Public Act 099-0751
SB3080 EnrolledLRB099 20371 KTG 44853 b

    AN ACT concerning public aid.
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
    Section 5. The Illinois Public Aid Code is amended by
changing Section 5-30.1 as follows:
    (305 ILCS 5/5-30.1)
    Sec. 5-30.1. Managed care protections.
    (a) As used in this Section:
    "Managed care organization" or "MCO" means any entity which
contracts with the Department to provide services where payment
for medical services is made on a capitated basis.
    "Emergency services" include:
        (1) emergency services, as defined by Section 10 of the
    Managed Care Reform and Patient Rights Act;
        (2) emergency medical screening examinations, as
    defined by Section 10 of the Managed Care Reform and
    Patient Rights Act;
        (3) post-stabilization medical services, as defined by
    Section 10 of the Managed Care Reform and Patient Rights
    Act; and
        (4) emergency medical conditions, as defined by
    Section 10 of the Managed Care Reform and Patient Rights
    (b) As provided by Section 5-16.12, managed care
organizations are subject to the provisions of the Managed Care
Reform and Patient Rights Act.
    (c) An MCO shall pay any provider of emergency services
that does not have in effect a contract with the contracted
Medicaid MCO. The default rate of reimbursement shall be the
rate paid under Illinois Medicaid fee-for-service program
methodology, including all policy adjusters, including but not
limited to Medicaid High Volume Adjustments, Medicaid
Percentage Adjustments, Outpatient High Volume Adjustments,
and all outlier add-on adjustments to the extent such
adjustments are incorporated in the development of the
applicable MCO capitated rates.
    (d) An MCO shall pay for all post-stabilization services as
a covered service in any of the following situations:
        (1) the MCO authorized such services;
        (2) such services were administered to maintain the
    enrollee's stabilized condition within one hour after a
    request to the MCO for authorization of further
    post-stabilization services;
        (3) the MCO did not respond to a request to authorize
    such services within one hour;
        (4) the MCO could not be contacted; or
        (5) the MCO and the treating provider, if the treating
    provider is a non-affiliated provider, could not reach an
    agreement concerning the enrollee's care and an affiliated
    provider was unavailable for a consultation, in which case
    the MCO must pay for such services rendered by the treating
    non-affiliated provider until an affiliated provider was
    reached and either concurred with the treating
    non-affiliated provider's plan of care or assumed
    responsibility for the enrollee's care. Such payment shall
    be made at the default rate of reimbursement paid under
    Illinois Medicaid fee-for-service program methodology,
    including all policy adjusters, including but not limited
    to Medicaid High Volume Adjustments, Medicaid Percentage
    Adjustments, Outpatient High Volume Adjustments and all
    outlier add-on adjustments to the extent that such
    adjustments are incorporated in the development of the
    applicable MCO capitated rates.
    (e) The following requirements apply to MCOs in determining
payment for all emergency services:
        (1) MCOs shall not impose any requirements for prior
    approval of emergency services.
        (2) The MCO shall cover emergency services provided to
    enrollees who are temporarily away from their residence and
    outside the contracting area to the extent that the
    enrollees would be entitled to the emergency services if
    they still were within the contracting area.
        (3) The MCO shall have no obligation to cover medical
    services provided on an emergency basis that are not
    covered services under the contract.
        (4) The MCO shall not condition coverage for emergency
    services on the treating provider notifying the MCO of the
    enrollee's screening and treatment within 10 days after
    presentation for emergency services.
        (5) The determination of the attending emergency
    physician, or the provider actually treating the enrollee,
    of whether an enrollee is sufficiently stabilized for
    discharge or transfer to another facility, shall be binding
    on the MCO. The MCO shall cover emergency services for all
    enrollees whether the emergency services are provided by an
    affiliated or non-affiliated provider.
        (6) The MCO's financial responsibility for
    post-stabilization care services it has not pre-approved
    ends when:
            (A) a plan physician with privileges at the
        treating hospital assumes responsibility for the
        enrollee's care;
            (B) a plan physician assumes responsibility for
        the enrollee's care through transfer;
            (C) a contracting entity representative and the
        treating physician reach an agreement concerning the
        enrollee's care; or
            (D) the enrollee is discharged.
    (f) Network adequacy and transparency.
        (1) The Department shall:
            (A) ensure that an adequate provider network is in
        place, taking into consideration health professional
        shortage areas and medically underserved areas;
            (B) publicly release an explanation of its process
        for analyzing network adequacy;
            (C) periodically ensure that an MCO continues to
        have an adequate network in place; and
            (D) require MCOs to maintain an updated and public
        list of network providers.
        (2) Each MCO shall confirm its receipt of information
    submitted specific to physician additions or physician
    deletions from the MCO's provider network within 3 days
    after receiving all required information from contracted
    physicians, and electronic physician directories must be
    updated consistent with current rules as published by the
    Centers for Medicare and Medicaid Services or its successor
    (g) Timely payment of claims.
        (1) The MCO shall pay a claim within 30 days of
    receiving a claim that contains all the essential
    information needed to adjudicate the claim.
        (2) The MCO shall notify the billing party of its
    inability to adjudicate a claim within 30 days of receiving
    that claim.
        (3) The MCO shall pay a penalty that is at least equal
    to the penalty imposed under the Illinois Insurance Code
    for any claims not timely paid.
        (4) The Department may establish a process for MCOs to
    expedite payments to providers based on criteria
    established by the Department.
    (g-5) Recognizing that the rapid transformation of the
Illinois Medicaid program may have unintended operational
challenges for both payers and providers:
        (1) in no instance shall a medically necessary covered
    service rendered in good faith, based upon eligibility
    information documented by the provider, be denied coverage
    or diminished in payment amount if the eligibility or
    coverage information available at the time the service was
    rendered is later found to be inaccurate; and
        (2) the Department shall, by December 31, 2016, adopt
    rules establishing policies that shall be included in the
    Medicaid managed care policy and procedures manual
    addressing payment resolutions in situations in which a
    provider renders services based upon information obtained
    after verifying a patient's eligibility and coverage plan
    through either the Department's current enrollment system
    or a system operated by the coverage plan identified by the
    patient presenting for services:
            (A) such medically necessary covered services
        shall be considered rendered in good faith;
            (B) such policies and procedures shall be
        developed in consultation with industry
        representatives of the Medicaid managed care health
        plans and representatives of provider associations
        representing the majority of providers within the
        identified provider industry; and
            (C) such rules shall be published for a review and
        comment period of no less than 30 days on the
        Department's website with final rules remaining
        available on the Department's website.
        (3) The rules on payment resolutions shall include, but
    not be limited to:
            (A) the extension of the timely filing period;
            (B) retroactive prior authorizations; and
            (C) guaranteed minimum payment rate of no less than
        the current, as of the date of service, fee-for-service
        rate, plus all applicable add-ons, when the resulting
        service relationship is out of network.
        (4) The rules shall be applicable for both MCO coverage
    and fee-for-service coverage.
    (g-6) MCO Performance Metrics Report.
        (1) The Department shall publish, on at least a
    quarterly basis, each MCO's operational performance,
    including, but not limited to, the following categories of
            (A) claims payment, including timeliness and
            (B) prior authorizations;
            (C) grievance and appeals;
            (D) utilization statistics;
            (E) provider disputes;
            (F) provider credentialing; and
            (G) member and provider customer service.
        (2) The Department shall ensure that the metrics report
    is accessible to providers online by January 1, 2017.
        (3) The metrics shall be developed in consultation with
    industry representatives of the Medicaid managed care
    health plans and representatives of associations
    representing the majority of providers within the
    identified industry.
        (4) Metrics shall be defined and incorporated into the
    applicable Managed Care Policy Manual issued by the
    (h) The Department shall not expand mandatory MCO
enrollment into new counties beyond those counties already
designated by the Department as of June 1, 2014 for the
individuals whose eligibility for medical assistance is not the
seniors or people with disabilities population until the
Department provides an opportunity for accountable care
entities and MCOs to participate in such newly designated
    (i) The requirements of this Section apply to contracts
with accountable care entities and MCOs entered into, amended,
or renewed after the effective date of this amendatory Act of
the 98th General Assembly.
(Source: P.A. 98-651, eff. 6-16-14.)
    Section 99. Effective date. This Act takes effect upon
becoming law.