
the Department. As used in this subsection (h-5), "MCO" has the
meaning ascribed to that term in Section 5-30.1 of this Code.
    (i) Unless otherwise required by federal law, Medicaid
Managed Care Entities and their respective business associates
shall not disclose divulge, directly or indirectly, including
by sending a bill or explanation of benefits, information
concerning the sensitive health services received by enrollees
of the Medicaid Managed Care Entity to any person other than
covered entities and business associates, which may receive,
use, and further disclose such information solely for the
purposes permitted under applicable federal and State laws and
regulations if such use and further disclosure satisfies all
applicable requirements of such laws and regulations providers
and care coordinators caring for the enrollee and employees of
the entity in the course of the entity's internal operations.
The Medicaid Managed Care Entity or its respective business
associates may disclose divulge information concerning the
sensitive health services if the enrollee who received the
sensitive health services requests the information from the
Medicaid Managed Care Entity or its respective business
associates and authorized the sending of a bill or explanation
of benefits. Communications including, but not limited to,
statements of care received or appointment reminders either
directly or indirectly to the enrollee from the health care
provider, health care professional, and care coordinators,
remain permissible. Medicaid Managed Care Entities or their
respective business associates may communicate directly with
their enrollees regarding care coordination activities for
those enrollees.
    For the purposes of this subsection, the term "Medicaid
Managed Care Entity" includes Care Coordination Entities,
Accountable Care Entities, Managed Care Organizations, and
Managed Care Community Networks.
    For purposes of this subsection, the term "sensitive health
services" means mental health services, substance abuse
treatment services, reproductive health services, family
planning services, services for sexually transmitted
infections and sexually transmitted diseases, and services for
sexual assault or domestic abuse. Services include prevention,
screening, consultation, examination, treatment, or follow-up.
    For purposes of this subsection, "business associate",
"covered entity", "disclosure", and "use" have the meanings
ascribed to those terms in 45 CFR 160.103.
    Nothing in this subsection shall be construed to relieve a
Medicaid Managed Care Entity or the Department of any duty to
report incidents of sexually transmitted infections to the
Department of Public Health or to the local board of health in
accordance with regulations adopted under a statute or
ordinance or to report incidents of sexually transmitted
infections as necessary to comply with the requirements under
Section 5 of the Abused and Neglected Child Reporting Act or as
otherwise required by State or federal law.
    The Department shall create policy in order to implement
the requirements in this subsection.
    (j) (i) Managed Care Entities (MCEs), including MCOs and
all other care coordination organizations, shall develop and
maintain a written language access policy that sets forth the
standards, guidelines, and operational plan to ensure language
appropriate services and that is consistent with the standard
of meaningful access for populations with limited English
proficiency. The language access policy shall describe how the
MCEs will provide all of the following required services:
        (1) Translation (the written replacement of text from
    one language into another) of all vital documents and forms
    as identified by the Department.
        (2) Qualified interpreter services (the oral
    communication of a message from one language into another
    by a qualified interpreter).
        (3) Staff training on the language access policy,
    including how to identify language needs, access and
    provide language assistance services, work with
    interpreters, request translations, and track the use of
    language assistance services.
        (4) Data tracking that identifies the language need.
        (5) Notification to participants on the availability
    of language access services and on how to access such
(Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14;
99-106, eff. 1-1-16; 99-181, eff. 7-29-15; revised 10-26-15.)

Effective Date: 1/1/2017