    (305 ILCS 5/5-30.8)
    (Text of Section before amendment by P.A. 103-102)
    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.

(2) The Department shall not limit the number of 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.

(3) The Department and its contracted actuary shall 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.

(4) Any quality incentive or other incentive withholding of any portion of

the actuarially certified     capitation rates must be budget-neutral. The entirety of any aggregate     withheld amounts must be returned to the MCOs in proportion     to their performance on the relevant performance metric. No     amounts shall be returned to the Department if     all performance measures are not achieved to the extent allowable by federal law and regulations.

(5) Upon request, the Department shall 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.

(b) For the development of capitation base rates for new capitation rate years:
(1) The Department shall take into account emerging 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.

(2) No later than January 1 of each year, the 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:

(A) An initial meeting for the Department to review MCO data and draft rate

assumptions to be used in the development of capitation base rates for the following year.

(B) A draft rate meeting after the Department provides the MCOs with the draft

capitation base rates to discuss, review, and seek feedback regarding the draft capitation base rates.

(3) Prior to the submission of final capitation 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.

(c) For the development of capitation base rates reflecting policy changes:
(1) Unless contrary to federal law and regulation, 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.

(2) No later than 60 days after the effective 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.

(3) No later than 60 days after the effective date of 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.

(4) No later than 60 days after the effective 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.

(d) For the development of capitation base rates for retroactive policy or
fee schedule changes:

(1) 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 the data that shall be utilized to develop capitation base     rates.

(2) 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. The Department shall     provide opportunities for questions to be asked and     answered.

(3) The Department shall provide the MCOs with draft capitation rates and shall also

conduct a draft rate meeting     with MCOs to discuss, review, and seek feedback regarding the draft capitation base rates.

(4) The Department shall inform MCOs no less than quarterly of upcoming benefit and

policy changes to the Medicaid program.

(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. 100-646, eff. 7-27-18; 101-81, eff. 7-12-19.)

    (Text of Section after amendment by P.A. 103-102)
    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: