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Public Act 102-0454 | ||||
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AN ACT concerning public aid.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Illinois Public Aid Code is amended by | ||||
changing Section 5-30.1 as follows: | ||||
(305 ILCS 5/5-30.1) | ||||
Sec. 5-30.1. Managed care protections. | ||||
(a) As used in this Section: | ||||
"Managed care organization" or "MCO" means any entity | ||||
which contracts with the Department to provide services where | ||||
payment for medical services is made on a capitated basis. | ||||
"Emergency services" include: | ||||
(1) emergency services, as defined by Section 10 of | ||||
the Managed Care Reform and Patient Rights Act; | ||||
(2) emergency medical screening examinations, as | ||||
defined by Section 10 of the Managed Care Reform and | ||||
Patient Rights Act; | ||||
(3) post-stabilization medical services, as defined by | ||||
Section 10 of the Managed Care Reform and Patient Rights | ||||
Act; and | ||||
(4) emergency medical conditions, as defined by
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Section 10 of the Managed Care Reform and Patient Rights
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Act. |
(b) As provided by Section 5-16.12, managed care | ||
organizations are subject to the provisions of the Managed | ||
Care Reform and Patient Rights Act. | ||
(c) An MCO shall pay any provider of emergency services | ||
that does not have in effect a contract with the contracted | ||
Medicaid MCO. The default rate of reimbursement shall be the | ||
rate paid under Illinois Medicaid fee-for-service program | ||
methodology, including all policy adjusters, including but not | ||
limited to Medicaid High Volume Adjustments, Medicaid | ||
Percentage Adjustments, Outpatient High Volume Adjustments, | ||
and all outlier add-on adjustments to the extent such | ||
adjustments are incorporated in the development of the | ||
applicable MCO capitated rates. | ||
(d) An MCO shall pay for all post-stabilization services | ||
as a covered service in any of the following situations: | ||
(1) the MCO authorized such services; | ||
(2) such services were administered to maintain the | ||
enrollee's stabilized condition within one hour after a | ||
request to the MCO for authorization of further | ||
post-stabilization services; | ||
(3) the MCO did not respond to a request to authorize | ||
such services within one hour; | ||
(4) the MCO could not be contacted; or | ||
(5) the MCO and the treating provider, if the treating | ||
provider is a non-affiliated provider, could not reach an | ||
agreement concerning the enrollee's care and an affiliated |
provider was unavailable for a consultation, in which case | ||
the MCO
must pay for such services rendered by the | ||
treating non-affiliated provider until an affiliated | ||
provider was reached and either concurred with the | ||
treating non-affiliated provider's plan of care or assumed | ||
responsibility for the enrollee's care. Such payment shall | ||
be made at the default rate of reimbursement paid under | ||
Illinois Medicaid fee-for-service program methodology, | ||
including all policy adjusters, including but not limited | ||
to Medicaid High Volume Adjustments, Medicaid Percentage | ||
Adjustments, Outpatient High Volume Adjustments and all | ||
outlier add-on adjustments to the extent that such | ||
adjustments are incorporated in the development of the | ||
applicable MCO capitated rates. | ||
(e) The following requirements apply to MCOs in | ||
determining payment for all emergency services: | ||
(1) MCOs shall not impose any requirements for prior | ||
approval of emergency services. | ||
(2) The MCO shall cover emergency services provided to | ||
enrollees who are temporarily away from their residence | ||
and outside the contracting area to the extent that the | ||
enrollees would be entitled to the emergency services if | ||
they still were within the contracting area. | ||
(3) The MCO shall have no obligation to cover medical | ||
services provided on an emergency basis that are not | ||
covered services under the contract. |
(4) The MCO shall not condition coverage for emergency | ||
services on the treating provider notifying the MCO of the | ||
enrollee's screening and treatment within 10 days after | ||
presentation for emergency services. | ||
(5) The determination of the attending emergency | ||
physician, or the provider actually treating the enrollee, | ||
of whether an enrollee is sufficiently stabilized for | ||
discharge or transfer to another facility, shall be | ||
binding on the MCO. The MCO shall cover emergency services | ||
for all enrollees whether the emergency services are | ||
provided by an affiliated or non-affiliated provider. | ||
(6) The MCO's financial responsibility for | ||
post-stabilization care services it has not pre-approved | ||
ends when: | ||
(A) a plan physician with privileges at the | ||
treating hospital assumes responsibility for the | ||
enrollee's care; | ||
(B) a plan physician assumes responsibility for | ||
the enrollee's care through transfer; | ||
(C) a contracting entity representative and the | ||
treating physician reach an agreement concerning the | ||
enrollee's care; or | ||
(D) the enrollee is discharged. | ||
(f) Network adequacy and transparency. | ||
(1) The Department shall: | ||
(A) ensure that an adequate provider network is in |
place, taking into consideration health professional | ||
shortage areas and medically underserved areas; | ||
(B) publicly release an explanation of its process | ||
for analyzing network adequacy; | ||
(C) periodically ensure that an MCO continues to | ||
have an adequate network in place; and | ||
(D) require MCOs, including Medicaid Managed Care | ||
Entities as defined in Section 5-30.2, to meet | ||
provider directory requirements under Section 5-30.3. | ||
(2) Each MCO shall confirm its receipt of information | ||
submitted specific to physician or dentist additions or | ||
physician or dentist deletions from the MCO's provider | ||
network within 3 days after receiving all required | ||
information from contracted physicians or dentists, and | ||
electronic physician and dental directories must be | ||
updated consistent with current rules as published by the | ||
Centers for Medicare and Medicaid Services or its | ||
successor agency. | ||
(g) Timely payment of claims. | ||
(1) The MCO shall pay a claim within 30 days of | ||
receiving a claim that contains all the essential | ||
information needed to adjudicate the claim. | ||
(2) The MCO shall notify the billing party of its | ||
inability to adjudicate a claim within 30 days of | ||
receiving that claim. | ||
(3) The MCO shall pay a penalty that is at least equal |
to the timely payment interest penalty imposed under | ||
Section 368a of the Illinois Insurance Code for any claims | ||
not timely paid. | ||
(A) When an MCO is required to pay a timely payment | ||
interest penalty to a provider, the MCO must calculate | ||
and pay the timely payment interest penalty that is | ||
due to the provider within 30 days after the payment of | ||
the claim. In no event shall a provider be required to | ||
request or apply for payment of any owed timely | ||
payment interest penalties. | ||
(B) Such payments shall be reported separately | ||
from the claim payment for services rendered to the | ||
MCO's enrollee and clearly identified as interest | ||
payments. | ||
(4)(A) The Department shall require MCOs to expedite | ||
payments to providers identified on the Department's | ||
expedited provider list, determined in accordance with 89 | ||
Ill. Adm. Code 140.71(b), on a schedule at least as | ||
frequently as the providers are paid under the | ||
Department's fee-for-service expedited provider schedule. | ||
(B) Compliance with the expedited provider requirement | ||
may be satisfied by an MCO through the use of a Periodic | ||
Interim Payment (PIP) program that has been mutually | ||
agreed to and documented between the MCO and the provider, | ||
and the PIP program ensures that any expedited provider | ||
receives regular and periodic payments based on prior |
period payment experience from that MCO. Total payments | ||
under the PIP program may be reconciled against future PIP | ||
payments on a schedule mutually agreed to between the MCO | ||
and the provider. | ||
(C) The Department shall share at least monthly its | ||
expedited provider list and the frequency with which it | ||
pays providers on the expedited list. | ||
(g-5) Recognizing that the rapid transformation of the | ||
Illinois Medicaid program may have unintended operational | ||
challenges for both payers and providers: | ||
(1) in no instance shall a medically necessary covered | ||
service rendered in good faith, based upon eligibility | ||
information documented by the provider, be denied coverage | ||
or diminished in payment amount if the eligibility or | ||
coverage information available at the time the service was | ||
rendered is later found to be inaccurate in the assignment | ||
of coverage responsibility between MCOs or the | ||
fee-for-service system, except for instances when an | ||
individual is deemed to have not been eligible for | ||
coverage under the Illinois Medicaid program; and | ||
(2) the Department shall, by December 31, 2016, adopt | ||
rules establishing policies that shall be included in the | ||
Medicaid managed care policy and procedures manual | ||
addressing payment resolutions in situations in which a | ||
provider renders services based upon information obtained | ||
after verifying a patient's eligibility and coverage plan |
through either the Department's current enrollment system | ||
or a system operated by the coverage plan identified by | ||
the patient presenting for services: | ||
(A) such medically necessary covered services | ||
shall be considered rendered in good faith; | ||
(B) such policies and procedures shall be | ||
developed in consultation with industry | ||
representatives of the Medicaid managed care health | ||
plans and representatives of provider associations | ||
representing the majority of providers within the | ||
identified provider industry; and | ||
(C) such rules shall be published for a review and | ||
comment period of no less than 30 days on the | ||
Department's website with final rules remaining | ||
available on the Department's website. | ||
The rules on payment resolutions shall include, but not be | ||
limited to: | ||
(A) the extension of the timely filing period; | ||
(B) retroactive prior authorizations; and | ||
(C) guaranteed minimum payment rate of no less than | ||
the current, as of the date of service, fee-for-service | ||
rate, plus all applicable add-ons, when the resulting | ||
service relationship is out of network. | ||
The rules shall be applicable for both MCO coverage and | ||
fee-for-service coverage. | ||
If the fee-for-service system is ultimately determined to |
have been responsible for coverage on the date of service, the | ||
Department shall provide for an extended period for claims | ||
submission outside the standard timely filing requirements. | ||
(g-6) MCO Performance Metrics Report. | ||
(1) The Department shall publish, on at least a | ||
quarterly basis, each MCO's operational performance, | ||
including, but not limited to, the following categories of | ||
metrics: | ||
(A) claims payment, including timeliness and | ||
accuracy; | ||
(B) prior authorizations; | ||
(C) grievance and appeals; | ||
(D) utilization statistics; | ||
(E) provider disputes; | ||
(F) provider credentialing; and | ||
(G) member and provider customer service. | ||
(2) The Department shall ensure that the metrics | ||
report is accessible to providers online by January 1, | ||
2017. | ||
(3) The metrics shall be developed in consultation | ||
with industry representatives of the Medicaid managed care | ||
health plans and representatives of associations | ||
representing the majority of providers within the | ||
identified industry. | ||
(4) Metrics shall be defined and incorporated into the | ||
applicable Managed Care Policy Manual issued by the |
Department. | ||
(g-7) MCO claims processing and performance analysis. In | ||
order to monitor MCO payments to hospital providers, pursuant | ||
to this amendatory Act of the 100th General Assembly, the | ||
Department shall post an analysis of MCO claims processing and | ||
payment performance on its website every 6 months. Such | ||
analysis shall include a review and evaluation of a | ||
representative sample of hospital claims that are rejected and | ||
denied for clean and unclean claims and the top 5 reasons for | ||
such actions and timeliness of claims adjudication, which | ||
identifies the percentage of claims adjudicated within 30, 60, | ||
90, and over 90 days, and the dollar amounts associated with | ||
those claims. The Department shall post the contracted claims | ||
report required by HealthChoice Illinois on its website every | ||
3 months. | ||
(g-8) Dispute resolution process. The Department shall | ||
maintain a provider complaint portal through which a provider | ||
can submit to the Department unresolved disputes with an MCO. | ||
An unresolved dispute means an MCO's decision that denies in | ||
whole or in part a claim for reimbursement to a provider for | ||
health care services rendered by the provider to an enrollee | ||
of the MCO with which the provider disagrees. Disputes shall | ||
not be submitted to the portal until the provider has availed | ||
itself of the MCO's internal dispute resolution process. | ||
Disputes that are submitted to the MCO internal dispute | ||
resolution process may be submitted to the Department of |
Healthcare and Family Services' complaint portal no sooner | ||
than 30 days after submitting to the MCO's internal process | ||
and not later than 30 days after the unsatisfactory resolution | ||
of the internal MCO process or 60 days after submitting the | ||
dispute to the MCO internal process. Multiple claim disputes | ||
involving the same MCO may be submitted in one complaint, | ||
regardless of whether the claims are for different enrollees, | ||
when the specific reason for non-payment of the claims | ||
involves a common question of fact or policy. Within 10 | ||
business days of receipt of a complaint, the Department shall | ||
present such disputes to the appropriate MCO, which shall then | ||
have 30 days to issue its written proposal to resolve the | ||
dispute. The Department may grant one 30-day extension of this | ||
time frame to one of the parties to resolve the dispute. If the | ||
dispute remains unresolved at the end of this time frame or the | ||
provider is not satisfied with the MCO's written proposal to | ||
resolve the dispute, the provider may, within 30 days, request | ||
the Department to review the dispute and make a final | ||
determination. Within 30 days of the request for Department | ||
review of the dispute, both the provider and the MCO shall | ||
present all relevant information to the Department for | ||
resolution and make individuals with knowledge of the issues | ||
available to the Department for further inquiry if needed. | ||
Within 30 days of receiving the relevant information on the | ||
dispute, or the lapse of the period for submitting such | ||
information, the Department shall issue a written decision on |
the dispute based on contractual terms between the provider | ||
and the MCO, contractual terms between the MCO and the | ||
Department of Healthcare and Family Services and applicable | ||
Medicaid policy. The decision of the Department shall be | ||
final. By January 1, 2020, the Department shall establish by | ||
rule further details of this dispute resolution process. | ||
Disputes between MCOs and providers presented to the | ||
Department for resolution are not contested cases, as defined | ||
in Section 1-30 of the Illinois Administrative Procedure Act, | ||
conferring any right to an administrative hearing. | ||
(g-9)(1) The Department shall publish annually on its | ||
website a report on the calculation of each managed care | ||
organization's medical loss ratio showing the following: | ||
(A) Premium revenue, with appropriate adjustments. | ||
(B) Benefit expense, setting forth the aggregate | ||
amount spent for the following: | ||
(i) Direct paid claims. | ||
(ii) Subcapitation payments. | ||
(iii)
Other claim payments. | ||
(iv)
Direct reserves. | ||
(v)
Gross recoveries. | ||
(vi)
Expenses for activities that improve health | ||
care quality as allowed by the Department. | ||
(2) The medical loss ratio shall be calculated consistent | ||
with federal law and regulation following a claims runout | ||
period determined by the Department. |
(g-10)(1) "Liability effective date" means the date on | ||
which an MCO becomes responsible for payment for medically | ||
necessary and covered services rendered by a provider to one | ||
of its enrollees in accordance with the contract terms between | ||
the MCO and the provider. The liability effective date shall | ||
be the later of: | ||
(A) The execution date of a network participation | ||
contract agreement. | ||
(B) The date the provider or its representative | ||
submits to the MCO the complete and accurate standardized | ||
roster form for the provider in the format approved by the | ||
Department. | ||
(C) The provider effective date contained within the | ||
Department's provider enrollment subsystem within the | ||
Illinois Medicaid Program Advanced Cloud Technology | ||
(IMPACT) System. | ||
(2) The standardized roster form may be submitted to the | ||
MCO at the same time that the provider submits an enrollment | ||
application to the Department through IMPACT. | ||
(3) By October 1, 2019, the Department shall require all | ||
MCOs to update their provider directory with information for | ||
new practitioners of existing contracted providers within 30 | ||
days of receipt of a complete and accurate standardized roster | ||
template in the format approved by the Department provided | ||
that the provider is effective in the Department's provider | ||
enrollment subsystem within the IMPACT system. Such provider |
directory shall be readily accessible for purposes of | ||
selecting an approved health care provider and comply with all | ||
other federal and State requirements. | ||
(g-11) The Department shall work with relevant | ||
stakeholders on the development of operational guidelines to | ||
enhance and improve operational performance of Illinois' | ||
Medicaid managed care program, including, but not limited to, | ||
improving provider billing practices, reducing claim | ||
rejections and inappropriate payment denials, and | ||
standardizing processes, procedures, definitions, and response | ||
timelines, with the goal of reducing provider and MCO | ||
administrative burdens and conflict. The Department shall | ||
include a report on the progress of these program improvements | ||
and other topics in its Fiscal Year 2020 annual report to the | ||
General Assembly. | ||
(h) The Department shall not expand mandatory MCO | ||
enrollment into new counties beyond those counties already | ||
designated by the Department as of June 1, 2014 for the | ||
individuals whose eligibility for medical assistance is not | ||
the seniors or people with disabilities population until the | ||
Department provides an opportunity for accountable care | ||
entities and MCOs to participate in such newly designated | ||
counties. | ||
(i) The requirements of this Section apply to contracts | ||
with accountable care entities and MCOs entered into, amended, | ||
or renewed after June 16, 2014 (the effective date of Public |
Act 98-651).
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(j) Health care information released to managed care | ||
organizations. A health care provider shall release to a | ||
Medicaid managed care organization, upon request, and subject | ||
to the Health Insurance Portability and Accountability Act of | ||
1996 and any other law applicable to the release of health | ||
information, the health care information of the MCO's | ||
enrollee, if the enrollee has completed and signed a general | ||
release form that grants to the health care provider | ||
permission to release the recipient's health care information | ||
to the recipient's insurance carrier. | ||
(Source: P.A. 100-201, eff. 8-18-17; 100-580, eff. 3-12-18; | ||
100-587, eff. 6-4-18; 101-209, eff. 8-5-19.)
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Section 99. Effective date. This Act takes effect upon | ||
becoming law.
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