Illinois General Assembly - Full Text of SB1041
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Full Text of SB1041  102nd General Assembly


Sen. Ann Gillespie

Filed: 4/16/2021





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2    AMENDMENT NO. ______. Amend Senate Bill 1041 by replacing
3everything after the enacting clause with the following:
4    "Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-30.1 as follows:
6    (305 ILCS 5/5-30.1)
7    Sec. 5-30.1. Managed care protections.
8    (a) As used in this Section:
9    "Managed care organization" or "MCO" means any entity
10which contracts with the Department to provide services where
11payment for medical services is made on a capitated basis.
12    "Emergency services" include:
13        (1) emergency services, as defined by Section 10 of
14    the Managed Care Reform and Patient Rights Act;
15        (2) emergency medical screening examinations, as
16    defined by Section 10 of the Managed Care Reform and



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



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



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



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1            (C) a contracting entity representative and the
2        treating physician reach an agreement concerning the
3        enrollee's care; or
4            (D) the enrollee is discharged.
5    (f) Network adequacy and transparency.
6        (1) The Department shall:
7            (A) ensure that an adequate provider network is in
8        place, taking into consideration health professional
9        shortage areas and medically underserved areas;
10            (B) publicly release an explanation of its process
11        for analyzing network adequacy;
12            (C) periodically ensure that an MCO continues to
13        have an adequate network in place; and
14            (D) require MCOs, including Medicaid Managed Care
15        Entities as defined in Section 5-30.2, to meet
16        provider directory requirements under Section 5-30.3.
17        (2) Each MCO shall confirm its receipt of information
18    submitted specific to physician or dentist additions or
19    physician or dentist deletions from the MCO's provider
20    network within 3 days after receiving all required
21    information from contracted physicians or dentists, and
22    electronic physician and dental directories must be
23    updated consistent with current rules as published by the
24    Centers for Medicare and Medicaid Services or its
25    successor agency.
26    (g) Timely payment of claims.



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1        (1) The MCO shall pay a claim within 30 days of
2    receiving a claim that contains all the essential
3    information needed to adjudicate the claim.
4        (2) The MCO shall notify the billing party of its
5    inability to adjudicate a claim within 30 days of
6    receiving that claim.
7        (3) The MCO shall pay a penalty that is at least equal
8    to the timely payment interest penalty imposed under
9    Section 368a of the Illinois Insurance Code for any claims
10    not timely paid.
11            (A) When an MCO is required to pay a timely payment
12        interest penalty to a provider, the MCO must calculate
13        and pay the timely payment interest penalty that is
14        due to the provider within 30 days after the payment of
15        the claim. In no event shall a provider be required to
16        request or apply for payment of any owed timely
17        payment interest penalties.
18            (B) Such payments shall be reported separately
19        from the claim payment for services rendered to the
20        MCO's enrollee and clearly identified as interest
21        payments.
22        (4)(A) The Department shall require MCOs to expedite
23    payments to providers identified on the Department's
24    expedited provider list, determined in accordance with 89
25    Ill. Adm. Code 140.71(b), on a schedule at least as
26    frequently as the providers are paid under the



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1    Department's fee-for-service expedited provider schedule.
2        (B) Compliance with the expedited provider requirement
3    may be satisfied by an MCO through the use of a Periodic
4    Interim Payment (PIP) program that has been mutually
5    agreed to and documented between the MCO and the provider,
6    and the PIP program ensures that any expedited provider
7    receives regular and periodic payments based on prior
8    period payment experience from that MCO. Total payments
9    under the PIP program may be reconciled against future PIP
10    payments on a schedule mutually agreed to between the MCO
11    and the provider.
12        (C) The Department shall share at least monthly its
13    expedited provider list and the frequency with which it
14    pays providers on the expedited list.
15    (g-5) Recognizing that the rapid transformation of the
16Illinois Medicaid program may have unintended operational
17challenges for both payers and providers:
18        (1) in no instance shall a medically necessary covered
19    service rendered in good faith, based upon eligibility
20    information documented by the provider, be denied coverage
21    or diminished in payment amount if the eligibility or
22    coverage information available at the time the service was
23    rendered is later found to be inaccurate in the assignment
24    of coverage responsibility between MCOs or the
25    fee-for-service system, except for instances when an
26    individual is deemed to have not been eligible for



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1    coverage under the Illinois Medicaid program; and
2        (2) the Department shall, by December 31, 2016, adopt
3    rules establishing policies that shall be included in the
4    Medicaid managed care policy and procedures manual
5    addressing payment resolutions in situations in which a
6    provider renders services based upon information obtained
7    after verifying a patient's eligibility and coverage plan
8    through either the Department's current enrollment system
9    or a system operated by the coverage plan identified by
10    the patient presenting for services:
11            (A) such medically necessary covered services
12        shall be considered rendered in good faith;
13            (B) such policies and procedures shall be
14        developed in consultation with industry
15        representatives of the Medicaid managed care health
16        plans and representatives of provider associations
17        representing the majority of providers within the
18        identified provider industry; and
19            (C) such rules shall be published for a review and
20        comment period of no less than 30 days on the
21        Department's website with final rules remaining
22        available on the Department's website.
23    The rules on payment resolutions shall include, but not be
24limited to:
25        (A) the extension of the timely filing period;
26        (B) retroactive prior authorizations; and



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



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1        (3) The metrics shall be developed in consultation
2    with industry representatives of the Medicaid managed care
3    health plans and representatives of associations
4    representing the majority of providers within the
5    identified industry.
6        (4) Metrics shall be defined and incorporated into the
7    applicable Managed Care Policy Manual issued by the
8    Department.
9    (g-7) MCO claims processing and performance analysis. In
10order to monitor MCO payments to hospital providers, pursuant
11to this amendatory Act of the 100th General Assembly, the
12Department shall post an analysis of MCO claims processing and
13payment performance on its website every 6 months. Such
14analysis shall include a review and evaluation of a
15representative sample of hospital claims that are rejected and
16denied for clean and unclean claims and the top 5 reasons for
17such actions and timeliness of claims adjudication, which
18identifies the percentage of claims adjudicated within 30, 60,
1990, and over 90 days, and the dollar amounts associated with
20those claims. The Department shall post the contracted claims
21report required by HealthChoice Illinois on its website every
223 months.
23    (g-8) Dispute resolution process. The Department shall
24maintain a provider complaint portal through which a provider
25can submit to the Department unresolved disputes with an MCO.
26An unresolved dispute means an MCO's decision that denies in



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1whole or in part a claim for reimbursement to a provider for
2health care services rendered by the provider to an enrollee
3of the MCO with which the provider disagrees. Disputes shall
4not be submitted to the portal until the provider has availed
5itself of the MCO's internal dispute resolution process.
6Disputes that are submitted to the MCO internal dispute
7resolution process may be submitted to the Department of
8Healthcare and Family Services' complaint portal no sooner
9than 30 days after submitting to the MCO's internal process
10and not later than 30 days after the unsatisfactory resolution
11of the internal MCO process or 60 days after submitting the
12dispute to the MCO internal process. Multiple claim disputes
13involving the same MCO may be submitted in one complaint,
14regardless of whether the claims are for different enrollees,
15when the specific reason for non-payment of the claims
16involves a common question of fact or policy. Within 10
17business days of receipt of a complaint, the Department shall
18present such disputes to the appropriate MCO, which shall then
19have 30 days to issue its written proposal to resolve the
20dispute. The Department may grant one 30-day extension of this
21time frame to one of the parties to resolve the dispute. If the
22dispute remains unresolved at the end of this time frame or the
23provider is not satisfied with the MCO's written proposal to
24resolve the dispute, the provider may, within 30 days, request
25the Department to review the dispute and make a final
26determination. Within 30 days of the request for Department



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1review of the dispute, both the provider and the MCO shall
2present all relevant information to the Department for
3resolution and make individuals with knowledge of the issues
4available to the Department for further inquiry if needed.
5Within 30 days of receiving the relevant information on the
6dispute, or the lapse of the period for submitting such
7information, the Department shall issue a written decision on
8the dispute based on contractual terms between the provider
9and the MCO, contractual terms between the MCO and the
10Department of Healthcare and Family Services and applicable
11Medicaid policy. The decision of the Department shall be
12final. By January 1, 2020, the Department shall establish by
13rule further details of this dispute resolution process.
14Disputes between MCOs and providers presented to the
15Department for resolution are not contested cases, as defined
16in Section 1-30 of the Illinois Administrative Procedure Act,
17conferring any right to an administrative hearing.
18    (g-9)(1) The Department shall publish annually on its
19website a report on the calculation of each managed care
20organization's medical loss ratio showing the following:
21        (A) Premium revenue, with appropriate adjustments.
22        (B) Benefit expense, setting forth the aggregate
23    amount spent for the following:
24            (i) Direct paid claims.
25            (ii) Subcapitation payments.
26            (iii) Other claim payments.



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1            (iv) Direct reserves.
2            (v) Gross recoveries.
3            (vi) Expenses for activities that improve health
4        care quality as allowed by the Department.
5    (2) The medical loss ratio shall be calculated consistent
6with federal law and regulation following a claims runout
7period determined by the Department.
8    (g-10)(1) "Liability effective date" means the date on
9which an MCO becomes responsible for payment for medically
10necessary and covered services rendered by a provider to one
11of its enrollees in accordance with the contract terms between
12the MCO and the provider. The liability effective date shall
13be the later of:
14        (A) The execution date of a network participation
15    contract agreement.
16        (B) The date the provider or its representative
17    submits to the MCO the complete and accurate standardized
18    roster form for the provider in the format approved by the
19    Department.
20        (C) The provider effective date contained within the
21    Department's provider enrollment subsystem within the
22    Illinois Medicaid Program Advanced Cloud Technology
23    (IMPACT) System.
24    (2) The standardized roster form may be submitted to the
25MCO at the same time that the provider submits an enrollment
26application to the Department through IMPACT.



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1    (3) By October 1, 2019, the Department shall require all
2MCOs to update their provider directory with information for
3new practitioners of existing contracted providers within 30
4days of receipt of a complete and accurate standardized roster
5template in the format approved by the Department provided
6that the provider is effective in the Department's provider
7enrollment subsystem within the IMPACT system. Such provider
8directory shall be readily accessible for purposes of
9selecting an approved health care provider and comply with all
10other federal and State requirements.
11    (g-11) The Department shall work with relevant
12stakeholders on the development of operational guidelines to
13enhance and improve operational performance of Illinois'
14Medicaid managed care program, including, but not limited to,
15improving provider billing practices, reducing claim
16rejections and inappropriate payment denials, and
17standardizing processes, procedures, definitions, and response
18timelines, with the goal of reducing provider and MCO
19administrative burdens and conflict. The Department shall
20include a report on the progress of these program improvements
21and other topics in its Fiscal Year 2020 annual report to the
22General Assembly.
23    (h) The Department shall not expand mandatory MCO
24enrollment into new counties beyond those counties already
25designated by the Department as of June 1, 2014 for the
26individuals whose eligibility for medical assistance is not



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1the seniors or people with disabilities population until the
2Department provides an opportunity for accountable care
3entities and MCOs to participate in such newly designated
5    (i) The requirements of this Section apply to contracts
6with accountable care entities and MCOs entered into, amended,
7or renewed after June 16, 2014 (the effective date of Public
8Act 98-651).
9    (j) Health care information released to managed care
10organizations. A health care provider shall release to a
11Medicaid managed care organization, upon request, and subject
12to the Health Insurance Portability and Accountability Act of
131996 and any other law applicable to the release of health
14information, the health care information of the MCO's
15enrollee, if the enrollee has completed and signed a general
16release form that grants to the health care provider
17permission to release the recipient's health care information
18to the recipient's insurance carrier.
19(Source: P.A. 100-201, eff. 8-18-17; 100-580, eff. 3-12-18;
20100-587, eff. 6-4-18; 101-209, eff. 8-5-19.)
21    Section 99. Effective date. This Act takes effect upon
22becoming law.".