Rep. Jackie Haas

Filed: 3/25/2021

 

 


 

 


 
10200HB2832ham001LRB102 13984 KTG 24357 a

1
AMENDMENT TO HOUSE BILL 2832

2    AMENDMENT NO. ______. Amend House Bill 2832 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Public Aid Code is amended by
5adding Section 5-43 and by changing Section 5-30.1 and by
6adding Section 5-30.12a as follows:
 
7    (305 ILCS 5/5-30.1)
8    Sec. 5-30.1. Managed care protections.
9    (a) As used in this Section:
10    "Managed care organization" or "MCO" means any entity
11which contracts with the Department to provide services where
12payment for medical services is made on a capitated basis.
13    "Emergency services" include:
14        (1) emergency services, as defined by Section 10 of
15    the Managed Care Reform and Patient Rights Act;
16        (2) emergency medical screening examinations, as

 

 

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1    defined by Section 10 of the Managed Care Reform and
2    Patient Rights Act;
3        (3) post-stabilization medical services, as defined by
4    Section 10 of the Managed Care Reform and Patient Rights
5    Act; and
6        (4) emergency medical conditions, as defined by
7    Section 10 of the Managed Care Reform and Patient Rights
8    Act.
9    (b) As provided by Section 5-16.12, managed care
10organizations are subject to the provisions of the Managed
11Care Reform and Patient Rights Act.
12    (c) An MCO shall pay any provider of emergency services
13that does not have in effect a contract with the contracted
14Medicaid MCO. The default rate of reimbursement shall be the
15rate paid under Illinois Medicaid fee-for-service program
16methodology, including all policy adjusters, including but not
17limited to Medicaid High Volume Adjustments, Medicaid
18Percentage Adjustments, Outpatient High Volume Adjustments,
19and all outlier add-on adjustments to the extent such
20adjustments are incorporated in the development of the
21applicable MCO capitated rates.
22    (d) An MCO shall pay for all post-stabilization services
23as a covered service in any of the following situations:
24        (1) the MCO authorized such services;
25        (2) such services were administered to maintain the
26    enrollee's stabilized condition within one hour after a

 

 

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1    request to the MCO for authorization of further
2    post-stabilization services;
3        (3) the MCO did not respond to a request to authorize
4    such services within one hour;
5        (4) the MCO could not be contacted; or
6        (5) the MCO and the treating provider, if the treating
7    provider is a non-affiliated provider, could not reach an
8    agreement concerning the enrollee's care and an affiliated
9    provider was unavailable for a consultation, in which case
10    the MCO must pay for such services rendered by the
11    treating non-affiliated provider until an affiliated
12    provider was reached and either concurred with the
13    treating non-affiliated provider's plan of care or assumed
14    responsibility for the enrollee's care. Such payment shall
15    be made at the default rate of reimbursement paid under
16    Illinois Medicaid fee-for-service program methodology,
17    including all policy adjusters, including but not limited
18    to Medicaid High Volume Adjustments, Medicaid Percentage
19    Adjustments, Outpatient High Volume Adjustments and all
20    outlier add-on adjustments to the extent that such
21    adjustments are incorporated in the development of the
22    applicable MCO capitated rates.
23    (e) The following requirements apply to MCOs in
24determining payment for all emergency services:
25        (1) MCOs shall not impose any requirements for prior
26    approval of emergency services.

 

 

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1        (2) The MCO shall cover emergency services provided to
2    enrollees who are temporarily away from their residence
3    and outside the contracting area to the extent that the
4    enrollees would be entitled to the emergency services if
5    they still were within the contracting area.
6        (3) The MCO shall have no obligation to cover medical
7    services provided on an emergency basis that are not
8    covered services under the contract.
9        (4) The MCO shall not condition coverage for emergency
10    services on the treating provider notifying the MCO of the
11    enrollee's screening and treatment within 10 days after
12    presentation for emergency services.
13        (5) The determination of the attending emergency
14    physician, or the provider actually treating the enrollee,
15    of whether an enrollee is sufficiently stabilized for
16    discharge or transfer to another facility, shall be
17    binding on the MCO. The MCO shall cover emergency services
18    for all enrollees whether the emergency services are
19    provided by an affiliated or non-affiliated provider.
20        (6) The MCO's financial responsibility for
21    post-stabilization care services it has not pre-approved
22    ends when:
23            (A) a plan physician with privileges at the
24        treating hospital assumes responsibility for the
25        enrollee's care;
26            (B) a plan physician assumes responsibility for

 

 

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1        the enrollee's care through transfer;
2            (C) a contracting entity representative and the
3        treating physician reach an agreement concerning the
4        enrollee's care; or
5            (D) the enrollee is discharged.
6    (f) Network adequacy and transparency.
7        (1) The Department shall:
8            (A) ensure that an adequate provider network is in
9        place, taking into consideration health professional
10        shortage areas and medically underserved areas;
11            (B) publicly release an explanation of its process
12        for analyzing network adequacy;
13            (C) periodically ensure that an MCO continues to
14        have an adequate network in place; and
15            (D) require MCOs, including Medicaid Managed Care
16        Entities as defined in Section 5-30.2, to meet
17        provider directory requirements under Section 5-30.3.
18        (2) Each MCO shall confirm its receipt of information
19    submitted specific to physician or dentist additions or
20    physician or dentist deletions from the MCO's provider
21    network within 3 days after receiving all required
22    information from contracted physicians or dentists, and
23    electronic physician and dental directories must be
24    updated consistent with current rules as published by the
25    Centers for Medicare and Medicaid Services or its
26    successor agency.

 

 

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1    (g) Timely payment of claims.
2        (1) The MCO shall pay a claim within 30 days of
3    receiving a claim that contains all the essential
4    information needed to adjudicate the claim.
5        (2) The MCO shall notify the billing party of its
6    inability to adjudicate a claim within 30 days of
7    receiving that claim.
8        (3) The MCO shall pay a penalty for any claims not
9    timely paid at an interest rate of 9%, annually,
10    compounded semiannually, from the date payment was
11    required to be made to the date of the late payment that is
12    at least equal to the timely payment interest penalty
13    imposed under Section 368a of the Illinois Insurance Code
14    for any claims not timely paid.
15            (A) When an MCO is required to pay a timely payment
16        interest penalty to a provider, the MCO must calculate
17        and pay the timely payment interest penalty that is
18        due to the provider within 30 days after the payment of
19        the claim. In no event shall a provider be required to
20        request or apply for payment of any owed timely
21        payment interest penalties.
22            (B) Such payments shall be reported separately
23        from the claim payment for services rendered to the
24        MCO's enrollee and clearly identified as interest
25        payments.
26        (4)(A) The Department shall require MCOs to expedite

 

 

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1    payments to providers identified on the Department's
2    expedited provider list, determined in accordance with 89
3    Ill. Adm. Code 140.71(b), on a schedule at least as
4    frequently as the providers are paid under the
5    Department's fee-for-service expedited provider schedule.
6        (B) Compliance with the expedited provider requirement
7    may be satisfied by an MCO through the use of a Periodic
8    Interim Payment (PIP) program that has been mutually
9    agreed to and documented between the MCO and the provider,
10    and the PIP program ensures that any expedited provider
11    receives regular and periodic payments based on prior
12    period payment experience from that MCO. Total payments
13    under the PIP program may be reconciled against future PIP
14    payments on a schedule mutually agreed to between the MCO
15    and the provider.
16        (C) The Department shall share at least monthly its
17    expedited provider list and the frequency with which it
18    pays providers on the expedited list.
19    (g-5) Recognizing that the rapid transformation of the
20Illinois Medicaid program may have unintended operational
21challenges for both payers and providers:
22        (1) in no instance shall a medically necessary covered
23    service rendered in good faith, based upon eligibility
24    information documented by the provider, be denied coverage
25    or diminished in payment amount if the eligibility or
26    coverage information available at the time the service was

 

 

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1    rendered is later found to be inaccurate in the assignment
2    of coverage responsibility between MCOs or the
3    fee-for-service system, except for instances when an
4    individual is deemed to have not been eligible for
5    coverage under the Illinois Medicaid program; and
6        (2) the Department shall, by December 31, 2016, adopt
7    rules establishing policies that shall be included in the
8    Medicaid managed care policy and procedures manual
9    addressing payment resolutions in situations in which a
10    provider renders services based upon information obtained
11    after verifying a patient's eligibility and coverage plan
12    through either the Department's current enrollment system
13    or a system operated by the coverage plan identified by
14    the patient presenting for services:
15            (A) such medically necessary covered services
16        shall be considered rendered in good faith;
17            (B) such policies and procedures shall be
18        developed in consultation with industry
19        representatives of the Medicaid managed care health
20        plans and representatives of provider associations
21        representing the majority of providers within the
22        identified provider industry; and
23            (C) such rules shall be published for a review and
24        comment period of no less than 30 days on the
25        Department's website with final rules remaining
26        available on the Department's website.

 

 

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1    The rules on payment resolutions shall include, but not be
2limited to:
3        (A) the extension of the timely filing period;
4        (B) retroactive prior authorizations; and
5        (C) guaranteed minimum payment rate of no less than
6    the current, as of the date of service, fee-for-service
7    rate, plus all applicable add-ons, when the resulting
8    service relationship is out of network.
9    The rules shall be applicable for both MCO coverage and
10fee-for-service coverage.
11    If the fee-for-service system is ultimately determined to
12have been responsible for coverage on the date of service, the
13Department shall provide for an extended period for claims
14submission outside the standard timely filing requirements.
15    (g-6) MCO Performance Metrics Report.
16        (1) The Department shall publish, on at least a
17    quarterly basis, each MCO's operational performance,
18    including, but not limited to, the following categories of
19    metrics:
20            (A) claims payment, including timeliness and
21        accuracy;
22            (B) prior authorizations;
23            (C) grievance and appeals;
24            (D) utilization statistics;
25            (E) provider disputes;
26            (F) provider credentialing; and

 

 

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1            (G) member and provider customer service.
2        (2) The Department shall ensure that the metrics
3    report is accessible to providers online by January 1,
4    2017.
5        (3) The metrics shall be developed in consultation
6    with industry representatives of the Medicaid managed care
7    health plans and representatives of associations
8    representing the majority of providers within the
9    identified industry.
10        (4) Metrics shall be defined and incorporated into the
11    applicable Managed Care Policy Manual issued by the
12    Department.
13    (g-7) MCO claims processing and performance analysis. In
14order to monitor MCO payments to hospital providers, pursuant
15to this amendatory Act of the 100th General Assembly, the
16Department shall post an analysis of MCO claims processing and
17payment performance on its website every 6 months. Such
18analysis shall include a review and evaluation of a
19representative sample of hospital claims that are rejected and
20denied for clean and unclean claims and the top 5 reasons for
21such actions and timeliness of claims adjudication, which
22identifies the percentage of claims adjudicated within 30, 60,
2390, and over 90 days, and the dollar amounts associated with
24those claims. The Department shall post the contracted claims
25report required by HealthChoice Illinois on its website every
263 months.

 

 

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1    (g-8) Dispute resolution process. The Department shall
2maintain a provider complaint portal through which a provider
3can submit to the Department unresolved disputes with an MCO.
4An unresolved dispute means an MCO's decision that denies in
5whole or in part a claim for reimbursement to a provider for
6health care services rendered by the provider to an enrollee
7of the MCO with which the provider disagrees. Disputes shall
8not be submitted to the portal until the provider has availed
9itself of the MCO's internal dispute resolution process.
10Disputes that are submitted to the MCO internal dispute
11resolution process may be submitted to the Department of
12Healthcare and Family Services' complaint portal no sooner
13than 30 days after submitting to the MCO's internal process
14and not later than 30 days after the unsatisfactory resolution
15of the internal MCO process or 60 days after submitting the
16dispute to the MCO internal process. Multiple claim disputes
17involving the same MCO may be submitted in one complaint,
18regardless of whether the claims are for different enrollees,
19when the specific reason for non-payment of the claims
20involves a common question of fact or policy. Within 10
21business days of receipt of a complaint, the Department shall
22present such disputes to the appropriate MCO, which shall then
23have 30 days to issue its written proposal to resolve the
24dispute. The Department may grant one 30-day extension of this
25time frame to one of the parties to resolve the dispute. If the
26dispute remains unresolved at the end of this time frame or the

 

 

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1provider is not satisfied with the MCO's written proposal to
2resolve the dispute, the provider may, within 30 days, request
3the Department to review the dispute and make a final
4determination. Within 30 days of the request for Department
5review of the dispute, both the provider and the MCO shall
6present all relevant information to the Department for
7resolution and make individuals with knowledge of the issues
8available to the Department for further inquiry if needed.
9Within 30 days of receiving the relevant information on the
10dispute, or the lapse of the period for submitting such
11information, the Department shall issue a written decision on
12the dispute based on contractual terms between the provider
13and the MCO, contractual terms between the MCO and the
14Department of Healthcare and Family Services and applicable
15Medicaid policy. The decision of the Department shall be
16final. By January 1, 2020, the Department shall establish by
17rule further details of this dispute resolution process.
18Disputes between MCOs and providers presented to the
19Department for resolution are not contested cases, as defined
20in Section 1-30 of the Illinois Administrative Procedure Act,
21conferring any right to an administrative hearing.
22    (g-9)(1) The Department shall publish annually on its
23website a report on the calculation of each managed care
24organization's medical loss ratio showing the following:
25        (A) Premium revenue, with appropriate adjustments.
26        (B) Benefit expense, setting forth the aggregate

 

 

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1    amount spent for the following:
2            (i) Direct paid claims.
3            (ii) Subcapitation payments.
4            (iii) Other claim payments.
5            (iv) Direct reserves.
6            (v) Gross recoveries.
7            (vi) Expenses for activities that improve health
8        care quality as allowed by the Department.
9    (2) The medical loss ratio shall be calculated consistent
10with federal law and regulation following a claims runout
11period determined by the Department.
12    (g-10)(1) "Liability effective date" means the date on
13which an MCO becomes responsible for payment for medically
14necessary and covered services rendered by a provider to one
15of its enrollees in accordance with the contract terms between
16the MCO and the provider. The liability effective date shall
17be the later of:
18        (A) The execution date of a network participation
19    contract agreement.
20        (B) The date the provider or its representative
21    submits to the MCO the complete and accurate standardized
22    roster form for the provider in the format approved by the
23    Department.
24        (C) The provider effective date contained within the
25    Department's provider enrollment subsystem within the
26    Illinois Medicaid Program Advanced Cloud Technology

 

 

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1    (IMPACT) System.
2    (2) The standardized roster form may be submitted to the
3MCO at the same time that the provider submits an enrollment
4application to the Department through IMPACT.
5    (3) By October 1, 2019, the Department shall require all
6MCOs to update their provider directory with information for
7new practitioners of existing contracted providers within 30
8days of receipt of a complete and accurate standardized roster
9template in the format approved by the Department provided
10that the provider is effective in the Department's provider
11enrollment subsystem within the IMPACT system. Such provider
12directory shall be readily accessible for purposes of
13selecting an approved health care provider and comply with all
14other federal and State requirements.
15    (g-11) The Department shall work with relevant
16stakeholders on the development of operational guidelines to
17enhance and improve operational performance of Illinois'
18Medicaid managed care program, including, but not limited to,
19improving provider billing practices, reducing claim
20rejections and inappropriate payment denials, and
21standardizing processes, procedures, definitions, and response
22timelines, with the goal of reducing provider and MCO
23administrative burdens and conflict. The Department shall
24include a report on the progress of these program improvements
25and other topics in its Fiscal Year 2020 annual report to the
26General Assembly.

 

 

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1    (h) The Department shall not expand mandatory MCO
2enrollment into new counties beyond those counties already
3designated by the Department as of June 1, 2014 for the
4individuals whose eligibility for medical assistance is not
5the seniors or people with disabilities population until the
6Department provides an opportunity for accountable care
7entities and MCOs to participate in such newly designated
8counties.
9    (i) The requirements of this Section apply to contracts
10with accountable care entities and MCOs entered into, amended,
11or renewed after June 16, 2014 (the effective date of Public
12Act 98-651).
13    (j) Health care information released to managed care
14organizations. A health care provider shall release to a
15Medicaid managed care organization, upon request, and subject
16to the Health Insurance Portability and Accountability Act of
171996 and any other law applicable to the release of health
18information, the health care information of the MCO's
19enrollee, if the enrollee has completed and signed a general
20release form that grants to the health care provider
21permission to release the recipient's health care information
22to the recipient's insurance carrier.
23(Source: P.A. 100-201, eff. 8-18-17; 100-580, eff. 3-12-18;
24100-587, eff. 6-4-18; 101-209, eff. 8-5-19.)
 
25    (305 ILCS 5/5-30.12a new)

 

 

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1    Sec. 5-30.12a. Medical Electronic Data Interchange system
2upgrade. By July 1, 2022, the Department of Healthcare and
3Family Services shall explore the availability of and, if
4reasonably available, procure technology that: (i) allows the
5Department's Medical Electronic Data Interchange (MEDI) system
6to update recipient eligibility and coverage information for
7providers in real time; and (ii) allows the Department to
8transmit updated recipient eligibility and coverage
9information to managed care organizations under contract with
10the Department to ensure the information contained in the MEDI
11system corresponds with the information maintained by managed
12care organizations in their web-based provider portals.
 
13    (305 ILCS 5/5-43 new)
14    Sec. 5-43. MCO post-payment audit; time period limitation.
15Notwithstanding any provision of this Code to the contrary, in
16order to recover an overpayment by recoupment or offset of
17future payments, a managed care organization's post-payment
18audit of any claim submitted by a provider must be completed no
19later than 2 years after the claim's payment date. The 2-year
20time limit does not apply to claims that are (i) submitted
21fraudulently, (ii) known, or should have been known, by the
22provider to be a pattern of inappropriate billing according to
23standard provider billing practices, or (iii) subject to any
24federal law or regulation that permits post-payment audits
25beyond 2 years.
 

 

 

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1    Section 99. Effective date. This Act takes effect upon
2becoming law.".