99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
SB3080

 

Introduced 2/19/2016, by Sen. Donne E. Trotter

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-30.1

    Amends the Medical Assistance Article of the Illinois Public Aid Code. In a provision concerning network adequacy for managed care organizations (MCO) contracted with the Department of Healthcare and Family Services, provides that each MCO shall (i) on a monthly basis, jointly validate with contracted providers any changes in provider information, including, but not limited to, changes concerning new providers, terminated providers, updated address information, hours of operation, or other information that is material to a Medicaid beneficiary in the enrollment and provider selection process; and (ii) be required to produce system reports that validate that all MCO systems reflect updated provider information. Provides that in situations in which an enrolled Medicaid provider renders services based on information obtained after verifying a patient's eligibility and coverage plan through either the Department's current enrollment system or the coverage plan identified by the patient presenting for services, such services shall be considered rendered in good faith. Requires the Department to create and maintain a MCO Performance Metrics Comparison Tool that provides periodic reporting, on at least a quarterly basis, of each MCO's performance in various administrative measures. Requires the tool to be accessible in both a print and online format, with the online format allowing for Medicaid beneficiaries and providers to access additional detailed MCO performance information. 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    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 which
10contracts with the Department to provide services where payment
11for medical services is made on a capitated basis.
12    "Emergency services" include:
13        (1) emergency services, as defined by Section 10 of the
14    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.

 

 

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1    (b) As provided by Section 5-16.12, managed care
2organizations are subject to the provisions of the Managed Care
3Reform 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 as
15a 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

 

 

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1    provider was unavailable for a consultation, in which case
2    the MCO must pay for such services rendered by the treating
3    non-affiliated provider until an affiliated provider was
4    reached and either concurred with the treating
5    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 determining
16payment 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 and
21    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.

 

 

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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 binding
9    on the MCO. The MCO shall cover emergency services for all
10    enrollees whether the emergency services are provided by an
11    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

 

 

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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; and
7            (D) require MCOs to maintain an updated and public
8        list of network providers.
9        (2) Each MCO shall:
10            (A) on a monthly basis, jointly validate with
11        contracted providers, including contracted provider
12        groups, any changes in provider information,
13        including, but not limited to, changes concerning new
14        providers, terminated providers, updated address
15        information, hours of operation, or other information
16        that is material to a Medicaid beneficiary in the
17        enrollment and provider selection process; and
18            (B) be required to produce system reports that
19        validate that all MCO systems reflect updated provider
20        information.
21    (g) Timely payment of claims.
22        (1) The MCO shall pay a claim within 30 days of
23    receiving a claim that contains all the essential
24    information needed to adjudicate the claim.
25        (2) The MCO shall notify the billing party of its
26    inability to adjudicate a claim within 30 days of receiving

 

 

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1    that claim.
2        (3) The MCO shall pay a penalty that is at least equal
3    to the penalty imposed under the Illinois Insurance Code
4    for any claims not timely paid.
5        (4) The Department may establish a process for MCOs to
6    expedite payments to providers based on criteria
7    established by the Department.
8    (g-5) In situations in which an enrolled Medicaid provider
9renders services based on information obtained after verifying
10a patient's eligibility and coverage plan through either the
11Department's current enrollment system or the coverage plan
12identified by the patient presenting for services, such
13services shall be considered rendered in good faith. In no
14instance shall a service rendered in good faith be denied
15coverage or payment if the information available at the time
16the service was rendered is later found to be inaccurate.
17        (1) The provider of services shall be reimbursed by the
18    MCO identified at the time services were rendered and based
19    either on the current contract between the provider and the
20    MCO or, when a contract does not exist, at the current
21    Medicaid fee-for-service rate, including all applicable
22    adjustors.
23        (2) The MCO as identified in paragraph (1) of this
24    subsection, which pays the provider of services, shall be
25    responsible for contacting either the Department or the
26    appropriate MCO to request reimbursement for expenses

 

 

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1    incurred to reimburse the provider of services.
2        (3) The responsible MCO may not attempt any collection
3    efforts through subrogation on the provider of services if
4    the provider can document that the services were provided
5    based on information obtained at the time the services were
6    rendered.
7    (g-6) MCO Performance Metrics Comparison Tool.
8        (1) The Department shall create and maintain a MCO
9    Performance Metrics Comparison Tool that provides periodic
10    reporting, on at least a quarterly basis, of each MCO's
11    performance in various administrative measures, including,
12    but not limited to, the following:
13            (A) Timely payment of claims, which shall mean the
14        number of days between the date upon which the MCO
15        receives a clean claim, as provided in Section 368a of
16        the Illinois Insurance Code, and the date upon which
17        payment from the MCO is received by the provider.
18            (B) Accuracy of the payment of claims, which shall
19        mean the expected amount of reimbursement as defined in
20        the provider's contract or the Medicaid
21        fee-for-service rate, whichever is applicable,
22        compared to the actual reimbursement amount received
23        by the provider.
24            (C) Total number of provider denials.
25            (D) Total number of provider denials appealed and
26        overturned.

 

 

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1            (E) Total number of patient complaints and
2        grievances.
3            (F) Total timeframe average for completion of
4        provider credentialing, which shall mean the
5        difference between the date upon which a clean
6        application is submitted to the MCO and the date upon
7        which the MCO gives final approval and assigns an
8        effective date for participation in the MCO's network,
9        for the applicable reporting period.
10            (G) Total timeframe average for loading provider
11        information into the MCO's approved provider
12        directory, which shall mean the date upon which the
13        provider is approved to the time in which the MCO
14        validates loading in its directory system.
15            (H) Total timeframe average for loading provider
16        information into the MCO's claims system, which shall
17        mean the date upon which the provider is approved to
18        the time in which the provider appears in the MCO's
19        claim system.
20            (I) Total timeframe average for response times
21        from MCO staff, which shall mean the length of time
22        from initial contact by the provider to the time in
23        which an identified issue is officially documented as
24        resolved.
25            (J) Total timeframe average for responses from the
26        MCO that approve the provider's request to render care

 

 

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1        to the patient.
2        (2) The Department shall ensure that the tool shall be
3    accessible in both a print and online format, with the
4    online format allowing for Medicaid beneficiaries and
5    providers to access additional detailed MCO performance
6    information.
7        (3) At a minimum, the print version of the tool shall
8    be provided by the Department on an annual basis to
9    providers and to Medicaid beneficiaries who are required by
10    the Department to enroll in a MCO during an enrollees open
11    enrollment period.
12    (h) The Department shall not expand mandatory MCO
13enrollment into new counties beyond those counties already
14designated by the Department as of June 1, 2014 for the
15individuals whose eligibility for medical assistance is not the
16seniors or people with disabilities population until the
17Department provides an opportunity for accountable care
18entities and MCOs to participate in such newly designated
19counties.
20    (i) The requirements of this Section apply to contracts
21with accountable care entities and MCOs entered into, amended,
22or renewed after the effective date of this amendatory Act of
23the 98th General Assembly.
24(Source: P.A. 98-651, eff. 6-16-14.)
 
25    Section 99. Effective date. This Act takes effect upon
26becoming law.