Sen. Donne E. Trotter

Filed: 5/11/2016





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2    AMENDMENT NO. ______. Amend Senate Bill 3080 by replacing
3everything after the enacting clause with the following:
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



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



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



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1    enrollees who are temporarily away from their residence and
2    outside the contracting area to the extent that the
3    enrollees would be entitled to the emergency services if
4    they still were within the contracting area.
5        (3) The MCO shall have no obligation to cover medical
6    services provided on an emergency basis that are not
7    covered services under the contract.
8        (4) The MCO shall not condition coverage for emergency
9    services on the treating provider notifying the MCO of the
10    enrollee's screening and treatment within 10 days after
11    presentation for emergency services.
12        (5) The determination of the attending emergency
13    physician, or the provider actually treating the enrollee,
14    of whether an enrollee is sufficiently stabilized for
15    discharge or transfer to another facility, shall be binding
16    on the MCO. The MCO shall cover emergency services for all
17    enrollees whether the emergency services are provided by an
18    affiliated or non-affiliated provider.
19        (6) The MCO's financial responsibility for
20    post-stabilization care services it has not pre-approved
21    ends when:
22            (A) a plan physician with privileges at the
23        treating hospital assumes responsibility for the
24        enrollee's care;
25            (B) a plan physician assumes responsibility for
26        the enrollee's care through transfer;



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1            (C) a contracting entity representative and the
2        treating physician reach an agreement concerning the
3        enrollee's care; or
4            (D) the enrollee is discharged.
5    (f) Network adequacy and transparency.
6        (1) The Department shall:
7            (A) ensure that an adequate provider network is in
8        place, taking into consideration health professional
9        shortage areas and medically underserved areas;
10            (B) publicly release an explanation of its process
11        for analyzing network adequacy;
12            (C) periodically ensure that an MCO continues to
13        have an adequate network in place; and
14            (D) require MCOs to maintain an updated and public
15        list of network providers.
16        (2) Each MCO shall confirm its receipt of information
17    submitted specific to physician additions or physician
18    deletions from the MCO's provider network within 3 days
19    after receiving all required information from contracted
20    physicians, and electronic physician directories must be
21    updated consistent with current rules as published by the
22    Centers for Medicare and Medicaid Services or its successor
23    agency.
24    (g) Timely payment of claims.
25        (1) The MCO shall pay a claim within 30 days of
26    receiving a claim that contains all the essential



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1    information needed to adjudicate the claim.
2        (2) The MCO shall notify the billing party of its
3    inability to adjudicate a claim within 30 days of receiving
4    that claim.
5        (3) The MCO shall pay a penalty that is at least equal
6    to the penalty imposed under the Illinois Insurance Code
7    for any claims not timely paid.
8        (4) The Department may establish a process for MCOs to
9    expedite payments to providers based on criteria
10    established by the Department.
11    (g-5) Recognizing that the rapid transformation of the
12Illinois Medicaid program may have unintended operational
13challenges for both payers and providers:
14        (1) in no instance shall a medically necessary covered
15    service rendered in good faith, based upon eligibility
16    information documented by the provider, be denied coverage
17    or diminished in payment amount if the eligibility or
18    coverage information available at the time the service was
19    rendered is later found to be inaccurate; and
20        (2) the Department shall, by December 31, 2016, adopt
21    rules establishing policies that shall be included in the
22    Medicaid managed care policy and procedures manual
23    addressing payment resolutions in situations in which a
24    provider renders services based upon information obtained
25    after verifying a patient's eligibility and coverage plan
26    through either the Department's current enrollment system



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



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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 report
13    is accessible to providers online by January 1, 2017.
14        (3) The metrics shall be developed in consultation with
15    industry representatives of the Medicaid managed care
16    health plans and representatives of associations
17    representing the majority of providers within the
18    identified industry.
19        (4) Metrics shall be defined and incorporated into the
20    applicable Managed Care Policy Manual issued by the
21    Department.
22    (h) The Department shall not expand mandatory MCO
23enrollment into new counties beyond those counties already
24designated by the Department as of June 1, 2014 for the
25individuals whose eligibility for medical assistance is not the
26seniors or people with disabilities population until the



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1Department provides an opportunity for accountable care
2entities and MCOs to participate in such newly designated
4    (i) The requirements of this Section apply to contracts
5with accountable care entities and MCOs entered into, amended,
6or renewed after the effective date of this amendatory Act of
7the 98th General Assembly.
8(Source: P.A. 98-651, eff. 6-16-14.)
9    Section 99. Effective date. This Act takes effect upon
10becoming law.".