Bill Text: IL SB1573 | 2017-2018 | 100th General Assembly | Chaptered

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Bill Title: Amends the Medical Assistance Article of the Illinois Public Aid Code. In a provision limiting medical assistance recipients to one pair of adult eyeglasses every 2 years, provides that the limitation does not apply to an individual who needs different eyeglasses following a surgical procedure such as cataract surgery. Effective immediately.

Spectrum: Slight Partisan Bill (Democrat 10-4)

Status: (Passed) 2018-05-17 - Added as Co-Sponsor Sen. Laura M. Murphy [SB1573 Detail]

Download: Illinois-2017-SB1573-Chaptered.html

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Public Act 100-0580
SB1573 Enrolled LRB100 08465 KTG 18583 b
AN ACT concerning public aid.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Procurement Code is amended by
changing Section 1-10 as follows:
(30 ILCS 500/1-10)
Sec. 1-10. Application.
(a) This Code applies only to procurements for which
bidders, offerors, potential contractors, or contractors were
first solicited on or after July 1, 1998. This Code shall not
be construed to affect or impair any contract, or any provision
of a contract, entered into based on a solicitation prior to
the implementation date of this Code as described in Article
99, including but not limited to any covenant entered into with
respect to any revenue bonds or similar instruments. All
procurements for which contracts are solicited between the
effective date of Articles 50 and 99 and July 1, 1998 shall be
substantially in accordance with this Code and its intent.
(b) This Code shall apply regardless of the source of the
funds with which the contracts are paid, including federal
assistance moneys. This Except as specifically provided in this
Code, this Code shall not apply to:
(1) Contracts between the State and its political

subdivisions or other governments, or between State
governmental bodies, except as specifically provided in
this Code.
(2) Grants, except for the filing requirements of
Section 20-80.
(3) Purchase of care, except as provided in Section
5-30.6 of the Illinois Public Aid Code and this Section.
(4) Hiring of an individual as employee and not as an
independent contractor, whether pursuant to an employment
code or policy or by contract directly with that
individual.
(5) Collective bargaining contracts.
(6) Purchase of real estate, except that notice of this
type of contract with a value of more than $25,000 must be
published in the Procurement Bulletin within 10 calendar
days after the deed is recorded in the county of
jurisdiction. The notice shall identify the real estate
purchased, the names of all parties to the contract, the
value of the contract, and the effective date of the
contract.
(7) Contracts necessary to prepare for anticipated
litigation, enforcement actions, or investigations,
provided that the chief legal counsel to the Governor shall
give his or her prior approval when the procuring agency is
one subject to the jurisdiction of the Governor, and
provided that the chief legal counsel of any other

procuring entity subject to this Code shall give his or her
prior approval when the procuring entity is not one subject
to the jurisdiction of the Governor.
(8) (Blank).
(9) Procurement expenditures by the Illinois
Conservation Foundation when only private funds are used.
(10) (Blank).
(11) Public-private agreements entered into according
to the procurement requirements of Section 20 of the
Public-Private Partnerships for Transportation Act and
design-build agreements entered into according to the
procurement requirements of Section 25 of the
Public-Private Partnerships for Transportation Act.
(12) Contracts for legal, financial, and other
professional and artistic services entered into on or
before December 31, 2018 by the Illinois Finance Authority
in which the State of Illinois is not obligated. Such
contracts shall be awarded through a competitive process
authorized by the Board of the Illinois Finance Authority
and are subject to Sections 5-30, 20-160, 50-13, 50-20,
50-35, and 50-37 of this Code, as well as the final
approval by the Board of the Illinois Finance Authority of
the terms of the contract.
(13) Contracts for services, commodities, and
equipment to support the delivery of timely forensic
science services in consultation with and subject to the

approval of the Chief Procurement Officer as provided in
subsection (d) of Section 5-4-3a of the Unified Code of
Corrections, except for the requirements of Sections
20-60, 20-65, 20-70, and 20-160 and Article 50 of this
Code; however, the Chief Procurement Officer may, in
writing with justification, waive any certification
required under Article 50 of this Code. For any contracts
for services which are currently provided by members of a
collective bargaining agreement, the applicable terms of
the collective bargaining agreement concerning
subcontracting shall be followed.
On and after January 1, 2019, this paragraph (13),
except for this sentence, is inoperative.
(14) Contracts for participation expenditures required
by a domestic or international trade show or exhibition of
an exhibitor, member, or sponsor.
(15) Contracts with a railroad or utility that requires
the State to reimburse the railroad or utilities for the
relocation of utilities for construction or other public
purpose. Contracts included within this paragraph (15)
shall include, but not be limited to, those associated
with: relocations, crossings, installations, and
maintenance. For the purposes of this paragraph (15),
"railroad" means any form of non-highway ground
transportation that runs on rails or electromagnetic
guideways and "utility" means: (1) public utilities as

defined in Section 3-105 of the Public Utilities Act, (2)
telecommunications carriers as defined in Section 13-202
of the Public Utilities Act, (3) electric cooperatives as
defined in Section 3.4 of the Electric Supplier Act, (4)
telephone or telecommunications cooperatives as defined in
Section 13-212 of the Public Utilities Act, (5) rural water
or waste water systems with 10,000 connections or less, (6)
a holder as defined in Section 21-201 of the Public
Utilities Act, and (7) municipalities owning or operating
utility systems consisting of public utilities as that term
is defined in Section 11-117-2 of the Illinois Municipal
Code.
Notwithstanding any other provision of law, for contracts
entered into on or after October 1, 2017 under an exemption
provided in any paragraph of this subsection (b), except
paragraph (1), (2), or (5), each State agency shall post to the
appropriate procurement bulletin the name of the contractor, a
description of the supply or service provided, the total amount
of the contract, the term of the contract, and the exception to
the Code utilized. The chief procurement officer shall submit a
report to the Governor and General Assembly no later than
November 1 of each year that shall include, at a minimum, an
annual summary of the monthly information reported to the chief
procurement officer.
(c) This Code does not apply to the electric power
procurement process provided for under Section 1-75 of the

Illinois Power Agency Act and Section 16-111.5 of the Public
Utilities Act.
(d) Except for Section 20-160 and Article 50 of this Code,
and as expressly required by Section 9.1 of the Illinois
Lottery Law, the provisions of this Code do not apply to the
procurement process provided for under Section 9.1 of the
Illinois Lottery Law.
(e) This Code does not apply to the process used by the
Capital Development Board to retain a person or entity to
assist the Capital Development Board with its duties related to
the determination of costs of a clean coal SNG brownfield
facility, as defined by Section 1-10 of the Illinois Power
Agency Act, as required in subsection (h-3) of Section 9-220 of
the Public Utilities Act, including calculating the range of
capital costs, the range of operating and maintenance costs, or
the sequestration costs or monitoring the construction of clean
coal SNG brownfield facility for the full duration of
construction.
(f) (Blank).
(g) (Blank).
(h) This Code does not apply to the process to procure or
contracts entered into in accordance with Sections 11-5.2 and
11-5.3 of the Illinois Public Aid Code.
(i) Each chief procurement officer may access records
necessary to review whether a contract, purchase, or other
expenditure is or is not subject to the provisions of this

Code, unless such records would be subject to attorney-client
privilege.
(j) This Code does not apply to the process used by the
Capital Development Board to retain an artist or work or works
of art as required in Section 14 of the Capital Development
Board Act.
(k) This Code does not apply to the process to procure
contracts, or contracts entered into, by the State Board of
Elections or the State Electoral Board for hearing officers
appointed pursuant to the Election Code.
(l) This Code does not apply to the processes used by the
Illinois Student Assistance Commission to procure supplies and
services paid for from the private funds of the Illinois
Prepaid Tuition Fund. As used in this subsection (l), "private
funds" means funds derived from deposits paid into the Illinois
Prepaid Tuition Trust Fund and the earnings thereon.
(Source: P.A. 99-801, eff. 1-1-17; 100-43, eff. 8-9-17.)
Section 10. The Illinois Insurance Code is amended by
changing Section 35A-10 as follows:
(215 ILCS 5/35A-10)
Sec. 35A-10. RBC Reports.
(a) On or before each March 1 (the "filing date"), every
domestic insurer shall prepare and submit to the Director a
report of its RBC levels as of the end of the previous calendar

year in the form and containing the information required by the
RBC Instructions. Every domestic insurer shall also file its
RBC Report with the NAIC in accordance with the RBC
Instructions. In addition, if requested in writing by the chief
insurance regulatory official of any state in which it is
authorized to do business, every domestic insurer shall file
its RBC Report with that official no later than the later of 15
days after the insurer receives the written request or the
filing date.
(b) A life, health, or life and health insurer's or
fraternal benefit society's RBC shall be determined under the
formula set forth in the RBC Instructions. The formula shall
take into account (and may adjust for the covariance between):
(1) the risk with respect to the insurer's assets;
(2) the risk of adverse insurance experience with
respect to the insurer's liabilities and obligations;
(3) the interest rate risk with respect to the
insurer's business; and
(4) all other business risks and other relevant risks
set forth in the RBC Instructions.
These risks shall be determined in each case by applying the
factors in the manner set forth in the RBC Instructions.
Notwithstanding the foregoing, and notwithstanding the RBC
Instructions, health maintenance organizations operating as
Medicaid managed care plans under contract with the Department
of Healthcare and Family Services shall not be required to

include in its RBC calculations any capitation revenue
identified by Medicaid managed care plans as authorized under
Section 5A-12.6(r) of the Illinois Public Aid Code.
(c) A property and casualty insurer's RBC shall be
determined in accordance with the formula set forth in the RBC
Instructions. The formula shall take into account (and may
adjust for the covariance between):
(1) asset risk;
(2) credit risk;
(3) underwriting risk; and
(4) all other business risks and other relevant risks
set forth in the RBC Instructions.
These risks shall be determined in each case by applying the
factors in the manner set forth in the RBC Instructions.
(d) A health organization's RBC shall be determined in
accordance with the formula set forth in the RBC Instructions.
The formula shall take the following into account (and may
adjust for the covariance between):
(1) asset risk;
(2) credit risk;
(3) underwriting risk; and
(4) all other business risks and other relevant risks
set forth in the RBC Instructions.
These risks shall be determined in each case by applying the
factors in the manner set forth in the RBC Instructions.
(e) An excess of capital over the amount produced by the

risk-based capital requirements contained in this Code and the
formulas, schedules, and instructions referenced in this Code
is desirable in the business of insurance. Accordingly,
insurers should seek to maintain capital above the RBC levels
required by this Code. Additional capital is used and useful in
the insurance business and helps to secure an insurer against
various risks inherent in, or affecting, the business of
insurance and not accounted for or only partially measured by
the risk-based capital requirements contained in this Code.
(f) If a domestic insurer files an RBC Report that, in the
judgment of the Director, is inaccurate, the Director shall
adjust the RBC Report to correct the inaccuracy and shall
notify the insurer of the adjustment. The notice shall contain
a statement of the reason for the adjustment.
(Source: P.A. 98-157, eff. 8-2-13.)
Section 15. The Illinois Public Aid Code is amended by
changing Sections 5-5.02, 5-30.1, and 5A-15 and by adding
Sections 5-30.6 and 5-30.7 as follows:
(305 ILCS 5/5-5.02) (from Ch. 23, par. 5-5.02)
Sec. 5-5.02. Hospital reimbursements.
(a) Reimbursement to Hospitals; July 1, 1992 through
September 30, 1992. Notwithstanding any other provisions of
this Code or the Illinois Department's Rules promulgated under
the Illinois Administrative Procedure Act, reimbursement to

hospitals for services provided during the period July 1, 1992
through September 30, 1992, shall be as follows:
(1) For inpatient hospital services rendered, or if
applicable, for inpatient hospital discharges occurring,
on or after July 1, 1992 and on or before September 30,
1992, the Illinois Department shall reimburse hospitals
for inpatient services under the reimbursement
methodologies in effect for each hospital, and at the
inpatient payment rate calculated for each hospital, as of
June 30, 1992. For purposes of this paragraph,
"reimbursement methodologies" means all reimbursement
methodologies that pertain to the provision of inpatient
hospital services, including, but not limited to, any
adjustments for disproportionate share, targeted access,
critical care access and uncompensated care, as defined by
the Illinois Department on June 30, 1992.
(2) For the purpose of calculating the inpatient
payment rate for each hospital eligible to receive
quarterly adjustment payments for targeted access and
critical care, as defined by the Illinois Department on
June 30, 1992, the adjustment payment for the period July
1, 1992 through September 30, 1992, shall be 25% of the
annual adjustment payments calculated for each eligible
hospital, as of June 30, 1992. The Illinois Department
shall determine by rule the adjustment payments for
targeted access and critical care beginning October 1,

1992.
(3) For the purpose of calculating the inpatient
payment rate for each hospital eligible to receive
quarterly adjustment payments for uncompensated care, as
defined by the Illinois Department on June 30, 1992, the
adjustment payment for the period August 1, 1992 through
September 30, 1992, shall be one-sixth of the total
uncompensated care adjustment payments calculated for each
eligible hospital for the uncompensated care rate year, as
defined by the Illinois Department, ending on July 31,
1992. The Illinois Department shall determine by rule the
adjustment payments for uncompensated care beginning
October 1, 1992.
(b) Inpatient payments. For inpatient services provided on
or after October 1, 1993, in addition to rates paid for
hospital inpatient services pursuant to the Illinois Health
Finance Reform Act, as now or hereafter amended, or the
Illinois Department's prospective reimbursement methodology,
or any other methodology used by the Illinois Department for
inpatient services, the Illinois Department shall make
adjustment payments, in an amount calculated pursuant to the
methodology described in paragraph (c) of this Section, to
hospitals that the Illinois Department determines satisfy any
one of the following requirements:
(1) Hospitals that are described in Section 1923 of the
federal Social Security Act, as now or hereafter amended,

except that for rate year 2015 and after a hospital
described in Section 1923(b)(1)(B) of the federal Social
Security Act and qualified for the payments described in
subsection (c) of this Section for rate year 2014 provided
the hospital continues to meet the description in Section
1923(b)(1)(B) in the current determination year; or
(2) Illinois hospitals that have a Medicaid inpatient
utilization rate which is at least one-half a standard
deviation above the mean Medicaid inpatient utilization
rate for all hospitals in Illinois receiving Medicaid
payments from the Illinois Department; or
(3) Illinois hospitals that on July 1, 1991 had a
Medicaid inpatient utilization rate, as defined in
paragraph (h) of this Section, that was at least the mean
Medicaid inpatient utilization rate for all hospitals in
Illinois receiving Medicaid payments from the Illinois
Department and which were located in a planning area with
one-third or fewer excess beds as determined by the Health
Facilities and Services Review Board, and that, as of June
30, 1992, were located in a federally designated Health
Manpower Shortage Area; or
(4) Illinois hospitals that:
(A) have a Medicaid inpatient utilization rate
that is at least equal to the mean Medicaid inpatient
utilization rate for all hospitals in Illinois
receiving Medicaid payments from the Department; and

(B) also have a Medicaid obstetrical inpatient
utilization rate that is at least one standard
deviation above the mean Medicaid obstetrical
inpatient utilization rate for all hospitals in
Illinois receiving Medicaid payments from the
Department for obstetrical services; or
(5) Any children's hospital, which means a hospital
devoted exclusively to caring for children. A hospital
which includes a facility devoted exclusively to caring for
children shall be considered a children's hospital to the
degree that the hospital's Medicaid care is provided to
children if either (i) the facility devoted exclusively to
caring for children is separately licensed as a hospital by
a municipality prior to February 28, 2013; or (ii) the
hospital has been designated by the State as a Level III
perinatal care facility, has a Medicaid Inpatient
Utilization rate greater than 55% for the rate year 2003
disproportionate share determination, and has more than
10,000 qualified children days as defined by the Department
in rulemaking; (iii) the hospital has been designated as a
Perinatal Level III center by the State as of December 1,
2017, is a Pediatric Critical Care Center designated by the
State as of December 1, 2017 and has a 2017 Medicaid
inpatient utilization rate equal to or greater than 45%; or
(iv) the hospital has been designated as a Perinatal Level
II center by the State as of December 1, 2017, has a 2017

Medicaid Inpatient Utilization Rate greater than 70%, and
has at least 10 pediatric beds as listed on the IDPH 2015
calendar year hospital profile.
(c) Inpatient adjustment payments. The adjustment payments
required by paragraph (b) shall be calculated based upon the
hospital's Medicaid inpatient utilization rate as follows:
(1) hospitals with a Medicaid inpatient utilization
rate below the mean shall receive a per day adjustment
payment equal to $25;
(2) hospitals with a Medicaid inpatient utilization
rate that is equal to or greater than the mean Medicaid
inpatient utilization rate but less than one standard
deviation above the mean Medicaid inpatient utilization
rate shall receive a per day adjustment payment equal to
the sum of $25 plus $1 for each one percent that the
hospital's Medicaid inpatient utilization rate exceeds the
mean Medicaid inpatient utilization rate;
(3) hospitals with a Medicaid inpatient utilization
rate that is equal to or greater than one standard
deviation above the mean Medicaid inpatient utilization
rate but less than 1.5 standard deviations above the mean
Medicaid inpatient utilization rate shall receive a per day
adjustment payment equal to the sum of $40 plus $7 for each
one percent that the hospital's Medicaid inpatient
utilization rate exceeds one standard deviation above the
mean Medicaid inpatient utilization rate; and

(4) hospitals with a Medicaid inpatient utilization
rate that is equal to or greater than 1.5 standard
deviations above the mean Medicaid inpatient utilization
rate shall receive a per day adjustment payment equal to
the sum of $90 plus $2 for each one percent that the
hospital's Medicaid inpatient utilization rate exceeds 1.5
standard deviations above the mean Medicaid inpatient
utilization rate.
(d) Supplemental adjustment payments. In addition to the
adjustment payments described in paragraph (c), hospitals as
defined in clauses (1) through (5) of paragraph (b), excluding
county hospitals (as defined in subsection (c) of Section 15-1
of this Code) and a hospital organized under the University of
Illinois Hospital Act, shall be paid supplemental inpatient
adjustment payments of $60 per day. For purposes of Title XIX
of the federal Social Security Act, these supplemental
adjustment payments shall not be classified as adjustment
payments to disproportionate share hospitals.
(e) The inpatient adjustment payments described in
paragraphs (c) and (d) shall be increased on October 1, 1993
and annually thereafter by a percentage equal to the lesser of
(i) the increase in the DRI hospital cost index for the most
recent 12 month period for which data are available, or (ii)
the percentage increase in the statewide average hospital
payment rate over the previous year's statewide average
hospital payment rate. The sum of the inpatient adjustment

payments under paragraphs (c) and (d) to a hospital, other than
a county hospital (as defined in subsection (c) of Section 15-1
of this Code) or a hospital organized under the University of
Illinois Hospital Act, however, shall not exceed $275 per day;
that limit shall be increased on October 1, 1993 and annually
thereafter by a percentage equal to the lesser of (i) the
increase in the DRI hospital cost index for the most recent
12-month period for which data are available or (ii) the
percentage increase in the statewide average hospital payment
rate over the previous year's statewide average hospital
payment rate.
(f) Children's hospital inpatient adjustment payments. For
children's hospitals, as defined in clause (5) of paragraph
(b), the adjustment payments required pursuant to paragraphs
(c) and (d) shall be multiplied by 2.0.
(g) County hospital inpatient adjustment payments. For
county hospitals, as defined in subsection (c) of Section 15-1
of this Code, there shall be an adjustment payment as
determined by rules issued by the Illinois Department.
(h) For the purposes of this Section the following terms
shall be defined as follows:
(1) "Medicaid inpatient utilization rate" means a
fraction, the numerator of which is the number of a
hospital's inpatient days provided in a given 12-month
period to patients who, for such days, were eligible for
Medicaid under Title XIX of the federal Social Security

Act, and the denominator of which is the total number of
the hospital's inpatient days in that same period.
(2) "Mean Medicaid inpatient utilization rate" means
the total number of Medicaid inpatient days provided by all
Illinois Medicaid-participating hospitals divided by the
total number of inpatient days provided by those same
hospitals.
(3) "Medicaid obstetrical inpatient utilization rate"
means the ratio of Medicaid obstetrical inpatient days to
total Medicaid inpatient days for all Illinois hospitals
receiving Medicaid payments from the Illinois Department.
(i) Inpatient adjustment payment limit. In order to meet
the limits of Public Law 102-234 and Public Law 103-66, the
Illinois Department shall by rule adjust disproportionate
share adjustment payments.
(j) University of Illinois Hospital inpatient adjustment
payments. For hospitals organized under the University of
Illinois Hospital Act, there shall be an adjustment payment as
determined by rules adopted by the Illinois Department.
(k) The Illinois Department may by rule establish criteria
for and develop methodologies for adjustment payments to
hospitals participating under this Article.
(l) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in

accordance with Section 5-5e.
(Source: P.A. 97-689, eff. 6-14-12; 98-104, eff. 7-22-13.)
(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
Section 10 of the Managed Care Reform and Patient Rights
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 additions or physician
deletions from the MCO's provider network within 3 days
after receiving all required information from contracted
physicians, and electronic physician 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 penalty imposed under the Illinois Insurance Code
for any claims not timely paid.
(4) The Department may establish a process for MCOs to
expedite payments to providers based on criteria
established by the Department.
(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; 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.
(3) 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.
(4) The rules shall be applicable for both MCO coverage
and fee-for-service coverage.
(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.
(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).
(Source: P.A. 99-725, eff. 8-5-16; 99-751, eff. 8-5-16;
100-201, eff. 8-18-17.)
(305 ILCS 5/5-30.6 new)
Sec. 5-30.6. Managed care organization contracts
procurement requirement. Beginning on the effective date of
this amendatory Act of the 100th General Assembly, any new
contract between the Department and a managed care organization
as defined in Section 5-30.1 shall be procured in accordance
with the Illinois Procurement Code.
(a) Application.
(1) This Section does not apply to the State of
Illinois Medicaid Managed Care Organization Request for
Proposals (2018-24-001) or any agreement, regardless of
what it may be called, related to or arising from this
procurement, including, but not limited to, contracts,

renewals, renegotiated contracts, amendments, and change
orders.
(2) This Section does not apply to Medicare-Medicaid
Alignment Initiative contracts executed under Article V-F
of this Code.
(b) In the event any provision of this Section or of the
Illinois Procurement Code is inconsistent with applicable
federal law or would have the effect of foreclosing the use,
potential use, or receipt of federal financial participation,
the applicable federal law or funding condition shall prevail,
but only to the extent of such inconsistency.
(305 ILCS 5/5-30.7 new)
Sec. 5-30.7. Encounter data guidelines; provider fee
schedule.
(a) No later than 60 days after the effective date of this
amendatory Act of the 100th General Assembly, the Department
shall publish on its website comprehensive written guidance on
the submission of encounter data by managed care organizations.
This information shall be updated and published as needed, but
at least quarterly. The Department shall inform providers and
managed care organizations of any updates via provider notices.
(b) The Department shall publish on its website provider
fee schedules on both a portable document format (PDF) and
EXCEL format. The portable document format shall serve as the
ultimate source if there is a discrepancy.

(305 ILCS 5/5A-15)
Sec. 5A-15. Protection of federal revenue.
(a) If the federal Centers for Medicare and Medicaid
Services finds that any federal upper payment limit applicable
to the payments under this Article is exceeded then:
(1) the payments under this Article that exceed the
applicable federal upper payment limit shall be reduced
uniformly to the extent necessary to comply with the
applicable federal upper payment limit; and
(2) any assessment rate imposed under this Article
shall be reduced such that the aggregate assessment is
reduced by the same percentage reduction applied in
paragraph (1); and
(3) any transfers from the Hospital Provider Fund under
Section 5A-8 shall be reduced by the same percentage
reduction applied in paragraph (1).
(b) Any payment reductions made under the authority granted
in this Section are exempt from the requirements and actions
under Section 5A-10.
(c) If any payments made as a result of the requirements of
this Article are subject to a disallowance, deferral, or
adjustment of federal matching funds then:
(1) the Department shall recoup the payments related to
those federal matching funds paid by the Department from
the parties paid by the Department;

(2) if the payments that are subject to a disallowance,
deferral, or adjustment of federal matching funds were made
to MCOs, the Department shall recoup the payments related
to the disallowance, deferral, or adjustment from the MCOs
no sooner than the Department is required to remit federal
matching funds to the Centers for Medicare and Medicaid
Services or any other federal agency, and hospitals that
received payments from the MCOs that were made with such
disallowed, deferred, or adjusted federal matching funds
must return those payments to the MCOs at least 10 business
days before the MCOs are required to remit such payments to
the Department; and
(3) any assessment paid to the Department by hospitals
under this Article that is attributable to the payments
that are subject to a disallowance, deferral, or adjustment
of federal matching funds, shall be refunded to the
hospitals by the Department.
If an MCO is unable to recoup funds from a hospital for any
reason, then the Department, upon written notice from an MCO,
shall work in good faith with the MCO to mitigate losses
associated with the lack of recoupment. Losses by an MCO shall
not exceed 1% of the total payments distributed by the MCO to
hospitals pursuant to the Hospital Assessment Program.
(Source: P.A. 97-688, eff. 6-14-12; 97-689, eff. 6-14-12.)
Section 99. Effective date. This Act takes effect upon
becoming law, but this Act does not take effect at all unless

Senate Bill 1773 of the 100th General Assembly, as amended,
becomes law.