101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB3055

 

Introduced , by Rep. Jaime M. Andrade, Jr.

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-30.1

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that for services other than emergency services and post-stabilization services, if a managed care organization and a medical service provider or a hospital cannot agree to contract terms, the non-participant reimbursement rate that the managed care organization is obligated to pay for any medical hospital or hospital-affiliated medical service claim on a fee-for-service basis shall not exceed 90% of the established State rates. Makes the provision applicable to contracts between managed care organizations and medical providers, including hospitals, that are located in neighboring states and provide services to Illinois Medicaid beneficiaries. Effective immediately.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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1    AN ACT concerning public aid.
 
2    WHEREAS, Providing access to healthcare as well as
3comprehensive care coordination are both essential elements of
4care coordination under the Medical Assistance Program; and
 
5    WHEREAS, Medicaid managed care organizations are required
6to provide geographically appropriate access to healthcare for
7their Medicaid enrollees; and
 
8    WHEREAS, Geographic access is dependent on partnerships
9with provider organizations such as hospitals; and
 
10    WHEREAS, Reimbursement rates between Medicaid managed care
11organizations and providers, including hospitals, are to be
12mutually negotiated and agreed upon; however, often in some
13geographic areas where few providers exist, contracted rates
14are often inappropriate; and
 
15    WHEREAS, The State has an interest to ensure that providers
16do not exploit the State or Medicaid managed care
17organizations; and
 
18    WHEREAS, Contractual reimbursement rates that are
19excessively high cost the State as well as Medicaid managed
20care organizations; and
 

 

 

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1    WHEREAS, The State has an interest in providing a financial
2incentive to all parties to negotiate rates in good faith;
3therefore
 
4    Be it enacted by the People of the State of Illinois,
5represented in the General Assembly:
 
6    Section 5. The Illinois Public Aid Code is amended by
7changing Section 5-30.1 as follows:
 
8    (305 ILCS 5/5-30.1)
9    Sec. 5-30.1. Managed care protections.
10    (a) As used in this Section:
11    "Managed care organization" or "MCO" means any entity which
12contracts with the Department to provide services where payment
13for medical services is made on a capitated basis.
14    "Emergency services" include:
15        (1) emergency services, as defined by Section 10 of the
16    Managed Care Reform and Patient Rights Act;
17        (2) emergency medical screening examinations, as
18    defined by Section 10 of the Managed Care Reform and
19    Patient Rights Act;
20        (3) post-stabilization medical services, as defined by
21    Section 10 of the Managed Care Reform and Patient Rights
22    Act; and
23        (4) emergency medical conditions, as defined by

 

 

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

 

 

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

 

 

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

 

 

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1post-stabilization services, if a managed care organization
2and a medical service provider or a hospital cannot agree to
3contract terms, the non-participant reimbursement rate that
4the managed care organization is obligated to pay for any
5medical hospital or hospital-affiliated medical service claim
6on a fee-for-service basis shall not exceed 90% of the
7established State rates. The payment rate under this subsection
8shall also apply to contracts between managed care
9organizations and medical providers, including hospitals, that
10are located in neighboring states and provide medical services
11to Illinois Medicaid beneficiaries.
12    (f) Network adequacy and transparency.
13        (1) The Department shall:
14            (A) ensure that an adequate provider network is in
15        place, taking into consideration health professional
16        shortage areas and medically underserved areas;
17            (B) publicly release an explanation of its process
18        for analyzing network adequacy;
19            (C) periodically ensure that an MCO continues to
20        have an adequate network in place; and
21            (D) require MCOs, including Medicaid Managed Care
22        Entities as defined in Section 5-30.2, to meet provider
23        directory requirements under Section 5-30.3.
24        (2) Each MCO shall confirm its receipt of information
25    submitted specific to physician or dentist additions or
26    physician or dentist deletions from the MCO's provider

 

 

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

 

 

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1    coverage information available at the time the service was
2    rendered is later found to be inaccurate; and
3        (2) the Department shall, by December 31, 2016, adopt
4    rules establishing policies that shall be included in the
5    Medicaid managed care policy and procedures manual
6    addressing payment resolutions in situations in which a
7    provider renders services based upon information obtained
8    after verifying a patient's eligibility and coverage plan
9    through either the Department's current enrollment system
10    or a system operated by the coverage plan identified by the
11    patient presenting for services:
12            (A) such medically necessary covered services
13        shall be considered rendered in good faith;
14            (B) such policies and procedures shall be
15        developed in consultation with industry
16        representatives of the Medicaid managed care health
17        plans and representatives of provider associations
18        representing the majority of providers within the
19        identified provider industry; and
20            (C) such rules shall be published for a review and
21        comment period of no less than 30 days on the
22        Department's website with final rules remaining
23        available on the Department's website.
24        (3) The rules on payment resolutions shall include, but
25    not be limited to:
26            (A) the extension of the timely filing period;

 

 

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

 

 

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1    identified industry.
2        (4) Metrics shall be defined and incorporated into the
3    applicable Managed Care Policy Manual issued by the
4    Department.
5    (g-7) MCO claims processing and performance analysis. In
6order to monitor MCO payments to hospital providers, pursuant
7to this amendatory Act of the 100th General Assembly, the
8Department shall post an analysis of MCO claims processing and
9payment performance on its website every 6 months. Such
10analysis shall include a review and evaluation of a
11representative sample of hospital claims that are rejected and
12denied for clean and unclean claims and the top 5 reasons for
13such actions and timeliness of claims adjudication, which
14identifies the percentage of claims adjudicated within 30, 60,
1590, and over 90 days, and the dollar amounts associated with
16those claims. The Department shall post the contracted claims
17report required by HealthChoice Illinois on its website every 3
18months.
19    (h) The Department shall not expand mandatory MCO
20enrollment into new counties beyond those counties already
21designated by the Department as of June 1, 2014 for the
22individuals whose eligibility for medical assistance is not the
23seniors or people with disabilities population until the
24Department provides an opportunity for accountable care
25entities and MCOs to participate in such newly designated
26counties.

 

 

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1    (i) The requirements of this Section apply to contracts
2with accountable care entities and MCOs entered into, amended,
3or renewed after June 16, 2014 (the effective date of Public
4Act 98-651).
5(Source: P.A. 99-725, eff. 8-5-16; 99-751, eff. 8-5-16;
6100-201, eff. 8-18-17; 100-580, eff. 3-12-18; 100-587, eff.
76-4-18.)
 
8    Section 99. Effective date. This Act takes effect upon
9becoming law.