Full Text of SB1773 100th General Assembly
SB1773ham007 100TH GENERAL ASSEMBLY | Rep. Mary E. Flowers Filed: 2/7/2018
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| 1 | | AMENDMENT TO SENATE BILL 1773
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 1773, AS AMENDED, | 3 | | with reference to page and line numbers of House Amendment No. | 4 | | 4 as follows:
| 5 | | on page 152, immediately below line 15, by inserting the | 6 | | following: | 7 | | "Section 20. The Illinois Public Aid Code is amended by | 8 | | changing the heading of Article V-F and Sections 5F-1, 5F-5, | 9 | | 5F-10, 5F-15, 5F-25, 5F-30, 5F-32, and 5F-33 and by adding | 10 | | Sections 5F-2.5 and 5F-17 as follows: | 11 | | (305 ILCS 5/Art. V-F heading) | 12 | | ARTICLE V-F. MEDICARE-MEDICAID ALIGNMENT | 13 | | INITIATIVE (MMAI) NURSING HOME | 14 | | RESIDENTS' MANAGED CARE RIGHTS LAW
| 15 | | (Source: P.A. 98-651, eff. 6-16-14.) |
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| 1 | | (305 ILCS 5/5F-1) | 2 | | Sec. 5F-1. Short title. This Article may be referred to as | 3 | | the Medicare-Medicaid Alignment Initiative (MMAI) Nursing Home | 4 | | Residents' Managed Care Rights Law.
| 5 | | (Source: P.A. 98-651, eff. 6-16-14.) | 6 | | (305 ILCS 5/5F-2.5 new) | 7 | | Sec. 5F-2.5. Declaration. The General Assembly declares it | 8 | | is in the best interest of the citizenry of the State of | 9 | | Illinois for the Department of Healthcare and Family Services | 10 | | to maintain strict oversight of all Medicaid managed care | 11 | | programs covering nursing home residents to ensure that medical | 12 | | care and services are delivered in a manner consistent with the | 13 | | unique needs and circumstances of nursing home residents and | 14 | | that providers are appropriately and promptly paid in full for | 15 | | all services rendered in good faith. Further, the General | 16 | | Assembly expressly prohibits the Department of Healthcare and | 17 | | Family Services from delegating to a third party authority and | 18 | | responsibility for ensuring that provider agreements issued by | 19 | | managed care organizations under contract with the Department | 20 | | are in compliance with all federal and State laws and | 21 | | regulations and the master contract and directs the Department | 22 | | to review all provider agreements and intervene to ensure full | 23 | | compliance. |
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| 1 | | (305 ILCS 5/5F-5) | 2 | | Sec. 5F-5. Findings. The General Assembly finds that | 3 | | elderly Illinoisans residing in a nursing home have the right | 4 | | to: | 5 | | (1) quality health care regardless of the payer; | 6 | | (2) receive medically necessary care prescribed by | 7 | | their doctors; | 8 | | (3) a simple appeal process when care is denied; and | 9 | | (4) make decisions about their care and where they | 10 | | receive it ; .
| 11 | | (5) receive long term services and supports upon | 12 | | achieving a DON score of 29 or higher, without further | 13 | | limitations; and
receive medical care, services, and | 14 | | supports in a manner consistent with each individual's | 15 | | level of frailty, mobility, and immediacy of medical | 16 | | condition and consistent with rights and protections | 17 | | contained in State and federal laws and regulations. | 18 | | (Source: P.A. 98-651, eff. 6-16-14.) | 19 | | (305 ILCS 5/5F-10) | 20 | | Sec. 5F-10. Scope. This Article applies to policies and | 21 | | contracts amended, delivered, issued, or renewed on or after | 22 | | the effective date of this amendatory Act of the 98th General | 23 | | Assembly for the nursing home component of any Medicaid managed | 24 | | care program established by statute, rule, or contract | 25 | | including, but not limited to, the Medicare-Medicaid Alignment |
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| 1 | | Initiative Program, the Integrated Care Program, the | 2 | | HealthChoices Program, and the Managed Long-Term Services and | 3 | | Support Program , and any and all successor programs . This | 4 | | Article does not diminish a managed care organization's duties | 5 | | and responsibilities under other federal or State laws or rules | 6 | | adopted under those laws and the 3-way Medicare-Medicaid | 7 | | Alignment Initiative contract , the Integrated Care Program | 8 | | contract, the HealthChoices Program contract, and the Managed | 9 | | Long-Term Services and Support Program contract , and | 10 | | contracts, statutes, or rules specific to any and all successor | 11 | | programs .
| 12 | | On or after the effective date of this amendatory Act of | 13 | | the 100th General Assembly, the Department shall review the | 14 | | requirements and make all policy changes, adopt administrative | 15 | | rules, modify existing contracts with managed care | 16 | | organizations, and direct the issuance of revised provider | 17 | | agreements necessary to achieve the full implementation of this | 18 | | amendatory Act of the 100th General Assembly. | 19 | | (Source: P.A. 98-651, eff. 6-16-14; 99-719, eff. 1-1-17 .) | 20 | | (305 ILCS 5/5F-15) | 21 | | Sec. 5F-15. Definitions. As used in this Article: | 22 | | "Appeal" means any of the procedures that deal with the | 23 | | review of adverse organization determinations on the health | 24 | | care services the enrollee believes he or she is entitled to | 25 | | receive, including delay in providing, arranging for, or |
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| 1 | | approving the health care services, such that a delay would | 2 | | adversely affect the health of the enrollee or on any amounts | 3 | | the enrollee must pay for a service, as defined under 42 CFR | 4 | | 422.566(b). These procedures include reconsiderations by the | 5 | | managed care organization and, if necessary, an independent | 6 | | review entity as provided by the Health Carrier External Review | 7 | | Act, hearings before administrative law judges, review by the | 8 | | Medicare Appeals Council, and judicial review. | 9 | | "Demonstration Project" means the nursing home component | 10 | | of the Medicare-Medicaid Alignment Initiative Demonstration | 11 | | Project. | 12 | | "Department" means the Department of Healthcare and Family | 13 | | Services. | 14 | | "Enrollee" means an individual who resides in a nursing | 15 | | home or is qualified to be admitted to a nursing home and is | 16 | | enrolled or is a prospective enrollee with a Medicaid managed | 17 | | care organization participating in the Demonstration Project. | 18 | | "Health care services" means the diagnosis, treatment, and | 19 | | prevention of disease and includes medication, primary care, | 20 | | nursing or medical care, mental health treatment, psychiatric | 21 | | rehabilitation, memory loss services, physical, occupational, | 22 | | and speech rehabilitation, enhanced care, medical supplies and | 23 | | equipment and the repair of such equipment, and assistance with | 24 | | activities of daily living. | 25 | | "Managed care organization" or "MCO" means an entity that | 26 | | meets the definition of health maintenance organization as |
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| 1 | | defined in the Health Maintenance Organization Act, is | 2 | | licensed, regulated and in good standing with the Department of | 3 | | Insurance, and is authorized to participate in the nursing home | 4 | | component of the Medicare-Medicaid Alignment Initiative | 5 | | Demonstration Project by a 3-way contract with the Department | 6 | | of Healthcare and Family Services and the Centers for Medicare | 7 | | and Medicaid Services or is under contract with the Department | 8 | | to participate in the Integrated Care Program, the Managed | 9 | | Long-Term Services and Support Program, the HealthChoices | 10 | | Program, and any and all successor programs . | 11 | | "Medical professional" means a physician, physician | 12 | | assistant, or nurse practitioner. | 13 | | "Medically necessary" means health care services that a | 14 | | medical professional, exercising prudent clinical judgment, | 15 | | would provide to a patient for the purpose of preventing, | 16 | | evaluating, diagnosing, or treating an illness, injury, or | 17 | | disease or its symptoms, and that are: (i) in accordance with | 18 | | the generally accepted standards of medical practice; (ii) | 19 | | clinically appropriate, in terms of type, frequency, extent, | 20 | | site, and duration, and considered effective for the patient's | 21 | | illness, injury, or disease; and (iii) not primarily for the | 22 | | convenience of the patient, a medical professional, other | 23 | | health care provider, caregiver, family member, or other | 24 | | interested party. | 25 | | "Nursing home" means a facility licensed under the Nursing | 26 | | Home Care Act. |
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| 1 | | "Nurse practitioner" means an individual properly licensed | 2 | | as a nurse practitioner under the Nurse Practice Act. | 3 | | "Physician" means an individual licensed to practice in all | 4 | | branches of medicine under the Medical Practice Act of 1987. | 5 | | "Physician assistant" means an individual properly | 6 | | licensed under the Physician Assistant Practice Act of 1987. | 7 | | "Resident" means an enrollee who is receiving personal or | 8 | | medical care, including, but not limited to, mental health | 9 | | treatment, psychiatric rehabilitation, physical | 10 | | rehabilitation, and assistance with activities of daily | 11 | | living, from a nursing home. | 12 | | "RAI Manual" means the most recent Resident Assessment | 13 | | Instrument Manual, published by the Centers for Medicare and | 14 | | Medicaid Services. | 15 | | "Resident's representative" means a person designated in | 16 | | writing by a resident to be the resident's representative or | 17 | | the resident's guardian, as described by the Nursing Home Care | 18 | | Act. | 19 | | "SNFist" means a medical professional specializing in the | 20 | | care of individuals residing in nursing homes employed by or | 21 | | under contract with a MCO. | 22 | | "Transition period" means a period of time immediately | 23 | | following enrollment into a managed care organization the | 24 | | Demonstration Project or an enrollee's movement from one | 25 | | managed care organization to another managed care organization | 26 | | or one care setting to another care setting.
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| 1 | | (Source: P.A. 98-651, eff. 6-16-14.) | 2 | | (305 ILCS 5/5F-17 new) | 3 | | Sec. 5F-17. Contracting. All contracts issued by the | 4 | | Department to managed care organizations for Medicaid services | 5 | | provided to nursing home residents shall be solely for services | 6 | | provided to nursing home residents and tailored to meet the | 7 | | unique medical needs and circumstances of nursing home | 8 | | residents and shall be consistent with all federal and State | 9 | | statutes and regulations governing nursing homes and the | 10 | | delivery of care to residents. Contracts governing the delivery | 11 | | of care to nursing home residents shall at a minimum include | 12 | | the following provisions: | 13 | | (1) 30 minute time and distance standards to primary | 14 | | care physicians and specialists and hospitals regardless | 15 | | of geographic locations; | 16 | | (2) no longer than 24-hour wait time for physician, | 17 | | laboratory, and medical procedure appointments; and | 18 | | (3) automatic authorization for custodial care for | 19 | | residents scoring a 29 or higher on the Determination of | 20 | | Need instrument. | 21 | | (305 ILCS 5/5F-25) | 22 | | Sec. 5F-25. Care coordination. Care coordination provided | 23 | | to all enrollees in the Demonstration Project shall conform to | 24 | | the following requirements: |
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| 1 | | (1) care coordination services shall be | 2 | | enrollee-driven and person-centered; | 3 | | (2) all enrollees in the Demonstration Project shall | 4 | | have the right to receive health care services in the care | 5 | | setting of their choice, except as permitted by Part 4 of | 6 | | Article III of the Nursing Home Care Act with respect to | 7 | | involuntary transfers and discharges; and | 8 | | (3) decisions shall be based on the enrollee's best | 9 | | interests.
| 10 | | (Source: P.A. 98-651, eff. 6-16-14.) | 11 | | (305 ILCS 5/5F-30) | 12 | | Sec. 5F-30. Continuity of care. When a nursing home | 13 | | resident first transitions to a managed care organization from | 14 | | the fee-for-service system or from another managed care | 15 | | organization, the managed care organization shall honor the | 16 | | existing care plan and any necessary changes to that care plan | 17 | | until the managed care organization MCO has completed a | 18 | | comprehensive assessment and new care plan, to the extent such | 19 | | services are covered benefits under the contract , which shall | 20 | | be consistent with the requirements of the RAI Manual. | 21 | | When an enrollee of a managed care organization is moving | 22 | | from a community setting to a nursing home, and the managed | 23 | | care organization MCO is properly notified of the proposed | 24 | | admission by a network nursing home, and the managed care | 25 | | organization fails to participate in developing a care plan |
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| 1 | | within the time frames required by nursing home regulations, | 2 | | the managed care organization MCO must honor a care plan | 3 | | developed by the nursing home until the managed care | 4 | | organization MCO has completed a comprehensive assessment and a | 5 | | new care plan to the extent such services are covered benefits | 6 | | under the contract , consistent with the requirements of the RAI | 7 | | Manual. | 8 | | A nursing home shall have the ability to refuse admission | 9 | | of an enrollee for whom care is required that the nursing home | 10 | | determines is outside the scope of its license and healthcare | 11 | | capabilities.
| 12 | | (Source: P.A. 98-651, eff. 6-16-14.) | 13 | | (305 ILCS 5/5F-32) | 14 | | Sec. 5F-32. Non-emergency prior approval and appeal. | 15 | | (a) Managed care organizations MCOs must have a method of | 16 | | receiving prior approval requests 24 hours a day, 7 days a | 17 | | week, 365 days a year from nursing home residents, physicians, | 18 | | or providers. If a response is not provided within 24 hours of | 19 | | the request and the nursing home is required by regulation to | 20 | | provide a service because a physician ordered it, the managed | 21 | | care organization MCO must pay for the service if it is a | 22 | | covered service under the managed care organization's MCO's | 23 | | contract in the Demonstration Project , provided that the | 24 | | request is consistent with the policies and procedures of the | 25 | | managed care organization MCO . |
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| 1 | | In a non-emergency situation, notwithstanding any | 2 | | provisions in State law to the contrary, in the event a | 3 | | resident's physician orders a service, treatment, or test that | 4 | | is not approved by the managed care organization MCO , the | 5 | | enrollee, physician, or provider may utilize an expedited | 6 | | appeal to the managed care organization MCO . | 7 | | If an enrollee, physician, or provider requests an | 8 | | expedited appeal pursuant to 42 CFR 438.410, the managed care | 9 | | organization MCO shall notify the individual filing the appeal, | 10 | | whether it is the enrollee, physician, or provider, within 24 | 11 | | hours after the submission of the appeal of all information | 12 | | from the enrollee, physician, or provider that the managed care | 13 | | organization MCO requires to evaluate the appeal. The managed | 14 | | care organization MCO shall notify the individual filing the | 15 | | appeal of the managed care organization's MCO's decision on an | 16 | | expedited appeal within 24 hours after receipt of the required | 17 | | information. | 18 | | (b) While the appeal is pending or if the ordered service, | 19 | | treatment, or test is denied after appeal, the Department of | 20 | | Public Health may not cite the nursing home for failure to | 21 | | provide the ordered service, treatment, or test. The nursing | 22 | | home shall not be liable or responsible for an injury in any | 23 | | regulatory proceeding for the following: | 24 | | (1) failure to follow the appealed or denied order; or | 25 | | (2) injury to the extent it was caused by the delay or | 26 | | failure to perform the appealed or denied service, |
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| 1 | | treatment, or test. | 2 | | Provided however, a nursing home shall continue to monitor, | 3 | | document, and ensure the patient's safety. Nothing in this | 4 | | subsection (b) is intended to otherwise change the nursing | 5 | | home's existing obligations under State and federal law to | 6 | | appropriately care for its residents.
| 7 | | (Source: P.A. 98-651, eff. 6-16-14; 99-719, eff. 1-1-17 .) | 8 | | (305 ILCS 5/5F-33) | 9 | | Sec. 5F-33. Payment of claims. | 10 | | (a) Clean claims, as defined by the Department by rule , | 11 | | submitted by a provider to a managed care organization in the | 12 | | form and manner requested by the managed care organization | 13 | | shall be reviewed and paid within 30 days of receipt. | 14 | | (b) A managed care organization must provide a status | 15 | | update within 30 60 days of the submission of a claim. | 16 | | (c) A claim that is rejected or denied , which shall clearly | 17 | | state the reason for the rejection or denial in sufficient | 18 | | detail to permit the provider to understand the justification | 19 | | for the action. | 20 | | (d) The Department shall work with stakeholders, | 21 | | including, but not limited to, managed care organizations and | 22 | | nursing home providers, to train them on the application of | 23 | | standardized codes for long-term care services. | 24 | | (e) Managed care organizations shall provide a manual | 25 | | clearly explaining billing and claims payment procedures, |
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| 1 | | including points of contact for provider services centers, | 2 | | within 15 days of a provider entering into a contract with a | 3 | | managed care organization. The manual shall include all | 4 | | necessary coding and documentation requirements. Providers | 5 | | under contract with a managed care organization on the | 6 | | effective date of this amendatory Act of the 99th General | 7 | | Assembly shall be provided with an electronic copy of these | 8 | | requirements within 30 days of the effective date of this | 9 | | amendatory Act of the 99th General Assembly. Any changes to | 10 | | these requirements shall be delivered electronically to all | 11 | | providers under contract with the managed care organization 30 | 12 | | days prior to the effective date of the change.
| 13 | | (Source: P.A. 99-719, eff. 1-1-17 .)".
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