Full Text of HB0068 100th General Assembly
HB0068ham003 100TH GENERAL ASSEMBLY | Rep. Lou Lang Filed: 4/6/2018
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| 1 | | AMENDMENT TO HOUSE BILL 68
| 2 | | AMENDMENT NO. ______. Amend House Bill 68, AS AMENDED, by | 3 | | inserting immediately below the enacting clause the following:
| 4 | | "Section 3. The State Employees Group Insurance Act of 1971 | 5 | | is amended by changing Section 6.11 as follows:
| 6 | | (5 ILCS 375/6.11)
| 7 | | Sec. 6.11. Required health benefits; Illinois Insurance | 8 | | Code
requirements. The program of health
benefits shall provide | 9 | | the post-mastectomy care benefits required to be covered
by a | 10 | | policy of accident and health insurance under Section 356t of | 11 | | the Illinois
Insurance Code. The program of health benefits | 12 | | shall provide the coverage
required under Sections 356g, | 13 | | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, | 14 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 15 | | 356z.14, 356z.15, 356z.17, 356z.22, and 356z.25 , and 356z.26 of | 16 | | the
Illinois Insurance Code.
The program of health benefits |
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| 1 | | must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, | 2 | | and 370c.1 of the
Illinois Insurance Code. The Department of | 3 | | Insurance shall enforce the requirements of this Section.
| 4 | | Rulemaking authority to implement Public Act 95-1045, if | 5 | | any, is conditioned on the rules being adopted in accordance | 6 | | with all provisions of the Illinois Administrative Procedure | 7 | | Act and all rules and procedures of the Joint Committee on | 8 | | Administrative Rules; any purported rule not so adopted, for | 9 | | whatever reason, is unauthorized. | 10 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 11 | | 100-138, eff. 8-18-17; revised 10-3-17.)"; and
| 12 | | by inserting immediately below Section 5 the following: | 13 | | "Section 6. The Counties Code is amended by changing | 14 | | Section 5-1069.3 as follows: | 15 | | (55 ILCS 5/5-1069.3)
| 16 | | Sec. 5-1069.3. Required health benefits. If a county, | 17 | | including a home
rule
county, is a self-insurer for purposes of | 18 | | providing health insurance coverage
for its employees, the | 19 | | coverage shall include coverage for the post-mastectomy
care | 20 | | benefits required to be covered by a policy of accident and | 21 | | health
insurance under Section 356t and the coverage required | 22 | | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | 23 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
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| 1 | | 356z.14, 356z.15, 356z.22, and 356z.25 , and 356z.26 of
the | 2 | | Illinois Insurance Code. The coverage shall comply with | 3 | | Sections 155.22a, 355b, 356z.19, and 370c of
the Illinois | 4 | | Insurance Code. The Department of Insurance shall enforce the | 5 | | requirements of this Section. The requirement that health | 6 | | benefits be covered
as provided in this Section is an
exclusive | 7 | | power and function of the State and is a denial and limitation | 8 | | under
Article VII, Section 6, subsection (h) of the Illinois | 9 | | Constitution. A home
rule county to which this Section applies | 10 | | must comply with every provision of
this Section.
| 11 | | Rulemaking authority to implement Public Act 95-1045, if | 12 | | any, is conditioned on the rules being adopted in accordance | 13 | | with all provisions of the Illinois Administrative Procedure | 14 | | Act and all rules and procedures of the Joint Committee on | 15 | | Administrative Rules; any purported rule not so adopted, for | 16 | | whatever reason, is unauthorized. | 17 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 18 | | 100-138, eff. 8-18-17; revised 10-5-17.) | 19 | | Section 7. The Illinois Municipal Code is amended by | 20 | | changing Section 10-4-2.3 as follows: | 21 | | (65 ILCS 5/10-4-2.3)
| 22 | | Sec. 10-4-2.3. Required health benefits. If a | 23 | | municipality, including a
home rule municipality, is a | 24 | | self-insurer for purposes of providing health
insurance |
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| 1 | | coverage for its employees, the coverage shall include coverage | 2 | | for
the post-mastectomy care benefits required to be covered by | 3 | | a policy of
accident and health insurance under Section 356t | 4 | | and the coverage required
under Sections 356g, 356g.5, | 5 | | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | 6 | | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, and | 7 | | 356z.25 , and 356z.26 of the Illinois
Insurance
Code. The | 8 | | coverage shall comply with Sections 155.22a, 355b, 356z.19, and | 9 | | 370c of
the Illinois Insurance Code. The Department of | 10 | | Insurance shall enforce the requirements of this Section. The | 11 | | requirement that health
benefits be covered as provided in this | 12 | | is an exclusive power and function of
the State and is a denial | 13 | | and limitation under Article VII, Section 6,
subsection (h) of | 14 | | the Illinois Constitution. A home rule municipality to which
| 15 | | this Section applies must comply with every provision of this | 16 | | Section.
| 17 | | Rulemaking authority to implement Public Act 95-1045, if | 18 | | any, is conditioned on the rules being adopted in accordance | 19 | | with all provisions of the Illinois Administrative Procedure | 20 | | Act and all rules and procedures of the Joint Committee on | 21 | | Administrative Rules; any purported rule not so adopted, for | 22 | | whatever reason, is unauthorized. | 23 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 24 | | 100-138, eff. 8-18-17; revised 10-5-17.) | 25 | | Section 8. The School Code is amended by changing Section |
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| 1 | | 10-22.3f as follows: | 2 | | (105 ILCS 5/10-22.3f)
| 3 | | Sec. 10-22.3f. Required health benefits. Insurance | 4 | | protection and
benefits
for employees shall provide the | 5 | | post-mastectomy care benefits required to be
covered by a | 6 | | policy of accident and health insurance under Section 356t and | 7 | | the
coverage required under Sections 356g, 356g.5, 356g.5-1, | 8 | | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, | 9 | | 356z.13, 356z.14, 356z.15, 356z.22, and 356z.25 , and 356z.26 of
| 10 | | the
Illinois Insurance Code.
Insurance policies shall comply | 11 | | with Section 356z.19 of the Illinois Insurance Code. The | 12 | | coverage shall comply with Sections 155.22a , and 355b , and 370c | 13 | | of
the Illinois Insurance Code. The Department of Insurance | 14 | | shall enforce the requirements of this Section.
| 15 | | Rulemaking authority to implement Public Act 95-1045, if | 16 | | any, is conditioned on the rules being adopted in accordance | 17 | | with all provisions of the Illinois Administrative Procedure | 18 | | Act and all rules and procedures of the Joint Committee on | 19 | | Administrative Rules; any purported rule not so adopted, for | 20 | | whatever reason, is unauthorized. | 21 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 22 | | revised 9-25-17.)"; and
| 23 | | in Section 10, by inserting immediately below paragraph (6) of | 24 | | subsection (b) of Sec. 370c the following: |
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| 1 | | " (6.5) An individual or group health benefit plan amended, | 2 | | delivered, issued, or renewed on or after the effective date of | 3 | | this amendatory Act of the 100th General Assembly: | 4 | | (A) shall not impose prior authorization requirements | 5 | | on a prescription medication approved by the United States | 6 | | Food and Drug Administration for the treatment of substance | 7 | | use disorders; | 8 | | (B) shall not impose any step therapy requirements | 9 | | before authorizing coverage for a prescription medication | 10 | | approved by the United States Food and Drug Administration | 11 | | for the treatment of substance use disorders; | 12 | | (C) shall place all prescription medications approved | 13 | | by the United States Food and Drug Administration for the | 14 | | treatment of substance use disorders on the lowest tier of | 15 | | the drug formulary developed and maintained by the insurer; | 16 | | and | 17 | | (D) shall not exclude coverage for a prescription | 18 | | medication approved by the United States Food and Drug | 19 | | Administration for the treatment of substance use | 20 | | disorders and any associated counseling or wraparound | 21 | | services on the grounds that such medications and services | 22 | | were court ordered. "; and
| 23 | | in Section 10, by replacing subsection (d) of Sec. 370c with | 24 | | the following: | 25 | | " (d) With respect to a group or individual policy of |
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| 1 | | accident and health insurance or a qualified health plan | 2 | | offered through the health insurance marketplace, the | 3 | | Department and, with respect to medical assistance, the | 4 | | Department of Healthcare and Family Services shall each enforce | 5 | | the requirements of this Section and Sections 356z.23 and | 6 | | 370c.1 of this Code, the Paul Wellstone and Pete Domenici | 7 | | Mental Health Parity and Addiction Equity Act of 2008, 42 | 8 | | U.S.C. 18031(j), and any amendments to, and federal guidance or | 9 | | regulations issued under, those Acts, including, but not | 10 | | limited to, final regulations issued under the Paul Wellstone | 11 | | and Pete Domenici Mental Health Parity and Addiction Equity Act | 12 | | of 2008 and final regulations applying the Paul Wellstone and | 13 | | Pete Domenici Mental Health Parity and Addiction Equity Act of | 14 | | 2008 to Medicaid managed care organizations, the Children's | 15 | | Health Insurance Program, and alternative benefit plans. | 16 | | Specifically, the Department and the Department of Healthcare | 17 | | and Family Services shall take action: | 18 | | (1) proactively ensuring compliance by individual and | 19 | | group policies; | 20 | | (2) evaluating all consumer or provider complaints | 21 | | regarding mental, emotional, nervous, or substance use | 22 | | disorder or condition coverage for possible parity | 23 | | violations; | 24 | | (3) maintaining and regularly reviewing for possible | 25 | | parity violations a publicly available consumer complaint | 26 | | log regarding mental, emotional, nervous, or substance use |
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| 1 | | disorders or conditions coverage; | 2 | | (4) requiring that insurers submit comparative | 3 | | analyses during the form or contract review process | 4 | | demonstrating how they design and apply nonquantitative | 5 | | treatment limitations, both as written and in operation, | 6 | | for mental, emotional, nervous, or substance use disorder | 7 | | or condition benefits as compared to how they design and | 8 | | apply nonquantitative treatment limitations, as written | 9 | | and in operation, for medical and surgical benefits; | 10 | | (5) performing parity compliance market conduct | 11 | | examinations of individual and group plans and policies, | 12 | | including, but not limited to, reviews of: | 13 | | (A) nonquantitative treatment limitations, | 14 | | including, but not limited to, prior authorization | 15 | | requirements, concurrent review, retrospective review, | 16 | | step therapy, network admission standards, | 17 | | reimbursement rates, and geographic restrictions; | 18 | | (B) denials of authorization, payment, and | 19 | | coverage; and | 20 | | (C) other specific criteria as set forth in rules | 21 | | adopted by the Department. | 22 | | The findings and the conclusions of the parity compliance | 23 | | market conduct examinations shall be made public and shall be | 24 | | reported to the General Assembly. | 25 | | The Director shall adopt rules to effectuate any provisions | 26 | | of the Paul Wellstone and Pete Domenici Mental Health Parity |
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| 1 | | and Addiction Equity Act of 2008 that relate to the business of | 2 | | insurance. | 3 | | (d) The Department shall enforce the requirements of State | 4 | | and federal parity law, which includes ensuring compliance by | 5 | | individual and group policies; detecting violations of the law | 6 | | by individual and group policies proactively monitoring | 7 | | discriminatory practices; accepting, evaluating, and | 8 | | responding to complaints regarding such violations; and | 9 | | ensuring violations are appropriately remedied and deterred. "; | 10 | | and
| 11 | | in Section 10, by deleting paragraph (4) of subsection (h) of | 12 | | Sec. 370c.1; and
| 13 | | in Section 10, by replacing paragraph (18) of subsection (j) of | 14 | | Sec. 370c.1 with the following: | 15 | | " (18) A description of the process used to develop or | 16 | | select the medical necessity criteria for mental, | 17 | | emotional, nervous, or substance use disorder or condition | 18 | | benefits and the process used to develop or select the | 19 | | medical necessity criteria for medical and surgical | 20 | | benefits. | 21 | | (19) Identification of all nonquantitative treatment | 22 | | limitations that are applied to both mental, emotional, | 23 | | nervous, or substance use disorder or condition benefits | 24 | | and medical and surgical benefits within each |
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| 1 | | classification of benefits; there may be no separate | 2 | | nonquantitative treatment limitations that apply to | 3 | | mental, emotional, nervous, or substance use disorder or | 4 | | condition benefits but do not apply to medical and surgical | 5 | | benefits within any classification of benefits. | 6 | | (20) The results of an analysis that demonstrates that | 7 | | for the medical necessity criteria described in | 8 | | subparagraph (A) and for each nonquantitative treatment | 9 | | limitation identified in subparagraph (B), as written and | 10 | | in operation, the processes, strategies, evidentiary | 11 | | standards, or other factors used in applying the medical | 12 | | necessity criteria and each nonquantitative treatment | 13 | | limitation to mental, emotional, nervous, or substance use | 14 | | disorder or condition benefits within each classification | 15 | | of benefits are comparable to, and are applied no more | 16 | | stringently than, the processes, strategies, evidentiary | 17 | | standards, or other factors used in applying the medical | 18 | | necessity criteria and each nonquantitative treatment | 19 | | limitation to medical and surgical benefits within the | 20 | | corresponding classification of benefits; at a minimum, | 21 | | the results of the analysis shall: | 22 | | (A) identify the factors used to determine that a | 23 | | nonquantitative treatment limitation applies to a | 24 | | benefit, including factors that were considered but | 25 | | rejected; | 26 | | (B) identify and define the specific evidentiary |
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| 1 | | standards used to define the factors and any other | 2 | | evidence relied upon in designing each nonquantitative | 3 | | treatment limitation; | 4 | | (C) provide the comparative analyses, including | 5 | | the results of the analyses, performed to determine | 6 | | that the processes and strategies used to design each | 7 | | nonquantitative treatment limitation, as written, for | 8 | | mental, emotional, nervous, or substance use disorder | 9 | | or condition benefits are comparable to, and are | 10 | | applied no more stringently than, the processes and | 11 | | strategies used to design each nonquantitative | 12 | | treatment limitation, as written, for medical and | 13 | | surgical benefits; | 14 | | (D) provide the comparative analyses, including | 15 | | the results of the analyses, performed to determine | 16 | | that the processes and strategies used to apply each | 17 | | nonquantitative treatment limitation, in operation, | 18 | | for mental, emotional, nervous, or substance use | 19 | | disorder or condition benefits are comparable to, and | 20 | | applied no more stringently than, the processes or | 21 | | strategies used to apply each nonquantitative | 22 | | treatment limitation, in operation, for medical and | 23 | | surgical benefits; and | 24 | | (E) disclose the specific findings and conclusions | 25 | | reached by the insurer that the results of the analyses | 26 | | described in subparagraphs (C) and (D) indicate that |
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| 1 | | the insurer is in compliance with this Section and the | 2 | | Mental Health Parity and Addiction Equity Act of 2008 | 3 | | and its implementing regulations, which includes 42 | 4 | | CFR Parts 438, 440, and 457 and 45 CFR 146.136 and any | 5 | | other related federal regulations found in the Code of | 6 | | Federal Regulations. "; and
| 7 | | in Section 10, in paragraph (19) of subsection (j) of Sec. | 8 | | 370c.1, by replacing " (19) " with " (21) "; and
| 9 | | in Section 10, in paragraph (20) of subsection (j) of Sec. | 10 | | 370c.1, by replacing " (20) " with " (22) "; and
| 11 | | in Section 10, by replacing subsection (k) of Sec. 370c.1 with | 12 | | the following: | 13 | | " (k) An insurer that amends, delivers, issues, or renews a | 14 | | group or individual policy of accident and health insurance or | 15 | | a qualified health plan offered through the health insurance | 16 | | marketplace in this State providing coverage for hospital or | 17 | | medical treatment and for the treatment of mental, emotional, | 18 | | nervous, or substance use disorders or conditions on or after | 19 | | the effective date of this amendatory Act of the 100th General | 20 | | Assembly shall, in advance of the plan year, make available to | 21 | | the Department or, with respect to medical assistance, the | 22 | | Department of Healthcare and Family Services and to all plan | 23 | | participants and beneficiaries the information required in |
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| 1 | | subparagraphs (C) through (E) of paragraph (20) of subsection | 2 | | (j). For plan participants and medical assistance | 3 | | beneficiaries, the information required in subparagraphs (C) | 4 | | through (E) of paragraph (20) of subsection (j) shall be made | 5 | | available on a publicly-available website whose web address is | 6 | | prominently displayed in plan and managed care organization | 7 | | informational and marketing materials. | 8 | | (l) In accordance with the Illinois State Auditing Act, the | 9 | | Auditor General shall undertake a review of compliance by the | 10 | | Department and the Department of Healthcare and Family Services | 11 | | with the provisions set forth in Section 370c and this Section | 12 | | and report to the General Assembly within 6 months after the | 13 | | effective date of this amendatory Act of the 100th General | 14 | | Assembly and annually thereafter. "; and
| 15 | | by inserting immediately below Section 10 the following: | 16 | | "Section 15. The Illinois Public Aid Code is amended by | 17 | | changing Section 5-30.1 as follows: | 18 | | (305 ILCS 5/5-30.1) | 19 | | Sec. 5-30.1. Managed care protections. | 20 | | (a) As used in this Section: | 21 | | "Managed care organization" or "MCO" means any entity which | 22 | | contracts with the Department to provide services where payment | 23 | | for medical services is made on a capitated basis. |
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| 1 | | "Emergency services" include: | 2 | | (1) emergency services, as defined by Section 10 of the | 3 | | Managed Care Reform and Patient Rights Act; | 4 | | (2) emergency medical screening examinations, as | 5 | | defined by Section 10 of the Managed Care Reform and | 6 | | Patient Rights Act; | 7 | | (3) post-stabilization medical services, as defined by | 8 | | Section 10 of the Managed Care Reform and Patient Rights | 9 | | Act; and | 10 | | (4) emergency medical conditions, as defined by
| 11 | | Section 10 of the Managed Care Reform and Patient Rights
| 12 | | Act. | 13 | | (b) As provided by Section 5-16.12, managed care | 14 | | organizations are subject to the provisions of the Managed Care | 15 | | Reform and Patient Rights Act. | 16 | | (c) An MCO shall pay any provider of emergency services | 17 | | that does not have in effect a contract with the contracted | 18 | | Medicaid MCO. The default rate of reimbursement shall be the | 19 | | rate paid under Illinois Medicaid fee-for-service program | 20 | | methodology, including all policy adjusters, including but not | 21 | | limited to Medicaid High Volume Adjustments, Medicaid | 22 | | Percentage Adjustments, Outpatient High Volume Adjustments, | 23 | | and all outlier add-on adjustments to the extent such | 24 | | adjustments are incorporated in the development of the | 25 | | applicable MCO capitated rates. | 26 | | (d) An MCO shall pay for all post-stabilization services as |
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| 1 | | a covered service in any of the following situations: | 2 | | (1) the MCO authorized such services; | 3 | | (2) such services were administered to maintain the | 4 | | enrollee's stabilized condition within one hour after a | 5 | | request to the MCO for authorization of further | 6 | | post-stabilization services; | 7 | | (3) the MCO did not respond to a request to authorize | 8 | | such services within one hour; | 9 | | (4) the MCO could not be contacted; or | 10 | | (5) the MCO and the treating provider, if the treating | 11 | | provider is a non-affiliated provider, could not reach an | 12 | | agreement concerning the enrollee's care and an affiliated | 13 | | provider was unavailable for a consultation, in which case | 14 | | the MCO
must pay for such services rendered by the treating | 15 | | non-affiliated provider until an affiliated provider was | 16 | | reached and either concurred with the treating | 17 | | non-affiliated provider's plan of care or assumed | 18 | | responsibility for the enrollee's care. Such payment shall | 19 | | be made at the default rate of reimbursement paid under | 20 | | Illinois Medicaid fee-for-service program methodology, | 21 | | including all policy adjusters, including but not limited | 22 | | to Medicaid High Volume Adjustments, Medicaid Percentage | 23 | | Adjustments, Outpatient High Volume Adjustments and all | 24 | | outlier add-on adjustments to the extent that such | 25 | | adjustments are incorporated in the development of the | 26 | | applicable MCO capitated rates. |
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| 1 | | (e) The following requirements apply to MCOs in determining | 2 | | payment for all emergency services: | 3 | | (1) MCOs shall not impose any requirements for prior | 4 | | approval of emergency services. | 5 | | (2) The MCO shall cover emergency services provided to | 6 | | enrollees who are temporarily away from their residence and | 7 | | outside the contracting area to the extent that the | 8 | | enrollees would be entitled to the emergency services if | 9 | | they still were within the contracting area. | 10 | | (3) The MCO shall have no obligation to cover medical | 11 | | services provided on an emergency basis that are not | 12 | | covered services under the contract. | 13 | | (4) The MCO shall not condition coverage for emergency | 14 | | services on the treating provider notifying the MCO of the | 15 | | enrollee's screening and treatment within 10 days after | 16 | | presentation for emergency services. | 17 | | (5) The determination of the attending emergency | 18 | | physician, or the provider actually treating the enrollee, | 19 | | of whether an enrollee is sufficiently stabilized for | 20 | | discharge or transfer to another facility, shall be binding | 21 | | on the MCO. The MCO shall cover emergency services for all | 22 | | enrollees whether the emergency services are provided by an | 23 | | affiliated or non-affiliated provider. | 24 | | (6) The MCO's financial responsibility for | 25 | | post-stabilization care services it has not pre-approved | 26 | | ends when: |
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| 1 | | (A) a plan physician with privileges at the | 2 | | treating hospital assumes responsibility for the | 3 | | enrollee's care; | 4 | | (B) a plan physician assumes responsibility for | 5 | | the enrollee's care through transfer; | 6 | | (C) a contracting entity representative and the | 7 | | treating physician reach an agreement concerning the | 8 | | enrollee's care; or | 9 | | (D) the enrollee is discharged. | 10 | | (f) Network adequacy and transparency. | 11 | | (1) The Department shall: | 12 | | (A) ensure that an adequate provider network is in | 13 | | place, taking into consideration health professional | 14 | | shortage areas and medically underserved areas; | 15 | | (B) publicly release an explanation of its process | 16 | | for analyzing network adequacy; | 17 | | (C) periodically ensure that an MCO continues to | 18 | | have an adequate network in place; and | 19 | | (D) require MCOs, including Medicaid Managed Care | 20 | | Entities as defined in Section 5-30.2, to meet provider | 21 | | directory requirements under Section 5-30.3. | 22 | | (2) Each MCO shall confirm its receipt of information | 23 | | submitted specific to physician additions or physician | 24 | | deletions from the MCO's provider network within 3 days | 25 | | after receiving all required information from contracted | 26 | | physicians, and electronic physician directories must be |
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| 1 | | updated consistent with current rules as published by the | 2 | | Centers for Medicare and Medicaid Services or its successor | 3 | | agency. | 4 | | (g) Timely payment of claims. | 5 | | (1) The MCO shall pay a claim within 30 days of | 6 | | receiving a claim that contains all the essential | 7 | | information needed to adjudicate the claim. | 8 | | (2) The MCO shall notify the billing party of its | 9 | | inability to adjudicate a claim within 30 days of receiving | 10 | | that claim. | 11 | | (3) The MCO shall pay a penalty that is at least equal | 12 | | to the penalty imposed under the Illinois Insurance Code | 13 | | for any claims not timely paid. | 14 | | (4) The Department may establish a process for MCOs to | 15 | | expedite payments to providers based on criteria | 16 | | established by the Department. | 17 | | (g-5) Recognizing that the rapid transformation of the | 18 | | Illinois Medicaid program may have unintended operational | 19 | | challenges for both payers and providers: | 20 | | (1) in no instance shall a medically necessary covered | 21 | | service rendered in good faith, based upon eligibility | 22 | | information documented by the provider, be denied coverage | 23 | | or diminished in payment amount if the eligibility or | 24 | | coverage information available at the time the service was | 25 | | rendered is later found to be inaccurate; and | 26 | | (2) the Department shall, by December 31, 2016, adopt |
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| 1 | | rules establishing policies that shall be included in the | 2 | | Medicaid managed care policy and procedures manual | 3 | | addressing payment resolutions in situations in which a | 4 | | provider renders services based upon information obtained | 5 | | after verifying a patient's eligibility and coverage plan | 6 | | through either the Department's current enrollment system | 7 | | or a system operated by the coverage plan identified by the | 8 | | patient presenting for services: | 9 | | (A) such medically necessary covered services | 10 | | shall be considered rendered in good faith; | 11 | | (B) such policies and procedures shall be | 12 | | developed in consultation with industry | 13 | | representatives of the Medicaid managed care health | 14 | | plans and representatives of provider associations | 15 | | representing the majority of providers within the | 16 | | identified provider industry; and | 17 | | (C) such rules shall be published for a review and | 18 | | comment period of no less than 30 days on the | 19 | | Department's website with final rules remaining | 20 | | available on the Department's website. | 21 | | (3) The rules on payment resolutions shall include, but | 22 | | not be limited to: | 23 | | (A) the extension of the timely filing period; | 24 | | (B) retroactive prior authorizations; and | 25 | | (C) guaranteed minimum payment rate of no less than | 26 | | the current, as of the date of service, fee-for-service |
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| 1 | | rate, plus all applicable add-ons, when the resulting | 2 | | service relationship is out of network. | 3 | | (4) The rules shall be applicable for both MCO coverage | 4 | | and fee-for-service coverage. | 5 | | (g-6) MCO Performance Metrics Report. | 6 | | (1) The Department shall publish, on at least a | 7 | | quarterly basis, each MCO's operational performance, | 8 | | including, but not limited to, the following categories of | 9 | | metrics: | 10 | | (A) claims payment, including timeliness and | 11 | | accuracy; | 12 | | (B) prior authorizations; | 13 | | (C) grievance and appeals; | 14 | | (D) utilization statistics; | 15 | | (E) provider disputes; | 16 | | (F) provider credentialing; and | 17 | | (G) member and provider customer service. | 18 | | (2) The Department shall collect and report on the | 19 | | metrics identified in subparagraphs (A), (B), (D), (E), and | 20 | | (F) of paragraph (1) by behavioral health providers and | 21 | | non-behavioral health providers. The Department shall | 22 | | specifically report data on the following provider types | 23 | | independent of each other, but within the same behavioral | 24 | | health umbrella: | 25 | | (A) community mental health centers; and | 26 | | (B) alcohol and substance abuse providers. |
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| 1 | | (3) (2) The Department shall ensure that the metrics | 2 | | report is accessible to providers online by January 1, | 3 | | 2017. | 4 | | (4) (3) The metrics shall be developed in consultation | 5 | | with industry representatives of the Medicaid managed care | 6 | | health plans and representatives of associations | 7 | | representing the majority of providers within the | 8 | | identified industry. | 9 | | (5) (4) Metrics shall be defined and incorporated into | 10 | | the applicable Managed Care Policy Manual issued by the | 11 | | Department. | 12 | | (g-7) MCO claims processing and performance analysis. In | 13 | | order to monitor MCO payments to hospital providers, pursuant | 14 | | to this amendatory Act of the 100th General Assembly, the | 15 | | Department shall post an analysis of MCO claims processing and | 16 | | payment performance on its website every 6 months. Such | 17 | | analysis shall include a review and evaluation of a | 18 | | representative sample of hospital claims that are rejected and | 19 | | denied for clean and unclean claims and the top 5 reasons for | 20 | | such actions and timeliness of claims adjudication, which | 21 | | identifies the percentage of claims adjudicated within 30, 60, | 22 | | 90, and over 90 days, and the dollar amounts associated with | 23 | | those claims. The Department shall post the contracted claims | 24 | | report required by HealthChoice Illinois on its website every 3 | 25 | | months. | 26 | | (g-8) An MCO shall enter into a contract with any willing |
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| 1 | | and qualified alcohol and substance abuse provider or certified | 2 | | community health center so long as the alcohol and substance | 3 | | abuse provider or certified community health center agrees to | 4 | | the MCO's rate and adheres to the MCO's requirements. | 5 | | (h) The Department shall not expand mandatory MCO | 6 | | enrollment into new counties beyond those counties already | 7 | | designated by the Department as of June 1, 2014 for the | 8 | | individuals whose eligibility for medical assistance is not the | 9 | | seniors or people with disabilities population until the | 10 | | Department provides an opportunity for accountable care | 11 | | entities and MCOs to participate in such newly designated | 12 | | counties. | 13 | | (i) The requirements of this Section apply to contracts | 14 | | with accountable care entities and MCOs entered into, amended, | 15 | | or renewed after June 16, 2014 (the effective date of Public | 16 | | Act 98-651).
| 17 | | (Source: P.A. 99-725, eff. 8-5-16; 99-751, eff. 8-5-16; | 18 | | 100-201, eff. 8-18-17; 100-580, eff. 3-12-18.)
| 19 | | Section 99. Effective date. This Act takes effect upon | 20 | | becoming law.".
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