Illinois General Assembly - Full Text of SB0471
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Full Text of SB0471  102nd General Assembly

SB0471sam001 102ND GENERAL ASSEMBLY

Sen. Laura Fine

Filed: 4/6/2021

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 471

2    AMENDMENT NO. ______. Amend Senate Bill 471 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Network Adequacy and Transparency Act is
5amended by changing Section 10 as follows:
 
6    (215 ILCS 124/10)
7    Sec. 10. Network adequacy.
8    (a) An insurer providing a network plan shall file a
9description of all of the following with the Director:
10        (1) The written policies and procedures for adding
11    providers to meet patient needs based on increases in the
12    number of beneficiaries, changes in the
13    patient-to-provider ratio, changes in medical and health
14    care capabilities, and increased demand for services.
15        (2) The written policies and procedures for making
16    referrals within and outside the network.

 

 

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1        (3) The written policies and procedures on how the
2    network plan will provide 24-hour, 7-day per week access
3    to network-affiliated primary care, emergency services,
4    and woman's principal health care providers.
5    An insurer shall not prohibit a preferred provider from
6discussing any specific or all treatment options with
7beneficiaries irrespective of the insurer's position on those
8treatment options or from advocating on behalf of
9beneficiaries within the utilization review, grievance, or
10appeals processes established by the insurer in accordance
11with any rights or remedies available under applicable State
12or federal law.
13    (b) Insurers must file for review a description of the
14services to be offered through a network plan. The description
15shall include all of the following:
16        (1) A geographic map of the area proposed to be served
17    by the plan by county service area and zip code, including
18    marked locations for preferred providers.
19        (2) As deemed necessary by the Department, the names,
20    addresses, phone numbers, and specialties of the providers
21    who have entered into preferred provider agreements under
22    the network plan.
23        (3) The number of beneficiaries anticipated to be
24    covered by the network plan.
25        (4) An Internet website and toll-free telephone number
26    for beneficiaries and prospective beneficiaries to access

 

 

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1    current and accurate lists of preferred providers,
2    additional information about the plan, as well as any
3    other information required by Department rule.
4        (5) A description of how health care services to be
5    rendered under the network plan are reasonably accessible
6    and available to beneficiaries. The description shall
7    address all of the following:
8            (A) the type of health care services to be
9        provided by the network plan;
10            (B) the ratio of physicians and other providers to
11        beneficiaries, by specialty and including primary care
12        physicians and facility-based physicians when
13        applicable under the contract, necessary to meet the
14        health care needs and service demands of the currently
15        enrolled population;
16            (C) the travel and distance standards for plan
17        beneficiaries in county service areas; and
18            (D) a description of how the use of telemedicine,
19        telehealth, or mobile care services may be used to
20        partially meet the network adequacy standards, if
21        applicable.
22        (6) A provision ensuring that whenever a beneficiary
23    has made a good faith effort, as evidenced by accessing
24    the provider directory, calling the network plan, and
25    calling the provider, to utilize preferred providers for a
26    covered service and it is determined the insurer does not

 

 

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1    have the appropriate preferred providers due to
2    insufficient number, type, or unreasonable travel distance
3    or delay, the insurer shall ensure, directly or
4    indirectly, by terms contained in the payer contract, that
5    the beneficiary will be provided the covered service at no
6    greater cost to the beneficiary than if the service had
7    been provided by a preferred provider. This paragraph (6)
8    does not apply to: (A) a beneficiary who willfully chooses
9    to access a non-preferred provider for health care
10    services available through the panel of preferred
11    providers, or (B) a beneficiary enrolled in a health
12    maintenance organization. In these circumstances, the
13    contractual requirements for non-preferred provider
14    reimbursements shall apply.
15        (7) A provision that the beneficiary shall receive
16    emergency care coverage such that payment for this
17    coverage is not dependent upon whether the emergency
18    services are performed by a preferred or non-preferred
19    provider and the coverage shall be at the same benefit
20    level as if the service or treatment had been rendered by a
21    preferred provider. For purposes of this paragraph (7),
22    "the same benefit level" means that the beneficiary is
23    provided the covered service at no greater cost to the
24    beneficiary than if the service had been provided by a
25    preferred provider.
26        (8) A limitation that, if the plan provides that the

 

 

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1    beneficiary will incur a penalty for failing to
2    pre-certify inpatient hospital treatment, the penalty may
3    not exceed $1,000 per occurrence in addition to the plan
4    cost sharing provisions.
5    (c) The network plan shall demonstrate to the Director a
6minimum ratio of providers to plan beneficiaries as required
7by the Department.
8        (1) The ratio of physicians or other providers to plan
9    beneficiaries shall be established annually by the
10    Department in consultation with the Department of Public
11    Health based upon the guidance from the federal Centers
12    for Medicare and Medicaid Services. The Department shall
13    not establish ratios for vision or dental providers who
14    provide services under dental-specific or vision-specific
15    benefits. The Department shall consider establishing
16    ratios for the following physicians or other providers:
17            (A) Primary Care;
18            (B) Pediatrics;
19            (C) Cardiology;
20            (D) Gastroenterology;
21            (E) General Surgery;
22            (F) Neurology;
23            (G) OB/GYN;
24            (H) Oncology/Radiation;
25            (I) Ophthalmology;
26            (J) Urology;

 

 

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1            (K) Behavioral Health;
2            (L) Allergy/Immunology;
3            (M) Chiropractic;
4            (N) Dermatology;
5            (O) Endocrinology;
6            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
7            (Q) Infectious Disease;
8            (R) Nephrology;
9            (S) Neurosurgery;
10            (T) Orthopedic Surgery;
11            (U) Physiatry/Rehabilitative;
12            (V) Plastic Surgery;
13            (W) Pulmonary;
14            (X) Rheumatology;
15            (Y) Anesthesiology;
16            (Z) Pain Medicine;
17            (AA) Pediatric Specialty Services;
18            (BB) Outpatient Dialysis; and
19            (CC) HIV.
20        (2) The Director shall establish a process for the
21    review of the adequacy of these standards, along with an
22    assessment of additional specialties to be included in the
23    list under this subsection (c).
24    (d) The network plan shall demonstrate to the Director
25maximum travel and distance standards for plan beneficiaries,
26which shall be established annually by the Department in

 

 

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1consultation with the Department of Public Health based upon
2the guidance from the federal Centers for Medicare and
3Medicaid Services. These standards shall consist of the
4maximum minutes or miles to be traveled by a plan beneficiary
5for each county type, such as large counties, metro counties,
6or rural counties as defined by Department rule.
7    The maximum travel time and distance standards must
8include standards for each physician and other provider
9category listed for which ratios have been established.
10    The Director shall establish a process for the review of
11the adequacy of these standards along with an assessment of
12additional specialties to be included in the list under this
13subsection (d).
14    (d-5) (1) Every insurer shall ensure that beneficiaries
15have timely and proximate access to treatment for mental,
16emotional, nervous, or substance use disorders or conditions
17in accordance with the provisions of paragraph (4) of
18subsection (a) of Section 370c of the Illinois Insurance Code.
19Insurers shall use a comparable process, strategy, evidentiary
20standard, and other factors in the development and application
21of the network adequacy standards for timely and proximate
22access to treatment for mental, emotional, nervous, or
23substance use disorders or conditions and those for the access
24to treatment for medical and surgical conditions. As such, the
25network adequacy standards for timely and proximate access
26shall equally be applied to treatment facilities and providers

 

 

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1for mental, emotional, nervous, or substance use disorders or
2conditions and specialists providing medical or surgical
3benefits pursuant to the parity requirements of Section 370c.1
4of the Illinois Insurance Code and the federal Paul Wellstone
5and Pete Domenici Mental Health Parity and Addiction Equity
6Act of 2008. Notwithstanding the foregoing, the network
7adequacy standards for timely and proximate access to
8treatment for mental, emotional, nervous, or substance use
9disorders or conditions shall, at a minimum, satisfy the
10following requirements:
11            (A) For beneficiaries residing in the metropolitan
12        counties of Cook, DuPage, Kane, Lake, McHenry, and
13        Will, network adequacy standards for timely and
14        proximate access to treatment for mental, emotional,
15        nervous, or substance use disorders or conditions
16        means a beneficiary shall not have to travel longer
17        than 30 minutes or 30 miles from the beneficiary's
18        residence to receive outpatient treatment for mental,
19        emotional, nervous, or substance use disorders or
20        conditions. Beneficiaries shall not be required to
21        wait longer than 10 business days between requesting
22        an initial appointment and being seen by the facility
23        or provider of mental, emotional, nervous, or
24        substance use disorders or conditions for outpatient
25        treatment or to wait longer than 20 business days
26        between requesting a repeat or follow-up appointment

 

 

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1        and being seen by the facility or provider of mental,
2        emotional, nervous, or substance use disorders or
3        conditions for outpatient treatment; however, subject
4        to the protections of paragraph (3) of this
5        subsection, a network plan shall not be held
6        responsible if the beneficiary or provider voluntarily
7        chooses to schedule an appointment outside of these
8        required time frames.
9            (B) For beneficiaries residing in Illinois
10        counties other than those counties listed in
11        subparagraph (A) of this paragraph, network adequacy
12        standards for timely and proximate access to treatment
13        for mental, emotional, nervous, or substance use
14        disorders or conditions means a beneficiary shall not
15        have to travel longer than 60 minutes or 60 miles from
16        the beneficiary's residence to receive outpatient
17        treatment for mental, emotional, nervous, or substance
18        use disorders or conditions. Beneficiaries shall not
19        be required to wait longer than 10 business days
20        between requesting an initial appointment and being
21        seen by the facility or provider of mental, emotional,
22        nervous, or substance use disorders or conditions for
23        outpatient treatment or to wait longer than 20
24        business days between requesting a repeat or follow-up
25        appointment and being seen by the facility or provider
26        of mental, emotional, nervous, or substance use

 

 

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1        disorders or conditions for outpatient treatment;
2        however, subject to the protections of paragraph (3)
3        of this subsection, a network plan shall not be held
4        responsible if the beneficiary or provider voluntarily
5        chooses to schedule an appointment outside of these
6        required time frames.
7        (2) For beneficiaries residing in all Illinois
8    counties, network adequacy standards for timely and
9    proximate access to treatment for mental, emotional,
10    nervous, or substance use disorders or conditions means a
11    beneficiary shall not have to travel longer than 60
12    minutes or 60 miles from the beneficiary's residence to
13    receive inpatient or residential treatment for mental,
14    emotional, nervous, or substance use disorders or
15    conditions.
16        (3) If there is no in-network facility or provider
17    available for a beneficiary to receive timely and
18    proximate access to treatment for mental, emotional,
19    nervous, or substance use disorders or conditions in
20    accordance with the network adequacy standards outlined in
21    this subsection, the insurer shall provide necessary
22    exceptions to its network to ensure admission and
23    treatment with a provider or at a treatment facility in
24    accordance with the network adequacy standards in this
25    subsection.
26    (e) Except for network plans solely offered as a group

 

 

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1health plan, these ratio and time and distance standards apply
2to the lowest cost-sharing tier of any tiered network.
3    (f) The network plan may consider use of other health care
4service delivery options, such as telemedicine or telehealth,
5mobile clinics, and centers of excellence, or other ways of
6delivering care to partially meet the requirements set under
7this Section.
8    (g) Except for the requirements set forth in subsection
9(d-5), insurers Insurers who are not able to comply with the
10provider ratios and time and distance standards established by
11the Department may request an exception to these requirements
12from the Department. The Department may grant an exception in
13the following circumstances:
14        (1) if no providers or facilities meet the specific
15    time and distance standard in a specific service area and
16    the insurer (i) discloses information on the distance and
17    travel time points that beneficiaries would have to travel
18    beyond the required criterion to reach the next closest
19    contracted provider outside of the service area and (ii)
20    provides contact information, including names, addresses,
21    and phone numbers for the next closest contracted provider
22    or facility;
23        (2) if patterns of care in the service area do not
24    support the need for the requested number of provider or
25    facility type and the insurer provides data on local
26    patterns of care, such as claims data, referral patterns,

 

 

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1    or local provider interviews, indicating where the
2    beneficiaries currently seek this type of care or where
3    the physicians currently refer beneficiaries, or both; or
4        (3) other circumstances deemed appropriate by the
5    Department consistent with the requirements of this Act.
6    (h) Insurers are required to report to the Director any
7material change to an approved network plan within 15 days
8after the change occurs and any change that would result in
9failure to meet the requirements of this Act. Upon notice from
10the insurer, the Director shall reevaluate the network plan's
11compliance with the network adequacy and transparency
12standards of this Act.
13(Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)
 
14    Section 10. The Illinois Public Aid Code is amended by
15changing Sections 5-16.8 and 5-30.1 as follows:
 
16    (305 ILCS 5/5-16.8)
17    Sec. 5-16.8. Required health benefits. The medical
18assistance program shall (i) provide the post-mastectomy care
19benefits required to be covered by a policy of accident and
20health insurance under Section 356t and the coverage required
21under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.26,
22356z.29, 356z.32, 356z.33, 356z.34, and 356z.35 of the
23Illinois Insurance Code, and (ii) be subject to the provisions
24of Sections 356z.19, 364.01, 370c, and 370c.1 of the Illinois

 

 

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1Insurance Code, and (iii) be subject to the provisions of
2subsection (d-5) of Section 10 of the Network Adequacy and
3Transparency Act.
4    The Department, by rule, shall adopt a model similar to
5the requirements of Section 356z.39 of the Illinois Insurance
6Code.
7    On and after July 1, 2012, the Department shall reduce any
8rate of reimbursement for services or other payments or alter
9any methodologies authorized by this Code to reduce any rate
10of reimbursement for services or other payments in accordance
11with Section 5-5e.
12    To ensure full access to the benefits set forth in this
13Section, on and after January 1, 2016, the Department shall
14ensure that provider and hospital reimbursement for
15post-mastectomy care benefits required under this Section are
16no lower than the Medicare reimbursement rate.
17(Source: P.A. 100-138, eff. 8-18-17; 100-863, eff. 8-14-18;
18100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff.
197-12-19; 101-218, eff. 1-1-20; 101-281, eff. 1-1-20; 101-371,
20eff. 1-1-20; 101-574, eff. 1-1-20; 101-649, eff. 7-7-20.)
 
21    (305 ILCS 5/5-30.1)
22    Sec. 5-30.1. Managed care protections.
23    (a) As used in this Section:
24    "Managed care organization" or "MCO" means any entity
25which contracts with the Department to provide services where

 

 

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1payment for medical services is made on a capitated basis.
2    "Emergency services" include:
3        (1) emergency services, as defined by Section 10 of
4    the Managed Care Reform and Patient Rights Act;
5        (2) emergency medical screening examinations, as
6    defined by Section 10 of the Managed Care Reform and
7    Patient Rights Act;
8        (3) post-stabilization medical services, as defined by
9    Section 10 of the Managed Care Reform and Patient Rights
10    Act; and
11        (4) emergency medical conditions, as defined by
12    Section 10 of the Managed Care Reform and Patient Rights
13    Act.
14    (b) As provided by Section 5-16.12, managed care
15organizations are subject to the provisions of the Managed
16Care Reform and Patient Rights Act.
17    (c) An MCO shall pay any provider of emergency services
18that does not have in effect a contract with the contracted
19Medicaid MCO. The default rate of reimbursement shall be the
20rate paid under Illinois Medicaid fee-for-service program
21methodology, including all policy adjusters, including but not
22limited to Medicaid High Volume Adjustments, Medicaid
23Percentage Adjustments, Outpatient High Volume Adjustments,
24and all outlier add-on adjustments to the extent such
25adjustments are incorporated in the development of the
26applicable MCO capitated rates.

 

 

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1    (d) An MCO shall pay for all post-stabilization services
2as a covered service in any of the following situations:
3        (1) the MCO authorized such services;
4        (2) such services were administered to maintain the
5    enrollee's stabilized condition within one hour after a
6    request to the MCO for authorization of further
7    post-stabilization services;
8        (3) the MCO did not respond to a request to authorize
9    such services within one hour;
10        (4) the MCO could not be contacted; or
11        (5) the MCO and the treating provider, if the treating
12    provider is a non-affiliated provider, could not reach an
13    agreement concerning the enrollee's care and an affiliated
14    provider was unavailable for a consultation, in which case
15    the MCO must pay for such services rendered by the
16    treating non-affiliated provider until an affiliated
17    provider was reached and either concurred with the
18    treating non-affiliated provider's plan of care or assumed
19    responsibility for the enrollee's care. Such payment shall
20    be made at the default rate of reimbursement paid under
21    Illinois Medicaid fee-for-service program methodology,
22    including all policy adjusters, including but not limited
23    to Medicaid High Volume Adjustments, Medicaid Percentage
24    Adjustments, Outpatient High Volume Adjustments and all
25    outlier add-on adjustments to the extent that such
26    adjustments are incorporated in the development of the

 

 

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1    applicable MCO capitated rates.
2    (e) The following requirements apply to MCOs in
3determining payment for all emergency services:
4        (1) MCOs shall not impose any requirements for prior
5    approval of emergency services.
6        (2) The MCO shall cover emergency services provided to
7    enrollees who are temporarily away from their residence
8    and outside the contracting area to the extent that the
9    enrollees would be entitled to the emergency services if
10    they still were within the contracting area.
11        (3) The MCO shall have no obligation to cover medical
12    services provided on an emergency basis that are not
13    covered services under the contract.
14        (4) The MCO shall not condition coverage for emergency
15    services on the treating provider notifying the MCO of the
16    enrollee's screening and treatment within 10 days after
17    presentation for emergency services.
18        (5) The determination of the attending emergency
19    physician, or the provider actually treating the enrollee,
20    of whether an enrollee is sufficiently stabilized for
21    discharge or transfer to another facility, shall be
22    binding on the MCO. The MCO shall cover emergency services
23    for all enrollees whether the emergency services are
24    provided by an affiliated or non-affiliated provider.
25        (6) The MCO's financial responsibility for
26    post-stabilization care services it has not pre-approved

 

 

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1    ends when:
2            (A) a plan physician with privileges at the
3        treating hospital assumes responsibility for the
4        enrollee's care;
5            (B) a plan physician assumes responsibility for
6        the enrollee's care through transfer;
7            (C) a contracting entity representative and the
8        treating physician reach an agreement concerning the
9        enrollee's care; or
10            (D) the enrollee is discharged.
11    (f) Network adequacy and transparency.
12        (1) The Department shall:
13            (A) ensure that an adequate provider network is in
14        place, taking into consideration health professional
15        shortage areas and medically underserved areas;
16            (B) publicly release an explanation of its process
17        for analyzing network adequacy;
18            (C) periodically ensure that an MCO continues to
19        have an adequate network in place; and
20            (D) require MCOs, including Medicaid Managed Care
21        Entities as defined in Section 5-30.2, to meet
22        provider directory requirements under Section 5-30.3;
23        and .
24            (E) require MCOs, including Medicaid Managed Care
25        Entities as defined in Section 5-30.2, to meet each of
26        the requirements under subsection (d-5) of Section 10

 

 

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1        of the Network Adequacy and Transparency Act; with
2        necessary exceptions to the MCO's network to ensure
3        that admission and treatment with a provider or at a
4        treatment facility in accordance with the network
5        adequacy standards in paragraph (3) of subsection
6        (d-5) of Section 10 of the Network Adequacy and
7        Transparency Act is limited to providers or facilities
8        that are Medicaid certified.
9        (2) Each MCO shall confirm its receipt of information
10    submitted specific to physician or dentist additions or
11    physician or dentist deletions from the MCO's provider
12    network within 3 days after receiving all required
13    information from contracted physicians or dentists, and
14    electronic physician and dental directories must be
15    updated consistent with current rules as published by the
16    Centers for Medicare and Medicaid Services or its
17    successor agency.
18    (g) Timely payment of claims.
19        (1) The MCO shall pay a claim within 30 days of
20    receiving a claim that contains all the essential
21    information needed to adjudicate the claim.
22        (2) The MCO shall notify the billing party of its
23    inability to adjudicate a claim within 30 days of
24    receiving that claim.
25        (3) The MCO shall pay a penalty that is at least equal
26    to the timely payment interest penalty imposed under

 

 

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1    Section 368a of the Illinois Insurance Code for any claims
2    not timely paid.
3            (A) When an MCO is required to pay a timely payment
4        interest penalty to a provider, the MCO must calculate
5        and pay the timely payment interest penalty that is
6        due to the provider within 30 days after the payment of
7        the claim. In no event shall a provider be required to
8        request or apply for payment of any owed timely
9        payment interest penalties.
10            (B) Such payments shall be reported separately
11        from the claim payment for services rendered to the
12        MCO's enrollee and clearly identified as interest
13        payments.
14        (4)(A) The Department shall require MCOs to expedite
15    payments to providers identified on the Department's
16    expedited provider list, determined in accordance with 89
17    Ill. Adm. Code 140.71(b), on a schedule at least as
18    frequently as the providers are paid under the
19    Department's fee-for-service expedited provider schedule.
20        (B) Compliance with the expedited provider requirement
21    may be satisfied by an MCO through the use of a Periodic
22    Interim Payment (PIP) program that has been mutually
23    agreed to and documented between the MCO and the provider,
24    and the PIP program ensures that any expedited provider
25    receives regular and periodic payments based on prior
26    period payment experience from that MCO. Total payments

 

 

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1    under the PIP program may be reconciled against future PIP
2    payments on a schedule mutually agreed to between the MCO
3    and the provider.
4        (C) The Department shall share at least monthly its
5    expedited provider list and the frequency with which it
6    pays providers on the expedited list.
7    (g-5) Recognizing that the rapid transformation of the
8Illinois Medicaid program may have unintended operational
9challenges for both payers and providers:
10        (1) in no instance shall a medically necessary covered
11    service rendered in good faith, based upon eligibility
12    information documented by the provider, be denied coverage
13    or diminished in payment amount if the eligibility or
14    coverage information available at the time the service was
15    rendered is later found to be inaccurate in the assignment
16    of coverage responsibility between MCOs or the
17    fee-for-service system, except for instances when an
18    individual is deemed to have not been eligible for
19    coverage under the Illinois Medicaid program; and
20        (2) the Department shall, by December 31, 2016, adopt
21    rules establishing policies that shall be included in the
22    Medicaid managed care policy and procedures manual
23    addressing payment resolutions in situations in which a
24    provider renders services based upon information obtained
25    after verifying a patient's eligibility and coverage plan
26    through either the Department's current enrollment system

 

 

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1    or a system operated by the coverage plan identified by
2    the patient presenting for services:
3            (A) such medically necessary covered services
4        shall be considered rendered in good faith;
5            (B) such policies and procedures shall be
6        developed in consultation with industry
7        representatives of the Medicaid managed care health
8        plans and representatives of provider associations
9        representing the majority of providers within the
10        identified provider industry; and
11            (C) such rules shall be published for a review and
12        comment period of no less than 30 days on the
13        Department's website with final rules remaining
14        available on the Department's website.
15    The rules on payment resolutions shall include, but not be
16limited to:
17        (A) the extension of the timely filing period;
18        (B) retroactive prior authorizations; and
19        (C) guaranteed minimum payment rate of no less than
20    the current, as of the date of service, fee-for-service
21    rate, plus all applicable add-ons, when the resulting
22    service relationship is out of network.
23    The rules shall be applicable for both MCO coverage and
24fee-for-service coverage.
25    If the fee-for-service system is ultimately determined to
26have been responsible for coverage on the date of service, the

 

 

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1Department shall provide for an extended period for claims
2submission outside the standard timely filing requirements.
3    (g-6) MCO Performance Metrics Report.
4        (1) The Department shall publish, on at least a
5    quarterly basis, each MCO's operational performance,
6    including, but not limited to, the following categories of
7    metrics:
8            (A) claims payment, including timeliness and
9        accuracy;
10            (B) prior authorizations;
11            (C) grievance and appeals;
12            (D) utilization statistics;
13            (E) provider disputes;
14            (F) provider credentialing; and
15            (G) member and provider customer service.
16        (2) The Department shall ensure that the metrics
17    report is accessible to providers online by January 1,
18    2017.
19        (3) The metrics shall be developed in consultation
20    with industry representatives of the Medicaid managed care
21    health plans and representatives of associations
22    representing the majority of providers within the
23    identified industry.
24        (4) Metrics shall be defined and incorporated into the
25    applicable Managed Care Policy Manual issued by the
26    Department.

 

 

10200SB0471sam001- 23 -LRB102 09983 BMS 24397 a

1    (g-7) MCO claims processing and performance analysis. In
2order to monitor MCO payments to hospital providers, pursuant
3to this amendatory Act of the 100th General Assembly, the
4Department shall post an analysis of MCO claims processing and
5payment performance on its website every 6 months. Such
6analysis shall include a review and evaluation of a
7representative sample of hospital claims that are rejected and
8denied for clean and unclean claims and the top 5 reasons for
9such actions and timeliness of claims adjudication, which
10identifies the percentage of claims adjudicated within 30, 60,
1190, and over 90 days, and the dollar amounts associated with
12those claims. The Department shall post the contracted claims
13report required by HealthChoice Illinois on its website every
143 months.
15    (g-8) Dispute resolution process. The Department shall
16maintain a provider complaint portal through which a provider
17can submit to the Department unresolved disputes with an MCO.
18An unresolved dispute means an MCO's decision that denies in
19whole or in part a claim for reimbursement to a provider for
20health care services rendered by the provider to an enrollee
21of the MCO with which the provider disagrees. Disputes shall
22not be submitted to the portal until the provider has availed
23itself of the MCO's internal dispute resolution process.
24Disputes that are submitted to the MCO internal dispute
25resolution process may be submitted to the Department of
26Healthcare and Family Services' complaint portal no sooner

 

 

10200SB0471sam001- 24 -LRB102 09983 BMS 24397 a

1than 30 days after submitting to the MCO's internal process
2and not later than 30 days after the unsatisfactory resolution
3of the internal MCO process or 60 days after submitting the
4dispute to the MCO internal process. Multiple claim disputes
5involving the same MCO may be submitted in one complaint,
6regardless of whether the claims are for different enrollees,
7when the specific reason for non-payment of the claims
8involves a common question of fact or policy. Within 10
9business days of receipt of a complaint, the Department shall
10present such disputes to the appropriate MCO, which shall then
11have 30 days to issue its written proposal to resolve the
12dispute. The Department may grant one 30-day extension of this
13time frame to one of the parties to resolve the dispute. If the
14dispute remains unresolved at the end of this time frame or the
15provider is not satisfied with the MCO's written proposal to
16resolve the dispute, the provider may, within 30 days, request
17the Department to review the dispute and make a final
18determination. Within 30 days of the request for Department
19review of the dispute, both the provider and the MCO shall
20present all relevant information to the Department for
21resolution and make individuals with knowledge of the issues
22available to the Department for further inquiry if needed.
23Within 30 days of receiving the relevant information on the
24dispute, or the lapse of the period for submitting such
25information, the Department shall issue a written decision on
26the dispute based on contractual terms between the provider

 

 

10200SB0471sam001- 25 -LRB102 09983 BMS 24397 a

1and the MCO, contractual terms between the MCO and the
2Department of Healthcare and Family Services and applicable
3Medicaid policy. The decision of the Department shall be
4final. By January 1, 2020, the Department shall establish by
5rule further details of this dispute resolution process.
6Disputes between MCOs and providers presented to the
7Department for resolution are not contested cases, as defined
8in Section 1-30 of the Illinois Administrative Procedure Act,
9conferring any right to an administrative hearing.
10    (g-9)(1) The Department shall publish annually on its
11website a report on the calculation of each managed care
12organization's medical loss ratio showing the following:
13        (A) Premium revenue, with appropriate adjustments.
14        (B) Benefit expense, setting forth the aggregate
15    amount spent for the following:
16            (i) Direct paid claims.
17            (ii) Subcapitation payments.
18            (iii) Other claim payments.
19            (iv) Direct reserves.
20            (v) Gross recoveries.
21            (vi) Expenses for activities that improve health
22        care quality as allowed by the Department.
23    (2) The medical loss ratio shall be calculated consistent
24with federal law and regulation following a claims runout
25period determined by the Department.
26    (g-10)(1) "Liability effective date" means the date on

 

 

10200SB0471sam001- 26 -LRB102 09983 BMS 24397 a

1which an MCO becomes responsible for payment for medically
2necessary and covered services rendered by a provider to one
3of its enrollees in accordance with the contract terms between
4the MCO and the provider. The liability effective date shall
5be the later of:
6        (A) The execution date of a network participation
7    contract agreement.
8        (B) The date the provider or its representative
9    submits to the MCO the complete and accurate standardized
10    roster form for the provider in the format approved by the
11    Department.
12        (C) The provider effective date contained within the
13    Department's provider enrollment subsystem within the
14    Illinois Medicaid Program Advanced Cloud Technology
15    (IMPACT) System.
16    (2) The standardized roster form may be submitted to the
17MCO at the same time that the provider submits an enrollment
18application to the Department through IMPACT.
19    (3) By October 1, 2019, the Department shall require all
20MCOs to update their provider directory with information for
21new practitioners of existing contracted providers within 30
22days of receipt of a complete and accurate standardized roster
23template in the format approved by the Department provided
24that the provider is effective in the Department's provider
25enrollment subsystem within the IMPACT system. Such provider
26directory shall be readily accessible for purposes of

 

 

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1selecting an approved health care provider and comply with all
2other federal and State requirements.
3    (g-11) The Department shall work with relevant
4stakeholders on the development of operational guidelines to
5enhance and improve operational performance of Illinois'
6Medicaid managed care program, including, but not limited to,
7improving provider billing practices, reducing claim
8rejections and inappropriate payment denials, and
9standardizing processes, procedures, definitions, and response
10timelines, with the goal of reducing provider and MCO
11administrative burdens and conflict. The Department shall
12include a report on the progress of these program improvements
13and other topics in its Fiscal Year 2020 annual report to the
14General Assembly.
15    (h) The Department shall not expand mandatory MCO
16enrollment into new counties beyond those counties already
17designated by the Department as of June 1, 2014 for the
18individuals whose eligibility for medical assistance is not
19the seniors or people with disabilities population until the
20Department provides an opportunity for accountable care
21entities and MCOs to participate in such newly designated
22counties.
23    (i) The requirements of this Section apply to contracts
24with accountable care entities and MCOs entered into, amended,
25or renewed after June 16, 2014 (the effective date of Public
26Act 98-651).

 

 

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1    (j) Health care information released to managed care
2organizations. A health care provider shall release to a
3Medicaid managed care organization, upon request, and subject
4to the Health Insurance Portability and Accountability Act of
51996 and any other law applicable to the release of health
6information, the health care information of the MCO's
7enrollee, if the enrollee has completed and signed a general
8release form that grants to the health care provider
9permission to release the recipient's health care information
10to the recipient's insurance carrier.
11(Source: P.A. 100-201, eff. 8-18-17; 100-580, eff. 3-12-18;
12100-587, eff. 6-4-18; 101-209, eff. 8-5-19.)".