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


Sen. Daniel Biss

Filed: 5/6/2016





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2    AMENDMENT NO. ______. Amend House Bill 6213 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 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



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



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



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



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1        the enrollee's care through transfer;
2            (C) a contracting entity representative and the
3        treating physician reach an agreement concerning the
4        enrollee's care; or
5            (D) the enrollee is discharged.
6    (f) Network adequacy.
7        (1) The Department shall:
8            (A) ensure that an adequate provider network is in
9        place, taking into consideration health professional
10        shortage areas and medically underserved areas;
11            (B) publicly release an explanation of its process
12        for analyzing network adequacy;
13            (C) periodically ensure that an MCO continues to
14        have an adequate network in place; and
15            (D) require MCOs, including Medicaid Managed Care
16        Entities as defined in Section 5-30.2, to meet provider
17        directory requirements under Section 5-30.3. require
18        MCOs to maintain an updated and public list of network
19        providers.
20    (g) Timely payment of claims.
21        (1) The MCO shall pay a claim within 30 days of
22    receiving a claim that contains all the essential
23    information needed to adjudicate the claim.
24        (2) The MCO shall notify the billing party of its
25    inability to adjudicate a claim within 30 days of receiving
26    that claim.



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1        (3) The MCO shall pay a penalty that is at least equal
2    to the penalty imposed under the Illinois Insurance Code
3    for any claims not timely paid.
4        (4) The Department may establish a process for MCOs to
5    expedite payments to providers based on criteria
6    established by the Department.
7    (h) The Department shall not expand mandatory MCO
8enrollment into new counties beyond those counties already
9designated by the Department as of June 1, 2014 for the
10individuals whose eligibility for medical assistance is not the
11seniors or people with disabilities population until the
12Department provides an opportunity for accountable care
13entities and MCOs to participate in such newly designated
15    (i) The requirements of this Section apply to contracts
16with accountable care entities and MCOs entered into, amended,
17or renewed after the effective date of this amendatory Act of
18the 98th General Assembly.
19(Source: P.A. 98-651, eff. 6-16-14.)
20    (305 ILCS 5/5-30.3 new)
21    Sec. 5-30.3. Empowering meaningful patient choice in
22Medicaid Managed Care.
23    (a) Definitions. As used in this Section:
24    "Client enrollment services broker" means a vendor the
25Department contracts with to carry out activities related to



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1Medicaid recipients' enrollment, disenrollment, and renewal
2with Medicaid Managed Care Entities.
3    "Composite domains" means the synthesized categories
4reflecting the standardized quality performance measures
5included in the consumer quality comparison tool. At a minimum,
6these composite domains shall display Medicaid Managed Care
7Entities' individual Plan performance on standardized quality,
8timeliness, and access measures.
9    "Consumer quality comparison tool" means an online and
10paper tool developed by the Department with input from
11interested stakeholders reflecting the performance of Medicaid
12Managed Care Entity Plans on standardized quality performance
13measures. This tool shall be designed in a consumer-friendly
14and easily understandable format.
15    "Covered services" means those health care services to
16which a covered person is entitled to under the terms of the
17Medicaid Managed Care Entity Plan.
18    "Facilities" includes, but is not limited to, federally
19qualified health centers, skilled nursing facilities, and
20rehabilitation centers.
21    "Hospitals" includes, but is not limited to, acute care,
22rehabilitation, children's, and cancer hospitals.
23    "Integrated provider directory" means a searchable
24database bringing together network data from multiple Medicaid
25Managed Care Entities that is available through client
26enrollment services.



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1    "Medicaid eligibility redetermination" means the process
2by which the eligibility of a Medicaid recipient is reviewed by
3the Department to determine if the recipient's medical benefits
4will continue, be modified, or terminated.
5    "Medicaid Managed Care Entity" has the same meaning as
6defined in Section 5-30.2 of this Code.
7    (b) Provider directory transparency.
8        (1) Each Medicaid Managed Care Entity shall:
9            (A) Make available on the entity's website a
10        provider directory in a machine readable file and
11        format.
12            (B) Make provider directories publicly accessible
13        without the necessity of providing a password, a
14        username, or personally identifiable information.
15            (C) Comply with all federal and State statutes and
16        regulations, including 42 CFR 438.10, pertaining to
17        provider directories within Medicaid Managed Care.
18            (D) Request, at least annually, provider office
19        hours for each of the following provider types:
20                (i) Health care professionals, including
21            dental and vision providers.
22                (ii) Hospitals.
23                (iii) Facilities, other than hospitals.
24                (iv) Pharmacies, other than hospitals.
25                (v) Durable medical equipment suppliers, other
26            than hospitals.



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1            Medicaid Managed Care Entities shall publish the
2        provider office hours in the provider directory upon
3        receipt.
4            (E) Confirm with the Medicaid Managed Care
5        Entity's contracted providers who have not submitted
6        claims within the past 6 months that the contracted
7        providers intend to remain in the network and correct
8        any incorrect provider directory information as
9        necessary.
10            (F) Ensure that in situations in which a Medicaid
11        Managed Care Entity Plan enrollee receives covered
12        services from a non-participating provider due to a
13        material misrepresentation in a Medicaid Managed Care
14        Entity's online electronic provider directory, the
15        Medicaid Managed Care Entity Plan enrollee shall not be
16        held responsible for any costs resulting from that
17        material misrepresentation.
18            (G) Conspicuously display an e-mail address and a
19        toll-free telephone number to which any individual may
20        report any inaccuracy in the provider directory. If the
21        Medicaid Managed Care Entity receives a report from any
22        person who specifically identifies provider directory
23        information as inaccurate, the Medicaid Managed Care
24        Entity shall investigate the report and correct any
25        inaccurate information displayed in the electronic
26        directory.



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1        (2) The Department shall:
2            (A) Regularly monitor Medicaid Managed Care
3        Entities to ensure that they are compliant with the
4        requirements under paragraph (1) of subsection (b).
5            (B) Require that the client enrollment services
6        broker use the Medicaid provider number to populate the
7        provider information in the integrated provider
8        directory.
9            (C) Ensure that each Medicaid Managed Care Entity
10        shall, at minimum, make the information in
11        subparagraph (D) of paragraph (1) of subsection (b)
12        available to the client enrollment services broker.
13            (D) Ensure that the client enrollment services
14        broker shall, at minimum, have the information in
15        subparagraph (D) of paragraph (1) of subsection (b)
16        available and searchable through the integrated
17        provider directory on its website as soon as possible
18        but no later than January 1, 2017.
19            (E) Require the client enrollment services broker
20        to conspicuously display near the integrated provider
21        directory an email address and a toll-free telephone
22        number provided by the Department to which any
23        individual may report inaccuracies in the integrated
24        provider directory. If the Department receives a
25        report that identifies an inaccuracy in the integrated
26        provider directory, the Department shall provide the



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1        information about the reported inaccuracy to the
2        appropriate Medicaid Managed Care Entity within 3
3        business days after the reported inaccuracy is
4        received.
5    (c) Formulary transparency.
6        (1) Medicaid Managed Care Entities shall publish on
7    their respective websites a formulary for each Medicaid
8    Managed Care Entity Plan offered and make the formularies
9    easily understandable and publicly accessible without the
10    necessity of providing a password, a username, or
11    personally identifiable information.
12        (2) Medicaid Managed Care Entities shall provide
13    printed formularies upon request.
14        (3) Electronic and print formularies shall display:
15            (A) the medications covered (both generic and name
16        brand);
17            (B) if the medication is preferred or not
18        preferred, and what each term means;
19            (C) what tier each medication is in and the meaning
20        of each tier;
21            (D) any utilization controls including, but not
22        limited to, step therapy, prior approval, dosage
23        limits, gender or age restrictions, quantity limits,
24        or other policies that affect access to medications;
25            (E) any required cost-sharing;
26            (F) a glossary of key terms and explanation of



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1        utilization controls and cost-sharing requirements;
2            (G) a key or legend for all utilization controls
3        visible on every page in which specific medication
4        coverage information is displayed; and
5            (H) directions explaining the process or processes
6        a consumer may follow to obtain more information if a
7        medication the consumer requires is not covered or
8        listed in the formulary.
9        (4) Each Medicaid Managed Care Entity shall display
10    conspicuously with each electronic and printed medication
11    formulary an e-mail address and a toll-free telephone
12    number to which any individual may report any inaccuracy in
13    the formulary. If the Medicaid Managed Care Entity receives
14    a report that the formulary information is inaccurate, the
15    Medicaid Managed Care Entity shall investigate the report
16    and correct any inaccurate information displayed in the
17    electronic formulary.
18        (5) Each Medicaid Managed Care Entity shall include a
19    disclosure in the electronic and requested print
20    formularies that provides the date of publication, a
21    statement that the formulary is up to date as of
22    publication, and contact information for questions and
23    requests to receive updated information.
24        (6) The client enrollment services broker's website
25    shall display prominently a website URL link to each
26    Medicaid Managed Care Entity's Plan formulary. If a



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1    Medicaid enrollee calls the client enrollment services
2    broker with questions regarding formularies, the client
3    enrollment services broker shall offer a brief description
4    of what a formulary is and shall refer the Medicaid
5    enrollee to the appropriate Medicaid Managed Care Entity
6    regarding his or her questions about a specific entity's
7    formulary.
8    (d) Grievances and appeals. The Department shall require
9the client enrollment services broker to display prominently on
10the client enrollment services broker's website a description
11of where a Medicaid enrollee can access information on how to
12file a complaint or grievance or request a fair hearing for any
13adverse action taken by the Department or the Medicaid Managed
14Care Entity.
15    (e) Medicaid redetermination information. The Department
16shall require the client enrollment services broker to display
17prominently on the client enrollment services broker's website
18a description of where a Medicaid enrollee can access
19information regarding the Medicaid redetermination process.
20    (f) Medicaid care coordination information. The client
21enrollment services broker shall display prominently on its
22website, in an easily understandable format, consumer-oriented
23information regarding the role of care coordination services
24within Medicaid Managed Care. Such information shall include,
25but shall not be limited to:
26        (1) a basic description of the role of care



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1    coordination services and examples of specific care
2    coordination activities; and
3        (2) how a Medicaid enrollee may request care
4    coordination services from a Medicaid Managed Care Entity.
5    (g) Consumer quality comparison tool.
6        (1) The Department shall create a consumer quality
7    comparison tool to assist Medicaid enrollees with Medicaid
8    Managed Care Entity Plan selection. This tool shall provide
9    Medicaid Managed Care Entities' individual Plan
10    performance on a set of standardized quality performance
11    measures. The Department shall ensure that this tool shall
12    be accessible in both a print and online format, with the
13    online format allowing for individuals to access
14    additional detailed Plan performance information.
15        (2) At a minimum, a printed version of the consumer
16    quality comparison tool shall be provided by the Department
17    on an annual basis to Medicaid enrollees who are required
18    by the Department to enroll in a Medicaid Managed Care
19    Entity Plan during an enrollee's open enrollment period.
20    The consumer quality comparison tool shall also meet all of
21    the following criteria:
22            (A) Display Medicaid Managed Care Entities'
23        individual Plan performance on at least 4 composite
24        domains that reflect Plan quality, timeliness, and
25        access. The composite domains shall draw from the most
26        current available performance data sets including, but



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1        not limited to:
2                (i) Healthcare Effectiveness Data and
3            Information Set (HEDIS) measures.
4                (ii) Core Set of Children's Health Care
5            Quality measures as required under the Children's
6            Health Insurance Program Reauthorization Act
7            (CHIPRA).
8                (iii) Adult Core Set measures.
9                (iv) Consumer Assessment of Healthcare
10            Providers and Systems (CAHPS) survey results.
11                (v) Additional performance measures the
12            Department deems appropriate to populate the
13            composite domains.
14            (B) Use a quality rating system developed by the
15        Department to reflect Medicaid Managed Care Entities'
16        individual Plan performance. The quality rating system
17        for each composite domain shall reflect the Medicaid
18        Managed Care Entities' individual Plan performance
19        and, when possible, plan performance relative to
20        national Medicaid percentiles.
21            (C) Be customized to reflect the specific Medicaid
22        Managed Care Entities' Plans available to the Medicaid
23        enrollee based on his or her geographic location and
24        Medicaid eligibility category.
25            (D) Include contact information for the client
26        enrollment services broker and contact information for



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



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1        and, when possible, plan performance relative to
2        national Medicaid percentiles.
3            (D) Include the specific Medicaid Managed Care
4        Entity Plans available to the Medicaid enrollee based
5        on his or her geographic location and Medicaid
6        eligibility category.
7            (E) Include a sort function to view Medicaid
8        Managed Care Entities' individual Plan performance by
9        quality rating and by standardized quality performance
10        measures.
11            (F) Include contact information for the client
12        enrollment services broker and for each Medicaid
13        Managed Care Entity.
14            (G) Include guiding questions designed to assist
15        individuals in selecting a Medicaid Managed Care
16        Entity Plan.
17            (H) Prominently display current notice of quality
18        performance sanctions against Medicaid Managed Care
19        Entities. Notice of the sanctions shall remain present
20        on the online version of the consumer quality
21        comparison tool until the sanctions are lifted.
22        (4) The online version of the consumer quality
23    comparison tool shall be displayed prominently on the
24    client enrollment services broker's website.
25        (5) In the development of the consumer quality
26    comparison tool, the Department shall establish and



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1    publicize a formal process to collect and consider written
2    and oral feedback from consumers, advocates, and
3    stakeholders on aspects of the consumer quality comparison
4    tool, including, but not limited to, the following:
5            (A) The standardized data sets and surveys,
6        specific performance measures, and composite domains
7        represented in the consumer quality comparison tool.
8            (B) The format and presentation of the consumer
9        quality comparison tool.
10            (C) The methods undertaken by the Department to
11        notify Medicaid enrollees of the availability of the
12        consumer quality comparison tool.
13        (6) The Department shall review and update as
14    appropriate the composite domains and performance measures
15    represented in the print and online versions of the
16    consumer quality comparison tool at least once every 3
17    years. During the Department's review process, the
18    Department shall solicit engagement in the public feedback
19    process described in paragraph (5).
20        (7) The Department shall ensure that the consumer
21    quality comparison tool is available for consumer use as
22    soon as possible but no later than January 1, 2018.
23    (h) The Department may adopt rules and take any other
24appropriate action necessary to implement its responsibilities
25under this Section.



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1    Section 99. Effective date. This Act takes effect upon
2becoming law.".