Sen. Julie A. Morrison
Filed: 4/20/2023
 
 


 




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1
AMENDMENT TO SENATE BILL 647 




2 AMENDMENT NO. ______. Amend Senate Bill 647 by replacing 
3everything after the enacting clause with the following:


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. 
14For purposes of this Section, "coordinated care" or "care 
15coordination" means delivery systems where recipients will 
16receive their care from providers who participate under 
 
 
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1contract in integrated delivery systems that are responsible 
2for providing or arranging the majority of care, including 
3primary care physician services, referrals from primary care 
4physicians, diagnostic and treatment services, behavioral 
5health services, in-patient and outpatient hospital services, 
6dental services, and rehabilitation and long-term care 
7services. The Department shall designate or contract for such 
8integrated delivery systems (i) to ensure enrollees have a 
9choice of systems and of primary care providers within such 
10systems; (ii) to ensure that enrollees receive quality care in 
11a culturally and linguistically appropriate manner; and (iii) 
12to ensure that coordinated care programs meet the diverse 
13needs of enrollees with developmental, mental health, 
14physical, and age-related disabilities. 
15 (b) Payment for such coordinated care shall be based on 
16arrangements where the State pays for performance related to 
17health care outcomes, the use of evidence-based practices, the 
18use of primary care delivered through comprehensive medical 
19homes, the use of electronic medical records, and the 
20appropriate exchange of health information electronically made 
21either on a capitated basis in which a fixed monthly premium 
22per recipient is paid and full financial risk is assumed for 
23the delivery of services, or through other risk-based payment 
24arrangements. 
25 (c) To qualify for compliance with this Section, the 50% 
26goal shall be achieved by enrolling medical assistance 
 
 
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1enrollees from each medical assistance enrollment category, 
2including parents, children, seniors, and people with 
3disabilities to the extent that current State Medicaid payment 
4laws would not limit federal matching funds for recipients in 
5care coordination programs. In addition, services must be more 
6comprehensively defined and more risk shall be assumed than in 
7the Department's primary care case management program as of 
8January 25, 2011 (the effective date of Public Act 96-1501). 
9 (d) The Department shall report to the General Assembly in 
10a separate part of its annual medical assistance program 
11report, beginning April, 2012 until April, 2016, on the 
12progress and implementation of the care coordination program 
13initiatives established by the provisions of Public Act 
1496-1501. The Department shall include in its April 2011 report 
15a full analysis of federal laws or regulations regarding upper 
16payment limitations to providers and the necessary revisions 
17or adjustments in rate methodologies and payments to providers 
18under this Code that would be necessary to implement 
19coordinated care with full financial risk by a party other 
20than the Department. 

21 (e) Integrated Care Program for individuals with chronic 
22mental health conditions. 
23  (1) The Integrated Care Program shall encompass 
24 services administered to recipients of medical assistance 
25 under this Article to prevent exacerbations and 
26 complications using cost-effective, evidence-based 
 
 
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1 practice guidelines and mental health management 
2 strategies.
3  (2) The Department may utilize and expand upon 
4 existing contractual arrangements with integrated care 
5 plans under the Integrated Care Program for providing the 
6 coordinated care provisions of this Section.
7  (3) Payment for such coordinated care shall be based 
8 on arrangements where the State pays for performance 
9 related to mental health outcomes on a capitated basis in 
10 which a fixed monthly premium per recipient is paid and 
11 full financial risk is assumed for the delivery of 
12 services, or through other risk-based payment arrangements 
13 such as provider-based care coordination.
14  (4) The Department shall examine whether chronic 
15 mental health management programs and services for 
16 recipients with specific chronic mental health conditions 
17 do any or all of the following: 
18   (A) Improve the patient's overall mental health in 
19 a more expeditious and cost-effective manner.
20   (B) Lower costs in other aspects of the medical 
21 assistance program, such as hospital admissions, 
22 emergency room visits, or more frequent and 
23 inappropriate psychotropic drug use. 
24  (5) The Department shall work with the facilities and 
25 any integrated care plan participating in the program to 
26 identify and correct barriers to the successful 
 
 
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1 implementation of this subsection (e) prior to and during 
2 the implementation to best facilitate the goals and 
3 objectives of this subsection (e).
4 (f) A hospital that is located in a county of the State in 
5which the Department mandates some or all of the beneficiaries 
6of the Medical Assistance Program residing in the county to 
7enroll in a Care Coordination Program, as set forth in Section 
85-30 of this Code, shall not be eligible for any non-claims 
9based payments not mandated by Article V-A of this Code for 
10which it would otherwise be qualified to receive, unless the 
11hospital is a Coordinated Care Participating Hospital no later 
12than 60 days after June 14, 2012 (the effective date of Public 
13Act 97-689) or 60 days after the first mandatory enrollment of 
14a beneficiary in a Coordinated Care program. For purposes of 
15this subsection, "Coordinated Care Participating Hospital" 
16means a hospital that meets one of the following criteria: 
17  (1) The hospital has entered into a contract to 
18 provide hospital services with one or more MCOs to 
19 enrollees of the care coordination program. 
20  (2) The hospital has not been offered a contract by a 
21 care coordination plan that the Department has determined 
22 to be a good faith offer and that pays at least as much as 
23 the Department would pay, on a fee-for-service basis, not 
24 including disproportionate share hospital adjustment 
25 payments or any other supplemental adjustment or add-on 
26 payment to the base fee-for-service rate, except to the 
 
 
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1 extent such adjustments or add-on payments are 
2 incorporated into the development of the applicable MCO 
3 capitated rates. 
4 As used in this subsection (f), "MCO" means any entity 
5which contracts with the Department to provide services where 
6payment for medical services is made on a capitated basis. 
7 (g) No later than August 1, 2013, the Department shall 
8issue a purchase of care solicitation for Accountable Care 
9Entities (ACE) to serve any children and parents or caretaker 
10relatives of children eligible for medical assistance under 
11this Article. An ACE may be a single corporate structure or a 
12network of providers organized through contractual 
13relationships with a single corporate entity. The solicitation 
14shall require that: 
15  (1) An ACE operating in Cook County be capable of 
16 serving at least 40,000 eligible individuals in that 
17 county; an ACE operating in Lake, Kane, DuPage, or Will 
18 Counties be capable of serving at least 20,000 eligible 
19 individuals in those counties and an ACE operating in 
20 other regions of the State be capable of serving at least 
21 10,000 eligible individuals in the region in which it 
22 operates. During initial periods of mandatory enrollment, 
23 the Department shall require its enrollment services 
24 contractor to use a default assignment algorithm that 
25 ensures if possible an ACE reaches the minimum enrollment 
26 levels set forth in this paragraph. 
 
 
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1  (2) An ACE must include at a minimum the following 
2 types of providers: primary care, specialty care, 
3 hospitals, and behavioral healthcare. 
4  (3) An ACE shall have a governance structure that 
5 includes the major components of the health care delivery 
6 system, including one representative from each of the 
7 groups listed in paragraph (2). 
8  (4) An ACE must be an integrated delivery system, 
9 including a network able to provide the full range of 
10 services needed by Medicaid beneficiaries and system 
11 capacity to securely pass clinical information across 
12 participating entities and to aggregate and analyze that 
13 data in order to coordinate care. 
14  (5) An ACE must be capable of providing both care 
15 coordination and complex case management, as necessary, to 
16 beneficiaries. To be responsive to the solicitation, a 
17 potential ACE must outline its care coordination and 
18 complex case management model and plan to reduce the cost 
19 of care. 
20  (6) In the first 18 months of operation, unless the 
21 ACE selects a shorter period, an ACE shall be paid care 
22 coordination fees on a per member per month basis that are 
23 projected to be cost neutral to the State during the term 
24 of their payment and, subject to federal approval, be 
25 eligible to share in additional savings generated by their 
26 care coordination. 
 
 
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1  (7) In months 19 through 36 of operation, unless the 
2 ACE selects a shorter period, an ACE shall be paid on a 
3 pre-paid capitation basis for all medical assistance 
4 covered services, under contract terms similar to Managed 
5 Care Organizations (MCO), with the Department sharing the 
6 risk through either stop-loss insurance for extremely high 
7 cost individuals or corridors of shared risk based on the 
8 overall cost of the total enrollment in the ACE. The ACE 
9 shall be responsible for claims processing, encounter data 
10 submission, utilization control, and quality assurance. 
11  (8) In the fourth and subsequent years of operation, 
12 an ACE shall convert to a Managed Care Community Network 
13 (MCCN), as defined in this Article, or Health Maintenance 
14 Organization pursuant to the Illinois Insurance Code, 
15 accepting full-risk capitation payments. 
16 The Department shall allow potential ACE entities 5 months 
17from the date of the posting of the solicitation to submit 
18proposals. After the solicitation is released, in addition to 
19the MCO rate development data available on the Department's 
20website, subject to federal and State confidentiality and 
21privacy laws and regulations, the Department shall provide 2 
22years of de-identified summary service data on the targeted 
23population, split between children and adults, showing the 
24historical type and volume of services received and the cost 
25of those services to those potential bidders that sign a data 
26use agreement. The Department may add up to 2 non-state 
 
 
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1government employees with expertise in creating integrated 
2delivery systems to its review team for the purchase of care 
3solicitation described in this subsection. Any such 
4individuals must sign a no-conflict disclosure and 
5confidentiality agreement and agree to act in accordance with 
6all applicable State laws. 
7 During the first 2 years of an ACE's operation, the 
8Department shall provide claims data to the ACE on its 
9enrollees on a periodic basis no less frequently than monthly. 
10 Nothing in this subsection shall be construed to limit the 
11Department's mandate to enroll 50% of its beneficiaries into 
12care coordination systems by January 1, 2015, using all 
13available care coordination delivery systems, including Care 
14Coordination Entities (CCE), MCCNs, or MCOs, nor be construed 
15to affect the current CCEs, MCCNs, and MCOs selected to serve 
16seniors and persons with disabilities prior to that date. 
17 Nothing in this subsection precludes the Department from 
18considering future proposals for new ACEs or expansion of 
19existing ACEs at the discretion of the Department. 
20 (h) Department contracts with MCOs and other entities 
21reimbursed by risk based capitation shall have a minimum 
22medical loss ratio of 85%, shall require the entity to 
23establish an appeals and grievances process for consumers and 
24providers, and shall require the entity to provide a quality 
25assurance and utilization review program. Entities contracted 
26with the Department to coordinate healthcare regardless of 
 
 
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1risk shall be measured utilizing the same quality metrics. The 
2quality metrics may be population specific. Any contracted 
3entity serving at least 5,000 seniors or people with 
4disabilities or 15,000 individuals in other populations 
5covered by the Medical Assistance Program that has been 
6receiving full-risk capitation for a year shall be accredited 
7by a national accreditation organization authorized by the 
8Department within 2 years after the date it is eligible to 
9become accredited. The requirements of this subsection shall 
10apply to contracts with MCOs entered into or renewed or 
11extended 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 
21the meaning ascribed to that term in Section 5-30.1 of this 
22Code. 
23 (i) Unless otherwise required by federal law, Medicaid 
24Managed Care Entities and their respective business associates 
25shall not disclose, directly or indirectly, including by 
26sending a bill or explanation of benefits, information 
 
 
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1concerning the sensitive health services received by enrollees 
2of the Medicaid Managed Care Entity to any person other than 
3covered entities and business associates, which may receive, 
4use, and further disclose such information solely for the 
5purposes permitted under applicable federal and State laws and 
6regulations if such use and further disclosure satisfies all 
7applicable requirements of such laws and regulations. The 
8Medicaid Managed Care Entity or its respective business 
9associates may disclose information concerning the sensitive 
10health services if the enrollee who received the sensitive 
11health services requests the information from the Medicaid 
12Managed Care Entity or its respective business associates and 
13authorized the sending of a bill or explanation of benefits. 
14Communications including, but not limited to, statements of 
15care received or appointment reminders either directly or 
16indirectly to the enrollee from the health care provider, 
17health care professional, and care coordinators, remain 
18permissible. Medicaid Managed Care Entities or their 
19respective business associates may communicate directly with 
20their enrollees regarding care coordination activities for 
21those enrollees. 
22 For the purposes of this subsection, the term "Medicaid 
23Managed Care Entity" includes Care Coordination Entities, 
24Accountable Care Entities, Managed Care Organizations, and 
25Managed Care Community Networks. 
26 For purposes of this subsection, the term "sensitive 
 
 
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1health services" means mental health services, substance abuse 
2treatment services, reproductive health services, family 
3planning services, services for sexually transmitted 
4infections and sexually transmitted diseases, and services for 
5sexual assault or domestic abuse. Services include prevention, 
6screening, consultation, examination, treatment, or follow-up. 
7 For purposes of this subsection, "business associate", 
8"covered entity", "disclosure", and "use" have the meanings 
9ascribed to those terms in 45 CFR 160.103. 
10 Nothing in this subsection shall be construed to relieve a 
11Medicaid Managed Care Entity or the Department of any duty to 
12report incidents of sexually transmitted infections to the 
13Department of Public Health or to the local board of health in 
14accordance with regulations adopted under a statute or 
15ordinance or to report incidents of sexually transmitted 
16infections as necessary to comply with the requirements under 
17Section 5 of the Abused and Neglected Child Reporting Act or as 
18otherwise required by State or federal law.
19 The Department shall create policy in order to implement 
20the requirements in this subsection. 
21 (j) Managed Care Entities (MCEs), including MCOs and all 
22other care coordination organizations, shall develop and 
23maintain a written language access policy that sets forth the 
24standards, guidelines, and operational plan to ensure language 
25appropriate services and that is consistent with the standard 
26of meaningful access for populations with limited English 
 
 
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1proficiency. The language access policy shall describe how the 
2MCEs will provide all of the following required services:
3  (1) Translation (the written replacement of text from 
4 one language into another) of all vital documents and 
5 forms as identified by the Department.
6  (2) Qualified interpreter services (the oral 
7 communication of a message from one language into another 
8 by a qualified interpreter).
9  (3) Staff training on the language access policy, 
10 including how to identify language needs, access and 
11 provide language assistance services, work with 
12 interpreters, request translations, and track the use of 
13 language assistance services.
14  (4) Data tracking that identifies the language need.
15  (5) Notification to participants on the availability 
16 of language access services and on how to access such 
17 services. 
18 (k) The Department shall actively monitor the contractual 
19relationship between Managed Care Organizations (MCOs) and any 
20dental administrator contracted by an MCO to provide dental 
21services. The Department shall adopt appropriate dental 
22Healthcare Effectiveness Data and Information Set (HEDIS) 
23measures and shall include the Annual Dental Visit (ADV) HEDIS 
24measure in its Health Plan Comparison Tool and Illinois 
25Medicaid Plan Report Card that is available on the 
26Department's website for enrolled individuals.
 
 
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1 The Department shall collect from each MCO specific 
2information about the types of contracted, broad-based care 
3coordination occurring between the MCO and any dental 
4administrator, including, but not limited to, pregnant women 
5and diabetic patients in need of oral care. 
6 (l) Notwithstanding any other provision of this Code, the 
7Department may not impose and a dental provider shall not be 
8required to pay any assessment, tax, or fee, the proceeds of 
9which will fund any coordinated care program authorized by 
10this Section. 
11(Source: P.A. 99-106, eff. 1-1-16; 99-181, eff. 7-29-15; 
1299-566, eff. 1-1-17; 99-642, eff. 7-28-16; 100-587, eff. 
136-4-18.)".