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,
3represented in the General Assembly:
4 Section 5. The Illinois Public Aid Code is amended by
5changing Section 14-13 as follows:
6 (305 ILCS 5/14-13)
7 Sec. 14-13. Reimbursement for hospital inpatient stays
8extended beyond medical necessity.
9 (a) The By October 1, 2019, the Department shall by rule
10implement a methodology effective for dates of service July 1,
112019 and later to reimburse hospitals for inpatient stays
12extended beyond medical necessity due to the inability of the
13Department or the managed care organization in which a
14recipient is enrolled or the hospital discharge planner to
15find an appropriate placement after discharge from the
16hospital to the next level of care, including, but not limited
17to, care provided in a nursing facility, ICF/DD facility,
18MC/DD facility, rehabilitation hospital or rehabilitation
19unit, psychiatric hospital or psychiatric unit, long-term
20acute care hospital, long-term services and supports waiver
21setting, residence when home health care services are
22required, or other post-acute or sub-acute care setting. The
23Department shall evaluate the effectiveness of the current

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1reimbursement rate for inpatient hospital stays beyond medical
2necessity.
3 (a-2) By October 1, 2024, the Department shall by rule
4implement a methodology effective for dates of service January
51, 2025 and later to reimburse hospitals for emergency
6department stays extended beyond medical necessity due to the
7inability of the Department or the managed care organization
8in which a recipient is enrolled or the hospital discharge
9planner to find an appropriate placement after discharge from
10the hospital setting to the next appropriate level of care,
11including, but not limited to, care provided in a nursing
12facility, ICF/DD facility, MC/DD facility, rehabilitation
13hospital or rehabilitation unit, psychiatric hospital or
14psychiatric unit, long-term acute care hospital, long-term
15services and supports waiver setting, residence when home
16health care services are required, or other post-acute or
17sub-acute care setting.
18 (b) The methodology developed under subsection (a) shall
19provide reasonable compensation for the services provided
20attributable to the days of the extended stay for which the
21prevailing rate methodology provides no reimbursement. The
22Department may use a day outlier program to satisfy this
23requirement. The methodology developed under subsection (a-2)
24shall provide reasonable compensation for the services
25provided attributable to the hours of the extended stay for
26which the prevailing rate methodology provides no

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1reimbursement. The reimbursement rate shall be set at a level
2so as not to act as an incentive to avoid transfer to the
3appropriate level of care needed or placement, after
4discharge.
5 (b-5) Effective January 1, 2025, the Department shall set
6the rate for inpatient days of care, referenced in subsection
7(a), equal to the statewide average rate paid per day
8including Medicaid High Volume Adjustment (MHVA) and the
9Medicaid Percentage Adjustment (MPA), for inpatient services,
10specific to each category of services, provided by all
11Illinois hospitals, based on dates of service in State Fiscal
12Year 2023. Effective January 1, 2026, the Department shall
13update this rate for dates of service on or after January 1 of
14each calendar year, based on dates of service from the State
15fiscal year ending 18 months before the beginning of the new
16calendar year.
17 (b-6) Effective January 1, 2025, and each January 1
18thereafter, the Department shall set the hourly rate of
19reimbursement for emergency department stays, referenced
20subsection (a-2), equal to the inpatient rate established in
21subsection (b-5) divided by 24, and shall pay for each hour the
22patient is unable to be transferred to the next appropriate
23level of care. Effective January 1, 2026, the Department shall
24update this rate for dates of service on or after January 1 of
25each calendar year, coinciding with the update required in
26subsection (b-5).

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1 (c) For recipients who require a level of care described
2in subsection (a) and subsection (a-2), the The Department
3shall require managed care organizations to adopt this
4methodology or an alternative methodology that pays at least
5as much as the Department's adopted methodology unless
6otherwise mutually agreed upon contractual language is
7developed by the provider and the managed care organization
8for a risk-based or innovative payment methodology.
9 (d) Days beyond medical necessity shall not be separately
10eligible for per diem add-on payments under the MHVA or MPA
11Medicaid High Volume Adjustment (MHVA) or the Medicaid
12Percentage Adjustment (MPA) programs.
13 (e) For services covered by the fee-for-service program,
14reimbursement under this Section shall only be made for stays
15days beyond medical necessity that occur after the hospital
16has notified the Department of the need for post-discharge
17placement. The Department shall not restrict coverage under
18this Section due to delays caused by the Department, or its
19designated contractor, in completing the Pre-Admission
20Screening and Resident Review process.
21 (f) For services covered by a managed care organization,
22hospitals shall notify the appropriate managed care
23organization of an admission within 24 hours of admission. For
24every 24-hour period beyond the initial 24 hours after
25admission that the hospital fails to notify the managed care
26organization of the admission, reimbursement under this

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1subsection shall be reduced by one day. Managed care
2organizations (MCOs) shall not restrict coverage under this
3Section 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
14from imposing authorization or documentation requirements,
15exclusionary criteria, or other conditions of reimbursement
16that are more restrictive than the standards adopted by the
17Department for the fee-for-service program.
18 (h) The Department shall impose sanctions on an MCO for
19violating provisions of this Section, including, but not
20limited to, financial penalties, suspension of enrollment, or
21termination of the MCO's contract with the Department.
22 (i) The Department shall adopt or amend administrative
23rules, as necessary, to implement the provisions of this
24Section.
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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