SB2006 102ND GENERAL ASSEMBLY

LRB102 15657 KTG 21020 b

102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
SB2006

Introduced 2/26/2021, by Sen. David Koehler

SYNOPSIS AS INTRODUCED:

305 ILCS 5/5-2.01
305 ILCS 5/5-30.1

Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that no later than 90 days after the effective date of the amendatory Act, the Department of Healthcare and Family Services shall post on its official website: (i) a copy of all current, executed, or adopted contracts with each managed care organization (MCO), including all amendments, attachments, and exhibits, that are in effect as of January 1, 2021; (ii) all changes made to each MCO contract that are in effect on or after January 1, 2021; (iii) all operational policy changes issued to MCOs; and (iv) a copy of all contracts and operational policy changes for a period of not less than 24 months after the termination or expiration of any MCO contract. Provides that the Department shall prohibit each MCO from operating, implementing, or modifying any program or policy that concerns, but it not limited to, reducing potentially preventable hospital readmissions (PPR) until after the Department has adopted an updated PPR policy for services provided to individuals not covered under managed care. Contains provisions concerning prohibited PPR policy measures. Provides that if the Department elects to implement a comprehensive PPR policy that applies to both the fee-for-service and managed care medical assistance programs, then no MCO may operate a similar PPR policy. Provides that an MCO shall not make a material change unless the material change has been approved by the Department or agreed upon in writing by the MCO and the health care provider. Requires the Department to publish on its website a process through which an MCO may submit a written proposed material change request. Effective immediately.

FISCAL NOTE ACT MAY APPLY

A BILL FOR

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 Sections 5-2.01 and 5-30.1 as follows:

(305 ILCS 5/5-2.01)

Sec. 5-2.01. Medicaid accountability through transparency program.

(a) Internet-based transparency program. The Director of the Department of Healthcare and Family Services shall be authorized to implement a program under which the Director shall make available through the Department's public Internet website information on medical claims reimbursed under the State's medical assistance program insofar as such information has been de-identified in accordance with regulations promulgated pursuant to the Illinois Health Insurance Portability and Accountability Act. In implementing the program, the Director shall ensure the following:

(1) The information made so available shall be in a format that is easily accessible, useable, and understandable to the public, including individuals interested in improving the quality of care provided to individuals eligible for items and services under this Article, researchers, health care providers, and individuals interested in reducing the prevalence of waste and fraud under this Article.

(2) The information made so available shall be as current as deemed practical by the Director and shall be updated at least once per calendar quarter.

(3) The information made so available shall be aggregated to a level to ensure patient confidentiality, but shall, to the extent feasible, allow for posting of information by provider or vendor name and county, number of individuals served, total patient visits, payment for bills submitted, average cost for bills submitted, adjustments to payments, and total amounts paid.

(4) The Director periodically solicits comments from a sampling of individuals who access the information through the program on how to best improve the utility of the program.

(b) Use of contractor. For purposes of implementing the program under subsection (a) of this Section and ensuring the information made available through the program is periodically updated, the Director may select and enter into a contract with a public or private entity meeting the criteria and qualifications the Director determines appropriate.

(c) Annual Reports. Not later than 12 months after the effective date of this amendatory Act of the 96th General Assembly and annually thereafter, the Director shall submit to the General Assembly a report on the status of the program authorized under subsection (a). The report shall include details including, but not limited to, the estimated or actual costs of developing and maintaining the reporting system, the actual or potential benefit or adverse consequences associated with the system, and, if applicable, the extent to which information made available through the program is accessed and the extent to which comments received under paragraph (4) of subsection (a) of this Section were used to improve the utility of the program.

(d) Managed care contracts and operational policy changes.

(1) No later than 90 days after the effective date of this amendatory Act of the 102nd General Assembly, the Department shall post on its official website a copy of all current, executed, or adopted contracts with each managed care organization (MCO), including all amendments, attachments, and exhibits, that are in effect as of January 1, 2021. The Department shall post on its official website, within 60 days of execution or adoption, all changes made to each MCO contract, including all amendments, attachments, and exhibits, that are in effect on or after January 1, 2021.

(2) The Department shall post to its official website all operational policy changes, as defined in paragraph (1) of subsection (c) of Section 5-30.8, issued to MCOs no later than 60 days prior to the effective date of the change.

(3) No later than 180 days after the effective date of this amendatory Act of the 102nd General Assembly, the Department shall post all operational policy changes issued during the 12 months preceding the effective date of this amendatory Act of the 102nd General Assembly.

(4) The Department shall maintain a copy of all contracts and operational policy changes required under this subsection on its official website for a period of not less than 24 months after the termination or expiration of any MCO contract.

(Source: P.A. 96-941, eff. 6-25-10.)

(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.

(g-12)(1) The Department shall prohibit each MCO from operating, implementing, or modifying any program or policy similar to subsection (d) of Section 5-5f, including, but not limited to, hospital potentially preventable readmissions (PPR), until after:

(A) the Department has adopted, by rule, an updated PPR policy for services provided to individuals not covered by the capitated managed care program, and has published on its website guidelines for an approvable MCO PPR policy that is consistent with and aligned with the adopted fee-for-service PPR policy;

(B) the MCO has published its proposed PPR policy for public comment on its public website for a period of no fewer than 60 days and has publicly responded to comments; and

(C) the Department has approved the MCO's proposed policy and posted such approval on its official website, after considering all public comments received by the MCO.

(2) No PPR policy, whether adopted by the Department or an MCO, may result in the denial of payment for a hospital stay that may be considered a PPR that is the result of a previous discharge from another hospital.

(3) No PPR policy, whether adopted by the Department or an MCO, may apply to behavioral health care services, including mental health and substance use disorder treatment.

(4) No PPR policy, whether adopted by the Department or an MCO, may be effective any sooner than 60 days after the Department has published its approval of an MCO's policy.

(5) If the Department elects to implement a comprehensive PPR policy which encompasses both individuals covered under the fee-for-service and capitated managed care programs, then no MCO may operate a similar PPR policy.

(g-13) MCO provider agreement material changes. As used in this subsection:

"Adverse effect" means a change to a provision of a contract between an MCO and a health care provider that results in a reduction to reimbursement received by a health care provider or an increase in administrative responsibilities or expenses incurred by a health care provider.

"Material change" means any action taken by an MCO to implement, amend, add, expand, or otherwise alter a provision of a contract with a health care provider, including by amending a manual, policy, procedure document, or other document referenced in the contract, that has an adverse effect on the provider.

(1) An MCO shall not impose obligations, duties, or other requirements on a provider that are inconsistent with federal or State laws, regulations, or policies, or the contract between the Department and the MCO.

(2) An MCO shall not make a material change unless the material change has been approved by the Department, in accordance with paragraph (6), or the material change has been mutually agreed upon in writing by the MCO and the health care provider.

(3) No provider shall be required to accept any material change that has not been approved by the Department consistent with the approval process outlined in this subsection.

(4) A material change that is necessary to comply with federal or State laws, regulations, or policies shall not require prior approval by the Department. The Department and the MCO shall provide written and electronic notification of the material change to the health care provider no less than 90 business days prior to implementation.

(5) Within 120 days after the effective date of this amendatory Act of the 102nd General Assembly, the Department shall establish, and publish on its website, a process through which an MCO may submit a written proposed material change request for prior approval to the Department.

(6) Prior to issuing a determination on any proposed material change request, the Department shall:

(A) publish on its website a public notice that includes a comprehensive description of the proposed material change request;

(B) accept, consider, and provide responses to all public comments submitted within 45 business days of publication of the public notice; and

(C) review the proposed material change request for compliance with federal and State laws, regulations, and policies and the Department's contract with the MCO.

(7) The Department shall issue a written determination to deny or approve the proposed material change request within 60 days of the close of the 45-day public notice period. The Department's determination shall be made readily accessible to the public on its website and shall include a mechanism for providers to report MCO noncompliance with the determination.

(8) A material change request that has been approved by the Department shall take effect no earlier than 90 business days from the date the Department has made the written determination of approval publicly available on its website and the MCO has met the following criteria:

(A) offered providers and their employees, agents, subcontractors, and others acting on their behalf comprehensive training and education on the material change; and

(B) notified providers of the material change, in written and electronic form, at least 90 business days prior to the effective date of the material change. The notice shall be published on the MCO's public website and shall include the following information:

(i) the effective date of the material change;

(ii) a comprehensive description of the material change and references to any related policies; and

(iii) contact information to discuss the material change or to request individual education.

(9) A provider retains the right to terminate, with proper notification, its agreement with an MCO prior to implementation of a material change approved by the Department.

(10) Any provision of a provider agreement with an MCO that violates this subsection shall be void, unlawful, and unenforceable.

(11) The requirements of this subsection apply to and must be described in any provider agreement with an MCO issued, amended, or renewed on or after the effective date of this amendatory Act of the 102nd 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.