Bill Amendment: IL SB1573 | 2017-2018 | 100th General Assembly
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: DHFS-CONTRACTS-MANAGED CARE
Status: 2018-05-17 - Added as Co-Sponsor Sen. Laura M. Murphy [SB1573 Detail]
Download: Illinois-2017-SB1573-House_Amendment_002.html
Bill Title: DHFS-CONTRACTS-MANAGED CARE
Status: 2018-05-17 - Added as Co-Sponsor Sen. Laura M. Murphy [SB1573 Detail]
Download: Illinois-2017-SB1573-House_Amendment_002.html
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1 | AMENDMENT TO SENATE BILL 1573
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2 | AMENDMENT NO. ______. Amend Senate Bill 1573, AS AMENDED, | ||||||
3 | by replacing everything after the enacting clause with the | ||||||
4 | following:
| ||||||
5 | "Section 5. The Illinois Procurement Code is amended by | ||||||
6 | changing Section 1-10 as follows:
| ||||||
7 | (30 ILCS 500/1-10)
| ||||||
8 | Sec. 1-10. Application.
| ||||||
9 | (a) This Code applies only to procurements for which | ||||||
10 | bidders, offerors, potential contractors, or contractors were | ||||||
11 | first
solicited on or after July 1, 1998. This Code shall not | ||||||
12 | be construed to affect
or impair any contract, or any provision | ||||||
13 | of a contract, entered into based on a
solicitation prior to | ||||||
14 | the implementation date of this Code as described in
Article | ||||||
15 | 99, including but not limited to any covenant entered into with | ||||||
16 | respect
to any revenue bonds or similar instruments.
All |
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1 | procurements for which contracts are solicited between the | ||||||
2 | effective date
of Articles 50 and 99 and July 1, 1998 shall be | ||||||
3 | substantially in accordance
with this Code and its intent.
| ||||||
4 | (b) This Code shall apply regardless of the source of the | ||||||
5 | funds with which
the contracts are paid, including federal | ||||||
6 | assistance moneys. This Except as specifically provided in this | ||||||
7 | Code, this
Code shall
not apply to:
| ||||||
8 | (1) Contracts between the State and its political | ||||||
9 | subdivisions or other
governments, or between State | ||||||
10 | governmental bodies , except as specifically provided in | ||||||
11 | this Code .
| ||||||
12 | (2) Grants, except for the filing requirements of | ||||||
13 | Section 20-80.
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14 | (3) Purchase of care , except as provided in Section | ||||||
15 | 5-30.6 of the Illinois Public Aid
Code and this Section .
| ||||||
16 | (4) Hiring of an individual as employee and not as an | ||||||
17 | independent
contractor, whether pursuant to an employment | ||||||
18 | code or policy or by contract
directly with that | ||||||
19 | individual.
| ||||||
20 | (5) Collective bargaining contracts.
| ||||||
21 | (6) Purchase of real estate, except that notice of this | ||||||
22 | type of contract with a value of more than $25,000 must be | ||||||
23 | published in the Procurement Bulletin within 10 calendar | ||||||
24 | days after the deed is recorded in the county of | ||||||
25 | jurisdiction. The notice shall identify the real estate | ||||||
26 | purchased, the names of all parties to the contract, the |
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1 | value of the contract, and the effective date of the | ||||||
2 | contract.
| ||||||
3 | (7) Contracts necessary to prepare for anticipated | ||||||
4 | litigation, enforcement
actions, or investigations, | ||||||
5 | provided
that the chief legal counsel to the Governor shall | ||||||
6 | give his or her prior
approval when the procuring agency is | ||||||
7 | one subject to the jurisdiction of the
Governor, and | ||||||
8 | provided that the chief legal counsel of any other | ||||||
9 | procuring
entity
subject to this Code shall give his or her | ||||||
10 | prior approval when the procuring
entity is not one subject | ||||||
11 | to the jurisdiction of the Governor.
| ||||||
12 | (8) (Blank).
| ||||||
13 | (9) Procurement expenditures by the Illinois | ||||||
14 | Conservation Foundation
when only private funds are used.
| ||||||
15 | (10) (Blank). | ||||||
16 | (11) Public-private agreements entered into according | ||||||
17 | to the procurement requirements of Section 20 of the | ||||||
18 | Public-Private Partnerships for Transportation Act and | ||||||
19 | design-build agreements entered into according to the | ||||||
20 | procurement requirements of Section 25 of the | ||||||
21 | Public-Private Partnerships for Transportation Act. | ||||||
22 | (12) Contracts for legal, financial, and other | ||||||
23 | professional and artistic services entered into on or | ||||||
24 | before December 31, 2018 by the Illinois Finance Authority | ||||||
25 | in which the State of Illinois is not obligated. Such | ||||||
26 | contracts shall be awarded through a competitive process |
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| |||||||
1 | authorized by the Board of the Illinois Finance Authority | ||||||
2 | and are subject to Sections 5-30, 20-160, 50-13, 50-20, | ||||||
3 | 50-35, and 50-37 of this Code, as well as the final | ||||||
4 | approval by the Board of the Illinois Finance Authority of | ||||||
5 | the terms of the contract. | ||||||
6 | (13) Contracts for services, commodities, and | ||||||
7 | equipment to support the delivery of timely forensic | ||||||
8 | science services in consultation with and subject to the | ||||||
9 | approval of the Chief Procurement Officer as provided in | ||||||
10 | subsection (d) of Section 5-4-3a of the Unified Code of | ||||||
11 | Corrections, except for the requirements of Sections | ||||||
12 | 20-60, 20-65, 20-70, and 20-160 and Article 50 of this | ||||||
13 | Code; however, the Chief Procurement Officer may, in | ||||||
14 | writing with justification, waive any certification | ||||||
15 | required under Article 50 of this Code. For any contracts | ||||||
16 | for services which are currently provided by members of a | ||||||
17 | collective bargaining agreement, the applicable terms of | ||||||
18 | the collective bargaining agreement concerning | ||||||
19 | subcontracting shall be followed. | ||||||
20 | On and after January 1, 2019, this paragraph (13), | ||||||
21 | except for this sentence, is inoperative. | ||||||
22 | (14) Contracts for participation expenditures required | ||||||
23 | by a domestic or international trade show or exhibition of | ||||||
24 | an exhibitor, member, or sponsor. | ||||||
25 | (15) Contracts with a railroad or utility that requires | ||||||
26 | the State to reimburse the railroad or utilities for the |
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1 | relocation of utilities for construction or other public | ||||||
2 | purpose. Contracts included within this paragraph (15) | ||||||
3 | shall include, but not be limited to, those associated | ||||||
4 | with: relocations, crossings, installations, and | ||||||
5 | maintenance. For the purposes of this paragraph (15), | ||||||
6 | "railroad" means any form of non-highway ground | ||||||
7 | transportation that runs on rails or electromagnetic | ||||||
8 | guideways and "utility" means: (1) public utilities as | ||||||
9 | defined in Section 3-105 of the Public Utilities Act, (2) | ||||||
10 | telecommunications carriers as defined in Section 13-202 | ||||||
11 | of the Public Utilities Act, (3) electric cooperatives as | ||||||
12 | defined in Section 3.4 of the Electric Supplier Act, (4) | ||||||
13 | telephone or telecommunications cooperatives as defined in | ||||||
14 | Section 13-212 of the Public Utilities Act, (5) rural water | ||||||
15 | or waste water systems with 10,000 connections or less, (6) | ||||||
16 | a holder as defined in Section 21-201 of the Public | ||||||
17 | Utilities Act, and (7) municipalities owning or operating | ||||||
18 | utility systems consisting of public utilities as that term | ||||||
19 | is defined in Section 11-117-2 of the Illinois Municipal | ||||||
20 | Code. | ||||||
21 | Notwithstanding any other provision of law, for contracts | ||||||
22 | entered into on or after October 1, 2017 under an exemption | ||||||
23 | provided in any paragraph of this subsection (b), except | ||||||
24 | paragraph (1), (2), or (5), each State agency shall post to the | ||||||
25 | appropriate procurement bulletin the name of the contractor, a | ||||||
26 | description of the supply or service provided, the total amount |
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1 | of the contract, the term of the contract, and the exception to | ||||||
2 | the Code utilized. The chief procurement officer shall submit a | ||||||
3 | report to the Governor and General Assembly no later than | ||||||
4 | November 1 of each year that shall include, at a minimum, an | ||||||
5 | annual summary of the monthly information reported to the chief | ||||||
6 | procurement officer. | ||||||
7 | (c) This Code does not apply to the electric power | ||||||
8 | procurement process provided for under Section 1-75 of the | ||||||
9 | Illinois Power Agency Act and Section 16-111.5 of the Public | ||||||
10 | Utilities Act. | ||||||
11 | (d) Except for Section 20-160 and Article 50 of this Code, | ||||||
12 | and as expressly required by Section 9.1 of the Illinois | ||||||
13 | Lottery Law, the provisions of this Code do not apply to the | ||||||
14 | procurement process provided for under Section 9.1 of the | ||||||
15 | Illinois Lottery Law. | ||||||
16 | (e) This Code does not apply to the process used by the | ||||||
17 | Capital Development Board to retain a person or entity to | ||||||
18 | assist the Capital Development Board with its duties related to | ||||||
19 | the determination of costs of a clean coal SNG brownfield | ||||||
20 | facility, as defined by Section 1-10 of the Illinois Power | ||||||
21 | Agency Act, as required in subsection (h-3) of Section 9-220 of | ||||||
22 | the Public Utilities Act, including calculating the range of | ||||||
23 | capital costs, the range of operating and maintenance costs, or | ||||||
24 | the sequestration costs or monitoring the construction of clean | ||||||
25 | coal SNG brownfield facility for the full duration of | ||||||
26 | construction. |
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1 | (f) (Blank). | ||||||
2 | (g) (Blank). | ||||||
3 | (h) This Code does not apply to the process to procure or | ||||||
4 | contracts entered into in accordance with Sections 11-5.2 and | ||||||
5 | 11-5.3 of the Illinois Public Aid Code. | ||||||
6 | (i) Each chief procurement officer may access records | ||||||
7 | necessary to review whether a contract, purchase, or other | ||||||
8 | expenditure is or is not subject to the provisions of this | ||||||
9 | Code, unless such records would be subject to attorney-client | ||||||
10 | privilege. | ||||||
11 | (j) This Code does not apply to the process used by the | ||||||
12 | Capital Development Board to retain an artist or work or works | ||||||
13 | of art as required in Section 14 of the Capital Development | ||||||
14 | Board Act. | ||||||
15 | (k) This Code does not apply to the process to procure | ||||||
16 | contracts, or contracts entered into, by the State Board of | ||||||
17 | Elections or the State Electoral Board for hearing officers | ||||||
18 | appointed pursuant to the Election Code. | ||||||
19 | (l) This Code does not apply to the processes used by the | ||||||
20 | Illinois Student Assistance Commission to procure supplies and | ||||||
21 | services paid for from the private funds of the Illinois | ||||||
22 | Prepaid Tuition Fund. As used in this subsection (l), "private | ||||||
23 | funds" means funds derived from deposits paid into the Illinois | ||||||
24 | Prepaid Tuition Trust Fund and the earnings thereon. | ||||||
25 | (Source: P.A. 99-801, eff. 1-1-17; 100-43, eff. 8-9-17.)
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1 | Section 10. The Illinois Insurance Code is amended by | ||||||
2 | changing Section 35A-10 as follows:
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3 | (215 ILCS 5/35A-10)
| ||||||
4 | Sec. 35A-10. RBC Reports.
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5 | (a) On or before each March 1 (the "filing date"), every | ||||||
6 | domestic
insurer
shall prepare and submit to the Director a | ||||||
7 | report of its RBC levels as of the
end of the previous calendar | ||||||
8 | year in the form and containing the information
required by the | ||||||
9 | RBC Instructions. Every domestic insurer shall also file its
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10 | RBC Report with the NAIC in accordance with the RBC | ||||||
11 | Instructions. In addition,
if requested in writing by the chief | ||||||
12 | insurance regulatory official of any state
in which it
is | ||||||
13 | authorized to do business, every domestic insurer shall file | ||||||
14 | its RBC Report
with that official no later than the later of 15 | ||||||
15 | days after the insurer
receives the written request
or the | ||||||
16 | filing date.
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17 | (b) A life, health, or life and health insurer's or | ||||||
18 | fraternal benefit society's RBC shall be
determined under the | ||||||
19 | formula set
forth in the RBC Instructions. The formula shall | ||||||
20 | take into account (and may
adjust for the covariance between):
| ||||||
21 | (1) the risk with respect to the insurer's assets;
| ||||||
22 | (2) the risk of adverse insurance experience with | ||||||
23 | respect to the insurer's
liabilities and obligations;
| ||||||
24 | (3) the interest rate risk with respect to the | ||||||
25 | insurer's business; and
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1 | (4) all other business risks and other relevant risks | ||||||
2 | set forth in the RBC
Instructions.
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3 | These risks shall be determined in each case by applying
the | ||||||
4 | factors in the
manner set forth in the RBC Instructions. | ||||||
5 | Notwithstanding the foregoing, and notwithstanding the RBC | ||||||
6 | Instructions, health maintenance organizations operating as | ||||||
7 | Medicaid managed care plans under contract with the Department | ||||||
8 | of Healthcare and Family Services shall not be required to | ||||||
9 | include in its RBC calculations any capitation revenue | ||||||
10 | identified by Medicaid managed care plans as authorized under | ||||||
11 | Section 5A-12.6(r) of the Illinois Public Aid Code.
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12 | (c) A property and casualty insurer's RBC shall be | ||||||
13 | determined in
accordance
with the formula set forth in the RBC | ||||||
14 | Instructions. The formula shall take
into account (and may | ||||||
15 | adjust for the covariance between):
| ||||||
16 | (1) asset risk;
| ||||||
17 | (2) credit risk;
| ||||||
18 | (3) underwriting risk; and
| ||||||
19 | (4) all other business risks and other relevant risks | ||||||
20 | set
forth in the RBC Instructions.
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21 | These risks shall be determined in each case by applying the | ||||||
22 | factors in the
manner
set forth in the RBC Instructions.
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23 | (d) A health organization's RBC shall be determined in | ||||||
24 | accordance with the
formula set forth in the RBC Instructions. | ||||||
25 | The formula shall take the
following into account (and may | ||||||
26 | adjust for the covariance between):
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| |||||||
1 | (1) asset risk;
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2 | (2) credit risk;
| ||||||
3 | (3) underwriting risk; and
| ||||||
4 | (4) all other business risks and other relevant risks | ||||||
5 | set forth in the RBC
Instructions.
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6 | These risks shall be determined in each case by applying the | ||||||
7 | factors in the
manner set forth in the RBC Instructions.
| ||||||
8 | (e) An excess of capital over the amount produced by the
| ||||||
9 | risk-based
capital requirements contained in this Code and the | ||||||
10 | formulas, schedules, and
instructions referenced in this Code | ||||||
11 | is desirable in the business of insurance.
Accordingly, | ||||||
12 | insurers should seek to maintain capital above the RBC levels
| ||||||
13 | required by this Code. Additional capital is used and useful in | ||||||
14 | the insurance
business and helps to secure an insurer against | ||||||
15 | various risks inherent in, or
affecting, the business of | ||||||
16 | insurance and not accounted for or only partially
measured by | ||||||
17 | the risk-based capital requirements contained in this Code.
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18 | (f) If a domestic insurer files an RBC Report that, in the
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19 | judgment of the
Director, is inaccurate, the Director shall | ||||||
20 | adjust the RBC Report to correct
the inaccuracy and shall | ||||||
21 | notify the insurer of the adjustment. The notice
shall contain | ||||||
22 | a statement of the reason for the adjustment.
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23 | (Source: P.A. 98-157, eff. 8-2-13.)
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24 | Section 15. The Illinois Public Aid Code is amended by | ||||||
25 | changing Sections 5-5.02, 5-30.1, and 5A-15 and by adding |
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1 | Sections 5-30.6 and 5-30.7 as follows:
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2 | (305 ILCS 5/5-5.02) (from Ch. 23, par. 5-5.02)
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3 | Sec. 5-5.02. Hospital reimbursements.
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4 | (a) Reimbursement to Hospitals; July 1, 1992 through | ||||||
5 | September 30, 1992.
Notwithstanding any other provisions of | ||||||
6 | this Code or the Illinois
Department's Rules promulgated under | ||||||
7 | the Illinois Administrative Procedure
Act, reimbursement to | ||||||
8 | hospitals for services provided during the period
July 1, 1992 | ||||||
9 | through September 30, 1992, shall be as follows:
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10 | (1) For inpatient hospital services rendered, or if | ||||||
11 | applicable, for
inpatient hospital discharges occurring, | ||||||
12 | on or after July 1, 1992 and on
or before September 30, | ||||||
13 | 1992, the Illinois Department shall reimburse
hospitals | ||||||
14 | for inpatient services under the reimbursement | ||||||
15 | methodologies in
effect for each hospital, and at the | ||||||
16 | inpatient payment rate calculated for
each hospital, as of | ||||||
17 | June 30, 1992. For purposes of this paragraph,
| ||||||
18 | "reimbursement methodologies" means all reimbursement | ||||||
19 | methodologies that
pertain to the provision of inpatient | ||||||
20 | hospital services, including, but not
limited to, any | ||||||
21 | adjustments for disproportionate share, targeted access,
| ||||||
22 | critical care access and uncompensated care, as defined by | ||||||
23 | the Illinois
Department on June 30, 1992.
| ||||||
24 | (2) For the purpose of calculating the inpatient | ||||||
25 | payment rate for each
hospital eligible to receive |
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| |||||||
1 | quarterly adjustment payments for targeted
access and | ||||||
2 | critical care, as defined by the Illinois Department on | ||||||
3 | June 30,
1992, the adjustment payment for the period July | ||||||
4 | 1, 1992 through September
30, 1992, shall be 25% of the | ||||||
5 | annual adjustment payments calculated for
each eligible | ||||||
6 | hospital, as of June 30, 1992. The Illinois Department | ||||||
7 | shall
determine by rule the adjustment payments for | ||||||
8 | targeted access and critical
care beginning October 1, | ||||||
9 | 1992.
| ||||||
10 | (3) For the purpose of calculating the inpatient | ||||||
11 | payment rate for each
hospital eligible to receive | ||||||
12 | quarterly adjustment payments for
uncompensated care, as | ||||||
13 | defined by the Illinois Department on June 30, 1992,
the | ||||||
14 | adjustment payment for the period August 1, 1992 through | ||||||
15 | September 30,
1992, shall be one-sixth of the total | ||||||
16 | uncompensated care adjustment payments
calculated for each | ||||||
17 | eligible hospital for the uncompensated care rate year,
as | ||||||
18 | defined by the Illinois Department, ending on July 31, | ||||||
19 | 1992. The
Illinois Department shall determine by rule the | ||||||
20 | adjustment payments for
uncompensated care beginning | ||||||
21 | October 1, 1992.
| ||||||
22 | (b) Inpatient payments. For inpatient services provided on | ||||||
23 | or after October
1, 1993, in addition to rates paid for | ||||||
24 | hospital inpatient services pursuant to
the Illinois Health | ||||||
25 | Finance Reform Act, as now or hereafter amended, or the
| ||||||
26 | Illinois Department's prospective reimbursement methodology, |
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| |||||||
1 | or any other
methodology used by the Illinois Department for | ||||||
2 | inpatient services, the
Illinois Department shall make | ||||||
3 | adjustment payments, in an amount calculated
pursuant to the | ||||||
4 | methodology described in paragraph (c) of this Section, to
| ||||||
5 | hospitals that the Illinois Department determines satisfy any | ||||||
6 | one of the
following requirements:
| ||||||
7 | (1) Hospitals that are described in Section 1923 of the | ||||||
8 | federal Social
Security Act, as now or hereafter amended, | ||||||
9 | except that for rate year 2015 and after a hospital | ||||||
10 | described in Section 1923(b)(1)(B) of the federal Social | ||||||
11 | Security Act and qualified for the payments described in | ||||||
12 | subsection (c) of this Section for rate year 2014 provided | ||||||
13 | the hospital continues to meet the description in Section | ||||||
14 | 1923(b)(1)(B) in the current determination year; or
| ||||||
15 | (2) Illinois hospitals that have a Medicaid inpatient | ||||||
16 | utilization
rate which is at least one-half a standard | ||||||
17 | deviation above the mean Medicaid
inpatient utilization | ||||||
18 | rate for all hospitals in Illinois receiving Medicaid
| ||||||
19 | payments from the Illinois Department; or
| ||||||
20 | (3) Illinois hospitals that on July 1, 1991 had a | ||||||
21 | Medicaid inpatient
utilization rate, as defined in | ||||||
22 | paragraph (h) of this Section,
that was at least the mean | ||||||
23 | Medicaid inpatient utilization rate for all
hospitals in | ||||||
24 | Illinois receiving Medicaid payments from the Illinois
| ||||||
25 | Department and which were located in a planning area with | ||||||
26 | one-third or
fewer excess beds as determined by the Health |
| |||||||
| |||||||
1 | Facilities and Services Review Board, and that, as of June | ||||||
2 | 30, 1992, were located in a federally
designated Health | ||||||
3 | Manpower Shortage Area; or
| ||||||
4 | (4) Illinois hospitals that:
| ||||||
5 | (A) have a Medicaid inpatient utilization rate | ||||||
6 | that is at least
equal to the mean Medicaid inpatient | ||||||
7 | utilization rate for all hospitals in
Illinois | ||||||
8 | receiving Medicaid payments from the Department; and
| ||||||
9 | (B) also have a Medicaid obstetrical inpatient | ||||||
10 | utilization
rate that is at least one standard | ||||||
11 | deviation above the mean Medicaid
obstetrical | ||||||
12 | inpatient utilization rate for all hospitals in | ||||||
13 | Illinois
receiving Medicaid payments from the | ||||||
14 | Department for obstetrical services; or
| ||||||
15 | (5) Any children's hospital, which means a hospital | ||||||
16 | devoted exclusively
to caring for children. A hospital | ||||||
17 | which includes a facility devoted
exclusively to caring for | ||||||
18 | children shall be considered a
children's hospital to the | ||||||
19 | degree that the hospital's Medicaid care is
provided to | ||||||
20 | children
if either (i) the facility devoted exclusively to | ||||||
21 | caring for children is
separately licensed as a hospital by | ||||||
22 | a municipality prior to February 28, 2013 ;
or
(ii) the | ||||||
23 | hospital has been
designated
by the State
as a Level III | ||||||
24 | perinatal care facility, has a Medicaid Inpatient
| ||||||
25 | Utilization rate
greater than 55% for the rate year 2003 | ||||||
26 | disproportionate share determination,
and has more than |
| |||||||
| |||||||
1 | 10,000 qualified children days as defined by
the
Department | ||||||
2 | in rulemaking ; (iii) the hospital has been designated as a | ||||||
3 | Perinatal Level III center by the State as of December 1, | ||||||
4 | 2017, is a Pediatric Critical Care Center designated by the | ||||||
5 | State as of December 1, 2017 and has a 2017 Medicaid | ||||||
6 | inpatient utilization rate equal to or greater than 45%; or | ||||||
7 | (iv) the hospital has been designated as a Perinatal Level | ||||||
8 | II center by the State as of December 1, 2017, has a 2017 | ||||||
9 | Medicaid Inpatient Utilization Rate greater than 70%, and | ||||||
10 | has at least 10 pediatric beds as listed on the IDPH 2015 | ||||||
11 | calendar year hospital profile .
| ||||||
12 | (c) Inpatient adjustment payments. The adjustment payments | ||||||
13 | required by
paragraph (b) shall be calculated based upon the | ||||||
14 | hospital's Medicaid
inpatient utilization rate as follows:
| ||||||
15 | (1) hospitals with a Medicaid inpatient utilization | ||||||
16 | rate below the mean
shall receive a per day adjustment | ||||||
17 | payment equal to $25;
| ||||||
18 | (2) hospitals with a Medicaid inpatient utilization | ||||||
19 | rate
that is equal to or greater than the mean Medicaid | ||||||
20 | inpatient utilization rate
but less than one standard | ||||||
21 | deviation above the mean Medicaid inpatient
utilization | ||||||
22 | rate shall receive a per day adjustment payment
equal to | ||||||
23 | the sum of $25 plus $1 for each one percent that the | ||||||
24 | hospital's
Medicaid inpatient utilization rate exceeds the | ||||||
25 | mean Medicaid inpatient
utilization rate;
| ||||||
26 | (3) hospitals with a Medicaid inpatient utilization |
| |||||||
| |||||||
1 | rate that is equal
to or greater than one standard | ||||||
2 | deviation above the mean Medicaid inpatient
utilization | ||||||
3 | rate but less than 1.5 standard deviations above the mean | ||||||
4 | Medicaid
inpatient utilization rate shall receive a per day | ||||||
5 | adjustment payment equal to
the sum of $40 plus $7 for each | ||||||
6 | one percent that the hospital's Medicaid
inpatient | ||||||
7 | utilization rate exceeds one standard deviation above the | ||||||
8 | mean
Medicaid inpatient utilization rate; and
| ||||||
9 | (4) hospitals with a Medicaid inpatient utilization | ||||||
10 | rate that is equal
to or greater than 1.5 standard | ||||||
11 | deviations above the mean Medicaid inpatient
utilization | ||||||
12 | rate shall receive a per day adjustment payment equal to | ||||||
13 | the sum of
$90 plus $2 for each one percent that the | ||||||
14 | hospital's Medicaid inpatient
utilization rate exceeds 1.5 | ||||||
15 | standard deviations above the mean Medicaid
inpatient | ||||||
16 | utilization rate.
| ||||||
17 | (d) Supplemental adjustment payments. In addition to the | ||||||
18 | adjustment
payments described in paragraph (c), hospitals as | ||||||
19 | defined in clauses
(1) through (5) of paragraph (b), excluding | ||||||
20 | county hospitals (as defined in
subsection (c) of Section 15-1 | ||||||
21 | of this Code) and a hospital organized under the
University of | ||||||
22 | Illinois Hospital Act, shall be paid supplemental inpatient
| ||||||
23 | adjustment payments of $60 per day. For purposes of Title XIX | ||||||
24 | of the federal
Social Security Act, these supplemental | ||||||
25 | adjustment payments shall not be
classified as adjustment | ||||||
26 | payments to disproportionate share hospitals.
|
| |||||||
| |||||||
1 | (e) The inpatient adjustment payments described in | ||||||
2 | paragraphs (c) and (d)
shall be increased on October 1, 1993 | ||||||
3 | and annually thereafter by a percentage
equal to the lesser of | ||||||
4 | (i) the increase in the DRI hospital cost index for the
most | ||||||
5 | recent 12 month period for which data are available, or (ii) | ||||||
6 | the
percentage increase in the statewide average hospital | ||||||
7 | payment rate over the
previous year's statewide average | ||||||
8 | hospital payment rate. The sum of the
inpatient adjustment | ||||||
9 | payments under paragraphs (c) and (d) to a hospital, other
than | ||||||
10 | a county hospital (as defined in subsection (c) of Section 15-1 | ||||||
11 | of this
Code) or a hospital organized under the University of | ||||||
12 | Illinois Hospital Act,
however, shall not exceed $275 per day; | ||||||
13 | that limit shall be increased on
October 1, 1993 and annually | ||||||
14 | thereafter by a percentage equal to the lesser of
(i) the | ||||||
15 | increase in the DRI hospital cost index for the most recent | ||||||
16 | 12-month
period for which data are available or (ii) the | ||||||
17 | percentage increase in the
statewide average hospital payment | ||||||
18 | rate over the previous year's statewide
average hospital | ||||||
19 | payment rate.
| ||||||
20 | (f) Children's hospital inpatient adjustment payments. For | ||||||
21 | children's
hospitals, as defined in clause (5) of paragraph | ||||||
22 | (b), the adjustment payments
required pursuant to paragraphs | ||||||
23 | (c) and (d) shall be multiplied by 2.0.
| ||||||
24 | (g) County hospital inpatient adjustment payments. For | ||||||
25 | county hospitals,
as defined in subsection (c) of Section 15-1 | ||||||
26 | of this Code, there shall be an
adjustment payment as |
| |||||||
| |||||||
1 | determined by rules issued by the Illinois Department.
| ||||||
2 | (h) For the purposes of this Section the following terms | ||||||
3 | shall be defined
as follows:
| ||||||
4 | (1) "Medicaid inpatient utilization rate" means a | ||||||
5 | fraction, the numerator
of which is the number of a | ||||||
6 | hospital's inpatient days provided in a given
12-month | ||||||
7 | period to patients who, for such days, were eligible for | ||||||
8 | Medicaid
under Title XIX of the federal Social Security | ||||||
9 | Act, and the denominator of
which is the total number of | ||||||
10 | the hospital's inpatient days in that same period.
| ||||||
11 | (2) "Mean Medicaid inpatient utilization rate" means | ||||||
12 | the total number
of Medicaid inpatient days provided by all | ||||||
13 | Illinois Medicaid-participating
hospitals divided by the | ||||||
14 | total number of inpatient days provided by those same
| ||||||
15 | hospitals.
| ||||||
16 | (3) "Medicaid obstetrical inpatient utilization rate" | ||||||
17 | means the
ratio of Medicaid obstetrical inpatient days to | ||||||
18 | total Medicaid inpatient
days for all Illinois hospitals | ||||||
19 | receiving Medicaid payments from the
Illinois Department.
| ||||||
20 | (i) Inpatient adjustment payment limit. In order to meet | ||||||
21 | the limits
of Public Law 102-234 and Public Law 103-66, the
| ||||||
22 | Illinois Department shall by rule adjust
disproportionate | ||||||
23 | share adjustment payments.
| ||||||
24 | (j) University of Illinois Hospital inpatient adjustment | ||||||
25 | payments. For
hospitals organized under the University of | ||||||
26 | Illinois Hospital Act, there shall
be an adjustment payment as |
| |||||||
| |||||||
1 | determined by rules adopted by the Illinois
Department.
| ||||||
2 | (k) The Illinois Department may by rule establish criteria | ||||||
3 | for and develop
methodologies for adjustment payments to | ||||||
4 | hospitals participating under this
Article.
| ||||||
5 | (l) On and after July 1, 2012, the Department shall reduce | ||||||
6 | any rate of reimbursement for services or other payments or | ||||||
7 | alter any methodologies authorized by this Code to reduce any | ||||||
8 | rate of reimbursement for services or other payments in | ||||||
9 | accordance with Section 5-5e. | ||||||
10 | (Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)
| ||||||
11 | (305 ILCS 5/5-30.1) | ||||||
12 | Sec. 5-30.1. Managed care protections. | ||||||
13 | (a) As used in this Section: | ||||||
14 | "Managed care organization" or "MCO" means any entity which | ||||||
15 | contracts with the Department to provide services where payment | ||||||
16 | for medical services is made on a capitated basis. | ||||||
17 | "Emergency services" include: | ||||||
18 | (1) emergency services, as defined by Section 10 of the | ||||||
19 | Managed Care Reform and Patient Rights Act; | ||||||
20 | (2) emergency medical screening examinations, as | ||||||
21 | defined by Section 10 of the Managed Care Reform and | ||||||
22 | Patient Rights Act; | ||||||
23 | (3) post-stabilization medical services, as defined by | ||||||
24 | Section 10 of the Managed Care Reform and Patient Rights | ||||||
25 | Act; and |
| |||||||
| |||||||
1 | (4) emergency medical conditions, as defined by
| ||||||
2 | Section 10 of the Managed Care Reform and Patient Rights
| ||||||
3 | Act. | ||||||
4 | (b) As provided by Section 5-16.12, managed care | ||||||
5 | organizations are subject to the provisions of the Managed Care | ||||||
6 | Reform and Patient Rights Act. | ||||||
7 | (c) An MCO shall pay any provider of emergency services | ||||||
8 | that does not have in effect a contract with the contracted | ||||||
9 | Medicaid MCO. The default rate of reimbursement shall be the | ||||||
10 | rate paid under Illinois Medicaid fee-for-service program | ||||||
11 | methodology, including all policy adjusters, including but not | ||||||
12 | limited to Medicaid High Volume Adjustments, Medicaid | ||||||
13 | Percentage Adjustments, Outpatient High Volume Adjustments, | ||||||
14 | and all outlier add-on adjustments to the extent such | ||||||
15 | adjustments are incorporated in the development of the | ||||||
16 | applicable MCO capitated rates. | ||||||
17 | (d) An MCO shall pay for all post-stabilization services as | ||||||
18 | a covered service in any of the following situations: | ||||||
19 | (1) the MCO authorized such services; | ||||||
20 | (2) such services were administered to maintain the | ||||||
21 | enrollee's stabilized condition within one hour after a | ||||||
22 | request to the MCO for authorization of further | ||||||
23 | post-stabilization services; | ||||||
24 | (3) the MCO did not respond to a request to authorize | ||||||
25 | such services within one hour; | ||||||
26 | (4) the MCO could not be contacted; or |
| |||||||
| |||||||
1 | (5) the MCO and the treating provider, if the treating | ||||||
2 | provider is a non-affiliated provider, could not reach an | ||||||
3 | agreement concerning the enrollee's care and an affiliated | ||||||
4 | provider was unavailable for a consultation, in which case | ||||||
5 | the MCO
must pay for such services rendered by the treating | ||||||
6 | non-affiliated provider until an affiliated provider was | ||||||
7 | reached and either concurred with the treating | ||||||
8 | non-affiliated provider's plan of care or assumed | ||||||
9 | responsibility for the enrollee's care. Such payment shall | ||||||
10 | be made at the default rate of reimbursement paid under | ||||||
11 | Illinois Medicaid fee-for-service program methodology, | ||||||
12 | including all policy adjusters, including but not limited | ||||||
13 | to Medicaid High Volume Adjustments, Medicaid Percentage | ||||||
14 | Adjustments, Outpatient High Volume Adjustments and all | ||||||
15 | outlier add-on adjustments to the extent that such | ||||||
16 | adjustments are incorporated in the development of the | ||||||
17 | applicable MCO capitated rates. | ||||||
18 | (e) The following requirements apply to MCOs in determining | ||||||
19 | payment for all emergency services: | ||||||
20 | (1) MCOs shall not impose any requirements for prior | ||||||
21 | approval of emergency services. | ||||||
22 | (2) The MCO shall cover emergency services provided to | ||||||
23 | enrollees who are temporarily away from their residence and | ||||||
24 | outside the contracting area to the extent that the | ||||||
25 | enrollees would be entitled to the emergency services if | ||||||
26 | they still were within the contracting area. |
| |||||||
| |||||||
1 | (3) The MCO shall have no obligation to cover medical | ||||||
2 | services provided on an emergency basis that are not | ||||||
3 | covered services under the contract. | ||||||
4 | (4) The MCO shall not condition coverage for emergency | ||||||
5 | services on the treating provider notifying the MCO of the | ||||||
6 | enrollee's screening and treatment within 10 days after | ||||||
7 | presentation for emergency services. | ||||||
8 | (5) The determination of the attending emergency | ||||||
9 | physician, or the provider actually treating the enrollee, | ||||||
10 | of whether an enrollee is sufficiently stabilized for | ||||||
11 | discharge or transfer to another facility, shall be binding | ||||||
12 | on the MCO. The MCO shall cover emergency services for all | ||||||
13 | enrollees whether the emergency services are provided by an | ||||||
14 | affiliated or non-affiliated provider. | ||||||
15 | (6) The MCO's financial responsibility for | ||||||
16 | post-stabilization care services it has not pre-approved | ||||||
17 | ends when: | ||||||
18 | (A) a plan physician with privileges at the | ||||||
19 | treating hospital assumes responsibility for the | ||||||
20 | enrollee's care; | ||||||
21 | (B) a plan physician assumes responsibility for | ||||||
22 | the enrollee's care through transfer; | ||||||
23 | (C) a contracting entity representative and the | ||||||
24 | treating physician reach an agreement concerning the | ||||||
25 | enrollee's care; or | ||||||
26 | (D) the enrollee is discharged. |
| |||||||
| |||||||
1 | (f) Network adequacy and transparency. | ||||||
2 | (1) The Department shall: | ||||||
3 | (A) ensure that an adequate provider network is in | ||||||
4 | place, taking into consideration health professional | ||||||
5 | shortage areas and medically underserved areas; | ||||||
6 | (B) publicly release an explanation of its process | ||||||
7 | for analyzing network adequacy; | ||||||
8 | (C) periodically ensure that an MCO continues to | ||||||
9 | have an adequate network in place; and | ||||||
10 | (D) require MCOs, including Medicaid Managed Care | ||||||
11 | Entities as defined in Section 5-30.2, to meet provider | ||||||
12 | directory requirements under Section 5-30.3. | ||||||
13 | (2) Each MCO shall confirm its receipt of information | ||||||
14 | submitted specific to physician additions or physician | ||||||
15 | deletions from the MCO's provider network within 3 days | ||||||
16 | after receiving all required information from contracted | ||||||
17 | physicians, and electronic physician directories must be | ||||||
18 | updated consistent with current rules as published by the | ||||||
19 | Centers for Medicare and Medicaid Services or its successor | ||||||
20 | agency. | ||||||
21 | (g) Timely payment of claims. | ||||||
22 | (1) The MCO shall pay a claim within 30 days of | ||||||
23 | receiving a claim that contains all the essential | ||||||
24 | information needed to adjudicate the claim. | ||||||
25 | (2) The MCO shall notify the billing party of its | ||||||
26 | inability to adjudicate a claim within 30 days of receiving |
| |||||||
| |||||||
1 | that claim. | ||||||
2 | (3) The MCO shall pay a penalty that is at least equal | ||||||
3 | to the penalty imposed under the Illinois Insurance Code | ||||||
4 | for any claims not timely paid. | ||||||
5 | (4) The Department may establish a process for MCOs to | ||||||
6 | expedite payments to providers based on criteria | ||||||
7 | established by the Department. | ||||||
8 | (g-5) Recognizing that the rapid transformation of the | ||||||
9 | Illinois Medicaid program may have unintended operational | ||||||
10 | challenges for both payers and providers: | ||||||
11 | (1) in no instance shall a medically necessary covered | ||||||
12 | service rendered in good faith, based upon eligibility | ||||||
13 | information documented by the provider, be denied coverage | ||||||
14 | or diminished in payment amount if the eligibility or | ||||||
15 | coverage information available at the time the service was | ||||||
16 | rendered is later found to be inaccurate; and | ||||||
17 | (2) the Department shall, by December 31, 2016, adopt | ||||||
18 | rules establishing policies that shall be included in the | ||||||
19 | Medicaid managed care policy and procedures manual | ||||||
20 | addressing payment resolutions in situations in which a | ||||||
21 | provider renders services based upon information obtained | ||||||
22 | after verifying a patient's eligibility and coverage plan | ||||||
23 | through either the Department's current enrollment system | ||||||
24 | or a system operated by the coverage plan identified by the | ||||||
25 | patient presenting for services: | ||||||
26 | (A) such medically necessary covered services |
| |||||||
| |||||||
1 | shall be considered rendered in good faith; | ||||||
2 | (B) such policies and procedures shall be | ||||||
3 | developed in consultation with industry | ||||||
4 | representatives of the Medicaid managed care health | ||||||
5 | plans and representatives of provider associations | ||||||
6 | representing the majority of providers within the | ||||||
7 | identified provider industry; and | ||||||
8 | (C) such rules shall be published for a review and | ||||||
9 | comment period of no less than 30 days on the | ||||||
10 | Department's website with final rules remaining | ||||||
11 | available on the Department's website. | ||||||
12 | (3) The rules on payment resolutions shall include, but | ||||||
13 | not be limited to: | ||||||
14 | (A) the extension of the timely filing period; | ||||||
15 | (B) retroactive prior authorizations; and | ||||||
16 | (C) guaranteed minimum payment rate of no less than | ||||||
17 | the current, as of the date of service, fee-for-service | ||||||
18 | rate, plus all applicable add-ons, when the resulting | ||||||
19 | service relationship is out of network. | ||||||
20 | (4) The rules shall be applicable for both MCO coverage | ||||||
21 | and fee-for-service coverage. | ||||||
22 | (g-6) MCO Performance Metrics Report. | ||||||
23 | (1) The Department shall publish, on at least a | ||||||
24 | quarterly basis, each MCO's operational performance, | ||||||
25 | including, but not limited to, the following categories of | ||||||
26 | metrics: |
| |||||||
| |||||||
1 | (A) claims payment, including timeliness and | ||||||
2 | accuracy; | ||||||
3 | (B) prior authorizations; | ||||||
4 | (C) grievance and appeals; | ||||||
5 | (D) utilization statistics; | ||||||
6 | (E) provider disputes; | ||||||
7 | (F) provider credentialing; and | ||||||
8 | (G) member and provider customer service. | ||||||
9 | (2) The Department shall ensure that the metrics report | ||||||
10 | is accessible to providers online by January 1, 2017. | ||||||
11 | (3) The metrics shall be developed in consultation with | ||||||
12 | industry representatives of the Medicaid managed care | ||||||
13 | health plans and representatives of associations | ||||||
14 | representing the majority of providers within the | ||||||
15 | identified industry. | ||||||
16 | (4) Metrics shall be defined and incorporated into the | ||||||
17 | applicable Managed Care Policy Manual issued by the | ||||||
18 | Department. | ||||||
19 | (g-7) MCO claims processing and performance analysis. In | ||||||
20 | order to monitor MCO payments to hospital providers, pursuant | ||||||
21 | to this amendatory Act of the 100th General Assembly, the | ||||||
22 | Department shall post an analysis of MCO claims processing and | ||||||
23 | payment performance on its website every 6 months. Such | ||||||
24 | analysis shall include a review and evaluation of a | ||||||
25 | representative sample of hospital claims that are rejected and | ||||||
26 | denied for clean and unclean claims and the top 5 reasons for |
| |||||||
| |||||||
1 | such actions and timeliness of claims adjudication, which | ||||||
2 | identifies the percentage of claims adjudicated within 30, 60, | ||||||
3 | 90, and over 90 days, and the dollar amounts associated with | ||||||
4 | those claims. The Department shall post the contracted claims | ||||||
5 | report required by HealthChoice Illinois on its website every 3 | ||||||
6 | months. | ||||||
7 | (h) The Department shall not expand mandatory MCO | ||||||
8 | enrollment into new counties beyond those counties already | ||||||
9 | designated by the Department as of June 1, 2014 for the | ||||||
10 | individuals whose eligibility for medical assistance is not the | ||||||
11 | seniors or people with disabilities population until the | ||||||
12 | Department provides an opportunity for accountable care | ||||||
13 | entities and MCOs to participate in such newly designated | ||||||
14 | counties. | ||||||
15 | (i) The requirements of this Section apply to contracts | ||||||
16 | with accountable care entities and MCOs entered into, amended, | ||||||
17 | or renewed after June 16, 2014 (the effective date of Public | ||||||
18 | Act 98-651).
| ||||||
19 | (Source: P.A. 99-725, eff. 8-5-16; 99-751, eff. 8-5-16; | ||||||
20 | 100-201, eff. 8-18-17.)
| ||||||
21 | (305 ILCS 5/5-30.6 new) | ||||||
22 | Sec. 5-30.6. Managed care organization contracts | ||||||
23 | procurement requirement. Beginning on the effective date of | ||||||
24 | this amendatory Act of the 100th General Assembly, any new | ||||||
25 | contract between the Department and a managed care organization |
| |||||||
| |||||||
1 | as defined in Section 5-30.1 shall be procured in accordance | ||||||
2 | with the Illinois Procurement Code. | ||||||
3 | (a) Application. | ||||||
4 | (1) This Section does not apply to the State of | ||||||
5 | Illinois Medicaid Managed Care Organization Request for | ||||||
6 | Proposals (2018-24-001) or any agreement, regardless of | ||||||
7 | what it may be called, related to or arising from this | ||||||
8 | procurement, including, but not limited to, contracts, | ||||||
9 | renewals, renegotiated contracts, amendments, and change | ||||||
10 | orders. | ||||||
11 | (2) This Section does not apply to Medicare-Medicaid | ||||||
12 | Alignment Initiative contracts executed under Article V-F | ||||||
13 | of this Code. | ||||||
14 | (b) In the event any provision of this Section or of the | ||||||
15 | Illinois Procurement Code is inconsistent with applicable | ||||||
16 | federal law or would have the effect of foreclosing the use, | ||||||
17 | potential use, or receipt of federal financial participation | ||||||
18 | the applicable federal law or funding condition shall prevail, | ||||||
19 | but only to the extent of such inconsistency.
| ||||||
20 | (305 ILCS 5/5-30.7 new) | ||||||
21 | Sec. 5-30.7. Encounter data guidelines; provider fee | ||||||
22 | schedule. | ||||||
23 | (a) No later than 60 days after the effective date of this | ||||||
24 | amendatory Act of the 100th General Assembly, the Department | ||||||
25 | shall publish on its website comprehensive written guidance on |
| |||||||
| |||||||
1 | the submission of encounter data by managed care organizations. | ||||||
2 | This information shall be updated and published as needed, but | ||||||
3 | at least quarterly. The Department shall inform providers and | ||||||
4 | managed care organizations of any updates via provider notices. | ||||||
5 | (b) The Department shall publish on its website provider | ||||||
6 | fee schedules on both a portable document format (PDF) and | ||||||
7 | EXCEL format. The portable document format shall serve as the | ||||||
8 | ultimate source if there is a discrepancy.
| ||||||
9 | (305 ILCS 5/5A-15) | ||||||
10 | Sec. 5A-15. Protection of federal revenue. | ||||||
11 | (a) If the federal Centers for Medicare and Medicaid | ||||||
12 | Services finds that any federal upper payment limit applicable | ||||||
13 | to the payments under this Article is exceeded then: | ||||||
14 | (1) the payments under this Article that exceed the | ||||||
15 | applicable federal upper payment limit shall be reduced | ||||||
16 | uniformly to the extent necessary to comply with the | ||||||
17 | applicable federal upper payment limit; and | ||||||
18 | (2) any assessment rate imposed under this Article | ||||||
19 | shall be reduced such that the aggregate assessment is | ||||||
20 | reduced by the same percentage reduction applied in | ||||||
21 | paragraph (1); and | ||||||
22 | (3) any transfers from the Hospital Provider Fund under | ||||||
23 | Section 5A-8 shall be reduced by the same percentage | ||||||
24 | reduction applied in paragraph (1). | ||||||
25 | (b) Any payment reductions made under the authority granted |
| |||||||
| |||||||
1 | in this Section are exempt from the requirements and actions | ||||||
2 | under Section 5A-10.
| ||||||
3 | (c) If any payments made as a result of the requirements of | ||||||
4 | this Article are subject to a disallowance, deferral, or | ||||||
5 | adjustment of federal matching funds then: | ||||||
6 | (1) the Department shall recoup the payments related to | ||||||
7 | those federal matching funds paid by the Department from | ||||||
8 | the parties paid by the Department; | ||||||
9 | (2) if the payments that are subject to a disallowance, | ||||||
10 | deferral, or adjustment of federal matching funds were made | ||||||
11 | to MCOs, the Department shall recoup the payments related | ||||||
12 | to the disallowance, deferral, or adjustment from the MCOs | ||||||
13 | no sooner than the Department is required to remit federal | ||||||
14 | matching funds to the Centers for Medicare and Medicaid | ||||||
15 | Services or any other federal agency, and hospitals that | ||||||
16 | received payments from the MCOs that were made with such | ||||||
17 | disallowed, deferred, or adjusted federal matching funds | ||||||
18 | must return those payments to the MCOs at least 10 business | ||||||
19 | days before the MCOs are required to remit such payments to | ||||||
20 | the Department; and | ||||||
21 | (3) any assessment paid to the Department by hospitals | ||||||
22 | under this Article that is attributable to the payments | ||||||
23 | that are subject to a disallowance, deferral, or adjustment | ||||||
24 | of federal matching funds, shall be refunded to the | ||||||
25 | hospitals by the Department. | ||||||
26 | If an MCO is unable to recoup funds from a hospital for any |
| |||||||
| |||||||
1 | reason, then the Department, upon written notice from an MCO, | ||||||
2 | shall work in good faith with the MCO to mitigate losses | ||||||
3 | associated with the lack of recoupment. Losses by an MCO shall | ||||||
4 | not exceed 1% of the total payments distributed by the MCO to | ||||||
5 | hospitals pursuant to the Hospital Assessment Program. | ||||||
6 | (Source: P.A. 97-688, eff. 6-14-12; 97-689, eff. 6-14-12.)
| ||||||
7 | Section 99. Effective date. This Act takes effect upon | ||||||
8 | becoming law, but this Act does not take effect at all unless | ||||||
9 | Senate Bill 1773 of the 100th General Assembly, as amended, | ||||||
10 | becomes law.".
|