State of Illinois
2017 and 2018


Introduced 2/15/2018, by Sen. David Koehler


305 ILCS 5/Art. V-F heading
305 ILCS 5/5F-1
305 ILCS 5/5F-2.5 new
305 ILCS 5/5F-10
305 ILCS 5/5F-15

    Amends the Illinois Public Aid Code. Changes the heading of Article V-F to the Nursing Home Residents' Managed Care Rights Law (rather than the Medicare-Medicaid Alignment Initiative (MMAI) Nursing Home Residents' Managed Care Rights Law). Expands the scope of the Article to apply to policies and contracts for the nursing home component of any Medicaid managed care program established by statute, rule, or contract, including, but not limited to, the Medicare-Medicaid Alignment Initiative Program, the Integrated Care Program, the HealthChoices Program, the Managed Long-Term Services and Support Program, and any and all successor programs. Grants the Department of Healthcare and Family Services rulemaking authority to implement this provision. Makes changes to the definitions for "enrollee", "managed care organization", and "transition period". Effective immediately.

LRB100 19856 KTG 35134 b






SB3290LRB100 19856 KTG 35134 b

1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing the heading of Article V-F and Sections 5F-1, 5F-10,
6and 5F-15 and by adding Sections 5F-2.5 and 5F-17 as follows:
7    (305 ILCS 5/Art. V-F heading)
11(Source: P.A. 98-651, eff. 6-16-14.)
12    (305 ILCS 5/5F-1)
13    Sec. 5F-1. Short title. This Article may be referred to as
14the Medicare-Medicaid Alignment Initiative (MMAI) Nursing Home
15Residents' Managed Care Rights Law.
16(Source: P.A. 98-651, eff. 6-16-14.)
17    (305 ILCS 5/5F-2.5 new)
18    Sec. 5F-2.5. Declaration. The General Assembly declares it
19is in the best interest of the citizenry of the State of
20Illinois for the Department of Healthcare and Family Services
21to maintain strict oversight of all Medicaid managed care



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1programs covering nursing home residents to ensure that medical
2care and services are delivered in a manner consistent with the
3unique needs and circumstances of nursing home residents and
4that providers are appropriately and promptly paid in full for
5all services rendered in good faith. Further, the General
6Assembly expressly prohibits the Department of Healthcare and
7Family Services from delegating to a third party authority and
8responsibility for ensuring that provider agreements issued by
9managed care organizations under contract with the Department
10are in compliance with all federal and State laws and
11regulations and the master contract and directs the Department
12to review all provider agreements and intervene to ensure full
13compliance. The General Assembly also expressly prohibits
14managed care organizations under contract with the Department
15of Healthcare and Family Services to subcontract to a third
16party any and all care, services, supports, and functions that
17the managed care organization is required by law or contract to
18provide to Medicaid beneficiaries residing in nursing homes,
19including, but not limited to, case coordination, care
20management, prior authorizations, and claims processing.
21    (305 ILCS 5/5F-10)
22    Sec. 5F-10. Scope. This Article applies to policies and
23contracts amended, delivered, issued, or renewed on or after
24the effective date of this amendatory Act of the 98th General
25Assembly for the nursing home component of any Medicaid managed



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1care program established by statute, rule, or contract
2including, but not limited to, the Medicare-Medicaid Alignment
3Initiative Program, the Integrated Care Program, the
4HealthChoices Program, and the Managed Long-Term Services and
5Support Program, and any and all successor programs. This
6Article does not diminish a managed care organization's duties
7and responsibilities under other federal or State laws or rules
8adopted under those laws and the 3-way Medicare-Medicaid
9Alignment Initiative contract, the Integrated Care Program
10contract, the HealthChoices Program contract, and the Managed
11Long-Term Services and Support Program contract, and
12contracts, statutes, or rules specific to any and all successor
14    On or after the effective date of this amendatory Act of
15the 100th General Assembly, the Department shall review the
16requirements and make all policy changes, adopt administrative
17rules, modify existing contracts with managed care
18organizations, and direct the issuance of revised provider
19agreements necessary to achieve the full implementation of this
20amendatory Act of the 100th General Assembly.
21(Source: P.A. 98-651, eff. 6-16-14; 99-719, eff. 1-1-17.)
22    (305 ILCS 5/5F-15)
23    Sec. 5F-15. Definitions. As used in this Article:
24    "Appeal" means any of the procedures that deal with the
25review of adverse organization determinations on the health



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1care services the enrollee believes he or she is entitled to
2receive, including delay in providing, arranging for, or
3approving the health care services, such that a delay would
4adversely affect the health of the enrollee or on any amounts
5the enrollee must pay for a service, as defined under 42 CFR
6422.566(b). These procedures include reconsiderations by the
7managed care organization and, if necessary, an independent
8review entity as provided by the Health Carrier External Review
9Act, hearings before administrative law judges, review by the
10Medicare Appeals Council, and judicial review.
11    "Demonstration Project" means the nursing home component
12of the Medicare-Medicaid Alignment Initiative Demonstration
14    "Department" means the Department of Healthcare and Family
16    "Enrollee" means an individual who resides in a nursing
17home or is qualified to be admitted to a nursing home and is
18enrolled or is a prospective enrollee with a Medicaid managed
19care organization participating in the Demonstration Project.
20    "Health care services" means the diagnosis, treatment, and
21prevention of disease and includes medication, primary care,
22nursing or medical care, mental health treatment, psychiatric
23rehabilitation, memory loss services, physical, occupational,
24and speech rehabilitation, enhanced care, medical supplies and
25equipment and the repair of such equipment, and assistance with
26activities of daily living.



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1    "Managed care organization" or "MCO" means an entity that
2meets the definition of health maintenance organization as
3defined in the Health Maintenance Organization Act, is
4licensed, regulated and in good standing with the Department of
5Insurance, and is authorized to participate in the nursing home
6component of the Medicare-Medicaid Alignment Initiative
7Demonstration Project by a 3-way contract with the Department
8of Healthcare and Family Services and the Centers for Medicare
9and Medicaid Services or is under contract with the Department
10to participate in the Integrated Care Program, the Managed
11Long-Term Services and Support Program, the HealthChoices
12Program, and any and all successor programs.
13    "Medical professional" means a physician, physician
14assistant, or nurse practitioner.
15    "Medically necessary" means health care services that a
16medical professional, exercising prudent clinical judgment,
17would provide to a patient for the purpose of preventing,
18evaluating, diagnosing, or treating an illness, injury, or
19disease or its symptoms, and that are: (i) in accordance with
20the generally accepted standards of medical practice; (ii)
21clinically appropriate, in terms of type, frequency, extent,
22site, and duration, and considered effective for the patient's
23illness, injury, or disease; and (iii) not primarily for the
24convenience of the patient, a medical professional, other
25health care provider, caregiver, family member, or other
26interested party.



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1    "Nursing home" means a facility licensed under the Nursing
2Home Care Act.
3    "Nurse practitioner" means an individual properly licensed
4as a nurse practitioner under the Nurse Practice Act.
5    "Physician" means an individual licensed to practice in all
6branches of medicine under the Medical Practice Act of 1987.
7    "Physician assistant" means an individual properly
8licensed under the Physician Assistant Practice Act of 1987.
9    "Resident" means an enrollee who is receiving personal or
10medical care, including, but not limited to, mental health
11treatment, psychiatric rehabilitation, physical
12rehabilitation, and assistance with activities of daily
13living, from a nursing home.
14    "RAI Manual" means the most recent Resident Assessment
15Instrument Manual, published by the Centers for Medicare and
16Medicaid Services.
17    "Resident's representative" means a person designated in
18writing by a resident to be the resident's representative or
19the resident's guardian, as described by the Nursing Home Care
21    "SNFist" means a medical professional specializing in the
22care of individuals residing in nursing homes employed by or
23under contract with a MCO.
24    "Transition period" means a period of time immediately
25following enrollment into a managed care organization the
26Demonstration Project or an enrollee's movement from one



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1managed care organization to another managed care organization
2or one care setting to another care setting.
3(Source: P.A. 98-651, eff. 6-16-14.)
4    Section 99. Effective date. This Act takes effect upon
5becoming law.