103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB4979

 

Introduced 2/8/2024, by Rep. Robyn Gabel

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-30.18 new

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to adopt rules, by no later than January 1, 2025, to establish a process under which any provider meeting certain performance standards outlined in the amendatory Act shall be certified for a service authorization exemption from all service authorization programs for a period of no less than one year. Provides that qualification for a service authorization exemption shall be determined by the Department, or its contracted utilization review organization (URO), and shall be binding on a managed care organization (MCO) or the MCO's contracted URO. Provides that a provider shall be eligible for a service authorization exemption if the provider submitted at least 25 service authorization requests to a service authorization program in the preceding calendar year and the service authorization program approved at least 80% of the service authorization requests. Provides that no later than December 1 of each calendar year, each service authorization program shall provide written notification to all providers who qualify for a service authorization exemption for the subsequent calendar year. Requires the Department to adopt rules by January 1, 2025 to establish: (i) a standard method the Department, or its contracted URO, shall use to evaluate whether a provider meets the criteria to qualify for a service authorization exemption; (ii) a standard method the Department, or its contracted URO, shall use to accept and process provider appeals of denied or rescinded exemptions; and (iii) a standard method the MCOs shall use to accept and process professional claims and facility claims, as billed by the provider, for a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. Contains provisions concerning annual reviews by the Department of service authorization denials made under each service authorization program; quarterly reports issued by the Department that detail the performance of each service authorization program; sanctions on MCOs for noncompliance with any provision of the amendatory Act. Effective immediately.


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A BILL FOR

 

HB4979LRB103 37685 KTG 67812 b

1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5adding Section 5-30.18 as follows:
 
6    (305 ILCS 5/5-30.18 new)
7    Sec. 5-30.18. Service authorization program performance.
8    (a) Definitions. As used in this Section:
9    "Health care service" means any medical or behavioral
10health service covered under the medical assistance program
11that is rendered in the inpatient or outpatient hospital
12setting and subject to review under a service authorization
13program.
14    "Provider" means a facility or individual, or group of
15individuals operating under the same tax identification
16number, actively enrolled in the medical assistance program
17and licensed or otherwise authorized to order, prescribe,
18refer, or render health care services in this State.
19    "Service authorization determination" means a decision
20made by a service authorization program to approve, change the
21level of care, partially deny, or deny coverage and
22reimbursement for a health care service upon review of a
23service authorization request submitted by a provider.

 

 

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1    "Service authorization exemption" means an exception
2granted by a service authorization program to a provider under
3which all service authorization requests for covered health
4care services are automatically deemed to be medically
5necessary, clinically appropriate, and approved for
6reimbursement as ordered.
7    "Service authorization program" means any utilization
8review, utilization management, peer review, quality review,
9or other medical management activity conducted in advance of,
10concurrent to, or after the provision of a health care service
11by a Medicaid managed care organization, either directly or
12through a contracted utilization review organization (URO),
13including, but not limited to, prior authorization,
14pre-certification, certification of admission, concurrent
15review, and retrospective review of health care services.
16    "Service authorization request" means a request by a
17provider to a service authorization program to determine
18whether a health care service that is otherwise covered under
19the medical assistance program meets the reimbursement
20requirements established by the managed care organization
21(MCO), or its contracted URO, for medically necessary,
22clinically appropriate care and to issue a service
23authorization determination.
24    "Utilization review organization" or "URO" means a managed
25care organization or other entity that has established or
26administers one or more service authorization programs.

 

 

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1    (b) By no later than January 1, 2025, the Department shall
2adopt rules to establish a process under which any provider
3meeting the performance standards outlined in subsection (c)
4shall be certified for a service authorization exemption from
5all service authorization programs for a period of no less
6than one year. Qualification for a service authorization
7exemption shall be determined by the Department, or its
8contracted URO, and shall be binding on the MCO or the MCO's
9contracted URO.
10    (c) A provider shall be eligible for a service
11authorization exemption if the provider submitted at least 25
12service authorization requests to a service authorization
13program in the preceding calendar year and the service
14authorization program approved at least 80% of the service
15authorization requests. A provider shall not be required to
16request a service authorization exemption to qualify for such
17exemption.
18    (d) No later than December 1 of each calendar year, each
19service authorization program shall provide written
20notification to all providers who qualify for a service
21authorization exemption, as determined by the Department, for
22the subsequent calendar year.
23    (e) A service authorization program shall not deny,
24partially deny, reduce the level of care, or otherwise limit
25reimbursement to the rendering or supervising provider,
26including the rendering facility, for health care services

 

 

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1ordered by a provider who qualifies for a service
2authorization exemption, except in cases of fraud.
3    (f) In consultation with the Medicaid managed care
4organizations, a statewide association representing managed
5care organizations, a statewide association representing the
6majority of Illinois hospitals, a statewide association
7representing physicians, and a statewide association
8representing nursing homes, the Department shall by January 1,
92025 adopt administrative rules to establish:
10        (1) a standard method the Department, or its
11    contracted URO, shall use to evaluate whether a provider
12    meets the criteria to qualify for a service authorization
13    exemption under subsection (c) and to determine the
14    conditions under which a service authorization exemption
15    may be rescinded, including review of the provider's
16    utilization during the preceding calendar year.
17        (2) a standard method the Department, or its
18    contracted URO, shall use to accept and process provider
19    appeals of denied or rescinded exemptions;
20        (3) a standard method the MCOs shall use to accept and
21    process professional claims and facility claims, as billed
22    by the provider, for a health care service that is
23    rendered, prescribed, or ordered by a provider granted a
24    service authorization exemption, except in cases of fraud.
25    (g) To ensure covered services furnished to individuals
26enrolled in an MCO are no less in amount, duration, and scope

 

 

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1than the same services furnished to individuals enrolled in
2the State's fee-for-service medical assistance program,
3beginning January 1, 2026, the Department, or its external
4quality review organization, shall conduct and make publicly
5available the results of an annual review of a sample of
6service authorization denials made under each service
7authorization program, stratified by MCO during the preceding
8calendar year, including denials based on initial review of a
9service authorization request and denials overturned on appeal
10to the service authorization program's internal process. The
11review shall, at a minimum, evaluate whether the
12determinations were made:
13        (1) using consistent application of established,
14    evidence-based, and professionally recognized medical
15    necessity criteria that is no more restrictive that the
16    criteria used in the State's fee-for-service medical
17    assistance program; and
18        (2) in compliance with the Department's administrative
19    rules, the terms of the contract between the Department
20    and the MCOs, and other applicable federal and State laws,
21    regulations, and policies.
22    (h) The Department shall publish quarterly reports
23detailing the performance of each service authorization
24program, stratified by MCO, including concurrent review and
25continued stay review requests, that details, at a minimum,
26the number of service authorization requests received, the

 

 

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1number of requests approved based on review of the initial
2request, the number of requests denied based on review of the
3initial request and the reasons for the denials, the number of
4requests downgraded to a lower level of care and the reasons
5for the change in level of care, and the number of denied
6requests overturned on appeal and the reasons the requests
7were overturned.
8    (i) The Department shall impose sanctions on a managed
9care organization for violating provisions of this Section
10that include, but are not limited to, financial penalties,
11suspension of enrollment of new enrollees, and termination of
12the MCO's contract with the Department.
 
13    Section 99. Effective date. This Act takes effect upon
14becoming law.