Rep. Carol Ammons

Filed: 4/15/2016

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 6213

2    AMENDMENT NO. ______. Amend House Bill 6213 by replacing
3everything after the enacting clause with the following:
 
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

 

 

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

 

 

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1    request to the MCO for authorization of further
2    post-stabilization services;
3        (3) the MCO did not respond to a request to authorize
4    such services within one hour;
5        (4) the MCO could not be contacted; or
6        (5) the MCO and the treating provider, if the treating
7    provider is a non-affiliated provider, could not reach an
8    agreement concerning the enrollee's care and an affiliated
9    provider was unavailable for a consultation, in which case
10    the MCO must pay for such services rendered by the treating
11    non-affiliated provider until an affiliated provider was
12    reached and either concurred with the treating
13    non-affiliated provider's plan of care or assumed
14    responsibility for the enrollee's care. Such payment shall
15    be made at the default rate of reimbursement paid under
16    Illinois Medicaid fee-for-service program methodology,
17    including all policy adjusters, including but not limited
18    to Medicaid High Volume Adjustments, Medicaid Percentage
19    Adjustments, Outpatient High Volume Adjustments and all
20    outlier add-on adjustments to the extent that such
21    adjustments are incorporated in the development of the
22    applicable MCO capitated rates.
23    (e) The following requirements apply to MCOs in determining
24payment for all emergency services:
25        (1) MCOs shall not impose any requirements for prior
26    approval of emergency services.

 

 

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1        (2) The MCO shall cover emergency services provided to
2    enrollees who are temporarily away from their residence and
3    outside the contracting area to the extent that the
4    enrollees would be entitled to the emergency services if
5    they still were within the contracting area.
6        (3) The MCO shall have no obligation to cover medical
7    services provided on an emergency basis that are not
8    covered services under the contract.
9        (4) The MCO shall not condition coverage for emergency
10    services on the treating provider notifying the MCO of the
11    enrollee's screening and treatment within 10 days after
12    presentation for emergency services.
13        (5) The determination of the attending emergency
14    physician, or the provider actually treating the enrollee,
15    of whether an enrollee is sufficiently stabilized for
16    discharge or transfer to another facility, shall be binding
17    on the MCO. The MCO shall cover emergency services for all
18    enrollees whether the emergency services are provided by an
19    affiliated or non-affiliated provider.
20        (6) The MCO's financial responsibility for
21    post-stabilization care services it has not pre-approved
22    ends when:
23            (A) a plan physician with privileges at the
24        treating hospital assumes responsibility for the
25        enrollee's care;
26            (B) a plan physician assumes responsibility for

 

 

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1        the enrollee's care through transfer;
2            (C) a contracting entity representative and the
3        treating physician reach an agreement concerning the
4        enrollee's care; or
5            (D) the enrollee is discharged.
6    (f) Network adequacy.
7        (1) The Department shall:
8            (A) ensure that an adequate provider network is in
9        place, taking into consideration health professional
10        shortage areas and medically underserved areas;
11            (B) publicly release an explanation of its process
12        for analyzing network adequacy;
13            (C) periodically ensure that an MCO continues to
14        have an adequate network in place; and
15            (D) require MCOs, including Medicaid Managed Care
16        Entities as defined in Section 5-30.2, to meet provider
17        directory requirements under Section 5-30.3. require
18        MCOs to maintain an updated and public list of network
19        providers.
20    (g) Timely payment of claims.
21        (1) The MCO shall pay a claim within 30 days of
22    receiving a claim that contains all the essential
23    information needed to adjudicate the claim.
24        (2) The MCO shall notify the billing party of its
25    inability to adjudicate a claim within 30 days of receiving
26    that claim.

 

 

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1        (3) The MCO shall pay a penalty that is at least equal
2    to the penalty imposed under the Illinois Insurance Code
3    for any claims not timely paid.
4        (4) The Department may establish a process for MCOs to
5    expedite payments to providers based on criteria
6    established by the Department.
7    (h) The Department shall not expand mandatory MCO
8enrollment into new counties beyond those counties already
9designated by the Department as of June 1, 2014 for the
10individuals whose eligibility for medical assistance is not the
11seniors or people with disabilities population until the
12Department provides an opportunity for accountable care
13entities and MCOs to participate in such newly designated
14counties.
15    (i) The requirements of this Section apply to contracts
16with accountable care entities and MCOs entered into, amended,
17or renewed after the effective date of this amendatory Act of
18the 98th General Assembly.
19(Source: P.A. 98-651, eff. 6-16-14.)
 
20    (305 ILCS 5/5-30.3 new)
21    Sec. 5-30.3. Empowering meaningful patient choice in
22Medicaid Managed Care.
23    (a) Definitions. As used in this Section:
24    "Client enrollment services broker" means a vendor the
25Department contracts with to carry out activities related to

 

 

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1Medicaid recipients' enrollment, disenrollment, and renewal
2with Medicaid Managed Care Entities.
3    "Clinical interest" includes, but is not limited to,
4experience working with specific patient populations such as
5people living with HIV/AIDS, people experiencing homelessness,
6people who identify as LGBTQ, and adolescents.
7    "Composite domains" means the synthesized categories
8reflecting the standardized quality performance measures
9included in the print and online version of the consumer
10quality comparison tool. At a minimum, these composite domains
11shall display Medicaid Managed Care Entities' individual Plan
12performance on standardized quality, timeliness, and access
13measures.
14    "Consumer quality comparison tool" means an online and
15paper tool developed by the Department with input from
16interested stakeholders reflecting the performance of Medicaid
17Managed Care Entity Plans on standardized quality performance
18measures. This tool shall be designed in a consumer-friendly
19and easily understandable format.
20    "Covered services" means those health care services to
21which a covered person is entitled to under the terms of the
22Medicaid Managed Care Entity Plan.
23    "Facility type" includes, but is not limited to, federally
24qualified health centers, skilled nursing facilities, and
25rehabilitation centers.
26    "Hospital type" includes, but is not limited to, acute

 

 

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1care, rehabilitation, children's, and cancer hospitals.
2    "Integrated provider directory" means a searchable
3database bringing together network data from multiple Medicaid
4Managed Care Entities that is available through client
5enrollment services.
6    "Medicaid eligibility redetermination" means the process
7by which the eligibility of a Medicaid recipient is reviewed by
8the Department to determine if the recipient's medical benefits
9will continue, be modified, or terminated.
10    "Medicaid Managed Care Entity" has the same meaning as
11defined in Section 5-30.2 of this Code.
12    (b) Provider directory transparency.
13        (1) Each Medicaid Managed Care Entity shall:
14            (A) Make available on the entity's website a
15        provider directory in a machine readable file and
16        format.
17            (B) Make provider directories publicly accessible
18        without the necessity of providing a password, a
19        username, or personally identifiable information.
20            (C) Comply with all federal and State statutes and
21        regulations pertaining to provider directories within
22        Medicaid Managed Care.
23            (D) Request, at least annually, provider office
24        hours for each of the following provider types:
25                (i) Health care professionals, including
26            dental and vision providers.

 

 

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1                (ii) Hospitals.
2                (iii) Facilities, other than hospitals.
3                (iv) Pharmacies, other than hospitals.
4                (v) Durable medical equipment suppliers, other
5            than hospitals.
6            Medicaid Managed Care Entities shall publish the
7        provider office hours in the provider directory upon
8        receipt.
9            (E) Confirm with the Medicaid Managed Care
10        Entity's contracted providers who have not submitted
11        claims within the past 6 months that the contracted
12        providers intend to remain in the network and correct
13        any incorrect provider directory information as
14        necessary.
15            (F) Ensure that in situations in which a Medicaid
16        Managed Care Entity Plan enrollee receives covered
17        services from a non-participating provider due to a
18        material misrepresentation in a Medicaid Managed Care
19        Entity's online electronic provider directory, the
20        Medicaid Managed Care Entity Plan enrollee shall not be
21        held responsible for any costs resulting from that
22        material misrepresentation.
23            (G) Conspicuously display an e-mail address and a
24        toll-free telephone number to which any individual may
25        report any inaccuracy in the provider directory. If the
26        Medicaid Managed Care Entity receives a report from any

 

 

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1        person who specifically identifies provider directory
2        information as inaccurate, the Medicaid Managed Care
3        Entity shall investigate the report and correct any
4        inaccurate information displayed in the electronic
5        directory.
6        (2) The Department shall:
7            (A) Regularly monitor Medicaid Managed Care
8        Entities to ensure that they are compliant with the
9        requirements under paragraph (1) of subsection (b).
10            (B) Require that the client enrollment services
11        broker use the Medicaid provider number to populate the
12        provider information in the integrated provider
13        directory.
14            (C) Ensure that each Medicaid Managed Care Entity
15        shall, at minimum, make the information in
16        subparagraph (D) of paragraph (1) of subsection (b)
17        available to the client enrollment services broker.
18            (D) Ensure that the client enrollment services
19        broker shall, at minimum, have the information in
20        subparagraph (D) of paragraph (1) of subsection (b)
21        available and searchable through the integrated
22        provider directory on its website.
23            (E) Require the client enrollment services broker
24        to conspicuously display near the integrated provider
25        directory an email address and a toll-free telephone
26        number to which any individual may report inaccuracies

 

 

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1        in the integrated provider directory. If the client
2        enrollment services broker receives a report that
3        identifies an inaccuracy in the integrated provider
4        directory, the client enrollment services broker shall
5        provide the information about the reported inaccuracy
6        to the appropriate Medicaid Managed Care Entity within
7        3 business days after the reported inaccuracy is
8        received.
9    (c) Formulary transparency.
10        (1) Medicaid Managed Care Entities shall publish on
11    their respective websites a formulary for each Medicaid
12    Managed Care Entity Plan offered and make the formularies
13    easily understandable and publicly accessible without the
14    necessity of providing a password, a username, or
15    personally identifiable information.
16        (2) Medicaid Managed Care Entities shall provide
17    printed formularies upon request.
18        (3) Electronic and print formularies shall display:
19            (A) the medications covered (both generic and name
20        brand);
21            (B) if the medication is preferred or not
22        preferred, and what each term means;
23            (C) what tier each medication is in and the meaning
24        of each tier;
25            (D) any utilization controls including, but not
26        limited to, step therapy, prior approval, dosage

 

 

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1        limits, gender or age restrictions, quantity limits,
2        or other policies that affect access to medications;
3            (E) any required cost-sharing;
4            (F) a glossary of key terms and explanation of
5        utilization controls and cost-sharing requirements;
6            (G) a key or legend for all utilization controls
7        visible on every page in which specific medication
8        coverage information is displayed; and
9            (H) directions explaining the process or processes
10        a consumer may follow to obtain more information if a
11        medication the consumer requires is not covered or
12        listed in the formulary.
13        (4) Each Medicaid Managed Care Entity shall display
14    conspicuously with each electronic and printed medication
15    formulary an e-mail address and a toll-free telephone
16    number to which any individual may report any inaccuracy in
17    the formulary. If the Medicaid Managed Care Entity receives
18    a report that the formulary information is inaccurate, the
19    Medicaid Managed Care Entity shall investigate the report
20    and correct any incorrect information, as necessary, no
21    later than the third business day after the date the report
22    is received.
23        (5) Each Medicaid Managed Care Entity shall include a
24    disclosure in the electronic and requested print
25    formularies that provides the date of publication, a
26    statement that the formulary is up to date as of

 

 

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1    publication, and contact information for questions and
2    requests to receive updated information.
3        (6) The client enrollment services broker's website
4    shall display prominently a website URL link to each
5    Medicaid Managed Care Entity's Plan formulary.
6    (d) Grievances and appeals. The Department shall require
7the client enrollment services broker to display prominently on
8the client enrollment services broker's website a description
9of where a Medicaid enrollee can access information on how to
10file a complaint or grievance or request a fair hearing for any
11adverse action taken by the Department or the Medicaid Managed
12Care Entity.
13    (e) Medicaid redetermination information. The Department
14shall require the client enrollment services broker to display
15prominently on the client enrollment services broker's website
16a description of where a Medicaid enrollee can access
17information regarding the Medicaid redetermination process.
18    (f) Medicaid care coordination information. The client
19enrollment services broker shall display prominently on its
20website, in an easily understandable format, consumer-oriented
21information regarding the role of care coordination services
22within Medicaid Managed Care. Such information shall include,
23but shall not be limited to:
24        (1) a basic description of the role of care
25    coordination services and examples of specific care
26    coordination activities; and

 

 

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1        (2) how a Medicaid enrollee may request care
2    coordination services from a Medicaid Managed Care Entity.
3    (g) Consumer quality comparison tool.
4        (1) The Department shall create a consumer quality
5    comparison tool to assist Medicaid enrollees with Medicaid
6    Managed Care Entity Plan selection. This tool shall provide
7    Medicaid Managed Care Entities' individual Plan
8    performance on a set of standardized quality performance
9    measures. The Department shall ensure that this tool shall
10    be accessible in both a print and online format, with the
11    online format allowing for individuals to access
12    additional detailed Plan performance information.
13        (2) At a minimum, the print version of the consumer
14    quality comparison tool shall be provided by the Department
15    on an annual basis to Medicaid enrollees who are required
16    by the Department to enroll in a Medicaid Managed Care
17    Entity Plan during an enrollee's open enrollment period.
18    The consumer quality comparison tool shall also meet all of
19    the following criteria:
20            (A) Display Medicaid Managed Care Entities'
21        individual Plan performance on at least 4 composite
22        domains that reflect Plan quality, timeliness, and
23        access. The composite domains shall draw from the most
24        current available performance data sets including, but
25        not limited to:
26                (i) Healthcare Effectiveness Data and

 

 

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1            Information Set (HEDIS) measures.
2                (ii) Core Set of Children's Health Care
3            Quality measures as required under the Children's
4            Health Insurance Program Reauthorization Act
5            (CHIPRA).
6                (iii) Adult Core Set measures.
7                (iv) Consumer Assessment of Healthcare
8            Providers and Systems (CAHPS) survey results.
9                (v) Additional performance measures the
10            Department deems appropriate to populate the
11            composite domains.
12            (B) Use a quality rating system developed by the
13        Department to reflect Medicaid Managed Care Entities'
14        individual Plan performance. The quality rating system
15        for each composite domain shall reflect the Medicaid
16        Managed Care Entities' individual Plan performance
17        and, when possible, plan performance relative to
18        national Medicaid percentiles.
19            (C) Be customized to reflect the specific Medicaid
20        Managed Care Entities' Plans available to the Medicaid
21        enrollee based on his or her geographic location and
22        Medicaid eligibility category.
23            (D) Include contact information for the client
24        enrollment services broker and contact information for
25        Medicaid Managed Care Entities available to the
26        Medicaid enrollee based on his or her geographic

 

 

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1        location and Medicaid eligibility category.
2            (E) Include guiding questions designed to assist
3        individuals selecting a Medicaid Managed Care Entity
4        Plan.
5        (3) At a minimum, the online version of the consumer
6    quality comparison tool shall meet all of the following
7    criteria:
8            (A) Display Medicaid Managed Care Entities'
9        individual Plan performance for the same composite
10        domains selected by the Department. The Department may
11        display additional composite domains in the online
12        version of the consumer quality comparison tool as
13        appropriate.
14            (B) Display Medicaid Managed Care Entities'
15        individual Plan performance on each of the
16        standardized performance measures that contribute to
17        each composite domain displayed on the online version
18        of the consumer quality comparison tool.
19            (C) Use a quality rating system developed by the
20        Department to reflect Medicaid Managed Care Entities'
21        individual Plan performance. The quality rating system
22        for each composite domain shall reflect the Medicaid
23        Managed Care Entities' individual Plan performance
24        compared to national benchmark performance averages
25        when national benchmarks are available.
26            (D) Include the specific Medicaid Managed Care

 

 

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1        Entity Plans available to the Medicaid enrollee based
2        on his or her geographic location and Medicaid
3        eligibility category.
4            (E) Include a sort function to view Medicaid
5        Managed Care Entities' individual Plan performance by
6        star rating and by standardized quality performance
7        measures.
8            (F) Include contact information for the client
9        enrollment services broker and for each Medicaid
10        Managed Care Entity.
11            (G) Include guiding questions designed to assist
12        individuals in selecting a Medicaid Managed Care
13        Entity Plan.
14            (H) Prominently display current notice of quality
15        performance sanctions against Medicaid Managed Care
16        Entities. Notice of the sanctions shall remain present
17        on the online version of the consumer quality
18        comparison tool until the sanctions are lifted.
19        (4) The online version of the consumer quality
20    comparison tool shall be displayed prominently on the
21    client enrollment services broker's website.
22        (5) In the development of the consumer quality
23    comparison tool, the Department shall establish and
24    publicize a formal process to collect and consider written
25    and oral feedback from consumers, advocates, and
26    stakeholders on aspects of the consumer quality comparison

 

 

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1    tool, including, but not limited to, the following:
2            (A) The standardized data sets and surveys,
3        specific performance measures, and composite domains
4        represented in the consumer quality comparison tool.
5            (B) The format and presentation of the consumer
6        quality comparison tool.
7            (C) The methods undertaken by the Department to
8        notify Medicaid enrollees of the availability of the
9        consumer quality comparison tool.
10        (6) The Department shall review and update as
11    appropriate the composite domains and performance measures
12    represented in the print and online versions of the
13    consumer quality comparison tool at least once every 3
14    years. During the Department's review process, the
15    Department shall solicit engagement in the public feedback
16    process described in paragraph (5).
17        (7) The Department shall ensure that the consumer
18    quality comparison tool is available for consumer use as
19    soon as possible but no later than January 1, 2018.
20    (h) The Department may adopt rules and take any other
21appropriate action necessary to implement its responsibilities
22under this Section.
 
23    Section 99. Effective date. This Act takes effect upon
24becoming law.".