Illinois-2023-HB4978-Introduced

103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4978

Introduced , by Rep. Robyn Gabel

SYNOPSIS AS INTRODUCED:

305 ILCS 5/14-13

Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to by rule implement a methodology to reimburse hospitals for inpatient stays extended beyond medical necessity due to the inability of the Department, the managed care organization (MCO) in which a medical assistance recipient is enrolled in, or the hospital discharge planner to find an appropriate placement after discharge from the hospital to the next level of care. Requires the Department to by rule implement a methodology effective for dates of service January 1, 2025 and later to reimburse hospitals for emergency department stays extended beyond medical necessity due to the inability of the Department, the MCO, or the hospital discharge planner to find an appropriate placement after discharge from the hospital setting to the next appropriate level of care. Provides that both methodologies shall provide reasonable compensation for the services provided attributable to the hours of the extended stay for which the prevailing rate methodology provides no reimbursement. Contains provisions concerning the rate for inpatient days of care; hourly rates of reimbursement for emergency department stays; a prohibition on MCOs restricting coverage due to delays caused by the Department or the MCOs in completing the pre-admission screening and resident review process; a prohibition on MCOs imposing authorization or documentation requirements and other conditions of reimbursement that are more restrictive than standards under the fee-for-service medical assistance program; sanctions on MCOs for noncompliance; and administrative rules. Effective immediately.

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A BILL FOR

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1 AN ACT concerning public aid.

2 Be it enacted by the People of the State of Illinois,

3 represented in the General Assembly:

4 Section 5. The Illinois Public Aid Code is amended by

5 changing Section 14-13 as follows:

6 (305 ILCS 5/14-13)

7 Sec. 14-13. Reimbursement for hospital ~~inpatient~~ stays

8 extended beyond medical necessity.

9 (a) The ~~By October 1, 2019, the~~ Department shall by rule

10 implement a methodology effective for dates of service July 1,

11 2019 and later to reimburse hospitals for inpatient stays

12 extended beyond medical necessity due to the inability of the

13 Department or the managed care organization in which a

14 recipient is enrolled or the hospital discharge planner to

15 find an appropriate placement after discharge from the

16 hospital to the next level of care, including, but not limited

17 to, care provided in a nursing facility, ICF/DD facility,

18 MC/DD facility, rehabilitation hospital or rehabilitation

19 unit, psychiatric hospital or psychiatric unit, long-term

20 acute care hospital, long-term services and supports waiver

21 setting, residence when home health care services are

22 required, or other post-acute or sub-acute care setting. ~~The~~

23 ~~Department shall evaluate the effectiveness of the current~~

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1 ~~reimbursement rate for inpatient hospital stays beyond medical~~

2 ~~necessity.~~

3 (a-2) By October 1, 2024, the Department shall by rule

4 implement a methodology effective for dates of service January

5 1, 2025 and later to reimburse hospitals for emergency

6 department stays extended beyond medical necessity due to the

7 inability of the Department or the managed care organization

8 in which a recipient is enrolled or the hospital discharge

9 planner to find an appropriate placement after discharge from

10 the hospital setting to the next appropriate level of care,

11 including, but not limited to, care provided in a nursing

12 facility, ICF/DD facility, MC/DD facility, rehabilitation

13 hospital or rehabilitation unit, psychiatric hospital or

14 psychiatric unit, long-term acute care hospital, long-term

15 services and supports waiver setting, residence when home

16 health care services are required, or other post-acute or

17 sub-acute care setting.

18 (b) The methodology developed under subsection (a) shall

19 provide reasonable compensation for the services provided

20 attributable to the days of the extended stay for which the

21 prevailing rate methodology provides no reimbursement. The

22 Department may use a day outlier program to satisfy this

23 requirement. The methodology developed under subsection (a-2)

24 shall provide reasonable compensation for the services

25 provided attributable to the hours of the extended stay for

26 which the prevailing rate methodology provides no

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1 reimbursement. The reimbursement rate shall be set at a level

2 so as not to act as an incentive to avoid transfer to the

3 appropriate level of care needed or placement, after

4 discharge.

5 (b-5) Effective January 1, 2025, the Department shall set

6 the rate for inpatient days of care, referenced in subsection

7 (a), equal to the statewide average rate paid per day

8 including Medicaid High Volume Adjustment (MHVA) and the

9 Medicaid Percentage Adjustment (MPA), for inpatient services,

10 specific to each category of services, provided by all

11 Illinois hospitals, based on dates of service in State Fiscal

12 Year 2023. Effective January 1, 2026, the Department shall

13 update this rate for dates of service on or after January 1 of

14 each calendar year, based on dates of service from the State

15 fiscal year ending 18 months before the beginning of the new

16 calendar year.

17 (b-6) Effective January 1, 2025, and each January 1

18 thereafter, the Department shall set the hourly rate of

19 reimbursement for emergency department stays, referenced

20 subsection (a-2), equal to the inpatient rate established in

21 subsection (b-5) divided by 24, and shall pay for each hour the

22 patient is unable to be transferred to the next appropriate

23 level of care. Effective January 1, 2026, the Department shall

24 update this rate for dates of service on or after January 1 of

25 each calendar year, coinciding with the update required in

26 subsection (b-5).

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1 (c) For recipients who require a level of care described

2 in subsection (a) and subsection (a-2), the ~~The~~ Department

3 shall require managed care organizations to adopt this

4 methodology or an alternative methodology that pays at least

5 as much as the Department's adopted methodology unless

6 otherwise mutually agreed upon contractual language is

7 developed by the provider and the managed care organization

8 for a risk-based or innovative payment methodology.

9 (d) Days beyond medical necessity shall not be separately

10 eligible for per diem add-on payments under the MHVA or MPA

11 ~~Medicaid High Volume Adjustment (MHVA) or the Medicaid~~

12 ~~Percentage Adjustment (MPA)~~ programs.

13 (e) For services covered by the fee-for-service program,

14 reimbursement under this Section shall only be made for stays

15 ~~days~~ beyond medical necessity that occur after the hospital

16 has notified the Department of the need for post-discharge

17 placement. The Department shall not restrict coverage under

18 this Section due to delays caused by the Department, or its

19 designated contractor, in completing the Pre-Admission

20 Screening and Resident Review process.

21 (f) For services covered by a managed care organization,

22 hospitals shall notify the appropriate managed care

23 organization of an admission within 24 hours of admission. For

24 every 24-hour period beyond the initial 24 hours after

25 admission that the hospital fails to notify the managed care

26 organization of the admission, reimbursement under this

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1 subsection shall be reduced by one day. Managed care

2 organizations (MCOs) shall not restrict coverage under this

3 Section due to delays caused by:

4 (1) The MCO or its designated contractor, or the

5 Department or its designated contractor, in completing the

6 Pre-Admission Screening and Resident Review process.

7 (2) Processing authorization requests, as submitted by

8 the provider, for post-acute care for enrollees who are

9 approved for discharge, including, but not limited to any

10 MCO action to extend the timeframe for issuing a

11 determination by changing the provider's request from

12 urgent to routine.

13 (g) The Department shall, by contract, prohibit the MCOs

14 from imposing authorization or documentation requirements,

15 exclusionary criteria, or other conditions of reimbursement

16 that are more restrictive than the standards adopted by the

17 Department for the fee-for-service program.

18 (h) The Department shall impose sanctions on an MCO for

19 violating provisions of this Section, including, but not

20 limited to, financial penalties, suspension of enrollment, or

21 termination of the MCO's contract with the Department.

22 (i) The Department shall adopt or amend administrative

23 rules, as necessary, to implement the provisions of this

24 Section.

25 (Source: P.A. 101-209, eff. 8-5-19; 102-4, eff. 4-27-21.)

26 Section 99. Effective date. This Act takes effect upon

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