101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
SB1604

 

Introduced 2/15/2019, by Sen. Elgie R. Sims, Jr.

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-30.1

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to establish, by rule, minimum quality standards for providers of medical supplies, equipment, and related services applicable to contracted managed care organizations for all services rendered to MCO enrollees. Requires the minimum quality standards to be based upon recognized national standards promulgated by national bodies and by the Centers for Medicare and Medicaid Services. Requires the Department to set a rate of reimbursement payable by contracted managed care organizations to contracted, in-network providers of medical supplies, equipment, and related services at the default rate of reimbursement paid under the Illinois Medicaid fee-for-service program methodology for such medical supplies, equipment, and related services in effect as of June 30, 2017. Requires contracted managed care organizations to offer a reimbursement rate to contracted, in-network providers of medical supplies, equipment, and related services at not less than 90% of the default rate of reimbursement paid under the Illinois Medicaid fee-for-service program methodology, including all policy adjusters, for such medical supplies, equipment, and related services of similar quality. Provides that these provisions shall not be construed to allow the Department or its contracted MCOs to enter into sole source contracts for the provision of durable medical equipment, supplies, or related services to Medicaid beneficiaries and Medicaid managed care enrollees. Effective immediately.


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FISCAL NOTE ACT MAY APPLY

 

 

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 5-30.1 as follows:
 
6    (305 ILCS 5/5-30.1)
7    Sec. 5-30.1. Managed care protections.
8    (a) As used in this Section:
9    "Managed care organization" or "MCO" means any entity which
10contracts with the Department to provide services where payment
11for medical services is made on a capitated basis.
12    "Emergency services" include:
13        (1) emergency services, as defined by Section 10 of the
14    Managed Care Reform and Patient Rights Act;
15        (2) emergency medical screening examinations, as
16    defined by Section 10 of the Managed Care Reform and
17    Patient Rights Act;
18        (3) post-stabilization medical services, as defined by
19    Section 10 of the Managed Care Reform and Patient Rights
20    Act; and
21        (4) emergency medical conditions, as defined by
22    Section 10 of the Managed Care Reform and Patient Rights
23    Act.

 

 

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1    (b) As provided by Section 5-16.12, managed care
2organizations are subject to the provisions of the Managed Care
3Reform and Patient Rights Act.
4    (c) An MCO shall pay any provider of emergency services
5that does not have in effect a contract with the contracted
6Medicaid MCO. The default rate of reimbursement shall be the
7rate paid under Illinois Medicaid fee-for-service program
8methodology, including all policy adjusters, including but not
9limited to Medicaid High Volume Adjustments, Medicaid
10Percentage Adjustments, Outpatient High Volume Adjustments,
11and all outlier add-on adjustments to the extent such
12adjustments are incorporated in the development of the
13applicable MCO capitated rates.
14    (d) An MCO shall pay for all post-stabilization services as
15a covered service in any of the following situations:
16        (1) the MCO authorized such services;
17        (2) such services were administered to maintain the
18    enrollee's stabilized condition within one hour after a
19    request to the MCO for authorization of further
20    post-stabilization services;
21        (3) the MCO did not respond to a request to authorize
22    such services within one hour;
23        (4) the MCO could not be contacted; or
24        (5) the MCO and the treating provider, if the treating
25    provider is a non-affiliated provider, could not reach an
26    agreement concerning the enrollee's care and an affiliated

 

 

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1    provider was unavailable for a consultation, in which case
2    the MCO must pay for such services rendered by the treating
3    non-affiliated provider until an affiliated provider was
4    reached and either concurred with the treating
5    non-affiliated provider's plan of care or assumed
6    responsibility for the enrollee's care. Such payment shall
7    be made at the default rate of reimbursement paid under
8    Illinois Medicaid fee-for-service program methodology,
9    including all policy adjusters, including but not limited
10    to Medicaid High Volume Adjustments, Medicaid Percentage
11    Adjustments, Outpatient High Volume Adjustments and all
12    outlier add-on adjustments to the extent that such
13    adjustments are incorporated in the development of the
14    applicable MCO capitated rates.
15    (e) The following requirements apply to MCOs in determining
16payment for all emergency services:
17        (1) MCOs shall not impose any requirements for prior
18    approval of emergency services.
19        (2) The MCO shall cover emergency services provided to
20    enrollees who are temporarily away from their residence and
21    outside the contracting area to the extent that the
22    enrollees would be entitled to the emergency services if
23    they still were within the contracting area.
24        (3) The MCO shall have no obligation to cover medical
25    services provided on an emergency basis that are not
26    covered services under the contract.

 

 

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1        (4) The MCO shall not condition coverage for emergency
2    services on the treating provider notifying the MCO of the
3    enrollee's screening and treatment within 10 days after
4    presentation for emergency services.
5        (5) The determination of the attending emergency
6    physician, or the provider actually treating the enrollee,
7    of whether an enrollee is sufficiently stabilized for
8    discharge or transfer to another facility, shall be binding
9    on the MCO. The MCO shall cover emergency services for all
10    enrollees whether the emergency services are provided by an
11    affiliated or non-affiliated provider.
12        (6) The MCO's financial responsibility for
13    post-stabilization care services it has not pre-approved
14    ends when:
15            (A) a plan physician with privileges at the
16        treating hospital assumes responsibility for the
17        enrollee's care;
18            (B) a plan physician assumes responsibility for
19        the enrollee's care through transfer;
20            (C) a contracting entity representative and the
21        treating physician reach an agreement concerning the
22        enrollee's care; or
23            (D) the enrollee is discharged.
24    (f) Network adequacy and transparency.
25        (1) The Department shall:
26            (A) ensure that an adequate provider network is in

 

 

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1        place, taking into consideration health professional
2        shortage areas and medically underserved areas;
3            (B) publicly release an explanation of its process
4        for analyzing network adequacy;
5            (C) periodically ensure that an MCO continues to
6        have an adequate network in place; and
7            (D) require MCOs, including Medicaid Managed Care
8        Entities as defined in Section 5-30.2, to meet provider
9        directory requirements under Section 5-30.3.
10        (2) Each MCO shall confirm its receipt of information
11    submitted specific to physician or dentist additions or
12    physician or dentist deletions from the MCO's provider
13    network within 3 days after receiving all required
14    information from contracted physicians or dentists, and
15    electronic physician and dental directories must be
16    updated consistent with current rules as published by the
17    Centers for Medicare and Medicaid Services or its successor
18    agency.
19    (g) Timely payment of claims.
20        (1) The MCO shall pay a claim within 30 days of
21    receiving a claim that contains all the essential
22    information needed to adjudicate the claim.
23        (2) The MCO shall notify the billing party of its
24    inability to adjudicate a claim within 30 days of receiving
25    that claim.
26        (3) The MCO shall pay a penalty that is at least equal

 

 

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1    to the penalty imposed under the Illinois Insurance Code
2    for any claims not timely paid.
3        (4) The Department may establish a process for MCOs to
4    expedite payments to providers based on criteria
5    established by the Department.
6    (g-5) Recognizing that the rapid transformation of the
7Illinois Medicaid program may have unintended operational
8challenges for both payers and providers:
9        (1) in no instance shall a medically necessary covered
10    service rendered in good faith, based upon eligibility
11    information documented by the provider, be denied coverage
12    or diminished in payment amount if the eligibility or
13    coverage information available at the time the service was
14    rendered is later found to be inaccurate; and
15        (2) the Department shall, by December 31, 2016, adopt
16    rules establishing policies that shall be included in the
17    Medicaid managed care policy and procedures manual
18    addressing payment resolutions in situations in which a
19    provider renders services based upon information obtained
20    after verifying a patient's eligibility and coverage plan
21    through either the Department's current enrollment system
22    or a system operated by the coverage plan identified by the
23    patient presenting for services:
24            (A) such medically necessary covered services
25        shall be considered rendered in good faith;
26            (B) such policies and procedures shall be

 

 

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1        developed in consultation with industry
2        representatives of the Medicaid managed care health
3        plans and representatives of provider associations
4        representing the majority of providers within the
5        identified provider industry; and
6            (C) such rules shall be published for a review and
7        comment period of no less than 30 days on the
8        Department's website with final rules remaining
9        available on the Department's website.
10        (3) The rules on payment resolutions shall include, but
11    not be limited to:
12            (A) the extension of the timely filing period;
13            (B) retroactive prior authorizations; and
14            (C) guaranteed minimum payment rate of no less than
15        the current, as of the date of service, fee-for-service
16        rate, plus all applicable add-ons, when the resulting
17        service relationship is out of network.
18        (4) The rules shall be applicable for both MCO coverage
19    and fee-for-service coverage.
20    (g-6) MCO Performance Metrics Report.
21        (1) The Department shall publish, on at least a
22    quarterly basis, each MCO's operational performance,
23    including, but not limited to, the following categories of
24    metrics:
25            (A) claims payment, including timeliness and
26        accuracy;

 

 

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1            (B) prior authorizations;
2            (C) grievance and appeals;
3            (D) utilization statistics;
4            (E) provider disputes;
5            (F) provider credentialing; and
6            (G) member and provider customer service.
7        (2) The Department shall ensure that the metrics report
8    is accessible to providers online by January 1, 2017.
9        (3) The metrics shall be developed in consultation with
10    industry representatives of the Medicaid managed care
11    health plans and representatives of associations
12    representing the majority of providers within the
13    identified industry.
14        (4) Metrics shall be defined and incorporated into the
15    applicable Managed Care Policy Manual issued by the
16    Department.
17    (g-7) MCO claims processing and performance analysis. In
18order to monitor MCO payments to hospital providers, pursuant
19to this amendatory Act of the 100th General Assembly, the
20Department shall post an analysis of MCO claims processing and
21payment performance on its website every 6 months. Such
22analysis shall include a review and evaluation of a
23representative sample of hospital claims that are rejected and
24denied for clean and unclean claims and the top 5 reasons for
25such actions and timeliness of claims adjudication, which
26identifies the percentage of claims adjudicated within 30, 60,

 

 

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190, and over 90 days, and the dollar amounts associated with
2those claims. The Department shall post the contracted claims
3report required by HealthChoice Illinois on its website every 3
4months.
5    (h) The Department shall not expand mandatory MCO
6enrollment into new counties beyond those counties already
7designated by the Department as of June 1, 2014 for the
8individuals whose eligibility for medical assistance is not the
9seniors or people with disabilities population until the
10Department provides an opportunity for accountable care
11entities and MCOs to participate in such newly designated
12counties.
13    (i) The requirements of this Section apply to contracts
14with accountable care entities and MCOs entered into, amended,
15or renewed after June 16, 2014 (the effective date of Public
16Act 98-651).
17    (j) Notwithstanding any other Public Act or contract terms
18and conditions, the Department shall establish, by rule,
19minimum quality standards for providers of medical supplies,
20equipment, and related services applicable to contracted
21managed care organizations for all services rendered to MCO
22enrollees. The minimum quality standards shall be based upon
23recognized national standards promulgated by national bodies
24and by the Centers for Medicare and Medicaid Services.
25    The Department shall set a rate of reimbursement payable by
26contracted managed care organizations to contracted,

 

 

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1in-network providers of medical supplies, equipment, and
2related services at the default rate of reimbursement paid
3under the Illinois Medicaid fee-for-service program
4methodology, including all policy adjusters, for such medical
5supplies, equipment, and related services in effect as of June
630, 2017. Such rates shall be held in effect until the
7Department adopts minimum quality standards as required in this
8subsection.
9    After the Department adopts minimum quality standards as
10required in this subsection, contracted managed care
11organizations shall offer a reimbursement rate to contracted,
12in-network providers of medical supplies, equipment, and
13related services at not less than 90% of the default rate of
14reimbursement paid under the Illinois Medicaid fee-for-service
15program methodology, including all policy adjusters, for such
16medical supplies, equipment, and related services of similar
17quality.
18    Notwithstanding any other Public Act or contract terms and
19conditions, nothing in this subsection shall be construed to
20allow the Department or its contracted MCOs to enter into sole
21source contracts for the provision of durable medical
22equipment, supplies, or related services to Medicaid
23beneficiaries and Medicaid managed care enrollees.
24(Source: P.A. 99-725, eff. 8-5-16; 99-751, eff. 8-5-16;
25100-201, eff. 8-18-17; 100-580, eff. 3-12-18; 100-587, eff.
266-4-18.)
 

 

 

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1    Section 99. Effective date. This Act takes effect upon
2becoming law.