(305 ILCS 5/5-30.5) Sec. 5-30.5. Managed care; automatic assignment. The
Department shall, within a reasonable period of time after
relevant data from managed care entities has been collected and
analyzed, but no earlier than January 1, 2017, seek input from the managed care entities and other stakeholders and develop and
implement within each enrollment region an algorithm preserving existing provider-beneficiary relationships that takes
into account quality scores and other operational proficiency
criteria developed, defined, and adopted by the Department, to
automatically assign Medicaid enrollees served under the
Family Health Plan and the Integrated Care Program and those
Medicaid enrollees eligible for medical assistance pursuant to
the Patient Protection and Affordable Care Act (Public Law 111-148) into managed care entities, including Accountable
Care Entities, Managed Care Community Networks, and Managed
Care Organizations. The quality metrics used shall be
measurable for all entities. The algorithm shall not use the
quality and proficiency metrics to reassign enrollees out of
any plan in which they are enrolled at the time and shall only
be used if the client has not voluntarily selected a primary
care physician and a managed care entity or care coordination
entity. Clients shall have one opportunity within 90 calendar
days after auto-assignment by algorithm to select a different
managed care entity. The algorithm developed and implemented
shall favor assignment into managed care entities with the
highest quality scores and levels of compliance with the
operational proficiency criteria established, taking into consideration existing provider-beneficiary relationship as defined by 42 CFR 438.50(f)(3) if one exists.
(Source: P.A. 99-898, eff. 1-1-17; 100-201, eff. 8-18-17.) |