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1 | AN ACT concerning public aid.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Illinois Public Aid Code is amended by | ||||||||||||||||||||||||||
5 | changing Section 5-30.1 and by adding Section 5-30.11 as | ||||||||||||||||||||||||||
6 | follows: | ||||||||||||||||||||||||||
7 | (305 ILCS 5/5-30.1) | ||||||||||||||||||||||||||
8 | Sec. 5-30.1. Managed care protections. | ||||||||||||||||||||||||||
9 | (a) As used in this Section: | ||||||||||||||||||||||||||
10 | "Managed care organization" or "MCO" means any entity which | ||||||||||||||||||||||||||
11 | contracts with the Department to provide services where payment | ||||||||||||||||||||||||||
12 | for medical services is made on a capitated basis. | ||||||||||||||||||||||||||
13 | "Emergency services" include: | ||||||||||||||||||||||||||
14 | (1) emergency services, as defined by Section 10 of the | ||||||||||||||||||||||||||
15 | Managed Care Reform and Patient Rights Act; | ||||||||||||||||||||||||||
16 | (2) emergency medical screening examinations, as | ||||||||||||||||||||||||||
17 | defined by Section 10 of the Managed Care Reform and | ||||||||||||||||||||||||||
18 | Patient Rights Act; | ||||||||||||||||||||||||||
19 | (3) post-stabilization medical services, as defined by | ||||||||||||||||||||||||||
20 | Section 10 of the Managed Care Reform and Patient Rights | ||||||||||||||||||||||||||
21 | Act; and | ||||||||||||||||||||||||||
22 | (4) emergency medical conditions, as defined by
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23 | Section 10 of the Managed Care Reform and Patient Rights
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1 | Act. | ||||||
2 | (b) As provided by Section 5-16.12, managed care | ||||||
3 | organizations are subject to the provisions of the Managed Care | ||||||
4 | Reform and Patient Rights Act. | ||||||
5 | (c) An MCO shall pay any provider of emergency services | ||||||
6 | that does not have in effect a contract with the contracted | ||||||
7 | Medicaid MCO. The default rate of reimbursement shall be the | ||||||
8 | rate paid under Illinois Medicaid fee-for-service program | ||||||
9 | methodology, including all policy adjusters, including but not | ||||||
10 | limited to Medicaid High Volume Adjustments, Medicaid | ||||||
11 | Percentage Adjustments, Outpatient High Volume Adjustments, | ||||||
12 | and all outlier add-on adjustments to the extent such | ||||||
13 | adjustments are incorporated in the development of the | ||||||
14 | applicable MCO capitated rates. | ||||||
15 | (d) An MCO shall pay for all post-stabilization services as | ||||||
16 | a covered service in any of the following situations: | ||||||
17 | (1) the MCO authorized such services; | ||||||
18 | (2) such services were administered to maintain the | ||||||
19 | enrollee's stabilized condition within one hour after a | ||||||
20 | request to the MCO for authorization of further | ||||||
21 | post-stabilization services; | ||||||
22 | (3) the MCO did not respond to a request to authorize | ||||||
23 | such services within one hour; | ||||||
24 | (4) the MCO could not be contacted; or | ||||||
25 | (5) the MCO and the treating provider, if the treating | ||||||
26 | provider is a non-affiliated provider, could not reach an |
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1 | agreement concerning the enrollee's care and an affiliated | ||||||
2 | provider was unavailable for a consultation, in which case | ||||||
3 | the MCO
must pay for such services rendered by the treating | ||||||
4 | non-affiliated provider until an affiliated provider was | ||||||
5 | reached and either concurred with the treating | ||||||
6 | non-affiliated provider's plan of care or assumed | ||||||
7 | responsibility for the enrollee's care. Such payment shall | ||||||
8 | be made at the default rate of reimbursement paid under | ||||||
9 | Illinois Medicaid fee-for-service program methodology, | ||||||
10 | including all policy adjusters, including but not limited | ||||||
11 | to Medicaid High Volume Adjustments, Medicaid Percentage | ||||||
12 | Adjustments, Outpatient High Volume Adjustments and all | ||||||
13 | outlier add-on adjustments to the extent that such | ||||||
14 | adjustments are incorporated in the development of the | ||||||
15 | applicable MCO capitated rates. | ||||||
16 | (e) The following requirements apply to MCOs in determining | ||||||
17 | payment for all emergency services: | ||||||
18 | (1) MCOs shall not impose any requirements for prior | ||||||
19 | approval of emergency services. | ||||||
20 | (2) The MCO shall cover emergency services provided to | ||||||
21 | enrollees who are temporarily away from their residence and | ||||||
22 | outside the contracting area to the extent that the | ||||||
23 | enrollees would be entitled to the emergency services if | ||||||
24 | they still were within the contracting area. | ||||||
25 | (3) The MCO shall have no obligation to cover medical | ||||||
26 | services provided on an emergency basis that are not |
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1 | covered services under the contract. | ||||||
2 | (4) The MCO shall not condition coverage for emergency | ||||||
3 | services on the treating provider notifying the MCO of the | ||||||
4 | enrollee's screening and treatment within 10 days after | ||||||
5 | presentation for emergency services. | ||||||
6 | (5) The determination of the attending emergency | ||||||
7 | physician, or the provider actually treating the enrollee, | ||||||
8 | of whether an enrollee is sufficiently stabilized for | ||||||
9 | discharge or transfer to another facility, shall be binding | ||||||
10 | on the MCO. The MCO shall cover emergency services for all | ||||||
11 | enrollees whether the emergency services are provided by an | ||||||
12 | affiliated or non-affiliated provider. | ||||||
13 | (6) The MCO's financial responsibility for | ||||||
14 | post-stabilization care services it has not pre-approved | ||||||
15 | ends when: | ||||||
16 | (A) a plan physician with privileges at the | ||||||
17 | treating hospital assumes responsibility for the | ||||||
18 | enrollee's care; | ||||||
19 | (B) a plan physician assumes responsibility for | ||||||
20 | the enrollee's care through transfer; | ||||||
21 | (C) a contracting entity representative and the | ||||||
22 | treating physician reach an agreement concerning the | ||||||
23 | enrollee's care; or | ||||||
24 | (D) the enrollee is discharged. | ||||||
25 | (f) Network adequacy and transparency. | ||||||
26 | (1) The Department shall: |
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1 | (A) ensure that an adequate provider network is in | ||||||
2 | place, taking into consideration health professional | ||||||
3 | shortage areas and medically underserved areas; | ||||||
4 | (B) publicly release an explanation of its process | ||||||
5 | for analyzing network adequacy; | ||||||
6 | (C) periodically ensure that an MCO continues to | ||||||
7 | have an adequate network in place; and | ||||||
8 | (D) require MCOs, including Medicaid Managed Care | ||||||
9 | Entities as defined in Section 5-30.2, to meet provider | ||||||
10 | directory requirements under Section 5-30.3 ; and . | ||||||
11 | (E) require MCOs to: (i) ensure that any provider | ||||||
12 | under contract with an MCO on the date of service is | ||||||
13 | paid for any medically necessary service rendered to | ||||||
14 | any of the MCO's enrollees, regardless of inclusion on | ||||||
15 | the MCO's published and publicly available roster of | ||||||
16 | available providers; and (ii) ensure that all | ||||||
17 | contracted providers are listed on an updated roster | ||||||
18 | within 7 days of entering into a contract with the MCO | ||||||
19 | and that such roster is readily accessible to all | ||||||
20 | medical assistance enrollees for purposes of selecting | ||||||
21 | an approved healthcare provider. | ||||||
22 | (2) Each MCO shall confirm its receipt of information | ||||||
23 | submitted specific to physician or dentist additions or | ||||||
24 | physician or dentist deletions from the MCO's provider | ||||||
25 | network within 3 days after receiving all required | ||||||
26 | information from contracted physicians or dentists, and |
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1 | electronic physician and dental directories must be | ||||||
2 | updated consistent with current rules as published by the | ||||||
3 | Centers for Medicare and Medicaid Services or its successor | ||||||
4 | agency. | ||||||
5 | (g) Timely payment of claims. | ||||||
6 | (1) The MCO shall pay a claim within 30 days of | ||||||
7 | receiving a claim that contains all the essential | ||||||
8 | information needed to adjudicate the claim. | ||||||
9 | (2) The MCO shall notify the billing party of its | ||||||
10 | inability to adjudicate a claim within 30 days of receiving | ||||||
11 | that claim. | ||||||
12 | (3) The MCO shall pay a penalty that is at least equal | ||||||
13 | to the penalty imposed under the Illinois Insurance Code | ||||||
14 | for any claims not timely paid. | ||||||
15 | (4) The Department shall require MCOs to expedite | ||||||
16 | payments to providers based on criteria that include, but | ||||||
17 | are not limited to: may establish a process for MCOs to | ||||||
18 | expedite payments to providers based on criteria | ||||||
19 | established by the Department. | ||||||
20 | (A) At a minimum, each MCO shall ensure that | ||||||
21 | providers identified on the Department's expedited | ||||||
22 | provider list, determined in accordance with 89 Ill. | ||||||
23 | Adm. Code 140.71(b), are paid by the MCO on a schedule | ||||||
24 | at least as frequently as the providers are paid under | ||||||
25 | the Department's fee-for-service expedited provider | ||||||
26 | schedule. |
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1 | (B) Compliance with the expedited provider | ||||||
2 | requirement may be satisfied by an MCO through the use | ||||||
3 | of a Periodic Interim Payment (PIP) program that has | ||||||
4 | been mutually agreed to and documented between the MCO | ||||||
5 | and the provider, if the PIP program ensures that any | ||||||
6 | expedited provider receives regular and periodic | ||||||
7 | payments based on prior period payment experience from | ||||||
8 | that MCO. Total payments under the PIP program may be | ||||||
9 | reconciled against future PIP payments on a schedule | ||||||
10 | mutually agreed to between the MCO and the provider. | ||||||
11 | (g-5) Recognizing that the rapid transformation of the | ||||||
12 | Illinois Medicaid program may have unintended operational | ||||||
13 | challenges for both payers and providers: | ||||||
14 | (1) in no instance shall a medically necessary covered | ||||||
15 | service rendered in good faith, based upon eligibility | ||||||
16 | information documented by the provider, be denied coverage | ||||||
17 | or diminished in payment amount if the eligibility or | ||||||
18 | coverage information available at the time the service was | ||||||
19 | rendered is later found to be inaccurate; and | ||||||
20 | (2) the Department shall, by December 31, 2016, adopt | ||||||
21 | rules establishing policies that shall be included in the | ||||||
22 | Medicaid managed care policy and procedures manual | ||||||
23 | addressing payment resolutions in situations in which a | ||||||
24 | provider renders services based upon information obtained | ||||||
25 | after verifying a patient's eligibility and coverage plan | ||||||
26 | through either the Department's current enrollment system |
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1 | or a system operated by the coverage plan identified by the | ||||||
2 | patient presenting for services: | ||||||
3 | (A) such medically necessary covered services | ||||||
4 | shall be considered rendered in good faith; | ||||||
5 | (B) such policies and procedures shall be | ||||||
6 | developed in consultation with industry | ||||||
7 | representatives of the Medicaid managed care health | ||||||
8 | plans and representatives of provider associations | ||||||
9 | representing the majority of providers within the | ||||||
10 | identified provider industry; and | ||||||
11 | (C) such rules shall be published for a review and | ||||||
12 | comment period of no less than 30 days on the | ||||||
13 | Department's website with final rules remaining | ||||||
14 | available on the Department's website. | ||||||
15 | (3) The rules on payment resolutions shall include, but | ||||||
16 | not be limited to: | ||||||
17 | (A) the extension of the timely filing period; | ||||||
18 | (B) retroactive prior authorizations; and | ||||||
19 | (C) guaranteed minimum payment rate of no less than | ||||||
20 | the current, as of the date of service, fee-for-service | ||||||
21 | rate, plus all applicable add-ons, when the resulting | ||||||
22 | service relationship is out of network. | ||||||
23 | (4) The rules shall be applicable for both MCO coverage | ||||||
24 | and fee-for-service coverage. | ||||||
25 | (g-6) MCO Performance Metrics Report. | ||||||
26 | (1) The Department shall publish, on at least a |
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1 | quarterly basis, each MCO's operational performance, | ||||||
2 | including, but not limited to, the following categories of | ||||||
3 | metrics: | ||||||
4 | (A) claims payment, including timeliness and | ||||||
5 | accuracy; | ||||||
6 | (B) prior authorizations; | ||||||
7 | (C) grievance and appeals; | ||||||
8 | (D) utilization statistics; | ||||||
9 | (E) provider disputes; | ||||||
10 | (F) provider credentialing; and | ||||||
11 | (G) member and provider customer service. | ||||||
12 | (2) The Department shall ensure that the metrics report | ||||||
13 | is accessible to providers online by January 1, 2017. | ||||||
14 | (3) The metrics shall be developed in consultation with | ||||||
15 | industry representatives of the Medicaid managed care | ||||||
16 | health plans and representatives of associations | ||||||
17 | representing the majority of providers within the | ||||||
18 | identified industry. | ||||||
19 | (4) Metrics shall be defined and incorporated into the | ||||||
20 | applicable Managed Care Policy Manual issued by the | ||||||
21 | Department. | ||||||
22 | (g-7) MCO claims processing and performance analysis. In | ||||||
23 | order to monitor MCO payments to hospital providers, pursuant | ||||||
24 | to this amendatory Act of the 100th General Assembly, the | ||||||
25 | Department shall post an analysis of MCO claims processing and | ||||||
26 | payment performance on its website every 6 months. Such |
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1 | analysis shall include a review and evaluation of a | ||||||
2 | representative sample of hospital claims that are rejected and | ||||||
3 | denied for clean and unclean claims and the top 5 reasons for | ||||||
4 | such actions and timeliness of claims adjudication, which | ||||||
5 | identifies the percentage of claims adjudicated within 30, 60, | ||||||
6 | 90, and over 90 days, and the dollar amounts associated with | ||||||
7 | those claims. The Department shall post the contracted claims | ||||||
8 | report required by HealthChoice Illinois on its website every 3 | ||||||
9 | months. | ||||||
10 | (g-8) Notwithstanding any other provision of law, if the | ||||||
11 | Department or an MCO requires submission of a claim for payment | ||||||
12 | in a non-electronic format, a provider shall always be afforded | ||||||
13 | a period of no less than 90 business days, as a correction | ||||||
14 | period, following any notification of rejection by either the | ||||||
15 | Department or the MCO to correct errors or omissions in the | ||||||
16 | original submission. | ||||||
17 | Under no circumstances, either by an MCO or under the | ||||||
18 | State's fee-for-service system, shall a provider be denied | ||||||
19 | payment for failure to comply with any timely claims submission | ||||||
20 | requirements under this Code or under any existing contract, | ||||||
21 | unless the non-electronic format claim submission occurs after | ||||||
22 | the initial 180 days following the latest date of service on | ||||||
23 | the claim, or after the 90 business days correction period | ||||||
24 | following notification to the provider of rejection or denial | ||||||
25 | of payment. | ||||||
26 | (h) The Department shall not expand mandatory MCO |
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1 | enrollment into new counties beyond those counties already | ||||||
2 | designated by the Department as of June 1, 2014 for the | ||||||
3 | individuals whose eligibility for medical assistance is not the | ||||||
4 | seniors or people with disabilities population until the | ||||||
5 | Department provides an opportunity for accountable care | ||||||
6 | entities and MCOs to participate in such newly designated | ||||||
7 | counties. | ||||||
8 | (i) The requirements of this Section apply to contracts | ||||||
9 | with accountable care entities and MCOs entered into, amended, | ||||||
10 | or renewed after June 16, 2014 (the effective date of Public | ||||||
11 | Act 98-651).
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12 | (j) The requirements of this Section added by this | ||||||
13 | amendatory Act of the 101st General Assembly shall apply to | ||||||
14 | services provided on or after the first day of the month that | ||||||
15 | begins 60 days after the effective date of this amendatory Act | ||||||
16 | of the 101st General Assembly. | ||||||
17 | (Source: P.A. 99-725, eff. 8-5-16; 99-751, eff. 8-5-16; | ||||||
18 | 100-201, eff. 8-18-17; 100-580, eff. 3-12-18; 100-587, eff. | ||||||
19 | 6-4-18.) | ||||||
20 | (305 ILCS 5/5-30.11 new) | ||||||
21 | Sec. 5-30.11. Discharge notification and facility | ||||||
22 | placement of individuals; managed care. Whenever a hospital | ||||||
23 | provides notice to a managed care organization (MCO) that an | ||||||
24 | individual covered under the State's medical assistance | ||||||
25 | program has received a discharge order from the attending |
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1 | physician and is ready for discharge from an inpatient hospital | ||||||
2 | stay to another level of care, the MCO shall secure the | ||||||
3 | individual's placement in or transfer to another facility | ||||||
4 | within 24 hours of receiving the hospital's notification, or | ||||||
5 | shall pay the hospital a daily rate equal to the hospital's | ||||||
6 | daily rate associated with the stay ending, including all | ||||||
7 | applicable add-on adjustment payments.
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8 | Section 99. Effective date. This Act takes effect upon | ||||||
9 | becoming law.
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