Illinois General Assembly - Full Text of SB1041
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Full Text of SB1041  102nd General Assembly

SB1041eng 102ND GENERAL ASSEMBLY



 


 
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1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5changing 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
10which contracts with the Department to provide services where
11payment 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.

 

 

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1    (b) As provided by Section 5-16.12, managed care
2organizations are subject to the provisions of the Managed
3Care Reform and Patient Rights Act.
4    (c) An MCO shall pay any provider of emergency services
5that does not have in effect a contract with the contracted
6Medicaid MCO. The default rate of reimbursement shall be the
7rate paid under Illinois Medicaid fee-for-service program
8methodology, including all policy adjusters, including but not
9limited to Medicaid High Volume Adjustments, Medicaid
10Percentage Adjustments, Outpatient High Volume Adjustments,
11and all outlier add-on adjustments to the extent such
12adjustments are incorporated in the development of the
13applicable MCO capitated rates.
14    (d) An MCO shall pay for all post-stabilization services
15as 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

 

 

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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
16determining 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.

 

 

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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

 

 

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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

 

 

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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

 

 

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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
9Illinois Medicaid program may have unintended operational
10challenges 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

 

 

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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
17limited 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
25fee-for-service coverage.
26    If the fee-for-service system is ultimately determined to

 

 

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1have been responsible for coverage on the date of service, the
2Department shall provide for an extended period for claims
3submission 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

 

 

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1    Department.
2    (g-7) MCO claims processing and performance analysis. In
3order to monitor MCO payments to hospital providers, pursuant
4to this amendatory Act of the 100th General Assembly, the
5Department shall post an analysis of MCO claims processing and
6payment performance on its website every 6 months. Such
7analysis shall include a review and evaluation of a
8representative sample of hospital claims that are rejected and
9denied for clean and unclean claims and the top 5 reasons for
10such actions and timeliness of claims adjudication, which
11identifies the percentage of claims adjudicated within 30, 60,
1290, and over 90 days, and the dollar amounts associated with
13those claims. The Department shall post the contracted claims
14report required by HealthChoice Illinois on its website every
153 months.
16    (g-8) Dispute resolution process. The Department shall
17maintain a provider complaint portal through which a provider
18can submit to the Department unresolved disputes with an MCO.
19An unresolved dispute means an MCO's decision that denies in
20whole or in part a claim for reimbursement to a provider for
21health care services rendered by the provider to an enrollee
22of the MCO with which the provider disagrees. Disputes shall
23not be submitted to the portal until the provider has availed
24itself of the MCO's internal dispute resolution process.
25Disputes that are submitted to the MCO internal dispute
26resolution process may be submitted to the Department of

 

 

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1Healthcare and Family Services' complaint portal no sooner
2than 30 days after submitting to the MCO's internal process
3and not later than 30 days after the unsatisfactory resolution
4of the internal MCO process or 60 days after submitting the
5dispute to the MCO internal process. Multiple claim disputes
6involving the same MCO may be submitted in one complaint,
7regardless of whether the claims are for different enrollees,
8when the specific reason for non-payment of the claims
9involves a common question of fact or policy. Within 10
10business days of receipt of a complaint, the Department shall
11present such disputes to the appropriate MCO, which shall then
12have 30 days to issue its written proposal to resolve the
13dispute. The Department may grant one 30-day extension of this
14time frame to one of the parties to resolve the dispute. If the
15dispute remains unresolved at the end of this time frame or the
16provider is not satisfied with the MCO's written proposal to
17resolve the dispute, the provider may, within 30 days, request
18the Department to review the dispute and make a final
19determination. Within 30 days of the request for Department
20review of the dispute, both the provider and the MCO shall
21present all relevant information to the Department for
22resolution and make individuals with knowledge of the issues
23available to the Department for further inquiry if needed.
24Within 30 days of receiving the relevant information on the
25dispute, or the lapse of the period for submitting such
26information, the Department shall issue a written decision on

 

 

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1the dispute based on contractual terms between the provider
2and the MCO, contractual terms between the MCO and the
3Department of Healthcare and Family Services and applicable
4Medicaid policy. The decision of the Department shall be
5final. By January 1, 2020, the Department shall establish by
6rule further details of this dispute resolution process.
7Disputes between MCOs and providers presented to the
8Department for resolution are not contested cases, as defined
9in Section 1-30 of the Illinois Administrative Procedure Act,
10conferring any right to an administrative hearing.
11    (g-9)(1) The Department shall publish annually on its
12website a report on the calculation of each managed care
13organization'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
25with federal law and regulation following a claims runout
26period determined by the Department.

 

 

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1    (g-10)(1) "Liability effective date" means the date on
2which an MCO becomes responsible for payment for medically
3necessary and covered services rendered by a provider to one
4of its enrollees in accordance with the contract terms between
5the MCO and the provider. The liability effective date shall
6be 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
18MCO at the same time that the provider submits an enrollment
19application to the Department through IMPACT.
20    (3) By October 1, 2019, the Department shall require all
21MCOs to update their provider directory with information for
22new practitioners of existing contracted providers within 30
23days of receipt of a complete and accurate standardized roster
24template in the format approved by the Department provided
25that the provider is effective in the Department's provider
26enrollment subsystem within the IMPACT system. Such provider

 

 

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1directory shall be readily accessible for purposes of
2selecting an approved health care provider and comply with all
3other federal and State requirements.
4    (g-11) The Department shall work with relevant
5stakeholders on the development of operational guidelines to
6enhance and improve operational performance of Illinois'
7Medicaid managed care program, including, but not limited to,
8improving provider billing practices, reducing claim
9rejections and inappropriate payment denials, and
10standardizing processes, procedures, definitions, and response
11timelines, with the goal of reducing provider and MCO
12administrative burdens and conflict. The Department shall
13include a report on the progress of these program improvements
14and other topics in its Fiscal Year 2020 annual report to the
15General Assembly.
16    (h) The Department shall not expand mandatory MCO
17enrollment into new counties beyond those counties already
18designated by the Department as of June 1, 2014 for the
19individuals whose eligibility for medical assistance is not
20the seniors or people with disabilities population until the
21Department provides an opportunity for accountable care
22entities and MCOs to participate in such newly designated
23counties.
24    (i) The requirements of this Section apply to contracts
25with accountable care entities and MCOs entered into, amended,
26or renewed after June 16, 2014 (the effective date of Public

 

 

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1Act 98-651).
2    (j) Health care information released to managed care
3organizations. A health care provider shall release to a
4Medicaid managed care organization, upon request, and subject
5to the Health Insurance Portability and Accountability Act of
61996 and any other law applicable to the release of health
7information, the health care information of the MCO's
8enrollee, if the enrollee has completed and signed a general
9release form that grants to the health care provider
10permission to release the recipient's health care information
11to the recipient's insurance carrier.
12(Source: P.A. 100-201, eff. 8-18-17; 100-580, eff. 3-12-18;
13100-587, eff. 6-4-18; 101-209, eff. 8-5-19.)
 
14    Section 99. Effective date. This Act takes effect upon
15becoming law.