Full Text of HR0100 100th General Assembly
HR0100 100TH GENERAL ASSEMBLY |
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| 1 | | HOUSE RESOLUTION
| 2 | | WHEREAS, The Medicaid program in Illinois has an immense, | 3 | | and growing, impact,
both in terms of taxpayer dollars and the | 4 | | effect it has on citizens across the State; and
| 5 | | WHEREAS, State resources for healthcare services are | 6 | | currently so scarce that many
healthcare providers are | 7 | | discontinuing services, leading to a profoundly detrimental | 8 | | impact on
our communities; and
| 9 | | WHEREAS, Enrollment under the Illinois Department of | 10 | | Healthcare and Family
Services' Medical Assistance Programs | 11 | | (Medicaid) exceeds three million; and
| 12 | | WHEREAS, A sizable portion of the Medicaid population is | 13 | | currently enrolled, often
mandatorily, in Managed Care | 14 | | Organizations (MCOs), making outlays to MCOS, measured
in | 15 | | billions of dollars, one of the largest resource uses in the | 16 | | State; and
| 17 | | WHEREAS, There has been little information disseminated to | 18 | | the General
Assembly in terms of how State resources are being | 19 | | spent on MCOs and on the overall
healthcare outcomes for | 20 | | individuals enrolled in these MCOs; and
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| 1 | | WHEREAS, In this quickly evolving environment, the General | 2 | | Assembly must stay
engaged in Medicaid funding and | 3 | | corresponding healthcare outcome issues and must be prepared
to | 4 | | make legislative and administrative recommendations; | 5 | | therefore, be it
| 6 | | RESOLVED, BY THE HOUSE OF REPRESENTATIVES OF THE ONE | 7 | | HUNDREDTH GENERAL ASSEMBLY OF THE STATE OF ILLINOIS, that the | 8 | | Auditor General is directed to conduct an audit of Medicaid | 9 | | MCOs, which includes a
comparison of State expenditures between | 10 | | MCOs and fee-for-service entities; and be it further | 11 | | RESOLVED, That the audit shall examine capitation rate | 12 | | setting and reimbursement
issues for Medicaid MCOs for fiscal | 13 | | year 2015 with respect to the following issues: | 14 | | (1) Compare the total dollar amount of all reported | 15 | | encounter data submitted to the
Illinois Department of | 16 | | Family Services (DHFS) during SFY 2015 to the total dollar
| 17 | | amount of reported claims payments made on behalf of | 18 | | Illinois Medicaid
individuals by MCOs as reported to DHFS | 19 | | during SPY 2015; | 20 | | (2) Whether encounter data is used by the Department of | 21 | | Healthcare and Family
Services (DHFS) to set capitation | 22 | | rates; |
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| 1 | | (3) Calculate the aggregate amount of MCO capitation | 2 | | payments made by DHFS
during SFY2015 (exclude Hospital | 3 | | Assessment pass-through payments from this
calculation); | 4 | | (4) The amount of payments made by DHFS to reimburse | 5 | | for-profit MCOs for the
ACA Health Insurance Fee (HIP); | 6 | | determine if this HIP payment is mandated by
federal CMS; | 7 | | (5) The amount of payments made by DHFS to reimburse | 8 | | for-profit MCOs for "gros-sup"
related to the HIP payment; | 9 | | determine the purpose of the "gross-up"
payments; | 10 | | (6) The incidence to which the MCO capitation rates | 11 | | contain supplemental, ORF-based
payments to providers; for | 12 | | these payments, determine the amount of the
supplemental, | 13 | | which providers received these payments, and whether these | 14 | | monies
were directly tied to services actually provided (do | 15 | | not include payments associated
with the Hospital | 16 | | Assessment Program); | 17 | | (7) What administrative costs are paid to MCOs in terms | 18 | | of total dollars and percent of
overall MCO medical | 19 | | based-payments; | 20 | | (8) What is the overall average medical loss ratio |
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| 1 | | (MLR) for all MCOs in aggregate
and for each MCO | 2 | | individually; for the purposes of this audit, MLR is | 3 | | defined as
all paid claims made by MCOs as reported to HFS | 4 | | for state fiscal year 2015 divided
by aggregate MCO | 5 | | capitation payments made by DHFS during the fiscal year; | 6 | | (9) What the denial rates are for MCOs and for | 7 | | fee-for-service providers billing the
DHFS; determine | 8 | | whether there is a higher denial rate for services paid by | 9 | | MCOs; and | 10 | | (10) To the extent information is available, determine | 11 | | how Illinois' rate setting
methodology compares to other | 12 | | comparable states; and be it further | 13 | | RESOLVED, That the Illinois Department of Healthcare and | 14 | | Family Services and any
other State agency having information | 15 | | relevant to this audit cooperate fully and promptly
with the | 16 | | Auditor General's Office in its conduct; and be it further
| 17 | | RESOLVED, That the Auditor General commence this audit as | 18 | | soon as possible and
report his findings and recommendations | 19 | | upon completion in accordance with the provisions
of Section | 20 | | 3-14 of the Illinois State Auditing Act.
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