SB2021 101ST GENERAL ASSEMBLY

LRB101 10004 KTG 55106 b

101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
SB2021

Introduced 2/15/2019, by Sen. Heather A. Steans

SYNOPSIS AS INTRODUCED:

See Index

Creates the Medicaid Eligibility Determination and Renewal Reform Act. Requires the Department of Healthcare and Family Services (Department) to work with the Department of Human Services to achieve the following goals related to eligibility determinations and renewals under the Medical Assistance Program: (i) reduce procedural terminations so that no more than 10% of medical assistance beneficiaries who remain eligible for medical assistance experience any lapse in contemporaneous medical coverage; and (ii) use technology to lower administrative burdens and increase beneficiary continuity of coverage by providing real-time eligibility determination decisions for at least 75% of all medical assistance applicants, increasing automatic renewals for medical assistance beneficiaries, and offering an electronic means by which medical assistance beneficiaries can track and maintain their benefits. Provides that the goals must be meet by December 31, 2020. Requires the Department to submit Medicaid and CHIP State Plan amendments to implement express lane eligibility for all beneficiaries of medical assistance and benefits under the Children's Health Insurance Program Act. Contains provisions concerning community-based enrollment and redetermination assistance; the creation of enhanced user permission; and other matters. Amends the Illinois Public Aid Code. Requires the Department to reduce administrative burdens and minimize delay utilizing its income, residency, and identity verification system; and to utilize federal or State electronic data sources to obtain certain financial, employment, and residency information. Contains provisions concerning data matching; the waiver of residency verification requirements; rulemaking authority; and other matters. Effective immediately.

FISCAL NOTE ACT MAY APPLY

A BILL FOR

AN ACT concerning public aid.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 1. Short title. This Act may be referred to as the Medicaid Eligibility Determination and Renewal Reform Act.

Section 5. Purpose. The processes currently in place for eligibility determination and renewal (also known as redetermination) under the State's medical assistance programs lead to delayed access to benefits, disruptions in care delivery, decreased quality of care, waste in spending on unnecessary administrative costs, and worse overall health and well-being for enrollees. To improve continuity of care for beneficiaries and remedy significant administrative challenges, to the benefit of both the State and beneficiaries, this Act implements improvements and efficiencies to increase accountability and transparency, minimize delay and procedural terminations, and improve the overall integrity of the State's medical assistance programs.

Section 10. Medicaid eligibility determination and renewal goals.

(a) The Department of Healthcare and Family Services shall work with the Department of Human Services, as well as other stakeholders, to achieve the following goals related to eligibility determinations and renewals under the Medical Assistance Program established under Article V of the Illinois Public Aid Code:

(1) Reduce procedural terminations under the Medical Assistance Program so that no more than 10% of medical assistance beneficiaries who remain eligible for medical assistance experience any lapse in contemporaneous medical coverage.

(2) Use technology to lower administrative burdens and increase beneficiary continuity of coverage by providing real-time eligibility determination decisions under the Medical Assistance Program for at least 75% of all medical assistance applicants, increasing automatic renewals for medical assistance beneficiaries, and offering an electronic means by which a broad array of medical assistance beneficiaries can track and maintain their benefits.

(b) The Department of Healthcare and Family Services and the Department of Human Services shall work together with stakeholders, including, but not limited to, beneficiaries of medical assistance, consumer advocates, governmental staff, provider, and managed care organizations, to achieve the goals described in subsection (a) by December 31, 2020. The Department of Healthcare and Family Services shall provide a report to the General Assembly on the Department's progress toward achieving those goals by December 31, 2019. The report shall be posted on the Department of Healthcare and Family Services' website and shall describe the policy changes the Department has made, any challenges the Department has faced, the Department's plan to achieve the goals by the deadline, and the current rate of procedural termination, data-driven renewals, and electronic portal use.

Section 15. Express lane eligibility State Plan amendment; implementation timeline.

(a) As used in this Section:

"CHIP" means the Children's Health Insurance Program established under the Children's Health Insurance Program Act.

"Medicaid" means medical assistance authorized under Section 1902 of the Social Security Act.

(b) Federal approval for express lane eligibility. The Department of Healthcare and Family Services shall submit Medicaid and CHIP State Plan amendments to the federal Centers for Medicare and Medicaid Services to implement express lane eligibility for all Medicaid and CHIP beneficiaries as permitted by Section 203 of the Children's Health Insurance Program Reauthorization Act of 2009 (Public Law 111-3), no later than 90 days after the effective date of this Act. The Department of Healthcare and Family Services shall cooperate with the federal Centers for Medicare and Medicaid Services to obtain approval, if necessary, to implement an express lane eligibility option to ensure that children eligible for Medicaid or CHIP have a fast and simplified process for having their eligibility determined or renewed to facilitate enrollment in Medicaid and CHIP.

(c) Content of State Plan amendment. At a minimum, the State Plan amendment shall specify that express lane eligibility shall apply to all Medicaid and CHIP beneficiaries. If federal approval is granted, the Department of Healthcare and Family Services shall seek an 1115 waiver to apply the express lane eligibility option to beneficiaries age 21 or older no later than 90 days after approval. The State Plan amendment shall identify, at a minimum, the Supplemental Nutrition Assistance Program as its express lane agency. The State Plan amendment shall also specify that the express lane eligibility option will be used for both applications and renewals. The Department of Healthcare and Family Services may select more than one express lane agency, consistent with the Centers for Medicare and Medicaid Services' rules governing express lane eligibility. The Department of Healthcare and Family Services may also elect to obtain and use information directly from State income tax records or returns, consistent with the Centers for Medicare and Medicaid Services' rules governing express lane eligibility.

(d) Implementation. After the Department of Healthcare and Family Services secures federal approval (if required) from the Centers for Medicare and Medicaid Services, the Department shall implement express lane eligibility within 90 days after the date of federal approval.

Section 20. Reinstatement upon renewal.

(a) If an individual who failed to cooperate during the renewal process cooperates and submits all required verifications prior to the end of the third month (or 90 days if longer) following the last day of coverage, and the case remains eligible, the Department of Healthcare and Family Services shall restore assistance immediately, with no loss of coverage and back to the date of cancellation, without requiring a new application from the individual. In restoring assistance, the Department shall act to ensure that an eligible individual has the shortest time possible, if any, when his or her case shows as inactive to providers. Retroactive coverage alone does not satisfy the objective of this Section if eligible individuals still experience real-time periods of an inactive case.

(b) Individuals who are reinstated and who are enrolled in a managed care organization prior to initial cancellation of coverage shall be reinstated to the same managed care organization, regardless of when the individual's coverage is reinstated, and the annual HealthChoice Illinois open enrollment period for the individual shall remain the same. Managed care organizations shall be paid the appropriate per member per month payment retroactively for reinstated members.

(c) Providers serving individuals in the State's fee-for-service system may submit prior approval requests to the Department of Healthcare and Family Services for review and retroactive processing for medical assistance provided during the reinstatement period. Providers serving individuals enrolled in managed care may have their prior approval requests submitted and processed retroactively for medical assistance provided during the reinstatement period, provided that appropriate member attribution and associated payment are also made to the managed care organization for the reinstated coverage period.

Section 25. Community-based enrollment and redetermination assistance.

(a) The Department of Healthcare and Family Services shall create and support agency-associated permission and enhanced user permission within the Department's integrated eligibility system to provide authorized access to client cases to better enable providers and community-based organizations to support applicants and clients enrolling in, renewing, or otherwise maintaining their benefits.

(b) Creation of agency-associated permission.

(1) The Department of Healthcare and Family Services shall authorize, create, support, and administer a process by which a provider or community-based organization can access each client case that is associated with that provider or community-based organization in the Department's integrated eligibility system for each client, provider, and community-based organization that seeks such access, and cooperates with the Department's screening, training, and security protocols. Such access shall enable the provider or community-based organization to assist its clients with their benefits cases.

(2) A client must authorize the Department of Healthcare and Family Services to associate his or her case with one or more particular providers or community-based organizations before the provider or organization may access the client's case. Such authorization must be given in writing and may be revoked in writing by the client, provider, or community-based organization at any time. The permission to access the case shall be granted to the provider or community-based organization as a whole and not specific to any particular employee or staff member. The Department of Healthcare and Family Services shall process all requests to associate a case or revoke an association with particular providers or community-based organizations promptly.

(3) For each provider and community-based organization that seeks such access, the Department of Healthcare and Family Services shall authorize and create agency-associated permission within the Department's integrated eligibility system to view the specific case for each client associated with the provider or community-based organization. This agency-associated permission shall permit staff authorized by the provider or community-based organization to access and interact with all client cases associated with the provider or community-based organization in ways that are otherwise accessible to the client. The provider or community-based organization shall identify and supervise authorized staff. Such agency-associated permission shall enable the provider or community-based organization to access all client-facing aspects of the case for each client associated with the provider or community-based organization who has authorized such access.

(4) The Department of Healthcare and Family Services shall ensure that the provider or community-based organization has been granted permission within the Department's integrated eligibility system (or other electronic systems) to receive and view notifications and alerts for all associated client cases, and to perform certain actions in associated client cases. Permitted actions shall include, but are not limited to: (i) viewing notifications, (ii) uploading documentation such as spend-down verifications and renewal forms, and (iii) initiating contact with and continuing communication with Department staff.

(c) Administration of agency-associated permission.

(1) The Department of Healthcare and Family Services shall develop criteria and policies for granting permission to providers and community-based organizations that seek agency-associated permission.

(2) The Department of Healthcare and Family Services shall create criteria and policies to ensure that agency-associated permission is granted only for accounts where the authorized user has agreed to (i) obtain the written consent of the individual, (ii) act in the best interest of the individual, (iii) maintain the integrity of the Department's programs, and (iv) act in compliance with applicable State and federal law.

(3) Agency-associated permission shall be authorized by the Department of Healthcare and Family Services in accordance with the criteria and policies to be developed by the Department under this Act.

(4) The Department of Healthcare and Family Services shall not unreasonably restrict or limit agency-associated permission.

(d) Creation of enhanced user permission.

(1) The Department of Healthcare and Family Services shall authorize, create, support, and administer an enhanced user permission under which particular individuals have authority to manually verify information and work around error messages in the Department's integrated eligibility system. Individuals who are associated with navigators, providers, or community-based organizations may apply for such access, and the Department shall grant enhanced user permission in compliance with this Section to those who cooperate with the Department's screening, training, and security protocols.

(2) Enhanced user permissions shall permit individuals to work in the integrated eligibility system with enhanced permissions beyond the consumer-facing portal. Such enhanced permissions shall include, but not be limited to, addressing common challenges, including (i) resolving common error codes, (ii) manually verifying data in the integrated eligibility system, and (iii) performing identity verification for the purposes of eligibility determination in accordance with requirements set forth by State and federal law. Nothing in this Act shall be interpreted as changing program eligibility or renewal criteria.

(e) Administration of enhanced user permission.

(1) Providers and community-based organizations shall nominate and supervise individual staff that serve as assisters, navigators, or who are otherwise proficient with Manage My Case to be granted enhanced user permissions by the Department of Healthcare and Family Services.

(2) The Department of Healthcare and Family Services shall develop criteria and policies for granting enhanced user permission.

(3) The Department of Healthcare and Family Services shall provide support and training to individuals granted enhanced user permission.

(4) The Department of Healthcare and Family Services shall maintain and publish online a list of providers and community-based organizations that employ staff who have been granted enhanced user permission, to help individuals and families looking for assistance enrolling in and maintaining benefits.

(5) The Department of Healthcare and Family Services shall create criteria and policies to ensure that individuals with enhanced user permission agree to (i) obtain the written consent of the individual, (ii) act in the best interest of the individual, (iii) maintain the integrity of the Department's programs, and (iv) act in compliance with applicable State and federal law.

(6) Enhanced user permission shall be authorized by the Department of Healthcare and Family Services in accordance with the criteria and policies to be developed by the Department under this Act.

(7) The Department of Healthcare and Family Services shall not unreasonably restrict or limit enhanced user permission.

Section 30. The Department shall adopt any rules or policies necessary to implement this Act.

Section 35. The Illinois Public Aid Code is amended by changing Section 11-5.2 as follows:

(305 ILCS 5/11-5.2)

Sec. 11-5.2. Income, Residency, and Identity Verification System.

(a) The Department shall ensure that its proposed integrated eligibility system shall include the computerized functions of income, residency, and identity eligibility verification to verify eligibility, eliminate duplication of medical assistance, and deter fraud, reduce administrative burdens on the Department and the applicant or recipient, and minimize delay. Until the integrated eligibility system is operational, the Department may enter into a contract with the vendor selected pursuant to Section 11-5.3 as necessary to obtain the electronic data matching described in this Section. This contract shall be exempt from the Illinois Procurement Code pursuant to subsection (h) of Section 1-10 of that Code.

(b) Prior to awarding medical assistance at application under Article V of this Code, the Department shall, to the extent such databases are available to the Department, conduct data matches using the name, date of birth, address, and Social Security Number of each applicant or recipient or responsible relative of an applicant or recipient through one or more federal or State electronic data sources including against the following:

(1) Income tax information.

(2) Employer reports of income and unemployment insurance payment information maintained by the Department of Employment Security.

(3) Earned and unearned income, citizenship and death, and other relevant information maintained by the Social Security Administration.

(4) Immigration status information maintained by the United States Citizenship and Immigration Services.

(5) Wage reporting and similar information maintained by states contiguous to this State.

(6) Employment information maintained by the Department of Employment Security in its New Hire Directory database.

(7) Employment information maintained by the United States Department of Health and Human Services in its National Directory of New Hires database.

(8) Veterans' benefits information maintained by the United States Department of Health and Human Services, in coordination with the Department of Health and Human Services and the Department of Veterans' Affairs, in the federal Public Assistance Reporting Information System (PARIS) database.

(9) Residency information maintained by the Illinois Secretary of State.

(10) A database which is substantially similar to or a successor of a database described in this Section that contains information relevant for verifying eligibility for medical assistance.

(c) (Blank).

(c-5) Financial information shall be data matched by first using the electronic data source with the most recent data. The most recent data source shall be accepted as a reliable electronic data source for determining reasonable compatibility with the applicant's or recipient's attestation or records. The Department may use a less recent data source only if it will maximize accuracy, minimize delay, and meet other applicable requirements.

(d) If information provided by or on behalf of an individual (on the application or renewal form or otherwise) is reasonably compatible with the information obtained by the Department in accordance with subsection (b), the Department must determine or renew eligibility based on such information without making additional requests for verification, information, or documentation to the individual. "Reasonable compatibility" means an allowable difference or discrepancy between the income reported by an applicant or recipient and the income reported by an electronic data source. a discrepancy results between information provided by an applicant, recipient, or responsible relative and information contained in one or more of the databases or information tools listed under subsection (b) of this Section or subsection (c) of Section 11-5.3 and that discrepancy calls into question the accuracy of information relevant to a condition of eligibility provided by the applicant, recipient, or responsible relative, the Department or its contractor shall review the applicant's or recipient's case using the following procedures:

(1) Income information obtained through an electronic data source shall be considered reasonably compatible with income information provided by or on behalf of the individual if both are either above or at or below the applicable income threshold. If the information discovered under subsection (b) of this Section or subsection (c) of Section 11-5.3 does not result in the Department finding the applicant or recipient ineligible for assistance under Article V of this Code, the Department shall finalize the determination or redetermination of eligibility.

(1.5) Income information is reasonably compatible if the discrepancy between the information provided by or on behalf of the individual is within 10% of the federal poverty level (above or below) of the information from the electronic data source. "Federal poverty level" means the poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services. These guidelines set poverty levels by family size.

(1.6) The reasonable compatibility standard for financial information shall also be met when the information provided by or on behalf of the individual is zero income or income that is below the program's applicable income standard, or when no income data is available from electronic data sources.

(1.7) If information provided by or on behalf of the individual is not reasonably compatible with information obtained through an electronic data match, the Department shall provide written notice to the applicant or recipient which shall describe in sufficient detail the circumstances and sources of the discrepancy, the information or documentation required, the manner in which the applicant or recipient may respond, and the consequences of failing to take action. The applicant or recipient shall have 10 business days to respond.

(2) If the information from both the electronic data source and the applicant or recipient discovered results in the Department finding the applicant or recipient ineligible for assistance, the Department shall provide notice as set forth in Section 11-7 of this Article.

(3) (Blank). If the information discovered is insufficient to determine that the applicant or recipient is eligible or ineligible, the Department shall provide written notice to the applicant or recipient which shall describe in sufficient detail the circumstances of the discrepancy, the information or documentation required, the manner in which the applicant or recipient may respond, and the consequences of failing to take action. The applicant or recipient shall have 10 business days to respond.

(4) If the applicant or recipient does not respond to the notice, the Department shall deny assistance for failure to cooperate, in which case the Department shall provide notice as set forth in Section 11-7. Eligibility for assistance shall not be established until the discrepancy has been resolved.

(5) If an applicant or recipient responds to the notice, the Department shall determine the effect of the information or documentation provided on the applicant's or recipient's case and shall take appropriate action. Written notice of the Department's action shall be provided as set forth in Section 11-7 of this Article.

(6) Suspected cases of fraud shall be referred to the Department's Inspector General.

(e) Excepting citizenship and satisfactory immigration status, the Department may waive its verification requirements for exceptional circumstances, including: The Department shall adopt any rules necessary to implement this Section.

(1) homelessness;

(2) domestic violence;

(3) instances where a noncustodial parent refuses to release documentation germane to verification of one or more eligibility factors;

(4) natural disaster; and

(5) other circumstances as identified on a case-by-case basis and approved by the Department, including, but not limited to, when documentation does not exist at the time of application or renewal or is not reasonably available.

(f) The Department shall ensure the integrated eligibility system shall include an applicant portal that allows electronic submission of eligibility documentation, updating of family and demographic information, tracking application status, and receiving electronic notifications from the Department. The Department shall actively promote the use of this portal through materials provided at Family and Community Resource Centers, staff communications with applicants, and electronic and print media. The portal and materials used to promote the portal must be available, at a minimum, in English, Spanish, and the next 4 most commonly used languages. The portal shall be available to all applicants and recipients of medical assistance provided they satisfy electronic identity verification requirements through one of the following processes:

(1) Providing personally identifying credit history information.

(2) Providing requested personally identifying documentation to the Department.

(3) Completing an email, text, or mobile phone verification where a message is sent to the email or phone associated with the account and the applicant or recipient must respond to that message.

(4) Completing any alternative process developed by the Department for ensuring the electronic security of applicants and recipients.

(g) The Department shall adopt any rules necessary to implement this Section.

(Source: P.A. 97-689, eff. 6-14-12; 98-756, eff. 7-16-14.)

Section 99. Effective date. This Act takes effect upon becoming law.