(305 ILCS 5/5-30.3) Sec. 5-30.3. Empowering meaningful patient choice in Medicaid Managed Care. (a) Definitions. As used in this Section: "Client enrollment services broker" means a vendor the Department contracts with to carry out activities related to Medicaid recipients' enrollment, disenrollment, and renewal with Medicaid Managed Care Entities. "Composite domains" means the synthesized categories reflecting the standardized quality performance measures included in the consumer quality comparison tool. At a minimum, these composite domains shall display Medicaid Managed Care Entities' individual Plan performance on standardized quality, timeliness, and access measures. "Consumer quality comparison tool" means an online and paper tool developed by the Department with input from interested stakeholders reflecting the performance of Medicaid Managed Care Entity Plans on standardized quality performance measures. This tool shall be designed in a consumer-friendly and easily understandable format. "Covered services" means those health care services to which a covered person is entitled to under the terms of the Medicaid Managed Care Entity Plan. "Facilities" includes, but is not limited to, federally qualified health centers, skilled nursing facilities, and rehabilitation centers. "Hospitals" includes, but is not limited to, acute care, rehabilitation, children's, and cancer hospitals. "Integrated provider directory" means a searchable database bringing together network data from multiple Medicaid Managed Care Entities that is available through client enrollment services. "Medicaid eligibility redetermination" means the process by which the eligibility of a Medicaid recipient is reviewed by the Department to determine if the recipient's medical benefits will continue, be modified, or terminated. "Medicaid Managed Care Entity" has the same meaning as defined in Section 5-30.2 of this Code. (b) Provider directory transparency. (1) Each Medicaid Managed Care Entity shall: (A) Make available on the entity's website a |
| provider directory in a machine readable file and format.
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(B) Make provider directories publicly accessible
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| without the necessity of providing a password, a username, or personally identifiable information.
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(C) Comply with all federal and State statutes
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| and regulations, including 42 CFR 438.10, pertaining to provider directories within Medicaid Managed Care.
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(D) Request, at least annually, provider office
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| hours for each of the following provider types:
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(i) Health care professionals, including
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| dental and vision providers.
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(ii) Hospitals.
(iii) Facilities, other than hospitals.
(iv) Pharmacies, other than hospitals.
(v) Durable medical equipment suppliers,
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Medicaid Managed Care Entities shall publish the
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| provider office hours in the provider directory upon receipt.
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(E) Confirm with the Medicaid Managed Care
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| Entity's contracted providers who have not submitted claims within the past 6 months that the contracted providers intend to remain in the network and correct any incorrect provider directory information as necessary.
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(F) Ensure that in situations in which a Medicaid
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| Managed Care Entity Plan enrollee receives covered services from a non-participating provider due to a material misrepresentation in a Medicaid Managed Care Entity's online electronic provider directory, the Medicaid Managed Care Entity Plan enrollee shall not be held responsible for any costs resulting from that material misrepresentation.
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(G) Conspicuously display an e-mail address and a
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| toll-free telephone number to which any individual may report any inaccuracy in the provider directory. If the Medicaid Managed Care Entity receives a report from any person who specifically identifies provider directory information as inaccurate, the Medicaid Managed Care Entity shall investigate the report and correct any inaccurate information displayed in the electronic directory.
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(2) The Department shall:
(A) Regularly monitor Medicaid Managed Care
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| Entities to ensure that they are compliant with the requirements under paragraph (1) of subsection (b).
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(B) Require that the client enrollment services
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| broker use the Medicaid provider number for all providers with a Medicaid Provider number to populate the provider information in the integrated provider directory.
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(C) Ensure that each Medicaid Managed Care Entity
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| shall, at minimum, make the information in subparagraph (D) of paragraph (1) of subsection (b) available to the client enrollment services broker.
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(D) Ensure that the client enrollment services
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| broker shall, at minimum, have the information in subparagraph (D) of paragraph (1) of subsection (b) available and searchable through the integrated provider directory on its website as soon as possible but no later than January 1, 2017.
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(E) Require the client enrollment services broker
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| to conspicuously display near the integrated provider directory an email address and a toll-free telephone number provided by the Department to which any individual may report inaccuracies in the integrated provider directory. If the Department receives a report that identifies an inaccuracy in the integrated provider directory, the Department shall provide the information about the reported inaccuracy to the appropriate Medicaid Managed Care Entity within 3 business days after the reported inaccuracy is received.
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(c) Formulary transparency.
(1) Medicaid Managed Care Entities shall publish on
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| their respective websites a formulary for each Medicaid Managed Care Entity Plan offered and make the formularies easily understandable and publicly accessible without the necessity of providing a password, a username, or personally identifiable information.
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(2) Medicaid Managed Care Entities shall provide
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| printed formularies upon request.
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(3) Electronic and print formularies shall display:
(A) the medications covered (both generic and
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(B) if the medication is preferred or not
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| preferred, and what each term means;
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(C) what tier each medication is in and the
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(D) any utilization controls including, but not
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| limited to, step therapy, prior approval, dosage limits, gender or age restrictions, quantity limits, or other policies that affect access to medications;
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(E) any required cost-sharing;
(F) a glossary of key terms and explanation of
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| utilization controls and cost-sharing requirements;
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(G) a key or legend for all utilization controls
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| visible on every page in which specific medication coverage information is displayed; and
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(H) directions explaining the process or
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| processes a consumer may follow to obtain more information if a medication the consumer requires is not covered or listed in the formulary.
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(4) Each Medicaid Managed Care Entity shall display
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| conspicuously with each electronic and printed medication formulary an e-mail address and a toll-free telephone number to which any individual may report any inaccuracy in the formulary. If the Medicaid Managed Care Entity receives a report that the formulary information is inaccurate, the Medicaid Managed Care Entity shall investigate the report and correct any inaccurate information displayed in the electronic formulary.
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(5) Each Medicaid Managed Care Entity shall include a
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| disclosure in the electronic and requested print formularies that provides the date of publication, a statement that the formulary is up to date as of publication, and contact information for questions and requests to receive updated information.
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(6) The client enrollment services broker's website
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| shall display prominently a website URL link to each Medicaid Managed Care Entity's Plan formulary. If a Medicaid enrollee calls the client enrollment services broker with questions regarding formularies, the client enrollment services broker shall offer a brief description of what a formulary is and shall refer the Medicaid enrollee to the appropriate Medicaid Managed Care Entity regarding his or her questions about a specific entity's formulary.
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(d) Grievances and appeals. The Department shall display prominently on its website consumer-oriented information describing how a Medicaid enrollee can file a complaint or grievance, request a fair hearing for any adverse action taken by the Department or a Medicaid Managed Care Entity, and access free legal assistance or other assistance made available by the State for Medicaid enrollees to pursue an action.
(e) Medicaid redetermination information.
The Department shall require the client enrollment services broker to display prominently on the client enrollment services broker's website a description of where a Medicaid enrollee can access information regarding the Medicaid redetermination process.
(f) Medicaid care coordination information. The client enrollment services broker shall display prominently on its website, in an easily understandable format, consumer-oriented information regarding the role of care coordination services within Medicaid Managed Care. Such information shall include, but shall not be limited to:
(1) a basic description of the role of care
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| coordination services and examples of specific care coordination activities; and
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(2) how a Medicaid enrollee may request care
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| coordination services from a Medicaid Managed Care Entity.
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(g) Consumer quality comparison tool.
(1) The Department shall create a consumer quality
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| comparison tool to assist Medicaid enrollees with Medicaid Managed Care Entity Plan selection. This tool shall provide Medicaid Managed Care Entities' individual Plan performance on a set of standardized quality performance measures. The Department shall ensure that this tool shall be accessible in both a print and online format, with the online format allowing for individuals to access additional detailed Plan performance information.
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(2) At a minimum, a printed version of the consumer
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| quality comparison tool shall be provided by the Department on an annual basis to Medicaid enrollees who are required by the Department to enroll in a Medicaid Managed Care Entity Plan during an enrollee's open enrollment period. The consumer quality comparison tool shall also meet all of the following criteria:
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(A) Display Medicaid Managed Care Entities'
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| individual Plan performance on at least 4 composite domains that reflect Plan quality, timeliness, and access. The composite domains shall draw from the most current available performance data sets including, but not limited to:
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(i) Healthcare Effectiveness Data and
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| Information Set (HEDIS) measures.
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(ii) Core Set of Children's Health Care
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| Quality measures as required under the Children's Health Insurance Program Reauthorization Act (CHIPRA).
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(iii) Adult Core Set measures.
(iv) Consumer Assessment of Healthcare
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| Providers and Systems (CAHPS) survey results.
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(v) Additional performance measures the
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| Department deems appropriate to populate the composite domains.
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(B) Use a quality rating system developed by the
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| Department to reflect Medicaid Managed Care Entities' individual Plan performance. The quality rating system for each composite domain shall reflect the Medicaid Managed Care Entities' individual Plan performance and, when possible, plan performance relative to national Medicaid percentiles.
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(C) Be customized to reflect the specific
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| Medicaid Managed Care Entities' Plans available to the Medicaid enrollee based on his or her geographic location and Medicaid eligibility category.
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(D) Include contact information for the client
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| enrollment services broker and contact information for Medicaid Managed Care Entities available to the Medicaid enrollee based on his or her geographic location and Medicaid eligibility category.
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(E) Include guiding questions designed to assist
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| individuals selecting a Medicaid Managed Care Entity Plan.
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(3) At a minimum, the online version of the consumer
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| quality comparison tool shall meet all of the following criteria:
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(A) Display Medicaid Managed Care Entities'
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| individual Plan performance for the same composite domains selected by the Department in the printed version of the consumer quality comparison tool. The Department may display additional composite domains in the online version of the consumer quality comparison tool as appropriate.
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(B) Display Medicaid Managed Care Entities'
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| individual Plan performance on each of the standardized performance measures that contribute to each composite domain displayed on the online version of the consumer quality comparison tool.
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(C) Use a quality rating system developed by the
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| Department to reflect Medicaid Managed Care Entities' individual Plan performance. The quality rating system for each composite domain shall reflect the Medicaid Managed Care Entities' individual Plan performance and, when possible, plan performance relative to national Medicaid percentiles.
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(D) Include the specific Medicaid Managed Care
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| Entity Plans available to the Medicaid enrollee based on his or her geographic location and Medicaid eligibility category.
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(E) Include a sort function to view Medicaid
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| Managed Care Entities' individual Plan performance by quality rating and by standardized quality performance measures.
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(F) Include contact information for the client
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| enrollment services broker and for each Medicaid Managed Care Entity.
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(G) Include guiding questions designed to assist
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| individuals in selecting a Medicaid Managed Care Entity Plan.
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(H) Prominently display current notice of quality
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| performance sanctions against Medicaid Managed Care Entities. Notice of the sanctions shall remain present on the online version of the consumer quality comparison tool until the sanctions are lifted.
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(4) The online version of the consumer quality
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| comparison tool shall be displayed prominently on the client enrollment services broker's website.
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(5) In the development of the consumer quality
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| comparison tool, the Department shall establish and publicize a formal process to collect and consider written and oral feedback from consumers, advocates, and stakeholders on aspects of the consumer quality comparison tool, including, but not limited to, the following:
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(A) The standardized data sets and surveys,
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| specific performance measures, and composite domains represented in the consumer quality comparison tool.
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(B) The format and presentation of the consumer
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(C) The methods undertaken by the Department to
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| notify Medicaid enrollees of the availability of the consumer quality comparison tool.
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(6) The Department shall review and update as
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| appropriate the composite domains and performance measures represented in the print and online versions of the consumer quality comparison tool at least once every 3 years. During the Department's review process, the Department shall solicit engagement in the public feedback process described in paragraph (5).
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(7) The Department shall ensure that the consumer
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| quality comparison tool is available for consumer use as soon as possible but no later than January 1, 2018.
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(h)
The Department may adopt rules and take any other appropriate action necessary to implement its responsibilities under this Section.
(Source: P.A. 99-725, eff. 8-5-16; 100-201, eff. 8-18-17.)
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(305 ILCS 5/5-30.8) Sec. 5-30.8. Managed care organization rate transparency. (a) For the establishment of managed care
organization (MCO) capitation base rate payments from the State,
including, but not limited to: (i) hospital fee schedule
reforms and updates, (ii) rates related to a single
State-mandated preferred drug list, (iii) rate updates related
to the State's preferred drug list, (iv) inclusion of coverage
for children with special needs, (v) inclusion of coverage for
children within the child welfare system, (vi) annual MCO
capitation rates, and (vii) any retroactive provider fee
schedule adjustments or other changes required by legislation
or other actions, the Department of Healthcare and Family
Services shall implement a capitation base rate setting process beginning
on July 27, 2018 (the effective date of Public Act 100-646) which shall include all of the following
elements of transparency: (1) The Department shall include participating |
| MCOs and a statewide trade association representing a majority of participating MCOs in meetings to discuss the impact to base capitation rates as a result of any new or updated hospital fee schedules or other provider fee schedules. Additionally, the Department shall share any data or reports used to develop MCO capitation rates with participating MCOs. This data shall be comprehensive enough for MCO actuaries to recreate and verify the accuracy of the capitation base rate build-up.
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(2) The Department shall not limit the number of
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| experts that each MCO is allowed to bring to the draft capitation base rate meeting or the final capitation base rate review meeting. Draft and final capitation base rate review meetings shall be held in at least 2 locations.
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(3) The Department and its contracted actuary shall
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| meet with all participating MCOs simultaneously and together along with consulting actuaries contracted with statewide trade association representing a majority of Medicaid health plans at the request of the plans. Participating MCOs shall additionally, at their request, be granted individual capitation rate development meetings with the Department.
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(4) (Blank).
(4.5) Effective for calendar year 2024, a quality
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| withhold program may be established by the Department for the HealthChoice Illinois Managed Care Program or any successor program. If such program withholds a portion of the actuarially certified capitation rates, the program must meet the following criteria: (i) benchmarks must be discussed publicly, based on predetermined quality standards that align with the Department's federally approved quality strategy, and set by publication on the Department's website at least 4 months prior to the start of the calendar year; (ii) incentive measures and benchmarks must be reasonable and attainable within the measurement year; and (iii) no less than 75% of the metrics shall be tied to nationally recognized measures. Any non-nationally recognized measures shall be in the reporting category for at least 2 years of experience and evaluation for consistency among MCOs prior to setting a performance baseline. The Department shall provide MCOs with biannual industry average data on the quality withhold measures. If all the money withheld is not earned back by individual MCOs, the Department shall reallocate unearned funds among the MCOs in one or both of the following manners: based upon their quality performance or for quality and equity improvement projects. Nothing in this paragraph prohibits the Department and the MCOs from establishing any other quality performance program.
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(5) Upon request, the Department shall
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| provide written responses to questions regarding MCO capitation base rates, the capitation base development methodology, and MCO capitation rate data, and all other requests regarding capitation rates from MCOs. Upon request, the Department shall also provide to the MCOs materials used in incorporating provider fee schedules into base capitation rates.
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(b) For the development of capitation base rates for new capitation rate years:
(1) The Department shall take into account emerging
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| experience in the development of the annual MCO capitation base rates, including, but not limited to, current-year cost and utilization trends observed by MCOs in an actuarially sound manner and in accordance with federal law and regulations.
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(2) No later than January 1 of each year, the
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| Department shall release an agreed upon annual calendar that outlines dates for capitation rate setting meetings for that year. The calendar shall include at least the following meetings and deadlines:
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(A) An initial meeting for the Department to
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| review MCO data and draft rate assumptions to be used in the development of capitation base rates for the following year.
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(B) A draft rate meeting after the Department
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| provides the MCOs with the draft capitation base rates to discuss, review, and seek feedback regarding the draft capitation base rates.
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(3) Prior to the submission of final capitation
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| rates to the federal Centers for Medicare and Medicaid Services, the Department shall provide the MCOs with a final actuarial report including the final capitation base rates for the following year and subsequently conduct a final capitation base review meeting. Final capitation rates shall be marked final.
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(c) For the development of capitation base rates reflecting policy changes:
(1) Unless contrary to federal law and regulation,
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| the Department must provide notice to MCOs of any significant operational policy change no later than 60 days prior to the effective date of an operational policy change in order to give MCOs time to prepare for and implement the operational policy change and to ensure that the quality and delivery of enrollee health care is not disrupted. "Operational policy change" means a change to operational requirements such as reporting formats, encounter submission definitional changes, or required provider interfaces made at the sole discretion of the Department and not required by legislation with a retroactive effective date. Nothing in this Section shall be construed as a requirement to delay or prohibit implementation of policy changes that impact enrollee benefits as determined in the sole discretion of the Department.
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(2) No later than 60 days after the effective
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| date of the policy change or program implementation, the Department shall meet with the MCOs regarding the initial data collection needed to establish capitation base rates for the policy change. Additionally, the Department shall share with the participating MCOs what other data is needed to estimate the change and the processes for collection of that data that shall be utilized to develop capitation base rates.
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(3) No later than 60 days after the effective date of
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| the policy change or program implementation, the Department shall meet with MCOs to review data and the Department's written draft assumptions to be used in development of capitation base rates for the policy change, and shall provide opportunities for questions to be asked and answered.
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(4) No later than 60 days after the effective
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| date of the policy change or program implementation, the Department shall provide the MCOs with draft capitation base rates and shall also conduct a draft capitation base rate meeting with MCOs to discuss, review, and seek feedback regarding the draft capitation base rates.
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(d) For the development of capitation base rates for retroactive policy or
fee schedule changes:
(1) The Department shall meet with the MCOs regarding
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| the initial data collection needed to establish capitation base rates for the policy change. Additionally, the Department shall share with the participating MCOs what other data is needed to estimate the change and the processes for collection of the data that shall be utilized to develop capitation base rates.
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(2) The Department shall meet with MCOs to review
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| data and the Department's written draft assumptions to be used in development of capitation base rates for the policy change. The Department shall provide opportunities for questions to be asked and answered.
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(3) The Department shall provide the MCOs with draft
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| capitation rates and shall also conduct a draft rate meeting with MCOs to discuss, review, and seek feedback regarding the draft capitation base rates.
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(4) The Department shall inform MCOs no less than
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| quarterly of upcoming benefit and policy changes to the Medicaid program.
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(e) Meetings of the group established to discuss Medicaid capitation rates under this Section shall be closed to the public and shall not be subject to the Open Meetings Act. Records and information produced by the group established to discuss Medicaid capitation rates under this Section shall be confidential and not subject to the Freedom of Information Act.
(Source: P.A. 103-102, eff. 1-1-24 .)
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(305 ILCS 5/5-30.16) Sec. 5-30.16. Medicaid Business Opportunity Commission. (a) The Medicaid Business Opportunity Commission is
created within the Department of Healthcare and Family Services
to develop a program to support and grow minority, women, and persons with disability owned businesses. (b) The Commission shall consist of the following members: (1) Two members appointed by the Illinois Legislative |
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(2) Two members appointed by the Illinois Legislative
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(3) Two members appointed by the Conference of Women
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| Legislators of the Illinois General Assembly.
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(4) Two members representing a statewide Medicaid
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| health plan association, appointed by the Governor.
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(5) One member representing the Department of
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| Healthcare and Family Services, appointed by the Governor.
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(6) Three members representing businesses currently
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| registered with the Business Enterprise Program, appointed by the Governor.
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(7) One member representing the disability
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| community, appointed by the Governor.
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(8) One member representing the Business Enterprise
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| Council, appointed by the Governor.
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(c) The Director of Healthcare and Family Services and chief of staff, or their designees, shall serve as the Commission's executive administrators in providing administrative support, research support, and other administrative tasks requested by the Commission's co-chairs. Any expenses, including, but not limited to, travel and housing, shall be paid for by the Department's existing budget.
(d) The members of the Commission shall receive no compensation for their services as members of the Commission.
(e) The members of the Commission shall designate co-chairs of the Commission to lead their efforts at the first meeting of the Commission.
(f) The Commission shall meet at least monthly beginning as soon as is practicable after the effective date of this amendatory Act of the 102nd General Assembly.
(g) The Commission shall:
(1) Develop a recommendation on a Medicaid Business
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| Opportunity Program for Minority, Women, and Persons with Disability Owned business contracting requirements to be included in the contracts between the Department of Healthcare and Family Services and the Managed Care entities for the provision of Medicaid Services.
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(2) Make recommendations on the process by which
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| vendors or providers would be certified as eligible to be included in the program and appropriate eligibility standards relative to the healthcare industry.
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(3) Make a recommendation on whether to include not
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| for profit organizations, diversity councils, or diversity chambers as eligible for certification.
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(4) Make a recommendation on whether diverse staff
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| shall be considered within the goals set for managed care entities.
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(5) Make a recommendation on whether a new platform
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| for certification is necessary to administer this program or if the existing platform for the Business Enterprise Program is capable of including recommended changes coming from this Commission.
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(6) Make a recommendation on the ongoing activity of
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| the Commission including structure, frequency of meetings, and agendas to ensure ongoing oversight of the program by the Commission.
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(h) The Commission shall provide recommendations to the Department and the General assembly by April 15, 2021 in order to ensure prompt implementation of the Medicaid Business Opportunity Program.
(i) Beginning January 1, 2022, and for each year thereafter, the Commission shall submit a report of its findings and recommendations to the General Assembly. The report to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.
(Source: P.A. 102-4, eff. 4-27-21.)
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(305 ILCS 5/5-30.17) Sec. 5-30.17. Medicaid Managed Care Oversight Commission. (a) The Medicaid Managed Care Oversight Commission is created within the Department of Healthcare and Family Services to evaluate the effectiveness of Illinois' managed care program. (b) The Commission shall consist of the following members: (1) One member of the Senate, appointed by the |
| Senate President, who shall serve as co-chair.
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(2) One member of the House of Representatives,
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| appointed by the Speaker of the House of Representatives, who shall serve as co-chair.
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(3) One member of the House of Representatives,
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| appointed by the Minority Leader of the House of Representatives.
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(4) One member of the Senate, appointed by the
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(5) One member representing the Department of
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| Healthcare and Family Services, appointed by the Governor.
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(6) One member representing the Department of
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| Public Health, appointed by the Governor.
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(7) One member representing the Department of Human
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| Services, appointed by the Governor.
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(8) One member representing the Department of
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| Children and Family Services, appointed by the Governor.
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(9) One member of a statewide association
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| representing Medicaid managed care plans, appointed by the Governor.
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(10) One member of a statewide association
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| representing a majority of hospitals, appointed by the Governor.
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(11) Two academic experts on Medicaid managed care
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| programs, appointed by the Governor.
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(12) One member of a statewide association
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| representing primary care providers, appointed by the Governor.
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(13) One member of a statewide association
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| representing behavioral health providers, appointed by the Governor.
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(14) Members representing Federally Qualified Health
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| Centers, a long-term care association, a dental association, pharmacies, pharmacists, a developmental disability association, a Medicaid consumer advocate, a Medicaid consumer, an association representing physicians, a behavioral health association, and an association representing pediatricians, appointed by the Governor.
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(15) A member of a statewide association representing
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| only safety-net hospitals, appointed by the Governor.
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(c) The Director of Healthcare and Family Services and chief of staff, or their designees, shall serve as the Commission's executive administrators in providing administrative support, research support, and other administrative tasks requested by the Commission's co-chairs. Any expenses, including, but not limited to, travel and housing, shall be paid for by the Department's existing budget.
(d) The members of the Commission shall receive no compensation for their services as members of the Commission.
(e) The Commission shall meet quarterly beginning as soon as is practicable after the effective date of this amendatory Act of the 102nd General Assembly.
(f) The Commission shall:
(1) review data on health outcomes of Medicaid
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(2) review current care coordination and case
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| management efforts and make recommendations on expanding care coordination to additional populations with a focus on the social determinants of health;
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(3) review and assess the appropriateness of
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| metrics used in the Pay-for-Performance programs;
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(4) review the Department's prior authorization and
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| utilization management requirements and recommend adaptations for the Medicaid population;
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(5) review managed care performance in meeting
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| diversity contracting goals and the use of funds dedicated to meeting such goals, including, but not limited to, contracting requirements set forth in the Business Enterprise for Minorities, Women, and Persons with Disabilities Act; recommend strategies to increase compliance with diversity contracting goals in collaboration with the Chief Procurement Officer for General Services and the Business Enterprise Council for Minorities, Women, and Persons with Disabilities; and recoup any misappropriated funds for diversity contracting;
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(6) review data on the effectiveness of
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| processing to medical providers;
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(7) review member access to health care services in
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| the Medicaid Program, including specialty care services;
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(8) review value-based and other alternative
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| payment methodologies to make recommendations to enhance program efficiency and improve health outcomes;
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(9) review the compliance of all managed care
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| entities in State contracts and recommend reasonable financial penalties for any noncompliance;
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(10) produce an annual report detailing the
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| Commission's findings based upon its review of research conducted under this Section, including specific recommendations, if any, and any other information the Commission may deem proper in furtherance of its duties under this Section;
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(11) review provider availability and make
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| recommendations to increase providers where needed, including reviewing the regulatory environment and making recommendations for reforms;
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(12) review capacity for culturally competent
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| services, including translation services among providers; and
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(13) review and recommend changes to the safety-net
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| hospital definition to create different classifications of safety-net hospitals.
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(f-5) The Department shall make available upon request the analytics of Medicaid managed care clearinghouse data regarding processing.
(g) Beginning January 1, 2022, and for each year thereafter, the Commission shall submit a report of its findings and recommendations to the General Assembly. The report to the General Assembly shall be filed with the Clerk of the House of Representatives and the Secretary of the Senate in electronic form only, in the manner that the Clerk and the Secretary shall direct.
(Source: P.A. 102-4, eff. 4-27-21.)
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(305 ILCS 5/5-30.18) (Section scheduled to be repealed on December 31, 2030) Sec. 5-30.18. Service authorization program performance. (a) Definitions. As used in this Section: "Gold Card provider" means a provider identified by each Medicaid Managed Care Organization (MCO) as qualified under the guidelines outlined by the Department in accordance with subsection (c) and thereby granted a service authorization exemption when ordering a health care service. "Health care service" means any medical or behavioral health service covered under the medical assistance program that is rendered in the inpatient or outpatient hospital setting, including hospital-based clinics, and subject to review under a service authorization program. "Provider" means an individual actively enrolled in the medical assistance program and licensed or otherwise authorized to order, prescribe, refer, or render health care services in this State, and, as determined by the Department, may also include hospitals that submit service authorization requests. "Service authorization exemption" means an exception granted by a Medicaid MCO to a provider under which all service authorization requests for covered health care services, excluding pharmacy services and durable medical equipment, are automatically deemed to be medically necessary, clinically appropriate, and approved for reimbursement as ordered. "Service authorization program" means any utilization review, utilization management, peer review, quality review, or other medical management activity conducted in advance of, concurrent to, or after the provision of a health care service by a Medicaid MCO, either directly or through a contracted utilization review organization (URO), including, but not limited to, prior authorization, pre-certification, certification of admission, concurrent review, and retrospective review of health care services. "Service authorization request" means a request by a provider to a service authorization program to determine whether a health care service that is otherwise covered under the medical assistance program meets the reimbursement requirements established by the Medicaid MCO, or its contracted URO, for medically necessary, clinically appropriate care and to issue a service authorization determination. "Utilization review organization" or "URO" means a managed care organization or other entity that has established or administers one or more service authorization programs. (b) In consultation with the Medicaid MCOs, a statewide association representing managed care organizations, a statewide association representing the majority of Illinois hospitals, and a statewide association representing physicians, the Department shall in accordance with the Illinois Administrative Procedure Act, adopt administrative rules, consistent with this Section, to require each Medicaid MCO to identify Gold Card providers with such identification initially being effective for health care services provided on and after July 1, 2025. (c) The Department shall adopt rules, in accordance with the Illinois Administrative Procedure Act, to implement this Section that include, but are not limited to, the following provisions: (1) Require each Medicaid MCO to provide a service |
| authorization exemption to a provider if the provider has submitted at least 50 service authorization requests to its service authorization program in the preceding calendar year and the service authorization program approved at least 90% of all service authorization requests, regardless of the type of health care services requested.
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(2) Require that service authorization exemptions be
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| limited to services provided in an inpatient or outpatient hospital setting inclusive of hospital-based clinics. Service authorization exemptions under this Section shall not pertain to pharmacy services and durable medical equipment and supplies.
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(3) The service authorization exemption shall be
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| valid for at least one year, shall be made by each Medicaid MCO or its URO, and shall be binding on the Medicaid MCO and its URO.
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(4) The provider shall be required to continue to
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| document medically necessary, clinically appropriate care and submit such documentation to the Medicaid MCO for the purpose of continuous performance monitoring. If a provider fails to maintain the 90% service authorization standard, as determined on no more frequent a basis than bi-annually, the provider's service authorization exemption is subject to temporary or permanent suspension.
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(5) Require that each Medicaid MCO publish on its
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| provider portal a list of all providers that have qualified for a service authorization exemption or indicate that a provider has qualified for a service authorization exemption on its provider-facing provider roster.
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(6) Require that no later than December 1 of each
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| calendar year, each Medicaid MCO shall provide written notification to all providers who qualify for a service authorization exemption, for the subsequent calendar year.
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(7) Require that each Medicaid MCO or its URO use the
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| policies and guidelines published by the Department to evaluate whether a provider meets the criteria to qualify for a service authorization exemption and the conditions under which a service authorization exemption may be rescinded, including review of the provider's service authorization determinations during the preceding calendar year.
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(8) Require each Medicaid MCO to provide the
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| Department a list of all providers who were denied a service authorization exemption or had a previously granted service authorization exemption suspended, with such denials being subject to an annual audit conducted by an independent third-party URO to ensure their appropriateness.
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(A) The independent third-party URO shall issue a
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| written report consistent with this paragraph.
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(B) The independent third-party URO shall not be
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| owned by, affiliated with, or employed by any Medicaid MCO or its contracted URO, nor shall it have any financial interest in the Medicaid MCO's service authorization exemption program.
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(d) Each Medicaid MCO must have a standard method to accept and process professional claims and facility claims, as billed by the provider, for a health care service that is rendered, prescribed, or ordered by a provider granted a service authorization exemption, except in cases of fraud.
(e) A service authorization program shall not deny, partially deny, reduce the level of care, or otherwise limit reimbursement to the rendering or supervising provider, including the rendering facility, for health care services ordered by a provider who qualifies for a service authorization exemption, except in cases of fraud.
(f) This Section is repealed on December 31, 2030.
(Source: P.A. 103-593, eff. 6-7-24.)
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(305 ILCS 5/5-36) Sec. 5-36. Pharmacy benefits. (a)(1) The Department may enter into a contract with a third party on a fee-for-service reimbursement model for the purpose of administering pharmacy benefits as provided in this Section for members not enrolled in a Medicaid managed care organization; however, these services shall be approved by the Department. The Department shall ensure coordination of care between the third-party administrator and managed care organizations as a consideration in any contracts established in accordance with this Section. Any managed care techniques, principles, or administration of benefits utilized in accordance with this subsection shall comply with State law. (2) The following shall apply to contracts between entities contracting relating to the Department's third-party administrators and pharmacies: (A) the Department shall approve any contract between |
| a third-party administrator and a pharmacy;
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(B) the Department's third-party administrator shall
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| not change the terms of a contract between a third-party administrator and a pharmacy without written approval by the Department; and
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(C) the Department's third-party administrator shall
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| not create, modify, implement, or indirectly establish any fee on a pharmacy, pharmacist, or a recipient of medical assistance without written approval by the Department.
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(b) The provisions of this Section shall not apply to outpatient pharmacy services provided by a health care facility registered as a covered entity pursuant to 42 U.S.C. 256b or any pharmacy owned by or contracted with the covered entity. A Medicaid managed care organization shall, either directly or through a pharmacy benefit manager, administer and reimburse outpatient pharmacy claims submitted by a health care facility registered as a covered entity pursuant to 42 U.S.C. 256b, its owned pharmacies, and contracted pharmacies in accordance with the contractual agreements the Medicaid managed care organization or its pharmacy benefit manager has with such facilities and pharmacies and in accordance with subsection (h-5).
(b-5) Any pharmacy benefit manager that contracts with a Medicaid managed care organization to administer and reimburse pharmacy claims as provided in this Section must be registered with the Director of Insurance in accordance with Section 513b2 of the Illinois Insurance Code.
(c) On at least an annual basis, the Director of the Department of Healthcare and Family Services shall submit a report beginning no later than one year after January 1, 2020 (the effective date of Public Act 101-452) that provides an update on any contract, contract issues, formulary, dispensing fees, and maximum allowable cost concerns regarding a third-party administrator and managed care. The requirement for reporting to the General Assembly shall be satisfied by filing copies of the report with the Speaker, the Minority Leader, and the Clerk of the House of Representatives and with the President, the Minority Leader, and the Secretary of the Senate. The Department shall take care that no proprietary information is included in the report required under this Section.
(d) A pharmacy benefit manager shall notify the Department in writing of any activity, policy, or practice of the pharmacy benefit manager that directly or indirectly presents a conflict of interest that interferes with the discharge of the pharmacy benefit manager's duty to a managed care organization to exercise its contractual duties. "Conflict of interest" shall be defined by rule by the Department.
(e) A pharmacy benefit manager shall, upon request, disclose to the Department the following information:
(1) whether the pharmacy benefit manager has a
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| contract, agreement, or other arrangement with a pharmaceutical manufacturer to exclusively dispense or provide a drug to a managed care organization's enrollees, and the aggregate amounts of consideration of economic benefits collected or received pursuant to that arrangement;
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(2) the percentage of claims payments made by the
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| pharmacy benefit manager to pharmacies owned, managed, or controlled by the pharmacy benefit manager or any of the pharmacy benefit manager's management companies, parent companies, subsidiary companies, or jointly held companies;
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(3) the aggregate amount of the fees or assessments
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| imposed on, or collected from, pharmacy providers;
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(4) the average annualized percentage of revenue
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| collected by the pharmacy benefit manager as a result of each contract it has executed with a managed care organization contracted by the Department to provide medical assistance benefits which is not paid by the pharmacy benefit manager to pharmacy providers and pharmaceutical manufacturers or labelers or in order to perform administrative functions pursuant to its contracts with managed care organizations;
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(5) the total number of prescriptions dispensed under
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| each contract the pharmacy benefit manager has with a managed care organization (MCO) contracted by the Department to provide medical assistance benefits;
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(6) the aggregate wholesale acquisition cost for
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| drugs that were dispensed to enrollees in each MCO with which the pharmacy benefit manager has a contract by any pharmacy owned, managed, or controlled by the pharmacy benefit manager or any of the pharmacy benefit manager's management companies, parent companies, subsidiary companies, or jointly-held companies;
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(7) the aggregate amount of administrative fees that
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| the pharmacy benefit manager received from all pharmaceutical manufacturers for prescriptions dispensed to MCO enrollees;
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(8) for each MCO with which the pharmacy benefit
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| manager has a contract, the aggregate amount of payments received by the pharmacy benefit manager from the MCO;
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(9) for each MCO with which the pharmacy benefit
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| manager has a contract, the aggregate amount of reimbursements the pharmacy benefit manager paid to contracting pharmacies; and
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(10) any other information considered necessary by
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(f) The information disclosed under subsection (e) shall include all retail, mail order, specialty, and compounded prescription products. All information made available to the Department under subsection (e) is confidential and not subject to disclosure under the Freedom of Information Act. All information made available to the Department under subsection (e) shall not be reported or distributed in any way that compromises its competitive, proprietary, or financial value. The information shall only be used by the Department to assess the contract, agreement, or other arrangements made between a pharmacy benefit manager and a pharmacy provider, pharmaceutical manufacturer or labeler, managed care organization, or other entity, as applicable.
(g) A pharmacy benefit manager shall disclose directly in writing to a pharmacy provider or pharmacy services administrative organization contracting with the pharmacy benefit manager of any material change to a contract provision that affects the terms of the reimbursement, the process for verifying benefits and eligibility, dispute resolution, procedures for verifying drugs included on the formulary, and contract termination at least 30 days prior to the date of the change to the provision. The terms of this subsection shall be deemed met if the pharmacy benefit manager posts the information on a website, viewable by the public. A pharmacy service administration organization shall notify all contract pharmacies of any material change, as described in this subsection, within 2 days of notification. As used in this Section, "pharmacy services administrative organization" means an entity operating within the State that contracts with independent pharmacies to conduct business on their behalf with third-party payers. A pharmacy services administrative organization may provide administrative services to pharmacies and negotiate and enter into contracts with third-party payers or pharmacy benefit managers on behalf of pharmacies.
(h) A pharmacy benefit manager shall not include the following in a contract with a pharmacy provider:
(1) a provision prohibiting the provider from
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| informing a patient of a less costly alternative to a prescribed medication; or
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(2) a provision that prohibits the provider from
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| dispensing a particular amount of a prescribed medication, if the pharmacy benefit manager allows that amount to be dispensed through a pharmacy owned or controlled by the pharmacy benefit manager, unless the prescription drug is subject to restricted distribution by the United States Food and Drug Administration or requires special handling, provider coordination, or patient education that cannot be provided by a retail pharmacy.
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(h-5) Unless required by law, a Medicaid managed care organization or pharmacy benefit manager administering or managing benefits on behalf of a Medicaid managed care organization shall not refuse to contract with a 340B entity or 340B pharmacy for refusing to accept less favorable payment terms or reimbursement methodologies when compared to similarly situated non-340B entities and shall not include in a contract with a 340B entity or 340B pharmacy a provision that:
(1) imposes any fee, chargeback, or rate adjustment
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| that is not similarly imposed on similarly situated pharmacies that are not 340B entities or 340B pharmacies;
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(2) imposes any fee, chargeback, or rate adjustment
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| that exceeds the fee, chargeback, or rate adjustment that is not similarly imposed on similarly situated pharmacies that are not 340B entities or 340B pharmacies;
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(3) prevents or interferes with an individual's
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| choice to receive a prescription drug from a 340B entity or 340B pharmacy through any legally permissible means;
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(4) excludes a 340B entity or 340B pharmacy from a
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| pharmacy network on the basis of whether the 340B entity or 340B pharmacy participates in the 340B drug discount program;
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(5) prevents a 340B entity or 340B pharmacy from
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| using a drug purchased under the 340B drug discount program so long as the drug recipient is a patient of the 340B entity; nothing in this Section exempts a 340B pharmacy from following the Department's preferred drug list or from any prior approval requirements of the Department or the Medicaid managed care organization that are imposed on the drug for all pharmacies; or
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(6) any other provision that discriminates against a
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| 340B entity or 340B pharmacy by treating a 340B entity or 340B pharmacy differently than non-340B entities or non-340B pharmacies for any reason relating to the entity's participation in the 340B drug discount program.
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A provision that violates this subsection in any contract between a Medicaid managed care organization or its pharmacy benefit manager and a 340B entity entered into, amended, or renewed after July 1, 2022 shall be void and unenforceable.
In this subsection (h-5):
"340B entity" means a covered entity as defined in 42 U.S.C. 256b(a)(4) authorized to participate in the 340B drug discount program.
"340B pharmacy" means any pharmacy used to dispense 340B drugs for a covered entity, whether entity-owned or external.
(i) Nothing in this Section shall be construed to prohibit a pharmacy benefit manager from requiring the same reimbursement and terms and conditions for a pharmacy provider as for a pharmacy owned, controlled, or otherwise associated with the pharmacy benefit manager.
(j) A pharmacy benefit manager shall establish and implement a process for the resolution of disputes arising out of this Section, which shall be approved by the Department.
(k) The Department shall adopt rules establishing reasonable dispensing fees for fee-for-service payments in accordance with guidance or guidelines from the federal Centers for Medicare and Medicaid Services.
(Source: P.A. 102-558, eff. 8-20-21; 102-778, eff. 7-1-22; 103-593, eff. 6-7-24.)
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