[ Search ] [ Legislation ]
[ Home ] [ Back ] [ Bottom ]
91_SB0657
LRB9104706DJcd
1 AN ACT to amend the Illinois Public Aid Code by adding
2 Section 5-5d.
3 Be it enacted by the People of the State of Illinois,
4 represented in the General Assembly:
5 Section 5. The Illinois Public Aid Code is amended by
6 adding Section 5-5d as follows:
7 (305 ILCS 5/5-5d new)
8 Sec. 5-5d. Establishment of system of periodic interim
9 payments.
10 (a) Definitions. In this Section:
11 "Claim" includes enrollment rosters or other data
12 submitted by a managed care organization for payment
13 purposes.
14 "Clean claim" means a claim for which no further
15 information or substantiation is required for payment to be
16 made.
17 "Qualified" means, with respect to a health care
18 professional, health care provider, or managed care
19 organization, that:
20 (1) the individual or entity meets the requirements
21 for participating in the medical assistance program under
22 this Article; and
23 (2) the total amount the Illinois Department paid to
24 the individual or entity for the most recently completed
25 fiscal year for services furnished to individuals who are
26 eligible for medical assistance under the plan meets a
27 minimum amount or percentage of total revenues specified
28 by the Illinois Department but, at a minimum, shall apply
29 to all providers designated as eligible for
30 disproportionate share adjustments pursuant to Section
31 5-5.02 of this Code.
-2- LRB9104706DJcd
1 (b) Establishment of system. Not later than October 1,
2 1999, the Illinois Department shall establish a system for
3 making periodic interim payments under the medical assistance
4 programs administered by the Illinois Department. Under the
5 system, a qualified health care provider, health care
6 professional, or managed care organization shall be paid in
7 periodic interim payments, rather than on the basis of claims
8 submitted, during a period specified in subsection (d).
9 (c) System requirements.
10 (1) In general. The system established pursuant to
11 subsection (b) shall include the following features:
12 (A) The Illinois Department shall pay a
13 qualified health care provider, health care
14 professional, or managed care organization once
15 every 2 weeks (during a period specified in
16 subsection (d)) an amount that equals one
17 twenty-sixth of the total amount that the Illinois
18 Department paid to the health care provider, health
19 care professional, or managed care organization for
20 medical assistance for the most recently completed
21 fiscal year.
22 (B) There shall be retrospective reconciliation
23 of the amounts paid to a qualified health care
24 provider, health care professional, or managed care
25 organization under the system with the amounts that
26 are payable on the basis of claims actually
27 submitted.
28 (2) Special rule. In the case of a health care
29 provider or health care professional that furnishes
30 services to individuals who are eligible for medical
31 assistance and are enrolled with a managed care
32 organization, the amount specified in subparagraph (1)(A)
33 of this subsection shall be increased by one twenty-sixth
34 of the total amount that the managed care organization
-3- LRB9104706DJcd
1 paid to the health care provider or health care
2 professional for the fiscal year referred to in
3 subparagraph (1)(A) of this subsection for services
4 furnished to such individuals for any 2-week period that
5 begins:
6 (A) after the first month for which the managed
7 care organization fails to meet the prompt payment
8 standard specified in subdivision (1)(A) of
9 subsection (d); and
10 (B) before the close of the third consecutive
11 month for which the managed care organization meets
12 the prompt payment standard specified in subsection
13 (d).
14 This paragraph (2) shall apply if the total amount
15 paid by a managed care organization to a health care
16 provider or health care professional for a fiscal year is
17 greater than a minimum amount or percentage of total
18 revenues specified by the Department but, at a minimum,
19 shall apply to all providers designated as eligible for
20 disproportionate share adjustments pursuant to Section
21 5-5.02 of this Code.
22 (3) Payments. For the period when the Illinois
23 Department is making payments under this subsection, the
24 Illinois Department shall not make payments to a managed
25 care organization for services the Illinois Department is
26 covering by this provision. When the managed care
27 organization resumes making payments to health care
28 providers and health care professionals, the Illinois
29 Department and the managed care organization shall
30 reconcile payments.
31 (d) Period for which system applies. The system
32 established pursuant to subsection (b) shall apply to a
33 qualified health care provider, health care professional, or
34 managed care organization:
-4- LRB9104706DJcd
1 (1) during the period that:
2 (A) begins with (and includes) the month
3 following the first month for which the Illinois
4 Department fails to pay at least 90% of all clean
5 claims submitted by or on behalf of the health care
6 provider, health care professional, or managed care
7 organization within 30 days after the receipt of the
8 claims; and
9 (B) ends with (and includes) the third
10 consecutive month for which the Illinois Department
11 meets the prompt payment standard specified in
12 subparagraph (A); or
13 (2) in the case of a health care provider, health
14 care professional, or managed care organization that
15 demonstrates to the Department that:
16 (A) there is good cause for the failure of the
17 computer systems used to process claims for
18 submission to the Illinois Department to do so in a
19 timely manner; and
20 (B) the health care provider, health care
21 professional, or managed care organization has made
22 a good faith effort to address the causes of such
23 failure.
24 (e) The system established pursuant to subsection (b)
25 shall apply to services furnished after November 30, 1999.
26 Section 99. Effective date. This Act takes effect upon
27 becoming law.