Public Act 90-0254 of the 90th General Assembly
Public Act 90-0254
SB648 Enrolled LRB9001222SMdv
AN ACT to amend the Illinois Public Aid Code by changing
Section 5-16.3.
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 5-16.3 as follows:
(305 ILCS 5/5-16.3)
(Text of Section before amendment by P.A. 89-507)
Sec. 5-16.3. System for integrated health care services.
(a) It shall be the public policy of the State to adopt,
to the extent practicable, a health care program that
encourages the integration of health care services and
manages the health care of program enrollees while preserving
reasonable choice within a competitive and cost-efficient
environment. In furtherance of this public policy, the
Illinois Department shall develop and implement an integrated
health care program consistent with the provisions of this
Section. The provisions of this Section apply only to the
integrated health care program created under this Section.
Persons enrolled in the integrated health care program, as
determined by the Illinois Department by rule, shall be
afforded a choice among health care delivery systems, which
shall include, but are not limited to, (i) fee for service
care managed by a primary care physician licensed to practice
medicine in all its branches, (ii) managed health care
entities, and (iii) federally qualified health centers
(reimbursed according to a prospective cost-reimbursement
methodology) and rural health clinics (reimbursed according
to the Medicare methodology), where available. Persons
enrolled in the integrated health care program also may be
offered indemnity insurance plans, subject to availability.
For purposes of this Section, a "managed health care
entity" means a health maintenance organization or a managed
care community network as defined in this Section. A "health
maintenance organization" means a health maintenance
organization as defined in the Health Maintenance
Organization Act. A "managed care community network" means
an entity, other than a health maintenance organization, that
is owned, operated, or governed by providers of health care
services within this State and that provides or arranges
primary, secondary, and tertiary managed health care services
under contract with the Illinois Department exclusively to
enrollees of the integrated health care program. A managed
care community network may contract with the Illinois
Department to provide only pediatric health care services. A
county provider as defined in Section 15-1 of this Code may
contract with the Illinois Department to provide services to
enrollees of the integrated health care program as a managed
care community network without the need to establish a
separate entity that provides services exclusively to
enrollees of the integrated health care program and shall be
deemed a managed care community network for purposes of this
Code only to the extent of the provision of services to those
enrollees in conjunction with the integrated health care
program. A county provider shall be entitled to contract
with the Illinois Department with respect to any contracting
region located in whole or in part within the county. A
county provider shall not be required to accept enrollees who
do not reside within the county.
Each managed care community network must demonstrate its
ability to bear the financial risk of serving enrollees under
this program. The Illinois Department shall by rule adopt
criteria for assessing the financial soundness of each
managed care community network. These rules shall consider
the extent to which a managed care community network is
comprised of providers who directly render health care and
are located within the community in which they seek to
contract rather than solely arrange or finance the delivery
of health care. These rules shall further consider a variety
of risk-bearing and management techniques, including the
sufficiency of quality assurance and utilization management
programs and whether a managed care community network has
sufficiently demonstrated its financial solvency and net
worth. The Illinois Department's criteria must be based on
sound actuarial, financial, and accounting principles. In
adopting these rules, the Illinois Department shall consult
with the Illinois Department of Insurance. The Illinois
Department is responsible for monitoring compliance with
these rules.
This Section may not be implemented before the effective
date of these rules, the approval of any necessary federal
waivers, and the completion of the review of an application
submitted, at least 60 days before the effective date of
rules adopted under this Section, to the Illinois Department
by a managed care community network.
All health care delivery systems that contract with the
Illinois Department under the integrated health care program
shall clearly recognize a health care provider's right of
conscience under the Right of Conscience Act. In addition to
the provisions of that Act, no health care delivery system
that contracts with the Illinois Department under the
integrated health care program shall be required to provide,
arrange for, or pay for any health care or medical service,
procedure, or product if that health care delivery system is
owned, controlled, or sponsored by or affiliated with a
religious institution or religious organization that finds
that health care or medical service, procedure, or product to
violate its religious and moral teachings and beliefs.
(b) The Illinois Department may, by rule, provide for
different benefit packages for different categories of
persons enrolled in the program. Mental health services,
alcohol and substance abuse services, services related to
children with chronic or acute conditions requiring
longer-term treatment and follow-up, and rehabilitation care
provided by a free-standing rehabilitation hospital or a
hospital rehabilitation unit may be excluded from a benefit
package if the State ensures that those services are made
available through a separate delivery system. An exclusion
does not prohibit the Illinois Department from developing and
implementing demonstration projects for categories of persons
or services. Benefit packages for persons eligible for
medical assistance under Articles V, VI, and XII shall be
based on the requirements of those Articles and shall be
consistent with the Title XIX of the Social Security Act.
Nothing in this Act shall be construed to apply to services
purchased by the Department of Children and Family Services
and the Department of Mental Health and Developmental
Disabilities under the provisions of Title 59 of the Illinois
Administrative Code, Part 132 ("Medicaid Community Mental
Health Services Program").
(c) The program established by this Section may be
implemented by the Illinois Department in various contracting
areas at various times. The health care delivery systems and
providers available under the program may vary throughout the
State. For purposes of contracting with managed health care
entities and providers, the Illinois Department shall
establish contracting areas similar to the geographic areas
designated by the Illinois Department for contracting
purposes under the Illinois Competitive Access and
Reimbursement Equity Program (ICARE) under the authority of
Section 3-4 of the Illinois Health Finance Reform Act or
similarly-sized or smaller geographic areas established by
the Illinois Department by rule. A managed health care entity
shall be permitted to contract in any geographic areas for
which it has a sufficient provider network and otherwise
meets the contracting terms of the State. The Illinois
Department is not prohibited from entering into a contract
with a managed health care entity at any time.
(d) A managed health care entity that contracts with the
Illinois Department for the provision of services under the
program shall do all of the following, solely for purposes of
the integrated health care program:
(1) Provide that any individual physician licensed
to practice medicine in all its branches, any pharmacy,
any federally qualified health center, any
therapeutically certified optometrist, and any
podiatrist, that consistently meets the reasonable terms
and conditions established by the managed health care
entity, including but not limited to credentialing
standards, quality assurance program requirements,
utilization management requirements, financial
responsibility standards, contracting process
requirements, and provider network size and accessibility
requirements, must be accepted by the managed health care
entity for purposes of the Illinois integrated health
care program. Any individual who is either terminated
from or denied inclusion in the panel of physicians of
the managed health care entity shall be given, within 10
business days after that determination, a written
explanation of the reasons for his or her exclusion or
termination from the panel. This paragraph (1) does not
apply to the following:
(A) A managed health care entity that
certifies to the Illinois Department that:
(i) it employs on a full-time basis 125
or more Illinois physicians licensed to
practice medicine in all of its branches; and
(ii) it will provide medical services
through its employees to more than 80% of the
recipients enrolled with the entity in the
integrated health care program; or
(B) A domestic stock insurance company
licensed under clause (b) of class 1 of Section 4 of
the Illinois Insurance Code if (i) at least 66% of
the stock of the insurance company is owned by a
professional corporation organized under the
Professional Service Corporation Act that has 125 or
more shareholders who are Illinois physicians
licensed to practice medicine in all of its branches
and (ii) the insurance company certifies to the
Illinois Department that at least 80% of those
physician shareholders will provide services to
recipients enrolled with the company in the
integrated health care program.
(2) Provide for reimbursement for providers for
emergency care, as defined by the Illinois Department by
rule, that must be provided to its enrollees, including
an emergency room screening fee, and urgent care that it
authorizes for its enrollees, regardless of the
provider's affiliation with the managed health care
entity. Providers shall be reimbursed for emergency care
at an amount equal to the Illinois Department's
fee-for-service rates for those medical services rendered
by providers not under contract with the managed health
care entity to enrollees of the entity.
(3) Provide that any provider affiliated with a
managed health care entity may also provide services on a
fee-for-service basis to Illinois Department clients not
enrolled in a managed health care entity.
(4) Provide client education services as determined
and approved by the Illinois Department, including but
not limited to (i) education regarding appropriate
utilization of health care services in a managed care
system, (ii) written disclosure of treatment policies and
any restrictions or limitations on health services,
including, but not limited to, physical services,
clinical laboratory tests, hospital and surgical
procedures, prescription drugs and biologics, and
radiological examinations, and (iii) written notice that
the enrollee may receive from another provider those
services covered under this program that are not provided
by the managed health care entity.
(5) Provide that enrollees within its system may
choose the site for provision of services and the panel
of health care providers.
(6) Not discriminate in its enrollment or
disenrollment practices among recipients of medical
services or program enrollees based on health status.
(7) Provide a quality assurance and utilization
review program that (i) for health maintenance
organizations meets the requirements of the Health
Maintenance Organization Act and (ii) for managed care
community networks meets the requirements established by
the Illinois Department in rules that incorporate those
standards set forth in the Health Maintenance
Organization Act.
(8) Issue a managed health care entity
identification card to each enrollee upon enrollment.
The card must contain all of the following:
(A) The enrollee's signature.
(B) The enrollee's health plan.
(C) The name and telephone number of the
enrollee's primary care physician.
(D) A telephone number to be used for
emergency service 24 hours per day, 7 days per week.
The telephone number required to be maintained
pursuant to this subparagraph by each managed health
care entity shall, at minimum, be staffed by
medically trained personnel and be provided
directly, or under arrangement, at an office or
offices in locations maintained solely within the
State of Illinois. For purposes of this
subparagraph, "medically trained personnel" means
licensed practical nurses or registered nurses
located in the State of Illinois who are licensed
pursuant to the Illinois Nursing Act of 1987.
(9) Ensure that every primary care physician and
pharmacy in the managed health care entity meets the
standards established by the Illinois Department for
accessibility and quality of care. The Illinois
Department shall arrange for and oversee an evaluation of
the standards established under this paragraph (9) and
may recommend any necessary changes to these standards.
The Illinois Department shall submit an annual report to
the Governor and the General Assembly by April 1 of each
year regarding the effect of the standards on ensuring
access and quality of care to enrollees.
(10) Provide a procedure for handling complaints
that (i) for health maintenance organizations meets the
requirements of the Health Maintenance Organization Act
and (ii) for managed care community networks meets the
requirements established by the Illinois Department in
rules that incorporate those standards set forth in the
Health Maintenance Organization Act.
(11) Maintain, retain, and make available to the
Illinois Department records, data, and information, in a
uniform manner determined by the Illinois Department,
sufficient for the Illinois Department to monitor
utilization, accessibility, and quality of care.
(12) Except for providers who are prepaid, pay all
approved claims for covered services that are completed
and submitted to the managed health care entity within 30
days after receipt of the claim or receipt of the
appropriate capitation payment or payments by the managed
health care entity from the State for the month in which
the services included on the claim were rendered,
whichever is later. If payment is not made or mailed to
the provider by the managed health care entity by the due
date under this subsection, an interest penalty of 1% of
any amount unpaid shall be added for each month or
fraction of a month after the due date, until final
payment is made. Nothing in this Section shall prohibit
managed health care entities and providers from mutually
agreeing to terms that require more timely payment.
(13) Provide integration with community-based
programs provided by certified local health departments
such as Women, Infants, and Children Supplemental Food
Program (WIC), childhood immunization programs, health
education programs, case management programs, and health
screening programs.
(14) Provide that the pharmacy formulary used by a
managed health care entity and its contract providers be
no more restrictive than the Illinois Department's
pharmaceutical program on the effective date of this
amendatory Act of 1994 and as amended after that date.
(15) Provide integration with community-based
organizations, including, but not limited to, any
organization that has operated within a Medicaid
Partnership as defined by this Code or by rule of the
Illinois Department, that may continue to operate under a
contract with the Illinois Department or a managed health
care entity under this Section to provide case management
services to Medicaid clients in designated high-need
areas.
The Illinois Department may, by rule, determine
methodologies to limit financial liability for managed health
care entities resulting from payment for services to
enrollees provided under the Illinois Department's integrated
health care program. Any methodology so determined may be
considered or implemented by the Illinois Department through
a contract with a managed health care entity under this
integrated health care program.
The Illinois Department shall contract with an entity or
entities to provide external peer-based quality assurance
review for the integrated health care program. The entity
shall be representative of Illinois physicians licensed to
practice medicine in all its branches and have statewide
geographic representation in all specialties of medical care
that are provided within the integrated health care program.
The entity may not be a third party payer and shall maintain
offices in locations around the State in order to provide
service and continuing medical education to physician
participants within the integrated health care program. The
review process shall be developed and conducted by Illinois
physicians licensed to practice medicine in all its branches.
In consultation with the entity, the Illinois Department may
contract with other entities for professional peer-based
quality assurance review of individual categories of services
other than services provided, supervised, or coordinated by
physicians licensed to practice medicine in all its branches.
The Illinois Department shall establish, by rule, criteria to
avoid conflicts of interest in the conduct of quality
assurance activities consistent with professional peer-review
standards. All quality assurance activities shall be
coordinated by the Illinois Department.
(e) All persons enrolled in the program shall be
provided with a full written explanation of all
fee-for-service and managed health care plan options and a
reasonable opportunity to choose among the options as
provided by rule. The Illinois Department shall provide to
enrollees, upon enrollment in the integrated health care
program and at least annually thereafter, notice of the
process for requesting an appeal under the Illinois
Department's administrative appeal procedures.
Notwithstanding any other Section of this Code, the Illinois
Department may provide by rule for the Illinois Department to
assign a person enrolled in the program to a specific
provider of medical services or to a specific health care
delivery system if an enrollee has failed to exercise choice
in a timely manner. An enrollee assigned by the Illinois
Department shall be afforded the opportunity to disenroll and
to select a specific provider of medical services or a
specific health care delivery system within the first 30 days
after the assignment. An enrollee who has failed to exercise
choice in a timely manner may be assigned only if there are 3
or more managed health care entities contracting with the
Illinois Department within the contracting area, except that,
outside the City of Chicago, this requirement may be waived
for an area by rules adopted by the Illinois Department after
consultation with all hospitals within the contracting area.
The Illinois Department shall establish by rule the procedure
for random assignment of enrollees who fail to exercise
choice in a timely manner to a specific managed health care
entity in proportion to the available capacity of that
managed health care entity. Assignment to a specific provider
of medical services or to a specific managed health care
entity may not exceed that provider's or entity's capacity as
determined by the Illinois Department. Any person who has
chosen a specific provider of medical services or a specific
managed health care entity, or any person who has been
assigned under this subsection, shall be given the
opportunity to change that choice or assignment at least once
every 12 months, as determined by the Illinois Department by
rule. The Illinois Department shall maintain a toll-free
telephone number for program enrollees' use in reporting
problems with managed health care entities.
(f) If a person becomes eligible for participation in
the integrated health care program while he or she is
hospitalized, the Illinois Department may not enroll that
person in the program until after he or she has been
discharged from the hospital. This subsection does not apply
to newborn infants whose mothers are enrolled in the
integrated health care program.
(g) The Illinois Department shall, by rule, establish
for managed health care entities rates that (i) are certified
to be actuarially sound, as determined by an actuary who is
an associate or a fellow of the Society of Actuaries or a
member of the American Academy of Actuaries and who has
expertise and experience in medical insurance and benefit
programs, in accordance with the Illinois Department's
current fee-for-service payment system, and (ii) take into
account any difference of cost to provide health care to
different populations based on gender, age, location, and
eligibility category. The rates for managed health care
entities shall be determined on a capitated basis.
The Illinois Department by rule shall establish a method
to adjust its payments to managed health care entities in a
manner intended to avoid providing any financial incentive to
a managed health care entity to refer patients to a county
provider, in an Illinois county having a population greater
than 3,000,000, that is paid directly by the Illinois
Department. The Illinois Department shall by April 1, 1997,
and annually thereafter, review the method to adjust
payments. Payments by the Illinois Department to the county
provider, for persons not enrolled in a managed care
community network owned or operated by a county provider,
shall be paid on a fee-for-service basis under Article XV of
this Code.
The Illinois Department by rule shall establish a method
to reduce its payments to managed health care entities to
take into consideration (i) any adjustment payments paid to
hospitals under subsection (h) of this Section to the extent
those payments, or any part of those payments, have been
taken into account in establishing capitated rates under this
subsection (g) and (ii) the implementation of methodologies
to limit financial liability for managed health care entities
under subsection (d) of this Section.
(h) For hospital services provided by a hospital that
contracts with a managed health care entity, adjustment
payments shall be paid directly to the hospital by the
Illinois Department. Adjustment payments may include but
need not be limited to adjustment payments to:
disproportionate share hospitals under Section 5-5.02 of this
Code; primary care access health care education payments (89
Ill. Adm. Code 149.140); payments for capital, direct medical
education, indirect medical education, certified registered
nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
Code 148.290(d)); perinatal center payments (89 Ill. Adm.
Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
148.290(h)); and outpatient indigent volume adjustments (89
Ill. Adm. Code 148.140(b)(5)).
(i) For any hospital eligible for the adjustment
payments described in subsection (h), the Illinois Department
shall maintain, through the period ending June 30, 1995,
reimbursement levels in accordance with statutes and rules in
effect on April 1, 1994.
(j) Nothing contained in this Code in any way limits or
otherwise impairs the authority or power of the Illinois
Department to enter into a negotiated contract pursuant to
this Section with a managed health care entity, including,
but not limited to, a health maintenance organization, that
provides for termination or nonrenewal of the contract
without cause upon notice as provided in the contract and
without a hearing.
(k) Section 5-5.15 does not apply to the program
developed and implemented pursuant to this Section.
(l) The Illinois Department shall, by rule, define those
chronic or acute medical conditions of childhood that require
longer-term treatment and follow-up care. The Illinois
Department shall ensure that services required to treat these
conditions are available through a separate delivery system.
A managed health care entity that contracts with the
Illinois Department may refer a child with medical conditions
described in the rules adopted under this subsection directly
to a children's hospital or to a hospital, other than a
children's hospital, that is qualified to provide inpatient
and outpatient services to treat those conditions. The
Illinois Department shall provide fee-for-service
reimbursement directly to a children's hospital for those
services pursuant to Title 89 of the Illinois Administrative
Code, Section 148.280(a), at a rate at least equal to the
rate in effect on March 31, 1994. For hospitals, other than
children's hospitals, that are qualified to provide inpatient
and outpatient services to treat those conditions, the
Illinois Department shall provide reimbursement for those
services on a fee-for-service basis, at a rate at least equal
to the rate in effect for those other hospitals on March 31,
1994.
A children's hospital shall be directly reimbursed for
all services provided at the children's hospital on a
fee-for-service basis pursuant to Title 89 of the Illinois
Administrative Code, Section 148.280(a), at a rate at least
equal to the rate in effect on March 31, 1994, until the
later of (i) implementation of the integrated health care
program under this Section and development of actuarially
sound capitation rates for services other than those chronic
or acute medical conditions of childhood that require
longer-term treatment and follow-up care as defined by the
Illinois Department in the rules adopted under this
subsection or (ii) March 31, 1996.
Notwithstanding anything in this subsection to the
contrary, a managed health care entity shall not consider
sources or methods of payment in determining the referral of
a child. The Illinois Department shall adopt rules to
establish criteria for those referrals. The Illinois
Department by rule shall establish a method to adjust its
payments to managed health care entities in a manner intended
to avoid providing any financial incentive to a managed
health care entity to refer patients to a provider who is
paid directly by the Illinois Department.
(m) Behavioral health services provided or funded by the
Department of Mental Health and Developmental Disabilities,
the Department of Alcoholism and Substance Abuse, the
Department of Children and Family Services, and the Illinois
Department shall be excluded from a benefit package.
Conditions of an organic or physical origin or nature,
including medical detoxification, however, may not be
excluded. In this subsection, "behavioral health services"
means mental health services and subacute alcohol and
substance abuse treatment services, as defined in the
Illinois Alcoholism and Other Drug Dependency Act. In this
subsection, "mental health services" includes, at a minimum,
the following services funded by the Illinois Department, the
Department of Mental Health and Developmental Disabilities,
or the Department of Children and Family Services: (i)
inpatient hospital services, including related physician
services, related psychiatric interventions, and
pharmaceutical services provided to an eligible recipient
hospitalized with a primary diagnosis of psychiatric
disorder; (ii) outpatient mental health services as defined
and specified in Title 59 of the Illinois Administrative
Code, Part 132; (iii) any other outpatient mental health
services funded by the Illinois Department pursuant to the
State of Illinois Medicaid Plan; (iv) partial
hospitalization; and (v) follow-up stabilization related to
any of those services. Additional behavioral health services
may be excluded under this subsection as mutually agreed in
writing by the Illinois Department and the affected State
agency or agencies. The exclusion of any service does not
prohibit the Illinois Department from developing and
implementing demonstration projects for categories of persons
or services. The Department of Mental Health and
Developmental Disabilities, the Department of Children and
Family Services, and the Department of Alcoholism and
Substance Abuse shall each adopt rules governing the
integration of managed care in the provision of behavioral
health services. The State shall integrate managed care
community networks and affiliated providers, to the extent
practicable, in any separate delivery system for mental
health services.
(n) The Illinois Department shall adopt rules to
establish reserve requirements for managed care community
networks, as required by subsection (a), and health
maintenance organizations to protect against liabilities in
the event that a managed health care entity is declared
insolvent or bankrupt. If a managed health care entity other
than a county provider is declared insolvent or bankrupt,
after liquidation and application of any available assets,
resources, and reserves, the Illinois Department shall pay a
portion of the amounts owed by the managed health care entity
to providers for services rendered to enrollees under the
integrated health care program under this Section based on
the following schedule: (i) from April 1, 1995 through June
30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
through June 30, 2001, 80% of the amounts owed; and (iii)
from July 1, 2001 through June 30, 2005, 75% of the amounts
owed. The amounts paid under this subsection shall be
calculated based on the total amount owed by the managed
health care entity to providers before application of any
available assets, resources, and reserves. After June 30,
2005, the Illinois Department may not pay any amounts owed to
providers as a result of an insolvency or bankruptcy of a
managed health care entity occurring after that date. The
Illinois Department is not obligated, however, to pay amounts
owed to a provider that has an ownership or other governing
interest in the managed health care entity. This subsection
applies only to managed health care entities and the services
they provide under the integrated health care program under
this Section.
(o) Notwithstanding any other provision of law or
contractual agreement to the contrary, providers shall not be
required to accept from any other third party payer the rates
determined or paid under this Code by the Illinois
Department, managed health care entity, or other health care
delivery system for services provided to recipients.
(p) The Illinois Department may seek and obtain any
necessary authorization provided under federal law to
implement the program, including the waiver of any federal
statutes or regulations. The Illinois Department may seek a
waiver of the federal requirement that the combined
membership of Medicare and Medicaid enrollees in a managed
care community network may not exceed 75% of the managed care
community network's total enrollment. The Illinois
Department shall not seek a waiver of this requirement for
any other category of managed health care entity. The
Illinois Department shall not seek a waiver of the inpatient
hospital reimbursement methodology in Section 1902(a)(13)(A)
of Title XIX of the Social Security Act even if the federal
agency responsible for administering Title XIX determines
that Section 1902(a)(13)(A) applies to managed health care
systems.
Notwithstanding any other provisions of this Code to the
contrary, the Illinois Department shall seek a waiver of
applicable federal law in order to impose a co-payment system
consistent with this subsection on recipients of medical
services under Title XIX of the Social Security Act who are
not enrolled in a managed health care entity. The waiver
request submitted by the Illinois Department shall provide
for co-payments of up to $0.50 for prescribed drugs and up to
$0.50 for x-ray services and shall provide for co-payments of
up to $10 for non-emergency services provided in a hospital
emergency room and up to $10 for non-emergency ambulance
services. The purpose of the co-payments shall be to deter
those recipients from seeking unnecessary medical care.
Co-payments may not be used to deter recipients from seeking
necessary medical care. No recipient shall be required to
pay more than a total of $150 per year in co-payments under
the waiver request required by this subsection. A recipient
may not be required to pay more than $15 of any amount due
under this subsection in any one month.
Co-payments authorized under this subsection may not be
imposed when the care was necessitated by a true medical
emergency. Co-payments may not be imposed for any of the
following classifications of services:
(1) Services furnished to person under 18 years of
age.
(2) Services furnished to pregnant women.
(3) Services furnished to any individual who is an
inpatient in a hospital, nursing facility, intermediate
care facility, or other medical institution, if that
person is required to spend for costs of medical care all
but a minimal amount of his or her income required for
personal needs.
(4) Services furnished to a person who is receiving
hospice care.
Co-payments authorized under this subsection shall not be
deducted from or reduce in any way payments for medical
services from the Illinois Department to providers. No
provider may deny those services to an individual eligible
for services based on the individual's inability to pay the
co-payment.
Recipients who are subject to co-payments shall be
provided notice, in plain and clear language, of the amount
of the co-payments, the circumstances under which co-payments
are exempted, the circumstances under which co-payments may
be assessed, and their manner of collection.
The Illinois Department shall establish a Medicaid
Co-Payment Council to assist in the development of co-payment
policies for the medical assistance program. The Medicaid
Co-Payment Council shall also have jurisdiction to develop a
program to provide financial or non-financial incentives to
Medicaid recipients in order to encourage recipients to seek
necessary health care. The Council shall be chaired by the
Director of the Illinois Department, and shall have 6
additional members. Two of the 6 additional members shall be
appointed by the Governor, and one each shall be appointed by
the President of the Senate, the Minority Leader of the
Senate, the Speaker of the House of Representatives, and the
Minority Leader of the House of Representatives. The Council
may be convened and make recommendations upon the appointment
of a majority of its members. The Council shall be appointed
and convened no later than September 1, 1994 and shall report
its recommendations to the Director of the Illinois
Department and the General Assembly no later than October 1,
1994. The chairperson of the Council shall be allowed to
vote only in the case of a tie vote among the appointed
members of the Council.
The Council shall be guided by the following principles
as it considers recommendations to be developed to implement
any approved waivers that the Illinois Department must seek
pursuant to this subsection:
(1) Co-payments should not be used to deter access
to adequate medical care.
(2) Co-payments should be used to reduce fraud.
(3) Co-payment policies should be examined in
consideration of other states' experience, and the
ability of successful co-payment plans to control
unnecessary or inappropriate utilization of services
should be promoted.
(4) All participants, both recipients and
providers, in the medical assistance program have
responsibilities to both the State and the program.
(5) Co-payments are primarily a tool to educate the
participants in the responsible use of health care
resources.
(6) Co-payments should not be used to penalize
providers.
(7) A successful medical program requires the
elimination of improper utilization of medical resources.
The integrated health care program, or any part of that
program, established under this Section may not be
implemented if matching federal funds under Title XIX of the
Social Security Act are not available for administering the
program.
The Illinois Department shall submit for publication in
the Illinois Register the name, address, and telephone number
of the individual to whom a request may be directed for a
copy of the request for a waiver of provisions of Title XIX
of the Social Security Act that the Illinois Department
intends to submit to the Health Care Financing Administration
in order to implement this Section. The Illinois Department
shall mail a copy of that request for waiver to all
requestors at least 16 days before filing that request for
waiver with the Health Care Financing Administration.
(q) After the effective date of this Section, the
Illinois Department may take all planning and preparatory
action necessary to implement this Section, including, but
not limited to, seeking requests for proposals relating to
the integrated health care program created under this
Section.
(r) In order to (i) accelerate and facilitate the
development of integrated health care in contracting areas
outside counties with populations in excess of 3,000,000 and
counties adjacent to those counties and (ii) maintain and
sustain the high quality of education and residency programs
coordinated and associated with local area hospitals, the
Illinois Department may develop and implement a demonstration
program for managed care community networks owned, operated,
or governed by State-funded medical schools. The Illinois
Department shall prescribe by rule the criteria, standards,
and procedures for effecting this demonstration program.
(s) (Blank).
(t) On April 1, 1995 and every 6 months thereafter, the
Illinois Department shall report to the Governor and General
Assembly on the progress of the integrated health care
program in enrolling clients into managed health care
entities. The report shall indicate the capacities of the
managed health care entities with which the State contracts,
the number of clients enrolled by each contractor, the areas
of the State in which managed care options do not exist, and
the progress toward meeting the enrollment goals of the
integrated health care program.
(u) The Illinois Department may implement this Section
through the use of emergency rules in accordance with Section
5-45 of the Illinois Administrative Procedure Act. For
purposes of that Act, the adoption of rules to implement this
Section is deemed an emergency and necessary for the public
interest, safety, and welfare.
(Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
89-673, eff. 8-14-96; revised 8-26-96.)
(Text of Section after amendment by P.A. 89-507)
Sec. 5-16.3. System for integrated health care services.
(a) It shall be the public policy of the State to adopt,
to the extent practicable, a health care program that
encourages the integration of health care services and
manages the health care of program enrollees while preserving
reasonable choice within a competitive and cost-efficient
environment. In furtherance of this public policy, the
Illinois Department shall develop and implement an integrated
health care program consistent with the provisions of this
Section. The provisions of this Section apply only to the
integrated health care program created under this Section.
Persons enrolled in the integrated health care program, as
determined by the Illinois Department by rule, shall be
afforded a choice among health care delivery systems, which
shall include, but are not limited to, (i) fee for service
care managed by a primary care physician licensed to practice
medicine in all its branches, (ii) managed health care
entities, and (iii) federally qualified health centers
(reimbursed according to a prospective cost-reimbursement
methodology) and rural health clinics (reimbursed according
to the Medicare methodology), where available. Persons
enrolled in the integrated health care program also may be
offered indemnity insurance plans, subject to availability.
For purposes of this Section, a "managed health care
entity" means a health maintenance organization or a managed
care community network as defined in this Section. A "health
maintenance organization" means a health maintenance
organization as defined in the Health Maintenance
Organization Act. A "managed care community network" means
an entity, other than a health maintenance organization, that
is owned, operated, or governed by providers of health care
services within this State and that provides or arranges
primary, secondary, and tertiary managed health care services
under contract with the Illinois Department exclusively to
enrollees of the integrated health care program. A managed
care community network may contract with the Illinois
Department to provide only pediatric health care services. A
county provider as defined in Section 15-1 of this Code may
contract with the Illinois Department to provide services to
enrollees of the integrated health care program as a managed
care community network without the need to establish a
separate entity that provides services exclusively to
enrollees of the integrated health care program and shall be
deemed a managed care community network for purposes of this
Code only to the extent of the provision of services to those
enrollees in conjunction with the integrated health care
program. A county provider shall be entitled to contract
with the Illinois Department with respect to any contracting
region located in whole or in part within the county. A
county provider shall not be required to accept enrollees who
do not reside within the county.
Each managed care community network must demonstrate its
ability to bear the financial risk of serving enrollees under
this program. The Illinois Department shall by rule adopt
criteria for assessing the financial soundness of each
managed care community network. These rules shall consider
the extent to which a managed care community network is
comprised of providers who directly render health care and
are located within the community in which they seek to
contract rather than solely arrange or finance the delivery
of health care. These rules shall further consider a variety
of risk-bearing and management techniques, including the
sufficiency of quality assurance and utilization management
programs and whether a managed care community network has
sufficiently demonstrated its financial solvency and net
worth. The Illinois Department's criteria must be based on
sound actuarial, financial, and accounting principles. In
adopting these rules, the Illinois Department shall consult
with the Illinois Department of Insurance. The Illinois
Department is responsible for monitoring compliance with
these rules.
This Section may not be implemented before the effective
date of these rules, the approval of any necessary federal
waivers, and the completion of the review of an application
submitted, at least 60 days before the effective date of
rules adopted under this Section, to the Illinois Department
by a managed care community network.
All health care delivery systems that contract with the
Illinois Department under the integrated health care program
shall clearly recognize a health care provider's right of
conscience under the Right of Conscience Act. In addition to
the provisions of that Act, no health care delivery system
that contracts with the Illinois Department under the
integrated health care program shall be required to provide,
arrange for, or pay for any health care or medical service,
procedure, or product if that health care delivery system is
owned, controlled, or sponsored by or affiliated with a
religious institution or religious organization that finds
that health care or medical service, procedure, or product to
violate its religious and moral teachings and beliefs.
(b) The Illinois Department may, by rule, provide for
different benefit packages for different categories of
persons enrolled in the program. Mental health services,
alcohol and substance abuse services, services related to
children with chronic or acute conditions requiring
longer-term treatment and follow-up, and rehabilitation care
provided by a free-standing rehabilitation hospital or a
hospital rehabilitation unit may be excluded from a benefit
package if the State ensures that those services are made
available through a separate delivery system. An exclusion
does not prohibit the Illinois Department from developing and
implementing demonstration projects for categories of persons
or services. Benefit packages for persons eligible for
medical assistance under Articles V, VI, and XII shall be
based on the requirements of those Articles and shall be
consistent with the Title XIX of the Social Security Act.
Nothing in this Act shall be construed to apply to services
purchased by the Department of Children and Family Services
and the Department of Human Services (as successor to the
Department of Mental Health and Developmental Disabilities)
under the provisions of Title 59 of the Illinois
Administrative Code, Part 132 ("Medicaid Community Mental
Health Services Program").
(c) The program established by this Section may be
implemented by the Illinois Department in various contracting
areas at various times. The health care delivery systems and
providers available under the program may vary throughout the
State. For purposes of contracting with managed health care
entities and providers, the Illinois Department shall
establish contracting areas similar to the geographic areas
designated by the Illinois Department for contracting
purposes under the Illinois Competitive Access and
Reimbursement Equity Program (ICARE) under the authority of
Section 3-4 of the Illinois Health Finance Reform Act or
similarly-sized or smaller geographic areas established by
the Illinois Department by rule. A managed health care entity
shall be permitted to contract in any geographic areas for
which it has a sufficient provider network and otherwise
meets the contracting terms of the State. The Illinois
Department is not prohibited from entering into a contract
with a managed health care entity at any time.
(d) A managed health care entity that contracts with the
Illinois Department for the provision of services under the
program shall do all of the following, solely for purposes of
the integrated health care program:
(1) Provide that any individual physician licensed
to practice medicine in all its branches, any pharmacy,
any federally qualified health center, any
therapeutically certified optometrist, and any
podiatrist, that consistently meets the reasonable terms
and conditions established by the managed health care
entity, including but not limited to credentialing
standards, quality assurance program requirements,
utilization management requirements, financial
responsibility standards, contracting process
requirements, and provider network size and accessibility
requirements, must be accepted by the managed health care
entity for purposes of the Illinois integrated health
care program. Any individual who is either terminated
from or denied inclusion in the panel of physicians of
the managed health care entity shall be given, within 10
business days after that determination, a written
explanation of the reasons for his or her exclusion or
termination from the panel. This paragraph (1) does not
apply to the following:
(A) A managed health care entity that
certifies to the Illinois Department that:
(i) it employs on a full-time basis 125
or more Illinois physicians licensed to
practice medicine in all of its branches; and
(ii) it will provide medical services
through its employees to more than 80% of the
recipients enrolled with the entity in the
integrated health care program; or
(B) A domestic stock insurance company
licensed under clause (b) of class 1 of Section 4 of
the Illinois Insurance Code if (i) at least 66% of
the stock of the insurance company is owned by a
professional corporation organized under the
Professional Service Corporation Act that has 125 or
more shareholders who are Illinois physicians
licensed to practice medicine in all of its branches
and (ii) the insurance company certifies to the
Illinois Department that at least 80% of those
physician shareholders will provide services to
recipients enrolled with the company in the
integrated health care program.
(2) Provide for reimbursement for providers for
emergency care, as defined by the Illinois Department by
rule, that must be provided to its enrollees, including
an emergency room screening fee, and urgent care that it
authorizes for its enrollees, regardless of the
provider's affiliation with the managed health care
entity. Providers shall be reimbursed for emergency care
at an amount equal to the Illinois Department's
fee-for-service rates for those medical services rendered
by providers not under contract with the managed health
care entity to enrollees of the entity.
(3) Provide that any provider affiliated with a
managed health care entity may also provide services on a
fee-for-service basis to Illinois Department clients not
enrolled in a managed health care entity.
(4) Provide client education services as determined
and approved by the Illinois Department, including but
not limited to (i) education regarding appropriate
utilization of health care services in a managed care
system, (ii) written disclosure of treatment policies and
any restrictions or limitations on health services,
including, but not limited to, physical services,
clinical laboratory tests, hospital and surgical
procedures, prescription drugs and biologics, and
radiological examinations, and (iii) written notice that
the enrollee may receive from another provider those
services covered under this program that are not provided
by the managed health care entity.
(5) Provide that enrollees within its system may
choose the site for provision of services and the panel
of health care providers.
(6) Not discriminate in its enrollment or
disenrollment practices among recipients of medical
services or program enrollees based on health status.
(7) Provide a quality assurance and utilization
review program that (i) for health maintenance
organizations meets the requirements of the Health
Maintenance Organization Act and (ii) for managed care
community networks meets the requirements established by
the Illinois Department in rules that incorporate those
standards set forth in the Health Maintenance
Organization Act.
(8) Issue a managed health care entity
identification card to each enrollee upon enrollment.
The card must contain all of the following:
(A) The enrollee's signature.
(B) The enrollee's health plan.
(C) The name and telephone number of the
enrollee's primary care physician.
(D) A telephone number to be used for
emergency service 24 hours per day, 7 days per week.
The telephone number required to be maintained
pursuant to this subparagraph by each managed health
care entity shall, at minimum, be staffed by
medically trained personnel and be provided
directly, or under arrangement, at an office or
offices in locations maintained solely within the
State of Illinois. For purposes of this
subparagraph, "medically trained personnel" means
licensed practical nurses or registered nurses
located in the State of Illinois who are licensed
pursuant to the Illinois Nursing Act of 1987.
(9) Ensure that every primary care physician and
pharmacy in the managed health care entity meets the
standards established by the Illinois Department for
accessibility and quality of care. The Illinois
Department shall arrange for and oversee an evaluation of
the standards established under this paragraph (9) and
may recommend any necessary changes to these standards.
The Illinois Department shall submit an annual report to
the Governor and the General Assembly by April 1 of each
year regarding the effect of the standards on ensuring
access and quality of care to enrollees.
(10) Provide a procedure for handling complaints
that (i) for health maintenance organizations meets the
requirements of the Health Maintenance Organization Act
and (ii) for managed care community networks meets the
requirements established by the Illinois Department in
rules that incorporate those standards set forth in the
Health Maintenance Organization Act.
(11) Maintain, retain, and make available to the
Illinois Department records, data, and information, in a
uniform manner determined by the Illinois Department,
sufficient for the Illinois Department to monitor
utilization, accessibility, and quality of care.
(12) Except for providers who are prepaid, pay all
approved claims for covered services that are completed
and submitted to the managed health care entity within 30
days after receipt of the claim or receipt of the
appropriate capitation payment or payments by the managed
health care entity from the State for the month in which
the services included on the claim were rendered,
whichever is later. If payment is not made or mailed to
the provider by the managed health care entity by the due
date under this subsection, an interest penalty of 1% of
any amount unpaid shall be added for each month or
fraction of a month after the due date, until final
payment is made. Nothing in this Section shall prohibit
managed health care entities and providers from mutually
agreeing to terms that require more timely payment.
(13) Provide integration with community-based
programs provided by certified local health departments
such as Women, Infants, and Children Supplemental Food
Program (WIC), childhood immunization programs, health
education programs, case management programs, and health
screening programs.
(14) Provide that the pharmacy formulary used by a
managed health care entity and its contract providers be
no more restrictive than the Illinois Department's
pharmaceutical program on the effective date of this
amendatory Act of 1994 and as amended after that date.
(15) Provide integration with community-based
organizations, including, but not limited to, any
organization that has operated within a Medicaid
Partnership as defined by this Code or by rule of the
Illinois Department, that may continue to operate under a
contract with the Illinois Department or a managed health
care entity under this Section to provide case management
services to Medicaid clients in designated high-need
areas.
The Illinois Department may, by rule, determine
methodologies to limit financial liability for managed health
care entities resulting from payment for services to
enrollees provided under the Illinois Department's integrated
health care program. Any methodology so determined may be
considered or implemented by the Illinois Department through
a contract with a managed health care entity under this
integrated health care program.
The Illinois Department shall contract with an entity or
entities to provide external peer-based quality assurance
review for the integrated health care program. The entity
shall be representative of Illinois physicians licensed to
practice medicine in all its branches and have statewide
geographic representation in all specialties of medical care
that are provided within the integrated health care program.
The entity may not be a third party payer and shall maintain
offices in locations around the State in order to provide
service and continuing medical education to physician
participants within the integrated health care program. The
review process shall be developed and conducted by Illinois
physicians licensed to practice medicine in all its branches.
In consultation with the entity, the Illinois Department may
contract with other entities for professional peer-based
quality assurance review of individual categories of services
other than services provided, supervised, or coordinated by
physicians licensed to practice medicine in all its branches.
The Illinois Department shall establish, by rule, criteria to
avoid conflicts of interest in the conduct of quality
assurance activities consistent with professional peer-review
standards. All quality assurance activities shall be
coordinated by the Illinois Department.
(e) All persons enrolled in the program shall be
provided with a full written explanation of all
fee-for-service and managed health care plan options and a
reasonable opportunity to choose among the options as
provided by rule. The Illinois Department shall provide to
enrollees, upon enrollment in the integrated health care
program and at least annually thereafter, notice of the
process for requesting an appeal under the Illinois
Department's administrative appeal procedures.
Notwithstanding any other Section of this Code, the Illinois
Department may provide by rule for the Illinois Department to
assign a person enrolled in the program to a specific
provider of medical services or to a specific health care
delivery system if an enrollee has failed to exercise choice
in a timely manner. An enrollee assigned by the Illinois
Department shall be afforded the opportunity to disenroll and
to select a specific provider of medical services or a
specific health care delivery system within the first 30 days
after the assignment. An enrollee who has failed to exercise
choice in a timely manner may be assigned only if there are 3
or more managed health care entities contracting with the
Illinois Department within the contracting area, except that,
outside the City of Chicago, this requirement may be waived
for an area by rules adopted by the Illinois Department after
consultation with all hospitals within the contracting area.
The Illinois Department shall establish by rule the procedure
for random assignment of enrollees who fail to exercise
choice in a timely manner to a specific managed health care
entity in proportion to the available capacity of that
managed health care entity. Assignment to a specific provider
of medical services or to a specific managed health care
entity may not exceed that provider's or entity's capacity as
determined by the Illinois Department. Any person who has
chosen a specific provider of medical services or a specific
managed health care entity, or any person who has been
assigned under this subsection, shall be given the
opportunity to change that choice or assignment at least once
every 12 months, as determined by the Illinois Department by
rule. The Illinois Department shall maintain a toll-free
telephone number for program enrollees' use in reporting
problems with managed health care entities.
(f) If a person becomes eligible for participation in
the integrated health care program while he or she is
hospitalized, the Illinois Department may not enroll that
person in the program until after he or she has been
discharged from the hospital. This subsection does not apply
to newborn infants whose mothers are enrolled in the
integrated health care program.
(g) The Illinois Department shall, by rule, establish
for managed health care entities rates that (i) are certified
to be actuarially sound, as determined by an actuary who is
an associate or a fellow of the Society of Actuaries or a
member of the American Academy of Actuaries and who has
expertise and experience in medical insurance and benefit
programs, in accordance with the Illinois Department's
current fee-for-service payment system, and (ii) take into
account any difference of cost to provide health care to
different populations based on gender, age, location, and
eligibility category. The rates for managed health care
entities shall be determined on a capitated basis.
The Illinois Department by rule shall establish a method
to adjust its payments to managed health care entities in a
manner intended to avoid providing any financial incentive to
a managed health care entity to refer patients to a county
provider, in an Illinois county having a population greater
than 3,000,000, that is paid directly by the Illinois
Department. The Illinois Department shall by April 1, 1997,
and annually thereafter, review the method to adjust
payments. Payments by the Illinois Department to the county
provider, for persons not enrolled in a managed care
community network owned or operated by a county provider,
shall be paid on a fee-for-service basis under Article XV of
this Code.
The Illinois Department by rule shall establish a method
to reduce its payments to managed health care entities to
take into consideration (i) any adjustment payments paid to
hospitals under subsection (h) of this Section to the extent
those payments, or any part of those payments, have been
taken into account in establishing capitated rates under this
subsection (g) and (ii) the implementation of methodologies
to limit financial liability for managed health care entities
under subsection (d) of this Section.
(h) For hospital services provided by a hospital that
contracts with a managed health care entity, adjustment
payments shall be paid directly to the hospital by the
Illinois Department. Adjustment payments may include but
need not be limited to adjustment payments to:
disproportionate share hospitals under Section 5-5.02 of this
Code; primary care access health care education payments (89
Ill. Adm. Code 149.140); payments for capital, direct medical
education, indirect medical education, certified registered
nurse anesthetist, and kidney acquisition costs (89 Ill. Adm.
Code 149.150(c)); uncompensated care payments (89 Ill. Adm.
Code 148.150(h)); trauma center payments (89 Ill. Adm. Code
148.290(c)); rehabilitation hospital payments (89 Ill. Adm.
Code 148.290(d)); perinatal center payments (89 Ill. Adm.
Code 148.290(e)); obstetrical care payments (89 Ill. Adm.
Code 148.290(f)); targeted access payments (89 Ill. Adm. Code
148.290(g)); Medicaid high volume payments (89 Ill. Adm. Code
148.290(h)); and outpatient indigent volume adjustments (89
Ill. Adm. Code 148.140(b)(5)).
(i) For any hospital eligible for the adjustment
payments described in subsection (h), the Illinois Department
shall maintain, through the period ending June 30, 1995,
reimbursement levels in accordance with statutes and rules in
effect on April 1, 1994.
(j) Nothing contained in this Code in any way limits or
otherwise impairs the authority or power of the Illinois
Department to enter into a negotiated contract pursuant to
this Section with a managed health care entity, including,
but not limited to, a health maintenance organization, that
provides for termination or nonrenewal of the contract
without cause upon notice as provided in the contract and
without a hearing.
(k) Section 5-5.15 does not apply to the program
developed and implemented pursuant to this Section.
(l) The Illinois Department shall, by rule, define those
chronic or acute medical conditions of childhood that require
longer-term treatment and follow-up care. The Illinois
Department shall ensure that services required to treat these
conditions are available through a separate delivery system.
A managed health care entity that contracts with the
Illinois Department may refer a child with medical conditions
described in the rules adopted under this subsection directly
to a children's hospital or to a hospital, other than a
children's hospital, that is qualified to provide inpatient
and outpatient services to treat those conditions. The
Illinois Department shall provide fee-for-service
reimbursement directly to a children's hospital for those
services pursuant to Title 89 of the Illinois Administrative
Code, Section 148.280(a), at a rate at least equal to the
rate in effect on March 31, 1994. For hospitals, other than
children's hospitals, that are qualified to provide inpatient
and outpatient services to treat those conditions, the
Illinois Department shall provide reimbursement for those
services on a fee-for-service basis, at a rate at least equal
to the rate in effect for those other hospitals on March 31,
1994.
A children's hospital shall be directly reimbursed for
all services provided at the children's hospital on a
fee-for-service basis pursuant to Title 89 of the Illinois
Administrative Code, Section 148.280(a), at a rate at least
equal to the rate in effect on March 31, 1994, until the
later of (i) implementation of the integrated health care
program under this Section and development of actuarially
sound capitation rates for services other than those chronic
or acute medical conditions of childhood that require
longer-term treatment and follow-up care as defined by the
Illinois Department in the rules adopted under this
subsection or (ii) March 31, 1996.
Notwithstanding anything in this subsection to the
contrary, a managed health care entity shall not consider
sources or methods of payment in determining the referral of
a child. The Illinois Department shall adopt rules to
establish criteria for those referrals. The Illinois
Department by rule shall establish a method to adjust its
payments to managed health care entities in a manner intended
to avoid providing any financial incentive to a managed
health care entity to refer patients to a provider who is
paid directly by the Illinois Department.
(m) Behavioral health services provided or funded by the
Department of Human Services, the Department of Children and
Family Services, and the Illinois Department shall be
excluded from a benefit package. Conditions of an organic or
physical origin or nature, including medical detoxification,
however, may not be excluded. In this subsection,
"behavioral health services" means mental health services and
subacute alcohol and substance abuse treatment services, as
defined in the Illinois Alcoholism and Other Drug Dependency
Act. In this subsection, "mental health services" includes,
at a minimum, the following services funded by the Illinois
Department, the Department of Human Services (as successor to
the Department of Mental Health and Developmental
Disabilities), or the Department of Children and Family
Services: (i) inpatient hospital services, including related
physician services, related psychiatric interventions, and
pharmaceutical services provided to an eligible recipient
hospitalized with a primary diagnosis of psychiatric
disorder; (ii) outpatient mental health services as defined
and specified in Title 59 of the Illinois Administrative
Code, Part 132; (iii) any other outpatient mental health
services funded by the Illinois Department pursuant to the
State of Illinois Medicaid Plan; (iv) partial
hospitalization; and (v) follow-up stabilization related to
any of those services. Additional behavioral health services
may be excluded under this subsection as mutually agreed in
writing by the Illinois Department and the affected State
agency or agencies. The exclusion of any service does not
prohibit the Illinois Department from developing and
implementing demonstration projects for categories of persons
or services. The Department of Children and Family Services
and the Department of Human Services shall each adopt rules
governing the integration of managed care in the provision of
behavioral health services. The State shall integrate managed
care community networks and affiliated providers, to the
extent practicable, in any separate delivery system for
mental health services.
(n) The Illinois Department shall adopt rules to
establish reserve requirements for managed care community
networks, as required by subsection (a), and health
maintenance organizations to protect against liabilities in
the event that a managed health care entity is declared
insolvent or bankrupt. If a managed health care entity other
than a county provider is declared insolvent or bankrupt,
after liquidation and application of any available assets,
resources, and reserves, the Illinois Department shall pay a
portion of the amounts owed by the managed health care entity
to providers for services rendered to enrollees under the
integrated health care program under this Section based on
the following schedule: (i) from April 1, 1995 through June
30, 1998, 90% of the amounts owed; (ii) from July 1, 1998
through June 30, 2001, 80% of the amounts owed; and (iii)
from July 1, 2001 through June 30, 2005, 75% of the amounts
owed. The amounts paid under this subsection shall be
calculated based on the total amount owed by the managed
health care entity to providers before application of any
available assets, resources, and reserves. After June 30,
2005, the Illinois Department may not pay any amounts owed to
providers as a result of an insolvency or bankruptcy of a
managed health care entity occurring after that date. The
Illinois Department is not obligated, however, to pay amounts
owed to a provider that has an ownership or other governing
interest in the managed health care entity. This subsection
applies only to managed health care entities and the services
they provide under the integrated health care program under
this Section.
(o) Notwithstanding any other provision of law or
contractual agreement to the contrary, providers shall not be
required to accept from any other third party payer the rates
determined or paid under this Code by the Illinois
Department, managed health care entity, or other health care
delivery system for services provided to recipients.
(p) The Illinois Department may seek and obtain any
necessary authorization provided under federal law to
implement the program, including the waiver of any federal
statutes or regulations. The Illinois Department may seek a
waiver of the federal requirement that the combined
membership of Medicare and Medicaid enrollees in a managed
care community network may not exceed 75% of the managed care
community network's total enrollment. The Illinois
Department shall not seek a waiver of this requirement for
any other category of managed health care entity. The
Illinois Department shall not seek a waiver of the inpatient
hospital reimbursement methodology in Section 1902(a)(13)(A)
of Title XIX of the Social Security Act even if the federal
agency responsible for administering Title XIX determines
that Section 1902(a)(13)(A) applies to managed health care
systems.
Notwithstanding any other provisions of this Code to the
contrary, the Illinois Department shall seek a waiver of
applicable federal law in order to impose a co-payment system
consistent with this subsection on recipients of medical
services under Title XIX of the Social Security Act who are
not enrolled in a managed health care entity. The waiver
request submitted by the Illinois Department shall provide
for co-payments of up to $0.50 for prescribed drugs and up to
$0.50 for x-ray services and shall provide for co-payments of
up to $10 for non-emergency services provided in a hospital
emergency room and up to $10 for non-emergency ambulance
services. The purpose of the co-payments shall be to deter
those recipients from seeking unnecessary medical care.
Co-payments may not be used to deter recipients from seeking
necessary medical care. No recipient shall be required to
pay more than a total of $150 per year in co-payments under
the waiver request required by this subsection. A recipient
may not be required to pay more than $15 of any amount due
under this subsection in any one month.
Co-payments authorized under this subsection may not be
imposed when the care was necessitated by a true medical
emergency. Co-payments may not be imposed for any of the
following classifications of services:
(1) Services furnished to person under 18 years of
age.
(2) Services furnished to pregnant women.
(3) Services furnished to any individual who is an
inpatient in a hospital, nursing facility, intermediate
care facility, or other medical institution, if that
person is required to spend for costs of medical care all
but a minimal amount of his or her income required for
personal needs.
(4) Services furnished to a person who is receiving
hospice care.
Co-payments authorized under this subsection shall not be
deducted from or reduce in any way payments for medical
services from the Illinois Department to providers. No
provider may deny those services to an individual eligible
for services based on the individual's inability to pay the
co-payment.
Recipients who are subject to co-payments shall be
provided notice, in plain and clear language, of the amount
of the co-payments, the circumstances under which co-payments
are exempted, the circumstances under which co-payments may
be assessed, and their manner of collection.
The Illinois Department shall establish a Medicaid
Co-Payment Council to assist in the development of co-payment
policies for the medical assistance program. The Medicaid
Co-Payment Council shall also have jurisdiction to develop a
program to provide financial or non-financial incentives to
Medicaid recipients in order to encourage recipients to seek
necessary health care. The Council shall be chaired by the
Director of the Illinois Department, and shall have 6
additional members. Two of the 6 additional members shall be
appointed by the Governor, and one each shall be appointed by
the President of the Senate, the Minority Leader of the
Senate, the Speaker of the House of Representatives, and the
Minority Leader of the House of Representatives. The Council
may be convened and make recommendations upon the appointment
of a majority of its members. The Council shall be appointed
and convened no later than September 1, 1994 and shall report
its recommendations to the Director of the Illinois
Department and the General Assembly no later than October 1,
1994. The chairperson of the Council shall be allowed to
vote only in the case of a tie vote among the appointed
members of the Council.
The Council shall be guided by the following principles
as it considers recommendations to be developed to implement
any approved waivers that the Illinois Department must seek
pursuant to this subsection:
(1) Co-payments should not be used to deter access
to adequate medical care.
(2) Co-payments should be used to reduce fraud.
(3) Co-payment policies should be examined in
consideration of other states' experience, and the
ability of successful co-payment plans to control
unnecessary or inappropriate utilization of services
should be promoted.
(4) All participants, both recipients and
providers, in the medical assistance program have
responsibilities to both the State and the program.
(5) Co-payments are primarily a tool to educate the
participants in the responsible use of health care
resources.
(6) Co-payments should not be used to penalize
providers.
(7) A successful medical program requires the
elimination of improper utilization of medical resources.
The integrated health care program, or any part of that
program, established under this Section may not be
implemented if matching federal funds under Title XIX of the
Social Security Act are not available for administering the
program.
The Illinois Department shall submit for publication in
the Illinois Register the name, address, and telephone number
of the individual to whom a request may be directed for a
copy of the request for a waiver of provisions of Title XIX
of the Social Security Act that the Illinois Department
intends to submit to the Health Care Financing Administration
in order to implement this Section. The Illinois Department
shall mail a copy of that request for waiver to all
requestors at least 16 days before filing that request for
waiver with the Health Care Financing Administration.
(q) After the effective date of this Section, the
Illinois Department may take all planning and preparatory
action necessary to implement this Section, including, but
not limited to, seeking requests for proposals relating to
the integrated health care program created under this
Section.
(r) In order to (i) accelerate and facilitate the
development of integrated health care in contracting areas
outside counties with populations in excess of 3,000,000 and
counties adjacent to those counties and (ii) maintain and
sustain the high quality of education and residency programs
coordinated and associated with local area hospitals, the
Illinois Department may develop and implement a demonstration
program for managed care community networks owned, operated,
or governed by State-funded medical schools. The Illinois
Department shall prescribe by rule the criteria, standards,
and procedures for effecting this demonstration program.
(s) (Blank).
(t) On April 1, 1995 and every 6 months thereafter, the
Illinois Department shall report to the Governor and General
Assembly on the progress of the integrated health care
program in enrolling clients into managed health care
entities. The report shall indicate the capacities of the
managed health care entities with which the State contracts,
the number of clients enrolled by each contractor, the areas
of the State in which managed care options do not exist, and
the progress toward meeting the enrollment goals of the
integrated health care program.
(u) The Illinois Department may implement this Section
through the use of emergency rules in accordance with Section
5-45 of the Illinois Administrative Procedure Act. For
purposes of that Act, the adoption of rules to implement this
Section is deemed an emergency and necessary for the public
interest, safety, and welfare.
(Source: P.A. 88-554, eff. 7-26-94; 89-21, eff. 7-1-95;
89-507, eff. 7-1-97; 89-673, eff. 8-14-96; revised 8-26-96.)
Section 95. No acceleration or delay. Where this Act
makes changes in a statute that is represented in this Act by
text that is not yet or no longer in effect (for example, a
Section represented by multiple versions), the use of that
text does not accelerate or delay the taking effect of (i)
the changes made by this Act or (ii) provisions derived from
any other Public Act.