Sen. Omar Aquino

Filed: 4/19/2018





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2    AMENDMENT NO. ______. Amend Senate Bill 2429, AS AMENDED,
3by replacing everything after the enacting clause with the
5    "Section 5. The Illinois Public Aid Code is amended by
6changing Sections 5-5, 5-30, and 5-30.1 as follows:
7    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
8    Sec. 5-5. Medical services. The Illinois Department, by
9rule, shall determine the quantity and quality of and the rate
10of reimbursement for the medical assistance for which payment
11will be authorized, and the medical services to be provided,
12which may include all or part of the following: (1) inpatient
13hospital services; (2) outpatient hospital services; (3) other
14laboratory and X-ray services; (4) skilled nursing home
15services; (5) physicians' services whether furnished in the
16office, the patient's home, a hospital, a skilled nursing home,



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1or elsewhere; (6) medical care, or any other type of remedial
2care furnished by licensed practitioners; (7) home health care
3services; (8) private duty nursing service; (9) clinic
4services; (10) dental services, including prevention and
5treatment of periodontal disease and dental caries disease for
6pregnant women, provided by an individual licensed to practice
7dentistry or dental surgery; for purposes of this item (10),
8"dental services" means diagnostic, preventive, or corrective
9procedures provided by or under the supervision of a dentist in
10the practice of his or her profession; (11) physical therapy
11and related services; (12) prescribed drugs, dentures, and
12prosthetic devices; and eyeglasses prescribed by a physician
13skilled in the diseases of the eye, or by an optometrist,
14whichever the person may select; (13) other diagnostic,
15screening, preventive, and rehabilitative services, including
16to ensure that the individual's need for intervention or
17treatment of mental disorders or substance use disorders or
18co-occurring mental health and substance use disorders is
19determined using a uniform screening, assessment, and
20evaluation process inclusive of criteria, for children and
21adults; for purposes of this item (13), a uniform screening,
22assessment, and evaluation process refers to a process that
23includes an appropriate evaluation and, as warranted, a
24referral; "uniform" does not mean the use of a singular
25instrument, tool, or process that all must utilize; (14)
26transportation and such other expenses as may be necessary;



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1(15) medical treatment of sexual assault survivors, as defined
2in Section 1a of the Sexual Assault Survivors Emergency
3Treatment Act, for injuries sustained as a result of the sexual
4assault, including examinations and laboratory tests to
5discover evidence which may be used in criminal proceedings
6arising from the sexual assault; (16) the diagnosis and
7treatment of sickle cell anemia; and (17) any other medical
8care, and any other type of remedial care recognized under the
9laws of this State. The term "any other type of remedial care"
10shall include nursing care and nursing home service for persons
11who rely on treatment by spiritual means alone through prayer
12for healing.
13    Notwithstanding any other provision of this Section, a
14comprehensive tobacco use cessation program that includes
15purchasing prescription drugs or prescription medical devices
16approved by the Food and Drug Administration shall be covered
17under the medical assistance program under this Article for
18persons who are otherwise eligible for assistance under this
20    Notwithstanding any other provision of this Code,
21reproductive health care that is otherwise legal in Illinois
22shall be covered under the medical assistance program for
23persons who are otherwise eligible for medical assistance under
24this Article.
25    Notwithstanding any other provision of this Code, the
26Illinois Department may not require, as a condition of payment



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1for any laboratory test authorized under this Article, that a
2physician's handwritten signature appear on the laboratory
3test order form. The Illinois Department may, however, impose
4other appropriate requirements regarding laboratory test order
6    Upon receipt of federal approval of an amendment to the
7Illinois Title XIX State Plan for this purpose, the Department
8shall authorize the Chicago Public Schools (CPS) to procure a
9vendor or vendors to manufacture eyeglasses for individuals
10enrolled in a school within the CPS system. CPS shall ensure
11that its vendor or vendors are enrolled as providers in the
12medical assistance program and in any capitated Medicaid
13managed care entity (MCE) serving individuals enrolled in a
14school within the CPS system. Under any contract procured under
15this provision, the vendor or vendors must serve only
16individuals enrolled in a school within the CPS system. Claims
17for services provided by CPS's vendor or vendors to recipients
18of benefits in the medical assistance program under this Code,
19the Children's Health Insurance Program, or the Covering ALL
20KIDS Health Insurance Program shall be submitted to the
21Department or the MCE in which the individual is enrolled for
22payment and shall be reimbursed at the Department's or the
23MCE's established rates or rate methodologies for eyeglasses.
24    On and after July 1, 2012, the Department of Healthcare and
25Family Services may provide the following services to persons
26eligible for assistance under this Article who are



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1participating in education, training or employment programs
2operated by the Department of Human Services as successor to
3the Department of Public Aid:
4        (1) dental services provided by or under the
5    supervision of a dentist; and
6        (2) eyeglasses prescribed by a physician skilled in the
7    diseases of the eye, or by an optometrist, whichever the
8    person may select.
9    On and after July 1, 2018, the Department of Healthcare and
10Family Services shall provide dental services to any adult who
11is otherwise eligible for assistance under the medical
12assistance program. As used in this paragraph, "dental
13services" means diagnostic, preventative, restorative, or
14corrective procedures, including procedures and services for
15the prevention and treatment of periodontal disease and dental
16caries disease, provided by an individual who is licensed to
17practice dentistry or dental surgery or who is under the
18supervision of a dentist in the practice of his or her
20    On and after July 1, 2018, targeted dental services, as set
21forth in Exhibit D of the Consent Decree entered by the United
22States District Court for the Northern District of Illinois,
23Eastern Division, in the matter of Memisovski v. Maram, Case
24No. 92 C 1982, that are provided to adults under the medical
25assistance program shall be established at no less than the
26rates set forth in the "New Rate" column in Exhibit D of the



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1Consent Decree for targeted dental services that are provided
2to persons under the age of 18 under the medical assistance
4    Notwithstanding any other provision of this Code and
5subject to federal approval, the Department may adopt rules to
6allow a dentist who is volunteering his or her service at no
7cost to render dental services through an enrolled
8not-for-profit health clinic without the dentist personally
9enrolling as a participating provider in the medical assistance
10program. A not-for-profit health clinic shall include a public
11health clinic or Federally Qualified Health Center or other
12enrolled provider, as determined by the Department, through
13which dental services covered under this Section are performed.
14The Department shall establish a process for payment of claims
15for reimbursement for covered dental services rendered under
16this provision.
17    The Illinois Department, by rule, may distinguish and
18classify the medical services to be provided only in accordance
19with the classes of persons designated in Section 5-2.
20    The Department of Healthcare and Family Services must
21provide coverage and reimbursement for amino acid-based
22elemental formulas, regardless of delivery method, for the
23diagnosis and treatment of (i) eosinophilic disorders and (ii)
24short bowel syndrome when the prescribing physician has issued
25a written order stating that the amino acid-based elemental
26formula is medically necessary.



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1    The Illinois Department shall authorize the provision of,
2and shall authorize payment for, screening by low-dose
3mammography for the presence of occult breast cancer for women
435 years of age or older who are eligible for medical
5assistance under this Article, as follows:
6        (A) A baseline mammogram for women 35 to 39 years of
7    age.
8        (B) An annual mammogram for women 40 years of age or
9    older.
10        (C) A mammogram at the age and intervals considered
11    medically necessary by the woman's health care provider for
12    women under 40 years of age and having a family history of
13    breast cancer, prior personal history of breast cancer,
14    positive genetic testing, or other risk factors.
15        (D) A comprehensive ultrasound screening and MRI of an
16    entire breast or breasts if a mammogram demonstrates
17    heterogeneous or dense breast tissue, when medically
18    necessary as determined by a physician licensed to practice
19    medicine in all of its branches.
20        (E) A screening MRI when medically necessary, as
21    determined by a physician licensed to practice medicine in
22    all of its branches.
23    All screenings shall include a physical breast exam,
24instruction on self-examination and information regarding the
25frequency of self-examination and its value as a preventative
26tool. For purposes of this Section, "low-dose mammography"



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1means the x-ray examination of the breast using equipment
2dedicated specifically for mammography, including the x-ray
3tube, filter, compression device, and image receptor, with an
4average radiation exposure delivery of less than one rad per
5breast for 2 views of an average size breast. The term also
6includes digital mammography and includes breast
7tomosynthesis. As used in this Section, the term "breast
8tomosynthesis" means a radiologic procedure that involves the
9acquisition of projection images over the stationary breast to
10produce cross-sectional digital three-dimensional images of
11the breast. If, at any time, the Secretary of the United States
12Department of Health and Human Services, or its successor
13agency, promulgates rules or regulations to be published in the
14Federal Register or publishes a comment in the Federal Register
15or issues an opinion, guidance, or other action that would
16require the State, pursuant to any provision of the Patient
17Protection and Affordable Care Act (Public Law 111-148),
18including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
19successor provision, to defray the cost of any coverage for
20breast tomosynthesis outlined in this paragraph, then the
21requirement that an insurer cover breast tomosynthesis is
22inoperative other than any such coverage authorized under
23Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
24the State shall not assume any obligation for the cost of
25coverage for breast tomosynthesis set forth in this paragraph.
26    On and after January 1, 2016, the Department shall ensure



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1that all networks of care for adult clients of the Department
2include access to at least one breast imaging Center of Imaging
3Excellence as certified by the American College of Radiology.
4    On and after January 1, 2012, providers participating in a
5quality improvement program approved by the Department shall be
6reimbursed for screening and diagnostic mammography at the same
7rate as the Medicare program's rates, including the increased
8reimbursement for digital mammography.
9    The Department shall convene an expert panel including
10representatives of hospitals, free-standing mammography
11facilities, and doctors, including radiologists, to establish
12quality standards for mammography.
13    On and after January 1, 2017, providers participating in a
14breast cancer treatment quality improvement program approved
15by the Department shall be reimbursed for breast cancer
16treatment at a rate that is no lower than 95% of the Medicare
17program's rates for the data elements included in the breast
18cancer treatment quality program.
19    The Department shall convene an expert panel, including
20representatives of hospitals, free standing breast cancer
21treatment centers, breast cancer quality organizations, and
22doctors, including breast surgeons, reconstructive breast
23surgeons, oncologists, and primary care providers to establish
24quality standards for breast cancer treatment.
25    Subject to federal approval, the Department shall
26establish a rate methodology for mammography at federally



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1qualified health centers and other encounter-rate clinics.
2These clinics or centers may also collaborate with other
3hospital-based mammography facilities. By January 1, 2016, the
4Department shall report to the General Assembly on the status
5of the provision set forth in this paragraph.
6    The Department shall establish a methodology to remind
7women who are age-appropriate for screening mammography, but
8who have not received a mammogram within the previous 18
9months, of the importance and benefit of screening mammography.
10The Department shall work with experts in breast cancer
11outreach and patient navigation to optimize these reminders and
12shall establish a methodology for evaluating their
13effectiveness and modifying the methodology based on the
15    The Department shall establish a performance goal for
16primary care providers with respect to their female patients
17over age 40 receiving an annual mammogram. This performance
18goal shall be used to provide additional reimbursement in the
19form of a quality performance bonus to primary care providers
20who meet that goal.
21    The Department shall devise a means of case-managing or
22patient navigation for beneficiaries diagnosed with breast
23cancer. This program shall initially operate as a pilot program
24in areas of the State with the highest incidence of mortality
25related to breast cancer. At least one pilot program site shall
26be in the metropolitan Chicago area and at least one site shall



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1be outside the metropolitan Chicago area. On or after July 1,
22016, the pilot program shall be expanded to include one site
3in western Illinois, one site in southern Illinois, one site in
4central Illinois, and 4 sites within metropolitan Chicago. An
5evaluation of the pilot program shall be carried out measuring
6health outcomes and cost of care for those served by the pilot
7program compared to similarly situated patients who are not
8served by the pilot program.
9    The Department shall require all networks of care to
10develop a means either internally or by contract with experts
11in navigation and community outreach to navigate cancer
12patients to comprehensive care in a timely fashion. The
13Department shall require all networks of care to include access
14for patients diagnosed with cancer to at least one academic
15commission on cancer-accredited cancer program as an
16in-network covered benefit.
17    Any medical or health care provider shall immediately
18recommend, to any pregnant woman who is being provided prenatal
19services and is suspected of drug abuse or is addicted as
20defined in the Alcoholism and Other Drug Abuse and Dependency
21Act, referral to a local substance abuse treatment provider
22licensed by the Department of Human Services or to a licensed
23hospital which provides substance abuse treatment services.
24The Department of Healthcare and Family Services shall assure
25coverage for the cost of treatment of the drug abuse or
26addiction for pregnant recipients in accordance with the



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1Illinois Medicaid Program in conjunction with the Department of
2Human Services.
3    All medical providers providing medical assistance to
4pregnant women under this Code shall receive information from
5the Department on the availability of services under the Drug
6Free Families with a Future or any comparable program providing
7case management services for addicted women, including
8information on appropriate referrals for other social services
9that may be needed by addicted women in addition to treatment
10for addiction.
11    The Illinois Department, in cooperation with the
12Departments of Human Services (as successor to the Department
13of Alcoholism and Substance Abuse) and Public Health, through a
14public awareness campaign, may provide information concerning
15treatment for alcoholism and drug abuse and addiction, prenatal
16health care, and other pertinent programs directed at reducing
17the number of drug-affected infants born to recipients of
18medical assistance.
19    Neither the Department of Healthcare and Family Services
20nor the Department of Human Services shall sanction the
21recipient solely on the basis of her substance abuse.
22    The Illinois Department shall establish such regulations
23governing the dispensing of health services under this Article
24as it shall deem appropriate. The Department should seek the
25advice of formal professional advisory committees appointed by
26the Director of the Illinois Department for the purpose of



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1providing regular advice on policy and administrative matters,
2information dissemination and educational activities for
3medical and health care providers, and consistency in
4procedures to the Illinois Department.
5    The Illinois Department may develop and contract with
6Partnerships of medical providers to arrange medical services
7for persons eligible under Section 5-2 of this Code.
8Implementation of this Section may be by demonstration projects
9in certain geographic areas. The Partnership shall be
10represented by a sponsor organization. The Department, by rule,
11shall develop qualifications for sponsors of Partnerships.
12Nothing in this Section shall be construed to require that the
13sponsor organization be a medical organization.
14    The sponsor must negotiate formal written contracts with
15medical providers for physician services, inpatient and
16outpatient hospital care, home health services, treatment for
17alcoholism and substance abuse, and other services determined
18necessary by the Illinois Department by rule for delivery by
19Partnerships. Physician services must include prenatal and
20obstetrical care. The Illinois Department shall reimburse
21medical services delivered by Partnership providers to clients
22in target areas according to provisions of this Article and the
23Illinois Health Finance Reform Act, except that:
24        (1) Physicians participating in a Partnership and
25    providing certain services, which shall be determined by
26    the Illinois Department, to persons in areas covered by the



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1    Partnership may receive an additional surcharge for such
2    services.
3        (2) The Department may elect to consider and negotiate
4    financial incentives to encourage the development of
5    Partnerships and the efficient delivery of medical care.
6        (3) Persons receiving medical services through
7    Partnerships may receive medical and case management
8    services above the level usually offered through the
9    medical assistance program.
10    Medical providers shall be required to meet certain
11qualifications to participate in Partnerships to ensure the
12delivery of high quality medical services. These
13qualifications shall be determined by rule of the Illinois
14Department and may be higher than qualifications for
15participation in the medical assistance program. Partnership
16sponsors may prescribe reasonable additional qualifications
17for participation by medical providers, only with the prior
18written approval of the Illinois Department.
19    Nothing in this Section shall limit the free choice of
20practitioners, hospitals, and other providers of medical
21services by clients. In order to ensure patient freedom of
22choice, the Illinois Department shall immediately promulgate
23all rules and take all other necessary actions so that provided
24services may be accessed from therapeutically certified
25optometrists to the full extent of the Illinois Optometric
26Practice Act of 1987 without discriminating between service



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2    The Department shall apply for a waiver from the United
3States Health Care Financing Administration to allow for the
4implementation of Partnerships under this Section.
5    The Illinois Department shall require health care
6providers to maintain records that document the medical care
7and services provided to recipients of Medical Assistance under
8this Article. Such records must be retained for a period of not
9less than 6 years from the date of service or as provided by
10applicable State law, whichever period is longer, except that
11if an audit is initiated within the required retention period
12then the records must be retained until the audit is completed
13and every exception is resolved. The Illinois Department shall
14require health care providers to make available, when
15authorized by the patient, in writing, the medical records in a
16timely fashion to other health care providers who are treating
17or serving persons eligible for Medical Assistance under this
18Article. All dispensers of medical services shall be required
19to maintain and retain business and professional records
20sufficient to fully and accurately document the nature, scope,
21details and receipt of the health care provided to persons
22eligible for medical assistance under this Code, in accordance
23with regulations promulgated by the Illinois Department. The
24rules and regulations shall require that proof of the receipt
25of prescription drugs, dentures, prosthetic devices and
26eyeglasses by eligible persons under this Section accompany



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1each claim for reimbursement submitted by the dispenser of such
2medical services. No such claims for reimbursement shall be
3approved for payment by the Illinois Department without such
4proof of receipt, unless the Illinois Department shall have put
5into effect and shall be operating a system of post-payment
6audit and review which shall, on a sampling basis, be deemed
7adequate by the Illinois Department to assure that such drugs,
8dentures, prosthetic devices and eyeglasses for which payment
9is being made are actually being received by eligible
10recipients. Within 90 days after September 16, 1984 (the
11effective date of Public Act 83-1439), the Illinois Department
12shall establish a current list of acquisition costs for all
13prosthetic devices and any other items recognized as medical
14equipment and supplies reimbursable under this Article and
15shall update such list on a quarterly basis, except that the
16acquisition costs of all prescription drugs shall be updated no
17less frequently than every 30 days as required by Section
19    Notwithstanding any other law to the contrary, the Illinois
20Department shall, within 365 days after July 22, 2013 (the
21effective date of Public Act 98-104), establish procedures to
22permit skilled care facilities licensed under the Nursing Home
23Care Act to submit monthly billing claims for reimbursement
24purposes. Following development of these procedures, the
25Department shall, by July 1, 2016, test the viability of the
26new system and implement any necessary operational or



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1structural changes to its information technology platforms in
2order to allow for the direct acceptance and payment of nursing
3home claims.
4    Notwithstanding any other law to the contrary, the Illinois
5Department shall, within 365 days after August 15, 2014 (the
6effective date of Public Act 98-963), establish procedures to
7permit ID/DD facilities licensed under the ID/DD Community Care
8Act and MC/DD facilities licensed under the MC/DD Act to submit
9monthly billing claims for reimbursement purposes. Following
10development of these procedures, the Department shall have an
11additional 365 days to test the viability of the new system and
12to ensure that any necessary operational or structural changes
13to its information technology platforms are implemented.
14    The Illinois Department shall require all dispensers of
15medical services, other than an individual practitioner or
16group of practitioners, desiring to participate in the Medical
17Assistance program established under this Article to disclose
18all financial, beneficial, ownership, equity, surety or other
19interests in any and all firms, corporations, partnerships,
20associations, business enterprises, joint ventures, agencies,
21institutions or other legal entities providing any form of
22health care services in this State under this Article.
23    The Illinois Department may require that all dispensers of
24medical services desiring to participate in the medical
25assistance program established under this Article disclose,
26under such terms and conditions as the Illinois Department may



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1by rule establish, all inquiries from clients and attorneys
2regarding medical bills paid by the Illinois Department, which
3inquiries could indicate potential existence of claims or liens
4for the Illinois Department.
5    Enrollment of a vendor shall be subject to a provisional
6period and shall be conditional for one year. During the period
7of conditional enrollment, the Department may terminate the
8vendor's eligibility to participate in, or may disenroll the
9vendor from, the medical assistance program without cause.
10Unless otherwise specified, such termination of eligibility or
11disenrollment is not subject to the Department's hearing
12process. However, a disenrolled vendor may reapply without
14    The Department has the discretion to limit the conditional
15enrollment period for vendors based upon category of risk of
16the vendor.
17    Prior to enrollment and during the conditional enrollment
18period in the medical assistance program, all vendors shall be
19subject to enhanced oversight, screening, and review based on
20the risk of fraud, waste, and abuse that is posed by the
21category of risk of the vendor. The Illinois Department shall
22establish the procedures for oversight, screening, and review,
23which may include, but need not be limited to: criminal and
24financial background checks; fingerprinting; license,
25certification, and authorization verifications; unscheduled or
26unannounced site visits; database checks; prepayment audit



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1reviews; audits; payment caps; payment suspensions; and other
2screening as required by federal or State law.
3    The Department shall define or specify the following: (i)
4by provider notice, the "category of risk of the vendor" for
5each type of vendor, which shall take into account the level of
6screening applicable to a particular category of vendor under
7federal law and regulations; (ii) by rule or provider notice,
8the maximum length of the conditional enrollment period for
9each category of risk of the vendor; and (iii) by rule, the
10hearing rights, if any, afforded to a vendor in each category
11of risk of the vendor that is terminated or disenrolled during
12the conditional enrollment period.
13    To be eligible for payment consideration, a vendor's
14payment claim or bill, either as an initial claim or as a
15resubmitted claim following prior rejection, must be received
16by the Illinois Department, or its fiscal intermediary, no
17later than 180 days after the latest date on the claim on which
18medical goods or services were provided, with the following
20        (1) In the case of a provider whose enrollment is in
21    process by the Illinois Department, the 180-day period
22    shall not begin until the date on the written notice from
23    the Illinois Department that the provider enrollment is
24    complete.
25        (2) In the case of errors attributable to the Illinois
26    Department or any of its claims processing intermediaries



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1    which result in an inability to receive, process, or
2    adjudicate a claim, the 180-day period shall not begin
3    until the provider has been notified of the error.
4        (3) In the case of a provider for whom the Illinois
5    Department initiates the monthly billing process.
6        (4) In the case of a provider operated by a unit of
7    local government with a population exceeding 3,000,000
8    when local government funds finance federal participation
9    for claims payments.
10    For claims for services rendered during a period for which
11a recipient received retroactive eligibility, claims must be
12filed within 180 days after the Department determines the
13applicant is eligible. For claims for which the Illinois
14Department is not the primary payer, claims must be submitted
15to the Illinois Department within 180 days after the final
16adjudication by the primary payer.
17    In the case of long term care facilities, within 45
18calendar days of receipt by the facility of required
19prescreening information, new admissions with associated
20admission documents shall be submitted through the Medical
21Electronic Data Interchange (MEDI) or the Recipient
22Eligibility Verification (REV) System or shall be submitted
23directly to the Department of Human Services using required
24admission forms. Effective September 1, 2014, admission
25documents, including all prescreening information, must be
26submitted through MEDI or REV. Confirmation numbers assigned to



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1an accepted transaction shall be retained by a facility to
2verify timely submittal. Once an admission transaction has been
3completed, all resubmitted claims following prior rejection
4are subject to receipt no later than 180 days after the
5admission transaction has been completed.
6    Claims that are not submitted and received in compliance
7with the foregoing requirements shall not be eligible for
8payment under the medical assistance program, and the State
9shall have no liability for payment of those claims.
10    To the extent consistent with applicable information and
11privacy, security, and disclosure laws, State and federal
12agencies and departments shall provide the Illinois Department
13access to confidential and other information and data necessary
14to perform eligibility and payment verifications and other
15Illinois Department functions. This includes, but is not
16limited to: information pertaining to licensure;
17certification; earnings; immigration status; citizenship; wage
18reporting; unearned and earned income; pension income;
19employment; supplemental security income; social security
20numbers; National Provider Identifier (NPI) numbers; the
21National Practitioner Data Bank (NPDB); program and agency
22exclusions; taxpayer identification numbers; tax delinquency;
23corporate information; and death records.
24    The Illinois Department shall enter into agreements with
25State agencies and departments, and is authorized to enter into
26agreements with federal agencies and departments, under which



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1such agencies and departments shall share data necessary for
2medical assistance program integrity functions and oversight.
3The Illinois Department shall develop, in cooperation with
4other State departments and agencies, and in compliance with
5applicable federal laws and regulations, appropriate and
6effective methods to share such data. At a minimum, and to the
7extent necessary to provide data sharing, the Illinois
8Department shall enter into agreements with State agencies and
9departments, and is authorized to enter into agreements with
10federal agencies and departments, including but not limited to:
11the Secretary of State; the Department of Revenue; the
12Department of Public Health; the Department of Human Services;
13and the Department of Financial and Professional Regulation.
14    Beginning in fiscal year 2013, the Illinois Department
15shall set forth a request for information to identify the
16benefits of a pre-payment, post-adjudication, and post-edit
17claims system with the goals of streamlining claims processing
18and provider reimbursement, reducing the number of pending or
19rejected claims, and helping to ensure a more transparent
20adjudication process through the utilization of: (i) provider
21data verification and provider screening technology; and (ii)
22clinical code editing; and (iii) pre-pay, pre- or
23post-adjudicated predictive modeling with an integrated case
24management system with link analysis. Such a request for
25information shall not be considered as a request for proposal
26or as an obligation on the part of the Illinois Department to



10000SB2429sam003- 23 -LRB100 16511 KTG 38692 a

1take any action or acquire any products or services.
2    The Illinois Department shall establish policies,
3procedures, standards and criteria by rule for the acquisition,
4repair and replacement of orthotic and prosthetic devices and
5durable medical equipment. Such rules shall provide, but not be
6limited to, the following services: (1) immediate repair or
7replacement of such devices by recipients; and (2) rental,
8lease, purchase or lease-purchase of durable medical equipment
9in a cost-effective manner, taking into consideration the
10recipient's medical prognosis, the extent of the recipient's
11needs, and the requirements and costs for maintaining such
12equipment. Subject to prior approval, such rules shall enable a
13recipient to temporarily acquire and use alternative or
14substitute devices or equipment pending repairs or
15replacements of any device or equipment previously authorized
16for such recipient by the Department. Notwithstanding any
17provision of Section 5-5f to the contrary, the Department may,
18by rule, exempt certain replacement wheelchair parts from prior
19approval and, for wheelchairs, wheelchair parts, wheelchair
20accessories, and related seating and positioning items,
21determine the wholesale price by methods other than actual
22acquisition costs.
23    The Department shall require, by rule, all providers of
24durable medical equipment to be accredited by an accreditation
25organization approved by the federal Centers for Medicare and
26Medicaid Services and recognized by the Department in order to



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1bill the Department for providing durable medical equipment to
2recipients. No later than 15 months after the effective date of
3the rule adopted pursuant to this paragraph, all providers must
4meet the accreditation requirement.
5    The Department shall execute, relative to the nursing home
6prescreening project, written inter-agency agreements with the
7Department of Human Services and the Department on Aging, to
8effect the following: (i) intake procedures and common
9eligibility criteria for those persons who are receiving
10non-institutional services; and (ii) the establishment and
11development of non-institutional services in areas of the State
12where they are not currently available or are undeveloped; and
13(iii) notwithstanding any other provision of law, subject to
14federal approval, on and after July 1, 2012, an increase in the
15determination of need (DON) scores from 29 to 37 for applicants
16for institutional and home and community-based long term care;
17if and only if federal approval is not granted, the Department
18may, in conjunction with other affected agencies, implement
19utilization controls or changes in benefit packages to
20effectuate a similar savings amount for this population; and
21(iv) no later than July 1, 2013, minimum level of care
22eligibility criteria for institutional and home and
23community-based long term care; and (v) no later than October
241, 2013, establish procedures to permit long term care
25providers access to eligibility scores for individuals with an
26admission date who are seeking or receiving services from the



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1long term care provider. In order to select the minimum level
2of care eligibility criteria, the Governor shall establish a
3workgroup that includes affected agency representatives and
4stakeholders representing the institutional and home and
5community-based long term care interests. This Section shall
6not restrict the Department from implementing lower level of
7care eligibility criteria for community-based services in
8circumstances where federal approval has been granted.
9    The Illinois Department shall develop and operate, in
10cooperation with other State Departments and agencies and in
11compliance with applicable federal laws and regulations,
12appropriate and effective systems of health care evaluation and
13programs for monitoring of utilization of health care services
14and facilities, as it affects persons eligible for medical
15assistance under this Code.
16    The Illinois Department shall report annually to the
17General Assembly, no later than the second Friday in April of
181979 and each year thereafter, in regard to:
19        (a) actual statistics and trends in utilization of
20    medical services by public aid recipients;
21        (b) actual statistics and trends in the provision of
22    the various medical services by medical vendors;
23        (c) current rate structures and proposed changes in
24    those rate structures for the various medical vendors; and
25        (d) efforts at utilization review and control by the
26    Illinois Department.



10000SB2429sam003- 26 -LRB100 16511 KTG 38692 a

1    The period covered by each report shall be the 3 years
2ending on the June 30 prior to the report. The report shall
3include suggested legislation for consideration by the General
4Assembly. The filing of one copy of the report with the
5Speaker, one copy with the Minority Leader and one copy with
6the Clerk of the House of Representatives, one copy with the
7President, one copy with the Minority Leader and one copy with
8the Secretary of the Senate, one copy with the Legislative
9Research Unit, and such additional copies with the State
10Government Report Distribution Center for the General Assembly
11as is required under paragraph (t) of Section 7 of the State
12Library Act shall be deemed sufficient to comply with this
14    Rulemaking authority to implement Public Act 95-1045, if
15any, is conditioned on the rules being adopted in accordance
16with all provisions of the Illinois Administrative Procedure
17Act and all rules and procedures of the Joint Committee on
18Administrative Rules; any purported rule not so adopted, for
19whatever reason, is unauthorized.
20    On and after July 1, 2012, the Department shall reduce any
21rate of reimbursement for services or other payments or alter
22any methodologies authorized by this Code to reduce any rate of
23reimbursement for services or other payments in accordance with
24Section 5-5e.
25    Because kidney transplantation can be an appropriate, cost
26effective alternative to renal dialysis when medically



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1necessary and notwithstanding the provisions of Section 1-11 of
2this Code, beginning October 1, 2014, the Department shall
3cover kidney transplantation for noncitizens with end-stage
4renal disease who are not eligible for comprehensive medical
5benefits, who meet the residency requirements of Section 5-3 of
6this Code, and who would otherwise meet the financial
7requirements of the appropriate class of eligible persons under
8Section 5-2 of this Code. To qualify for coverage of kidney
9transplantation, such person must be receiving emergency renal
10dialysis services covered by the Department. Providers under
11this Section shall be prior approved and certified by the
12Department to perform kidney transplantation and the services
13under this Section shall be limited to services associated with
14kidney transplantation.
15    Notwithstanding any other provision of this Code to the
16contrary, on or after July 1, 2015, all FDA approved forms of
17medication assisted treatment prescribed for the treatment of
18alcohol dependence or treatment of opioid dependence shall be
19covered under both fee for service and managed care medical
20assistance programs for persons who are otherwise eligible for
21medical assistance under this Article and shall not be subject
22to any (1) utilization control, other than those established
23under the American Society of Addiction Medicine patient
24placement criteria, (2) prior authorization mandate, or (3)
25lifetime restriction limit mandate.
26    On or after July 1, 2015, opioid antagonists prescribed for



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1the treatment of an opioid overdose, including the medication
2product, administration devices, and any pharmacy fees related
3to the dispensing and administration of the opioid antagonist,
4shall be covered under the medical assistance program for
5persons who are otherwise eligible for medical assistance under
6this Article. As used in this Section, "opioid antagonist"
7means a drug that binds to opioid receptors and blocks or
8inhibits the effect of opioids acting on those receptors,
9including, but not limited to, naloxone hydrochloride or any
10other similarly acting drug approved by the U.S. Food and Drug
12    Upon federal approval, the Department shall provide
13coverage and reimbursement for all drugs that are approved for
14marketing by the federal Food and Drug Administration and that
15are recommended by the federal Public Health Service or the
16United States Centers for Disease Control and Prevention for
17pre-exposure prophylaxis and related pre-exposure prophylaxis
18services, including, but not limited to, HIV and sexually
19transmitted infection screening, treatment for sexually
20transmitted infections, medical monitoring, assorted labs, and
21counseling to reduce the likelihood of HIV infection among
22individuals who are not infected with HIV but who are at high
23risk of HIV infection.
24(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
2599-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
26the effective date of P.A. 99-407); 99-433, eff. 8-21-15;



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199-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
27-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
3eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
4100-538, eff. 1-1-18; revised 10-26-17.)
5    (305 ILCS 5/5-30)
6    Sec. 5-30. Care coordination.
7    (a) At least 50% of recipients eligible for comprehensive
8medical benefits in all medical assistance programs or other
9health benefit programs administered by the Department,
10including the Children's Health Insurance Program Act and the
11Covering ALL KIDS Health Insurance Act, shall be enrolled in a
12care coordination program by no later than January 1, 2015. For
13purposes of this Section, "coordinated care" or "care
14coordination" means delivery systems where recipients will
15receive their care from providers who participate under
16contract in integrated delivery systems that are responsible
17for providing or arranging the majority of care, including
18primary care physician services, referrals from primary care
19physicians, diagnostic and treatment services, behavioral
20health services, in-patient and outpatient hospital services,
21dental services, and rehabilitation and long-term care
22services. The Department shall designate or contract for such
23integrated delivery systems (i) to ensure enrollees have a
24choice of systems and of primary care providers within such
25systems; (ii) to ensure that enrollees receive quality care in



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1a culturally and linguistically appropriate manner; and (iii)
2to ensure that coordinated care programs meet the diverse needs
3of enrollees with developmental, mental health, physical, and
4age-related disabilities.
5    (b) Payment for such coordinated care shall be based on
6arrangements where the State pays for performance related to
7health care outcomes, the use of evidence-based practices, the
8use of primary care delivered through comprehensive medical
9homes, the use of electronic medical records, and the
10appropriate exchange of health information electronically made
11either on a capitated basis in which a fixed monthly premium
12per recipient is paid and full financial risk is assumed for
13the delivery of services, or through other risk-based payment
15    (c) To qualify for compliance with this Section, the 50%
16goal shall be achieved by enrolling medical assistance
17enrollees from each medical assistance enrollment category,
18including parents, children, seniors, and people with
19disabilities to the extent that current State Medicaid payment
20laws would not limit federal matching funds for recipients in
21care coordination programs. In addition, services must be more
22comprehensively defined and more risk shall be assumed than in
23the Department's primary care case management program as of
24January 25, 2011 (the effective date of Public Act 96-1501).
25    (d) The Department shall report to the General Assembly in
26a separate part of its annual medical assistance program



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1report, beginning April, 2012 until April, 2016, on the
2progress and implementation of the care coordination program
3initiatives established by the provisions of Public Act
496-1501. The Department shall include in its April 2011 report
5a full analysis of federal laws or regulations regarding upper
6payment limitations to providers and the necessary revisions or
7adjustments in rate methodologies and payments to providers
8under this Code that would be necessary to implement
9coordinated care with full financial risk by a party other than
10the Department.
11    (e) Integrated Care Program for individuals with chronic
12mental health conditions.
13        (1) The Integrated Care Program shall encompass
14    services administered to recipients of medical assistance
15    under this Article to prevent exacerbations and
16    complications using cost-effective, evidence-based
17    practice guidelines and mental health management
18    strategies.
19        (2) The Department may utilize and expand upon existing
20    contractual arrangements with integrated care plans under
21    the Integrated Care Program for providing the coordinated
22    care provisions of this Section.
23        (3) Payment for such coordinated care shall be based on
24    arrangements where the State pays for performance related
25    to mental health outcomes on a capitated basis in which a
26    fixed monthly premium per recipient is paid and full



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1    financial risk is assumed for the delivery of services, or
2    through other risk-based payment arrangements such as
3    provider-based care coordination.
4        (4) The Department shall examine whether chronic
5    mental health management programs and services for
6    recipients with specific chronic mental health conditions
7    do any or all of the following:
8            (A) Improve the patient's overall mental health in
9        a more expeditious and cost-effective manner.
10            (B) Lower costs in other aspects of the medical
11        assistance program, such as hospital admissions,
12        emergency room visits, or more frequent and
13        inappropriate psychotropic drug use.
14        (5) The Department shall work with the facilities and
15    any integrated care plan participating in the program to
16    identify and correct barriers to the successful
17    implementation of this subsection (e) prior to and during
18    the implementation to best facilitate the goals and
19    objectives of this subsection (e).
20    (f) A hospital that is located in a county of the State in
21which the Department mandates some or all of the beneficiaries
22of the Medical Assistance Program residing in the county to
23enroll in a Care Coordination Program, as set forth in Section
245-30 of this Code, shall not be eligible for any non-claims
25based payments not mandated by Article V-A of this Code for
26which it would otherwise be qualified to receive, unless the



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1hospital is a Coordinated Care Participating Hospital no later
2than 60 days after June 14, 2012 (the effective date of Public
3Act 97-689) or 60 days after the first mandatory enrollment of
4a beneficiary in a Coordinated Care program. For purposes of
5this subsection, "Coordinated Care Participating Hospital"
6means a hospital that meets one of the following criteria:
7        (1) The hospital has entered into a contract to provide
8    hospital services with one or more MCOs to enrollees of the
9    care coordination program.
10        (2) The hospital has not been offered a contract by a
11    care coordination plan that the Department has determined
12    to be a good faith offer and that pays at least as much as
13    the Department would pay, on a fee-for-service basis, not
14    including disproportionate share hospital adjustment
15    payments or any other supplemental adjustment or add-on
16    payment to the base fee-for-service rate, except to the
17    extent such adjustments or add-on payments are
18    incorporated into the development of the applicable MCO
19    capitated rates.
20    As used in this subsection (f), "MCO" means any entity
21which contracts with the Department to provide services where
22payment for medical services is made on a capitated basis.
23    (g) No later than August 1, 2013, the Department shall
24issue a purchase of care solicitation for Accountable Care
25Entities (ACE) to serve any children and parents or caretaker
26relatives of children eligible for medical assistance under



10000SB2429sam003- 34 -LRB100 16511 KTG 38692 a

1this Article. An ACE may be a single corporate structure or a
2network of providers organized through contractual
3relationships with a single corporate entity. The solicitation
4shall require that:
5        (1) An ACE operating in Cook County be capable of
6    serving at least 40,000 eligible individuals in that
7    county; an ACE operating in Lake, Kane, DuPage, or Will
8    Counties be capable of serving at least 20,000 eligible
9    individuals in those counties and an ACE operating in other
10    regions of the State be capable of serving at least 10,000
11    eligible individuals in the region in which it operates.
12    During initial periods of mandatory enrollment, the
13    Department shall require its enrollment services
14    contractor to use a default assignment algorithm that
15    ensures if possible an ACE reaches the minimum enrollment
16    levels set forth in this paragraph.
17        (2) An ACE must include at a minimum the following
18    types of providers: primary care, specialty care,
19    hospitals, and behavioral healthcare.
20        (3) An ACE shall have a governance structure that
21    includes the major components of the health care delivery
22    system, including one representative from each of the
23    groups listed in paragraph (2).
24        (4) An ACE must be an integrated delivery system,
25    including a network able to provide the full range of
26    services needed by Medicaid beneficiaries and system



10000SB2429sam003- 35 -LRB100 16511 KTG 38692 a

1    capacity to securely pass clinical information across
2    participating entities and to aggregate and analyze that
3    data in order to coordinate care.
4        (5) An ACE must be capable of providing both care
5    coordination and complex case management, as necessary, to
6    beneficiaries. To be responsive to the solicitation, a
7    potential ACE must outline its care coordination and
8    complex case management model and plan to reduce the cost
9    of care.
10        (6) In the first 18 months of operation, unless the ACE
11    selects a shorter period, an ACE shall be paid care
12    coordination fees on a per member per month basis that are
13    projected to be cost neutral to the State during the term
14    of their payment and, subject to federal approval, be
15    eligible to share in additional savings generated by their
16    care coordination.
17        (7) In months 19 through 36 of operation, unless the
18    ACE selects a shorter period, an ACE shall be paid on a
19    pre-paid capitation basis for all medical assistance
20    covered services, under contract terms similar to Managed
21    Care Organizations (MCO), with the Department sharing the
22    risk through either stop-loss insurance for extremely high
23    cost individuals or corridors of shared risk based on the
24    overall cost of the total enrollment in the ACE. The ACE
25    shall be responsible for claims processing, encounter data
26    submission, utilization control, and quality assurance.



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1        (8) In the fourth and subsequent years of operation, an
2    ACE shall convert to a Managed Care Community Network
3    (MCCN), as defined in this Article, or Health Maintenance
4    Organization pursuant to the Illinois Insurance Code,
5    accepting full-risk capitation payments.
6    The Department shall allow potential ACE entities 5 months
7from the date of the posting of the solicitation to submit
8proposals. After the solicitation is released, in addition to
9the MCO rate development data available on the Department's
10website, subject to federal and State confidentiality and
11privacy laws and regulations, the Department shall provide 2
12years of de-identified summary service data on the targeted
13population, split between children and adults, showing the
14historical type and volume of services received and the cost of
15those services to those potential bidders that sign a data use
16agreement. The Department may add up to 2 non-state government
17employees with expertise in creating integrated delivery
18systems to its review team for the purchase of care
19solicitation described in this subsection. Any such
20individuals must sign a no-conflict disclosure and
21confidentiality agreement and agree to act in accordance with
22all applicable State laws.
23    During the first 2 years of an ACE's operation, the
24Department shall provide claims data to the ACE on its
25enrollees on a periodic basis no less frequently than monthly.
26    Nothing in this subsection shall be construed to limit the



10000SB2429sam003- 37 -LRB100 16511 KTG 38692 a

1Department's mandate to enroll 50% of its beneficiaries into
2care coordination systems by January 1, 2015, using all
3available care coordination delivery systems, including Care
4Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
5to affect the current CCEs, MCCNs, and MCOs selected to serve
6seniors and persons with disabilities prior to that date.
7    Nothing in this subsection precludes the Department from
8considering future proposals for new ACEs or expansion of
9existing ACEs at the discretion of the Department.
10    (h) Department contracts with MCOs and other entities
11reimbursed by risk based capitation shall have a minimum
12medical loss ratio of 85%, shall require the entity to
13establish an appeals and grievances process for consumers and
14providers, and shall require the entity to provide a quality
15assurance and utilization review program. Entities contracted
16with the Department to coordinate healthcare regardless of risk
17shall be measured utilizing the same quality metrics. The
18quality metrics may be population specific. Any contracted
19entity serving at least 5,000 seniors or people with
20disabilities or 15,000 individuals in other populations
21covered by the Medical Assistance Program that has been
22receiving full-risk capitation for a year shall be accredited
23by a national accreditation organization authorized by the
24Department within 2 years after the date it is eligible to
25become accredited. The requirements of this subsection shall
26apply to contracts with MCOs entered into or renewed or



10000SB2429sam003- 38 -LRB100 16511 KTG 38692 a

1extended after June 1, 2013.
2    (h-5) The Department shall monitor and enforce compliance
3by MCOs with agreements they have entered into with providers
4on issues that include, but are not limited to, timeliness of
5payment, payment rates, and processes for obtaining prior
6approval. The Department may impose sanctions on MCOs for
7violating provisions of those agreements that include, but are
8not limited to, financial penalties, suspension of enrollment
9of new enrollees, and termination of the MCO's contract with
10the Department. As used in this subsection (h-5), "MCO" has the
11meaning ascribed to that term in Section 5-30.1 of this Code.
12    (i) Unless otherwise required by federal law, Medicaid
13Managed Care Entities and their respective business associates
14shall not disclose, directly or indirectly, including by
15sending a bill or explanation of benefits, information
16concerning the sensitive health services received by enrollees
17of the Medicaid Managed Care Entity to any person other than
18covered entities and business associates, which may receive,
19use, and further disclose such information solely for the
20purposes permitted under applicable federal and State laws and
21regulations if such use and further disclosure satisfies all
22applicable requirements of such laws and regulations. The
23Medicaid Managed Care Entity or its respective business
24associates may disclose information concerning the sensitive
25health services if the enrollee who received the sensitive
26health services requests the information from the Medicaid



10000SB2429sam003- 39 -LRB100 16511 KTG 38692 a

1Managed Care Entity or its respective business associates and
2authorized the sending of a bill or explanation of benefits.
3Communications including, but not limited to, statements of
4care received or appointment reminders either directly or
5indirectly to the enrollee from the health care provider,
6health care professional, and care coordinators, remain
7permissible. Medicaid Managed Care Entities or their
8respective business associates may communicate directly with
9their enrollees regarding care coordination activities for
10those enrollees.
11    For the purposes of this subsection, the term "Medicaid
12Managed Care Entity" includes Care Coordination Entities,
13Accountable Care Entities, Managed Care Organizations, and
14Managed Care Community Networks.
15    For purposes of this subsection, the term "sensitive health
16services" means mental health services, substance abuse
17treatment services, reproductive health services, family
18planning services, services for sexually transmitted
19infections and sexually transmitted diseases, and services for
20sexual assault or domestic abuse. Services include prevention,
21screening, consultation, examination, treatment, or follow-up.
22    For purposes of this subsection, "business associate",
23"covered entity", "disclosure", and "use" have the meanings
24ascribed to those terms in 45 CFR 160.103.
25    Nothing in this subsection shall be construed to relieve a
26Medicaid Managed Care Entity or the Department of any duty to



10000SB2429sam003- 40 -LRB100 16511 KTG 38692 a

1report incidents of sexually transmitted infections to the
2Department of Public Health or to the local board of health in
3accordance with regulations adopted under a statute or
4ordinance or to report incidents of sexually transmitted
5infections as necessary to comply with the requirements under
6Section 5 of the Abused and Neglected Child Reporting Act or as
7otherwise required by State or federal law.
8    The Department shall create policy in order to implement
9the requirements in this subsection.
10    (j) Managed Care Entities (MCEs), including MCOs and all
11other care coordination organizations, shall develop and
12maintain a written language access policy that sets forth the
13standards, guidelines, and operational plan to ensure language
14appropriate services and that is consistent with the standard
15of meaningful access for populations with limited English
16proficiency. The language access policy shall describe how the
17MCEs will provide all of the following required services:
18        (1) Translation (the written replacement of text from
19    one language into another) of all vital documents and forms
20    as identified by the Department.
21        (2) Qualified interpreter services (the oral
22    communication of a message from one language into another
23    by a qualified interpreter).
24        (3) Staff training on the language access policy,
25    including how to identify language needs, access and
26    provide language assistance services, work with



10000SB2429sam003- 41 -LRB100 16511 KTG 38692 a

1    interpreters, request translations, and track the use of
2    language assistance services.
3        (4) Data tracking that identifies the language need.
4        (5) Notification to participants on the availability
5    of language access services and on how to access such
6    services.
7    (k) The Department shall actively monitor the contractual
8relationship between Managed Care Organizations (MCOs) and any
9dental administrator contracted by an MCO to provide dental
10services. The Department shall adopt appropriate dental
11Healthcare Effectiveness Data and Information Set (HEDIS)
12measures and shall include the Annual Dental Visit (ADV) HEDIS
13measure in its Health Plan Comparison Tool and Illinois
14Medicaid Plan Report Card that is available on the Department's
15website for enrolled individuals.
16    The Department shall collect from each MCO specific
17information about the types of contracted, broad-based care
18coordination occurring between the MCO and any dental
19administrator, including, but not limited to, pregnant women
20and diabetic patients in need of oral care.
21(Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14;
2299-106, eff. 1-1-16; 99-181, eff. 7-29-15; 99-566, eff. 1-1-17;
2399-642, eff. 7-28-16.)
24    (305 ILCS 5/5-30.1)
25    Sec. 5-30.1. Managed care protections.



10000SB2429sam003- 42 -LRB100 16511 KTG 38692 a

1    (a) As used in this Section:
2    "Managed care organization" or "MCO" means any entity which
3contracts with the Department to provide services where payment
4for medical services is made on a capitated basis.
5    "Emergency services" include:
6        (1) emergency services, as defined by Section 10 of the
7    Managed Care Reform and Patient Rights Act;
8        (2) emergency medical screening examinations, as
9    defined by Section 10 of the Managed Care Reform and
10    Patient Rights Act;
11        (3) post-stabilization medical services, as defined by
12    Section 10 of the Managed Care Reform and Patient Rights
13    Act; and
14        (4) emergency medical conditions, as defined by
15    Section 10 of the Managed Care Reform and Patient Rights
16    Act.
17    (b) As provided by Section 5-16.12, managed care
18organizations are subject to the provisions of the Managed Care
19Reform and Patient Rights Act.
20    (c) An MCO shall pay any provider of emergency services
21that does not have in effect a contract with the contracted
22Medicaid MCO. The default rate of reimbursement shall be the
23rate paid under Illinois Medicaid fee-for-service program
24methodology, including all policy adjusters, including but not
25limited to Medicaid High Volume Adjustments, Medicaid
26Percentage Adjustments, Outpatient High Volume Adjustments,



10000SB2429sam003- 43 -LRB100 16511 KTG 38692 a

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



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1    Adjustments, Outpatient High Volume Adjustments and all
2    outlier add-on adjustments to the extent that such
3    adjustments are incorporated in the development of the
4    applicable MCO capitated rates.
5    (e) The following requirements apply to MCOs in determining
6payment for all emergency services:
7        (1) MCOs shall not impose any requirements for prior
8    approval of emergency services.
9        (2) The MCO shall cover emergency services provided to
10    enrollees who are temporarily away from their residence and
11    outside the contracting area to the extent that the
12    enrollees would be entitled to the emergency services if
13    they still were within the contracting area.
14        (3) The MCO shall have no obligation to cover medical
15    services provided on an emergency basis that are not
16    covered services under the contract.
17        (4) The MCO shall not condition coverage for emergency
18    services on the treating provider notifying the MCO of the
19    enrollee's screening and treatment within 10 days after
20    presentation for emergency services.
21        (5) The determination of the attending emergency
22    physician, or the provider actually treating the enrollee,
23    of whether an enrollee is sufficiently stabilized for
24    discharge or transfer to another facility, shall be binding
25    on the MCO. The MCO shall cover emergency services for all
26    enrollees whether the emergency services are provided by an



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1    affiliated or non-affiliated provider.
2        (6) The MCO's financial responsibility for
3    post-stabilization care services it has not pre-approved
4    ends when:
5            (A) a plan physician with privileges at the
6        treating hospital assumes responsibility for the
7        enrollee's care;
8            (B) a plan physician assumes responsibility for
9        the enrollee's care through transfer;
10            (C) a contracting entity representative and the
11        treating physician reach an agreement concerning the
12        enrollee's care; or
13            (D) the enrollee is discharged.
14    (f) Network adequacy and transparency.
15        (1) The Department shall:
16            (A) ensure that an adequate provider network is in
17        place, taking into consideration health professional
18        shortage areas and medically underserved areas;
19            (B) publicly release an explanation of its process
20        for analyzing network adequacy;
21            (C) periodically ensure that an MCO continues to
22        have an adequate network in place; and
23            (D) require MCOs, including Medicaid Managed Care
24        Entities as defined in Section 5-30.2, to meet provider
25        directory requirements under Section 5-30.3.
26        (2) Each MCO shall confirm its receipt of information



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1    submitted specific to physician or dentist additions or
2    physician or dentist deletions from the MCO's provider
3    network within 3 days after receiving all required
4    information from contracted physicians or dentists, and
5    electronic physician and dental directories must be
6    updated consistent with current rules as published by the
7    Centers for Medicare and Medicaid Services or its successor
8    agency.
9    (g) Timely payment of claims.
10        (1) The MCO shall pay a claim within 30 days of
11    receiving a claim that contains all the essential
12    information needed to adjudicate the claim.
13        (2) The MCO shall notify the billing party of its
14    inability to adjudicate a claim within 30 days of receiving
15    that claim.
16        (3) The MCO shall pay a penalty that is at least equal
17    to the penalty imposed under the Illinois Insurance Code
18    for any claims not timely paid.
19        (4) The Department may establish a process for MCOs to
20    expedite payments to providers based on criteria
21    established by the Department.
22    (g-5) Recognizing that the rapid transformation of the
23Illinois Medicaid program may have unintended operational
24challenges for both payers and providers:
25        (1) in no instance shall a medically necessary covered
26    service rendered in good faith, based upon eligibility



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1    information documented by the provider, be denied coverage
2    or diminished in payment amount if the eligibility or
3    coverage information available at the time the service was
4    rendered is later found to be inaccurate; and
5        (2) the Department shall, by December 31, 2016, adopt
6    rules establishing policies that shall be included in the
7    Medicaid managed care policy and procedures manual
8    addressing payment resolutions in situations in which a
9    provider renders services based upon information obtained
10    after verifying a patient's eligibility and coverage plan
11    through either the Department's current enrollment system
12    or a system operated by the coverage plan identified by the
13    patient presenting for services:
14            (A) such medically necessary covered services
15        shall be considered rendered in good faith;
16            (B) such policies and procedures shall be
17        developed in consultation with industry
18        representatives of the Medicaid managed care health
19        plans and representatives of provider associations
20        representing the majority of providers within the
21        identified provider industry; and
22            (C) such rules shall be published for a review and
23        comment period of no less than 30 days on the
24        Department's website with final rules remaining
25        available on the Department's website.
26        (3) The rules on payment resolutions shall include, but



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1    not be limited to:
2            (A) the extension of the timely filing period;
3            (B) retroactive prior authorizations; and
4            (C) guaranteed minimum payment rate of no less than
5        the current, as of the date of service, fee-for-service
6        rate, plus all applicable add-ons, when the resulting
7        service relationship is out of network.
8        (4) The rules shall be applicable for both MCO coverage
9    and fee-for-service coverage.
10    (g-6) MCO Performance Metrics Report.
11        (1) The Department shall publish, on at least a
12    quarterly basis, each MCO's operational performance,
13    including, but not limited to, the following categories of
14    metrics:
15            (A) claims payment, including timeliness and
16        accuracy;
17            (B) prior authorizations;
18            (C) grievance and appeals;
19            (D) utilization statistics;
20            (E) provider disputes;
21            (F) provider credentialing; and
22            (G) member and provider customer service.
23        (2) The Department shall ensure that the metrics report
24    is accessible to providers online by January 1, 2017.
25        (3) The metrics shall be developed in consultation with
26    industry representatives of the Medicaid managed care



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1    health plans and representatives of associations
2    representing the majority of providers within the
3    identified industry.
4        (4) Metrics shall be defined and incorporated into the
5    applicable Managed Care Policy Manual issued by the
6    Department.
7    (g-7) MCO claims processing and performance analysis. In
8order to monitor MCO payments to hospital providers, pursuant
9to this amendatory Act of the 100th General Assembly, the
10Department shall post an analysis of MCO claims processing and
11payment performance on its website every 6 months. Such
12analysis shall include a review and evaluation of a
13representative sample of hospital claims that are rejected and
14denied for clean and unclean claims and the top 5 reasons for
15such actions and timeliness of claims adjudication, which
16identifies the percentage of claims adjudicated within 30, 60,
1790, and over 90 days, and the dollar amounts associated with
18those claims. The Department shall post the contracted claims
19report required by HealthChoice Illinois on its website every 3
21    (h) The Department shall not expand mandatory MCO
22enrollment into new counties beyond those counties already
23designated by the Department as of June 1, 2014 for the
24individuals whose eligibility for medical assistance is not the
25seniors or people with disabilities population until the
26Department provides an opportunity for accountable care



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1entities and MCOs to participate in such newly designated
3    (i) The requirements of this Section apply to contracts
4with accountable care entities and MCOs entered into, amended,
5or renewed after June 16, 2014 (the effective date of Public
6Act 98-651).
7(Source: P.A. 99-725, eff. 8-5-16; 99-751, eff. 8-5-16;
8100-201, eff. 8-18-17; 100-580, eff. 3-12-18.)
9    Section 99. Effective date. This Act takes effect upon
10becoming law.".