| ||||||||||||||||||||
| ||||||||||||||||||||
| ||||||||||||||||||||
| ||||||||||||||||||||
| ||||||||||||||||||||
1 | AN ACT concerning public aid.
| |||||||||||||||||||
2 | Be it enacted by the People of the State of Illinois,
| |||||||||||||||||||
3 | represented in the General Assembly:
| |||||||||||||||||||
4 | Section 5. The Illinois Public Aid Code is amended by | |||||||||||||||||||
5 | changing Section 5-30.1 as follows: | |||||||||||||||||||
6 | (305 ILCS 5/5-30.1) | |||||||||||||||||||
7 | Sec. 5-30.1. Managed care protections. | |||||||||||||||||||
8 | (a) As used in this Section: | |||||||||||||||||||
9 | "Managed care organization" or "MCO" means any entity | |||||||||||||||||||
10 | which contracts with the Department to provide services where | |||||||||||||||||||
11 | payment for medical services is made on a capitated basis. | |||||||||||||||||||
12 | "Emergency services" include: | |||||||||||||||||||
13 | (1) emergency services, as defined by Section 10 of | |||||||||||||||||||
14 | the Managed Care Reform and Patient Rights Act; | |||||||||||||||||||
15 | (2) emergency medical screening examinations, as | |||||||||||||||||||
16 | defined by Section 10 of the Managed Care Reform and | |||||||||||||||||||
17 | Patient Rights Act; | |||||||||||||||||||
18 | (3) post-stabilization medical services, as defined by | |||||||||||||||||||
19 | Section 10 of the Managed Care Reform and Patient Rights | |||||||||||||||||||
20 | Act; and | |||||||||||||||||||
21 | (4) emergency medical conditions, as defined by
| |||||||||||||||||||
22 | Section 10 of the Managed Care Reform and Patient Rights
| |||||||||||||||||||
23 | Act. |
| |||||||
| |||||||
1 | (b) As provided by Section 5-16.12, managed care | ||||||
2 | organizations are subject to the provisions of the Managed | ||||||
3 | Care Reform and Patient Rights Act. | ||||||
4 | (c) An MCO shall pay any provider of emergency services | ||||||
5 | that does not have in effect a contract with the contracted | ||||||
6 | Medicaid MCO. The default rate of reimbursement shall be the | ||||||
7 | rate paid under Illinois Medicaid fee-for-service program | ||||||
8 | methodology, including all policy adjusters, including but not | ||||||
9 | limited to Medicaid High Volume Adjustments, Medicaid | ||||||
10 | Percentage Adjustments, Outpatient High Volume Adjustments, | ||||||
11 | and all outlier add-on adjustments to the extent such | ||||||
12 | adjustments are incorporated in the development of the | ||||||
13 | applicable MCO capitated rates. | ||||||
14 | (d) An MCO shall pay for all post-stabilization services | ||||||
15 | as a covered service in any of the following situations: | ||||||
16 | (1) the MCO authorized such services; | ||||||
17 | (2) such services were administered to maintain the | ||||||
18 | enrollee's stabilized condition within one hour after a | ||||||
19 | request to the MCO for authorization of further | ||||||
20 | post-stabilization services; | ||||||
21 | (3) the MCO did not respond to a request to authorize | ||||||
22 | such services within one hour; | ||||||
23 | (4) the MCO could not be contacted; or | ||||||
24 | (5) the MCO and the treating provider, if the treating | ||||||
25 | provider is a non-affiliated provider, could not reach an | ||||||
26 | agreement concerning the enrollee's care and an affiliated |
| |||||||
| |||||||
1 | provider was unavailable for a consultation, in which case | ||||||
2 | the MCO
must pay for such services rendered by the | ||||||
3 | treating non-affiliated provider until an affiliated | ||||||
4 | provider was reached and either concurred with the | ||||||
5 | treating non-affiliated provider's plan of care or assumed | ||||||
6 | responsibility for the enrollee's care. Such payment shall | ||||||
7 | be made at the default rate of reimbursement paid under | ||||||
8 | Illinois Medicaid fee-for-service program methodology, | ||||||
9 | including all policy adjusters, including but not limited | ||||||
10 | to Medicaid High Volume Adjustments, Medicaid Percentage | ||||||
11 | Adjustments, Outpatient High Volume Adjustments and all | ||||||
12 | outlier add-on adjustments to the extent that such | ||||||
13 | adjustments are incorporated in the development of the | ||||||
14 | applicable MCO capitated rates. | ||||||
15 | (e) The following requirements apply to MCOs in | ||||||
16 | determining payment for all emergency services: | ||||||
17 | (1) MCOs shall not impose any requirements for prior | ||||||
18 | approval of emergency services. | ||||||
19 | (2) The MCO shall cover emergency services provided to | ||||||
20 | enrollees who are temporarily away from their residence | ||||||
21 | and outside the contracting area to the extent that the | ||||||
22 | enrollees would be entitled to the emergency services if | ||||||
23 | they still were within the contracting area. | ||||||
24 | (3) The MCO shall have no obligation to cover medical | ||||||
25 | services provided on an emergency basis that are not | ||||||
26 | covered services under the contract. |
| |||||||
| |||||||
1 | (4) The MCO shall not condition coverage for emergency | ||||||
2 | services on the treating provider notifying the MCO of the | ||||||
3 | enrollee's screening and treatment within 10 days after | ||||||
4 | presentation for emergency services. | ||||||
5 | (5) The determination of the attending emergency | ||||||
6 | physician, or the provider actually treating the enrollee, | ||||||
7 | of whether an enrollee is sufficiently stabilized for | ||||||
8 | discharge or transfer to another facility, shall be | ||||||
9 | binding on the MCO. The MCO shall cover emergency services | ||||||
10 | for all enrollees whether the emergency services are | ||||||
11 | provided by an affiliated or non-affiliated provider. | ||||||
12 | (6) The MCO's financial responsibility for | ||||||
13 | post-stabilization care services it has not pre-approved | ||||||
14 | ends when: | ||||||
15 | (A) a plan physician with privileges at the | ||||||
16 | treating hospital assumes responsibility for the | ||||||
17 | enrollee's care; | ||||||
18 | (B) a plan physician assumes responsibility for | ||||||
19 | the enrollee's care through transfer; | ||||||
20 | (C) a contracting entity representative and the | ||||||
21 | treating physician reach an agreement concerning the | ||||||
22 | enrollee's care; or | ||||||
23 | (D) the enrollee is discharged. | ||||||
24 | (f) Network adequacy and transparency. | ||||||
25 | (1) The Department shall: | ||||||
26 | (A) ensure that an adequate provider network is in |
| |||||||
| |||||||
1 | place, taking into consideration health professional | ||||||
2 | shortage areas and medically underserved areas; | ||||||
3 | (B) publicly release an explanation of its process | ||||||
4 | for analyzing network adequacy; | ||||||
5 | (C) periodically ensure that an MCO continues to | ||||||
6 | have an adequate network in place; and | ||||||
7 | (D) require MCOs, including Medicaid Managed Care | ||||||
8 | Entities as defined in Section 5-30.2, to meet | ||||||
9 | provider directory requirements under Section 5-30.3. | ||||||
10 | (2) Each MCO shall confirm its receipt of information | ||||||
11 | submitted specific to physician or dentist additions or | ||||||
12 | physician or dentist deletions from the MCO's provider | ||||||
13 | network within 3 days after receiving all required | ||||||
14 | information from contracted physicians or dentists, and | ||||||
15 | electronic physician and dental directories must be | ||||||
16 | updated consistent with current rules as published by the | ||||||
17 | Centers for Medicare and Medicaid Services or its | ||||||
18 | successor agency. | ||||||
19 | (g) Timely payment of claims. | ||||||
20 | (1) The MCO shall pay a claim within 30 days of | ||||||
21 | receiving a claim that contains all the essential | ||||||
22 | information needed to adjudicate the claim. | ||||||
23 | (2) The MCO shall notify the billing party of its | ||||||
24 | inability to adjudicate a claim within 30 days of | ||||||
25 | receiving that claim. | ||||||
26 | (3) The MCO shall pay a penalty that is at least equal |
| |||||||
| |||||||
1 | to the timely payment interest penalty imposed under | ||||||
2 | Section 368a of the Illinois Insurance Code for any claims | ||||||
3 | not timely paid. | ||||||
4 | (A) When an MCO is required to pay a timely payment | ||||||
5 | interest penalty to a provider, the MCO must calculate | ||||||
6 | and pay the timely payment interest penalty that is | ||||||
7 | due to the provider within 30 days after the payment of | ||||||
8 | the claim. In no event shall a provider be required to | ||||||
9 | request or apply for payment of any owed timely | ||||||
10 | payment interest penalties. | ||||||
11 | (B) Such payments shall be reported separately | ||||||
12 | from the claim payment for services rendered to the | ||||||
13 | MCO's enrollee and clearly identified as interest | ||||||
14 | payments. | ||||||
15 | (4)(A) The Department shall require MCOs to expedite | ||||||
16 | payments to providers identified on the Department's | ||||||
17 | expedited provider list, determined in accordance with 89 | ||||||
18 | Ill. Adm. Code 140.71(b), on a schedule at least as | ||||||
19 | frequently as the providers are paid under the | ||||||
20 | Department's fee-for-service expedited provider schedule. | ||||||
21 | (B) Compliance with the expedited provider requirement | ||||||
22 | may be satisfied by an MCO through the use of a Periodic | ||||||
23 | Interim Payment (PIP) program that has been mutually | ||||||
24 | agreed to and documented between the MCO and the provider, | ||||||
25 | and the PIP program ensures that any expedited provider | ||||||
26 | receives regular and periodic payments based on prior |
| |||||||
| |||||||
1 | period payment experience from that MCO. Total payments | ||||||
2 | under the PIP program may be reconciled against future PIP | ||||||
3 | payments on a schedule mutually agreed to between the MCO | ||||||
4 | and the provider. | ||||||
5 | (C) The Department shall share at least monthly its | ||||||
6 | expedited provider list and the frequency with which it | ||||||
7 | pays providers on the expedited list. | ||||||
8 | (g-5) Recognizing that the rapid transformation of the | ||||||
9 | Illinois Medicaid program may have unintended operational | ||||||
10 | challenges for both payers and providers: | ||||||
11 | (1) in no instance shall a medically necessary covered | ||||||
12 | service rendered in good faith, based upon eligibility | ||||||
13 | information documented by the provider, be denied coverage | ||||||
14 | or diminished in payment amount if the eligibility or | ||||||
15 | coverage information available at the time the service was | ||||||
16 | rendered is later found to be inaccurate in the assignment | ||||||
17 | of coverage responsibility between MCOs or the | ||||||
18 | fee-for-service system, except for instances when an | ||||||
19 | individual is deemed to have not been eligible for | ||||||
20 | coverage under the Illinois Medicaid program; and | ||||||
21 | (2) the Department shall, by December 31, 2016, adopt | ||||||
22 | rules establishing policies that shall be included in the | ||||||
23 | Medicaid managed care policy and procedures manual | ||||||
24 | addressing payment resolutions in situations in which a | ||||||
25 | provider renders services based upon information obtained | ||||||
26 | after verifying a patient's eligibility and coverage plan |
| |||||||
| |||||||
1 | through either the Department's current enrollment system | ||||||
2 | or a system operated by the coverage plan identified by | ||||||
3 | the patient presenting for services: | ||||||
4 | (A) such medically necessary covered services | ||||||
5 | shall be considered rendered in good faith; | ||||||
6 | (B) such policies and procedures shall be | ||||||
7 | developed in consultation with industry | ||||||
8 | representatives of the Medicaid managed care health | ||||||
9 | plans and representatives of provider associations | ||||||
10 | representing the majority of providers within the | ||||||
11 | identified provider industry; and | ||||||
12 | (C) such rules shall be published for a review and | ||||||
13 | comment period of no less than 30 days on the | ||||||
14 | Department's website with final rules remaining | ||||||
15 | available on the Department's website. | ||||||
16 | The rules on payment resolutions shall include, but not be | ||||||
17 | limited to: | ||||||
18 | (A) the extension of the timely filing period; | ||||||
19 | (B) retroactive prior authorizations; and | ||||||
20 | (C) guaranteed minimum payment rate of no less than | ||||||
21 | the current, as of the date of service, fee-for-service | ||||||
22 | rate, plus all applicable add-ons, when the resulting | ||||||
23 | service relationship is out of network. | ||||||
24 | The rules shall be applicable for both MCO coverage and | ||||||
25 | fee-for-service coverage. | ||||||
26 | If the fee-for-service system is ultimately determined to |
| |||||||
| |||||||
1 | have been responsible for coverage on the date of service, the | ||||||
2 | Department shall provide for an extended period for claims | ||||||
3 | submission outside the standard timely filing requirements. | ||||||
4 | (g-6) MCO Performance Metrics Report. | ||||||
5 | (1) The Department shall publish, on at least a | ||||||
6 | quarterly basis, each MCO's operational performance, | ||||||
7 | including, but not limited to, the following categories of | ||||||
8 | metrics: | ||||||
9 | (A) claims payment, including timeliness and | ||||||
10 | accuracy; | ||||||
11 | (B) prior authorizations; | ||||||
12 | (C) grievance and appeals; | ||||||
13 | (D) utilization statistics; | ||||||
14 | (E) provider disputes; | ||||||
15 | (F) provider credentialing; and | ||||||
16 | (G) member and provider customer service. | ||||||
17 | (2) The Department shall ensure that the metrics | ||||||
18 | report is accessible to providers online by January 1, | ||||||
19 | 2017. | ||||||
20 | (3) The metrics shall be developed in consultation | ||||||
21 | with industry representatives of the Medicaid managed care | ||||||
22 | health plans and representatives of associations | ||||||
23 | representing the majority of providers within the | ||||||
24 | identified industry. | ||||||
25 | (4) Metrics shall be defined and incorporated into the | ||||||
26 | applicable Managed Care Policy Manual issued by the |
| |||||||
| |||||||
1 | Department. | ||||||
2 | (g-7) MCO claims processing and performance analysis. In | ||||||
3 | order to monitor MCO payments to hospital providers, pursuant | ||||||
4 | to this amendatory Act of the 100th General Assembly, the | ||||||
5 | Department shall post an analysis of MCO claims processing and | ||||||
6 | payment performance on its website every 6 months. Such | ||||||
7 | analysis shall include a review and evaluation of a | ||||||
8 | representative sample of hospital claims that are rejected and | ||||||
9 | denied for clean and unclean claims and the top 5 reasons for | ||||||
10 | such actions and timeliness of claims adjudication, which | ||||||
11 | identifies the percentage of claims adjudicated within 30, 60, | ||||||
12 | 90, and over 90 days, and the dollar amounts associated with | ||||||
13 | those claims. The Department shall post the contracted claims | ||||||
14 | report required by HealthChoice Illinois on its website every | ||||||
15 | 3 months. | ||||||
16 | (g-8) Dispute resolution process. The Department shall | ||||||
17 | maintain a provider complaint portal through which a provider | ||||||
18 | can submit to the Department unresolved disputes with an MCO. | ||||||
19 | An unresolved dispute means an MCO's decision that denies in | ||||||
20 | whole or in part a claim for reimbursement to a provider for | ||||||
21 | health care services rendered by the provider to an enrollee | ||||||
22 | of the MCO with which the provider disagrees. Disputes shall | ||||||
23 | not be submitted to the portal until the provider has availed | ||||||
24 | itself of the MCO's internal dispute resolution process. | ||||||
25 | Disputes that are submitted to the MCO internal dispute | ||||||
26 | resolution process may be submitted to the Department of |
| |||||||
| |||||||
1 | Healthcare and Family Services' complaint portal no sooner | ||||||
2 | than 30 days after submitting to the MCO's internal process | ||||||
3 | and not later than 30 days after the unsatisfactory resolution | ||||||
4 | of the internal MCO process or 60 days after submitting the | ||||||
5 | dispute to the MCO internal process. Multiple claim disputes | ||||||
6 | involving the same MCO may be submitted in one complaint, | ||||||
7 | regardless of whether the claims are for different enrollees, | ||||||
8 | when the specific reason for non-payment of the claims | ||||||
9 | involves a common question of fact or policy. Within 10 | ||||||
10 | business days of receipt of a complaint, the Department shall | ||||||
11 | present such disputes to the appropriate MCO, which shall then | ||||||
12 | have 30 days to issue its written proposal to resolve the | ||||||
13 | dispute. The Department may grant one 30-day extension of this | ||||||
14 | time frame to one of the parties to resolve the dispute. If the | ||||||
15 | dispute remains unresolved at the end of this time frame or the | ||||||
16 | provider is not satisfied with the MCO's written proposal to | ||||||
17 | resolve the dispute, the provider may, within 30 days, request | ||||||
18 | the Department to review the dispute and make a final | ||||||
19 | determination. Within 30 days of the request for Department | ||||||
20 | review of the dispute, both the provider and the MCO shall | ||||||
21 | present all relevant information to the Department for | ||||||
22 | resolution and make individuals with knowledge of the issues | ||||||
23 | available to the Department for further inquiry if needed. | ||||||
24 | Within 30 days of receiving the relevant information on the | ||||||
25 | dispute, or the lapse of the period for submitting such | ||||||
26 | information, the Department shall issue a written decision on |
| |||||||
| |||||||
1 | the dispute based on contractual terms between the provider | ||||||
2 | and the MCO, contractual terms between the MCO and the | ||||||
3 | Department of Healthcare and Family Services and applicable | ||||||
4 | Medicaid policy. The decision of the Department shall be | ||||||
5 | final. By January 1, 2020, the Department shall establish by | ||||||
6 | rule further details of this dispute resolution process. | ||||||
7 | Disputes between MCOs and providers presented to the | ||||||
8 | Department for resolution are not contested cases, as defined | ||||||
9 | in Section 1-30 of the Illinois Administrative Procedure Act, | ||||||
10 | conferring any right to an administrative hearing. | ||||||
11 | (g-9)(1) The Department shall publish annually on its | ||||||
12 | website a report on the calculation of each managed care | ||||||
13 | organization's medical loss ratio showing the following: | ||||||
14 | (A) Premium revenue, with appropriate adjustments. | ||||||
15 | (B) Benefit expense, setting forth the aggregate | ||||||
16 | amount spent for the following: | ||||||
17 | (i) Direct paid claims. | ||||||
18 | (ii) Subcapitation payments. | ||||||
19 | (iii)
Other claim payments. | ||||||
20 | (iv)
Direct reserves. | ||||||
21 | (v)
Gross recoveries. | ||||||
22 | (vi)
Expenses for activities that improve health | ||||||
23 | care quality as allowed by the Department. | ||||||
24 | (2) The medical loss ratio shall be calculated consistent | ||||||
25 | with federal law and regulation following a claims runout | ||||||
26 | period determined by the Department. |
| |||||||
| |||||||
1 | (g-10)(1) "Liability effective date" means the date on | ||||||
2 | which an MCO becomes responsible for payment for medically | ||||||
3 | necessary and covered services rendered by a provider to one | ||||||
4 | of its enrollees in accordance with the contract terms between | ||||||
5 | the MCO and the provider. The liability effective date shall | ||||||
6 | be the later of: | ||||||
7 | (A) The execution date of a network participation | ||||||
8 | contract agreement. | ||||||
9 | (B) The date the provider or its representative | ||||||
10 | submits to the MCO the complete and accurate standardized | ||||||
11 | roster form for the provider in the format approved by the | ||||||
12 | Department. | ||||||
13 | (C) The provider effective date contained within the | ||||||
14 | Department's provider enrollment subsystem within the | ||||||
15 | Illinois Medicaid Program Advanced Cloud Technology | ||||||
16 | (IMPACT) System. | ||||||
17 | (2) The standardized roster form may be submitted to the | ||||||
18 | MCO at the same time that the provider submits an enrollment | ||||||
19 | application to the Department through IMPACT. | ||||||
20 | (3) By October 1, 2019, the Department shall require all | ||||||
21 | MCOs to update their provider directory with information for | ||||||
22 | new practitioners of existing contracted providers within 30 | ||||||
23 | days of receipt of a complete and accurate standardized roster | ||||||
24 | template in the format approved by the Department provided | ||||||
25 | that the provider is effective in the Department's provider | ||||||
26 | enrollment subsystem within the IMPACT system. Such provider |
| |||||||
| |||||||
1 | directory shall be readily accessible for purposes of | ||||||
2 | selecting an approved health care provider and comply with all | ||||||
3 | other federal and State requirements. | ||||||
4 | (g-11) The Department shall work with relevant | ||||||
5 | stakeholders on the development of operational guidelines to | ||||||
6 | enhance and improve operational performance of Illinois' | ||||||
7 | Medicaid managed care program, including, but not limited to, | ||||||
8 | improving provider billing practices, reducing claim | ||||||
9 | rejections and inappropriate payment denials, and | ||||||
10 | standardizing processes, procedures, definitions, and response | ||||||
11 | timelines, with the goal of reducing provider and MCO | ||||||
12 | administrative burdens and conflict. The Department shall | ||||||
13 | include a report on the progress of these program improvements | ||||||
14 | and other topics in its Fiscal Year 2020 annual report to the | ||||||
15 | General Assembly. | ||||||
16 | (h) The Department shall not expand mandatory MCO | ||||||
17 | enrollment into new counties beyond those counties already | ||||||
18 | designated by the Department as of June 1, 2014 for the | ||||||
19 | individuals whose eligibility for medical assistance is not | ||||||
20 | the seniors or people with disabilities population until the | ||||||
21 | Department provides an opportunity for accountable care | ||||||
22 | entities and MCOs to participate in such newly designated | ||||||
23 | counties. | ||||||
24 | (i) The requirements of this Section apply to contracts | ||||||
25 | with accountable care entities and MCOs entered into, amended, | ||||||
26 | or renewed after June 16, 2014 (the effective date of Public |
| |||||||
| |||||||
1 | Act 98-651).
| ||||||
2 | (j) Health care information released to managed care | ||||||
3 | organizations. A health care provider shall release to a | ||||||
4 | Medicaid managed care organization, upon request, and subject | ||||||
5 | to the Health Insurance Portability and Accountability Act of | ||||||
6 | 1996 and any other law applicable to the release of health | ||||||
7 | information, the health care information of the MCO's | ||||||
8 | enrollee, if the enrollee has completed and signed a general | ||||||
9 | release form that grants to the health care provider | ||||||
10 | permission to release the recipient's health care information | ||||||
11 | to the recipient's insurance carrier. | ||||||
12 | (Source: P.A. 100-201, eff. 8-18-17; 100-580, eff. 3-12-18; | ||||||
13 | 100-587, eff. 6-4-18; 101-209, eff. 8-5-19.)
| ||||||
14 | Section 99. Effective date. This Act takes effect upon | ||||||
15 | becoming law.
|