Full Text of HB6213 99th General Assembly
HB6213ham001 99TH GENERAL ASSEMBLY | Rep. Carol Ammons Filed: 4/15/2016
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| 1 | | AMENDMENT TO HOUSE BILL 6213
| 2 | | AMENDMENT NO. ______. Amend House Bill 6213 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Illinois Public Aid Code is amended by | 5 | | changing Section 5-30.1 and by adding Section 5-30.3 as | 6 | | follows: | 7 | | (305 ILCS 5/5-30.1) | 8 | | Sec. 5-30.1. Managed care protections. | 9 | | (a) As used in this Section: | 10 | | "Managed care organization" or "MCO" means any entity which | 11 | | contracts with the Department to provide services where payment | 12 | | for medical services is made on a capitated basis. | 13 | | "Emergency services" include: | 14 | | (1) emergency services, as defined by Section 10 of the | 15 | | Managed Care Reform and Patient Rights Act; | 16 | | (2) emergency medical screening examinations, as |
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| 1 | | defined by Section 10 of the Managed Care Reform and | 2 | | Patient Rights Act; | 3 | | (3) post-stabilization medical services, as defined by | 4 | | Section 10 of the Managed Care Reform and Patient Rights | 5 | | Act; and | 6 | | (4) emergency medical conditions, as defined by
| 7 | | Section 10 of the Managed Care Reform and Patient Rights
| 8 | | Act. | 9 | | (b) As provided by Section 5-16.12, managed care | 10 | | organizations are subject to the provisions of the Managed Care | 11 | | Reform and Patient Rights Act. | 12 | | (c) An MCO shall pay any provider of emergency services | 13 | | that does not have in effect a contract with the contracted | 14 | | Medicaid MCO. The default rate of reimbursement shall be the | 15 | | rate paid under Illinois Medicaid fee-for-service program | 16 | | methodology, including all policy adjusters, including but not | 17 | | limited to Medicaid High Volume Adjustments, Medicaid | 18 | | Percentage Adjustments, Outpatient High Volume Adjustments, | 19 | | and all outlier add-on adjustments to the extent such | 20 | | adjustments are incorporated in the development of the | 21 | | applicable MCO capitated rates. | 22 | | (d) An MCO shall pay for all post-stabilization services as | 23 | | a covered service in any of the following situations: | 24 | | (1) the MCO authorized such services; | 25 | | (2) such services were administered to maintain the | 26 | | enrollee's stabilized condition within one hour after a |
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| 1 | | request to the MCO for authorization of further | 2 | | post-stabilization services; | 3 | | (3) the MCO did not respond to a request to authorize | 4 | | such services within one hour; | 5 | | (4) the MCO could not be contacted; or | 6 | | (5) the MCO and the treating provider, if the treating | 7 | | provider is a non-affiliated provider, could not reach an | 8 | | agreement concerning the enrollee's care and an affiliated | 9 | | provider was unavailable for a consultation, in which case | 10 | | the MCO
must pay for such services rendered by the treating | 11 | | non-affiliated provider until an affiliated provider was | 12 | | reached and either concurred with the treating | 13 | | non-affiliated provider's plan of care or assumed | 14 | | responsibility for the enrollee's care. Such payment shall | 15 | | be made at the default rate of reimbursement paid under | 16 | | Illinois Medicaid fee-for-service program methodology, | 17 | | including all policy adjusters, including but not limited | 18 | | to Medicaid High Volume Adjustments, Medicaid Percentage | 19 | | Adjustments, Outpatient High Volume Adjustments and all | 20 | | outlier add-on adjustments to the extent that such | 21 | | adjustments are incorporated in the development of the | 22 | | applicable MCO capitated rates. | 23 | | (e) The following requirements apply to MCOs in determining | 24 | | payment for all emergency services: | 25 | | (1) MCOs shall not impose any requirements for prior | 26 | | approval of emergency services. |
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| 1 | | (2) The MCO shall cover emergency services provided to | 2 | | enrollees who are temporarily away from their residence and | 3 | | outside the contracting area to the extent that the | 4 | | enrollees would be entitled to the emergency services if | 5 | | they still were within the contracting area. | 6 | | (3) The MCO shall have no obligation to cover medical | 7 | | services provided on an emergency basis that are not | 8 | | covered services under the contract. | 9 | | (4) The MCO shall not condition coverage for emergency | 10 | | services on the treating provider notifying the MCO of the | 11 | | enrollee's screening and treatment within 10 days after | 12 | | presentation for emergency services. | 13 | | (5) The determination of the attending emergency | 14 | | physician, or the provider actually treating the enrollee, | 15 | | of whether an enrollee is sufficiently stabilized for | 16 | | discharge or transfer to another facility, shall be binding | 17 | | on the MCO. The MCO shall cover emergency services for all | 18 | | enrollees whether the emergency services are provided by an | 19 | | affiliated or non-affiliated provider. | 20 | | (6) The MCO's financial responsibility for | 21 | | post-stabilization care services it has not pre-approved | 22 | | ends when: | 23 | | (A) a plan physician with privileges at the | 24 | | treating hospital assumes responsibility for the | 25 | | enrollee's care; | 26 | | (B) a plan physician assumes responsibility for |
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| 1 | | the enrollee's care through transfer; | 2 | | (C) a contracting entity representative and the | 3 | | treating physician reach an agreement concerning the | 4 | | enrollee's care; or | 5 | | (D) the enrollee is discharged. | 6 | | (f) Network adequacy. | 7 | | (1) The Department shall: | 8 | | (A) ensure that an adequate provider network is in | 9 | | place, taking into consideration health professional | 10 | | shortage areas and medically underserved areas; | 11 | | (B) publicly release an explanation of its process | 12 | | for analyzing network adequacy; | 13 | | (C) periodically ensure that an MCO continues to | 14 | | have an adequate network in place; and | 15 | | (D) require MCOs, including Medicaid Managed Care | 16 | | Entities as defined in Section 5-30.2, to meet provider | 17 | | directory requirements under Section 5-30.3. require | 18 | | MCOs to maintain an updated and public list of network | 19 | | providers. | 20 | | (g) Timely payment of claims. | 21 | | (1) The MCO shall pay a claim within 30 days of | 22 | | receiving a claim that contains all the essential | 23 | | information needed to adjudicate the claim. | 24 | | (2) The MCO shall notify the billing party of its | 25 | | inability to adjudicate a claim within 30 days of receiving | 26 | | that claim. |
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| 1 | | (3) The MCO shall pay a penalty that is at least equal | 2 | | to the penalty imposed under the Illinois Insurance Code | 3 | | for any claims not timely paid. | 4 | | (4) The Department may establish a process for MCOs to | 5 | | expedite payments to providers based on criteria | 6 | | established by the Department. | 7 | | (h) The Department shall not expand mandatory MCO | 8 | | enrollment into new counties beyond those counties already | 9 | | designated by the Department as of June 1, 2014 for the | 10 | | individuals whose eligibility for medical assistance is not the | 11 | | seniors or people with disabilities population until the | 12 | | Department provides an opportunity for accountable care | 13 | | entities and MCOs to participate in such newly designated | 14 | | counties. | 15 | | (i) The requirements of this Section apply to contracts | 16 | | with accountable care entities and MCOs entered into, amended, | 17 | | or renewed after the effective date of this amendatory Act of | 18 | | the 98th General Assembly.
| 19 | | (Source: P.A. 98-651, eff. 6-16-14.) | 20 | | (305 ILCS 5/5-30.3 new) | 21 | | Sec. 5-30.3. Empowering meaningful patient choice in | 22 | | Medicaid Managed Care. | 23 | | (a) Definitions. As used in this Section: | 24 | | "Client enrollment services broker" means a vendor the | 25 | | Department contracts with to carry out activities related to |
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| 1 | | Medicaid recipients' enrollment, disenrollment, and renewal | 2 | | with Medicaid Managed Care Entities. | 3 | | "Clinical interest" includes, but is not limited to, | 4 | | experience working with specific patient populations such as | 5 | | people living with HIV/AIDS, people experiencing homelessness, | 6 | | people who identify as LGBTQ, and adolescents. | 7 | | "Composite domains" means the synthesized categories | 8 | | reflecting the standardized quality performance measures | 9 | | included in the print and online version of the consumer | 10 | | quality comparison tool. At a minimum, these composite domains | 11 | | shall display Medicaid Managed Care Entities' individual Plan | 12 | | performance on standardized quality, timeliness, and access | 13 | | measures. | 14 | | "Consumer quality comparison tool" means an online and | 15 | | paper tool developed by the Department with input from | 16 | | interested stakeholders reflecting the performance of Medicaid | 17 | | Managed Care Entity Plans on standardized quality performance | 18 | | measures. This tool shall be designed in a consumer-friendly | 19 | | and easily understandable format. | 20 | | "Covered services" means those health care services to | 21 | | which a covered person is entitled to under the terms of the | 22 | | Medicaid Managed Care Entity Plan. | 23 | | "Facility type" includes, but is not limited to, federally | 24 | | qualified health centers, skilled nursing facilities, and | 25 | | rehabilitation centers. | 26 | | "Hospital type" includes, but is not limited to, acute |
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| 1 | | care, rehabilitation, children's, and cancer hospitals. | 2 | | "Integrated provider directory" means a searchable | 3 | | database bringing together network data from multiple Medicaid | 4 | | Managed Care Entities that is available through client | 5 | | enrollment services. | 6 | | "Medicaid eligibility redetermination" means the process | 7 | | by which the eligibility of a Medicaid recipient is reviewed by | 8 | | the Department to determine if the recipient's medical benefits | 9 | | will continue, be modified, or terminated. | 10 | | "Medicaid Managed Care Entity" has the same meaning as | 11 | | defined in Section 5-30.2 of this Code. | 12 | | (b) Provider directory transparency. | 13 | | (1) Each Medicaid Managed Care Entity shall: | 14 | | (A) Make available on the entity's website a | 15 | | provider directory in a machine readable file and | 16 | | format. | 17 | | (B) Make provider directories publicly accessible | 18 | | without the necessity of providing a password, a | 19 | | username, or personally identifiable information. | 20 | | (C) Comply with all federal and State statutes and | 21 | | regulations pertaining to provider directories within | 22 | | Medicaid Managed Care. | 23 | | (D) Request, at least annually, provider office | 24 | | hours for each of the following provider types: | 25 | | (i) Health care professionals, including | 26 | | dental and vision providers. |
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| 1 | | (ii) Hospitals. | 2 | | (iii) Facilities, other than hospitals. | 3 | | (iv) Pharmacies, other than hospitals. | 4 | | (v) Durable medical equipment suppliers, other | 5 | | than hospitals. | 6 | | Medicaid Managed Care Entities shall publish the | 7 | | provider office hours in the provider directory upon | 8 | | receipt. | 9 | | (E) Confirm with the Medicaid Managed Care | 10 | | Entity's contracted providers who have not submitted | 11 | | claims within the past 6 months that the contracted | 12 | | providers intend to remain in the network and correct | 13 | | any incorrect provider directory information as | 14 | | necessary. | 15 | | (F) Ensure that in situations in which a Medicaid | 16 | | Managed Care Entity Plan enrollee receives covered | 17 | | services from a non-participating provider due to a | 18 | | material misrepresentation in a Medicaid Managed Care | 19 | | Entity's online electronic provider directory, the | 20 | | Medicaid Managed Care Entity Plan enrollee shall not be | 21 | | held responsible for any costs resulting from that | 22 | | material misrepresentation. | 23 | | (G) Conspicuously display an e-mail address and a | 24 | | toll-free telephone number to which any individual may | 25 | | report any inaccuracy in the provider directory. If the | 26 | | Medicaid Managed Care Entity receives a report from any |
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| 1 | | person who specifically identifies provider directory | 2 | | information as inaccurate, the Medicaid Managed Care | 3 | | Entity shall investigate the report and correct any | 4 | | inaccurate information displayed in the electronic | 5 | | directory. | 6 | | (2) The Department shall: | 7 | | (A) Regularly monitor Medicaid Managed Care | 8 | | Entities to ensure that they are compliant with the | 9 | | requirements under paragraph (1) of subsection (b). | 10 | | (B) Require that the client enrollment services | 11 | | broker use the Medicaid provider number to populate the | 12 | | provider information in the integrated provider | 13 | | directory. | 14 | | (C) Ensure that each Medicaid Managed Care Entity | 15 | | shall, at minimum, make the information in | 16 | | subparagraph (D) of paragraph (1) of subsection (b) | 17 | | available to the client enrollment services broker. | 18 | | (D) Ensure that the client enrollment services | 19 | | broker shall, at minimum, have the information in | 20 | | subparagraph (D) of paragraph (1) of subsection (b) | 21 | | available and searchable through the integrated | 22 | | provider directory on its website. | 23 | | (E) Require the client enrollment services broker | 24 | | to conspicuously display near the integrated provider | 25 | | directory an email address and a toll-free telephone | 26 | | number to which any individual may report inaccuracies |
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| 1 | | in the integrated provider directory. If the client | 2 | | enrollment services broker receives a report that | 3 | | identifies an inaccuracy in the integrated provider | 4 | | directory, the client enrollment services broker shall | 5 | | provide the information about the reported inaccuracy | 6 | | to the appropriate Medicaid Managed Care Entity within | 7 | | 3 business days after the reported inaccuracy is | 8 | | received. | 9 | | (c) Formulary transparency. | 10 | | (1) Medicaid Managed Care Entities shall publish on | 11 | | their respective websites a formulary for each Medicaid | 12 | | Managed Care Entity Plan offered and make the formularies | 13 | | easily understandable and publicly accessible without the | 14 | | necessity of providing a password, a username, or | 15 | | personally identifiable information. | 16 | | (2) Medicaid Managed Care Entities shall provide | 17 | | printed formularies upon request. | 18 | | (3) Electronic and print formularies shall display: | 19 | | (A) the medications covered (both generic and name | 20 | | brand); | 21 | | (B) if the medication is preferred or not | 22 | | preferred, and what each term means; | 23 | | (C) what tier each medication is in and the meaning | 24 | | of each tier; | 25 | | (D) any utilization controls including, but not | 26 | | limited to, step therapy, prior approval, dosage |
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| 1 | | limits, gender or age restrictions, quantity limits, | 2 | | or other policies that affect access to medications; | 3 | | (E) any required cost-sharing; | 4 | | (F) a glossary of key terms and explanation of | 5 | | utilization controls and cost-sharing requirements; | 6 | | (G) a key or legend for all utilization controls | 7 | | visible on every page in which specific medication | 8 | | coverage information is displayed; and | 9 | | (H) directions explaining the process or processes | 10 | | a consumer may follow to obtain more information if a | 11 | | medication the consumer requires is not covered or | 12 | | listed in the formulary. | 13 | | (4) Each Medicaid Managed Care Entity shall display | 14 | | conspicuously with each electronic and printed medication | 15 | | formulary an e-mail address and a toll-free telephone | 16 | | number to which any individual may report any inaccuracy in | 17 | | the formulary. If the Medicaid Managed Care Entity receives | 18 | | a report that the formulary information is inaccurate, the | 19 | | Medicaid Managed Care Entity shall investigate the report | 20 | | and correct any incorrect information, as necessary, no | 21 | | later than the third business day after the date the report | 22 | | is received. | 23 | | (5) Each Medicaid Managed Care Entity shall include a | 24 | | disclosure in the electronic and requested print | 25 | | formularies that provides the date of publication, a | 26 | | statement that the formulary is up to date as of |
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| 1 | | publication, and contact information for questions and | 2 | | requests to receive updated information. | 3 | | (6) The client enrollment services broker's website | 4 | | shall display prominently a website URL link to each | 5 | | Medicaid Managed Care Entity's Plan formulary. | 6 | | (d) Grievances and appeals. The Department shall require | 7 | | the client enrollment services broker to display prominently on | 8 | | the client enrollment services broker's website a description | 9 | | of where a Medicaid enrollee can access information on how to | 10 | | file a complaint or grievance or request a fair hearing for any | 11 | | adverse action taken by the Department or the Medicaid Managed | 12 | | Care Entity. | 13 | | (e) Medicaid redetermination information.
The Department | 14 | | shall require the client enrollment services broker to display | 15 | | prominently on the client enrollment services broker's website | 16 | | a description of where a Medicaid enrollee can access | 17 | | information regarding the Medicaid redetermination process. | 18 | | (f) Medicaid care coordination information. The client | 19 | | enrollment services broker shall display prominently on its | 20 | | website, in an easily understandable format, consumer-oriented | 21 | | information regarding the role of care coordination services | 22 | | within Medicaid Managed Care. Such information shall include, | 23 | | but shall not be limited to: | 24 | | (1) a basic description of the role of care | 25 | | coordination services and examples of specific care | 26 | | coordination activities; and |
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| 1 | | (2) how a Medicaid enrollee may request care | 2 | | coordination services from a Medicaid Managed Care Entity. | 3 | | (g) Consumer quality comparison tool. | 4 | | (1) The Department shall create a consumer quality | 5 | | comparison tool to assist Medicaid enrollees with Medicaid | 6 | | Managed Care Entity Plan selection. This tool shall provide | 7 | | Medicaid Managed Care Entities' individual Plan | 8 | | performance on a set of standardized quality performance | 9 | | measures. The Department shall ensure that this tool shall | 10 | | be accessible in both a print and online format, with the | 11 | | online format allowing for individuals to access | 12 | | additional detailed Plan performance information. | 13 | | (2) At a minimum, the print version of the consumer | 14 | | quality comparison tool shall be provided by the Department | 15 | | on an annual basis to Medicaid enrollees who are required | 16 | | by the Department to enroll in a Medicaid Managed Care | 17 | | Entity Plan during an enrollee's open enrollment period. | 18 | | The consumer quality comparison tool shall also meet all of | 19 | | the following criteria: | 20 | | (A) Display Medicaid Managed Care Entities' | 21 | | individual Plan performance on at least 4 composite | 22 | | domains that reflect Plan quality, timeliness, and | 23 | | access. The composite domains shall draw from the most | 24 | | current available performance data sets including, but | 25 | | not limited to: | 26 | | (i) Healthcare Effectiveness Data and |
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| 1 | | Information Set (HEDIS) measures. | 2 | | (ii) Core Set of Children's Health Care | 3 | | Quality measures as required under the Children's | 4 | | Health Insurance Program Reauthorization Act | 5 | | (CHIPRA). | 6 | | (iii) Adult Core Set measures. | 7 | | (iv) Consumer Assessment of Healthcare | 8 | | Providers and Systems (CAHPS) survey results. | 9 | | (v) Additional performance measures the | 10 | | Department deems appropriate to populate the | 11 | | composite domains. | 12 | | (B) Use a quality rating system developed by the | 13 | | Department to reflect Medicaid Managed Care Entities' | 14 | | individual Plan performance. The quality rating system | 15 | | for each composite domain shall reflect the Medicaid | 16 | | Managed Care Entities' individual Plan performance | 17 | | and, when possible, plan performance relative to | 18 | | national Medicaid percentiles. | 19 | | (C) Be customized to reflect the specific Medicaid | 20 | | Managed Care Entities' Plans available to the Medicaid | 21 | | enrollee based on his or her geographic location and | 22 | | Medicaid eligibility category. | 23 | | (D) Include contact information for the client | 24 | | enrollment services broker and contact information for | 25 | | Medicaid Managed Care Entities available to the | 26 | | Medicaid enrollee based on his or her geographic |
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| 1 | | location and Medicaid eligibility category. | 2 | | (E) Include guiding questions designed to assist | 3 | | individuals selecting a Medicaid Managed Care Entity | 4 | | Plan. | 5 | | (3) At a minimum, the online version of the consumer | 6 | | quality comparison tool shall meet all of the following | 7 | | criteria: | 8 | | (A) Display Medicaid Managed Care Entities' | 9 | | individual Plan performance for the same composite | 10 | | domains selected by the Department. The Department may | 11 | | display additional composite domains in the online | 12 | | version of the consumer quality comparison tool as | 13 | | appropriate. | 14 | | (B) Display Medicaid Managed Care Entities' | 15 | | individual Plan performance on each of the | 16 | | standardized performance measures that contribute to | 17 | | each composite domain displayed on the online version | 18 | | of the consumer quality comparison tool. | 19 | | (C) Use a quality rating system developed by the | 20 | | Department to reflect Medicaid Managed Care Entities' | 21 | | individual Plan performance. The quality rating system | 22 | | for each composite domain shall reflect the Medicaid | 23 | | Managed Care Entities' individual Plan performance | 24 | | compared to national benchmark performance averages | 25 | | when national benchmarks are available. | 26 | | (D) Include the specific Medicaid Managed Care |
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| 1 | | Entity Plans available to the Medicaid enrollee based | 2 | | on his or her geographic location and Medicaid | 3 | | eligibility category. | 4 | | (E) Include a sort function to view Medicaid | 5 | | Managed Care Entities' individual Plan performance by | 6 | | star rating and by standardized quality performance | 7 | | measures. | 8 | | (F) Include contact information for the client | 9 | | enrollment services broker and for each Medicaid | 10 | | Managed Care Entity. | 11 | | (G) Include guiding questions designed to assist | 12 | | individuals in selecting a Medicaid Managed Care | 13 | | Entity Plan. | 14 | | (H) Prominently display current notice of quality | 15 | | performance sanctions against Medicaid Managed Care | 16 | | Entities. Notice of the sanctions shall remain present | 17 | | on the online version of the consumer quality | 18 | | comparison tool until the sanctions are lifted. | 19 | | (4) The online version of the consumer quality | 20 | | comparison tool shall be displayed prominently on the | 21 | | client enrollment services broker's website. | 22 | | (5) In the development of the consumer quality | 23 | | comparison tool, the Department shall establish and | 24 | | publicize a formal process to collect and consider written | 25 | | and oral feedback from consumers, advocates, and | 26 | | stakeholders on aspects of the consumer quality comparison |
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| 1 | | tool, including, but not limited to, the following: | 2 | | (A) The standardized data sets and surveys, | 3 | | specific performance measures, and composite domains | 4 | | represented in the consumer quality comparison tool. | 5 | | (B) The format and presentation of the consumer | 6 | | quality comparison tool. | 7 | | (C) The methods undertaken by the Department to | 8 | | notify Medicaid enrollees of the availability of the | 9 | | consumer quality comparison tool. | 10 | | (6) The Department shall review and update as | 11 | | appropriate the composite domains and performance measures | 12 | | represented in the print and online versions of the | 13 | | consumer quality comparison tool at least once every 3 | 14 | | years. During the Department's review process, the | 15 | | Department shall solicit engagement in the public feedback | 16 | | process described in paragraph (5). | 17 | | (7) The Department shall ensure that the consumer | 18 | | quality comparison tool is available for consumer use as | 19 | | soon as possible but no later than January 1, 2018. | 20 | | (h)
The Department may adopt rules and take any other | 21 | | appropriate action necessary to implement its responsibilities | 22 | | under this Section.
| 23 | | Section 99. Effective date. This Act takes effect upon | 24 | | becoming law.".
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