Public Act 102-0454
 
HB3069 EnrolledLRB102 13330 KTG 18674 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

    Act. 
    (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, including Medicaid Managed Care 
        Entities as defined in Section 5-30.2,  to meet 
        provider directory requirements under Section 5-30.3.
        (2) Each MCO shall confirm its receipt of information 
    submitted specific to physician or dentist additions or 
    physician or dentist deletions from the MCO's provider 
    network within 3 days after receiving all required 
    information from contracted physicians or dentists, and 
    electronic physician and dental directories must be 
    updated consistent with current rules as published by the 
    Centers for Medicare and Medicaid Services or its 
    successor agency.
    (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 timely payment interest penalty imposed under 
    Section 368a of the Illinois Insurance Code for any claims 
    not timely paid.
            (A) When an MCO is required to pay a timely payment 
        interest penalty to a provider, the MCO must calculate 
        and pay the timely payment interest penalty that is 
        due to the provider within 30 days after the payment of 
        the claim. In no event shall a provider be required to 
        request or apply for payment of any owed timely 
        payment interest penalties. 
            (B) Such payments shall be reported separately 
        from the claim payment for services rendered to the 
        MCO's enrollee and clearly identified as interest 
        payments. 
        (4)(A) The Department shall require MCOs to expedite 
    payments to providers identified on the Department's 
    expedited provider list, determined in accordance with 89 
    Ill. Adm. Code 140.71(b), on a schedule  at least as 
    frequently as the providers are paid under  the 
    Department's fee-for-service expedited provider  schedule.
        (B) Compliance with the expedited provider requirement 
    may be satisfied by an MCO through the use of a Periodic 
    Interim Payment (PIP) program that has been mutually 
    agreed to and documented between the MCO and the provider, 
    and the PIP program ensures that any expedited provider 
    receives regular and periodic payments based on prior 
    period payment experience from that MCO. Total payments 
    under the PIP program may be reconciled against future PIP 
    payments on a schedule mutually agreed to between the MCO 
    and the provider.
        (C) The Department shall share at least monthly its 
    expedited provider list and the frequency with which it 
    pays providers on the expedited list.
    (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 in the assignment 
    of coverage responsibility  between MCOs or the 
    fee-for-service system, except for instances when an 
    individual is deemed to have not been eligible for 
    coverage under the Illinois Medicaid program; 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.
    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.
    The rules shall be applicable for both MCO coverage and 
fee-for-service coverage. 
    If the fee-for-service system is ultimately determined to 
have been responsible for coverage on the date of service, the 
Department shall provide for an extended period for claims 
submission outside the standard timely filing requirements. 
    (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 
    metrics:
            (A) claims payment, including timeliness and 
        accuracy;
            (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 
    Department.
    (g-7)  MCO claims processing and performance analysis. In 
order to monitor MCO payments to hospital providers, pursuant 
to this amendatory Act of the 100th General Assembly, the 
Department shall post  an analysis of MCO claims processing and 
payment performance on its website every 6 months.  Such 
analysis shall include a review and evaluation of a 
representative sample of hospital claims that are rejected and 
denied for clean and unclean claims and the top 5 reasons for 
such actions and timeliness of claims adjudication, which 
identifies the percentage of claims adjudicated within 30, 60, 
90, and over 90 days, and the dollar amounts associated with 
those claims. The Department shall post the contracted claims 
report required by HealthChoice Illinois on its website every 
3 months. 
    (g-8)  Dispute resolution process. The Department shall 
maintain a provider complaint portal through which a provider 
can submit to the Department unresolved disputes with an MCO.  
An unresolved dispute means an MCO's decision that denies in 
whole or in part a claim for reimbursement to a provider for 
health care services rendered by the provider to an enrollee 
of the MCO with which the provider disagrees.  Disputes shall 
not be submitted to the portal until the provider has availed 
itself of the MCO's internal dispute resolution process.  
Disputes that are submitted to the MCO internal dispute 
resolution process may be submitted to the Department of 
Healthcare and Family Services' complaint portal no sooner 
than 30 days after submitting to the MCO's internal process 
and not later than 30 days after the unsatisfactory resolution 
of the internal MCO process or 60 days after submitting the 
dispute to the MCO internal process. Multiple claim disputes 
involving the same MCO may be submitted in one complaint, 
regardless of whether the claims are for different enrollees, 
when the specific reason for non-payment of the claims 
involves a common question of fact or policy.  Within 10 
business days of receipt of a complaint, the Department shall 
present such disputes to the appropriate MCO, which shall then 
have 30 days to issue its written proposal to resolve the 
dispute.  The Department may grant one 30-day extension of this 
time frame to one of the parties to resolve the dispute. If the 
dispute remains unresolved at the end of this time frame or the 
provider is not satisfied with the MCO's written proposal to 
resolve the dispute, the provider may, within 30 days, request 
the Department to review the dispute and make a final 
determination.  Within 30 days of the request for Department 
review of the dispute, both the provider and the MCO shall 
present all relevant information to the Department for 
resolution and make individuals with knowledge of the issues 
available to the Department for further inquiry if needed.  
Within 30 days of receiving the relevant information on the 
dispute, or the lapse of the period for submitting such 
information, the Department shall issue a written decision on 
the dispute based on contractual terms between the provider 
and the MCO, contractual terms between the MCO and the 
Department of Healthcare and Family Services and applicable 
Medicaid policy.  The decision of the Department shall be 
final. By January 1, 2020, the Department shall establish by 
rule further details of this dispute resolution process.  
Disputes between MCOs and providers presented to the 
Department for resolution are not contested cases, as defined 
in Section 1-30 of the Illinois Administrative Procedure Act, 
conferring any right to an administrative hearing. 
    (g-9)(1) The Department shall publish annually on its 
website a report on the calculation of each managed care 
organization's medical loss ratio showing the following: 
        (A) Premium revenue, with appropriate adjustments. 
        (B) Benefit expense, setting forth the aggregate 
    amount spent for the following: 
            (i) Direct paid claims.
            (ii) Subcapitation payments.
            (iii)
Other claim payments.
            (iv)
Direct reserves.
            (v)
Gross recoveries.
            (vi)
Expenses for activities that improve health 
        care quality as allowed by the Department. 
    (2) The medical loss ratio shall be calculated consistent 
with federal law and regulation following a claims runout 
period determined by the Department. 
    (g-10)(1) "Liability effective date" means the date on 
which an MCO becomes responsible for payment for medically 
necessary and covered services rendered by a provider to one 
of its enrollees in accordance with the contract terms between 
the MCO and the provider. The liability effective date shall 
be the later of: 
        (A)  The execution date of a network participation 
    contract agreement.
        (B) The date the provider or its representative 
    submits to the MCO the complete and accurate standardized 
    roster form for the provider in the format approved by the 
    Department. 
        (C) The provider effective date contained within the 
    Department's provider enrollment subsystem within the 
    Illinois Medicaid Program Advanced Cloud Technology 
    (IMPACT) System. 
    (2) The standardized roster form may be submitted to the 
MCO at the same time that the provider submits an enrollment 
application to the Department through IMPACT.
    (3)  By October 1, 2019, the Department shall require all 
MCOs to update their provider directory with information for 
new practitioners of existing contracted providers within 30 
days of receipt of a complete and accurate standardized roster 
template in the format approved by the Department provided 
that the provider is effective in the Department's provider 
enrollment subsystem within the IMPACT system. Such provider 
directory shall be readily accessible for purposes of 
selecting an approved health care provider and comply with all 
other federal and State requirements. 
    (g-11) The Department shall work with relevant 
stakeholders on the development of operational guidelines to 
enhance and improve operational performance of Illinois' 
Medicaid managed care program, including, but not limited to, 
improving provider billing practices, reducing claim 
rejections and inappropriate payment denials, and 
standardizing processes, procedures, definitions, and response 
timelines, with the goal of reducing provider and MCO 
administrative burdens and conflict.  The Department shall 
include a report on the progress of these program improvements 
and other topics in its Fiscal Year 2020 annual report to the 
General Assembly. 
    (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 
counties.
    (i) The requirements of this Section apply to contracts 
with accountable care entities and MCOs entered into, amended, 
or renewed after June 16, 2014 (the effective date of Public 
Act 98-651).

    (j) Health care information released to managed care 
organizations. A health care provider shall release to a 
Medicaid managed care organization, upon request, and subject 
to the Health Insurance Portability and Accountability Act of 
1996 and  any other law applicable to the release of health 
information, the health care information of the MCO's 
enrollee, if the enrollee has completed and signed a general 
release form that grants to the health care provider 
permission to release the recipient's health care information 
to the recipient's insurance carrier. 
(Source: P.A. 100-201, eff. 8-18-17; 100-580, eff. 3-12-18; 
100-587, eff. 6-4-18; 101-209, eff. 8-5-19.)
 
 
    Section 99. Effective date. This Act takes effect upon 
becoming law.