305 ILCS 5/ Illinois Public Aid Code.

(305 ILCS 5/5-30.13)

Sec. 5-30.13. Managed care reports; minority-owned and women-owned businesses. Each Medicaid managed care health plan shall submit a report to the Department by March 1, 2020, and every March 1 thereafter, that includes the following information:

(1) The administrative expenses paid to the Medicaid managed care health plan.

(2) The amount of money the Medicaid managed care health plan has spent with Business Enterprise Program certified businesses.

(3) The amount of money the Medicaid managed care health plan has spent with minority-owned and women-owned businesses that are certified by other agencies or private organizations.

(4) The amount of money the Medicaid managed care health plan has spent with not-for-profit community-based organizations serving predominantly minority communities, as defined by the Department.

(5) The proportion of minorities, people with disabilities, and women that make up the staff of the Medicaid managed care health plan.

(6) Recommendations for increasing expenditures with minority-owned and women-owned businesses.

(7) A list of the types of services to which the Medicaid managed care health plan is contemplating adding new vendors.

(8) The certifications the Medicaid managed care health plan accepts for minority-owned and women-owned businesses.

(9) The point of contact for potential vendors seeking to do business with the Medicaid managed care health plan.

The Department shall publish the reports on its website and shall maintain each report on its website for 5 years. In May of 2020 and every May thereafter, the Department shall hold 2 annual public workshops, one in Chicago and one in Springfield. The workshops shall include each Medicaid managed care health plan and shall be open to vendor communities to discuss the submitted plans and to seek to connect vendors with the Medicaid managed care health plans.

(Source: P.A. 101-209, eff. 8-5-19; 102-558, eff. 8-20-21.)

(305 ILCS 5/5-30.14)

Sec. 5-30.14. Medicaid managed care organizations; preferred drug lists.

(a) No later than January 1, 2020, the Illinois Department shall develop a standardized format for all Medicaid managed care organization preferred drug lists in collaboration with Medicaid managed care organizations and other stakeholders, including, but not limited to, organizations that serve individuals impacted by HIV/AIDS or epilepsy, and community-based organizations, providers, and entities with expertise in drug formulary development.

(b) Following development of the standardized Preferred Drug List format, the Illinois Department shall allow Medicaid managed care organizations 6 months from the date of completion to comply with the new Preferred Drug List format. Each Medicaid managed care organization must post its preferred drug list on its website without restricting access and must update the preferred drug list posted on its website. Medicaid managed care organizations shall publish updates to their preferred drug lists no less than 30 days prior to the date upon which any update or change takes effect, including, but not limited to, any and all changes to requirements for prior approval requirements, step therapy, or other utilization controls.

(c)(1) No later than January 1, 2020, the Illinois Department shall establish and maintain the Illinois Drug and Therapeutics Advisory Board. The Board shall have the authority and responsibility to provide recommendations to the Illinois Department regarding which drug products to list on the Illinois Department's preferred drug list. The Illinois Department shall provide administrative support to the Board and the Board shall:

(A) convene and meet no less than once per calendar quarter;

(B) provide regular opportunities for public comment; and

(C) comply with the provisions of the Open Meetings Act.

All correspondence related to the Board, including correspondence to and from Board members, shall be subject to the Freedom of Information Act.

(2) The Board shall consist of the following voting members, all of whom shall be appointed by the Governor and shall serve terms of 3 years without compensation:

(A) one pharmacist licensed to practice pharmacy in Illinois who is recommended by a statewide organization representing pharmacists;

(B) 4 physicians, recommended by a statewide organization representing physicians, who are licensed to practice medicine in all its branches in Illinois, have knowledge of and adhere to best practice standards, and have experience treating Illinois Medicaid beneficiaries;

(C) at least one clinician who specializes in the prevention and treatment of HIV, recommended by an HIV healthcare advocacy organization;

(D) at least one clinician recommended by a healthcare advocacy organization that serves individuals who are affected by chronic diseases that require significant pharmaceutical treatments;

(E) one clinician representing the Illinois Department; and

(F) one licensed psychiatrist, recommended by a statewide organization representing psychiatrists, who has experience treating Illinois Medicaid beneficiaries.

One non-voting clinician recommended by an association of Medicaid managed care health plans shall serve a term of 3 years on the Board without compensation.

Organizations interested in nominating non-voting clinicians to advise the Board may submit requests to participate to the Illinois Department.

A licensed physician recommended by the Rare Disease Commission who is a rare disease specialist and possesses scientific knowledge and medical training with respect to rare diseases and is familiar with drug and biological products and treatment shall be notified in advance to attend an Illinois Drug and Therapeutics Advisory Board meeting when a drug or biological product is scheduled to be reviewed in order to advise and make recommendations on drugs or biological products.

(d) The Illinois Department shall adopt rules, to be in place no later than January 1, 2020, for the purpose of establishing and maintaining the Board.

(Source: P.A. 101-62, eff. 7-12-19; 102-558, eff. 8-20-21.)

(305 ILCS 5/5-30.16)

Sec. 5-30.16. Medicaid Business Opportunity Commission.

(a) The Medicaid Business Opportunity Commission is created within the Department of Healthcare and Family Services to develop a program to support and grow minority, women, and persons with disability owned businesses.

(b) The Commission shall consist of the following members:

(1) Two members appointed by the Illinois Legislative Black Caucus.

(2) Two members appointed by the Illinois Legislative Latino Caucus.

(3) Two members appointed by the Conference of Women Legislators of the Illinois General Assembly.

(4) Two members representing a statewide Medicaid health plan association, appointed by the Governor.

(5) One member representing the Department of Healthcare and Family Services, appointed by the Governor.

(6) Three members representing businesses currently registered with the Business Enterprise Program, appointed by the Governor.

(7) One member representing the disability community, appointed by the Governor.

(8) One member representing the Business Enterprise Council, appointed by the Governor.

(c) The Director of Healthcare and Family Services and chief of staff, or their designees, shall serve as the Commission's executive administrators in providing administrative support, research support, and other administrative tasks requested by the Commission's co-chairs. Any expenses, including, but not limited to, travel and housing, shall be paid for by the Department's existing budget.

(d) The members of the Commission shall receive no compensation for their services as members of the Commission.

(e) The members of the Commission shall designate co-chairs of the Commission to lead their efforts at the first meeting of the Commission.

(f) The Commission shall meet at least monthly beginning as soon as is practicable after the effective date of this amendatory Act of the 102nd General Assembly.

(g) The Commission shall:

(1) Develop a recommendation on a Medicaid Business Opportunity Program for Minority, Women, and Persons with Disability Owned business contracting requirements to be included in the contracts between the Department of Healthcare and Family Services and the Managed Care entities for the provision of Medicaid Services.

(2) Make recommendations on the process by which vendors or providers would be certified as eligible to be included in the program and appropriate eligibility standards relative to the healthcare industry.

(3) Make a recommendation on whether to include not for profit organizations, diversity councils, or diversity chambers as eligible for certification.

(4) Make a recommendation on whether diverse staff shall be considered within the goals set for managed care entities.

(5) Make a recommendation on whether a new platform for certification is necessary to administer this program or if the existing platform for the Business Enterprise Program is capable of including recommended changes coming from this Commission.

(6) Make a recommendation on the ongoing activity of the Commission including structure, frequency of meetings, and agendas to ensure ongoing oversight of the program by the Commission.

(h) The Commission shall provide recommendations to the Department and the General assembly by April 15, 2021 in order to ensure prompt implementation of the Medicaid Business Opportunity Program.

(i) Beginning January 1, 2022, and for each year thereafter, the Commission shall submit a report of its findings and recommendations to the General Assembly. The report to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.

(Source: P.A. 102-4, eff. 4-27-21.)

(305 ILCS 5/5-30.17)

Sec. 5-30.17. Medicaid Managed Care Oversight Commission.

(a) The Medicaid Managed Care Oversight Commission is created within the Department of Healthcare and Family Services to evaluate the effectiveness of Illinois' managed care program.

(b) The Commission shall consist of the following members:

(1) One member of the Senate, appointed by the Senate President, who shall serve as co-chair.

(2) One member of the House of Representatives, appointed by the Speaker of the House of Representatives, who shall serve as co-chair.

(3) One member of the House of Representatives, appointed by the Minority Leader of the House of Representatives.

(4) One member of the Senate, appointed by the Senate Minority Leader.

(5) One member representing the Department of Healthcare and Family Services, appointed by the Governor.

(6) One member representing the Department of Public Health, appointed by the Governor.

(7) One member representing the Department of Human Services, appointed by the Governor.

(8) One member representing the Department of Children and Family Services, appointed by the Governor.

(9) One member of a statewide association representing Medicaid managed care plans, appointed by the Governor.

(10) One member of a statewide association representing a majority of hospitals, appointed by the Governor.

(11) Two academic experts on Medicaid managed care programs, appointed by the Governor.

(12) One member of a statewide association representing primary care providers, appointed by the Governor.

(13) One member of a statewide association representing behavioral health providers, appointed by the Governor.

(14) Members representing Federally Qualified Health Centers, a long-term care association, a dental association, pharmacies, pharmacists, a developmental disability association, a Medicaid consumer advocate, a Medicaid consumer, an association representing physicians, a behavioral health association, and an association representing pediatricians, appointed by the Governor.

(15) A member of a statewide association representing only safety-net hospitals, appointed by the Governor.

(c) The Director of Healthcare and Family Services and chief of staff, or their designees, shall serve as the Commission's executive administrators in providing administrative support, research support, and other administrative tasks requested by the Commission's co-chairs. Any expenses, including, but not limited to, travel and housing, shall be paid for by the Department's existing budget.

(d) The members of the Commission shall receive no compensation for their services as members of the Commission.

(e) The Commission shall meet quarterly beginning as soon as is practicable after the effective date of this amendatory Act of the 102nd General Assembly.

(f) The Commission shall:

(1) review data on health outcomes of Medicaid managed care members;

(2) review current care coordination and case management efforts and make recommendations on expanding care coordination to additional populations with a focus on the social determinants of health;

(3) review and assess the appropriateness of metrics used in the Pay-for-Performance programs;

(4) review the Department's prior authorization and utilization management requirements and recommend adaptations for the Medicaid population;

(5) review managed care performance in meeting diversity contracting goals and the use of funds dedicated to meeting such goals, including, but not limited to, contracting requirements set forth in the Business Enterprise for Minorities, Women, and Persons with Disabilities Act; recommend strategies to increase compliance with diversity contracting goals in collaboration with the Chief Procurement Officer for General Services and the Business Enterprise Council for Minorities, Women, and Persons with Disabilities; and recoup any misappropriated funds for diversity contracting;

(6) review data on the effectiveness of processing to medical providers;

(7) review member access to health care services in the Medicaid Program, including specialty care services;

(8) review value-based and other alternative payment methodologies to make recommendations to enhance program efficiency and improve health outcomes;

(9) review the compliance of all managed care entities in State contracts and recommend reasonable financial penalties for any noncompliance;

(10) produce an annual report detailing the Commission's findings based upon its review of research conducted under this Section, including specific recommendations, if any, and any other information the Commission may deem proper in furtherance of its duties under this Section;

(11) review provider availability and make recommendations to increase providers where needed, including reviewing the regulatory environment and making recommendations for reforms;

(12) review capacity for culturally competent services, including translation services among providers; and

(13) review and recommend changes to the safety-net hospital definition to create different classifications of safety-net hospitals.

(f-5) The Department shall make available upon request the analytics of Medicaid managed care clearinghouse data regarding processing.

(g) Beginning January 1, 2022, and for each year thereafter, the Commission shall submit a report of its findings and recommendations to the General Assembly. The report to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.

(Source: P.A. 102-4, eff. 4-27-21.)

(305 ILCS 5/5-30.18)

(Section scheduled to be repealed on December 31, 2030)

Sec. 5-30.18. Service authorization program performance.

(a) Definitions. As used in this Section:

"Gold Card provider" means a provider identified by each Medicaid Managed Care Organization (MCO) as qualified under the guidelines outlined by the Department in accordance with subsection (c) and thereby granted a service authorization exemption when ordering a health care service.

"Health care service" means any medical or behavioral health service covered under the medical assistance program that is rendered in the inpatient or outpatient hospital setting, including hospital-based clinics, and subject to review under a service authorization program.

"Provider" means an individual actively enrolled in the medical assistance program and licensed or otherwise authorized to order, prescribe, refer, or render health care services in this State, and, as determined by the Department, may also include hospitals that submit service authorization requests.

"Service authorization exemption" means an exception granted by a Medicaid MCO to a provider under which all service authorization requests for covered health care services, excluding pharmacy services and durable medical equipment, are automatically deemed to be medically necessary, clinically appropriate, and approved for reimbursement as ordered.

"Service authorization program" means any utilization review, utilization management, peer review, quality review, or other medical management activity conducted in advance of, concurrent to, or after the provision of a health care service by a Medicaid MCO, either directly or through a contracted utilization review organization (URO), including, but not limited to, prior authorization, pre-certification, certification of admission, concurrent review, and retrospective review of health care services.

"Service authorization request" means a request by a provider to a service authorization program to determine whether a health care service that is otherwise covered under the medical assistance program meets the reimbursement requirements established by the Medicaid MCO, or its contracted URO, for medically necessary, clinically appropriate care and to issue a service authorization determination.

"Utilization review organization" or "URO" means a managed care organization or other entity that has established or administers one or more service authorization programs.

(b) In consultation with the Medicaid MCOs, a statewide association representing managed care organizations, a statewide association representing the majority of Illinois hospitals, and a statewide association representing physicians, the Department shall in accordance with the Illinois Administrative Procedure Act, adopt administrative rules, consistent with this Section, to require each Medicaid MCO to identify Gold Card providers with such identification initially being effective for health care services provided on and after July 1, 2025.

(c) The Department shall adopt rules, in accordance with the Illinois Administrative Procedure Act, to implement this Section that include, but are not limited to, the following provisions:

(1) Require each Medicaid MCO to provide a service authorization exemption to a provider if the provider has submitted at least 50 service authorization requests to its service authorization program in the preceding calendar year and the service authorization program approved at least 90% of all service authorization requests, regardless of the type of health care services requested.

(2) Require that service authorization exemptions be limited to services provided in an inpatient or outpatient hospital setting inclusive of hospital-based clinics. Service authorization exemptions under this Section shall not pertain to pharmacy services and durable medical equipment and supplies.

(3) The service authorization exemption shall be valid for at least one year, shall be made by each Medicaid MCO or its URO, and shall be binding on the Medicaid MCO and its URO.

(4) The provider shall be required to continue to document medically necessary, clinically appropriate care and submit such documentation to the Medicaid MCO for the purpose of continuous performance monitoring. If a provider fails to maintain the 90% service authorization standard, as determined on no more frequent a basis than bi-annually, the provider's service authorization exemption is subject to temporary or permanent suspension.

(5) Require that each Medicaid MCO publish on its provider portal a list of all providers that have qualified for a service authorization exemption or indicate that a provider has qualified for a service authorization exemption on its provider-facing provider roster.

(6) Require that no later than December 1 of each calendar year, each Medicaid MCO shall provide written notification to all providers who qualify for a service authorization exemption, for the subsequent calendar year.

(7) Require that each Medicaid MCO or its URO use the policies and guidelines published by the Department to evaluate whether a provider meets the criteria to qualify for a service authorization exemption and the conditions under which a service authorization exemption may be rescinded, including review of the provider's service authorization determinations during the preceding calendar year.

(8) Require each Medicaid MCO to provide the Department a list of all providers who were denied a service authorization exemption or had a previously granted service authorization exemption suspended, with such denials being subject to an annual audit conducted by an independent third-party URO to ensure their appropriateness.

(A) The independent third-party URO shall issue a written report consistent with this paragraph.

(B) The independent third-party URO shall not be owned by, affiliated with, or employed by any Medicaid MCO or its contracted URO, nor shall it have any financial interest in the Medicaid MCO's service authorization exemption program.

(d) Each Medicaid MCO must have a standard method to accept and process professional claims and facility claims, as billed by the provider, for a health care service that is rendered, prescribed, or ordered by a provider granted a service authorization exemption, except in cases of fraud.

(e) A service authorization program shall not deny, partially deny, reduce the level of care, or otherwise limit reimbursement to the rendering or supervising provider, including the rendering facility, for health care services ordered by a provider who qualifies for a service authorization exemption, except in cases of fraud.

(f) This Section is repealed on December 31, 2030.

(Source: P.A. 103-593, eff. 6-7-24.)

(305 ILCS 5/5-30a)

Sec. 5-30a. Exemptions from managed care enrollment; children. Notwithstanding any other provision of law, the Department shall not require any of the following children to enroll in or transition to the State's managed care medical assistance program:

(1) Children who are authorized by the Department to receive in-home shift nursing services as required by the federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provisions under 42 CFR 441.50 et seq.

(2) Children made eligible for medical assistance through any home and community-based services waiver program for medically fragile and technology dependent children authorized under Section 1915(c) of the Social Security Act.

Any children who meet the criteria under paragraph (1) or (2) and who are enrolled in the State's managed care medical assistance program on or before the effective date of this amendatory Act of the 100th General Assembly shall be given the option to disenroll from the State's managed care medical assistance program and receive medical assistance coverage under the State's traditional fee-for-service program.

(Source: P.A. 100-990, eff. 1-1-19.)

(305 ILCS 5/5-30b)

Sec. 5-30b. Exemptions from managed care; ground ambulance services. Notwithstanding any other provision of law, beginning on the effective date of this amendatory Act of the 102nd General Assembly, the Department shall exempt ground ambulance services as described in subsections (c-1) and (c-2) of Section 5-4.2. These services shall continue to be paid under the State's traditional fee-for-service program.

(Source: P.A. 102-661, eff. 1-1-22.)

(305 ILCS 5/5-30d)

Sec. 5-30d. Increased funding for transportation services. Beginning no later than January 1, 2023 and subject to federal approval, the amount allocated to fund rates for medi-car, service car, and attendant services provided to adults and children under the medical assistance program shall be increased by an approximate amount of $24,000,000.

(Source: P.A. 102-1037, eff. 6-2-22.)

(305 ILCS 5/5-31)

Sec. 5-31. (Repealed).

(Source: P.A. 98-104, eff. 7-22-13. Repealed by P.A. 103-593, eff. 6-7-24.)

(305 ILCS 5/5-32)

Sec. 5-32. (Repealed).

(Source: P.A. 98-104, eff. 7-22-13. Repealed by P.A. 103-593, eff. 6-7-24.)

(305 ILCS 5/5-33)

Sec. 5-33. (Repealed).

(Source: P.A. 98-674, eff. 6-30-14. Repealed internally, eff. 1-1-16.)