99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
SB1273
 
Introduced 2/17/2015, by Sen. Antonio Muņoz
 
SYNOPSIS AS INTRODUCED:



305 ILCS 5/5-30

 Amends the Medical Assistance Article of the Illinois Public Aid Code. In a provision concerning the Department of Healthcare and Family Services' contracts with Managed Care Organizations (MCOs) and other entities reimbursed by risk based capitation, provides that MCOs shall utilize the Department's established methodology for determining the medical necessity of non-emergency transports by ambulance as specified in the Code. Provides that MCOs shall establish an appeals process for denied claims using the same forms and criteria for approval as specified in the Code. Effective July 1, 2015.



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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,

3represented in the General Assembly:



4 Section 5. The Illinois Public Aid Code is amended by 
5changing Section 5-30 as follows:

6 (305 ILCS 5/5-30)
7 Sec. 5-30. Care coordination.
8 (a) At least 50% of recipients eligible for comprehensive 
9medical benefits in all medical assistance programs or other 
10health benefit programs administered by the Department, 
11including the Children's Health Insurance Program Act and the 
12Covering ALL KIDS Health Insurance Act, shall be enrolled in a 
13care coordination program by no later than January 1, 2015. For 
14purposes of this Section, "coordinated care" or "care 
15coordination" means delivery systems where recipients will 
16receive their care from providers who participate under 
17contract in integrated delivery systems that are responsible 
18for providing or arranging the majority of care, including 
19primary care physician services, referrals from primary care 
20physicians, diagnostic and treatment services, behavioral 
21health services, in-patient and outpatient hospital services, 
22dental services, and rehabilitation and long-term care 
23services. The Department shall designate or contract for such 
 
 
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1integrated delivery systems (i) to ensure enrollees have a 
2choice of systems and of primary care providers within such 
3systems; (ii) to ensure that enrollees receive quality care in 
4a culturally and linguistically appropriate manner; and (iii) 
5to ensure that coordinated care programs meet the diverse needs 
6of enrollees with developmental, mental health, physical, and 
7age-related disabilities. 
8 (b) Payment for such coordinated care shall be based on 
9arrangements where the State pays for performance related to 
10health care outcomes, the use of evidence-based practices, the 
11use of primary care delivered through comprehensive medical 
12homes, the use of electronic medical records, and the 
13appropriate exchange of health information electronically made 
14either on a capitated basis in which a fixed monthly premium 
15per recipient is paid and full financial risk is assumed for 
16the delivery of services, or through other risk-based payment 
17arrangements. 
18 (c) To qualify for compliance with this Section, the 50% 
19goal shall be achieved by enrolling medical assistance 
20enrollees from each medical assistance enrollment category, 
21including parents, children, seniors, and people with 
22disabilities to the extent that current State Medicaid payment 
23laws would not limit federal matching funds for recipients in 
24care coordination programs. In addition, services must be more 
25comprehensively defined and more risk shall be assumed than in 
26the Department's primary care case management program as of the 
 
 
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1effective date of this amendatory Act of the 96th General 
2Assembly. 
3 (d) The Department shall report to the General Assembly in 
4a separate part of its annual medical assistance program 
5report, beginning April, 2012 until April, 2016, on the 
6progress and implementation of the care coordination program 
7initiatives established by the provisions of this amendatory 
8Act of the 96th General Assembly. The Department shall include 
9in its April 2011 report a full analysis of federal laws or 
10regulations regarding upper payment limitations to providers 
11and the necessary revisions or adjustments in rate 
12methodologies and payments to providers under this Code that 
13would be necessary to implement coordinated care with full 
14financial risk by a party other than the Department. 

15 (e) Integrated Care Program for individuals with chronic 
16mental health conditions. 
17  (1) The Integrated Care Program shall encompass 
18 services administered to recipients of medical assistance 
19 under this Article to prevent exacerbations and 
20 complications using cost-effective, evidence-based 
21 practice guidelines and mental health management 
22 strategies.
23  (2) The Department may utilize and expand upon existing 
24 contractual arrangements with integrated care plans under 
25 the Integrated Care Program for providing the coordinated 
26 care provisions of this Section.
 
 
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1  (3) Payment for such coordinated care shall be based on 
2 arrangements where the State pays for performance related 
3 to mental health outcomes on a capitated basis in which a 
4 fixed monthly premium per recipient is paid and full 
5 financial risk is assumed for the delivery of services, or 
6 through other risk-based payment arrangements such as 
7 provider-based care coordination.
8  (4) The Department shall examine whether chronic 
9 mental health management programs and services for 
10 recipients with specific chronic mental health conditions 
11 do any or all of the following: 
12   (A) Improve the patient's overall mental health in 
13 a more expeditious and cost-effective manner.
14   (B) Lower costs in other aspects of the medical 
15 assistance program, such as hospital admissions, 
16 emergency room visits, or more frequent and 
17 inappropriate psychotropic drug use. 
18  (5) The Department shall work with the facilities and 
19 any integrated care plan participating in the program to 
20 identify and correct barriers to the successful 
21 implementation of this subsection (e) prior to and during 
22 the implementation to best facilitate the goals and 
23 objectives of this subsection (e).
24 (f) A hospital that is located in a county of the State in 
25which the Department mandates some or all of the beneficiaries 
26of the Medical Assistance Program residing in the county to 
 
 
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1enroll in a Care Coordination Program, as set forth in Section 
25-30 of this Code, shall not be eligible for any non-claims 
3based payments not mandated by Article V-A of this Code for 
4which it would otherwise be qualified to receive, unless the 
5hospital is a Coordinated Care Participating Hospital no later 
6than 60 days after the effective date of this amendatory Act of 
7the 97th General Assembly or 60 days after the first mandatory 
8enrollment of a beneficiary in a Coordinated Care program. For 
9purposes of this subsection, "Coordinated Care Participating 
10Hospital" means a hospital that meets one of the following 
11criteria: 
12  (1) The hospital has entered into a contract to provide 
13 hospital services with one or more MCOs to enrollees of the 
14 care coordination program. 
15  (2) The hospital has not been offered a contract by a 
16 care coordination plan that the Department has determined 
17 to be a good faith offer and that pays at least as much as 
18 the Department would pay, on a fee-for-service basis, not 
19 including disproportionate share hospital adjustment 
20 payments or any other supplemental adjustment or add-on 
21 payment to the base fee-for-service rate, except to the 
22 extent such adjustments or add-on payments are 
23 incorporated into the development of the applicable MCO 
24 capitated rates. 
25 As used in this subsection (f), "MCO" means any entity 
26which contracts with the Department to provide services where 
 
 
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1payment for medical services is made on a capitated basis. 
2 (g) No later than August 1, 2013, the Department shall 
3issue a purchase of care solicitation for Accountable Care 
4Entities (ACE) to serve any children and parents or caretaker 
5relatives of children eligible for medical assistance under 
6this Article. An ACE may be a single corporate structure or a 
7network of providers organized through contractual 
8relationships with a single corporate entity. The solicitation 
9shall require that: 
10  (1) An ACE operating in Cook County be capable of 
11 serving at least 40,000 eligible individuals in that 
12 county; an ACE operating in Lake, Kane, DuPage, or Will 
13 Counties be capable of serving at least 20,000 eligible 
14 individuals in those counties and an ACE operating in other 
15 regions of the State be capable of serving at least 10,000 
16 eligible individuals in the region in which it operates. 
17 During initial periods of mandatory enrollment, the 
18 Department shall require its enrollment services 
19 contractor to use a default assignment algorithm that 
20 ensures if possible an ACE reaches the minimum enrollment 
21 levels set forth in this paragraph. 
22  (2) An ACE must include at a minimum the following 
23 types of providers: primary care, specialty care, 
24 hospitals, and behavioral healthcare. 
25  (3) An ACE shall have a governance structure that 
26 includes the major components of the health care delivery 
 
 
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1 system, including one representative from each of the 
2 groups listed in paragraph (2). 
3  (4) An ACE must be an integrated delivery system, 
4 including a network able to provide the full range of 
5 services needed by Medicaid beneficiaries and system 
6 capacity to securely pass clinical information across 
7 participating entities and to aggregate and analyze that 
8 data in order to coordinate care. 
9  (5) An ACE must be capable of providing both care 
10 coordination and complex case management, as necessary, to 
11 beneficiaries. To be responsive to the solicitation, a 
12 potential ACE must outline its care coordination and 
13 complex case management model and plan to reduce the cost 
14 of care. 
15  (6) In the first 18 months of operation, unless the ACE 
16 selects a shorter period, an ACE shall be paid care 
17 coordination fees on a per member per month basis that are 
18 projected to be cost neutral to the State during the term 
19 of their payment and, subject to federal approval, be 
20 eligible to share in additional savings generated by their 
21 care coordination. 
22  (7) In months 19 through 36 of operation, unless the 
23 ACE selects a shorter period, an ACE shall be paid on a 
24 pre-paid capitation basis for all medical assistance 
25 covered services, under contract terms similar to Managed 
26 Care Organizations (MCO), with the Department sharing the 
 
 
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1 risk through either stop-loss insurance for extremely high 
2 cost individuals or corridors of shared risk based on the 
3 overall cost of the total enrollment in the ACE. The ACE 
4 shall be responsible for claims processing, encounter data 
5 submission, utilization control, and quality assurance. 
6  (8) In the fourth and subsequent years of operation, an 
7 ACE shall convert to a Managed Care Community Network 
8 (MCCN), as defined in this Article, or Health Maintenance 
9 Organization pursuant to the Illinois Insurance Code, 
10 accepting full-risk capitation payments. 
11 The Department shall allow potential ACE entities 5 months 
12from the date of the posting of the solicitation to submit 
13proposals. After the solicitation is released, in addition to 
14the MCO rate development data available on the Department's 
15website, subject to federal and State confidentiality and 
16privacy laws and regulations, the Department shall provide 2 
17years of de-identified summary service data on the targeted 
18population, split between children and adults, showing the 
19historical type and volume of services received and the cost of 
20those services to those potential bidders that sign a data use 
21agreement. The Department may add up to 2 non-state government 
22employees with expertise in creating integrated delivery 
23systems to its review team for the purchase of care 
24solicitation described in this subsection. Any such 
25individuals must sign a no-conflict disclosure and 
26confidentiality agreement and agree to act in accordance with 
 
 
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1all applicable State laws. 
2 During the first 2 years of an ACE's operation, the 
3Department shall provide claims data to the ACE on its 
4enrollees on a periodic basis no less frequently than monthly. 
5 Nothing in this subsection shall be construed to limit the 
6Department's mandate to enroll 50% of its beneficiaries into 
7care coordination systems by January 1, 2015, using all 
8available care coordination delivery systems, including Care 
9Coordination Entities (CCE), MCCNs, or MCOs, nor be construed 
10to affect the current CCEs, MCCNs, and MCOs selected to serve 
11seniors and persons with disabilities prior to that date. 
12 Nothing in this subsection precludes the Department from 
13considering future proposals for new ACEs or expansion of 
14existing ACEs at the discretion of the Department. 
15 (h) Department contracts with MCOs and other entities 
16reimbursed by risk based capitation shall have a minimum 
17medical loss ratio of 85%, shall require the entity to 
18establish an appeals and grievances process for consumers and 
19providers, and shall require the entity to provide a quality 
20assurance and utilization review program. Entities contracted 
21with the Department to coordinate healthcare regardless of risk 
22shall be measured utilizing the same quality metrics. The 
23quality metrics may be population specific. Any contracted 
24entity serving at least 5,000 seniors or people with 
25disabilities or 15,000 individuals in other populations 
26covered by the Medical Assistance Program that has been 
 
 
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1receiving full-risk capitation for a year shall be accredited 
2by a national accreditation organization authorized by the 
3Department within 2 years after the date it is eligible to 
4become accredited. MCOs shall utilize the Department's 
5established methodology for determining the medical necessity 
6of non-emergency transports by ambulance as specified in 
7Section 5-4.2 of this Code. MCOs shall establish an appeals 
8process for denied claims using the same forms and criteria for 
9approval as specified in Section 5-4.2 of this Code. The 
10requirements of this subsection shall apply to contracts with 
11MCOs entered into or renewed or extended after June 1, 2013. 
12 (h-5) The Department shall monitor and enforce compliance 
13by MCOs with agreements they have entered into with providers 
14on issues that include, but are not limited to, timeliness of 
15payment, payment rates, and processes for obtaining prior 
16approval. The Department may impose sanctions on MCOs for 
17violating provisions of those agreements that include, but are 
18not limited to, financial penalties, suspension of enrollment 
19of new enrollees, and termination of the MCO's contract with 
20the Department. As used in this subsection (h-5), "MCO" has the 
21meaning ascribed to that term in Section 5-30.1 of this Code. 
22(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13; 
2398-651, eff. 6-16-14.)


24 Section 99. Effective date. This Act takes effect July 1, 
252015.