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| Public Act 102-0454
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| HB3069 Enrolled | LRB102 13330 KTG 18674 b |
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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:
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(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. |
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(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 |
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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. |
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(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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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. |
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(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 |
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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 |
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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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