State of Illinois
2021 and 2022


Introduced 1/21/2022, by Rep. Robyn Gabel


305 ILCS 5/5-30.1

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to be responsible for and actively oversee managed care organization compliance and shall immediately modify all contractual arrangements with each of the managed care organizations in conflict with the provisions of the amendatory Act. Provides that a managed care organization's failure to agree to all necessary amendments to its contract with the State shall constitute the company's notice of withdrawal from the medical assistance program. Requires the Department to attest to each managed care organization's compliance with all provisions of the amendatory Act within 60 days after the effective date of the amendatory Act. Provides that if the Department cannot attest to each managed care organization's compliance by the end of the 60 days or after any of the audits required under the amendatory Act, then the Department shall prohibit the managed care organization from managing skilled nursing facilities patients under the medical assistance managed care program. Contains provisions concerning the transition of network residents to managed care organizations in good standing; quarterly audits of each managed care organization's business practices; monthly audits of each managed care organization's information technology and systems; Medicaid fee-for-service reimbursement rates for nursing facilities under contract with managed care organizations; fines for non-compliance; and other matters.

LRB102 24646 KTG 33885 b





HB4663LRB102 24646 KTG 33885 b

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



HB4663- 2 -LRB102 24646 KTG 33885 b

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



HB4663- 3 -LRB102 24646 KTG 33885 b

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



HB4663- 4 -LRB102 24646 KTG 33885 b

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



HB4663- 5 -LRB102 24646 KTG 33885 b

1        place, taking into consideration health professional
2        shortage areas and medically underserved areas;
3            (B) publicly release an explanation of its process
4        for analyzing network adequacy;
5            (C) periodically ensure that an MCO continues to
6        have an adequate network in place;
7            (D) require MCOs, including Medicaid Managed Care
8        Entities as defined in Section 5-30.2, to meet
9        provider directory requirements under Section 5-30.3;
10        and
11            (E) require MCOs to ensure that any
12        Medicaid-certified provider under contract with an MCO
13        and previously submitted on a roster on the date of
14        service is paid for any medically necessary,
15        Medicaid-covered, and authorized service rendered to
16        any of the MCO's enrollees, regardless of inclusion on
17        the MCO's published and publicly available directory
18        of available providers; and .
19            (F) (E) require MCOs, including Medicaid Managed
20        Care Entities as defined in Section 5-30.2, to meet
21        each of the requirements under subsection (d-5) of
22        Section 10 of the Network Adequacy and Transparency
23        Act; with necessary exceptions to the MCO's network to
24        ensure that admission and treatment with a provider or
25        at a treatment facility in accordance with the network
26        adequacy standards in paragraph (3) of subsection



HB4663- 6 -LRB102 24646 KTG 33885 b

1        (d-5) of Section 10 of the Network Adequacy and
2        Transparency Act is limited to providers or facilities
3        that are Medicaid certified.
4        (2) Each MCO shall confirm its receipt of information
5    submitted specific to physician or dentist additions or
6    physician or dentist deletions from the MCO's provider
7    network within 3 days after receiving all required
8    information from contracted physicians or dentists, and
9    electronic physician and dental directories must be
10    updated consistent with current rules as published by the
11    Centers for Medicare and Medicaid Services or its
12    successor agency.
13    (g) Timely payment of claims.
14        (1) The MCO shall pay a claim within 30 days of
15    receiving a claim that contains all the essential
16    information needed to adjudicate the claim.
17        (2) The MCO shall notify the billing party of its
18    inability to adjudicate a claim within 30 days of
19    receiving that claim.
20        (3) The MCO shall pay a penalty that is at least equal
21    to the timely payment interest penalty imposed under
22    Section 368a of the Illinois Insurance Code for any claims
23    not timely paid.
24            (A) When an MCO is required to pay a timely payment
25        interest penalty to a provider, the MCO must calculate
26        and pay the timely payment interest penalty that is



HB4663- 7 -LRB102 24646 KTG 33885 b

1        due to the provider within 30 days after the payment of
2        the claim. In no event shall a provider be required to
3        request or apply for payment of any owed timely
4        payment interest penalties.
5            (B) Such payments shall be reported separately
6        from the claim payment for services rendered to the
7        MCO's enrollee and clearly identified as interest
8        payments.
9        (4)(A) The Department shall require MCOs to expedite
10    payments to providers identified on the Department's
11    expedited provider list, determined in accordance with 89
12    Ill. Adm. Code 140.71(b), on a schedule at least as
13    frequently as the providers are paid under the
14    Department's fee-for-service expedited provider schedule.
15        (B) Compliance with the expedited provider requirement
16    may be satisfied by an MCO through the use of a Periodic
17    Interim Payment (PIP) program that has been mutually
18    agreed to and documented between the MCO and the provider,
19    if the PIP program ensures that any expedited provider
20    receives regular and periodic payments based on prior
21    period payment experience from that MCO. Total payments
22    under the PIP program may be reconciled against future PIP
23    payments on a schedule mutually agreed to between the MCO
24    and the provider.
25        (C) The Department shall share at least monthly its
26    expedited provider list and the frequency with which it



HB4663- 8 -LRB102 24646 KTG 33885 b

1    pays providers on the expedited list.
2    (g-5) Recognizing that the rapid transformation of the
3Illinois Medicaid program may have unintended operational
4challenges for both payers and providers:
5        (1) in no instance shall a medically necessary covered
6    service rendered in good faith, based upon eligibility
7    information documented by the provider, be denied coverage
8    or diminished in payment amount if the eligibility or
9    coverage information available at the time the service was
10    rendered is later found to be inaccurate in the assignment
11    of coverage responsibility between MCOs or the
12    fee-for-service system, except for instances when an
13    individual is deemed to have not been eligible for
14    coverage under the Illinois Medicaid program; and
15        (2) the Department shall, by December 31, 2016, adopt
16    rules establishing policies that shall be included in the
17    Medicaid managed care policy and procedures manual
18    addressing payment resolutions in situations in which a
19    provider renders services based upon information obtained
20    after verifying a patient's eligibility and coverage plan
21    through either the Department's current enrollment system
22    or a system operated by the coverage plan identified by
23    the patient presenting for services:
24            (A) such medically necessary covered services
25        shall be considered rendered in good faith;
26            (B) such policies and procedures shall be



HB4663- 9 -LRB102 24646 KTG 33885 b

1        developed in consultation with industry
2        representatives of the Medicaid managed care health
3        plans and representatives of provider associations
4        representing the majority of providers within the
5        identified provider industry; and
6            (C) such rules shall be published for a review and
7        comment period of no less than 30 days on the
8        Department's website with final rules remaining
9        available on the Department's website.
10        The rules on payment resolutions shall include, but
11    not be limited to:
12            (A) the extension of the timely filing period;
13            (B) retroactive prior authorizations; and
14            (C) guaranteed minimum payment rate of no less
15        than the current, as of the date of service,
16        fee-for-service rate, plus all applicable add-ons,
17        when the resulting service relationship is out of
18        network.
19        The rules shall be applicable for both MCO coverage
20    and fee-for-service coverage.
21    If the fee-for-service system is ultimately determined to
22have been responsible for coverage on the date of service, the
23Department shall provide for an extended period for claims
24submission outside the standard timely filing requirements.
25    (g-6) MCO Performance Metrics Report.
26        (1) The Department shall publish, on at least a



HB4663- 10 -LRB102 24646 KTG 33885 b

1    quarterly basis, each MCO's operational performance,
2    including, but not limited to, the following categories of
3    metrics:
4            (A) claims payment, including timeliness and
5        accuracy;
6            (B) prior authorizations;
7            (C) grievance and appeals;
8            (D) utilization statistics;
9            (E) provider disputes;
10            (F) provider credentialing; and
11            (G) member and provider customer service.
12        (2) The Department shall ensure that the metrics
13    report is accessible to providers online by January 1,
14    2017.
15        (3) The metrics shall be developed in consultation
16    with industry representatives of the Medicaid managed care
17    health plans and representatives of associations
18    representing the majority of providers within the
19    identified industry.
20        (4) Metrics shall be defined and incorporated into the
21    applicable Managed Care Policy Manual issued by the
22    Department.
23    (g-7) MCO claims processing and performance analysis. In
24order to monitor MCO payments to hospital providers, pursuant
25to Public Act 100-580 this amendatory Act of the 100th General
26Assembly, the Department shall post an analysis of MCO claims



HB4663- 11 -LRB102 24646 KTG 33885 b

1processing and payment performance on its website every 6
2months. Such analysis shall include a review and evaluation of
3a representative sample of hospital claims that are rejected
4and denied for clean and unclean claims and the top 5 reasons
5for such actions and timeliness of claims adjudication, which
6identifies the percentage of claims adjudicated within 30, 60,
790, and over 90 days, and the dollar amounts associated with
8those claims.
9    (g-8) Dispute resolution process. The Department shall
10maintain a provider complaint portal through which a provider
11can submit to the Department unresolved disputes with an MCO.
12An unresolved dispute means an MCO's decision that denies in
13whole or in part a claim for reimbursement to a provider for
14health care services rendered by the provider to an enrollee
15of the MCO with which the provider disagrees. Disputes shall
16not be submitted to the portal until the provider has availed
17itself of the MCO's internal dispute resolution process.
18Disputes that are submitted to the MCO internal dispute
19resolution process may be submitted to the Department of
20Healthcare and Family Services' complaint portal no sooner
21than 30 days after submitting to the MCO's internal process
22and not later than 30 days after the unsatisfactory resolution
23of the internal MCO process or 60 days after submitting the
24dispute to the MCO internal process. Multiple claim disputes
25involving the same MCO may be submitted in one complaint,
26regardless of whether the claims are for different enrollees,



HB4663- 12 -LRB102 24646 KTG 33885 b

1when the specific reason for non-payment of the claims
2involves a common question of fact or policy. Within 10
3business days of receipt of a complaint, the Department shall
4present such disputes to the appropriate MCO, which shall then
5have 30 days to issue its written proposal to resolve the
6dispute. The Department may grant one 30-day extension of this
7time frame to one of the parties to resolve the dispute. If the
8dispute remains unresolved at the end of this time frame or the
9provider is not satisfied with the MCO's written proposal to
10resolve the dispute, the provider may, within 30 days, request
11the Department to review the dispute and make a final
12determination. Within 30 days of the request for Department
13review of the dispute, both the provider and the MCO shall
14present all relevant information to the Department for
15resolution and make individuals with knowledge of the issues
16available to the Department for further inquiry if needed.
17Within 30 days of receiving the relevant information on the
18dispute, or the lapse of the period for submitting such
19information, the Department shall issue a written decision on
20the dispute based on contractual terms between the provider
21and the MCO, contractual terms between the MCO and the
22Department of Healthcare and Family Services and applicable
23Medicaid policy. The decision of the Department shall be
24final. By January 1, 2020, the Department shall establish by
25rule further details of this dispute resolution process.
26Disputes between MCOs and providers presented to the



HB4663- 13 -LRB102 24646 KTG 33885 b

1Department for resolution are not contested cases, as defined
2in Section 1-30 of the Illinois Administrative Procedure Act,
3conferring any right to an administrative hearing.
4    (g-9)(1) The Department shall publish annually on its
5website a report on the calculation of each managed care
6organization's medical loss ratio showing the following:
7        (A) Premium revenue, with appropriate adjustments.
8        (B) Benefit expense, setting forth the aggregate
9    amount spent for the following:
10            (i) Direct paid claims.
11            (ii) Subcapitation payments.
12            (iii) Other claim payments.
13            (iv) Direct reserves.
14            (v) Gross recoveries.
15            (vi) Expenses for activities that improve health
16        care quality as allowed by the Department.
17    (2) The medical loss ratio shall be calculated consistent
18with federal law and regulation following a claims runout
19period determined by the Department.
20    (g-10)(1) "Liability effective date" means the date on
21which an MCO becomes responsible for payment for medically
22necessary and covered services rendered by a provider to one
23of its enrollees in accordance with the contract terms between
24the MCO and the provider. The liability effective date shall
25be the later of:
26        (A) The execution date of a network participation



HB4663- 14 -LRB102 24646 KTG 33885 b

1    contract agreement.
2        (B) The date the provider or its representative
3    submits to the MCO the complete and accurate standardized
4    roster form for the provider in the format approved by the
5    Department.
6        (C) The provider effective date contained within the
7    Department's provider enrollment subsystem within the
8    Illinois Medicaid Program Advanced Cloud Technology
9    (IMPACT) System.
10    (2) The standardized roster form may be submitted to the
11MCO at the same time that the provider submits an enrollment
12application to the Department through IMPACT.
13    (3) By October 1, 2019, the Department shall require all
14MCOs to update their provider directory with information for
15new practitioners of existing contracted providers within 30
16days of receipt of a complete and accurate standardized roster
17template in the format approved by the Department provided
18that the provider is effective in the Department's provider
19enrollment subsystem within the IMPACT system. Such provider
20directory shall be readily accessible for purposes of
21selecting an approved health care provider and comply with all
22other federal and State requirements.
23    (g-11) The Department shall work with relevant
24stakeholders on the development of operational guidelines to
25enhance and improve operational performance of Illinois'
26Medicaid managed care program, including, but not limited to,



HB4663- 15 -LRB102 24646 KTG 33885 b

1improving provider billing practices, reducing claim
2rejections and inappropriate payment denials, and
3standardizing processes, procedures, definitions, and response
4timelines, with the goal of reducing provider and MCO
5administrative burdens and conflict. The Department shall
6include a report on the progress of these program improvements
7and other topics in its Fiscal Year 2020 annual report to the
8General Assembly.
9    (g-12) Notwithstanding any other provision of law, if the
10Department or an MCO requires submission of a claim for
11payment in a non-electronic format, a provider shall always be
12afforded a period of no less than 90 business days, as a
13correction period, following any notification of rejection by
14either the Department or the MCO to correct errors or
15omissions in the original submission.
16    Under no circumstances, either by an MCO or under the
17State's fee-for-service system, shall a provider be denied
18payment for failure to comply with any timely submission
19requirements under this Code or under any existing contract,
20unless the non-electronic format claim submission occurs after
21the initial 180 days following the latest date of service on
22the claim, or after the 90 business days correction period
23following notification to the provider of rejection or denial
24of payment.
25    (h) The Department shall not expand mandatory MCO
26enrollment into new counties beyond those counties already



HB4663- 16 -LRB102 24646 KTG 33885 b

1designated by the Department as of June 1, 2014 for the
2individuals whose eligibility for medical assistance is not
3the seniors or people with disabilities population until the
4Department provides an opportunity for accountable care
5entities and MCOs to participate in such newly designated
7    (i) The requirements of this Section apply to contracts
8with accountable care entities and MCOs entered into, amended,
9or renewed after June 16, 2014 (the effective date of Public
10Act 98-651).
11    (j) Health care information released to managed care
12organizations. A health care provider shall release to a
13Medicaid managed care organization, upon request, and subject
14to the Health Insurance Portability and Accountability Act of
151996 and any other law applicable to the release of health
16information, the health care information of the MCO's
17enrollee, if the enrollee has completed and signed a general
18release form that grants to the health care provider
19permission to release the recipient's health care information
20to the recipient's insurance carrier.
21    (k) The Department of Healthcare and Family Services,
22managed care organizations, a statewide organization
23representing hospitals, and a statewide organization
24representing safety-net hospitals shall explore ways to
25support billing departments in safety-net hospitals.
26    (l) The requirements of this Section added by Public Act



HB4663- 17 -LRB102 24646 KTG 33885 b

1102-4 this amendatory Act of the 102nd General Assembly shall
2apply to services provided on or after the first day of the
3month that begins 60 days after April 27, 2021 (the effective
4date of Public Act 102-4) this amendatory Act of the 102nd
5General Assembly.
6    (m) The Department shall be responsible for and actively
7oversee managed care organization compliance and shall
8immediately modify all contractual arrangements with each of
9the managed care organizations in conflict with the provisions
10of this Section. Failure of a managed care organization to
11agree to all necessary amendments to its contract with the
12State shall constitute the company's notice of withdrawal from
13the medical assistance program.
14    The Department shall attest to each managed care
15organization's compliance with all provisions of this Section
16within 60 days after the effective date of this amendatory Act
17of the 102nd General Assembly. If the Department cannot attest
18to each managed care organization's compliance by the end of
19the 60 days or after any of the audits required by this
20Section, then the Department shall prohibit the managed care
21organization from managing skilled nursing facilities patients
22under the medical assistance managed care program. The
23Department shall oversee the transition of all network
24residents to managed care organizations in good standing with
25the Department and under contract with the facility where the
26network member resides and shall guarantee the payment of all



HB4663- 18 -LRB102 24646 KTG 33885 b

1outstanding claims for services rendered to network members
2until a managed care organization in good standing with the
3Department has assumed responsibility for paying for Medicaid
4covered services.
5    The Department shall perform quarterly audits of each
6managed care organization's business practices to ensure they
7align with the provisions of this Section.
8    The Department shall require each managed care
9organization and its subcontractors to perform monthly audits
10of the managed care organization's information technology
11systems and practices to ensure that no claims are rejected or
12denied based on programming errors.
13    Managed care organizations under contract with the State
14must pay to each individual nursing facility no less than the
15Medicaid fee-for-service reimbursement rate established by the
16Department and in effect at the time the service is rendered.
17    Managed care organizations are expressly prohibited, at
18any time and for any reason, from offering, negotiating, or
19entering into contracts with a nursing facility for a level of
20compensation less than the Medicaid fee-for-service rate in
21effect at the time the service is rendered.
22    A sanction of $20,000 per incident shall be levied against
23a managed care organization for failure to comply with this
24Section, which shall double for each subsequent incident of
25the same or similar violation. All fines shall be deposited
26into the Long-Term Care Provider Fund. Use of the funds shall



HB4663- 19 -LRB102 24646 KTG 33885 b

1be limited to expenditures that qualify for federal matching
2funds and that promote quality of resident care.
3    A managed care organization's participation in the medical
4assistance program shall be terminated for failure to make all
5necessary changes to business practices in conflict with this
7(Source: P.A. 101-209, eff. 8-5-19; 102-4, eff. 4-27-21;
8102-43, eff. 7-6-21; 102-144, eff. 1-1-22; 102-454, eff.
98-20-21; revised 10-5-21.)