Illinois General Assembly - Full Text of HB6213
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Full Text of HB6213  99th General Assembly




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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 and by adding Section 5-30.3 as
7    (305 ILCS 5/5-30.1)
8    Sec. 5-30.1. Managed care protections.
9    (a) As used in this Section:
10    "Managed care organization" or "MCO" means any entity which
11contracts with the Department to provide services where payment
12for medical services is made on a capitated basis.
13    "Emergency services" include:
14        (1) emergency services, as defined by Section 10 of the
15    Managed Care Reform and Patient Rights Act;
16        (2) emergency medical screening examinations, as
17    defined by Section 10 of the Managed Care Reform and
18    Patient Rights Act;
19        (3) post-stabilization medical services, as defined by
20    Section 10 of the Managed Care Reform and Patient Rights
21    Act; and
22        (4) emergency medical conditions, as defined by
23    Section 10 of the Managed Care Reform and Patient Rights



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



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



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



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1            (A) ensure that an adequate provider network is in
2        place, taking into consideration health professional
3        shortage areas and medically underserved areas;
4            (B) publicly release an explanation of its process
5        for analyzing network adequacy;
6            (C) periodically ensure that an MCO continues to
7        have an adequate network in place; and
8            (D) require MCOs, including Medicaid Managed Care
9        Entities as defined in Section 5-30.2, to meet provider
10        directory requirements under Section 5-30.3. require
11        MCOs to maintain an updated and public list of network
12        providers.
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 receiving
19    that claim.
20        (3) The MCO shall pay a penalty that is at least equal
21    to the penalty imposed under the Illinois Insurance Code
22    for any claims not timely paid.
23        (4) The Department may establish a process for MCOs to
24    expedite payments to providers based on criteria
25    established by the Department.
26    (h) The Department shall not expand mandatory MCO



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1enrollment into new counties beyond those counties already
2designated by the Department as of June 1, 2014 for the
3individuals whose eligibility for medical assistance is not the
4seniors or people with disabilities population until the
5Department provides an opportunity for accountable care
6entities and MCOs to participate in such newly designated
8    (i) The requirements of this Section apply to contracts
9with accountable care entities and MCOs entered into, amended,
10or renewed after the effective date of this amendatory Act of
11the 98th General Assembly.
12(Source: P.A. 98-651, eff. 6-16-14.)
13    (305 ILCS 5/5-30.3 new)
14    Sec. 5-30.3. Empowering meaningful patient choice in
15Medicaid Managed Care.
16    (a) Definitions. As used in this Section:
17    "Client enrollment services broker" means a vendor the
18Department contracts with to carry out activities related to
19Medicaid recipients' enrollment, disenrollment, and renewal
20with Medicaid Managed Care Entities.
21    "Composite domains" means the synthesized categories
22reflecting the standardized quality performance measures
23included in the consumer quality comparison tool. At a minimum,
24these composite domains shall display Medicaid Managed Care
25Entities' individual Plan performance on standardized quality,



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1timeliness, and access measures.
2    "Consumer quality comparison tool" means an online and
3paper tool developed by the Department with input from
4interested stakeholders reflecting the performance of Medicaid
5Managed Care Entity Plans on standardized quality performance
6measures. This tool shall be designed in a consumer-friendly
7and easily understandable format.
8    "Covered services" means those health care services to
9which a covered person is entitled to under the terms of the
10Medicaid Managed Care Entity Plan.
11    "Facilities" includes, but is not limited to, federally
12qualified health centers, skilled nursing facilities, and
13rehabilitation centers.
14    "Hospitals" includes, but is not limited to, acute care,
15rehabilitation, children's, and cancer hospitals.
16    "Integrated provider directory" means a searchable
17database bringing together network data from multiple Medicaid
18Managed Care Entities that is available through client
19enrollment services.
20    "Medicaid eligibility redetermination" means the process
21by which the eligibility of a Medicaid recipient is reviewed by
22the Department to determine if the recipient's medical benefits
23will continue, be modified, or terminated.
24    "Medicaid Managed Care Entity" has the same meaning as
25defined in Section 5-30.2 of this Code.
26    (b) Provider directory transparency.



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1        (1) Each Medicaid Managed Care Entity shall:
2            (A) Make available on the entity's website a
3        provider directory in a machine readable file and
4        format.
5            (B) Make provider directories publicly accessible
6        without the necessity of providing a password, a
7        username, or personally identifiable information.
8            (C) Comply with all federal and State statutes and
9        regulations, including 42 CFR 438.10, pertaining to
10        provider directories within Medicaid Managed Care.
11            (D) Request, at least annually, provider office
12        hours for each of the following provider types:
13                (i) Health care professionals, including
14            dental and vision providers.
15                (ii) Hospitals.
16                (iii) Facilities, other than hospitals.
17                (iv) Pharmacies, other than hospitals.
18                (v) Durable medical equipment suppliers, other
19            than hospitals.
20            Medicaid Managed Care Entities shall publish the
21        provider office hours in the provider directory upon
22        receipt.
23            (E) Confirm with the Medicaid Managed Care
24        Entity's contracted providers who have not submitted
25        claims within the past 6 months that the contracted
26        providers intend to remain in the network and correct



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1        any incorrect provider directory information as
2        necessary.
3            (F) Ensure that in situations in which a Medicaid
4        Managed Care Entity Plan enrollee receives covered
5        services from a non-participating provider due to a
6        material misrepresentation in a Medicaid Managed Care
7        Entity's online electronic provider directory, the
8        Medicaid Managed Care Entity Plan enrollee shall not be
9        held responsible for any costs resulting from that
10        material misrepresentation.
11            (G) Conspicuously display an e-mail address and a
12        toll-free telephone number to which any individual may
13        report any inaccuracy in the provider directory. If the
14        Medicaid Managed Care Entity receives a report from any
15        person who specifically identifies provider directory
16        information as inaccurate, the Medicaid Managed Care
17        Entity shall investigate the report and correct any
18        inaccurate information displayed in the electronic
19        directory.
20        (2) The Department shall:
21            (A) Regularly monitor Medicaid Managed Care
22        Entities to ensure that they are compliant with the
23        requirements under paragraph (1) of subsection (b).
24            (B) Require that the client enrollment services
25        broker use the Medicaid provider number for all
26        providers with a Medicaid Provider number to populate



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1        the provider information in the integrated provider
2        directory.
3            (C) Ensure that each Medicaid Managed Care Entity
4        shall, at minimum, make the information in
5        subparagraph (D) of paragraph (1) of subsection (b)
6        available to the client enrollment services broker.
7            (D) Ensure that the client enrollment services
8        broker shall, at minimum, have the information in
9        subparagraph (D) of paragraph (1) of subsection (b)
10        available and searchable through the integrated
11        provider directory on its website as soon as possible
12        but no later than January 1, 2017.
13            (E) Require the client enrollment services broker
14        to conspicuously display near the integrated provider
15        directory an email address and a toll-free telephone
16        number provided by the Department to which any
17        individual may report inaccuracies in the integrated
18        provider directory. If the Department receives a
19        report that identifies an inaccuracy in the integrated
20        provider directory, the Department shall provide the
21        information about the reported inaccuracy to the
22        appropriate Medicaid Managed Care Entity within 3
23        business days after the reported inaccuracy is
24        received.
25    (c) Formulary transparency.
26        (1) Medicaid Managed Care Entities shall publish on



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1    their respective websites a formulary for each Medicaid
2    Managed Care Entity Plan offered and make the formularies
3    easily understandable and publicly accessible without the
4    necessity of providing a password, a username, or
5    personally identifiable information.
6        (2) Medicaid Managed Care Entities shall provide
7    printed formularies upon request.
8        (3) Electronic and print formularies shall display:
9            (A) the medications covered (both generic and name
10        brand);
11            (B) if the medication is preferred or not
12        preferred, and what each term means;
13            (C) what tier each medication is in and the meaning
14        of each tier;
15            (D) any utilization controls including, but not
16        limited to, step therapy, prior approval, dosage
17        limits, gender or age restrictions, quantity limits,
18        or other policies that affect access to medications;
19            (E) any required cost-sharing;
20            (F) a glossary of key terms and explanation of
21        utilization controls and cost-sharing requirements;
22            (G) a key or legend for all utilization controls
23        visible on every page in which specific medication
24        coverage information is displayed; and
25            (H) directions explaining the process or processes
26        a consumer may follow to obtain more information if a



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1        medication the consumer requires is not covered or
2        listed in the formulary.
3        (4) Each Medicaid Managed Care Entity shall display
4    conspicuously with each electronic and printed medication
5    formulary an e-mail address and a toll-free telephone
6    number to which any individual may report any inaccuracy in
7    the formulary. If the Medicaid Managed Care Entity receives
8    a report that the formulary information is inaccurate, the
9    Medicaid Managed Care Entity shall investigate the report
10    and correct any inaccurate information displayed in the
11    electronic formulary.
12        (5) Each Medicaid Managed Care Entity shall include a
13    disclosure in the electronic and requested print
14    formularies that provides the date of publication, a
15    statement that the formulary is up to date as of
16    publication, and contact information for questions and
17    requests to receive updated information.
18        (6) The client enrollment services broker's website
19    shall display prominently a website URL link to each
20    Medicaid Managed Care Entity's Plan formulary. If a
21    Medicaid enrollee calls the client enrollment services
22    broker with questions regarding formularies, the client
23    enrollment services broker shall offer a brief description
24    of what a formulary is and shall refer the Medicaid
25    enrollee to the appropriate Medicaid Managed Care Entity
26    regarding his or her questions about a specific entity's



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1    formulary.
2    (d) Grievances and appeals. The Department shall display
3prominently on its website consumer-oriented information
4describing how a Medicaid enrollee can file a complaint or
5grievance, request a fair hearing for any adverse action taken
6by the Department or a Medicaid Managed Care Entity, and access
7free legal assistance or other assistance made available by the
8State for Medicaid enrollees to pursue an action.
9    (e) Medicaid redetermination information. The Department
10shall require the client enrollment services broker to display
11prominently on the client enrollment services broker's website
12a description of where a Medicaid enrollee can access
13information regarding the Medicaid redetermination process.
14    (f) Medicaid care coordination information. The client
15enrollment services broker shall display prominently on its
16website, in an easily understandable format, consumer-oriented
17information regarding the role of care coordination services
18within Medicaid Managed Care. Such information shall include,
19but shall not be limited to:
20        (1) a basic description of the role of care
21    coordination services and examples of specific care
22    coordination activities; and
23        (2) how a Medicaid enrollee may request care
24    coordination services from a Medicaid Managed Care Entity.
25    (g) Consumer quality comparison tool.
26        (1) The Department shall create a consumer quality



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1    comparison tool to assist Medicaid enrollees with Medicaid
2    Managed Care Entity Plan selection. This tool shall provide
3    Medicaid Managed Care Entities' individual Plan
4    performance on a set of standardized quality performance
5    measures. The Department shall ensure that this tool shall
6    be accessible in both a print and online format, with the
7    online format allowing for individuals to access
8    additional detailed Plan performance information.
9        (2) At a minimum, a printed version of the consumer
10    quality comparison tool shall be provided by the Department
11    on an annual basis to Medicaid enrollees who are required
12    by the Department to enroll in a Medicaid Managed Care
13    Entity Plan during an enrollee's open enrollment period.
14    The consumer quality comparison tool shall also meet all of
15    the following criteria:
16            (A) Display Medicaid Managed Care Entities'
17        individual Plan performance on at least 4 composite
18        domains that reflect Plan quality, timeliness, and
19        access. The composite domains shall draw from the most
20        current available performance data sets including, but
21        not limited to:
22                (i) Healthcare Effectiveness Data and
23            Information Set (HEDIS) measures.
24                (ii) Core Set of Children's Health Care
25            Quality measures as required under the Children's
26            Health Insurance Program Reauthorization Act



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1            (CHIPRA).
2                (iii) Adult Core Set measures.
3                (iv) Consumer Assessment of Healthcare
4            Providers and Systems (CAHPS) survey results.
5                (v) Additional performance measures the
6            Department deems appropriate to populate the
7            composite domains.
8            (B) Use a quality rating system developed by the
9        Department to reflect Medicaid Managed Care Entities'
10        individual Plan performance. The quality rating system
11        for each composite domain shall reflect the Medicaid
12        Managed Care Entities' individual Plan performance
13        and, when possible, plan performance relative to
14        national Medicaid percentiles.
15            (C) Be customized to reflect the specific Medicaid
16        Managed Care Entities' Plans available to the Medicaid
17        enrollee based on his or her geographic location and
18        Medicaid eligibility category.
19            (D) Include contact information for the client
20        enrollment services broker and contact information for
21        Medicaid Managed Care Entities available to the
22        Medicaid enrollee based on his or her geographic
23        location and Medicaid eligibility category.
24            (E) Include guiding questions designed to assist
25        individuals selecting a Medicaid Managed Care Entity
26        Plan.



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1        (3) At a minimum, the online version of the consumer
2    quality comparison tool shall meet all of the following
3    criteria:
4            (A) Display Medicaid Managed Care Entities'
5        individual Plan performance for the same composite
6        domains selected by the Department in the printed
7        version of the consumer quality comparison tool. The
8        Department may display additional composite domains in
9        the online version of the consumer quality comparison
10        tool as appropriate.
11            (B) Display Medicaid Managed Care Entities'
12        individual Plan performance on each of the
13        standardized performance measures that contribute to
14        each composite domain displayed on the online version
15        of the consumer quality comparison tool.
16            (C) Use a quality rating system developed by the
17        Department to reflect Medicaid Managed Care Entities'
18        individual Plan performance. The quality rating system
19        for each composite domain shall reflect the Medicaid
20        Managed Care Entities' individual Plan performance
21        and, when possible, plan performance relative to
22        national Medicaid percentiles.
23            (D) Include the specific Medicaid Managed Care
24        Entity Plans available to the Medicaid enrollee based
25        on his or her geographic location and Medicaid
26        eligibility category.



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1            (E) Include a sort function to view Medicaid
2        Managed Care Entities' individual Plan performance by
3        quality rating and by standardized quality performance
4        measures.
5            (F) Include contact information for the client
6        enrollment services broker and for each Medicaid
7        Managed Care Entity.
8            (G) Include guiding questions designed to assist
9        individuals in selecting a Medicaid Managed Care
10        Entity Plan.
11            (H) Prominently display current notice of quality
12        performance sanctions against Medicaid Managed Care
13        Entities. Notice of the sanctions shall remain present
14        on the online version of the consumer quality
15        comparison tool until the sanctions are lifted.
16        (4) The online version of the consumer quality
17    comparison tool shall be displayed prominently on the
18    client enrollment services broker's website.
19        (5) In the development of the consumer quality
20    comparison tool, the Department shall establish and
21    publicize a formal process to collect and consider written
22    and oral feedback from consumers, advocates, and
23    stakeholders on aspects of the consumer quality comparison
24    tool, including, but not limited to, the following:
25            (A) The standardized data sets and surveys,
26        specific performance measures, and composite domains



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1        represented in the consumer quality comparison tool.
2            (B) The format and presentation of the consumer
3        quality comparison tool.
4            (C) The methods undertaken by the Department to
5        notify Medicaid enrollees of the availability of the
6        consumer quality comparison tool.
7        (6) The Department shall review and update as
8    appropriate the composite domains and performance measures
9    represented in the print and online versions of the
10    consumer quality comparison tool at least once every 3
11    years. During the Department's review process, the
12    Department shall solicit engagement in the public feedback
13    process described in paragraph (5).
14        (7) The Department shall ensure that the consumer
15    quality comparison tool is available for consumer use as
16    soon as possible but no later than January 1, 2018.
17    (h) The Department may adopt rules and take any other
18appropriate action necessary to implement its responsibilities
19under this Section.
20    Section 99. Effective date. This Act takes effect upon
21becoming law.