305 ILCS 5/ Illinois Public Aid Code.

(305 ILCS 5/5-30.7)

Sec. 5-30.7. Encounter data guidelines; provider fee schedule.

(a) No later than 60 days after the effective date of this amendatory Act of the 100th General Assembly, the Department shall publish on its website comprehensive written guidance on the submission of encounter data by managed care organizations. This information shall be updated and published as needed, but at least quarterly. The Department shall inform providers and managed care organizations of any updates via provider notices.

(b) The Department shall publish on its website provider fee schedules on both a portable document format (PDF) and EXCEL format. The portable document format shall serve as the ultimate source if there is a discrepancy.

(Source: P.A. 100-580, eff. 3-12-18.)

(305 ILCS 5/5-30.8)

Sec. 5-30.8. Managed care organization rate transparency.

(a) For the establishment of managed care organization (MCO) capitation base rate payments from the State, including, but not limited to: (i) hospital fee schedule reforms and updates, (ii) rates related to a single State-mandated preferred drug list, (iii) rate updates related to the State's preferred drug list, (iv) inclusion of coverage for children with special needs, (v) inclusion of coverage for children within the child welfare system, (vi) annual MCO capitation rates, and (vii) any retroactive provider fee schedule adjustments or other changes required by legislation or other actions, the Department of Healthcare and Family Services shall implement a capitation base rate setting process beginning on July 27, 2018 (the effective date of Public Act 100-646) which shall include all of the following elements of transparency:

(1) The Department shall include participating MCOs and a statewide trade association representing a majority of participating MCOs in meetings to discuss the impact to base capitation rates as a result of any new or updated hospital fee schedules or other provider fee schedules. Additionally, the Department shall share any data or reports used to develop MCO capitation rates with participating MCOs. This data shall be comprehensive enough for MCO actuaries to recreate and verify the accuracy of the capitation base rate build-up.

(2) The Department shall not limit the number of experts that each MCO is allowed to bring to the draft capitation base rate meeting or the final capitation base rate review meeting. Draft and final capitation base rate review meetings shall be held in at least 2 locations.

(3) The Department and its contracted actuary shall meet with all participating MCOs simultaneously and together along with consulting actuaries contracted with statewide trade association representing a majority of Medicaid health plans at the request of the plans. Participating MCOs shall additionally, at their request, be granted individual capitation rate development meetings with the Department.

(4) (Blank).

(4.5) Effective for calendar year 2024, a quality withhold program may be established by the Department for the HealthChoice Illinois Managed Care Program or any successor program. If such program withholds a portion of the actuarially certified capitation rates, the program must meet the following criteria: (i) benchmarks must be discussed publicly, based on predetermined quality standards that align with the Department's federally approved quality strategy, and set by publication on the Department's website at least 4 months prior to the start of the calendar year; (ii) incentive measures and benchmarks must be reasonable and attainable within the measurement year; and (iii) no less than 75% of the metrics shall be tied to nationally recognized measures. Any non-nationally recognized measures shall be in the reporting category for at least 2 years of experience and evaluation for consistency among MCOs prior to setting a performance baseline. The Department shall provide MCOs with biannual industry average data on the quality withhold measures. If all the money withheld is not earned back by individual MCOs, the Department shall reallocate unearned funds among the MCOs in one or both of the following manners: based upon their quality performance or for quality and equity improvement projects. Nothing in this paragraph prohibits the Department and the MCOs from establishing any other quality performance program.

(5) Upon request, the Department shall provide written responses to questions regarding MCO capitation base rates, the capitation base development methodology, and MCO capitation rate data, and all other requests regarding capitation rates from MCOs. Upon request, the Department shall also provide to the MCOs materials used in incorporating provider fee schedules into base capitation rates.

(b) For the development of capitation base rates for new capitation rate years:

(1) The Department shall take into account emerging experience in the development of the annual MCO capitation base rates, including, but not limited to, current-year cost and utilization trends observed by MCOs in an actuarially sound manner and in accordance with federal law and regulations.

(2) No later than January 1 of each year, the Department shall release an agreed upon annual calendar that outlines dates for capitation rate setting meetings for that year. The calendar shall include at least the following meetings and deadlines:

(A) An initial meeting for the Department to review MCO data and draft rate assumptions to be used in the development of capitation base rates for the following year.

(B) A draft rate meeting after the Department provides the MCOs with the draft capitation base rates to discuss, review, and seek feedback regarding the draft capitation base rates.

(3) Prior to the submission of final capitation rates to the federal Centers for Medicare and Medicaid Services, the Department shall provide the MCOs with a final actuarial report including the final capitation base rates for the following year and subsequently conduct a final capitation base review meeting. Final capitation rates shall be marked final.

(c) For the development of capitation base rates reflecting policy changes:

(1) Unless contrary to federal law and regulation, the Department must provide notice to MCOs of any significant operational policy change no later than 60 days prior to the effective date of an operational policy change in order to give MCOs time to prepare for and implement the operational policy change and to ensure that the quality and delivery of enrollee health care is not disrupted. "Operational policy change" means a change to operational requirements such as reporting formats, encounter submission definitional changes, or required provider interfaces made at the sole discretion of the Department and not required by legislation with a retroactive effective date. Nothing in this Section shall be construed as a requirement to delay or prohibit implementation of policy changes that impact enrollee benefits as determined in the sole discretion of the Department.

(2) No later than 60 days after the effective date of the policy change or program implementation, the Department shall meet with the MCOs regarding the initial data collection needed to establish capitation base rates for the policy change. Additionally, the Department shall share with the participating MCOs what other data is needed to estimate the change and the processes for collection of that data that shall be utilized to develop capitation base rates.

(3) No later than 60 days after the effective date of the policy change or program implementation, the Department shall meet with MCOs to review data and the Department's written draft assumptions to be used in development of capitation base rates for the policy change, and shall provide opportunities for questions to be asked and answered.

(4) No later than 60 days after the effective date of the policy change or program implementation, the Department shall provide the MCOs with draft capitation base rates and shall also conduct a draft capitation base rate meeting with MCOs to discuss, review, and seek feedback regarding the draft capitation base rates.

(d) For the development of capitation base rates for retroactive policy or fee schedule changes:

(1) The Department shall meet with the MCOs regarding the initial data collection needed to establish capitation base rates for the policy change. Additionally, the Department shall share with the participating MCOs what other data is needed to estimate the change and the processes for collection of the data that shall be utilized to develop capitation base rates.

(2) The Department shall meet with MCOs to review data and the Department's written draft assumptions to be used in development of capitation base rates for the policy change. The Department shall provide opportunities for questions to be asked and answered.

(3) The Department shall provide the MCOs with draft capitation rates and shall also conduct a draft rate meeting with MCOs to discuss, review, and seek feedback regarding the draft capitation base rates.

(4) The Department shall inform MCOs no less than quarterly of upcoming benefit and policy changes to the Medicaid program.

(e) Meetings of the group established to discuss Medicaid capitation rates under this Section shall be closed to the public and shall not be subject to the Open Meetings Act. Records and information produced by the group established to discuss Medicaid capitation rates under this Section shall be confidential and not subject to the Freedom of Information Act.

(Source: P.A. 103-102, eff. 1-1-24.)

(305 ILCS 5/5-30.9)

Sec. 5-30.9. Disenrollment requirements; managed care organization. Disenrollment of a Medicaid enrollee from a managed care organization under contract with the Department shall be in accordance with the requirements of 42 CFR 438.56 whenever a contract is terminated between a Medicaid managed care health plan and a primary care provider that results in a disruption to the Medicaid enrollee's provider-beneficiary relationship.

(Source: P.A. 100-950, eff. 8-19-18; 101-81, eff. 7-12-19.)

(305 ILCS 5/5-30.10)

Sec. 5-30.10. Electronic report submission. To preserve the quality of data and ensure productive oversight of Medicaid managed care organizations, all regular reports required, either by contract or statute, to be collected by the Department from managed care organizations shall be collected through a secure electronic format and medium as designated by the Department. The Department shall consider concerns raised by the contractor about potential burdens associated with producing the report. Ad hoc reports may be collected in alternative manners.

(Source: P.A. 100-1105, eff. 8-27-18; 101-81, eff. 7-12-19.)

(305 ILCS 5/5-30.11)

Sec. 5-30.11. Treatment of autism spectrum disorder. Treatment of autism spectrum disorder through applied behavior analysis shall be covered under the medical assistance program under this Article for children with a diagnosis of autism spectrum disorder when (1) ordered by a physician licensed to practice medicine in all its branches or a psychologist licensed by the Department of Financial and Professional Regulation and (2) evaluated by a behavior analyst as recognized by the Department or licensed by the Department of Financial and Professional Regulation to practice applied behavior analysis in this State. Such coverage may be limited to age ranges based on evidence-based best practices. Appropriate State plan amendments as well as rules regarding provision of services and providers will be submitted by September 1, 2019. Pursuant to the flexibilities allowed by the federal Centers for Medicare and Medicaid Services to Illinois under the Medical Assistance Program, the Department shall enroll and reimburse qualified staff to perform applied behavior analysis services in advance of Illinois licensure activities performed by the Department of Financial and Professional Regulation. These services shall be covered if they are provided in a home or community setting or in an office-based setting. The Department may conduct annual on-site reviews of the services authorized under this Section. Provider enrollment shall occur no later than September 1, 2023.

(Source: P.A. 102-558, eff. 8-20-21; 102-953, eff. 5-27-22; 103-102, eff. 7-1-23.)

(305 ILCS 5/5-30.12)

Sec. 5-30.12. Managed care claim rejection and denial management.

(a) In order to provide greater transparency to managed care organizations (MCOs) and providers, the Department shall explore the availability of and, if reasonably available, procure technology that, for all electronic claims, with the exception of direct data entry claims, meets the following needs:

(1) The technology shall allow the Department to fully analyze the root cause of claims denials in the Medicaid managed care programs operated by the Department and expedite solutions that reduce the number of denials to the extent possible.

(2) The technology shall create a single electronic pipeline through which all claims from all providers submitted for adjudication by the Department or a managed care organization under contract with the Department shall be directed by clearing houses and providers or other claims submitting entities not using clearing houses prior to forwarding to the Department or the appropriate managed care organization.

(3) The technology shall cause all HIPAA-compliant responses to submitted claims, including rejections, denials, and payments, returned to the submitting provider to pass through the established single pipeline.

(4) The technology shall give the Department the ability to create edits to be placed at the front end of the pipeline that will reject claims back to the submitting provider with an explanation of why the claim cannot be properly adjudicated by the payer.

(5) The technology shall allow the Department to customize the language used to explain why a claim is being rejected and how the claim can be corrected for adjudication.

(6) The technology shall send copies of all claims and claim responses that pass through the pipeline, regardless of the payer to whom they are directed, to the Department's Enterprise Data Warehouse.

(b) If the Department chooses to implement front end edits or customized responses to claims submissions, the MCOs and other stakeholders shall be consulted prior to implementation and providers shall be notified of edits at least 30 days prior to their effective date.

(c) Neither the technology nor MCO policy shall require providers to submit claims through a process other than the pipeline. MCOs may request supplemental information needed for adjudication which cannot be contained in the claim file to be submitted separately to the MCOs.

(d) The technology shall allow the Department to fully analyze and report on MCO claims processing and payment performance by provider type.

(Source: P.A. 101-209, eff. 8-5-19.)

(305 ILCS 5/5-30.13)

Sec. 5-30.13. Managed care reports; minority-owned and women-owned businesses. Each Medicaid managed care health plan shall submit a report to the Department by March 1, 2020, and every March 1 thereafter, that includes the following information:

(1) The administrative expenses paid to the Medicaid managed care health plan.

(2) The amount of money the Medicaid managed care health plan has spent with Business Enterprise Program certified businesses.

(3) The amount of money the Medicaid managed care health plan has spent with minority-owned and women-owned businesses that are certified by other agencies or private organizations.

(4) The amount of money the Medicaid managed care health plan has spent with not-for-profit community-based organizations serving predominantly minority communities, as defined by the Department.

(5) The proportion of minorities, people with disabilities, and women that make up the staff of the Medicaid managed care health plan.

(6) Recommendations for increasing expenditures with minority-owned and women-owned businesses.

(7) A list of the types of services to which the Medicaid managed care health plan is contemplating adding new vendors.

(8) The certifications the Medicaid managed care health plan accepts for minority-owned and women-owned businesses.

(9) The point of contact for potential vendors seeking to do business with the Medicaid managed care health plan.

The Department shall publish the reports on its website and shall maintain each report on its website for 5 years. In May of 2020 and every May thereafter, the Department shall hold 2 annual public workshops, one in Chicago and one in Springfield. The workshops shall include each Medicaid managed care health plan and shall be open to vendor communities to discuss the submitted plans and to seek to connect vendors with the Medicaid managed care health plans.

(Source: P.A. 101-209, eff. 8-5-19; 102-558, eff. 8-20-21.)

(305 ILCS 5/5-30.14)

Sec. 5-30.14. Medicaid managed care organizations; preferred drug lists.

(a) No later than January 1, 2020, the Illinois Department shall develop a standardized format for all Medicaid managed care organization preferred drug lists in collaboration with Medicaid managed care organizations and other stakeholders, including, but not limited to, organizations that serve individuals impacted by HIV/AIDS or epilepsy, and community-based organizations, providers, and entities with expertise in drug formulary development.

(b) Following development of the standardized Preferred Drug List format, the Illinois Department shall allow Medicaid managed care organizations 6 months from the date of completion to comply with the new Preferred Drug List format. Each Medicaid managed care organization must post its preferred drug list on its website without restricting access and must update the preferred drug list posted on its website. Medicaid managed care organizations shall publish updates to their preferred drug lists no less than 30 days prior to the date upon which any update or change takes effect, including, but not limited to, any and all changes to requirements for prior approval requirements, step therapy, or other utilization controls.

(c)(1) No later than January 1, 2020, the Illinois Department shall establish and maintain the Illinois Drug and Therapeutics Advisory Board. The Board shall have the authority and responsibility to provide recommendations to the Illinois Department regarding which drug products to list on the Illinois Department's preferred drug list. The Illinois Department shall provide administrative support to the Board and the Board shall:

(A) convene and meet no less than once per calendar quarter;

(B) provide regular opportunities for public comment; and

(C) comply with the provisions of the Open Meetings Act.

All correspondence related to the Board, including correspondence to and from Board members, shall be subject to the Freedom of Information Act.

(2) The Board shall consist of the following voting members, all of whom shall be appointed by the Governor and shall serve terms of 3 years without compensation:

(A) one pharmacist licensed to practice pharmacy in Illinois who is recommended by a statewide organization representing pharmacists;

(B) 4 physicians, recommended by a statewide organization representing physicians, who are licensed to practice medicine in all its branches in Illinois, have knowledge of and adhere to best practice standards, and have experience treating Illinois Medicaid beneficiaries;

(C) at least one clinician who specializes in the prevention and treatment of HIV, recommended by an HIV healthcare advocacy organization;

(D) at least one clinician recommended by a healthcare advocacy organization that serves individuals who are affected by chronic diseases that require significant pharmaceutical treatments;

(E) one clinician representing the Illinois Department; and

(F) one licensed psychiatrist, recommended by a statewide organization representing psychiatrists, who has experience treating Illinois Medicaid beneficiaries.

One non-voting clinician recommended by an association of Medicaid managed care health plans shall serve a term of 3 years on the Board without compensation.

Organizations interested in nominating non-voting clinicians to advise the Board may submit requests to participate to the Illinois Department.

A licensed physician recommended by the Rare Disease Commission who is a rare disease specialist and possesses scientific knowledge and medical training with respect to rare diseases and is familiar with drug and biological products and treatment shall be notified in advance to attend an Illinois Drug and Therapeutics Advisory Board meeting when a drug or biological product is scheduled to be reviewed in order to advise and make recommendations on drugs or biological products.

(d) The Illinois Department shall adopt rules, to be in place no later than January 1, 2020, for the purpose of establishing and maintaining the Board.

(Source: P.A. 101-62, eff. 7-12-19; 102-558, eff. 8-20-21.)

(305 ILCS 5/5-30.16)

Sec. 5-30.16. Medicaid Business Opportunity Commission.

(a) The Medicaid Business Opportunity Commission is created within the Department of Healthcare and Family Services to develop a program to support and grow minority, women, and persons with disability owned businesses.

(b) The Commission shall consist of the following members:

(1) Two members appointed by the Illinois Legislative Black Caucus.

(2) Two members appointed by the Illinois Legislative Latino Caucus.

(3) Two members appointed by the Conference of Women Legislators of the Illinois General Assembly.

(4) Two members representing a statewide Medicaid health plan association, appointed by the Governor.

(5) One member representing the Department of Healthcare and Family Services, appointed by the Governor.

(6) Three members representing businesses currently registered with the Business Enterprise Program, appointed by the Governor.

(7) One member representing the disability community, appointed by the Governor.

(8) One member representing the Business Enterprise Council, appointed by the Governor.

(c) The Director of Healthcare and Family Services and chief of staff, or their designees, shall serve as the Commission's executive administrators in providing administrative support, research support, and other administrative tasks requested by the Commission's co-chairs. Any expenses, including, but not limited to, travel and housing, shall be paid for by the Department's existing budget.

(d) The members of the Commission shall receive no compensation for their services as members of the Commission.

(e) The members of the Commission shall designate co-chairs of the Commission to lead their efforts at the first meeting of the Commission.

(f) The Commission shall meet at least monthly beginning as soon as is practicable after the effective date of this amendatory Act of the 102nd General Assembly.

(g) The Commission shall:

(1) Develop a recommendation on a Medicaid Business Opportunity Program for Minority, Women, and Persons with Disability Owned business contracting requirements to be included in the contracts between the Department of Healthcare and Family Services and the Managed Care entities for the provision of Medicaid Services.

(2) Make recommendations on the process by which vendors or providers would be certified as eligible to be included in the program and appropriate eligibility standards relative to the healthcare industry.

(3) Make a recommendation on whether to include not for profit organizations, diversity councils, or diversity chambers as eligible for certification.

(4) Make a recommendation on whether diverse staff shall be considered within the goals set for managed care entities.

(5) Make a recommendation on whether a new platform for certification is necessary to administer this program or if the existing platform for the Business Enterprise Program is capable of including recommended changes coming from this Commission.

(6) Make a recommendation on the ongoing activity of the Commission including structure, frequency of meetings, and agendas to ensure ongoing oversight of the program by the Commission.

(h) The Commission shall provide recommendations to the Department and the General assembly by April 15, 2021 in order to ensure prompt implementation of the Medicaid Business Opportunity Program.

(i) Beginning January 1, 2022, and for each year thereafter, the Commission shall submit a report of its findings and recommendations to the General Assembly. The report to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.

(Source: P.A. 102-4, eff. 4-27-21.)

(305 ILCS 5/5-30.17)

Sec. 5-30.17. Medicaid Managed Care Oversight Commission.

(a) The Medicaid Managed Care Oversight Commission is created within the Department of Healthcare and Family Services to evaluate the effectiveness of Illinois' managed care program.

(b) The Commission shall consist of the following members:

(1) One member of the Senate, appointed by the Senate President, who shall serve as co-chair.

(2) One member of the House of Representatives, appointed by the Speaker of the House of Representatives, who shall serve as co-chair.

(3) One member of the House of Representatives, appointed by the Minority Leader of the House of Representatives.

(4) One member of the Senate, appointed by the Senate Minority Leader.

(5) One member representing the Department of Healthcare and Family Services, appointed by the Governor.

(6) One member representing the Department of Public Health, appointed by the Governor.

(7) One member representing the Department of Human Services, appointed by the Governor.

(8) One member representing the Department of Children and Family Services, appointed by the Governor.

(9) One member of a statewide association representing Medicaid managed care plans, appointed by the Governor.

(10) One member of a statewide association representing a majority of hospitals, appointed by the Governor.

(11) Two academic experts on Medicaid managed care programs, appointed by the Governor.

(12) One member of a statewide association representing primary care providers, appointed by the Governor.

(13) One member of a statewide association representing behavioral health providers, appointed by the Governor.

(14) Members representing Federally Qualified Health Centers, a long-term care association, a dental association, pharmacies, pharmacists, a developmental disability association, a Medicaid consumer advocate, a Medicaid consumer, an association representing physicians, a behavioral health association, and an association representing pediatricians, appointed by the Governor.

(15) A member of a statewide association representing only safety-net hospitals, appointed by the Governor.

(c) The Director of Healthcare and Family Services and chief of staff, or their designees, shall serve as the Commission's executive administrators in providing administrative support, research support, and other administrative tasks requested by the Commission's co-chairs. Any expenses, including, but not limited to, travel and housing, shall be paid for by the Department's existing budget.

(d) The members of the Commission shall receive no compensation for their services as members of the Commission.

(e) The Commission shall meet quarterly beginning as soon as is practicable after the effective date of this amendatory Act of the 102nd General Assembly.

(f) The Commission shall:

(1) review data on health outcomes of Medicaid managed care members;

(2) review current care coordination and case management efforts and make recommendations on expanding care coordination to additional populations with a focus on the social determinants of health;

(3) review and assess the appropriateness of metrics used in the Pay-for-Performance programs;

(4) review the Department's prior authorization and utilization management requirements and recommend adaptations for the Medicaid population;

(5) review managed care performance in meeting diversity contracting goals and the use of funds dedicated to meeting such goals, including, but not limited to, contracting requirements set forth in the Business Enterprise for Minorities, Women, and Persons with Disabilities Act; recommend strategies to increase compliance with diversity contracting goals in collaboration with the Chief Procurement Officer for General Services and the Business Enterprise Council for Minorities, Women, and Persons with Disabilities; and recoup any misappropriated funds for diversity contracting;

(6) review data on the effectiveness of processing to medical providers;

(7) review member access to health care services in the Medicaid Program, including specialty care services;

(8) review value-based and other alternative payment methodologies to make recommendations to enhance program efficiency and improve health outcomes;

(9) review the compliance of all managed care entities in State contracts and recommend reasonable financial penalties for any noncompliance;

(10) produce an annual report detailing the Commission's findings based upon its review of research conducted under this Section, including specific recommendations, if any, and any other information the Commission may deem proper in furtherance of its duties under this Section;

(11) review provider availability and make recommendations to increase providers where needed, including reviewing the regulatory environment and making recommendations for reforms;

(12) review capacity for culturally competent services, including translation services among providers; and

(13) review and recommend changes to the safety-net hospital definition to create different classifications of safety-net hospitals.

(f-5) The Department shall make available upon request the analytics of Medicaid managed care clearinghouse data regarding processing.

(g) Beginning January 1, 2022, and for each year thereafter, the Commission shall submit a report of its findings and recommendations to the General Assembly. The report to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.

(Source: P.A. 102-4, eff. 4-27-21.)

(305 ILCS 5/5-30a)

Sec. 5-30a. Exemptions from managed care enrollment; children. Notwithstanding any other provision of law, the Department shall not require any of the following children to enroll in or transition to the State's managed care medical assistance program:

(1) Children who are authorized by the Department to receive in-home shift nursing services as required by the federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provisions under 42 CFR 441.50 et seq.

(2) Children made eligible for medical assistance through any home and community-based services waiver program for medically fragile and technology dependent children authorized under Section 1915(c) of the Social Security Act.

Any children who meet the criteria under paragraph (1) or (2) and who are enrolled in the State's managed care medical assistance program on or before the effective date of this amendatory Act of the 100th General Assembly shall be given the option to disenroll from the State's managed care medical assistance program and receive medical assistance coverage under the State's traditional fee-for-service program.

(Source: P.A. 100-990, eff. 1-1-19.)