99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
HB6213

 

Introduced 2/11/2016, by Rep. Carol Ammons

 

SYNOPSIS AS INTRODUCED:
 
See Index

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires each Medicaid Managed Care Entity (MMCE) contracted by the Department of Healthcare and Family Services to: (i) make available on the entity's website a provider directory in a machine readable file and format; (ii) make provider directories publicly accessible without the necessity of providing a password, a username, or personally identifiable information; (iii) make available through an electronic provider directory, for each Medicaid Managed Care Entity Plan offered by the entity, certain information in an easily understandable and searchable format, including the contact information and website URLs, if applicable, of all health care professionals, hospitals, pharmacies, and facilities that provide services to Medicaid recipients under the Medicaid Managed Care Entity Plan. Requires each MMCE to ensure that all information included in a print version of the provider directory is updated at least monthly and that the electronic provider directory is updated no later than 3 business days after the MMCE receives updated provider information. Provides that non-compliance with these and other specified requirements may subject the MMCE to certain sanctions. Requires the Department's client enrollment services broker to post certain information on the broker's website, including, information explaining the circumstances under which a Medicaid enrollee can file a grievance or request a hearing to appeal an adverse action by the Department or the MMCE; information on the Medicaid eligibility redetermination process; and information on Medicaid care coordination. Requires the Department to create a consumer quality comparison tool to assist enrollees with Medicaid Managed Care Entity Plan selection. Effective immediately.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB6213LRB099 19222 KTG 45140 b

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 and by adding Section 5-30.3 as
6follows:
 
7    (305 ILCS 5/5-30.1)
8    Sec. 5-30.1. Managed care protections.
9    (a) As used in this Section:
10    "Managed care organization" or "MCO" means any entity which
11contracts with the Department to provide services where payment
12for medical services is made on a capitated basis.
13    "Emergency services" include:
14        (1) emergency services, as defined by Section 10 of the
15    Managed Care Reform and Patient Rights Act;
16        (2) emergency medical screening examinations, as
17    defined by Section 10 of the Managed Care Reform and
18    Patient Rights Act;
19        (3) post-stabilization medical services, as defined by
20    Section 10 of the Managed Care Reform and Patient Rights
21    Act; and
22        (4) emergency medical conditions, as defined by
23    Section 10 of the Managed Care Reform and Patient Rights

 

 

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

 

 

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

 

 

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

 

 

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1            (A) ensure that an adequate provider network is in
2        place, taking into consideration health professional
3        shortage areas and medically underserved areas;
4            (B) publicly release an explanation of its process
5        for analyzing network adequacy;
6            (C) periodically ensure that an MCO continues to
7        have an adequate network in place; and
8            (D) require MCOs, including Medicaid Managed Care
9        Entities as defined in Section 5-30.2, to meet provider
10        directory requirements under Section 5-30.3. require
11        MCOs to maintain an updated and public list of network
12        providers.
13    (g) Timely payment of claims.
14        (1) The MCO shall pay a claim within 30 days of
15    receiving a claim that contains all the essential
16    information needed to adjudicate the claim.
17        (2) The MCO shall notify the billing party of its
18    inability to adjudicate a claim within 30 days of receiving
19    that claim.
20        (3) The MCO shall pay a penalty that is at least equal
21    to the penalty imposed under the Illinois Insurance Code
22    for any claims not timely paid.
23        (4) The Department may establish a process for MCOs to
24    expedite payments to providers based on criteria
25    established by the Department.
26    (h) The Department shall not expand mandatory MCO

 

 

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1enrollment into new counties beyond those counties already
2designated by the Department as of June 1, 2014 for the
3individuals whose eligibility for medical assistance is not the
4seniors or people with disabilities population until the
5Department provides an opportunity for accountable care
6entities and MCOs to participate in such newly designated
7counties.
8    (i) The requirements of this Section apply to contracts
9with accountable care entities and MCOs entered into, amended,
10or renewed after the effective date of this amendatory Act of
11the 98th General Assembly.
12(Source: P.A. 98-651, eff. 6-16-14.)
 
13    (305 ILCS 5/5-30.3 new)
14    Sec. 5-30.3. Empowering meaningful patient choice in
15Medicaid Managed Care.
16    (a) Definitions. As used in this Section:
17    "Client enrollment services broker" means a vendor the
18Department contracts with to carry out activities related to
19Medicaid recipients' enrollment, disenrollment, and renewal
20with Medicaid Managed Care Entities.
21    "Clinical interest" includes, but is not limited to,
22experience working with specific patient populations such as
23people living with HIV/AIDS, people experiencing homelessness,
24people who identify as LGBTQ, and adolescents.
25    "Composite domains" means the synthesized categories

 

 

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1reflecting the standardized quality performance measures
2included in the print and online version of the consumer
3quality comparison tool. At a minimum, these composite domains
4shall display Medicaid Managed Care Entities' individual Plan
5performance on standardized quality, timeliness, and access
6measures.
7    "Consumer quality comparison tool" means an online and
8paper tool developed by the Department with input from
9interested stakeholders reflecting the performance of Medicaid
10Managed Care Entity Plans on standardized quality performance
11measures. This tool shall be designed in a consumer-friendly
12and easily understandable format.
13    "Covered services" means those health care services to
14which a covered person is entitled to under the terms of the
15Medicaid Managed Care Entity Plan.
16    "Electronic composite provider directory" means the
17searchable provider directory tool that displays provider
18directory information from each Medicaid Managed Care Entity
19and is available through the client enrollment services broker.
20    "Facility type" includes, but is not limited to, federally
21qualified health centers, skilled nursing facilities, and
22rehabilitation centers.
23    "Hospital type" includes, but is not limited to, acute
24care, rehabilitation, children's, and cancer hospitals.
25    "Medicaid eligibility redetermination" means the process
26by which the eligibility of a Medicaid recipient is reviewed by

 

 

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1the Department to determine if the recipient's medical benefits
2will continue, be modified, or terminated.
3    "Medicaid Managed Care Entity" has the same meaning as
4defined in Section 5-30.2 of this Code.
5    (b) Provider directory transparency.
6        (1) Each Medicaid Managed Care Entity shall:
7            (A) Make available on the entity's website a
8        provider directory in a machine readable file and
9        format.
10            (B) Make provider directories publicly accessible
11        without the necessity of providing a password, a
12        username, or personally identifiable information.
13            (C) Make available through an electronic provider
14        directory, for each Medicaid Managed Care Entity Plan,
15        the following information in an easily understandable
16        and searchable format:
17                (i) For health care professionals, including
18            dental and vision care providers:
19                    (I) the provider's name;
20                    (II) the street address for each office
21                the provider operates, including each offices'
22                zip code and county location;
23                    (III) the telephone number for each office
24                the provider operates;
25                    (IV) whether the provider serves as a
26                primary care provider;

 

 

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1                    (V) the provider's specialty and clinical
2                interest if applicable;
3                    (VI) the provider's medical group
4                affiliation, if applicable;
5                    (VII) the provider's facility
6                affiliations, if applicable;
7                    (VIII) languages spoken, other than
8                English, by the clinical staff, if applicable;
9                    (IX) whether the provider is accepting new
10                patients;
11                    (X) the hours of operation for each office
12                the provider operates;
13                    (XI) whether each office or facility the
14                provider operates is accessible for people
15                with physical disabilities, including offices,
16                exam rooms, and equipment; and
17                    (XII) the provider's gender.
18                (ii) For hospitals:
19                    (I) the hospital's name and the name of
20                each hospital affiliate, if applicable;
21                    (II) the street address of the hospital
22                and all hospital affiliates, including zip
23                codes and county locations;
24                    (III) the hospital type;
25                    (IV) the hours of operation for the
26                hospital and each hospital affiliate;

 

 

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1                    (V) the types of services performed by the
2                hospital and each hospital affiliate; and
3                    (VI) the accreditation status of the
4                hospital and each hospital affiliate.
5                (iii) For facilities other than hospitals:
6                    (I) the facility's name;
7                    (II) the street address for the facility
8                and for each affiliate of the facility,
9                including zip codes and county locations;
10                    (III) the facility type;
11                    (IV) the hours of operation for the
12                facility and for each affiliate of the
13                facility; and
14                    (V) the types of services performed by the
15                facility and each affiliate of the facility.
16                (iv) For pharmacies other than hospitals:
17                    (I) the pharmacy's name;
18                    (II) the pharmacy's street address and the
19                street address of each store the pharmacy
20                operates, including zip codes and county
21                locations; and
22                    (III) the pharmacy's hours of operation.
23                (v) For durable medical equipment suppliers
24            other than hospitals:
25                    (I) the durable medical equipment
26                supplier's name;

 

 

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1                    (II) the supplier's street address or
2                street addresses if the supplier operates more
3                than one business, including zip codes and
4                county locations;
5                    (III) categories of supplies offered; and
6                    (IV) the supplier's hours of operation.
7            (D) Make available, for the electronic provider
8        directory of each Medicaid Managed Care Entity Plan,
9        the following information in addition to all of the
10        information under subparagraph (C):
11                (i) For health care professionals: types of
12            services performed; whether the provider is
13            accepting children, adults, or both; board
14            certification, if applicable; and website URL, if
15            applicable.
16                (ii) For hospitals: telephone number and
17            website URL.
18                (iii) For facilities other than hospitals:
19            telephone number and website URL.
20                (iv) For pharmacies: telephone number and, if
21            applicable, website URL.
22                (v) For durable medical equipment suppliers,
23            other than hospitals: telephone number and, if
24            applicable, website URL.
25                (vi) For non-emergency medical transportation:
26            provider contact information, including telephone

 

 

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1            number, hours of operation, areas served, and, if
2            applicable, website URL.
3            (E) Make the following provider directory
4        information for the applicable Medicaid Managed Care
5        Entity Plan available in print upon request in an
6        easily understandable format:
7                (i) For health care professionals:
8                    (I) the health care professional's name;
9                    (II) the street address for each office
10                the health care professional operates,
11                including each offices' zip code and county
12                location;
13                    (III) the telephone number for each office
14                the health care professional operates;
15                    (IV) whether the health care professional
16                serves as a primary care provider;
17                    (V) the health care professional's
18                specialty and clinical interest if applicable;
19                    (VI) the health care professional's board
20                certification, if applicable;
21                    (VII) the health care professional's
22                medical group affiliation, if applicable;
23                    (VII) the health care professional's
24                facility affiliations, if applicable;
25                    (VIII) languages spoken, other than
26                English, by the clinical staff, if applicable;

 

 

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1                    (IX) whether the health care professional
2                is accepting new patients;
3                    (X) the health care professional's office
4                hours;
5                    (XI) the health care professional's
6                website URL;
7                    (XII) whether the health care
8                professional's office or facility is
9                accessible for people with physical
10                disabilities, including offices, exam rooms,
11                and equipment; and
12                    (XIII) the health care professional's
13                gender.
14                (ii) For hospitals:
15                    (I) the hospital's name and the name of
16                each hospital affiliate, if applicable;
17                    (II) the hospital's street address and the
18                street address of each hospital affiliate,
19                including zip codes and county locations;
20                    (III) the hospital's telephone number and
21                website URL;
22                    (IV) the hospital type;
23                    (V) the hospital's hours of operation and
24                the hours of operation of each hospital
25                affiliate;
26                    (VI) the types of services offered at the

 

 

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1                hospital and at each hospital affiliate; and
2                    (VII) the accreditation status of the
3                hospital and each hospital affiliate.
4                (iii) For facilities other than hospitals:
5                    (I) the facility's name;
6                    (II) the street address for the facility
7                and for each affiliate of the facility,
8                including zip codes and county locations;
9                    (III) the facility's telephone number and
10                website URL;
11                    (IV) the facility type;
12                    (V) the facility's hours of operation; and
13                    (VI) the types of services performed by
14                the facility and each affiliate of the
15                facility, if applicable.
16                (iv) For pharmacies other than hospitals:
17                    (I) the pharmacy's name;
18                    (II) the pharmacy's street address and the
19                address of each store the pharmacy operates,
20                including zip codes and county locations;
21                    (III) the pharmacy's telephone number and,
22                if applicable, website URL; and
23                    (IV) the pharmacy's hours of operation.
24                (v) For durable medical equipment suppliers
25            other than hospitals:
26                    (I) the durable medical equipment

 

 

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1                supplier's name;
2                    (II) the supplier's street address or
3                street addresses if the supplier operates more
4                than one business, including zip codes and
5                county locations;
6                    (III) the supplier's telephone numbers
7                and, if applicable, website URL;
8                    (IV) categories of supplies offered; and
9                    (V) the supplier's hours of operation.
10                (vii) For non-emergency medical transportation
11            providers:
12                    (I) the provider's name;
13                    (II) the provider's street address or
14                street addresses if the provider operates more
15                than one office, including zip codes and county
16                locations;
17                    (III) the provider's telephone number and,
18                if applicable, website URL;
19                    (IV) areas where services are available;
20                and
21                    (V) the provider's hours of operation.
22            (F) Include a disclosure in any print version of
23        the provider directory that all information required
24        under subparagraph (E) of paragraph (1) of subsection
25        (b) is accurate as of the date of the directory
26        publication and that up-to-date information can be

 

 

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1        obtained by consulting the Medicaid Managed Care
2        Entity's online directory or by telephone. The
3        Medicaid Managed Care Entity shall include the
4        appropriate website URL and telephone number as part of
5        the disclosure.
6            (G) Ensure that all information included in a print
7        version of the provider directory is updated at least
8        monthly and that the electronic provider directory is
9        updated no later than 3 business days after the
10        Medicaid Managed Care Entity receives updated provider
11        information.
12            (H) Confirm with the Medicaid Managed Care
13        Entity's contracted providers who have not submitted
14        claims within the past 6 months that the contracted
15        providers intend to remain in the network and correct
16        any incorrect provider directory information as
17        necessary.
18            (I) Ensure that in situations in which a Medicaid
19        Managed Care Entity Plan enrollee receives covered
20        services from a non-participating provider due to a
21        material misrepresentation in a Medicaid Managed Care
22        Entity's provider directory, the Medicaid Managed Care
23        Entity Plan enrollee shall not be held responsible for
24        any costs resulting from that material
25        misrepresentation.
26            (J) Conspicuously display an e-mail address and a

 

 

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1        toll-free telephone number to which any individual may
2        report any inaccuracy in the respective print and
3        electronic versions of the provider directory. If the
4        Medicaid Managed Care Entity receives a report from any
5        person who specifically identifies provider directory
6        information as inaccurate, the Medicaid Managed Care
7        Entity shall investigate the report and correct any
8        inaccurate information displayed in the electronic
9        directory, as necessary, no later than the third
10        business day after the date the report is received.
11            (K) Make electronic and print provider directories
12        available in English, Spanish, and other prevalent
13        languages spoken by a significant number or percentage
14        of Medicaid enrollees within each Medicaid Managed
15        Care Entity's service areas.
16        (2) The Department shall:
17            (A) Regularly monitor Medicaid Managed Care
18        Entities to ensure that they are compliant with the
19        requirements under paragraph (1) of subsection (b).
20        Medicaid Managed Care Entities found materially
21        non-compliant with the requirements under paragraph
22        (1) of subsection (b) may be subject to sanctions
23        imposed by the Department, including, but not limited
24        to: (i) a suspension of the enrollment of potential
25        enrollees with the Medicaid Managed Care Entity; (ii) a
26        financial withhold of pay-for-performance funds; (iii)

 

 

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1        a withhold of some or all of the monthly capitation
2        payments; or (iv) any other penalties or sanctions
3        allowed by State or federal law.
4            (B) Require that the information specified in
5        subparagraphs (B) through (D) of paragraph (1) of
6        subsection (b) for each Medicaid Managed Care Entity
7        shall also be made available and searchable through the
8        electronic composite provider directory tool on the
9        client enrollment services broker's website.
10            (C) Require the client enrollment services broker
11        to conspicuously display near the electronic composite
12        provider directory tool an e-mail address and a
13        toll-free telephone number to which any individual may
14        report inaccuracies in the directory tool. If the
15        client enrollment services broker receives a report
16        that identifies an inaccuracy in the electronic
17        composite provider directory tool, the client
18        enrollment services broker shall report the complaint
19        about the inaccuracy to the appropriate Medicaid
20        Managed Care Entity within 3 business days after the
21        report is received. The Medicaid Managed Care Entity
22        shall investigate the information and, within 3
23        business days, provide the client enrollment services
24        broker updated information in order for the client
25        enrollment services broker to correct the electronic
26        composite provider directory. The Medicaid Managed

 

 

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1        Care Entity Plan shall, within 3 business days, also
2        update its provider directory tool based on this
3        corrected information.
4    (c) Formulary transparency.
5        (1) Medicaid Managed Care Entities shall publish on
6    their respective websites a formulary for each Medicaid
7    Managed Care Entity Plan offered and make the formularies
8    easily understandable and publicly accessible without the
9    necessity of providing a password, a username, or
10    personally identifiable information.
11        (2) Medicaid Managed Care Entities shall provide
12    printed formularies upon request.
13        (3) Electronic and print formularies shall display:
14            (A) the medications covered (both generic and name
15        brand);
16            (B) if the medication is preferred or not
17        preferred, and what each term means;
18            (C) what tier each medication is in and the meaning
19        of each tier;
20            (D) any utilization controls including, but not
21        limited to, step therapy, prior approval, dosage
22        limits, gender or age restrictions, quantity limits,
23        or other policies that affect access to medications;
24            (E) any required cost-sharing;
25            (F) a glossary of key terms and explanation of
26        utilization controls and cost-sharing requirements;

 

 

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1            (G) a key or legend for all utilization controls
2        visible on every page in which specific medication
3        coverage information is displayed; and
4            (H) directions explaining the process or processes
5        a consumer may follow to obtain more information if a
6        medication the consumer requires is not covered or
7        listed in the formulary.
8        (4) Each Medicaid Managed Care Entity shall display
9    conspicuously with each electronic and printed medication
10    formulary an e-mail address and a toll-free telephone
11    number to which any individual may report any inaccuracy in
12    the formulary. If the Medicaid Managed Care Entity receives
13    a report that the formulary information is inaccurate, the
14    Medicaid Managed Care Entity shall investigate the report
15    and correct any incorrect information, as necessary, no
16    later than the third business day after the date the report
17    is received.
18        (5) Each Medicaid Managed Care Entity shall update
19    electronic formularies within 3 business days of any
20    formulary change and update, at least monthly, printed
21    formularies. The Medicaid Managed Care Entity shall
22    include a disclosure in the electronic and print
23    formularies that provides the date of publication, a
24    statement that the formulary is up to date as of
25    publication, and contact information for questions and
26    requests to receive updated information.

 

 

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1        (6) Medicaid Managed Care Entities shall make their
2    electronic and print formularies available in English,
3    Spanish, and other prevalent languages spoken by a
4    significant number or percentage of Medicaid enrollees
5    within each Medicaid Managed Care Entity's service areas.
6        (7) Medicaid Managed Care Entities found materially
7    non-complaint with the requirements under paragraphs (1)
8    through (6) may be subject to sanctions imposed by the
9    Department, including, but not limited to: (i) a suspension
10    of the enrollment of potential enrollees with the Medicaid
11    Managed Care Entity; (ii) a financial withhold of
12    pay-for-performance funds; (iii) a withhold of some or all
13    of the monthly capitation payments; or (iv) any other
14    penalties or sanctions allowed by State or federal law.
15        (8) The client enrollment services broker's website
16    shall display prominently a website URL link to each
17    Medicaid Managed Care Entity's Plan formulary.
18    (d) Grievances and appeals.
19        (1) The Department shall require the client enrollment
20    services broker to display prominently on the client
21    enrollment services broker's website an explanation of the
22    circumstances and processes for a Medicaid enrollee to file
23    a complaint or grievance and of the enrollee's right to
24    appeal and request a fair hearing for any adverse action by
25    the Department or the Medicaid Managed Care Entity. This
26    information shall also be made available to Medicaid

 

 

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1    enrollees whenever an enrollee uses the client enrollment
2    services broker's toll-free telephone number regarding an
3    adverse action taken by the Department or the Medicaid
4    Managed Care Entity or regarding another complaint or
5    concern. This information shall include, but shall not be
6    limited to, explanations about procedures and timeframes
7    describing how an enrollee may pursue his or her rights
8    under the law and how he or she can access free legal
9    assistance or other assistance made available by the State
10    for Medicaid enrollees to pursue an action. The information
11    required under this subsection shall also be made available
12    to Medicaid enrollees upon request through the client
13    enrollment services broker's toll-free telephone number.
14        (2) The Department shall require the client enrollment
15    services broker to display prominently on the client
16    enrollment services broker's website the information
17    required under paragraph (1) in English, Spanish, and other
18    prevalent languages spoken by a significant number or
19    percentage of Medicaid enrollees in Illinois.
20    (e) Medicaid redetermination information.
21        (1) The client enrollment services broker shall
22    display prominently on its website, in an easily
23    understandable format, consumer-oriented information
24    regarding the Medicaid eligibility redetermination
25    process. Such information shall include, but shall not be
26    limited to:

 

 

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1            (A) the role of the Medicaid eligibility
2        redetermination process and how it differs from the
3        Medicaid Managed Care enrollment and renewal process;
4            (B) how the Department will inform Medicaid
5        enrollees when their Medicaid eligibility is under
6        redetermination review;
7            (C) a basic description of Medicaid enrollee
8        obligations under the Medicaid eligibility
9        redetermination process, including examples of
10        documentation that may be required by the Medicaid
11        enrollee to submit during the Medicaid eligibility
12        redetermination process; and
13            (D) appropriate resources to find additional
14        information on the Medicaid eligibility
15        redetermination process.
16        (2) The Department shall require the client enrollment
17    services broker to display prominently on the client
18    enrollment services broker's website the information
19    required under paragraph (1) in English, Spanish, and other
20    prevalent languages spoken by a significant number or
21    percentage of Medicaid enrollees in Illinois.
22    (f) Medicaid care coordination information.
23        (1) The client enrollment services broker shall
24    display prominently on its website, in an easily
25    understandable format, consumer-oriented information
26    regarding the role of care coordination services within

 

 

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1    Medicaid Managed Care. Such information shall include, but
2    shall not be limited to:
3            (A) a basic description of the role of care
4        coordination services and examples of specific care
5        coordination activities; and
6            (B) how a Medicaid enrollee may request care
7        coordination services from a Medicaid Managed Care
8        Entity.
9        (2) The Department shall require the client enrollment
10    services broker to display prominently on the client
11    enrollment services broker's website the information
12    required under paragraph (1) in English, Spanish, and other
13    prevalent languages spoken by a significant number or
14    percentage of Medicaid enrollees in Illinois.
15    (g) Consumer quality comparison tool.
16        (1) The Department shall create a consumer quality
17    comparison tool to assist Medicaid enrollees with Medicaid
18    Managed Care Entity Plan selection. This tool shall provide
19    Medicaid Managed Care Entities' individual Plan
20    performance on a set of standardized quality performance
21    measures. The Department shall ensure that this tool shall
22    be accessible in both a print and online format, with the
23    online format allowing for individuals to access
24    additional detailed Plan performance information.
25        (2) At a minimum, the print version of the consumer
26    quality comparison tool shall be provided by the Department

 

 

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1    on an annual basis to Medicaid enrollees who are required
2    by the Department to enroll in a Medicaid Managed Care
3    Entity Plan during an enrollee's open enrollment period.
4    The print version of the consumer quality comparison tool
5    shall also meet all of the following criteria:
6            (A) Display Medicaid Managed Care Entities'
7        individual Plan performance on at least 4 composite
8        domains that reflect Plan quality, timeliness, and
9        access. The composite domains shall draw from the most
10        current available performance data sets including, but
11        not limited to:
12                (i) Healthcare Effectiveness Data and
13            Information Set (HEDIS) measures.
14                (ii) Core Set of Children's Health Care
15            Quality measures as required under the Children's
16            Health Insurance Program Reauthorization Act
17            (CHIPRA).
18                (iii) Adult Core Set measures.
19                (iv) Consumer Assessment of Healthcare
20            Providers and Systems (CAHPS) survey results.
21                (v) Additional performance measures the
22            Department deems appropriate to populate the
23            composite domains.
24            (B) Use a 5-star rating system developed by the
25        Department to reflect Medicaid Managed Care Entities'
26        individual Plan performance. The quantity of stars for

 

 

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1        each composite domain shall reflect the Medicaid
2        Managed Care Entities' individual Plan performance
3        compared to national benchmark performance averages
4        when national benchmarks are available.
5            (C) Be customized to reflect the specific Medicaid
6        Managed Care Entities' Plans available to the Medicaid
7        enrollee based on his or her geographic location and
8        Medicaid eligibility category.
9            (D) Include contact information for the client
10        enrollment services broker and contact information for
11        Medicaid Managed Care Entities available to the
12        Medicaid enrollee based on his or her geographic
13        location and Medicaid eligibility category.
14            (E) Include guiding questions designed to assist
15        individuals selecting a Medicaid Managed Care Entity
16        Plan.
17            (F) Be made available in English, Spanish, and
18        other prevalent languages spoken by a significant
19        number or percentage of Medicaid enrollees within each
20        Medicaid Managed Care Entity's service areas.
21        (3) At a minimum, the online version of the consumer
22    quality comparison tool shall meet all of the following
23    criteria:
24            (A) Display Medicaid Managed Care Entities'
25        individual Plan performance for the same composite
26        domains selected by the Department for the print

 

 

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1        version of the consumer quality comparison tool. The
2        Department may display additional composite domains in
3        the online version of the consumer quality comparison
4        tool as appropriate.
5            (B) Display Medicaid Managed Care Entities'
6        individual Plan performance on each of the
7        standardized performance measures that contribute to
8        each composite domain displayed on the online version
9        of the consumer quality comparison tool.
10            (C) Use a 5-star rating system developed by the
11        Department to reflect Medicaid Managed Care Entities'
12        individual Plan performance. The quantity of stars for
13        each composite domain shall reflect the Medicaid
14        Managed Care Entities' individual Plan performance
15        compared to national benchmark performance averages
16        when national benchmarks are available.
17            (D) Include a sort function to reflect the specific
18        Medicaid Managed Care Entity Plans available to the
19        Medicaid enrollee based on his or her geographic
20        location and Medicaid eligibility category.
21            (E) Include a sort function to view Medicaid
22        Managed Care Entities' individual Plan performance by
23        star rating and by standardized quality performance
24        measures.
25            (F) Include contact information for the client
26        enrollment services broker and for each Medicaid

 

 

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1        Managed Care Entity.
2            (G) Include guiding questions designed to assist
3        individuals in selecting a Medicaid Managed Care
4        Entity Plan.
5            (H) Prominently display current notice of
6        sanctions against Medicaid Managed Care Entities.
7        Notice of the sanctions shall remain present on the
8        online version of the consumer quality comparison tool
9        until the sanctions are lifted.
10            (I) Be made available in English, Spanish, and
11        other prevalent languages spoken by a significant
12        number or percentage of Medicaid enrollees within each
13        of the Medicaid Managed Care Entity's service areas.
14        (4) The online version of the consumer quality
15    comparison tool shall be displayed prominently on the
16    client enrollment services broker's website.
17        (5) In the development of the consumer quality
18    comparison tool, the Department shall establish and
19    publicize a formal process to collect and consider written
20    and oral feedback from consumers, advocates, and
21    stakeholders on aspects of the consumer quality comparison
22    tool, including, but not limited to, the following:
23            (A) The standardized data sets and surveys,
24        specific performance measures, and composite domains
25        represented in the print and online versions of the
26        consumer quality comparison tool.

 

 

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1            (B) The format and presentation of the consumer
2        quality comparison tool.
3            (C) The methods undertaken by the Department to
4        notify Medicaid enrollees of the availability of the
5        print and online versions of the consumer quality
6        comparison tool.
7        (6) The Department shall review and update as
8    appropriate the composite domains and performance measures
9    represented in the print and online versions of the
10    consumer quality comparison tool at least once every 3
11    years. During the Department's review process, the
12    Department shall solicit engagement in the public feedback
13    process described in paragraph (5).
14        (7) The Department shall ensure that the consumer
15    quality comparison tool shall be available for consumer use
16    no later than 12 months following the effective date of
17    this amendatory Act of the 99th General Assembly.
18    (h) The Department may adopt rules and take any other
19appropriate action necessary to implement its responsibilities
20under this Section.
 
21    Section 99. Effective date. This Act takes effect upon
22becoming law.

 

 

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1 INDEX
2 Statutes amended in order of appearance
3    305 ILCS 5/5-30.1
4    305 ILCS 5/5-30.3 new