Illinois General Assembly - Full Text of SB2429
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Full Text of SB2429  100th General Assembly


Sen. Omar Aquino

Filed: 4/4/2018





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2    AMENDMENT NO. ______. Amend Senate Bill 2429 by replacing
3everything after the enacting clause with the following:
4    "Section 5. The Illinois Public Aid Code is amended by
5changing Sections 5-5, 5-30, and 5-30.1 as follows:
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    Sec. 5-5. Medical services. The Illinois Department, by
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing home,
16or elsewhere; (6) medical care, or any other type of remedial



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1care furnished by licensed practitioners; (7) home health care
2services; (8) private duty nursing service; (9) clinic
3services; (10) dental services, including prevention and
4treatment of periodontal disease and dental caries disease for
5pregnant women, provided by an individual licensed to practice
6dentistry or dental surgery; for purposes of this item (10),
7"dental services" means diagnostic, preventive, or corrective
8procedures provided by or under the supervision of a dentist in
9the practice of his or her profession; (11) physical therapy
10and related services; (12) prescribed drugs, dentures, and
11prosthetic devices; and eyeglasses prescribed by a physician
12skilled in the diseases of the eye, or by an optometrist,
13whichever the person may select; (13) other diagnostic,
14screening, preventive, and rehabilitative services, including
15to ensure that the individual's need for intervention or
16treatment of mental disorders or substance use disorders or
17co-occurring mental health and substance use disorders is
18determined using a uniform screening, assessment, and
19evaluation process inclusive of criteria, for children and
20adults; for purposes of this item (13), a uniform screening,
21assessment, and evaluation process refers to a process that
22includes an appropriate evaluation and, as warranted, a
23referral; "uniform" does not mean the use of a singular
24instrument, tool, or process that all must utilize; (14)
25transportation and such other expenses as may be necessary;
26(15) medical treatment of sexual assault survivors, as defined



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1in Section 1a of the Sexual Assault Survivors Emergency
2Treatment Act, for injuries sustained as a result of the sexual
3assault, including examinations and laboratory tests to
4discover evidence which may be used in criminal proceedings
5arising from the sexual assault; (16) the diagnosis and
6treatment of sickle cell anemia; and (17) any other medical
7care, and any other type of remedial care recognized under the
8laws of this State. The term "any other type of remedial care"
9shall include nursing care and nursing home service for persons
10who rely on treatment by spiritual means alone through prayer
11for healing.
12    Notwithstanding any other provision of this Section, a
13comprehensive tobacco use cessation program that includes
14purchasing prescription drugs or prescription medical devices
15approved by the Food and Drug Administration shall be covered
16under the medical assistance program under this Article for
17persons who are otherwise eligible for assistance under this
19    Notwithstanding any other provision of this Code,
20reproductive health care that is otherwise legal in Illinois
21shall be covered under the medical assistance program for
22persons who are otherwise eligible for medical assistance under
23this Article.
24    Notwithstanding any other provision of this Code, the
25Illinois Department may not require, as a condition of payment
26for any laboratory test authorized under this Article, that a



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1physician's handwritten signature appear on the laboratory
2test order form. The Illinois Department may, however, impose
3other appropriate requirements regarding laboratory test order
5    Upon receipt of federal approval of an amendment to the
6Illinois Title XIX State Plan for this purpose, the Department
7shall authorize the Chicago Public Schools (CPS) to procure a
8vendor or vendors to manufacture eyeglasses for individuals
9enrolled in a school within the CPS system. CPS shall ensure
10that its vendor or vendors are enrolled as providers in the
11medical assistance program and in any capitated Medicaid
12managed care entity (MCE) serving individuals enrolled in a
13school within the CPS system. Under any contract procured under
14this provision, the vendor or vendors must serve only
15individuals enrolled in a school within the CPS system. Claims
16for services provided by CPS's vendor or vendors to recipients
17of benefits in the medical assistance program under this Code,
18the Children's Health Insurance Program, or the Covering ALL
19KIDS Health Insurance Program shall be submitted to the
20Department or the MCE in which the individual is enrolled for
21payment and shall be reimbursed at the Department's or the
22MCE's established rates or rate methodologies for eyeglasses.
23    On and after July 1, 2012, the Department of Healthcare and
24Family Services may provide the following services to persons
25eligible for assistance under this Article who are
26participating in education, training or employment programs



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1operated by the Department of Human Services as successor to
2the Department of Public Aid:
3        (1) dental services provided by or under the
4    supervision of a dentist; and
5        (2) eyeglasses prescribed by a physician skilled in the
6    diseases of the eye, or by an optometrist, whichever the
7    person may select.
8    On and after July 1, 2018, the Department of Healthcare and
9Family Services shall provide dental services to any adult who
10is otherwise eligible for assistance under the medical
11assistance program. As used in this paragraph, "dental
12services" means diagnostic, preventative, restorative, or
13corrective procedures, including procedures and services for
14the prevention and treatment of periodontal disease and dental
15caries disease, provided by an individual who is licensed to
16practice dentistry or dental surgery or who is under the
17supervision of a dentist in the practice of his or her
19    On and after July 1, 2018, targeted dental services, as set
20forth in Exhibit D of the Consent Decree entered by the United
21States District Court for the Northern District of Illinois,
22Eastern Division, in the matter of Memisovski v. Maram, Case
23No. 92 C 1982, that are provided to adults under the medical
24assistance program shall be reimbursed at no less than the
25rates set forth in the "New Rate" column in Exhibit D of the
26Consent Decree for targeted dental services that are provided



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1to persons under the age of 18 under the medical assistance
3    Notwithstanding any other provision of this Code and
4subject to federal approval, the Department may adopt rules to
5allow a dentist who is volunteering his or her service at no
6cost to render dental services through an enrolled
7not-for-profit health clinic without the dentist personally
8enrolling as a participating provider in the medical assistance
9program. A not-for-profit health clinic shall include a public
10health clinic or Federally Qualified Health Center or other
11enrolled provider, as determined by the Department, through
12which dental services covered under this Section are performed.
13The Department shall establish a process for payment of claims
14for reimbursement for covered dental services rendered under
15this provision.
16    The Illinois Department, by rule, may distinguish and
17classify the medical services to be provided only in accordance
18with the classes of persons designated in Section 5-2.
19    The Department of Healthcare and Family Services must
20provide coverage and reimbursement for amino acid-based
21elemental formulas, regardless of delivery method, for the
22diagnosis and treatment of (i) eosinophilic disorders and (ii)
23short bowel syndrome when the prescribing physician has issued
24a written order stating that the amino acid-based elemental
25formula is medically necessary.
26    The Illinois Department shall authorize the provision of,



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1and shall authorize payment for, screening by low-dose
2mammography for the presence of occult breast cancer for women
335 years of age or older who are eligible for medical
4assistance under this Article, as follows:
5        (A) A baseline mammogram for women 35 to 39 years of
6    age.
7        (B) An annual mammogram for women 40 years of age or
8    older.
9        (C) A mammogram at the age and intervals considered
10    medically necessary by the woman's health care provider for
11    women under 40 years of age and having a family history of
12    breast cancer, prior personal history of breast cancer,
13    positive genetic testing, or other risk factors.
14        (D) A comprehensive ultrasound screening and MRI of an
15    entire breast or breasts if a mammogram demonstrates
16    heterogeneous or dense breast tissue, when medically
17    necessary as determined by a physician licensed to practice
18    medicine in all of its branches.
19        (E) A screening MRI when medically necessary, as
20    determined by a physician licensed to practice medicine in
21    all of its branches.
22    All screenings shall include a physical breast exam,
23instruction on self-examination and information regarding the
24frequency of self-examination and its value as a preventative
25tool. For purposes of this Section, "low-dose mammography"
26means the x-ray examination of the breast using equipment



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1dedicated specifically for mammography, including the x-ray
2tube, filter, compression device, and image receptor, with an
3average radiation exposure delivery of less than one rad per
4breast for 2 views of an average size breast. The term also
5includes digital mammography and includes breast
6tomosynthesis. As used in this Section, the term "breast
7tomosynthesis" means a radiologic procedure that involves the
8acquisition of projection images over the stationary breast to
9produce cross-sectional digital three-dimensional images of
10the breast. If, at any time, the Secretary of the United States
11Department of Health and Human Services, or its successor
12agency, promulgates rules or regulations to be published in the
13Federal Register or publishes a comment in the Federal Register
14or issues an opinion, guidance, or other action that would
15require the State, pursuant to any provision of the Patient
16Protection and Affordable Care Act (Public Law 111-148),
17including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
18successor provision, to defray the cost of any coverage for
19breast tomosynthesis outlined in this paragraph, then the
20requirement that an insurer cover breast tomosynthesis is
21inoperative other than any such coverage authorized under
22Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
23the State shall not assume any obligation for the cost of
24coverage for breast tomosynthesis set forth in this paragraph.
25    On and after January 1, 2016, the Department shall ensure
26that all networks of care for adult clients of the Department



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1include access to at least one breast imaging Center of Imaging
2Excellence as certified by the American College of Radiology.
3    On and after January 1, 2012, providers participating in a
4quality improvement program approved by the Department shall be
5reimbursed for screening and diagnostic mammography at the same
6rate as the Medicare program's rates, including the increased
7reimbursement for digital mammography.
8    The Department shall convene an expert panel including
9representatives of hospitals, free-standing mammography
10facilities, and doctors, including radiologists, to establish
11quality standards for mammography.
12    On and after January 1, 2017, providers participating in a
13breast cancer treatment quality improvement program approved
14by the Department shall be reimbursed for breast cancer
15treatment at a rate that is no lower than 95% of the Medicare
16program's rates for the data elements included in the breast
17cancer treatment quality program.
18    The Department shall convene an expert panel, including
19representatives of hospitals, free standing breast cancer
20treatment centers, breast cancer quality organizations, and
21doctors, including breast surgeons, reconstructive breast
22surgeons, oncologists, and primary care providers to establish
23quality standards for breast cancer treatment.
24    Subject to federal approval, the Department shall
25establish a rate methodology for mammography at federally
26qualified health centers and other encounter-rate clinics.



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1These clinics or centers may also collaborate with other
2hospital-based mammography facilities. By January 1, 2016, the
3Department shall report to the General Assembly on the status
4of the provision set forth in this paragraph.
5    The Department shall establish a methodology to remind
6women who are age-appropriate for screening mammography, but
7who have not received a mammogram within the previous 18
8months, of the importance and benefit of screening mammography.
9The Department shall work with experts in breast cancer
10outreach and patient navigation to optimize these reminders and
11shall establish a methodology for evaluating their
12effectiveness and modifying the methodology based on the
14    The Department shall establish a performance goal for
15primary care providers with respect to their female patients
16over age 40 receiving an annual mammogram. This performance
17goal shall be used to provide additional reimbursement in the
18form of a quality performance bonus to primary care providers
19who meet that goal.
20    The Department shall devise a means of case-managing or
21patient navigation for beneficiaries diagnosed with breast
22cancer. This program shall initially operate as a pilot program
23in areas of the State with the highest incidence of mortality
24related to breast cancer. At least one pilot program site shall
25be in the metropolitan Chicago area and at least one site shall
26be outside the metropolitan Chicago area. On or after July 1,



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12016, the pilot program shall be expanded to include one site
2in western Illinois, one site in southern Illinois, one site in
3central Illinois, and 4 sites within metropolitan Chicago. An
4evaluation of the pilot program shall be carried out measuring
5health outcomes and cost of care for those served by the pilot
6program compared to similarly situated patients who are not
7served by the pilot program.
8    The Department shall require all networks of care to
9develop a means either internally or by contract with experts
10in navigation and community outreach to navigate cancer
11patients to comprehensive care in a timely fashion. The
12Department shall require all networks of care to include access
13for patients diagnosed with cancer to at least one academic
14commission on cancer-accredited cancer program as an
15in-network covered benefit.
16    Any medical or health care provider shall immediately
17recommend, to any pregnant woman who is being provided prenatal
18services and is suspected of drug abuse or is addicted as
19defined in the Alcoholism and Other Drug Abuse and Dependency
20Act, referral to a local substance abuse treatment provider
21licensed by the Department of Human Services or to a licensed
22hospital which provides substance abuse treatment services.
23The Department of Healthcare and Family Services shall assure
24coverage for the cost of treatment of the drug abuse or
25addiction for pregnant recipients in accordance with the
26Illinois Medicaid Program in conjunction with the Department of



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1Human Services.
2    All medical providers providing medical assistance to
3pregnant women under this Code shall receive information from
4the Department on the availability of services under the Drug
5Free Families with a Future or any comparable program providing
6case management services for addicted women, including
7information on appropriate referrals for other social services
8that may be needed by addicted women in addition to treatment
9for addiction.
10    The Illinois Department, in cooperation with the
11Departments of Human Services (as successor to the Department
12of Alcoholism and Substance Abuse) and Public Health, through a
13public awareness campaign, may provide information concerning
14treatment for alcoholism and drug abuse and addiction, prenatal
15health care, and other pertinent programs directed at reducing
16the number of drug-affected infants born to recipients of
17medical assistance.
18    Neither the Department of Healthcare and Family Services
19nor the Department of Human Services shall sanction the
20recipient solely on the basis of her substance abuse.
21    The Illinois Department shall establish such regulations
22governing the dispensing of health services under this Article
23as it shall deem appropriate. The Department should seek the
24advice of formal professional advisory committees appointed by
25the Director of the Illinois Department for the purpose of
26providing regular advice on policy and administrative matters,



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1information dissemination and educational activities for
2medical and health care providers, and consistency in
3procedures to the Illinois Department.
4    The Illinois Department may develop and contract with
5Partnerships of medical providers to arrange medical services
6for persons eligible under Section 5-2 of this Code.
7Implementation of this Section may be by demonstration projects
8in certain geographic areas. The Partnership shall be
9represented by a sponsor organization. The Department, by rule,
10shall develop qualifications for sponsors of Partnerships.
11Nothing in this Section shall be construed to require that the
12sponsor organization be a medical organization.
13    The sponsor must negotiate formal written contracts with
14medical providers for physician services, inpatient and
15outpatient hospital care, home health services, treatment for
16alcoholism and substance abuse, and other services determined
17necessary by the Illinois Department by rule for delivery by
18Partnerships. Physician services must include prenatal and
19obstetrical care. The Illinois Department shall reimburse
20medical services delivered by Partnership providers to clients
21in target areas according to provisions of this Article and the
22Illinois Health Finance Reform Act, except that:
23        (1) Physicians participating in a Partnership and
24    providing certain services, which shall be determined by
25    the Illinois Department, to persons in areas covered by the
26    Partnership may receive an additional surcharge for such



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1    services.
2        (2) The Department may elect to consider and negotiate
3    financial incentives to encourage the development of
4    Partnerships and the efficient delivery of medical care.
5        (3) Persons receiving medical services through
6    Partnerships may receive medical and case management
7    services above the level usually offered through the
8    medical assistance program.
9    Medical providers shall be required to meet certain
10qualifications to participate in Partnerships to ensure the
11delivery of high quality medical services. These
12qualifications shall be determined by rule of the Illinois
13Department and may be higher than qualifications for
14participation in the medical assistance program. Partnership
15sponsors may prescribe reasonable additional qualifications
16for participation by medical providers, only with the prior
17written approval of the Illinois Department.
18    Nothing in this Section shall limit the free choice of
19practitioners, hospitals, and other providers of medical
20services by clients. In order to ensure patient freedom of
21choice, the Illinois Department shall immediately promulgate
22all rules and take all other necessary actions so that provided
23services may be accessed from therapeutically certified
24optometrists to the full extent of the Illinois Optometric
25Practice Act of 1987 without discriminating between service



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1    The Department shall apply for a waiver from the United
2States Health Care Financing Administration to allow for the
3implementation of Partnerships under this Section.
4    The Illinois Department shall require health care
5providers to maintain records that document the medical care
6and services provided to recipients of Medical Assistance under
7this Article. Such records must be retained for a period of not
8less than 6 years from the date of service or as provided by
9applicable State law, whichever period is longer, except that
10if an audit is initiated within the required retention period
11then the records must be retained until the audit is completed
12and every exception is resolved. The Illinois Department shall
13require health care providers to make available, when
14authorized by the patient, in writing, the medical records in a
15timely fashion to other health care providers who are treating
16or serving persons eligible for Medical Assistance under this
17Article. All dispensers of medical services shall be required
18to maintain and retain business and professional records
19sufficient to fully and accurately document the nature, scope,
20details and receipt of the health care provided to persons
21eligible for medical assistance under this Code, in accordance
22with regulations promulgated by the Illinois Department. The
23rules and regulations shall require that proof of the receipt
24of prescription drugs, dentures, prosthetic devices and
25eyeglasses by eligible persons under this Section accompany
26each claim for reimbursement submitted by the dispenser of such



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1medical services. No such claims for reimbursement shall be
2approved for payment by the Illinois Department without such
3proof of receipt, unless the Illinois Department shall have put
4into effect and shall be operating a system of post-payment
5audit and review which shall, on a sampling basis, be deemed
6adequate by the Illinois Department to assure that such drugs,
7dentures, prosthetic devices and eyeglasses for which payment
8is being made are actually being received by eligible
9recipients. Within 90 days after September 16, 1984 (the
10effective date of Public Act 83-1439), the Illinois Department
11shall establish a current list of acquisition costs for all
12prosthetic devices and any other items recognized as medical
13equipment and supplies reimbursable under this Article and
14shall update such list on a quarterly basis, except that the
15acquisition costs of all prescription drugs shall be updated no
16less frequently than every 30 days as required by Section
18    Notwithstanding any other law to the contrary, the Illinois
19Department shall, within 365 days after July 22, 2013 (the
20effective date of Public Act 98-104), establish procedures to
21permit skilled care facilities licensed under the Nursing Home
22Care Act to submit monthly billing claims for reimbursement
23purposes. Following development of these procedures, the
24Department shall, by July 1, 2016, test the viability of the
25new system and implement any necessary operational or
26structural changes to its information technology platforms in



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1order to allow for the direct acceptance and payment of nursing
2home claims.
3    Notwithstanding any other law to the contrary, the Illinois
4Department shall, within 365 days after August 15, 2014 (the
5effective date of Public Act 98-963), establish procedures to
6permit ID/DD facilities licensed under the ID/DD Community Care
7Act and MC/DD facilities licensed under the MC/DD Act to submit
8monthly billing claims for reimbursement purposes. Following
9development of these procedures, the Department shall have an
10additional 365 days to test the viability of the new system and
11to ensure that any necessary operational or structural changes
12to its information technology platforms are implemented.
13    The Illinois Department shall require all dispensers of
14medical services, other than an individual practitioner or
15group of practitioners, desiring to participate in the Medical
16Assistance program established under this Article to disclose
17all financial, beneficial, ownership, equity, surety or other
18interests in any and all firms, corporations, partnerships,
19associations, business enterprises, joint ventures, agencies,
20institutions or other legal entities providing any form of
21health care services in this State under this Article.
22    The Illinois Department may require that all dispensers of
23medical services desiring to participate in the medical
24assistance program established under this Article disclose,
25under such terms and conditions as the Illinois Department may
26by rule establish, all inquiries from clients and attorneys



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1regarding medical bills paid by the Illinois Department, which
2inquiries could indicate potential existence of claims or liens
3for the Illinois Department.
4    Enrollment of a vendor shall be subject to a provisional
5period and shall be conditional for one year. During the period
6of conditional enrollment, the Department may terminate the
7vendor's eligibility to participate in, or may disenroll the
8vendor from, the medical assistance program without cause.
9Unless otherwise specified, such termination of eligibility or
10disenrollment is not subject to the Department's hearing
11process. However, a disenrolled vendor may reapply without
13    The Department has the discretion to limit the conditional
14enrollment period for vendors based upon category of risk of
15the vendor.
16    Prior to enrollment and during the conditional enrollment
17period in the medical assistance program, all vendors shall be
18subject to enhanced oversight, screening, and review based on
19the risk of fraud, waste, and abuse that is posed by the
20category of risk of the vendor. The Illinois Department shall
21establish the procedures for oversight, screening, and review,
22which may include, but need not be limited to: criminal and
23financial background checks; fingerprinting; license,
24certification, and authorization verifications; unscheduled or
25unannounced site visits; database checks; prepayment audit
26reviews; audits; payment caps; payment suspensions; and other



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1screening as required by federal or State law.
2    The Department shall define or specify the following: (i)
3by provider notice, the "category of risk of the vendor" for
4each type of vendor, which shall take into account the level of
5screening applicable to a particular category of vendor under
6federal law and regulations; (ii) by rule or provider notice,
7the maximum length of the conditional enrollment period for
8each category of risk of the vendor; and (iii) by rule, the
9hearing rights, if any, afforded to a vendor in each category
10of risk of the vendor that is terminated or disenrolled during
11the conditional enrollment period.
12    To be eligible for payment consideration, a vendor's
13payment claim or bill, either as an initial claim or as a
14resubmitted claim following prior rejection, must be received
15by the Illinois Department, or its fiscal intermediary, no
16later than 180 days after the latest date on the claim on which
17medical goods or services were provided, with the following
19        (1) In the case of a provider whose enrollment is in
20    process by the Illinois Department, the 180-day period
21    shall not begin until the date on the written notice from
22    the Illinois Department that the provider enrollment is
23    complete.
24        (2) In the case of errors attributable to the Illinois
25    Department or any of its claims processing intermediaries
26    which result in an inability to receive, process, or



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1    adjudicate a claim, the 180-day period shall not begin
2    until the provider has been notified of the error.
3        (3) In the case of a provider for whom the Illinois
4    Department initiates the monthly billing process.
5        (4) In the case of a provider operated by a unit of
6    local government with a population exceeding 3,000,000
7    when local government funds finance federal participation
8    for claims payments.
9    For claims for services rendered during a period for which
10a recipient received retroactive eligibility, claims must be
11filed within 180 days after the Department determines the
12applicant is eligible. For claims for which the Illinois
13Department is not the primary payer, claims must be submitted
14to the Illinois Department within 180 days after the final
15adjudication by the primary payer.
16    In the case of long term care facilities, within 45
17calendar days of receipt by the facility of required
18prescreening information, new admissions with associated
19admission documents shall be submitted through the Medical
20Electronic Data Interchange (MEDI) or the Recipient
21Eligibility Verification (REV) System or shall be submitted
22directly to the Department of Human Services using required
23admission forms. Effective September 1, 2014, admission
24documents, including all prescreening information, must be
25submitted through MEDI or REV. Confirmation numbers assigned to
26an accepted transaction shall be retained by a facility to



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1verify timely submittal. Once an admission transaction has been
2completed, all resubmitted claims following prior rejection
3are subject to receipt no later than 180 days after the
4admission transaction has been completed.
5    Claims that are not submitted and received in compliance
6with the foregoing requirements shall not be eligible for
7payment under the medical assistance program, and the State
8shall have no liability for payment of those claims.
9    To the extent consistent with applicable information and
10privacy, security, and disclosure laws, State and federal
11agencies and departments shall provide the Illinois Department
12access to confidential and other information and data necessary
13to perform eligibility and payment verifications and other
14Illinois Department functions. This includes, but is not
15limited to: information pertaining to licensure;
16certification; earnings; immigration status; citizenship; wage
17reporting; unearned and earned income; pension income;
18employment; supplemental security income; social security
19numbers; National Provider Identifier (NPI) numbers; the
20National Practitioner Data Bank (NPDB); program and agency
21exclusions; taxpayer identification numbers; tax delinquency;
22corporate information; and death records.
23    The Illinois Department shall enter into agreements with
24State agencies and departments, and is authorized to enter into
25agreements with federal agencies and departments, under which
26such agencies and departments shall share data necessary for



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1medical assistance program integrity functions and oversight.
2The Illinois Department shall develop, in cooperation with
3other State departments and agencies, and in compliance with
4applicable federal laws and regulations, appropriate and
5effective methods to share such data. At a minimum, and to the
6extent necessary to provide data sharing, the Illinois
7Department shall enter into agreements with State agencies and
8departments, and is authorized to enter into agreements with
9federal agencies and departments, including but not limited to:
10the Secretary of State; the Department of Revenue; the
11Department of Public Health; the Department of Human Services;
12and the Department of Financial and Professional Regulation.
13    Beginning in fiscal year 2013, the Illinois Department
14shall set forth a request for information to identify the
15benefits of a pre-payment, post-adjudication, and post-edit
16claims system with the goals of streamlining claims processing
17and provider reimbursement, reducing the number of pending or
18rejected claims, and helping to ensure a more transparent
19adjudication process through the utilization of: (i) provider
20data verification and provider screening technology; and (ii)
21clinical code editing; and (iii) pre-pay, pre- or
22post-adjudicated predictive modeling with an integrated case
23management system with link analysis. Such a request for
24information shall not be considered as a request for proposal
25or as an obligation on the part of the Illinois Department to
26take any action or acquire any products or services.



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1    The Illinois Department shall establish policies,
2procedures, standards and criteria by rule for the acquisition,
3repair and replacement of orthotic and prosthetic devices and
4durable medical equipment. Such rules shall provide, but not be
5limited to, the following services: (1) immediate repair or
6replacement of such devices by recipients; and (2) rental,
7lease, purchase or lease-purchase of durable medical equipment
8in a cost-effective manner, taking into consideration the
9recipient's medical prognosis, the extent of the recipient's
10needs, and the requirements and costs for maintaining such
11equipment. Subject to prior approval, such rules shall enable a
12recipient to temporarily acquire and use alternative or
13substitute devices or equipment pending repairs or
14replacements of any device or equipment previously authorized
15for such recipient by the Department. Notwithstanding any
16provision of Section 5-5f to the contrary, the Department may,
17by rule, exempt certain replacement wheelchair parts from prior
18approval and, for wheelchairs, wheelchair parts, wheelchair
19accessories, and related seating and positioning items,
20determine the wholesale price by methods other than actual
21acquisition costs.
22    The Department shall require, by rule, all providers of
23durable medical equipment to be accredited by an accreditation
24organization approved by the federal Centers for Medicare and
25Medicaid Services and recognized by the Department in order to
26bill the Department for providing durable medical equipment to



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1recipients. No later than 15 months after the effective date of
2the rule adopted pursuant to this paragraph, all providers must
3meet the accreditation requirement.
4    The Department shall execute, relative to the nursing home
5prescreening project, written inter-agency agreements with the
6Department of Human Services and the Department on Aging, to
7effect the following: (i) intake procedures and common
8eligibility criteria for those persons who are receiving
9non-institutional services; and (ii) the establishment and
10development of non-institutional services in areas of the State
11where they are not currently available or are undeveloped; and
12(iii) notwithstanding any other provision of law, subject to
13federal approval, on and after July 1, 2012, an increase in the
14determination of need (DON) scores from 29 to 37 for applicants
15for institutional and home and community-based long term care;
16if and only if federal approval is not granted, the Department
17may, in conjunction with other affected agencies, implement
18utilization controls or changes in benefit packages to
19effectuate a similar savings amount for this population; and
20(iv) no later than July 1, 2013, minimum level of care
21eligibility criteria for institutional and home and
22community-based long term care; and (v) no later than October
231, 2013, establish procedures to permit long term care
24providers access to eligibility scores for individuals with an
25admission date who are seeking or receiving services from the
26long term care provider. In order to select the minimum level



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1of care eligibility criteria, the Governor shall establish a
2workgroup that includes affected agency representatives and
3stakeholders representing the institutional and home and
4community-based long term care interests. This Section shall
5not restrict the Department from implementing lower level of
6care eligibility criteria for community-based services in
7circumstances where federal approval has been granted.
8    The Illinois Department shall develop and operate, in
9cooperation with other State Departments and agencies and in
10compliance with applicable federal laws and regulations,
11appropriate and effective systems of health care evaluation and
12programs for monitoring of utilization of health care services
13and facilities, as it affects persons eligible for medical
14assistance under this Code.
15    The Illinois Department shall report annually to the
16General Assembly, no later than the second Friday in April of
171979 and each year thereafter, in regard to:
18        (a) actual statistics and trends in utilization of
19    medical services by public aid recipients;
20        (b) actual statistics and trends in the provision of
21    the various medical services by medical vendors;
22        (c) current rate structures and proposed changes in
23    those rate structures for the various medical vendors; and
24        (d) efforts at utilization review and control by the
25    Illinois Department.
26    The period covered by each report shall be the 3 years



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1ending on the June 30 prior to the report. The report shall
2include suggested legislation for consideration by the General
3Assembly. The filing of one copy of the report with the
4Speaker, one copy with the Minority Leader and one copy with
5the Clerk of the House of Representatives, one copy with the
6President, one copy with the Minority Leader and one copy with
7the Secretary of the Senate, one copy with the Legislative
8Research Unit, and such additional copies with the State
9Government Report Distribution Center for the General Assembly
10as is required under paragraph (t) of Section 7 of the State
11Library Act shall be deemed sufficient to comply with this
13    Rulemaking authority to implement Public Act 95-1045, if
14any, is conditioned on the rules being adopted in accordance
15with all provisions of the Illinois Administrative Procedure
16Act and all rules and procedures of the Joint Committee on
17Administrative Rules; any purported rule not so adopted, for
18whatever reason, is unauthorized.
19    On and after July 1, 2012, the Department shall reduce any
20rate of reimbursement for services or other payments or alter
21any methodologies authorized by this Code to reduce any rate of
22reimbursement for services or other payments in accordance with
23Section 5-5e.
24    Because kidney transplantation can be an appropriate, cost
25effective alternative to renal dialysis when medically
26necessary and notwithstanding the provisions of Section 1-11 of



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1this Code, beginning October 1, 2014, the Department shall
2cover kidney transplantation for noncitizens with end-stage
3renal disease who are not eligible for comprehensive medical
4benefits, who meet the residency requirements of Section 5-3 of
5this Code, and who would otherwise meet the financial
6requirements of the appropriate class of eligible persons under
7Section 5-2 of this Code. To qualify for coverage of kidney
8transplantation, such person must be receiving emergency renal
9dialysis services covered by the Department. Providers under
10this Section shall be prior approved and certified by the
11Department to perform kidney transplantation and the services
12under this Section shall be limited to services associated with
13kidney transplantation.
14    Notwithstanding any other provision of this Code to the
15contrary, on or after July 1, 2015, all FDA approved forms of
16medication assisted treatment prescribed for the treatment of
17alcohol dependence or treatment of opioid dependence shall be
18covered under both fee for service and managed care medical
19assistance programs for persons who are otherwise eligible for
20medical assistance under this Article and shall not be subject
21to any (1) utilization control, other than those established
22under the American Society of Addiction Medicine patient
23placement criteria, (2) prior authorization mandate, or (3)
24lifetime restriction limit mandate.
25    On or after July 1, 2015, opioid antagonists prescribed for
26the treatment of an opioid overdose, including the medication



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1product, administration devices, and any pharmacy fees related
2to the dispensing and administration of the opioid antagonist,
3shall be covered under the medical assistance program for
4persons who are otherwise eligible for medical assistance under
5this Article. As used in this Section, "opioid antagonist"
6means a drug that binds to opioid receptors and blocks or
7inhibits the effect of opioids acting on those receptors,
8including, but not limited to, naloxone hydrochloride or any
9other similarly acting drug approved by the U.S. Food and Drug
11    Upon federal approval, the Department shall provide
12coverage and reimbursement for all drugs that are approved for
13marketing by the federal Food and Drug Administration and that
14are recommended by the federal Public Health Service or the
15United States Centers for Disease Control and Prevention for
16pre-exposure prophylaxis and related pre-exposure prophylaxis
17services, including, but not limited to, HIV and sexually
18transmitted infection screening, treatment for sexually
19transmitted infections, medical monitoring, assorted labs, and
20counseling to reduce the likelihood of HIV infection among
21individuals who are not infected with HIV but who are at high
22risk of HIV infection.
23(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
2499-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
25the effective date of P.A. 99-407); 99-433, eff. 8-21-15;
2699-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.



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17-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
2eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
3100-538, eff. 1-1-18; revised 10-26-17.)
4    (305 ILCS 5/5-30)
5    Sec. 5-30. Care coordination.
6    (a) At least 50% of recipients eligible for comprehensive
7medical benefits in all medical assistance programs or other
8health benefit programs administered by the Department,
9including the Children's Health Insurance Program Act and the
10Covering ALL KIDS Health Insurance Act, shall be enrolled in a
11care coordination program by no later than January 1, 2015. For
12purposes of this Section, "coordinated care" or "care
13coordination" means delivery systems where recipients will
14receive their care from providers who participate under
15contract in integrated delivery systems that are responsible
16for providing or arranging the majority of care, including
17primary care physician services, referrals from primary care
18physicians, diagnostic and treatment services, behavioral
19health services, in-patient and outpatient hospital services,
20dental services, and rehabilitation and long-term care
21services. The Department shall designate or contract for such
22integrated delivery systems (i) to ensure enrollees have a
23choice of systems and of primary care providers within such
24systems; (ii) to ensure that enrollees receive quality care in
25a culturally and linguistically appropriate manner; and (iii)



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1to ensure that coordinated care programs meet the diverse needs
2of enrollees with developmental, mental health, physical, and
3age-related disabilities.
4    (b) Payment for such coordinated care shall be based on
5arrangements where the State pays for performance related to
6health care outcomes, the use of evidence-based practices, the
7use of primary care delivered through comprehensive medical
8homes, the use of electronic medical records, and the
9appropriate exchange of health information electronically made
10either on a capitated basis in which a fixed monthly premium
11per recipient is paid and full financial risk is assumed for
12the delivery of services, or through other risk-based payment
14    (c) To qualify for compliance with this Section, the 50%
15goal shall be achieved by enrolling medical assistance
16enrollees from each medical assistance enrollment category,
17including parents, children, seniors, and people with
18disabilities to the extent that current State Medicaid payment
19laws would not limit federal matching funds for recipients in
20care coordination programs. In addition, services must be more
21comprehensively defined and more risk shall be assumed than in
22the Department's primary care case management program as of
23January 25, 2011 (the effective date of Public Act 96-1501).
24    (d) The Department shall report to the General Assembly in
25a separate part of its annual medical assistance program
26report, beginning April, 2012 until April, 2016, on the



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1progress and implementation of the care coordination program
2initiatives established by the provisions of Public Act
396-1501. The Department shall include in its April 2011 report
4a full analysis of federal laws or regulations regarding upper
5payment limitations to providers and the necessary revisions or
6adjustments in rate methodologies and payments to providers
7under this Code that would be necessary to implement
8coordinated care with full financial risk by a party other than
9the Department.
10    (e) Integrated Care Program for individuals with chronic
11mental health conditions.
12        (1) The Integrated Care Program shall encompass
13    services administered to recipients of medical assistance
14    under this Article to prevent exacerbations and
15    complications using cost-effective, evidence-based
16    practice guidelines and mental health management
17    strategies.
18        (2) The Department may utilize and expand upon existing
19    contractual arrangements with integrated care plans under
20    the Integrated Care Program for providing the coordinated
21    care provisions of this Section.
22        (3) Payment for such coordinated care shall be based on
23    arrangements where the State pays for performance related
24    to mental health outcomes on a capitated basis in which a
25    fixed monthly premium per recipient is paid and full
26    financial risk is assumed for the delivery of services, or



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1    through other risk-based payment arrangements such as
2    provider-based care coordination.
3        (4) The Department shall examine whether chronic
4    mental health management programs and services for
5    recipients with specific chronic mental health conditions
6    do any or all of the following:
7            (A) Improve the patient's overall mental health in
8        a more expeditious and cost-effective manner.
9            (B) Lower costs in other aspects of the medical
10        assistance program, such as hospital admissions,
11        emergency room visits, or more frequent and
12        inappropriate psychotropic drug use.
13        (5) The Department shall work with the facilities and
14    any integrated care plan participating in the program to
15    identify and correct barriers to the successful
16    implementation of this subsection (e) prior to and during
17    the implementation to best facilitate the goals and
18    objectives of this subsection (e).
19    (f) A hospital that is located in a county of the State in
20which the Department mandates some or all of the beneficiaries
21of the Medical Assistance Program residing in the county to
22enroll in a Care Coordination Program, as set forth in Section
235-30 of this Code, shall not be eligible for any non-claims
24based payments not mandated by Article V-A of this Code for
25which it would otherwise be qualified to receive, unless the
26hospital is a Coordinated Care Participating Hospital no later



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1than 60 days after June 14, 2012 (the effective date of Public
2Act 97-689) or 60 days after the first mandatory enrollment of
3a beneficiary in a Coordinated Care program. For purposes of
4this subsection, "Coordinated Care Participating Hospital"
5means a hospital that meets one of the following criteria:
6        (1) The hospital has entered into a contract to provide
7    hospital services with one or more MCOs to enrollees of the
8    care coordination program.
9        (2) The hospital has not been offered a contract by a
10    care coordination plan that the Department has determined
11    to be a good faith offer and that pays at least as much as
12    the Department would pay, on a fee-for-service basis, not
13    including disproportionate share hospital adjustment
14    payments or any other supplemental adjustment or add-on
15    payment to the base fee-for-service rate, except to the
16    extent such adjustments or add-on payments are
17    incorporated into the development of the applicable MCO
18    capitated rates.
19    As used in this subsection (f), "MCO" means any entity
20which contracts with the Department to provide services where
21payment for medical services is made on a capitated basis.
22    (g) No later than August 1, 2013, the Department shall
23issue a purchase of care solicitation for Accountable Care
24Entities (ACE) to serve any children and parents or caretaker
25relatives of children eligible for medical assistance under
26this Article. An ACE may be a single corporate structure or a



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1network of providers organized through contractual
2relationships with a single corporate entity. The solicitation
3shall require that:
4        (1) An ACE operating in Cook County be capable of
5    serving at least 40,000 eligible individuals in that
6    county; an ACE operating in Lake, Kane, DuPage, or Will
7    Counties be capable of serving at least 20,000 eligible
8    individuals in those counties and an ACE operating in other
9    regions of the State be capable of serving at least 10,000
10    eligible individuals in the region in which it operates.
11    During initial periods of mandatory enrollment, the
12    Department shall require its enrollment services
13    contractor to use a default assignment algorithm that
14    ensures if possible an ACE reaches the minimum enrollment
15    levels set forth in this paragraph.
16        (2) An ACE must include at a minimum the following
17    types of providers: primary care, specialty care,
18    hospitals, and behavioral healthcare.
19        (3) An ACE shall have a governance structure that
20    includes the major components of the health care delivery
21    system, including one representative from each of the
22    groups listed in paragraph (2).
23        (4) An ACE must be an integrated delivery system,
24    including a network able to provide the full range of
25    services needed by Medicaid beneficiaries and system
26    capacity to securely pass clinical information across



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1    participating entities and to aggregate and analyze that
2    data in order to coordinate care.
3        (5) An ACE must be capable of providing both care
4    coordination and complex case management, as necessary, to
5    beneficiaries. To be responsive to the solicitation, a
6    potential ACE must outline its care coordination and
7    complex case management model and plan to reduce the cost
8    of care.
9        (6) In the first 18 months of operation, unless the ACE
10    selects a shorter period, an ACE shall be paid care
11    coordination fees on a per member per month basis that are
12    projected to be cost neutral to the State during the term
13    of their payment and, subject to federal approval, be
14    eligible to share in additional savings generated by their
15    care coordination.
16        (7) In months 19 through 36 of operation, unless the
17    ACE selects a shorter period, an ACE shall be paid on a
18    pre-paid capitation basis for all medical assistance
19    covered services, under contract terms similar to Managed
20    Care Organizations (MCO), with the Department sharing the
21    risk through either stop-loss insurance for extremely high
22    cost individuals or corridors of shared risk based on the
23    overall cost of the total enrollment in the ACE. The ACE
24    shall be responsible for claims processing, encounter data
25    submission, utilization control, and quality assurance.
26        (8) In the fourth and subsequent years of operation, an



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1    ACE shall convert to a Managed Care Community Network
2    (MCCN), as defined in this Article, or Health Maintenance
3    Organization pursuant to the Illinois Insurance Code,
4    accepting full-risk capitation payments.
5    The Department shall allow potential ACE entities 5 months
6from the date of the posting of the solicitation to submit
7proposals. After the solicitation is released, in addition to
8the MCO rate development data available on the Department's
9website, subject to federal and State confidentiality and
10privacy laws and regulations, the Department shall provide 2
11years of de-identified summary service data on the targeted
12population, split between children and adults, showing the
13historical type and volume of services received and the cost of
14those services to those potential bidders that sign a data use
15agreement. The Department may add up to 2 non-state government
16employees with expertise in creating integrated delivery
17systems to its review team for the purchase of care
18solicitation described in this subsection. Any such
19individuals must sign a no-conflict disclosure and
20confidentiality agreement and agree to act in accordance with
21all applicable State laws.
22    During the first 2 years of an ACE's operation, the
23Department shall provide claims data to the ACE on its
24enrollees on a periodic basis no less frequently than monthly.
25    Nothing in this subsection shall be construed to limit the
26Department's mandate to enroll 50% of its beneficiaries into



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1care coordination systems by January 1, 2015, using all
2available care coordination delivery systems, including Care
3Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
4to affect the current CCEs, MCCNs, and MCOs selected to serve
5seniors and persons with disabilities prior to that date.
6    Nothing in this subsection precludes the Department from
7considering future proposals for new ACEs or expansion of
8existing ACEs at the discretion of the Department.
9    (h) Department contracts with MCOs and other entities
10reimbursed by risk based capitation shall have a minimum
11medical loss ratio of 85%, shall require the entity to
12establish an appeals and grievances process for consumers and
13providers, and shall require the entity to provide a quality
14assurance and utilization review program. Entities contracted
15with the Department to coordinate healthcare regardless of risk
16shall be measured utilizing the same quality metrics. The
17quality metrics may be population specific. Any contracted
18entity serving at least 5,000 seniors or people with
19disabilities or 15,000 individuals in other populations
20covered by the Medical Assistance Program that has been
21receiving full-risk capitation for a year shall be accredited
22by a national accreditation organization authorized by the
23Department within 2 years after the date it is eligible to
24become accredited. The requirements of this subsection shall
25apply to contracts with MCOs entered into or renewed or
26extended after June 1, 2013.



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1    (h-5) The Department shall monitor and enforce compliance
2by MCOs with agreements they have entered into with providers
3on issues that include, but are not limited to, timeliness of
4payment, payment rates, and processes for obtaining prior
5approval. The Department may impose sanctions on MCOs for
6violating provisions of those agreements that include, but are
7not limited to, financial penalties, suspension of enrollment
8of new enrollees, and termination of the MCO's contract with
9the Department. As used in this subsection (h-5), "MCO" has the
10meaning ascribed to that term in Section 5-30.1 of this Code.
11    (i) Unless otherwise required by federal law, Medicaid
12Managed Care Entities and their respective business associates
13shall not disclose, directly or indirectly, including by
14sending a bill or explanation of benefits, information
15concerning the sensitive health services received by enrollees
16of the Medicaid Managed Care Entity to any person other than
17covered entities and business associates, which may receive,
18use, and further disclose such information solely for the
19purposes permitted under applicable federal and State laws and
20regulations if such use and further disclosure satisfies all
21applicable requirements of such laws and regulations. The
22Medicaid Managed Care Entity or its respective business
23associates may disclose information concerning the sensitive
24health services if the enrollee who received the sensitive
25health services requests the information from the Medicaid
26Managed Care Entity or its respective business associates and



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1authorized the sending of a bill or explanation of benefits.
2Communications including, but not limited to, statements of
3care received or appointment reminders either directly or
4indirectly to the enrollee from the health care provider,
5health care professional, and care coordinators, remain
6permissible. Medicaid Managed Care Entities or their
7respective business associates may communicate directly with
8their enrollees regarding care coordination activities for
9those enrollees.
10    For the purposes of this subsection, the term "Medicaid
11Managed Care Entity" includes Care Coordination Entities,
12Accountable Care Entities, Managed Care Organizations, and
13Managed Care Community Networks.
14    For purposes of this subsection, the term "sensitive health
15services" means mental health services, substance abuse
16treatment services, reproductive health services, family
17planning services, services for sexually transmitted
18infections and sexually transmitted diseases, and services for
19sexual assault or domestic abuse. Services include prevention,
20screening, consultation, examination, treatment, or follow-up.
21    For purposes of this subsection, "business associate",
22"covered entity", "disclosure", and "use" have the meanings
23ascribed to those terms in 45 CFR 160.103.
24    Nothing in this subsection shall be construed to relieve a
25Medicaid Managed Care Entity or the Department of any duty to
26report incidents of sexually transmitted infections to the



10000SB2429sam002- 40 -LRB100 16511 KTG 37891 a

1Department of Public Health or to the local board of health in
2accordance with regulations adopted under a statute or
3ordinance or to report incidents of sexually transmitted
4infections as necessary to comply with the requirements under
5Section 5 of the Abused and Neglected Child Reporting Act or as
6otherwise required by State or federal law.
7    The Department shall create policy in order to implement
8the requirements in this subsection.
9    (j) Managed Care Entities (MCEs), including MCOs and all
10other care coordination organizations, shall develop and
11maintain a written language access policy that sets forth the
12standards, guidelines, and operational plan to ensure language
13appropriate services and that is consistent with the standard
14of meaningful access for populations with limited English
15proficiency. The language access policy shall describe how the
16MCEs will provide all of the following required services:
17        (1) Translation (the written replacement of text from
18    one language into another) of all vital documents and forms
19    as identified by the Department.
20        (2) Qualified interpreter services (the oral
21    communication of a message from one language into another
22    by a qualified interpreter).
23        (3) Staff training on the language access policy,
24    including how to identify language needs, access and
25    provide language assistance services, work with
26    interpreters, request translations, and track the use of



10000SB2429sam002- 41 -LRB100 16511 KTG 37891 a

1    language assistance services.
2        (4) Data tracking that identifies the language need.
3        (5) Notification to participants on the availability
4    of language access services and on how to access such
5    services.
6    (k) The Department shall actively monitor the contractual
7relationship between Managed Care Organizations (MCOs) and any
8dental administrator contracted by an MCO to provide dental
9services. The Department shall adopt appropriate dental
10Healthcare Effectiveness Data and Information Set measures or
11other dental quality performance measures as part of its
12monitoring and shall include additional specific dental
13performance measurers in its Health Plan Comparison Tool and
14Illinois Medicaid Plan Report Card that is available on the
15Department's website for enrolled individuals.
16    The Department shall collect from each MCO specific
17information about the types of contracted, broad-based care
18coordination occurring between the MCO and any dental
19administrator, including, but not limited to, pregnant women
20and diabetic patients in need of oral care.
21(Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14;
2299-106, eff. 1-1-16; 99-181, eff. 7-29-15; 99-566, eff. 1-1-17;
2399-642, eff. 7-28-16.)
24    (305 ILCS 5/5-30.1)
25    Sec. 5-30.1. Managed care protections.



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1    (a) As used in this Section:
2    "Managed care organization" or "MCO" means any entity which
3contracts with the Department to provide services where payment
4for medical services is made on a capitated basis.
5    "Emergency services" include:
6        (1) emergency services, as defined by Section 10 of the
7    Managed Care Reform and Patient Rights Act;
8        (2) emergency medical screening examinations, as
9    defined by Section 10 of the Managed Care Reform and
10    Patient Rights Act;
11        (3) post-stabilization medical services, as defined by
12    Section 10 of the Managed Care Reform and Patient Rights
13    Act; and
14        (4) emergency medical conditions, as defined by
15    Section 10 of the Managed Care Reform and Patient Rights
16    Act.
17    (b) As provided by Section 5-16.12, managed care
18organizations are subject to the provisions of the Managed Care
19Reform and Patient Rights Act.
20    (c) An MCO shall pay any provider of emergency services
21that does not have in effect a contract with the contracted
22Medicaid MCO. The default rate of reimbursement shall be the
23rate paid under Illinois Medicaid fee-for-service program
24methodology, including all policy adjusters, including but not
25limited to Medicaid High Volume Adjustments, Medicaid
26Percentage Adjustments, Outpatient High Volume Adjustments,



10000SB2429sam002- 43 -LRB100 16511 KTG 37891 a

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



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1    Adjustments, Outpatient High Volume Adjustments and all
2    outlier add-on adjustments to the extent that such
3    adjustments are incorporated in the development of the
4    applicable MCO capitated rates.
5    (e) The following requirements apply to MCOs in determining
6payment for all emergency services:
7        (1) MCOs shall not impose any requirements for prior
8    approval of emergency services.
9        (2) The MCO shall cover emergency services provided to
10    enrollees who are temporarily away from their residence and
11    outside the contracting area to the extent that the
12    enrollees would be entitled to the emergency services if
13    they still were within the contracting area.
14        (3) The MCO shall have no obligation to cover medical
15    services provided on an emergency basis that are not
16    covered services under the contract.
17        (4) The MCO shall not condition coverage for emergency
18    services on the treating provider notifying the MCO of the
19    enrollee's screening and treatment within 10 days after
20    presentation for emergency services.
21        (5) The determination of the attending emergency
22    physician, or the provider actually treating the enrollee,
23    of whether an enrollee is sufficiently stabilized for
24    discharge or transfer to another facility, shall be binding
25    on the MCO. The MCO shall cover emergency services for all
26    enrollees whether the emergency services are provided by an



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1    affiliated or non-affiliated provider.
2        (6) The MCO's financial responsibility for
3    post-stabilization care services it has not pre-approved
4    ends when:
5            (A) a plan physician with privileges at the
6        treating hospital assumes responsibility for the
7        enrollee's care;
8            (B) a plan physician assumes responsibility for
9        the enrollee's care through transfer;
10            (C) a contracting entity representative and the
11        treating physician reach an agreement concerning the
12        enrollee's care; or
13            (D) the enrollee is discharged.
14    (f) Network adequacy and transparency.
15        (1) The Department shall:
16            (A) ensure that an adequate provider network is in
17        place, taking into consideration health professional
18        shortage areas and medically underserved areas;
19            (B) publicly release an explanation of its process
20        for analyzing network adequacy;
21            (C) periodically ensure that an MCO continues to
22        have an adequate network in place; and
23            (D) require MCOs, including Medicaid Managed Care
24        Entities as defined in Section 5-30.2, to meet provider
25        directory requirements under Section 5-30.3.
26        (2) Each MCO shall confirm its receipt of information



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1    submitted specific to physician or dentist additions or
2    physician or dentist deletions from the MCO's provider
3    network within 3 days after receiving all required
4    information from contracted physicians or dentists, and
5    electronic physician and dental directories must be
6    updated consistent with current rules as published by the
7    Centers for Medicare and Medicaid Services or its successor
8    agency.
9    (g) Timely payment of claims.
10        (1) The MCO shall pay a claim within 30 days of
11    receiving a claim that contains all the essential
12    information needed to adjudicate the claim.
13        (2) The MCO shall notify the billing party of its
14    inability to adjudicate a claim within 30 days of receiving
15    that claim.
16        (3) The MCO shall pay a penalty that is at least equal
17    to the penalty imposed under the Illinois Insurance Code
18    for any claims not timely paid.
19        (4) The Department may establish a process for MCOs to
20    expedite payments to providers based on criteria
21    established by the Department.
22    (g-5) Recognizing that the rapid transformation of the
23Illinois Medicaid program may have unintended operational
24challenges for both payers and providers:
25        (1) in no instance shall a medically necessary covered
26    service rendered in good faith, based upon eligibility



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1    information documented by the provider, be denied coverage
2    or diminished in payment amount if the eligibility or
3    coverage information available at the time the service was
4    rendered is later found to be inaccurate; and
5        (2) the Department shall, by December 31, 2016, adopt
6    rules establishing policies that shall be included in the
7    Medicaid managed care policy and procedures manual
8    addressing payment resolutions in situations in which a
9    provider renders services based upon information obtained
10    after verifying a patient's eligibility and coverage plan
11    through either the Department's current enrollment system
12    or a system operated by the coverage plan identified by the
13    patient presenting for services:
14            (A) such medically necessary covered services
15        shall be considered rendered in good faith;
16            (B) such policies and procedures shall be
17        developed in consultation with industry
18        representatives of the Medicaid managed care health
19        plans and representatives of provider associations
20        representing the majority of providers within the
21        identified provider industry; and
22            (C) such rules shall be published for a review and
23        comment period of no less than 30 days on the
24        Department's website with final rules remaining
25        available on the Department's website.
26        (3) The rules on payment resolutions shall include, but



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1    not be limited to:
2            (A) the extension of the timely filing period;
3            (B) retroactive prior authorizations; and
4            (C) guaranteed minimum payment rate of no less than
5        the current, as of the date of service, fee-for-service
6        rate, plus all applicable add-ons, when the resulting
7        service relationship is out of network.
8        (4) The rules shall be applicable for both MCO coverage
9    and fee-for-service coverage.
10    (g-6) MCO Performance Metrics Report.
11        (1) The Department shall publish, on at least a
12    quarterly basis, each MCO's operational performance,
13    including, but not limited to, the following categories of
14    metrics:
15            (A) claims payment, including timeliness and
16        accuracy;
17            (B) prior authorizations;
18            (C) grievance and appeals;
19            (D) utilization statistics;
20            (E) provider disputes;
21            (F) provider credentialing; and
22            (G) member and provider customer service.
23        (2) The Department shall ensure that the metrics report
24    is accessible to providers online by January 1, 2017.
25        (3) The metrics shall be developed in consultation with
26    industry representatives of the Medicaid managed care



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1    health plans and representatives of associations
2    representing the majority of providers within the
3    identified industry.
4        (4) Metrics shall be defined and incorporated into the
5    applicable Managed Care Policy Manual issued by the
6    Department.
7    (g-7) MCO claims processing and performance analysis. In
8order to monitor MCO payments to hospital providers, pursuant
9to this amendatory Act of the 100th General Assembly, the
10Department shall post an analysis of MCO claims processing and
11payment performance on its website every 6 months. Such
12analysis shall include a review and evaluation of a
13representative sample of hospital claims that are rejected and
14denied for clean and unclean claims and the top 5 reasons for
15such actions and timeliness of claims adjudication, which
16identifies the percentage of claims adjudicated within 30, 60,
1790, and over 90 days, and the dollar amounts associated with
18those claims. The Department shall post the contracted claims
19report required by HealthChoice Illinois on its website every 3
21    (h) The Department shall not expand mandatory MCO
22enrollment into new counties beyond those counties already
23designated by the Department as of June 1, 2014 for the
24individuals whose eligibility for medical assistance is not the
25seniors or people with disabilities population until the
26Department provides an opportunity for accountable care



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1entities and MCOs to participate in such newly designated
3    (i) The requirements of this Section apply to contracts
4with accountable care entities and MCOs entered into, amended,
5or renewed after June 16, 2014 (the effective date of Public
6Act 98-651).
7(Source: P.A. 99-725, eff. 8-5-16; 99-751, eff. 8-5-16;
8100-201, eff. 8-18-17; 100-580, eff. 3-12-18.)
9    Section 99. Effective date. This Act takes effect upon
10becoming law.".