Full Text of SB3450 98th General Assembly
SB3450sam001 98TH GENERAL ASSEMBLY | Sen. James F. Clayborne, Jr. Filed: 3/24/2014
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| 1 | | AMENDMENT TO SENATE BILL 3450
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 3450 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 1. Short title. This Act may be cited as the | 5 | | Nursing Home Residents' Managed Care Rights Act. | 6 | | Section 5. Findings. The General Assembly finds that | 7 | | elderly Illinoisans residing in a nursing home have the right | 8 | | to: | 9 | | (1) quality health care regardless of the payer; | 10 | | (2) receive medically necessary care prescribed by their | 11 | | doctor; | 12 | | (3) a simple appeal process when care is denied; | 13 | | (4) make decisions about their care; and | 14 | | (5) continue to live in the nursing home they call home. | 15 | | Section 10. Scope. This Act applies to policies and |
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| 1 | | contracts amended, delivered, issued, or renewed on or after | 2 | | the effective date of this Act. This Act does not diminish a | 3 | | managed care organization's duties and responsibilities under | 4 | | other federal or State laws or rules adopted under those laws. | 5 | | Section 15. Definitions. | 6 | | (a) As used in this Act: | 7 | | "Advanced practice nurse" means an individual properly | 8 | | licensed as an advanced practice nurse under the Nurse Practice | 9 | | Act. | 10 | | "Appeal" means any of the procedures that deal with the | 11 | | review of adverse organization determinations on the health | 12 | | care services the enrollee believes he or she is entitled to | 13 | | receive, including delay in providing, arranging for, or | 14 | | approving the health care services, such that a delay would | 15 | | adversely affect the health of the enrollee or on any amounts | 16 | | the enrollee must pay for a service, as defined under 42 CFR | 17 | | 422.566(b). These procedures include reconsiderations by the | 18 | | managed care organization and, if necessary, an independent | 19 | | review entity, hearings before administrative law judges | 20 | | (ALJs), review by the Medicare Appeals Council (MAC), and | 21 | | judicial review. | 22 | | "Authorized medical professional" means a physician, | 23 | | physician assistant, or advanced practice nurse. | 24 | | "Community" means a geographic area within a 15-mile or | 25 | | 30-minute radius from the enrollee's zip code of residence |
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| 1 | | prior to becoming a nursing home resident or from the zip code | 2 | | of the enrollee's spouse's residence if the spouse relocated | 3 | | after the enrollee became a nursing home resident. | 4 | | "Demonstration plan" means a 3-way contract entered into by | 5 | | a managed care organization with the United States Department | 6 | | of Health and Human Services' Centers for Medicare & Medicaid | 7 | | Services and the Department of Healthcare and Family Services | 8 | | to provide health care services, and any chosen flexible | 9 | | benefits, including long-term care and services. | 10 | | "Department" means the Department of Healthcare and Family | 11 | | Services. | 12 | | "Emergency" or "medical emergency" means a medical | 13 | | condition manifesting itself by acute symptoms of sufficient | 14 | | severity, including, but not limited to, severe pain, such that | 15 | | a prudent layperson who possesses an average knowledge of | 16 | | health and medicine could reasonably expect the absence of | 17 | | immediate medical attention to result in (1) placing the health | 18 | | of the individual in serious jeopardy; (2) serious impairment | 19 | | to bodily functions; or (3) serious dysfunction of any bodily | 20 | | organ or part. | 21 | | "Enhanced care" means a level of care in excess of | 22 | | traditional long-term care and includes, but is not limited to, | 23 | | ventilator care, traumatic brain injury services, pain | 24 | | management, wound care, bariatric services, and services | 25 | | provided to residents with diagnoses such as serious mental | 26 | | illness or Alzheimer's disease and other dementia-related |
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| 1 | | diseases. | 2 | | "Enrollee" means any individual who resides in a nursing | 3 | | home or is qualified to be admitted to a nursing home and is | 4 | | enrolled with a managed care organization participating in one | 5 | | of the demonstration projects. | 6 | | "Health care services" means the diagnosis, treatment, and | 7 | | prevention of disease and includes medication, primary care, | 8 | | nursing or medical care, mental health treatment, psychiatric | 9 | | rehabilitation, memory loss services, physical, occupational, | 10 | | and speech rehabilitation, enhanced care, and assistance with | 11 | | activities of daily living. | 12 | | "Managed care organization" means an entity that meets the | 13 | | definition of health maintenance organization as defined in the | 14 | | Health Maintenance Organization Act and operates under a 3-way | 15 | | contract that administers a health plan under the Integrated | 16 | | Care Program or the Medicare-Medicaid Alignment Initiative. | 17 | | "Marketing" means any written or oral communication from a | 18 | | managed care organization or its representative or a | 19 | | third-party broker under contract with the Department that can | 20 | | reasonably be interpreted as intended to influence a resident | 21 | | to enroll, not to enroll, or to disenroll from a health care | 22 | | delivery system. | 23 | | "Medically necessary" means health care services that an | 24 | | authorized medical professional, exercising prudent clinical | 25 | | judgment, would provide to a patient for the purpose of | 26 | | preventing, evaluating, diagnosing, or treating an illness, |
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| 1 | | injury, or disease or its symptoms, and that are (i) in | 2 | | accordance with the generally accepted standards of medical | 3 | | practice; (ii) clinically appropriate, in terms of type, | 4 | | frequency, extent, site, and duration, and considered | 5 | | effective for the patient's illness, injury, or disease; and | 6 | | (iii) not primarily for the convenience of the patient, an | 7 | | authorized medical professional, or other health care | 8 | | provider. Health care services that are ordered by an | 9 | | authorized medical professional shall be presumed medically | 10 | | necessary absent clear and substantial evidence to the | 11 | | contrary. Managed care organizations are responsible for | 12 | | ensuring the delivery of a all medically necessary services.
| 13 | | "Nursing home" means all facilities licensed under the | 14 | | Nursing Home Care Act. | 15 | | "Physician" means an individual licensed to practice in all | 16 | | branches of medicine under the Medical Practice Act of 1987. | 17 | | "Physician assistant" means an individual properly | 18 | | licensed under the Physician Assistant Practice Act of 1987. | 19 | | "Resident" means an enrollee who is receiving personal or | 20 | | medical care, including, but not limited to, mental health | 21 | | treatment, psychiatric rehabilitation, physical | 22 | | rehabilitation, and assistance with activities of daily living | 23 | | who is living in a nursing home. | 24 | | "Resident's representative" means a person designated in | 25 | | writing by a resident to be the resident's representative or | 26 | | the resident's guardian, as described by the Nursing Home Care |
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| 1 | | Act. | 2 | | "Single-case resident choice agreement" means an agreement | 3 | | between an out-of-network nursing home and a managed care | 4 | | organization to provide for the provision of long-term care | 5 | | services to an individual enrollee. | 6 | | "Transition care period" means a period of time within | 7 | | which the enrollee may remain in the nursing home where the | 8 | | enrollee currently resides whether or not the nursing home has | 9 | | a contract with a managed care organization participating in | 10 | | the demonstration project established under Section 20 of this | 11 | | Act or whether or not the nursing home has a contract with the | 12 | | managed care organization in which the resident is enrolled.
| 13 | | Section 20. Authorization. | 14 | | (a) The Department of Healthcare and Family Services is | 15 | | authorized to establish a managed care demonstration project to | 16 | | test the delivery of long-term care and services to Medicaid | 17 | | beneficiaries using private managed care organizations under a | 18 | | 3-way contract with the Department and the Center for Medicare & | 19 | | Medicaid. Two separate demonstration projects are | 20 | | authorized, with each focused on separate and distinct | 21 | | populations. The Integrated Care Program (ICP) is authorized to | 22 | | serve individuals who qualify for Medicaid-only assistance, | 23 | | and the Medicare-Medicaid Alignment Initiative (MMAI) is | 24 | | authorized to serve individuals who qualify for both Medicaid | 25 | | and Medicare assistance. The ICP program shall sunset on July |
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| 1 | | 1, 2016 and the MMAI program shall sunset on August 1, 2017. | 2 | | Either or both programs may be extended in whole or part, but | 3 | | only after an independent evaluation conducted by a university | 4 | | based in the State of Illinois determines that the plan has not | 5 | | adversely impacted the accessibility, availability, and | 6 | | quality of health care services and medications in nursing home | 7 | | settings in an arbitrary and capricious manner. | 8 | | (b) Individual counties shall be identified to participate | 9 | | in one or both demonstration projects. Network Adequacy shall | 10 | | include the availability of 2 or more nursing homes in each | 11 | | affected community. | 12 | | (c) Care coordination services offered by managed care | 13 | | organizations shall be resident-driven and person-centered. | 14 | | All Medicaid beneficiaries shall have the right to receive | 15 | | health care services in the care setting of their choice, to | 16 | | remain in the nursing home they reside in, and to live in their | 17 | | local community. Decision-making standards shall be based on | 18 | | the best interests of the Medicaid beneficiary. Managed care | 19 | | organizations are prohibited from using a cost-based or | 20 | | resource utilization model. Health care services ordered by an | 21 | | authorized medical professional shall be presumed to be | 22 | | medically necessary and subject to payment by the managed care | 23 | | organization. | 24 | | (d) Employees of the Department, the Department of | 25 | | Insurance, the managed care organizations, and third-party | 26 | | brokers having contact with enrollees shall be culturally |
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| 1 | | competent and trained in working with the elderly, individuals | 2 | | diagnosed with serious mental illness, and individuals with | 3 | | dementia. Translators shall be made available for individuals | 4 | | for whom English is a second language or individuals who are | 5 | | blind or deaf. | 6 | | (e) The State of Illinois shall retain the responsibility | 7 | | for oversight and compliance issues, which shall be proactive | 8 | | and ongoing. The State shall establish uniform policy and | 9 | | procedures to increase the effectiveness of the State's | 10 | | compliance monitoring, reduce beneficiary and provider | 11 | | confusion, and increase the quality of health care services | 12 | | provided. | 13 | | (f) Managed care organizations are required to ensure | 14 | | seamless delivery and payment of health care services as | 15 | | enrollees migrate from managed care organization to managed | 16 | | care organization and from one care setting to another. | 17 | | (g) Any and all providers willing to accept the terms and | 18 | | conditions offered by the managed care organization shall be | 19 | | offered a contract and shall be allowed to renew the contract | 20 | | at the end of the contract period. No managed care organization | 21 | | shall offer a contract to a provider or group of providers that | 22 | | includes terms and conditions designed to discourage the | 23 | | participation of one or more providers. | 24 | | (h) All Medicaid beneficiaries receiving long-term care | 25 | | and services shall have available to them the same package of | 26 | | health care services and ancillary services, regardless of |
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| 1 | | whether they reside in a managed care demonstration county or a | 2 | | fee-for-service county. All providers shall be held to the same | 3 | | standards as set forth in federal and State statutes, rules, | 4 | | and regulations regardless of whether they are located in a | 5 | | managed care demonstration county or a fee-for-service county. | 6 | | (i) No managed care organization shall penalize a nursing | 7 | | home for advocating on behalf of its residents, including the | 8 | | filing of appeals on behalf of the residents or on behalf of | 9 | | themselves. | 10 | | (j) Managed care organizations shall be required to pay all | 11 | | providers within 30 days after receipt of a valid invoice for | 12 | | health care services or be subject to penalties. All payments | 13 | | for health care services rendered shall be backed by the full | 14 | | faith and credit of the State. | 15 | | Section 25. Right to stay in their nursing home and | 16 | | community. | 17 | | (a) To achieve network adequacy, managed care | 18 | | organizations shall solicit contracts with all nursing homes | 19 | | located in demonstration counties and shall enter into | 20 | | contracts with any nursing home willing to accept the terms and | 21 | | conditions of the managed care organization, provided that the | 22 | | nursing home meets all applicable State and federal | 23 | | requirements for participation in the Medicaid program. No | 24 | | managed care organization shall be determined to achieve | 25 | | adequacy if it does not offer each enrollee at least 2 nursing |
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| 1 | | homes within a 15-mile or 30-minute radius from an enrollee's | 2 | | zip code of residence within each county of the service area. | 3 | | (b) Each resident shall be afforded a 180-day transition | 4 | | care period triggered by any one of the following qualifying | 5 | | events: | 6 | | (1) A resident of a nursing home becomes enrolled with | 7 | | a managed care organization either voluntarily or as | 8 | | assigned by the Department. | 9 | | (2) The nursing home in which the resident resides is | 10 | | not renewed or terminated or terminates or does not renew | 11 | | its contract with the managed care organization in which | 12 | | the resident is enrolled. | 13 | | (3) The managed care organization in which the resident | 14 | | is enrolled is not renewed or terminated or terminates or | 15 | | does not renew its contract with the Department. | 16 | | A resident who in the course of a 180-day transition care | 17 | | period experiences a subsequent qualifying event shall have the | 18 | | transition care period extended by an additional 180 days. | 19 | | During the course of a 180-day transition care period triggered | 20 | | by paragraph (1) or (3) of subsection (b) of this Section, a | 21 | | resident may exercise the right to voluntarily select another | 22 | | managed care organization without effecting the length of the | 23 | | transition care period or the rights guaranteed a resident | 24 | | during or after a transition care period. | 25 | | (c) A resident described in subsection (b) of this Section | 26 | | shall have 180 days to move to a nursing home under contract |
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| 1 | | with the managed care organization in which the resident is | 2 | | enrolled or select a managed care organization under contract | 3 | | with the nursing home in which the resident resides. If, by the | 4 | | end of the 180-day transition care period, the nursing home in | 5 | | which the resident resides chooses not to enter into a contract | 6 | | with the managed care organization and the resident does not | 7 | | elect to move to a network nursing home or enroll in managed | 8 | | care organization under contract with the nursing home in which | 9 | | the resident resides, the managed care organization in which | 10 | | the resident is enrolled shall enter into a single-case | 11 | | resident choice agreement with the nursing home in which the | 12 | | resident resides. | 13 | | (d) An enrollee shall be guaranteed the right to receive | 14 | | health care services in the enrollee's community. A managed | 15 | | care organization unable to offer the enrollee 2 or more | 16 | | nursing home options shall offer the enrollee the opportunity | 17 | | to select an out-of-network nursing home within the enrollee's | 18 | | community. The managed care organization shall enter into a | 19 | | single-case resident choice agreement with the selected | 20 | | nursing home. | 21 | | (e) An enrollee with an order signed by an authorized | 22 | | medical professional for enhanced care shall be entitled to | 23 | | receive such enhanced care within enrollee's community. If the | 24 | | managed care organization does not have a contract with a | 25 | | nursing home offering the type of enhanced care ordered in the | 26 | | enrollee's community, the enrollee shall be permitted to select |
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| 1 | | an out-of-network nursing home providing the enhanced care. The | 2 | | managed care organization shall enter into a single-case | 3 | | resident choice agreement with the selected nursing home. | 4 | | (f) A single-case resident choice agreement shall be | 5 | | subject to the same terms, conditions, and reimbursement of an | 6 | | agreement offered by the managed care organization for | 7 | | participation in demonstration project network. Only those | 8 | | nursing homes meeting all applicable State and federal | 9 | | requirements for participation in the Medicaid and Medicare | 10 | | programs are eligible to enter into a single-case resident | 11 | | choice agreement. The single-case resident choice agreement | 12 | | shall remain in force until the end of the demonstration period | 13 | | or the resident is discharged, which ever is longer. A resident | 14 | | who leaves the facility for a family visit or to receive | 15 | | diagnostic tests or treatment with the intent of returning to | 16 | | the nursing home shall not be deemed to have been discharged. | 17 | | Section 30. Continuity of care. | 18 | | (a) Continuity of care provisions shall cover, but need not | 19 | | be limited to, the following circumstances: | 20 | | (1) Events contained in subsection (b) of Section 25 of | 21 | | this Act. | 22 | | (2) The resident voluntarily changes managed care | 23 | | organization enrollment. | 24 | | (3) An enrollee is admitted into a nursing home, | 25 | | regardless of whether the enrollee has been determined to |
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| 1 | | qualify for Medicaid long-term care assistance prior to | 2 | | admission. | 3 | | (b) An interdisciplinary transition care team shall be | 4 | | assigned to each enrollee covered by this Section. The | 5 | | following provisions shall apply: | 6 | | (1) The interdisciplinary transition care team shall | 7 | | develop an individualized continuity of care plan, which | 8 | | shall guide all aspects of the transition to ensure | 9 | | continuity of care.
| 10 | | (2) The requirements of the individualized continuity | 11 | | of care plan shall be established by rule, but shall at a | 12 | | minimum include the following: | 13 | | (A) All on-going course of treatments and an | 14 | | evaluation of any proposed changes as the result of the | 15 | | transition to another managed care organization or a | 16 | | different care setting. | 17 | | (B) All enhanced care needs. | 18 | | (C) A medical evaluation. | 19 | | (D) A comprehensive medical history completed | 20 | | within 14 calendar days prior to the development of the | 21 | | plan. | 22 | | (E) A plan for the approval of all health care | 23 | | services required during and immediately following a | 24 | | transition from one care setting to another or from one | 25 | | managed care organization to another. | 26 | | (3) The interdisciplinary transition care team shall |
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| 1 | | include the enrollee, the resident representative, if any, | 2 | | a member of the enrollee's family at the enrollee's | 3 | | discretion, at least one nursing home designee of the | 4 | | nursing home's choosing, at least one authorized medical | 5 | | professional with first-hand knowledge of the enrollees | 6 | | physical and behavior medical needs and current course of | 7 | | treatment, and at least one representatives of the managed | 8 | | care organization. | 9 | | (4) The individualized continuity of care plan shall be | 10 | | signed by all members of the team and presented for | 11 | | approval to the enrollee, the resident representative, if | 12 | | any, and a member of the enrollee's family, at the | 13 | | enrollee's discretion. The enrollee or, in lieu of the | 14 | | enrollee, the resident representative or family member | 15 | | designated by the enrollee to act on the enrollee's behalf, | 16 | | may reject the plan or any portion of the plan. The | 17 | | enrollee or, in lieu of enrollee, the resident | 18 | | representative or a family member designated by the | 19 | | enrollee to act on the enrollee's behalf may appeal the | 20 | | plan in the name of the enrollee. If an appeal is | 21 | | initiated, all provisions of Section 35 shall apply. A plan | 22 | | shall not be agreed upon until the enrollee or, in lieu of | 23 | | the enrollee, the resident representative or a family | 24 | | member designated by the enrollee to act on their behalf | 25 | | has signed off on the plan in its entirety. | 26 | | (5) Both managed care organizations involved in an |
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| 1 | | enrollee's transition from one managed care organization | 2 | | to another managed care organization shall share equally in | 3 | | the responsibility to ensure a seamless transition and the | 4 | | continuity of the enrollee's care. | 5 | | (c) Health care services provided pursuant to a medical | 6 | | order signed by an authorized medical professional during the | 7 | | first 7 days after an enrollee transitions from one managed | 8 | | care organization to another or one care setting to another | 9 | | shall be deemed approved. | 10 | | (1) The nursing home shall, no later than the first | 11 | | business day after the beginning of such a transition, | 12 | | request post-approval of the health care services | 13 | | specified in the medical order in a form and manner | 14 | | established by rule. | 15 | | (2) The period of deemed approval shall be extended if | 16 | | at the end of the 7 days the nursing home has not received | 17 | | from the managed care organization an individual | 18 | | transition care plan signed by the enrollee or, in lieu of | 19 | | the enrollee, the resident's representative or a family | 20 | | member designated by the enrollee to act on enrollee's | 21 | | behalf, accompanied by the corresponding medical orders | 22 | | issued by the resident's physician after an in-person | 23 | | examination. All orders for health care services | 24 | | accompanying the individualized transition care plan shall | 25 | | be approved by the managed care organization prior to being | 26 | | conveyed to the nursing home. |
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| 1 | | (3) The managed care organization shall be responsible | 2 | | for the payment of all health care services provided | 3 | | pursuant to this Section. | 4 | | Section 35. Appeals and grievances. | 5 | | (a) The Department of Insurance shall establish by rule an | 6 | | appeal and grievance process that permits an enrollee to | 7 | | simultaneously file an appeal or grievance under Medicare and | 8 | | Medicaid, except Medicare Part D. The process shall at a | 9 | | minimum provide for the following: | 10 | | (1) submission of appeals orally, in writing, and on | 11 | | the Internet; | 12 | | (2) notices, timeframes, deadlines, and extensions; | 13 | | (3) a multi-level appeal process, including recourse | 14 | | to State or federal court, independent review entity | 15 | | hearings before administrative law judges, and the | 16 | | Medicare Appeals Council (MAC); and | 17 | | (4) an expedited appeal. | 18 | | (b) If an appeal to the managed care organization is | 19 | | incorporated into the appeal process, the managed care | 20 | | organization shall be limited to 24 hours, or one calendar day, | 21 | | to review and act on the appeal and shall provide access to an | 22 | | appeal process during non-business hours. | 23 | | (c) Enrollees shall have the right to assign their appeal | 24 | | or grievance rights to nursing homes or other providers. | 25 | | (d) At a minimum, enrollees and nursing homes shall have |
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| 1 | | the right to appeal or grieve the following: | 2 | | (1) coverage determinations, including, but not | 3 | | limited, to emergency care; | 4 | | (2) determinations of medical necessity; | 5 | | (3) denials of preauthorization or the appropriate | 6 | | date of preauthorization; | 7 | | (4) eligibility determinations; | 8 | | (5) recoupments or offsets of payments; and | 9 | | (6) timeliness of payments. | 10 | | (e) The managed care organization shall have the burden of | 11 | | proof in all appeals and grievances and all decisions shall be | 12 | | made based on the best interest of the enrollee. | 13 | | (f) For all appeals or grievances involving medical | 14 | | necessity, health care services that are ordered by an | 15 | | authorized medical professional shall be presumed medically | 16 | | necessary absent clear and substantial evidence to the | 17 | | contrary. The managed care organization shall be responsible | 18 | | for compensating the nursing home for all such health care | 19 | | services consistent with Section 60 of this Act. | 20 | | (g) Nothing shall limit an enrollee's right to seek relief | 21 | | by appealing or grieving directly to the Director of Insurance | 22 | | or directly through a court of jurisdiction at any time during | 23 | | the appeal process.
| 24 | | (h) The managed care organization shall be liable for all | 25 | | costs associated with an appeal or grievance upon a finding in | 26 | | favor of the plaintiff. |
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| 1 | | Section 40. Marketing. | 2 | | (a) Managed care marketing practices shall comply with all | 3 | | State and federal laws. Any additional rights and | 4 | | responsibilities created pursuant to this Section are in | 5 | | addition to those created by other State and federal laws. In | 6 | | the event of a conflict with another State law, provisions of | 7 | | this Act shall govern. | 8 | | (b) All marketing materials shall be approved in advance by | 9 | | the Director of Insurance, including, but not limited to, all | 10 | | written materials, promotional videos, websites, and scripts. | 11 | | (c) All marketing to nursing home residents shall involve a | 12 | | third-party broker under contract with the Department, which | 13 | | shall be required to comply with standards established by rule. | 14 | | These standards shall, at a minimum, include the following: | 15 | | (1) All solicitations shall be conducted based on the | 16 | | best interests of the resident. | 17 | | (2) All solicitations shall be face-to-face and shall | 18 | | involve the resident, the resident's representative, where | 19 | | applicable, and a member of the resident's family, at the | 20 | | resident's discretion. | 21 | | (3) Every nursing home resident residing in a | 22 | | demonstration county shall receive at least one | 23 | | face-to-face visit by the third-party broker at least 30 | 24 | | days prior to the Department selecting a plan on behalf of | 25 | | the resident. |
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| 1 | | (4) Brokers shall notify the nursing home in advance, | 2 | | arrange a mutually acceptable date and time, and present | 3 | | credentials to the nursing home administrator or the | 4 | | administrator's designee upon entering the building. | 5 | | (5) Brokers may not randomly approach residents and | 6 | | shall immediately cease contact at the resident's request. | 7 | | (6) Brokers shall provide the nursing home | 8 | | administrator with contact information, which may be | 9 | | provided to the resident, the resident's representative, | 10 | | or a member of the resident's family upon request. | 11 | | (d) Managed care organizations and third-party brokers | 12 | | under contract with the State are prohibited from the | 13 | | following: | 14 | | (1) The use of games, promotional giveaways, and any | 15 | | other monetary or non-monetary incentive to encourage a | 16 | | resident, the resident's representatives, or the | 17 | | resident's family to select one managed care organization | 18 | | over another. | 19 | | (2) Mailing promotional or informational materials | 20 | | directly to a nursing home resident or from soliciting a | 21 | | nursing home resident, the resident's representative, or a | 22 | | member of the resident's family by telephone. | 23 | | (3) Marketing directly to a resident for whom the court | 24 | | has appointed a legal guardian. Managed care organizations | 25 | | or brokers shall work with the nursing home administrator | 26 | | or their designee to determine, which residents, if any, |
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| 1 | | have court-appointed guardians. If a resident has a | 2 | | court-appointed guardian, all marketing shall be directed | 3 | | to the court-appointed guardian. The resident shall be held | 4 | | harmless if the court-appointed guardian fails to respond. | 5 | | Brokers and managed care organizations may contact the | 6 | | court of jurisdiction for assistance. | 7 | | (4) Marketing directly to a resident with an | 8 | | Alzheimer's or other dementia-related disease diagnosis. | 9 | | Managed care organizations or brokers shall work with the | 10 | | nursing home administrator or their designee to identify | 11 | | those residents with Alzheimer's or another | 12 | | dementia-related disease. If a legal guardian has not been | 13 | | appointed, the facility shall, upon request, provide the | 14 | | managed care organization or the broker the contact | 15 | | information for the resident's representative or family | 16 | | member acting on the resident's behalf. | 17 | | Section 45. Policies and procedures. | 18 | | (a) The Department shall define by rule minimum standards | 19 | | governing the relationship between managed care organizations, | 20 | | enrollees, and nursing homes. The list in this subsection (a) | 21 | | is not intended to be all-inclusive, but serves as examples of | 22 | | terms and conditions that require uniformity across all managed | 23 | | care organizations. Rules shall be adopted for the following: | 24 | | (1) best interest of the resident standard; | 25 | | (2) presumption of approval; |
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| 1 | | (3) medication prior approval; | 2 | | (4) prior-approval procedures; | 3 | | (5) post-approval procedures; | 4 | | (6) post-emergency approval procedures; | 5 | | (7) elective services; | 6 | | (8) services that are not prior-approval services; | 7 | | (9) clean claims; | 8 | | (10) billing codes; | 9 | | (11) look-back periods, which shall be at a minimum 10 | 10 | | days; | 11 | | (12) prompt payment; and | 12 | | (13) reporting requirements. | 13 | | (b) All managed care organizations shall establish a | 14 | | process for authorization or denial of health care services | 15 | | available 365 days a year, 24 hours a day, 7 days a week. The | 16 | | call line must at a minimum have a 2 minute or less hold time, | 17 | | with at least 80% of the calls answered in 30 seconds and no | 18 | | more than 5% of the calls disconnected. | 19 | | (c) Medication prior approval forms and procedures shall: | 20 | | (1) permit the nursing home staff to seek an exception | 21 | | to approval policies when making the initial request; | 22 | | (2) prohibit denial based on: | 23 | | (A) lack of a culture; or | 24 | | (B) multiple drugs of a same class for the same | 25 | | diagnosis; and | 26 | | (3) acknowledge the presumption that all medications |
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| 1 | | ordered by an authorized medical professional are | 2 | | medically necessary. | 3 | | Section 50. Contractual requirements | 4 | | (a) Contracts between managed care organizations and | 5 | | nursing homes are prohibited from including terms and | 6 | | conditions that: | 7 | | (1) limit or prohibit a nursing home from advocating on | 8 | | behalf of its residents to include the filing of appeals | 9 | | and grievances in the name of the resident at the | 10 | | resident's request or on behalf of the nursing home; | 11 | | (2) require prior approval of health care services if | 12 | | the managed care organization does not have a prior | 13 | | approval process available 365 days per year, 24 hours a | 14 | | day, 7 days a week; | 15 | | (3) offer incentives or disincentives that limit | 16 | | access to specific types of health care services; or | 17 | | (4) establish requirements in excess of federal and | 18 | | State law. | 19 | | (b) Managed care organizations shall offer contracts with | 20 | | at least a 36-month duration to any and all nursing homes in | 21 | | demonstration counties that meet all applicable State and | 22 | | federal requirements for participation in the Medicaid and | 23 | | Medicare Programs. | 24 | | (c) Renewals shall be consistent with the provisions of | 25 | | subsection (b) of this Section. A nursing home denied a renewal |
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| 1 | | or whose contract is terminated may appeal the denial or | 2 | | termination to the Director of Insurance. The appeal shall stay | 3 | | the termination or nonrenewal of the contract and the | 4 | | notification of enrollees residing in the nursing home pending | 5 | | the outcome of the appeal. The decision rendered by the | 6 | | Director of Insurance pursuant to this subsection (c) shall be | 7 | | a final appealable decision under the Administrative Review | 8 | | Law. The burden of proof shall rest with the managed care | 9 | | organization. It is the responsibility of the managed care | 10 | | organization to notify all enrollees affected by the | 11 | | termination or nonrenewal within 15 days after notice provided | 12 | | to the nursing home or within 15 days after final action on the | 13 | | appeal, whichever is later. Notice shall include a proposed | 14 | | transition plan consistent with the provisions of Sections 25 | 15 | | and 30 of this Act. | 16 | | (d) A nursing home has the right to terminate its contract | 17 | | with a managed care organization with 90 days' written notice, | 18 | | with or without cause. The managed care organization shall | 19 | | immediately notify all residents of all rights and | 20 | | responsibilities during and after the resident's 90-day | 21 | | transition period. | 22 | | (e) The managed care organization shall enter into a | 23 | | single-case resident choice agreement as required by Section 25 | 24 | | of this Act. | 25 | | Section 55. Prohibition.
No managed care organization or |
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| 1 | | contract shall contain any provision, policy, or procedure that | 2 | | limits, restricts, or waives any rights set forth in this Act | 3 | | or is expressly prohibited by this Act. Any such policy or | 4 | | procedure shall be void and unenforceable. | 5 | | Section 60. Reimbursement. | 6 | | (a) Nursing homes shall be reimbursed no less than the | 7 | | Illinois fee-for-service Medicaid rate at the time the health | 8 | | care services were rendered. The fee-for-service Medicaid rate | 9 | | shall include the amounts established by the Department for the | 10 | | direct care, support, and capital components of the rate and | 11 | | any and all add-ons. | 12 | | (b) The Department shall provide each managed care | 13 | | organization with the quarterly facility-specific RUG-IV | 14 | | nursing component per diem along with any add-ons for enhanced | 15 | | care services, support component per diem, and capital | 16 | | component per diem effective for each nursing home under | 17 | | contract with the managed care organization. | 18 | | (c) A nursing home under a single-case resident choice | 19 | | agreement shall be reimbursed at the rate paid a nursing home | 20 | | under contract with the managed care organization to provide | 21 | | services to Medicaid beneficiaries in the Demonstration | 22 | | Project. | 23 | | (d) Prior approval and post approval shall be secured in | 24 | | the form and manner established by rule pursuant to Section 45 | 25 | | of this Act. |
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| 1 | | (e) The managed care organization shall be liable for all | 2 | | health care services rendered. Payment may be denied if and | 3 | | only if: | 4 | | (1) health care services were provided outside the | 5 | | window of a deemed approval period and prior approval was | 6 | | not received; | 7 | | (2) a medical emergency did not exist and prior | 8 | | approval was not received; | 9 | | (3) health care services claimed were not delivered; | 10 | | (4) health care services were contrary to the | 11 | | instructions of the managed care organization and the | 12 | | nursing home was notified prior to the health care services | 13 | | being delivered; or | 14 | | (5) the resident was not an enrollee of the managed | 15 | | care organization. | 16 | | (f) A nursing home shall receive reimbursement for all | 17 | | health care services rendered no later than 30 days after a | 18 | | valid invoice is submitted to the managed care organization. If | 19 | | the managed care organization fails to reimburse the nursing | 20 | | home within 30 days, the managed care organization shall be | 21 | | liable for a past due penalty equal to the interest rate that | 22 | | lending institutions are charging for loans secured by State | 23 | | receivables. | 24 | | (g) A managed care organization failing to pay a nursing | 25 | | home or group of nursing homes in excess of 60 days after the | 26 | | date that a valid invoice was submitted shall be considered in |
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| 1 | | default. Upon notification that a managed care organization is | 2 | | in default, the Department shall notify the Comptroller to | 3 | | place a hold on all payments to the managed care organization | 4 | | until such time that all outstanding payments and past due | 5 | | penalties have been paid. The Department shall immediately | 6 | | notify nursing homes under contract with the managed care | 7 | | organization that copies of all outstanding invoices and all | 8 | | future invoices shall be sent directly to the Department for | 9 | | processing. | 10 | | (h) A managed care organization that either terminates or | 11 | | is terminated from participation in a Medicaid long-term care | 12 | | demonstration program in one or more areas of the State shall | 13 | | be liable for payment for all health care services rendered | 14 | | during the period of time the contract with the Department was | 15 | | in force. The Department shall notify all nursing homes under | 16 | | contract with the managed care organization within 10 business | 17 | | days after the date that the managed care organization notified | 18 | | the Department of its intent to terminate or the date the | 19 | | Department notifies the managed care organization of their | 20 | | intent to terminate the contract. Notice to nursing homes shall | 21 | | include a plan for the reassignment of all residents under | 22 | | contract with the managed care organization and procedures for | 23 | | the submission of any outstanding invoices directly to the | 24 | | Department for payment. The reassignment plan shall ensure that | 25 | | all medical orders in place are honored, that the resident does | 26 | | not experience an interruption in health care services, and |
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| 1 | | that the provider does not experience an interruption in | 2 | | payment. | 3 | | (i) A managed care organization that authorizes the | 4 | | admission of an enrollee into a nursing home assumes | 5 | | responsibility for compensation owed the nursing home for the | 6 | | provision of all health care services as specified in | 7 | | subsection (d) of this Section, regardless of whether the | 8 | | enrollee has been found eligible for Medicaid long-term care | 9 | | services. | 10 | | (j) The State of Illinois shall guarantee the payment of | 11 | | all valid invoices by managed care organizations subject to | 12 | | this Act. | 13 | | Section 65. Compliance. | 14 | | (a) The Department of Insurance shall be responsible for | 15 | | ensuring compliance with this Act. | 16 | | (b) Within 30 days after the effective date of this Act, | 17 | | the Department of Insurance shall notify all nursing homes in | 18 | | all demonstration counties of the Department's compliance | 19 | | responsibility and the policy and procedures for notifying the | 20 | | Director of Insurance of any violations of the provisions this | 21 | | Act. The Department of Insurance shall accept both oral and | 22 | | written complaints. An Internet-based reporting option shall | 23 | | be offered. | 24 | | (c) A managed care organization that is found to have used | 25 | | marketing materials or scripts that were not approved in |
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| 1 | | advance or provided such materials for use to a third-party or | 2 | | an employee, agent, or contractor of the State shall be subject | 3 | | to sanctions. An employee, agent, or contractor of the State | 4 | | using marketing materials or scripts that have not been | 5 | | approved in advance shall also be subject sanctions. | 6 | | (d) All sanctioning guidelines shall be established by rule | 7 | | and shall include monetary sanctions, termination, loss of | 8 | | privileges to sell products or policies or otherwise enroll | 9 | | individuals in health plans in the State of Illinois, and | 10 | | criminal charges. Monetary sanctions for a first offense shall | 11 | | not be less than $1,000 per offense per resident per nursing | 12 | | home per day. Second offenses shall not be less than $5,000 per | 13 | | offense per resident per nursing home per day. Third and | 14 | | subsequence offenses shall be double the previous sanction. | 15 | | (e) All monetary sanctions shall be paid into the Nursing | 16 | | Home Resident Managed Care Fund, which is hereby created in the | 17 | | State treasury. Disbursements from the Fund shall be subject to | 18 | | appropriations and shall be used to hire and train nursing home | 19 | | resident advocates in both the Senior Health Insurance Program | 20 | | and the Senior Health Assistance Program. Nursing home | 21 | | residents insurance advocates employed by the Senior Health | 22 | | Insurance Program shall assist nursing home residents, | 23 | | resident's representatives, and the resident's family to file | 24 | | appeals and grievance for the purpose of securing medically | 25 | | necessary health care services. Nursing home residents health | 26 | | assistance advocates employed by the Senior Health Assistance |
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| 1 | | Program shall assist residents, resident's representatives, | 2 | | and the resident's family to file applications and secure | 3 | | appropriate documentation to secure Medicaid long-term care | 4 | | coverage and to assist with the family in securing spousal | 5 | | impoverishment coverage. Moneys remaining in the fund at the | 6 | | end of each fiscal year shall be made available through | 7 | | competitive grants to nursing homes the following fiscal year | 8 | | for innovative programming to improve the quality of life of | 9 | | nursing home residents and the staff that serve them and | 10 | | transition assistance or modernization assistance. Grants | 11 | | shall be awarded by the Director of Public Health with the | 12 | | advice of the Department of Public Health's Long Term Care | 13 | | Advisory Committee. Moneys paid into the Fund may not be used | 14 | | for any purpose other than those specified in this subsection | 15 | | (e). | 16 | | Section 70. Solvency.
The Department of Insurance shall | 17 | | ensure that all managed care organizations contracting with the | 18 | | State shall meet the solvency requirements enumerated in the | 19 | | Illinois Health Maintenance Organization Act and the rules | 20 | | adopted under that Act by the Department of Insurance. The | 21 | | Department of Insurance shall adopt such rules as are necessary | 22 | | to carry out the provisions of this Section.
| 23 | | Section 75. Applicability. This Act applies to all | 24 | | contracts in effect on or after the effective date of this Act |
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| 1 | | and all claims that accrue after the effective date of this | 2 | | Act. | 3 | | Section 900. The Health Maintenance Organization Act is | 4 | | amended by changing Section 1-2 as follows:
| 5 | | (215 ILCS 125/1-2) (from Ch. 111 1/2, par. 1402)
| 6 | | Sec. 1-2. Definitions. As used in this Act, unless the | 7 | | context otherwise
requires, the following terms shall have the | 8 | | meanings ascribed to them:
| 9 | | (1) "Advertisement" means any printed or published | 10 | | material,
audiovisual material and descriptive literature of | 11 | | the health care plan
used in direct mail, newspapers, | 12 | | magazines, radio scripts, television
scripts, billboards and | 13 | | similar displays; and any descriptive literature or
sales aids | 14 | | of all kinds disseminated by a representative of the health | 15 | | care
plan for presentation to the public including, but not | 16 | | limited to, circulars,
leaflets, booklets, depictions, | 17 | | illustrations, form letters and prepared
sales presentations.
| 18 | | (2) "Director" means the Director of Insurance.
| 19 | | (3) "Basic health care services" means emergency care, and | 20 | | inpatient
hospital and physician care, outpatient medical | 21 | | services, mental
health services and care for alcohol and drug | 22 | | abuse, including any
reasonable deductibles and co-payments, | 23 | | all of which are subject to the
limitations described in | 24 | | Section 4-20 of this Act and as determined by the Director |
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| 1 | | pursuant to rule.
| 2 | | (4) "Enrollee" means an individual who has been enrolled in | 3 | | a health
care plan.
| 4 | | (5) "Evidence of coverage" means any certificate, | 5 | | agreement,
or contract issued to an enrollee setting out the | 6 | | coverage to which he is
entitled in exchange for a per capita | 7 | | prepaid sum.
| 8 | | (6) "Group contract" means a contract for health care | 9 | | services which
by its terms limits eligibility to members of a | 10 | | specified group.
| 11 | | (7) "Health care plan" means any arrangement whereby any | 12 | | organization
undertakes to provide or arrange for and pay for | 13 | | or reimburse the
cost of basic health care services, excluding | 14 | | any reasonable deductibles and copayments, from providers | 15 | | selected by
the Health Maintenance Organization and such | 16 | | arrangement
consists of arranging for or the provision of such | 17 | | health care services, as
distinguished from mere | 18 | | indemnification against the cost of such services,
except as | 19 | | otherwise authorized by Section 2-3 of this Act,
on a per | 20 | | capita prepaid basis, through insurance or otherwise. A "health
| 21 | | care plan" also includes any arrangement whereby an | 22 | | organization undertakes to
provide or arrange for or pay for or | 23 | | reimburse the cost of any health care
service for persons who | 24 | | are enrolled under Article V of the Illinois Public Aid
Code or | 25 | | under the Children's Health Insurance Program Act through
| 26 | | providers selected by the organization and the arrangement |
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| 1 | | consists of making
provision for the delivery of health care | 2 | | services, as distinguished from mere
indemnification. A | 3 | | "health care plan" also includes any arrangement pursuant
to | 4 | | Section 4-17. Nothing in this definition, however, affects the | 5 | | total
medical services available to persons eligible for | 6 | | medical assistance under the
Illinois Public Aid Code.
| 7 | | (8) "Health care services" means any services included in | 8 | | the furnishing
to any individual of medical or dental care, or | 9 | | the hospitalization or
incident to the furnishing of such care | 10 | | or hospitalization as well as the
furnishing to any person of | 11 | | any and all other services for the purpose of
preventing, | 12 | | alleviating, curing or healing human illness or injury.
| 13 | | (9) "Health Maintenance Organization" means any | 14 | | organization formed
under the laws of this or another state to | 15 | | provide or arrange for one or
more health care plans under a | 16 | | system which causes any part of the risk of
health care | 17 | | delivery to be borne by the organization or its providers.
| 18 | | (10) "Net worth" means admitted assets, as defined in | 19 | | Section 1-3 of
this Act, minus liabilities.
| 20 | | (11) "Organization" means any insurance company, a | 21 | | nonprofit
corporation authorized under the Dental
Service Plan | 22 | | Act or the Voluntary
Health Services Plans Act,
or a | 23 | | corporation organized under the laws of this or another state | 24 | | for the
purpose of operating one or more health care plans and | 25 | | doing no business other
than that of a Health Maintenance | 26 | | Organization or an insurance company.
"Organization" shall |
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| 1 | | also mean the University of Illinois Hospital as
defined in the | 2 | | University of Illinois Hospital Act.
| 3 | | (12) "Provider" means any physician, hospital facility, | 4 | | facility licensed under the Nursing Home Care Act,
or other | 5 | | person which is licensed or otherwise authorized
to furnish | 6 | | health care services and also includes any other entity that
| 7 | | arranges for the delivery or furnishing of health care service.
| 8 | | (13) "Producer" means a person directly or indirectly | 9 | | associated with a
health care plan who engages in solicitation | 10 | | or enrollment.
| 11 | | (14) "Per capita prepaid" means a basis of prepayment by | 12 | | which a fixed
amount of money is prepaid per individual or any | 13 | | other enrollment unit to
the Health Maintenance Organization or | 14 | | for health care services which are
provided during a definite | 15 | | time period regardless of the frequency or
extent of the | 16 | | services rendered
by the Health Maintenance Organization, | 17 | | except for copayments and deductibles
and except as provided in | 18 | | subsection (f) of Section 5-3 of this Act.
| 19 | | (15) "Subscriber" means a person who has entered into a | 20 | | contractual
relationship with the Health Maintenance | 21 | | Organization for the provision of
or arrangement of at least | 22 | | basic health care services to the beneficiaries
of such | 23 | | contract.
| 24 | | (Source: P.A. 97-1148, eff. 1-24-13.)
| 25 | | Section 905. The Managed Care Reform and Patient Rights Act |
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| 1 | | is amended by changing Section 10 as follows:
| 2 | | (215 ILCS 134/10)
| 3 | | Sec. 10. Definitions:
| 4 | | "Adverse determination" means a determination by a health | 5 | | care plan under
Section 45 or by a utilization review program | 6 | | under Section
85 that
a health care service is not medically | 7 | | necessary.
| 8 | | "Clinical peer" means a health care professional who is in | 9 | | the same
profession and the same or similar specialty as the | 10 | | health care provider who
typically manages the medical | 11 | | condition, procedures, or treatment under
review.
| 12 | | "Department" means the Department of Insurance.
| 13 | | "Emergency medical condition" means a medical condition | 14 | | manifesting itself by
acute symptoms of sufficient severity | 15 | | (including, but not limited to, severe
pain) such that a | 16 | | prudent
layperson, who possesses an average knowledge of health | 17 | | and medicine, could
reasonably expect the absence of immediate | 18 | | medical attention to result in:
| 19 | | (1) placing the health of the individual (or, with | 20 | | respect to a pregnant
woman, the
health of the woman or her | 21 | | unborn child) in serious jeopardy;
| 22 | | (2) serious
impairment to bodily functions; or
| 23 | | (3) serious dysfunction of any bodily organ
or part.
| 24 | | "Emergency medical screening examination" means a medical | 25 | | screening
examination and
evaluation by a physician licensed to |
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| 1 | | practice medicine in all its branches, or
to the extent | 2 | | permitted
by applicable laws, by other appropriately licensed | 3 | | personnel under the
supervision of or in
collaboration with a | 4 | | physician licensed to practice medicine in all its
branches to | 5 | | determine whether
the need for emergency services exists.
| 6 | | "Emergency services" means, with respect to an enrollee of | 7 | | a health care
plan,
transportation services, including but not | 8 | | limited to ambulance services, and
covered inpatient and | 9 | | outpatient hospital services
furnished by a provider
qualified | 10 | | to furnish those services that are needed to evaluate or | 11 | | stabilize an
emergency medical condition. "Emergency services" | 12 | | does not
refer to post-stabilization medical services.
| 13 | | "Enrollee" means any person and his or her dependents | 14 | | enrolled in or covered
by a health care plan.
| 15 | | "Health care plan" means a plan that establishes, operates, | 16 | | or maintains a
network of health care providers that has | 17 | | entered into an agreement with the
plan to provide health care | 18 | | services to enrollees to whom the plan has the
ultimate | 19 | | obligation to arrange for the provision of or payment for | 20 | | services
through organizational arrangements for ongoing | 21 | | quality assurance,
utilization review programs, or dispute | 22 | | resolution.
Nothing in this definition shall be construed to | 23 | | mean that an independent
practice association or a physician | 24 | | hospital organization that subcontracts
with
a health care plan | 25 | | is, for purposes of that subcontract, a health care plan.
| 26 | | For purposes of this definition, "health care plan" shall |
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| 1 | | not include the
following:
| 2 | | (1) indemnity health insurance policies including | 3 | | those using a contracted
provider network;
| 4 | | (2) health care plans that offer only dental or only | 5 | | vision coverage;
| 6 | | (3) preferred provider administrators, as defined in | 7 | | Section 370g(g) of
the
Illinois Insurance Code;
| 8 | | (4) employee or employer self-insured health benefit | 9 | | plans under the
federal Employee Retirement Income | 10 | | Security Act of 1974;
| 11 | | (5) health care provided pursuant to the Workers' | 12 | | Compensation Act or the
Workers' Occupational Diseases | 13 | | Act; and
| 14 | | (6) not-for-profit voluntary health services plans | 15 | | with health maintenance
organization
authority in | 16 | | existence as of January 1, 1999 that are affiliated with a | 17 | | union
and that
only extend coverage to union members and | 18 | | their dependents.
| 19 | | "Health care professional" means a physician, a registered | 20 | | professional
nurse,
or other individual appropriately licensed | 21 | | or registered
to provide health care services.
| 22 | | "Health care provider" means any physician, hospital | 23 | | facility, facility licensed under the Nursing Home Care Act, or | 24 | | other
person that is licensed or otherwise authorized to | 25 | | deliver health care
services. Nothing in this
Act shall be | 26 | | construed to define Independent Practice Associations or
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| 1 | | Physician-Hospital Organizations as health care providers.
| 2 | | "Health care services" means any services included in the | 3 | | furnishing to any
individual of medical care, or the
| 4 | | hospitalization incident to the furnishing of such care, as | 5 | | well as the
furnishing to any person of
any and all other | 6 | | services for the purpose of preventing,
alleviating, curing, or | 7 | | healing human illness or injury including home health
and | 8 | | pharmaceutical services and products.
| 9 | | "Medical director" means a physician licensed in any state | 10 | | to practice
medicine in all its
branches appointed by a health | 11 | | care plan.
| 12 | | "Person" means a corporation, association, partnership,
| 13 | | limited liability company, sole proprietorship, or any other | 14 | | legal entity.
| 15 | | "Physician" means a person licensed under the Medical
| 16 | | Practice Act of 1987.
| 17 | | "Post-stabilization medical services" means health care | 18 | | services
provided to an enrollee that are furnished in a | 19 | | licensed hospital by a provider
that is qualified to furnish | 20 | | such services, and determined to be medically
necessary and | 21 | | directly related to the emergency medical condition following
| 22 | | stabilization.
| 23 | | "Stabilization" means, with respect to an emergency | 24 | | medical condition, to
provide such medical treatment of the | 25 | | condition as may be necessary to assure,
within reasonable | 26 | | medical probability, that no material deterioration
of the |
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| 1 | | condition is likely to result.
| 2 | | "Utilization review" means the evaluation of the medical | 3 | | necessity,
appropriateness, and efficiency of the use of health | 4 | | care services, procedures,
and facilities.
| 5 | | "Utilization review program" means a program established | 6 | | by a person to
perform utilization review.
| 7 | | (Source: P.A. 91-617, eff. 1-1-00.)
| 8 | | Section 910. The Illinois Public Aid Code is amended by | 9 | | adding Section 5B-8.1 as follows: | 10 | | (305 ILCS 5/5B-8.1 new) | 11 | | Sec. 5B-8.1. Guarantee of payment. | 12 | | (a) Any money owed to a nursing home by a managed care | 13 | | organization, as that term is defined in the Nursing Home | 14 | | Residents' Managed Care Rights Act, shall be guaranteed by this | 15 | | State. Upon a finding that a managed care organization is in | 16 | | default, as described in Section 60 of the Nursing Home | 17 | | Residents' Managed Care Rights Act, the Department shall | 18 | | immediately notify the Comptroller to place on hold all | 19 | | outstanding payments to the managed care organization until | 20 | | such time as the managed care organization has paid all past | 21 | | due invoices and interest penalties. From the moneys owed the | 22 | | managed care organization by this State, the Department shall | 23 | | pay directly to all nursing homes under contract with the | 24 | | managed care all past due invoices and all future invoices |
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| 1 | | until such time as the managed care organization is no longer | 2 | | in default. | 3 | | (b) A managed care organization that terminates its managed | 4 | | care contract for long-term care services or is terminated by | 5 | | the Department from providing managed long-term care services | 6 | | during the life of the demonstration project and at the sunset | 7 | | of each demonstration plan shall submit to the Department a | 8 | | release from each nursing home under contract with the managed | 9 | | care organization stipulating that moneys due the nursing home | 10 | | now and in the future were paid in full prior to the Department | 11 | | sending to the Comptroller for payment an amount equivalent to | 12 | | the last 60 days of payment due the managed care organization. | 13 | | (c) All payments owed providers for health care services | 14 | | rendered which are payable under this Code shall be considered | 15 | | guaranteed by this State, and shall carry with it the full | 16 | | faith and credit of this State. Outstanding payments shall be | 17 | | considered receivables owed by this State for the purposes of | 18 | | borrowing against future payments or otherwise collateralizing | 19 | | or capitalizing these guaranteed funds. | 20 | | Section 915. The State Finance Act is amended by adding | 21 | | Section 5.855 as follows: | 22 | | (30 ILCS 105/5.855 new) | 23 | | Sec. 5.855. The Nursing Home Resident Managed Care Fund.
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| 1 | | Section 999. Effective date. This Act takes effect upon | 2 | | becoming law.".
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