Bill Text: IL HB2486 | 2019-2020 | 101st General Assembly | Introduced


Bill Title: Creates the Mental Health Modernization and Access Improvement Act. Requires the Department of Healthcare and Family Services to apply for a Medicaid waiver or State Plan amendment, or both, within 6 months after the effective date of the Act to develop and implement a regulatory framework that allows, incentivizes, and fosters payment reform models for all Medicaid community mental health services provided by community mental health centers or behavioral health clinics. Requires the regulatory framework to: (i) allow for and incentivize service innovation that is aimed at producing the best health outcomes for Medicaid enrollees with mental health conditions; (ii) reward high-quality care through annual incentive payments to community mental health centers and behavioral health clinics; (iii) require community mental health centers and behavioral health clinics to report on specified quality and outcomes metrics; and other matters. Provides that all documentation and reporting requirements under the regulatory framework must comply with the federal Mental Health Parity and Addiction Equity Act of 2008 and the State mental health parity requirements under the Illinois Insurance Code. Contains provisions concerning quality and outcomes metrics reporting; data sharing; the establishment of a Stakeholder Quality and Outcomes Metrics Development Working Group; statewide in-person trainings to ensure provider readiness for the regulatory framework; quality and patient safety protections; implementation timeline; certification of community mental health centers that opt into the regulatory framework; and other matters. Provides that the Act shall be implemented upon federal approval and only to the extent that federal financial participation is available. Effective immediately.

Spectrum: Strong Partisan Bill (Democrat 30-3)

Status: (Introduced) 2019-08-07 - Added Co-Sponsor Rep. Lindsey LaPointe [HB2486 Detail]

Download: Illinois-2019-HB2486-Introduced.html


101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB2486

Introduced , by Rep. Deb Conroy

SYNOPSIS AS INTRODUCED:
New Act

Creates the Mental Health Modernization and Access Improvement Act. Requires the Department of Healthcare and Family Services to apply for a Medicaid waiver or State Plan amendment, or both, within 6 months after the effective date of the Act to develop and implement a regulatory framework that allows, incentivizes, and fosters payment reform models for all Medicaid community mental health services provided by community mental health centers or behavioral health clinics. Requires the regulatory framework to: (i) allow for and incentivize service innovation that is aimed at producing the best health outcomes for Medicaid enrollees with mental health conditions; (ii) reward high-quality care through annual incentive payments to community mental health centers and behavioral health clinics; (iii) require community mental health centers and behavioral health clinics to report on specified quality and outcomes metrics; and other matters. Provides that all documentation and reporting requirements under the regulatory framework must comply with the federal Mental Health Parity and Addiction Equity Act of 2008 and the State mental health parity requirements under the Illinois Insurance Code. Contains provisions concerning quality and outcomes metrics reporting; data sharing; the establishment of a Stakeholder Quality and Outcomes Metrics Development Working Group; statewide in-person trainings to ensure provider readiness for the regulatory framework; quality and patient safety protections; implementation timeline; certification of community mental health centers that opt into the regulatory framework; and other matters. Provides that the Act shall be implemented upon federal approval and only to the extent that federal financial participation is available. Effective immediately.
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FISCAL NOTE ACT MAY APPLY

A BILL FOR

HB2486LRB101 04928 KTG 53067 b
1 AN ACT concerning mental health.
2 Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4 Section 1. Short title. This Act may be cited as the Mental
5Health Modernization and Access Improvement Act.
6 Section 5. Findings. The General Assembly finds as follows:
7 (1) Insufficient access to mental health care in
8 Illinois has led to numerous consent decrees, children
9 remaining in psychiatric hospitals beyond medical
10 necessity, custody relinquishment to get treatment, and
11 growing suicide rates. These major problems are direct
12 consequences of: (i) a State regulatory structure for
13 mental health services that does not allow for or align
14 with payment for outcomes, integration, or care delivery
15 innovation; and (ii) limited State investment in Medicaid
16 reimbursement rates for community mental health services.
17 (2) Illinois must align its regulatory framework for
18 community mental health services with the modern era of
19 health care delivery to enable and reward high-quality
20 health outcomes and to reduce costs, and must also reform
21 payment rates to allow for service growth and increased
22 participation of psychiatrists and other mental health
23 professionals in the State's Medicaid program.

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1 (3) The existing regulatory framework for Medicaid
2 mental health services is fee-for-service, even under
3 managed care. Nearly all Medicaid managed care contracts
4 with mental health providers are fee-for-service
5 contracts, rather than value-based contracts. This is due
6 largely to the fee-for-service regulatory framework for
7 mental health and an encounter-based Medicaid system that
8 stymies payment reform.
9 (4) The existing mental health fee-for-service
10 framework: (i) impedes delivery of care that produces the
11 best health outcomes and reduces unnecessary costs; (ii)
12 allows for no innovation; (iii) disincentivizes care
13 coordination and integration; and (iv) prevents the growth
14 of psychiatry and team-based treatment models that could
15 improve access to care.
16 (5) Pay-for-performance and value-based payment models
17 that provide financial incentives to providers for
18 achieving defined quality and outcomes metrics have shown
19 early evidence of producing better health outcomes and
20 reduced Medicaid costs.
21 (6) A value-based payment model for community mental
22 health care delivery will dovetail and further the
23 value-based payment model for care coordination and
24 integration being implemented through integrated health
25 homes.
26 (7) To modernize mental health service delivery,

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1 Illinois must develop a regulatory framework for mental
2 health services that allows for and encourages payment
3 reform consistent with the framework established by the
4 U.S. Department of Health and Human Services' Health Care
5 Payment Learning and Action Network (LAN) Alternative
6 Payment Model (such as incentive payments linked to quality
7 and outcomes metrics, shared savings, and bundled payment
8 models) combined with reimbursement rates that enable
9 service growth to meet Illinois' mental health treatment
10 needs. The payment reform models developed shall work with
11 both managed and unmanaged Medicaid.
12 Section 10. Community mental health payment reform model.
13 (a) Regulatory framework for community mental health
14providers. To move away from the antiquated fee-for-service
15payment model for community mental health services and to
16foster increased access to high-quality care, particularly for
17services for individuals with serious mental health
18conditions, the Department of Healthcare and Family Services,
19as the sole Medicaid State agency, in partnership with the
20Department of Human Services' Division of Mental Health, and
21with meaningful stakeholder involvement, shall apply for a
22Medicaid waiver or State Plan amendment, or both, within 6
23months after the effective date of this Act to develop and
24implement a regulatory framework that allows, incentivizes,
25and fosters payment reform models for all community mental

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1health services provided by community mental health centers
2licensed or certified by the Division of Mental Health and for
3behavioral health clinics established under 89 Ill. Adm. Code
4140. Such payment reform models shall be consistent with the
5Health Care Payment Learning and Action Network Alternative
6Payment Model framework developed by the U.S. Department of
7Health and Human Services. Upon federal approval, and the
8adoption of rules to implement this Act, all community mental
9health services provided by community mental health centers or
10behavioral health clinics shall be subject to the regulatory
11framework for providers that opt in. Providers that do not opt
12in shall be governed by the existing administrative rules for
13community mental health services. Community mental health
14centers and behavioral health clinics that opt into the
15regulatory framework shall be given the opportunity to opt out
16every 2 years. Community mental health centers and behavioral
17health clinics that do not opt in shall be given the
18opportunity to opt in annually. This Act shall be implemented
19only to the extent that federal approval is granted and federal
20financial participation is available.
21 (b) Incentivizing service innovation. The regulatory
22framework established under this Act shall allow for and
23incentivize service innovation, enabled through service and
24workforce flexibility, consistent with all scope of practice
25laws for all mental health professionals, that is aimed at
26producing the best health outcomes for Medicaid enrollees with

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1mental health conditions and combined with reporting quality
2and outcomes metrics. The regulatory framework shall reward
3high-quality care through annual incentive payments to
4community mental health centers and behavioral health clinics
5participating in the regulatory framework.
6 (c) Mental health professionals; practice. To address
7Illinois' mental health workforce challenges, the regulatory
8framework shall allow mental health professionals to practice
9at the top of their qualifications and the regulatory framework
10shall not restrict this ability (such as maximum use of advance
11practice nurses with a psychiatric specialty, maximum use of
12mental health professionals with a bachelor's degree, maximum
13use of licensed clinicians, and maximum use of persons with
14lived experience) enabling staffing flexibility that reflects
15the local workforce, particularly for team-based treatment
16models. All workforce requirements established pursuant to
17this regulatory framework shall comply with and be consistent
18with all scope of practice laws for all mental health
19professionals. In developing minimum staffing requirements
20within the regulatory framework, the Department of Healthcare
21and Family Services shall take into account the inability of
22community mental health centers and behavioral health clinics
23to hire and retain certain mental health professionals in
24workforce shortage areas across the State and the effect this
25has on restricting access to care, while recognizing the full
26value of mental health professionals not currently relied upon

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1or permitted in certain roles or to fulfill certain functions
2(such as mental health professionals with a bachelor's degree,
3advanced practice registered nurses with a psychiatric
4specialty, licensed clinicians, and persons with lived
5experience who are not certified recovery support specialists)
6and shall maximize the use of telehealth and telepsychiatry.
7 (d) Provider outreach and engagement. To address the need
8to encourage Medicaid enrollees with the most serious mental
9illnesses to participate in treatment, the regulatory
10framework shall allow for and incentivize significant provider
11outreach and engagement for individuals with serious mental
12illnesses who are often homeless, difficult to reach, and the
13hardest to connect to treatment. The regulatory framework shall
14also take into account the significant distances providers
15employing team-based treatment models must travel to
16effectively engage and treat such individuals.
17 (e) Quality and outcomes metrics. To ensure high-quality
18care, patient satisfaction, and patient safety, the regulatory
19framework shall require community mental health centers and
20behavioral health clinics opting into the regulatory framework
21to report on specified quality and outcomes metrics that shall
22be used to determine eligibility for an annual incentive
23payment. The quality and outcomes metrics established by the
24Department of Healthcare and Family Services shall be done in
25accordance with Section 15. Eligibility for an incentive
26payment is addressed in Section 25. Section 30 sets out the

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1consequences for community mental health centers and
2behavioral health clinics participating in the framework that
3do not meet a minimum level of quality and outcomes metrics.
4 (f) Mental health parity compliance. Provider utilization
5management processes, prior authorizations, assessment and
6treatment plan reviews and updates, and all related
7documentation and reporting required through the regulatory
8framework shall be in compliance with the federal Mental Health
9Parity and Addiction Equity Act of 2008 and the State mental
10health parity requirements set forth in Section 370c of the
11Illinois Insurance Code. The Department of Healthcare and
12Family Services shall not require more onerous processes for
13mental health treatment, treatment plans, assessments, or the
14frequency of provider reviews or updates of assessments and
15treatment plans, and related reporting or documentation than
16the processes the State imposes on treatment providers of other
17similar chronic medical conditions (such as providers treating
18diabetes or heart disease). More onerous requirements for
19access to treatment, treatment plan reviews and updates,
20utilization management processes, prior authorization
21requirements or documentation, and reporting requirements for
22mental health conditions compared to those requirements for
23other similar chronic medical conditions can be construed as
24non-quantitative treatment limitations, which would be a
25violation of the federal Mental Health Parity and Addiction
26Equity Act of 2008 and Section 370c of the Illinois Insurance

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1Code. To ensure and demonstrate to the General Assembly that
2the regulatory framework complies with the federal Mental
3Health Parity and Addiction Equity Act of 2008 and Section 370c
4of the Illinois Insurance Code, upon the date the Department of
5Healthcare and Family Services submits to the Joint Committee
6on Administrative Rules its proposed rule to implement this
7Act, as provided in Section 40, the Department shall also
8submit to the Joint Committee on Administrative Rules a
9detailed analysis demonstrating that the provider utilization
10management requirements, assessment or treatment planning
11frequency, and related documentation and reporting
12requirements imposed under the regulatory framework are no more
13onerous for mental health treatment than the requirements the
14State imposes on treatment providers of other comparable
15chronic medical conditions.
16 (g) Managed care contracts. The regulatory framework shall
17align with the ability of community mental health centers and
18behavioral health clinics to provide services through managed
19care contracts linked to (i) quality and performance metrics
20(LAN Category 2) or (ii) a shared savings or shared risk model
21or bundled or episode-based payments with managed care
22organizations (LAN Category 3), all of which require service
23and workforce flexibility to achieve quality and outcomes
24metrics. The documentation required by the State from community
25mental health centers and behavioral health clinics for
26services provided through these payment reform models through

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1managed care organization contracts shall not be duplicative or
2inconsistent with these payment reform models, meaning that
3State reporting and documentation requirements must align with
4what is required through managed care so duplicative processes
5or reporting are not required to the State and to managed care
6organizations. The Department of Healthcare and Family
7Services shall pay an annual incentive payment to community
8mental health centers and behavioral health clinics that
9achieve the State specified quality and mental health or health
10outcomes metrics for enrollees in Medicaid managed care. The
11incentive payment shall be in addition to the base Medicaid
12reimbursement rate and any Medicaid rate add-on payments for
13the specific service.
14 (h) Non-managed Medicaid services; community mental health
15centers and behavioral health clinics. Because a large
16percentage of Medicaid enrollees with serious mental health
17conditions are dually eligible for Medicare and Medicaid and
18therefore cannot be required to be in managed Medicaid under
19federal law, the regulatory framework shall also apply to
20non-managed Medicaid services delivered by community mental
21health centers and behavioral health clinics. For the
22non-managed Medicaid population, the payment model shall
23reward services with an annual incentive payment paid by the
24Department of Healthcare and Family Services to community
25mental health centers and behavioral health clinics that
26achieve specified quality and outcomes metrics. The incentive

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1payment shall be in addition to the base Medicaid reimbursement
2rate and any Medicaid add-on payments for the specific service.
3Shared risk or penalties shall not be a part of the regulatory
4framework for non-managed Medicaid services.
5 Section 15. Quality and outcomes metrics reporting.
6 (a) Quality and outcomes metrics. The Department of
7Healthcare and Family Services, in partnership with the
8Department of Human Services' Division of Mental Health and
9with meaningful stakeholder participation through the
10establishment of a Stakeholder Quality and Outcomes Metrics
11Development Working Group, shall establish or select (i)
12metrics that community mental health centers and behavioral
13health clinics opting into the regulatory framework must report
14on annually to the Department of Healthcare and Family Services
15upon implementation of this Act and (ii) metrics that determine
16eligibility for an annual incentive payment.
17 (1) For guidance in adoption of the most appropriate
18 and feasible quality and outcomes metrics, the Department
19 of Healthcare and Family Services shall use the relevant
20 metrics it uses for Illinois Medicaid managed care
21 organizations and integrated health homes, as well as those
22 established or used by the National Committee for Quality
23 Assurance or the federal Certified Community Behavioral
24 Health Clinic pilot program. The Department of Healthcare
25 and Family Services shall establish 4 categories of

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1 metrics:
2 (A) Quality metrics. Quality metrics are
3 claims-based and intended to be used to measure
4 business processes that lead to and support
5 high-quality care. The Department of Healthcare and
6 Family Services shall establish quality metrics, which
7 must include some of the relevant quality metrics the
8 Department of Healthcare and Family Services uses to
9 measure the performance of Medicaid managed care
10 organizations, by which to measure the quality of care
11 delivered by community mental health centers and
12 behavioral health clinics participating in the
13 regulatory framework. Annual reporting on quality
14 metrics shall begin in the first year after
15 implementation of this Act.
16 (B) Health outcomes metrics. Health outcomes
17 metrics are intended to measure improvement in health
18 outcomes across populations. These metrics must be
19 clinically relevant, feasible, and reliable. Any
20 health outcomes metrics established or used for
21 measuring mental and behavioral health outcomes for
22 community mental health centers and behavioral health
23 clinics participating in the regulatory framework
24 shall be claims-based, standard health outcome
25 measures. Annual reporting on claims-based standard
26 health outcomes metrics shall begin in the second full

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1 calendar year after the implementation of this Act.
2 (C) Patient experience and patient satisfaction
3 metrics. The Department of Healthcare and Family
4 Services shall develop quality of life and patient
5 experience measures. Reporting on these metrics shall
6 begin in the second full calendar year after
7 implementation of this Act.
8 (D) Social determinants of health metrics. Social
9 determinants of health metrics take into account a
10 person's social factors and the physical condition of
11 the environment in which the person lives, works,
12 learns, plays, and ages. Measuring the social
13 determinants of health may include evaluating improved
14 housing status, reduced justice involvement, and
15 school, work, civic, or volunteer participation that
16 are a result of mental health treatment. The Department
17 of Healthcare and Family Services shall include at
18 least 2 social determinants of health metrics that are
19 reported to the State for purposes of this Act.
20 Reporting on these metrics shall begin in the third
21 full calendar year after implementation of this Act.
22 (E) Payment-for-performance metrics. The
23 Department of Healthcare and Family Services, with
24 meaningful stakeholder input through the Stakeholder
25 Quality and Outcomes Metrics Development Working
26 Group, shall select clinically relevant, feasible, and

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1 reliable metrics that are claims-based metrics for
2 purposes of the payment-for-performance metrics. The
3 payment-for-performance metrics shall be used in
4 determining eligibility for an annual incentive
5 payment in year 3 of implementation of the regulatory
6 framework and every year thereafter. The Department of
7 Healthcare and Family Services shall use no more than 6
8 payment-for-performance metrics, including
9 sub-measures. To ensure provider certainty and
10 provider readiness to meet the payment-for-performance
11 metrics, payment-for-performance metrics shall be
12 established and shared with providers at least 6 months
13 prior to such metrics becoming operative and they shall
14 remain in effect for at least 2 years. Because the
15 payment-for-performance metrics will be a main driver
16 of provider behavior, the Department of Healthcare and
17 Family Services shall take into consideration what
18 metrics drive high-performing care that leads to
19 improved mental health symptom management over the
20 long term, as well as maintenance of recovery and
21 wellness for the individual. The Department of
22 Healthcare and Family Services shall ensure that the
23 payment-for-performance metrics it selects do not
24 result in providers serving those with the least severe
25 mental illnesses. The Department of Healthcare and
26 Family Services shall ensure that there are

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1 payment-for-performance metrics that encourage and
2 reward providers that serve those with the most serious
3 mental illnesses. The metrics developed must be aimed
4 at measuring care delivery that leads to positive
5 mental health and health outcomes for the individual
6 but must also reflect that mental health recovery can
7 be a life-long process with periods of stabilization
8 and wellness, but also may include periods of illness
9 exacerbation (i.e., serious mental health conditions
10 are chronic medical conditions and recovery is not
11 linear or static).
12 (2) To ensure that providers and the State are not
13 overburdened by data tracking and reporting, no more than
14 20 metrics in total, including sub-metrics, shall be
15 established.
16 (3) The Department of Healthcare and Family Services,
17 in partnership with the Department of Human Services'
18 Division of Mental Health, shall develop a formula for how
19 the payment-for-performance metrics are weighted for
20 purposes of determining a community mental health clinic's
21 or a behavioral health clinic's eligibility for an annual
22 incentive payment.
23 (4) Solely for purposes of evaluating provider credit
24 for achieving the metrics outlined in this Section, the
25 Department of Healthcare and Family Services, with
26 meaningful input from the Stakeholder Quality and Outcomes

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1 Metrics Development Working Group, shall determine a
2 minimum threshold of service provision any individual must
3 have received from a community mental health clinic or
4 behavioral health clinic participating in the regulatory
5 framework to include that individual's outcomes metrics in
6 that provider's total outcomes measurement.
7 (5) Given that the federal government and many states
8 are updating quality metrics for behavioral health as the
9 field modernizes, the Department of Healthcare and Family
10 Services may periodically update the metrics reported to
11 the State and the payment-for-performance metrics, but
12 only following meaningful input from stakeholders through
13 the Stakeholder Quality and Outcomes Metrics Development
14 Working Group on the value and feasibility of the new
15 metrics.
16 (6) Mental health parity compliance. The Department of
17 Healthcare and Family Services shall ensure that the
18 metrics established in accordance with this Act: (i) are in
19 compliance with the federal Mental Health Parity and
20 Addiction Equity Act and Section 370c of the Illinois
21 Insurance Code and (ii) do not result in a non-quantitative
22 treatment limitation.
23 (b) Data sharing. The State and Medicaid managed care
24organizations shall be required to timely share claims and
25encounter data with community mental health providers
26participating in the regulatory framework for the individuals

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1for which the provider is serving to enable the provider to
2evaluate and improve its own performance and to be able to
3deliver care that results in the best mental health and overall
4health outcomes. Data, including claims information,
5utilization management data, and health outcomes measures,
6shall be shared between the State and the community mental
7health clinic or behavioral health clinic assigned to the
8individual for purposes of metrics evaluation, and between the
9managed care organization and the community mental health
10clinic or behavioral health clinic assigned to the individual
11for purposes of metrics evaluation in compliance with all
12health information privacy laws. Standardized data elements,
13reporting methods, and data systems shall be established across
14managed care organizations and community mental health clinics
15or behavioral health clinics to prevent unnecessary
16development of different reporting systems for each managed
17care organization.
18 (c) Stakeholder Quality and Outcomes Metrics Development
19Working Group. The Department of Healthcare and Family
20Services, in partnership with the Department of Human Services'
21Division of Mental Health, shall establish and convene a
22Stakeholder Quality and Outcomes Metrics Development Working
23Group that includes mental health providers, advocates,
24including persons with lived experience of a mental health
25condition, and representatives from Medicaid managed care
26organizations to (i) assist in the development of the metrics

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1that will be reported to the State in accordance with this
2Section and (ii) assist with selecting the
3payment-for-performance metrics. The Stakeholder Quality and
4Outcomes Metrics Development Working Group shall be
5established and convened at least once prior to the date upon
6which the Department of Healthcare and Family Services applies
7for a Medicaid waiver or State Plan amendment as provided in
8subsection (a) of Section 10. The Stakeholder Quality and
9Outcomes Metrics Development Working Group shall meet at least
10monthly for no less than 8 months to assist in the development
11of the metrics that will be reported to the State and used to
12determine eligibility for incentive payments.
13 Section 20. Provider readiness.
14 (a) To ensure provider readiness for the implementation of
15the payment reform models developed in accordance with this
16Act, the Department of Healthcare and Family Services shall
17require community mental health centers and behavioral health
18clinics choosing to opt into the regulatory framework to submit
19an initial self-assessment of readiness, including
20demonstrating the delivery of person-centered care or
21family-centered care, the ability to track quality and outcomes
22data for Medicaid enrollees, and a data-driven quality
23improvement process. The Department of Healthcare and Family
24Services shall engage in statewide provider education for
25implementation of the regulatory framework and process through

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1statewide in-person trainings, train-the-trainer models, and
2webinars at least 6 months prior to implementation to enable
3provider readiness. Such education shall continue throughout
4the first year of implementation. The Department of Healthcare
5and Family Services shall establish an ongoing statewide
6learning collaborative for providers opting into the
7regulatory framework to share successes, challenges, lessons
8learned, and provider and systemic issues that need to be
9addressed to foster these payment reform models. The learning
10collaborative shall be convened by the Department of Healthcare
11and Family Services, in partnership with the Department of
12Human Services' Division of Mental Health, on a quarterly basis
13after the initial date of implementation of the regulatory
14framework.
15 (b) Provider infrastructure development for
16implementation. A total not to exceed $5,000,000 a year for
17each of 3 years shall be available for provider infrastructure
18development for implementation of this Act, including, but not
19limited to, systems for data tracking of the metrics outlined
20in Section 15, or other start-up or infrastructure costs, for
21providers opting into the regulatory framework. The Department
22of Healthcare and Family Services shall have the authority to
23determine the process for application and eligibility for
24provider infrastructure development dollars under this
25subsection.

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1 Section 25. Annual incentive payments for community mental
2health centers and behavioral health clinics.
3 (a) Annual incentive payment.
4 (1) Year one of implementation and the first 2 full
5 calendar years of implementation. For the first partial
6 calendar year of implementation (if implementation begins
7 mid-year) and for the first 2 full calendar years after
8 implementation of this Act, community mental health
9 centers and behavioral health clinics participating in the
10 regulatory framework that score above the median score of
11 the relevant quality metrics the Department of Healthcare
12 and Family Services uses for Medicaid managed care
13 organizations that the Department has selected to measure
14 the quality of care provided by community mental health
15 centers and behavioral health clinics as provided under
16 subparagraph (A) of paragraph (1) of subsection (a) of
17 Section 15 for at least 80% of such quality metrics for
18 that calendar year shall receive an incentive payment
19 related to that calendar year. If implementation begins in
20 the middle of a calendar year, a provider's incentive
21 payment for that year shall be prorated based on the date
22 the regulatory framework went into effect.
23 (2) Year 3 and every calendar year thereafter. For the
24 third full calendar year after implementation of this Act,
25 and every year thereafter, community mental health centers
26 and behavioral health clinics participating in the

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1 regulatory framework shall receive an annual incentive
2 payment related to that year if:
3 (A) the provider scores above the median score of
4 the quality metrics the Department of Healthcare and
5 Family Services uses for Medicaid managed care
6 organizations that the Department has selected to
7 measure the quality of care provided by community
8 mental health centers and behavioral health clinics as
9 provided under subparagraph (A) of paragraph (1) of
10 subsection (a) of Section 15, for at least 80% of such
11 quality metrics related to that calendar year; and
12 (B) the provider meets at least 75% of the
13 payment-for-performance metrics established in
14 accordance with this Act for that calendar year.
15 (3) For any calendar year following the first 2 full
16 calendar years after implementation, the Department of
17 Healthcare and Family Services shall have the ability to
18 adjust the benchmark for measuring minimum eligibility for
19 an incentive payment (the median score of the relevant
20 quality metrics used to measure Medicaid managed care
21 organizations that the Department of Healthcare and Family
22 Services applies to the regulatory framework) by 10% upward
23 or downward to ensure an appropriate benchmark for
24 eligibility for an annual incentive payment. The
25 Department of Healthcare and Family Services shall give
26 providers participating in the regulatory framework at

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1 least 6 months notice prior to the benchmark going into
2 effect for a calendar year.
3 (4) Number of metrics used to determine annual
4 incentive payments. No more than 10 metrics (including
5 sub-metrics), including the payment-for-performance
6 metrics, shall be used in any given year to determine
7 eligibility for an annual incentive payment to ensure that
8 neither the State nor providers are overwhelmed by data
9 tracking.
10 (5) Provider preparedness. The Department of
11 Healthcare and Family Services shall give all community
12 mental health centers and behavioral health clinics notice
13 of the metrics that will be used to determine eligibility
14 for an annual incentive payment at least 6 months prior to
15 those metrics taking effect for that calendar year.
16 (6) Amount of annual incentive payment. For community
17 mental health centers or behavioral health clinics that
18 meet the requirements set forth in this Act for an
19 incentive payment for any calendar year, the incentive
20 payment shall be equal to a 6 percentage point increase in
21 the base Medicaid reimbursement rates plus any rate add-on
22 payment, for all Medicaid community mental health services
23 that the provider delivered during that calendar year. The
24 incentive payment shall be paid to the community mental
25 health center or behavioral health clinic within 8 months
26 following the end of the calendar year.

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1 Section 30. Eligibility for participation. Community
2mental health centers and behavioral health clinics subject to
3the regulatory framework that do not meet the median score of
4the quality metrics the Department of Healthcare and Family
5Services uses for Medicaid managed care organizations and for
6which the Department has selected as provided under
7subparagraph (A) of paragraph (1) of subsection (a) of Section
815 for at least 50% of such quality metrics for that calendar
9year for 3 consecutive calendar years shall be ineligible for
10further participation under the regulatory framework for the
11following 3 calendar years. A community mental health center or
12behavioral health clinic that does not meet the median score of
13the quality metrics the Department of Healthcare and Family
14Services uses for Medicaid managed care organizations for which
15the Department has selected as provided under subparagraph (A)
16of paragraph (1) of subsection (a) of Section 15 for at least
1730% of such quality metrics for that calendar year shall no
18longer be eligible for participation under the regulatory
19framework until they are able to demonstrate to the Department,
20through a formal plan, that they can achieve at least 75% of
21these quality metrics.
22 Section 35. Community mental health services; rates.
23 (a) Beginning on July 1, 2019, Medicaid reimbursement rates
24for all community-based mental health services provided in

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1accordance with 59 Ill. Adm. Code 132 or 89 Ill. Adm. Code
2140.452 through 140.455 for which there was an enhanced payment
3rate or rate add-on in effect on November 1, 2017 for community
4mental health centers, or for behavioral health clinics that
5were formerly community mental health centers, shall be
6increased by the amount equal to the enhanced payment rate or
7rate add-on. The enhanced payment rate or rate add-on shall be
8simultaneously reduced by an equal amount. The Department of
9Healthcare and Family Services shall hold harmless community
10mental health centers, and any relevant behavioral health
11clinic that was formerly a community mental health center,
12receiving such mental or behavioral health enhanced payment
13rates or rate add-on payments. This subsection is intended to
14convert the enhanced rate and rate add-on payments into the
15Medicaid reimbursement rate for community-based mental health
16services.
17 (b) For State Fiscal Year 2020, Medicaid reimbursement
18rates for all community mental and behavioral health services
19that can be delivered by a community mental health center or
20behavioral health clinic in accordance with 89 Ill. Adm. Code
21140.452 through 140.455, for which there is no enhanced payment
22rate or rate add-on payment, and for all Medicaid psychiatry
23services provided by an advance practice nurse with a
24psychiatric specialty delivered through or on behalf of a
25community mental health center or a behavioral health clinic,
26shall be increased by 7% annually for each state fiscal year

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1for 3 years. Beginning in State Fiscal Year 2023, and every
2state fiscal year thereafter, Medicaid reimbursement rates for
3those community mental and behavioral health services and those
4services covered in subsection (a) provided by community mental
5health centers and behavioral health clinics shall be adjusted
6upward by an amount equal to the Consumer Price Index from the
7previous year, not to exceed 2% in any state fiscal year. If
8there is a decrease in the Consumer Price Index, rates shall
9remain unchanged for that state fiscal year.
10 (c) To increase the number of psychiatrists practicing in
11Illinois' Medicaid Program that serve individuals with the most
12serious mental health conditions, the Department of Healthcare
13and Family Services shall develop an encounter-based rate and a
14billing and payment mechanism for all Medicaid psychiatry
15services delivered by a psychiatrist to be paid at a rate equal
16to the average Medicaid reimbursement rate paid to
17Illinois-based federally qualified health clinics over the 3
18most recent years for such psychiatry services or for the same
19or comparable services. This encounter-based Medicaid rate,
20and billing and payment mechanism, may be a Medicaid
21reimbursement rate adjustment or an enhanced Medicaid payment.
22This rate adjustment shall be phased in equally over 4 calendar
23years beginning on January 1, 2020. The provisions of this
24subsection on psychiatry reimbursement shall not impact other
25provider reimbursement rates that may be tied to psychiatry
26rates.

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1 (d) To reduce the rate of children with serious mental
2health conditions remaining in psychiatric hospitals beyond
3medical necessity because there is a lack of residential
4treatment placements available for the child, reimbursement
5rates paid to providers for services provided under the Family
6Support Program, formerly known as the Individual Care Grant
7program, shall be adjusted upward by 7% a year for 3 years
8beginning July 1, 2019. Beginning in State Fiscal Year 2023,
9and each state fiscal year thereafter, such reimbursement rates
10shall be adjusted upward by an amount equal to the Consumer
11Price Index from the previous year, not to exceed 2% in any
12state fiscal year. If there is a decrease in the Consumer Price
13Index, such rates shall remain unchanged for that state fiscal
14year.
15 Section 40. Implementation timeline; rulemaking authority.
16 (a) The Department of Healthcare and Family Services shall
17file a proposed rule implementing this Act no later than 9
18months after the date of federal approval of its waiver or
19State Plan amendment filed pursuant to this Act.
20 (b) Stakeholder working group. The Department of
21Healthcare and Family Services, in partnership with the
22Department of Human Services' Division of Mental Health, shall
23establish and convene a stakeholder working group that includes
24community mental health providers across the State, advocates,
25persons with lived experience, and representatives from

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1Medicaid managed care organizations to help guide and assist
2the Department of Healthcare and Family Services in the
3development of the rule that implements this Act. This
4stakeholder working group shall meet at least monthly beginning
5immediately after federal approval of the State Plan amendment
6or waiver filed pursuant to this Act and shall continue until
7the filing of a proposed rule implementing this Act.
8 Section 45. Rule revision. 59 Ill Adm. Code 132 shall be
9revised to align with and match the regulatory framework
10developed pursuant to this Act for community mental health
11centers participating in the regulatory framework established
12by this Act and shall not impose service, staffing,
13certification, documentation, or reporting requirements that
14are inconsistent with this Act for those community mental
15health centers to enable the modernization of the community
16mental health regulatory framework. The Department of Human
17Services' Division of Mental Health shall file its proposed
18amendments to 59 Ill Adm. Code 132 with the Joint Commission on
19Administrative Rules simultaneously with the Department of
20Healthcare and Family Services' filing of the rule implementing
21this Act.
22 Section 99. Effective date. This Act takes effect upon
23becoming law.
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