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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 confirm its receipt of information
10    submitted specific to physician additions or physician
11    deletions from the MCO's provider network within 3 days
12    after receiving all required information from contracted
13    physicians, and electronic physician directories must be
14    updated consistent with current rules as published by the
15    Centers for Medicare and Medicaid Services or its successor
16    agency.
17    (g) Timely payment of claims.
18        (1) The MCO shall pay a claim within 30 days of
19    receiving a claim that contains all the essential
20    information needed to adjudicate the claim.
21        (2) The MCO shall notify the billing party of its
22    inability to adjudicate a claim within 30 days of receiving
23    that claim.
24        (3) The MCO shall pay a penalty that is at least equal
25    to the penalty imposed under the Illinois Insurance Code
26    for any claims not timely paid.



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1        (4) The Department may establish a process for MCOs to
2    expedite payments to providers based on criteria
3    established by the Department.
4    (g-5) Recognizing that the rapid transformation of the
5Illinois Medicaid program may have unintended operational
6challenges for both payers and providers:
7        (1) in no instance shall a medically necessary covered
8    service rendered in good faith, based upon eligibility
9    information documented by the provider, be denied coverage
10    or diminished in payment amount if the eligibility or
11    coverage information available at the time the service was
12    rendered is later found to be inaccurate; and
13        (2) the Department shall, by December 31, 2016, adopt
14    rules establishing policies that shall be included in the
15    Medicaid managed care policy and procedures manual
16    addressing payment resolutions in situations in which a
17    provider renders services based upon information obtained
18    after verifying a patient's eligibility and coverage plan
19    through either the Department's current enrollment system
20    or a system operated by the coverage plan identified by the
21    patient presenting for services:
22            (A) such medically necessary covered services
23        shall be considered rendered in good faith;
24            (B) such policies and procedures shall be
25        developed in consultation with industry
26        representatives of the Medicaid managed care health



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1        plans and representatives of provider associations
2        representing the majority of providers within the
3        identified provider industry; and
4            (C) such rules shall be published for a review and
5        comment period of no less than 30 days on the
6        Department's website with final rules remaining
7        available on the Department's website.
8        (3) The rules on payment resolutions shall include, but
9    not be limited to:
10            (A) the extension of the timely filing period;
11            (B) retroactive prior authorizations; and
12            (C) guaranteed minimum payment rate of no less than
13        the current, as of the date of service, fee-for-service
14        rate, plus all applicable add-ons, when the resulting
15        service relationship is out of network.
16        (4) The rules shall be applicable for both MCO coverage
17    and fee-for-service coverage.
18    (g-6) MCO Performance Metrics Report.
19        (1) The Department shall publish, on at least a
20    quarterly basis, each MCO's operational performance,
21    including, but not limited to, the following categories of
22    metrics:
23            (A) claims payment, including timeliness and
24        accuracy;
25            (B) prior authorizations;
26            (C) grievance and appeals;



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1            (D) utilization statistics;
2            (E) provider disputes;
3            (F) provider credentialing; and
4            (G) member and provider customer service.
5        (2) The Department shall ensure that the metrics report
6    is accessible to providers online by January 1, 2017.
7        (3) The metrics shall be developed in consultation with
8    industry representatives of the Medicaid managed care
9    health plans and representatives of associations
10    representing the majority of providers within the
11    identified industry.
12        (4) Metrics shall be defined and incorporated into the
13    applicable Managed Care Policy Manual issued by the
14    Department.
15    (h) The Department shall not expand mandatory MCO
16enrollment into new counties beyond those counties already
17designated by the Department as of June 1, 2014 for the
18individuals whose eligibility for medical assistance is not the
19seniors or people with disabilities population until the
20Department provides an opportunity for accountable care
21entities and MCOs to participate in such newly designated
23    (i) The requirements of this Section apply to contracts
24with accountable care entities and MCOs entered into, amended,
25or renewed after the effective date of this amendatory Act of
26the 98th General Assembly.



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1(Source: P.A. 98-651, eff. 6-16-14.)
2    Section 99. Effective date. This Act takes effect upon
3becoming law.