Public Act 099-0725
 
HB6213 EnrolledLRB099 19222 KTG 45140 b

    AN ACT concerning public aid.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The Illinois Public Aid Code is amended by
changing Section 5-30.1 and by adding Section 5-30.3 as
follows:
 
    (305 ILCS 5/5-30.1)
    Sec. 5-30.1. Managed care protections.
    (a) As used in this Section:
    "Managed care organization" or "MCO" means any entity which
contracts with the Department to provide services where payment
for medical services is made on a capitated basis.
    "Emergency services" include:
        (1) emergency services, as defined by Section 10 of the
    Managed Care Reform and Patient Rights Act;
        (2) emergency medical screening examinations, as
    defined by Section 10 of the Managed Care Reform and
    Patient Rights Act;
        (3) post-stabilization medical services, as defined by
    Section 10 of the Managed Care Reform and Patient Rights
    Act; and
        (4) emergency medical conditions, as defined by
    Section 10 of the Managed Care Reform and Patient Rights
    Act.
    (b) As provided by Section 5-16.12, managed care
organizations are subject to the provisions of the Managed Care
Reform and Patient Rights Act.
    (c) An MCO shall pay any provider of emergency services
that does not have in effect a contract with the contracted
Medicaid MCO. The default rate of reimbursement shall be the
rate paid under Illinois Medicaid fee-for-service program
methodology, including all policy adjusters, including but not
limited to Medicaid High Volume Adjustments, Medicaid
Percentage Adjustments, Outpatient High Volume Adjustments,
and all outlier add-on adjustments to the extent such
adjustments are incorporated in the development of the
applicable MCO capitated rates.
    (d) An MCO shall pay for all post-stabilization services as
a covered service in any of the following situations:
        (1) the MCO authorized such services;
        (2) such services were administered to maintain the
    enrollee's stabilized condition within one hour after a
    request to the MCO for authorization of further
    post-stabilization services;
        (3) the MCO did not respond to a request to authorize
    such services within one hour;
        (4) the MCO could not be contacted; or
        (5) the MCO and the treating provider, if the treating
    provider is a non-affiliated provider, could not reach an
    agreement concerning the enrollee's care and an affiliated
    provider was unavailable for a consultation, in which case
    the MCO must pay for such services rendered by the treating
    non-affiliated provider until an affiliated provider was
    reached and either concurred with the treating
    non-affiliated provider's plan of care or assumed
    responsibility for the enrollee's care. Such payment shall
    be made at the default rate of reimbursement paid under
    Illinois Medicaid fee-for-service program methodology,
    including all policy adjusters, including but not limited
    to Medicaid High Volume Adjustments, Medicaid Percentage
    Adjustments, Outpatient High Volume Adjustments and all
    outlier add-on adjustments to the extent that such
    adjustments are incorporated in the development of the
    applicable MCO capitated rates.
    (e) The following requirements apply to MCOs in determining
payment for all emergency services:
        (1) MCOs shall not impose any requirements for prior
    approval of emergency services.
        (2) The MCO shall cover emergency services provided to
    enrollees who are temporarily away from their residence and
    outside the contracting area to the extent that the
    enrollees would be entitled to the emergency services if
    they still were within the contracting area.
        (3) The MCO shall have no obligation to cover medical
    services provided on an emergency basis that are not
    covered services under the contract.
        (4) The MCO shall not condition coverage for emergency
    services on the treating provider notifying the MCO of the
    enrollee's screening and treatment within 10 days after
    presentation for emergency services.
        (5) The determination of the attending emergency
    physician, or the provider actually treating the enrollee,
    of whether an enrollee is sufficiently stabilized for
    discharge or transfer to another facility, shall be binding
    on the MCO. The MCO shall cover emergency services for all
    enrollees whether the emergency services are provided by an
    affiliated or non-affiliated provider.
        (6) The MCO's financial responsibility for
    post-stabilization care services it has not pre-approved
    ends when:
            (A) a plan physician with privileges at the
        treating hospital assumes responsibility for the
        enrollee's care;
            (B) a plan physician assumes responsibility for
        the enrollee's care through transfer;
            (C) a contracting entity representative and the
        treating physician reach an agreement concerning the
        enrollee's care; or
            (D) the enrollee is discharged.
    (f) Network adequacy.
        (1) The Department shall:
            (A) ensure that an adequate provider network is in
        place, taking into consideration health professional
        shortage areas and medically underserved areas;
            (B) publicly release an explanation of its process
        for analyzing network adequacy;
            (C) periodically ensure that an MCO continues to
        have an adequate network in place; and
            (D) require MCOs, including Medicaid Managed Care
        Entities as defined in Section 5-30.2, to meet provider
        directory requirements under Section 5-30.3. require
        MCOs to maintain an updated and public list of network
        providers.
    (g) Timely payment of claims.
        (1) The MCO shall pay a claim within 30 days of
    receiving a claim that contains all the essential
    information needed to adjudicate the claim.
        (2) The MCO shall notify the billing party of its
    inability to adjudicate a claim within 30 days of receiving
    that claim.
        (3) The MCO shall pay a penalty that is at least equal
    to the penalty imposed under the Illinois Insurance Code
    for any claims not timely paid.
        (4) The Department may establish a process for MCOs to
    expedite payments to providers based on criteria
    established by the Department.
    (h) The Department shall not expand mandatory MCO
enrollment into new counties beyond those counties already
designated by the Department as of June 1, 2014 for the
individuals whose eligibility for medical assistance is not the
seniors or people with disabilities population until the
Department provides an opportunity for accountable care
entities and MCOs to participate in such newly designated
counties.
    (i) The requirements of this Section apply to contracts
with accountable care entities and MCOs entered into, amended,
or renewed after the effective date of this amendatory Act of
the 98th General Assembly.
(Source: P.A. 98-651, eff. 6-16-14.)
 
    (305 ILCS 5/5-30.3 new)
    Sec. 5-30.3. Empowering meaningful patient choice in
Medicaid Managed Care.
    (a) Definitions. As used in this Section:
    "Client enrollment services broker" means a vendor the
Department contracts with to carry out activities related to
Medicaid recipients' enrollment, disenrollment, and renewal
with Medicaid Managed Care Entities.
    "Composite domains" means the synthesized categories
reflecting the standardized quality performance measures
included in the consumer quality comparison tool. At a minimum,
these composite domains shall display Medicaid Managed Care
Entities' individual Plan performance on standardized quality,
timeliness, and access measures.
    "Consumer quality comparison tool" means an online and
paper tool developed by the Department with input from
interested stakeholders reflecting the performance of Medicaid
Managed Care Entity Plans on standardized quality performance
measures. This tool shall be designed in a consumer-friendly
and easily understandable format.
    "Covered services" means those health care services to
which a covered person is entitled to under the terms of the
Medicaid Managed Care Entity Plan.
    "Facilities" includes, but is not limited to, federally
qualified health centers, skilled nursing facilities, and
rehabilitation centers.
    "Hospitals" includes, but is not limited to, acute care,
rehabilitation, children's, and cancer hospitals.
    "Integrated provider directory" means a searchable
database bringing together network data from multiple Medicaid
Managed Care Entities that is available through client
enrollment services.
    "Medicaid eligibility redetermination" means the process
by which the eligibility of a Medicaid recipient is reviewed by
the Department to determine if the recipient's medical benefits
will continue, be modified, or terminated.
    "Medicaid Managed Care Entity" has the same meaning as
defined in Section 5-30.2 of this Code.
    (b) Provider directory transparency.
        (1) Each Medicaid Managed Care Entity shall:
            (A) Make available on the entity's website a
        provider directory in a machine readable file and
        format.
            (B) Make provider directories publicly accessible
        without the necessity of providing a password, a
        username, or personally identifiable information.
            (C) Comply with all federal and State statutes and
        regulations, including 42 CFR 438.10, pertaining to
        provider directories within Medicaid Managed Care.
            (D) Request, at least annually, provider office
        hours for each of the following provider types:
                (i) Health care professionals, including
            dental and vision providers.
                (ii) Hospitals.
                (iii) Facilities, other than hospitals.
                (iv) Pharmacies, other than hospitals.
                (v) Durable medical equipment suppliers, other
            than hospitals.
            Medicaid Managed Care Entities shall publish the
        provider office hours in the provider directory upon
        receipt.
            (E) Confirm with the Medicaid Managed Care
        Entity's contracted providers who have not submitted
        claims within the past 6 months that the contracted
        providers intend to remain in the network and correct
        any incorrect provider directory information as
        necessary.
            (F) Ensure that in situations in which a Medicaid
        Managed Care Entity Plan enrollee receives covered
        services from a non-participating provider due to a
        material misrepresentation in a Medicaid Managed Care
        Entity's online electronic provider directory, the
        Medicaid Managed Care Entity Plan enrollee shall not be
        held responsible for any costs resulting from that
        material misrepresentation.
            (G) Conspicuously display an e-mail address and a
        toll-free telephone number to which any individual may
        report any inaccuracy in the provider directory. If the
        Medicaid Managed Care Entity receives a report from any
        person who specifically identifies provider directory
        information as inaccurate, the Medicaid Managed Care
        Entity shall investigate the report and correct any
        inaccurate information displayed in the electronic
        directory.
        (2) The Department shall:
            (A) Regularly monitor Medicaid Managed Care
        Entities to ensure that they are compliant with the
        requirements under paragraph (1) of subsection (b).
            (B) Require that the client enrollment services
        broker use the Medicaid provider number for all
        providers with a Medicaid Provider number to populate
        the provider information in the integrated provider
        directory.
            (C) Ensure that each Medicaid Managed Care Entity
        shall, at minimum, make the information in
        subparagraph (D) of paragraph (1) of subsection (b)
        available to the client enrollment services broker.
            (D) Ensure that the client enrollment services
        broker shall, at minimum, have the information in
        subparagraph (D) of paragraph (1) of subsection (b)
        available and searchable through the integrated
        provider directory on its website as soon as possible
        but no later than January 1, 2017.
            (E) Require the client enrollment services broker
        to conspicuously display near the integrated provider
        directory an email address and a toll-free telephone
        number provided by the Department to which any
        individual may report inaccuracies in the integrated
        provider directory. If the Department receives a
        report that identifies an inaccuracy in the integrated
        provider directory, the Department shall provide the
        information about the reported inaccuracy to the
        appropriate Medicaid Managed Care Entity within 3
        business days after the reported inaccuracy is
        received.
    (c) Formulary transparency.
        (1) Medicaid Managed Care Entities shall publish on
    their respective websites a formulary for each Medicaid
    Managed Care Entity Plan offered and make the formularies
    easily understandable and publicly accessible without the
    necessity of providing a password, a username, or
    personally identifiable information.
        (2) Medicaid Managed Care Entities shall provide
    printed formularies upon request.
        (3) Electronic and print formularies shall display:
            (A) the medications covered (both generic and name
        brand);
            (B) if the medication is preferred or not
        preferred, and what each term means;
            (C) what tier each medication is in and the meaning
        of each tier;
            (D) any utilization controls including, but not
        limited to, step therapy, prior approval, dosage
        limits, gender or age restrictions, quantity limits,
        or other policies that affect access to medications;
            (E) any required cost-sharing;
            (F) a glossary of key terms and explanation of
        utilization controls and cost-sharing requirements;
            (G) a key or legend for all utilization controls
        visible on every page in which specific medication
        coverage information is displayed; and
            (H) directions explaining the process or processes
        a consumer may follow to obtain more information if a
        medication the consumer requires is not covered or
        listed in the formulary.
        (4) Each Medicaid Managed Care Entity shall display
    conspicuously with each electronic and printed medication
    formulary an e-mail address and a toll-free telephone
    number to which any individual may report any inaccuracy in
    the formulary. If the Medicaid Managed Care Entity receives
    a report that the formulary information is inaccurate, the
    Medicaid Managed Care Entity shall investigate the report
    and correct any inaccurate information displayed in the
    electronic formulary.
        (5) Each Medicaid Managed Care Entity shall include a
    disclosure in the electronic and requested print
    formularies that provides the date of publication, a
    statement that the formulary is up to date as of
    publication, and contact information for questions and
    requests to receive updated information.
        (6) The client enrollment services broker's website
    shall display prominently a website URL link to each
    Medicaid Managed Care Entity's Plan formulary. If a
    Medicaid enrollee calls the client enrollment services
    broker with questions regarding formularies, the client
    enrollment services broker shall offer a brief description
    of what a formulary is and shall refer the Medicaid
    enrollee to the appropriate Medicaid Managed Care Entity
    regarding his or her questions about a specific entity's
    formulary.
    (d) Grievances and appeals. The Department shall display
prominently on its website consumer-oriented information
describing how a Medicaid enrollee can file a complaint or
grievance, request a fair hearing for any adverse action taken
by the Department or a Medicaid Managed Care Entity, and access
free legal assistance or other assistance made available by the
State for Medicaid enrollees to pursue an action.
    (e) Medicaid redetermination information. The Department
shall require the client enrollment services broker to display
prominently on the client enrollment services broker's website
a description of where a Medicaid enrollee can access
information regarding the Medicaid redetermination process.
    (f) Medicaid care coordination information. The client
enrollment services broker shall display prominently on its
website, in an easily understandable format, consumer-oriented
information regarding the role of care coordination services
within Medicaid Managed Care. Such information shall include,
but shall not be limited to:
        (1) a basic description of the role of care
    coordination services and examples of specific care
    coordination activities; and
        (2) how a Medicaid enrollee may request care
    coordination services from a Medicaid Managed Care Entity.
    (g) Consumer quality comparison tool.
        (1) The Department shall create a consumer quality
    comparison tool to assist Medicaid enrollees with Medicaid
    Managed Care Entity Plan selection. This tool shall provide
    Medicaid Managed Care Entities' individual Plan
    performance on a set of standardized quality performance
    measures. The Department shall ensure that this tool shall
    be accessible in both a print and online format, with the
    online format allowing for individuals to access
    additional detailed Plan performance information.
        (2) At a minimum, a printed version of the consumer
    quality comparison tool shall be provided by the Department
    on an annual basis to Medicaid enrollees who are required
    by the Department to enroll in a Medicaid Managed Care
    Entity Plan during an enrollee's open enrollment period.
    The consumer quality comparison tool shall also meet all of
    the following criteria:
            (A) Display Medicaid Managed Care Entities'
        individual Plan performance on at least 4 composite
        domains that reflect Plan quality, timeliness, and
        access. The composite domains shall draw from the most
        current available performance data sets including, but
        not limited to:
                (i) Healthcare Effectiveness Data and
            Information Set (HEDIS) measures.
                (ii) Core Set of Children's Health Care
            Quality measures as required under the Children's
            Health Insurance Program Reauthorization Act
            (CHIPRA).
                (iii) Adult Core Set measures.
                (iv) Consumer Assessment of Healthcare
            Providers and Systems (CAHPS) survey results.
                (v) Additional performance measures the
            Department deems appropriate to populate the
            composite domains.
            (B) Use a quality rating system developed by the
        Department to reflect Medicaid Managed Care Entities'
        individual Plan performance. The quality rating system
        for each composite domain shall reflect the Medicaid
        Managed Care Entities' individual Plan performance
        and, when possible, plan performance relative to
        national Medicaid percentiles.
            (C) Be customized to reflect the specific Medicaid
        Managed Care Entities' Plans available to the Medicaid
        enrollee based on his or her geographic location and
        Medicaid eligibility category.
            (D) Include contact information for the client
        enrollment services broker and contact information for
        Medicaid Managed Care Entities available to the
        Medicaid enrollee based on his or her geographic
        location and Medicaid eligibility category.
            (E) Include guiding questions designed to assist
        individuals selecting a Medicaid Managed Care Entity
        Plan.
        (3) At a minimum, the online version of the consumer
    quality comparison tool shall meet all of the following
    criteria:
            (A) Display Medicaid Managed Care Entities'
        individual Plan performance for the same composite
        domains selected by the Department in the printed
        version of the consumer quality comparison tool. The
        Department may display additional composite domains in
        the online version of the consumer quality comparison
        tool as appropriate.
            (B) Display Medicaid Managed Care Entities'
        individual Plan performance on each of the
        standardized performance measures that contribute to
        each composite domain displayed on the online version
        of the consumer quality comparison tool.
            (C) Use a quality rating system developed by the
        Department to reflect Medicaid Managed Care Entities'
        individual Plan performance. The quality rating system
        for each composite domain shall reflect the Medicaid
        Managed Care Entities' individual Plan performance
        and, when possible, plan performance relative to
        national Medicaid percentiles.
            (D) Include the specific Medicaid Managed Care
        Entity Plans available to the Medicaid enrollee based
        on his or her geographic location and Medicaid
        eligibility category.
            (E) Include a sort function to view Medicaid
        Managed Care Entities' individual Plan performance by
        quality rating and by standardized quality performance
        measures.
            (F) Include contact information for the client
        enrollment services broker and for each Medicaid
        Managed Care Entity.
            (G) Include guiding questions designed to assist
        individuals in selecting a Medicaid Managed Care
        Entity Plan.
            (H) Prominently display current notice of quality
        performance sanctions against Medicaid Managed Care
        Entities. Notice of the sanctions shall remain present
        on the online version of the consumer quality
        comparison tool until the sanctions are lifted.
        (4) The online version of the consumer quality
    comparison tool shall be displayed prominently on the
    client enrollment services broker's website.
        (5) In the development of the consumer quality
    comparison tool, the Department shall establish and
    publicize a formal process to collect and consider written
    and oral feedback from consumers, advocates, and
    stakeholders on aspects of the consumer quality comparison
    tool, including, but not limited to, the following:
            (A) The standardized data sets and surveys,
        specific performance measures, and composite domains
        represented in the consumer quality comparison tool.
            (B) The format and presentation of the consumer
        quality comparison tool.
            (C) The methods undertaken by the Department to
        notify Medicaid enrollees of the availability of the
        consumer quality comparison tool.
        (6) The Department shall review and update as
    appropriate the composite domains and performance measures
    represented in the print and online versions of the
    consumer quality comparison tool at least once every 3
    years. During the Department's review process, the
    Department shall solicit engagement in the public feedback
    process described in paragraph (5).
        (7) The Department shall ensure that the consumer
    quality comparison tool is available for consumer use as
    soon as possible but no later than January 1, 2018.
    (h) The Department may adopt rules and take any other
appropriate action necessary to implement its responsibilities
under this Section.
 
    Section 99. Effective date. This Act takes effect upon
becoming law.