Full Text of SB2552 100th General Assembly
SB2552sam001 100TH GENERAL ASSEMBLY | Sen. Heather A. Steans Filed: 3/20/2018
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| 1 | | AMENDMENT TO SENATE BILL 2552
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 2552 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Illinois Public Aid Code is amended by | 5 | | adding Section 5-30.8 as follows: | 6 | | (305 ILCS 5/5-30.8 new) | 7 | | Sec. 5-30.8. Managed care organization rate transparency. | 8 | | (a) For the establishment of Managed Care
Organization | 9 | | (MCO) capitated rate payments from the State,
including, but | 10 | | not limited to, (i) hospital fee schedule
reforms and updates, | 11 | | (ii) rates related to a single
State-mandated preferred drug | 12 | | list, (iii) rate updates related
to the State's preferred drug | 13 | | list, (iv) inclusion of coverage
for children with special | 14 | | needs, (v) inclusion of coverage for
children within the child | 15 | | welfare system, (vi) annual MCO
capitated rates, and (vii) any | 16 | | retroactive provider fee
schedule adjustments or other changes |
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| 1 | | required by legislation
or other actions, the Department of | 2 | | Healthcare and Family
Services shall implement a base rate | 3 | | setting process beginning
on the effective date of this | 4 | | amendatory Act of the 100th
General Assembly which shall | 5 | | include all of the following
elements of transparency: | 6 | | (1) The Department shall include participating MCOs
| 7 | | and a statewide trade association representing a majority
| 8 | | of participating MCOs in work groups to discuss the
| 9 | | development of any new or updated hospital fee schedules or
| 10 | | other provider fee schedules. Additionally, the Department
| 11 | | shall share any data or reports used to develop MCO rates
| 12 | | with participating MCOs. This data shall be comprehensive
| 13 | | enough for MCO actuaries to recreate and verify the
| 14 | | accuracy of the rate build-up. | 15 | | (2) The Department shall not limit the number of
| 16 | | experts that each MCO is allowed to bring to the draft rate
| 17 | | meeting or the final rate review meeting. | 18 | | (3) The Department and its contracted actuary shall
| 19 | | meet with all participating MCOs simultaneously and
| 20 | | together along with consulting actuaries contracted with
| 21 | | statewide trade association representing a majority of
| 22 | | Medicaid health plans at the request of the plans.
| 23 | | Participating MCOs shall additionally, at their request,
| 24 | | be granted individual rate development meetings with the
| 25 | | Department. | 26 | | (4) When a dispute remains between the MCOs and the
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| 1 | | State's actuaries about the base
capitation rates, an MCO | 2 | | or MCOs shall have the option to
seek an arbitration by a | 3 | | third party actuary to settle the
dispute. The third party | 4 | | actuary shall be selected by the
Department from a list of | 5 | | 3 actuary firms produced by the
participating and | 6 | | complaining MCOs to the Department, and
the arbitration | 7 | | costs shall be funded by the participating
and complaining | 8 | | MCOs. The decision of the third party
actuary shall be | 9 | | binding and shall apply to the base rates
of the entire | 10 | | program retroactively. | 11 | | (5) Any quality incentive or other incentive
| 12 | | withholding of any portion of the actuarially certified
| 13 | | rates must be budget-neutral; the entirety of any aggregate
| 14 | | withheld amounts must be returned to the MCOs in proportion
| 15 | | to their performance on the relevant performance metric. No
| 16 | | amounts shall be returned to the Department in the event
| 17 | | all performance measures are not achieved. | 18 | | (6) Upon request, the Department shall provide written | 19 | | responses to questions regarding MCO base rates, the rate | 20 | | development
methodology, MCO rate data, and all other | 21 | | requests regarding
rates from MCOs. Upon request, the | 22 | | Department shall also provide to the MCOs materials used in | 23 | | the development of provider fee schedules. | 24 | | (b) For the development of rates for new rate years: | 25 | | (1) the Department shall take into account emerging
| 26 | | experience in the development of the annual MCO base rates,
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| 1 | | including, but not limited to, current-year cost and
| 2 | | utilization trends observed by MCOs; | 3 | | (2) no less than 6 months prior to submission of the | 4 | | new rates to the Centers for Medicare and Medicaid | 5 | | Services,
the
Department shall meet with MCOs to review | 6 | | data and the
Department's written draft assumptions to be | 7 | | used in
the development of base rates for the following | 8 | | year, and shall
provide opportunities for questions to be | 9 | | asked and
answered; | 10 | | (3) no less than 2 months prior to the submission of | 11 | | the new rates to the Centers for Medicare and Medicaid | 12 | | Services,
the
Department shall provide the MCOs with draft | 13 | | capitated base
rates and shall also conduct a draft rate | 14 | | meeting with MCOs
to discuss, review, and seek feedback | 15 | | regarding the draft
rates; and | 16 | | (4) prior to the submission of final rates to the | 17 | | Centers for
Medicare and Medicaid Services, the Department | 18 | | shall
provide the MCOs with a final actuarial report | 19 | | regarding
the final base rates for the following year and
| 20 | | subsequently conduct a final rate review meeting; final
| 21 | | rates shall be marked final. | 22 | | (c) For the development of rates reflecting policy changes: | 23 | | (1) the Department must provide advance notice to MCOs
| 24 | | of any significant policy change no later than 90 days
| 25 | | prior to the effective date of the policy change. A
| 26 | | significant policy change is defined as a change to covered
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| 1 | | benefits, payment methodology, new member population, or
| 2 | | new service area made at the discretion of the Department
| 3 | | and not required by legislation with a retroactive
| 4 | | effective date; | 5 | | (2) prior to the effective date of the policy change or
| 6 | | program implementation, the Department shall meet with the
| 7 | | MCOs regarding the initial data collection needed to
| 8 | | establish base rates for the policy change. Additionally,
| 9 | | the Department shall share with the participating MCOs what
| 10 | | other data and the processes for collection shall be
| 11 | | utilized to develop base rates; | 12 | | (3) prior to the effective date of the policy change or
| 13 | | program implementation, the Department shall meet with
| 14 | | MCOs to review data and the Department's written draft
| 15 | | assumptions to be used in the development of rates for the
| 16 | | following year, and shall provide opportunities for
| 17 | | questions to be asked and answered; and | 18 | | (4) prior to the effective date of the policy change or
| 19 | | program implementation, the Department shall provide the
| 20 | | MCOs with draft capitated base rates and shall also conduct
| 21 | | a draft rate meeting with MCOs to discuss, review, and seek
| 22 | | feedback regarding the draft rates. | 23 | | (d) For the development of rates for retroactive policy or
| 24 | | rate changes: | 25 | | (1) the Department shall meet with the MCOs regarding
| 26 | | the initial data collection needed to establish rates for
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| 1 | | the policy change. Additionally, the Department shall
| 2 | | share with the participating MCOs what other data and the
| 3 | | processes for collection shall be utilized to develop
| 4 | | rates; | 5 | | (2) the Department shall meet with MCOs to review data
| 6 | | and the Department's written draft assumptions to be used
| 7 | | in the development of rates for the following year; and | 8 | | shall
provide opportunities for questions to be asked and
| 9 | | answered; and | 10 | | (3) the Department shall provide the MCOs with draft
| 11 | | capitated rates and shall also conduct a draft rate meeting
| 12 | | with MCOs to discuss, review, and seek feedback regarding
| 13 | | the draft rates. ".
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