Illinois General Assembly - Full Text of SB1773
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Full Text of SB1773  100th General Assembly


Rep. Mary E. Flowers

Filed: 2/7/2018





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2    AMENDMENT NO. ______. Amend Senate Bill 1773, AS AMENDED,
3with reference to page and line numbers of House Amendment No.
44 as follows:
5on page 152, immediately below line 15, by inserting the
7    "Section 20. The Illinois Public Aid Code is amended by
8changing the heading of Article V-F and Sections 5F-1, 5F-5,
95F-10, 5F-15, 5F-25, 5F-30, 5F-32, and 5F-33 and by adding
10Sections 5F-2.5 and 5F-17 as follows:
11    (305 ILCS 5/Art. V-F heading)
15(Source: P.A. 98-651, eff. 6-16-14.)



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1    (305 ILCS 5/5F-1)
2    Sec. 5F-1. Short title. This Article may be referred to as
3the Medicare-Medicaid Alignment Initiative (MMAI) Nursing Home
4Residents' Managed Care Rights Law.
5(Source: P.A. 98-651, eff. 6-16-14.)
6    (305 ILCS 5/5F-2.5 new)
7    Sec. 5F-2.5. Declaration. The General Assembly declares it
8is in the best interest of the citizenry of the State of
9Illinois for the Department of Healthcare and Family Services
10to maintain strict oversight of all Medicaid managed care
11programs covering nursing home residents to ensure that medical
12care and services are delivered in a manner consistent with the
13unique needs and circumstances of nursing home residents and
14that providers are appropriately and promptly paid in full for
15all services rendered in good faith. Further, the General
16Assembly expressly prohibits the Department of Healthcare and
17Family Services from delegating to a third party authority and
18responsibility for ensuring that provider agreements issued by
19managed care organizations under contract with the Department
20are in compliance with all federal and State laws and
21regulations and the master contract and directs the Department
22to review all provider agreements and intervene to ensure full



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1    (305 ILCS 5/5F-5)
2    Sec. 5F-5. Findings. The General Assembly finds that
3elderly Illinoisans residing in a nursing home have the right
5        (1) quality health care regardless of the payer;
6        (2) receive medically necessary care prescribed by
7    their doctors;
8        (3) a simple appeal process when care is denied; and
9        (4) make decisions about their care and where they
10    receive it; .
11        (5) receive long term services and supports upon
12    achieving a DON score of 29 or higher, without further
13    limitations; and receive medical care, services, and
14    supports in a manner consistent with each individual's
15    level of frailty, mobility, and immediacy of medical
16    condition and consistent with rights and protections
17    contained in State and federal laws and regulations.
18(Source: P.A. 98-651, eff. 6-16-14.)
19    (305 ILCS 5/5F-10)
20    Sec. 5F-10. Scope. This Article applies to policies and
21contracts amended, delivered, issued, or renewed on or after
22the effective date of this amendatory Act of the 98th General
23Assembly for the nursing home component of any Medicaid managed
24care program established by statute, rule, or contract
25including, but not limited to, the Medicare-Medicaid Alignment



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1Initiative Program, the Integrated Care Program, the
2HealthChoices Program, and the Managed Long-Term Services and
3Support Program, and any and all successor programs. This
4Article does not diminish a managed care organization's duties
5and responsibilities under other federal or State laws or rules
6adopted under those laws and the 3-way Medicare-Medicaid
7Alignment Initiative contract, the Integrated Care Program
8contract, the HealthChoices Program contract, and the Managed
9Long-Term Services and Support Program contract, and
10contracts, statutes, or rules specific to any and all successor
12    On or after the effective date of this amendatory Act of
13the 100th General Assembly, the Department shall review the
14requirements and make all policy changes, adopt administrative
15rules, modify existing contracts with managed care
16organizations, and direct the issuance of revised provider
17agreements necessary to achieve the full implementation of this
18amendatory Act of the 100th General Assembly.
19(Source: P.A. 98-651, eff. 6-16-14; 99-719, eff. 1-1-17.)
20    (305 ILCS 5/5F-15)
21    Sec. 5F-15. Definitions. As used in this Article:
22    "Appeal" means any of the procedures that deal with the
23review of adverse organization determinations on the health
24care services the enrollee believes he or she is entitled to
25receive, including delay in providing, arranging for, or



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1approving the health care services, such that a delay would
2adversely affect the health of the enrollee or on any amounts
3the enrollee must pay for a service, as defined under 42 CFR
4422.566(b). These procedures include reconsiderations by the
5managed care organization and, if necessary, an independent
6review entity as provided by the Health Carrier External Review
7Act, hearings before administrative law judges, review by the
8Medicare Appeals Council, and judicial review.
9    "Demonstration Project" means the nursing home component
10of the Medicare-Medicaid Alignment Initiative Demonstration
12    "Department" means the Department of Healthcare and Family
14    "Enrollee" means an individual who resides in a nursing
15home or is qualified to be admitted to a nursing home and is
16enrolled or is a prospective enrollee with a Medicaid managed
17care organization participating in the Demonstration Project.
18    "Health care services" means the diagnosis, treatment, and
19prevention of disease and includes medication, primary care,
20nursing or medical care, mental health treatment, psychiatric
21rehabilitation, memory loss services, physical, occupational,
22and speech rehabilitation, enhanced care, medical supplies and
23equipment and the repair of such equipment, and assistance with
24activities of daily living.
25    "Managed care organization" or "MCO" means an entity that
26meets the definition of health maintenance organization as



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1defined in the Health Maintenance Organization Act, is
2licensed, regulated and in good standing with the Department of
3Insurance, and is authorized to participate in the nursing home
4component of the Medicare-Medicaid Alignment Initiative
5Demonstration Project by a 3-way contract with the Department
6of Healthcare and Family Services and the Centers for Medicare
7and Medicaid Services or is under contract with the Department
8to participate in the Integrated Care Program, the Managed
9Long-Term Services and Support Program, the HealthChoices
10Program, and any and all successor programs.
11    "Medical professional" means a physician, physician
12assistant, or nurse practitioner.
13    "Medically necessary" means health care services that a
14medical professional, exercising prudent clinical judgment,
15would provide to a patient for the purpose of preventing,
16evaluating, diagnosing, or treating an illness, injury, or
17disease or its symptoms, and that are: (i) in accordance with
18the generally accepted standards of medical practice; (ii)
19clinically appropriate, in terms of type, frequency, extent,
20site, and duration, and considered effective for the patient's
21illness, injury, or disease; and (iii) not primarily for the
22convenience of the patient, a medical professional, other
23health care provider, caregiver, family member, or other
24interested party.
25    "Nursing home" means a facility licensed under the Nursing
26Home Care Act.



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1    "Nurse practitioner" means an individual properly licensed
2as a nurse practitioner under the Nurse Practice Act.
3    "Physician" means an individual licensed to practice in all
4branches of medicine under the Medical Practice Act of 1987.
5    "Physician assistant" means an individual properly
6licensed under the Physician Assistant Practice Act of 1987.
7    "Resident" means an enrollee who is receiving personal or
8medical care, including, but not limited to, mental health
9treatment, psychiatric rehabilitation, physical
10rehabilitation, and assistance with activities of daily
11living, from a nursing home.
12    "RAI Manual" means the most recent Resident Assessment
13Instrument Manual, published by the Centers for Medicare and
14Medicaid Services.
15    "Resident's representative" means a person designated in
16writing by a resident to be the resident's representative or
17the resident's guardian, as described by the Nursing Home Care
19    "SNFist" means a medical professional specializing in the
20care of individuals residing in nursing homes employed by or
21under contract with a MCO.
22    "Transition period" means a period of time immediately
23following enrollment into a managed care organization the
24Demonstration Project or an enrollee's movement from one
25managed care organization to another managed care organization
26or one care setting to another care setting.



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1(Source: P.A. 98-651, eff. 6-16-14.)
2    (305 ILCS 5/5F-17 new)
3    Sec. 5F-17. Contracting. All contracts issued by the
4Department to managed care organizations for Medicaid services
5provided to nursing home residents shall be solely for services
6provided to nursing home residents and tailored to meet the
7unique medical needs and circumstances of nursing home
8residents and shall be consistent with all federal and State
9statutes and regulations governing nursing homes and the
10delivery of care to residents. Contracts governing the delivery
11of care to nursing home residents shall at a minimum include
12the following provisions:
13        (1) 30 minute time and distance standards to primary
14    care physicians and specialists and hospitals regardless
15    of geographic locations;
16        (2) no longer than 24-hour wait time for physician,
17    laboratory, and medical procedure appointments; and
18        (3) automatic authorization for custodial care for
19    residents scoring a 29 or higher on the Determination of
20    Need instrument.
21    (305 ILCS 5/5F-25)
22    Sec. 5F-25. Care coordination. Care coordination provided
23to all enrollees in the Demonstration Project shall conform to
24the following requirements:



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1        (1) care coordination services shall be
2    enrollee-driven and person-centered;
3        (2) all enrollees in the Demonstration Project shall
4    have the right to receive health care services in the care
5    setting of their choice, except as permitted by Part 4 of
6    Article III of the Nursing Home Care Act with respect to
7    involuntary transfers and discharges; and
8        (3) decisions shall be based on the enrollee's best
9    interests.
10(Source: P.A. 98-651, eff. 6-16-14.)
11    (305 ILCS 5/5F-30)
12    Sec. 5F-30. Continuity of care. When a nursing home
13resident first transitions to a managed care organization from
14the fee-for-service system or from another managed care
15organization, the managed care organization shall honor the
16existing care plan and any necessary changes to that care plan
17until the managed care organization MCO has completed a
18comprehensive assessment and new care plan, to the extent such
19services are covered benefits under the contract, which shall
20be consistent with the requirements of the RAI Manual.
21    When an enrollee of a managed care organization is moving
22from a community setting to a nursing home, and the managed
23care organization MCO is properly notified of the proposed
24admission by a network nursing home, and the managed care
25organization fails to participate in developing a care plan



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1within the time frames required by nursing home regulations,
2the managed care organization MCO must honor a care plan
3developed by the nursing home until the managed care
4organization MCO has completed a comprehensive assessment and a
5new care plan to the extent such services are covered benefits
6under the contract, consistent with the requirements of the RAI
8    A nursing home shall have the ability to refuse admission
9of an enrollee for whom care is required that the nursing home
10determines is outside the scope of its license and healthcare
12(Source: P.A. 98-651, eff. 6-16-14.)
13    (305 ILCS 5/5F-32)
14    Sec. 5F-32. Non-emergency prior approval and appeal.
15    (a) Managed care organizations MCOs must have a method of
16receiving prior approval requests 24 hours a day, 7 days a
17week, 365 days a year from nursing home residents, physicians,
18or providers. If a response is not provided within 24 hours of
19the request and the nursing home is required by regulation to
20provide a service because a physician ordered it, the managed
21care organization MCO must pay for the service if it is a
22covered service under the managed care organization's MCO's
23contract in the Demonstration Project, provided that the
24request is consistent with the policies and procedures of the
25managed care organization MCO.



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1    In a non-emergency situation, notwithstanding any
2provisions in State law to the contrary, in the event a
3resident's physician orders a service, treatment, or test that
4is not approved by the managed care organization MCO, the
5enrollee, physician, or provider may utilize an expedited
6appeal to the managed care organization MCO.
7    If an enrollee, physician, or provider requests an
8expedited appeal pursuant to 42 CFR 438.410, the managed care
9organization MCO shall notify the individual filing the appeal,
10whether it is the enrollee, physician, or provider, within 24
11hours after the submission of the appeal of all information
12from the enrollee, physician, or provider that the managed care
13organization MCO requires to evaluate the appeal. The managed
14care organization MCO shall notify the individual filing the
15appeal of the managed care organization's MCO's decision on an
16expedited appeal within 24 hours after receipt of the required
18    (b) While the appeal is pending or if the ordered service,
19treatment, or test is denied after appeal, the Department of
20Public Health may not cite the nursing home for failure to
21provide the ordered service, treatment, or test. The nursing
22home shall not be liable or responsible for an injury in any
23regulatory proceeding for the following:
24        (1) failure to follow the appealed or denied order; or
25        (2) injury to the extent it was caused by the delay or
26    failure to perform the appealed or denied service,



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1    treatment, or test.
2Provided however, a nursing home shall continue to monitor,
3document, and ensure the patient's safety. Nothing in this
4subsection (b) is intended to otherwise change the nursing
5home's existing obligations under State and federal law to
6appropriately care for its residents.
7(Source: P.A. 98-651, eff. 6-16-14; 99-719, eff. 1-1-17.)
8    (305 ILCS 5/5F-33)
9    Sec. 5F-33. Payment of claims.
10    (a) Clean claims, as defined by the Department by rule,
11submitted by a provider to a managed care organization in the
12form and manner requested by the managed care organization
13shall be reviewed and paid within 30 days of receipt.
14    (b) A managed care organization must provide a status
15update within 30 60 days of the submission of a claim.
16    (c) A claim that is rejected or denied, which shall clearly
17state the reason for the rejection or denial in sufficient
18detail to permit the provider to understand the justification
19for the action.
20    (d) The Department shall work with stakeholders,
21including, but not limited to, managed care organizations and
22nursing home providers, to train them on the application of
23standardized codes for long-term care services.
24    (e) Managed care organizations shall provide a manual
25clearly explaining billing and claims payment procedures,



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1including points of contact for provider services centers,
2within 15 days of a provider entering into a contract with a
3managed care organization. The manual shall include all
4necessary coding and documentation requirements. Providers
5under contract with a managed care organization on the
6effective date of this amendatory Act of the 99th General
7Assembly shall be provided with an electronic copy of these
8requirements within 30 days of the effective date of this
9amendatory Act of the 99th General Assembly. Any changes to
10these requirements shall be delivered electronically to all
11providers under contract with the managed care organization 30
12days prior to the effective date of the change.
13(Source: P.A. 99-719, eff. 1-1-17.)".