103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
SB1962

 

Introduced 2/9/2023, by Sen. Ann Gillespie

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-30.1

    Amends the Illinois Public Aid. Makes a technical change in a Section concerning managed care protections.


LRB103 30582 KTG 57019 b

 

 

A BILL FOR

 

SB1962LRB103 30582 KTG 57019 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
5changing Section 5-30.1 as follows:
 
6    (305 ILCS 5/5-30.1)
7    Sec. 5-30.1. Managed care protections.
8    (a) As used in this Section:
9    "Managed care organization" or "MCO" means any entity
10which contracts with the the Department to provide services
11where payment for medical services is made on a capitated
12basis.
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
17    defined by Section 10 of the Managed Care Reform and
18    Patient Rights Act;
19        (3) post-stabilization medical services, as defined by
20    Section 10 of the Managed Care Reform and Patient Rights
21    Act; and
22        (4) emergency medical conditions, as defined by
23    Section 10 of the Managed Care Reform and Patient Rights

 

 

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

 

 

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1    agreement concerning the enrollee's care and an affiliated
2    provider was unavailable for a consultation, in which case
3    the MCO must pay for such services rendered by the
4    treating non-affiliated provider until an affiliated
5    provider was reached and either concurred with the
6    treating non-affiliated provider's plan of care or assumed
7    responsibility for the enrollee's care. Such payment shall
8    be made at the default rate of reimbursement paid under
9    Illinois Medicaid fee-for-service program methodology,
10    including all policy adjusters, including but not limited
11    to Medicaid High Volume Adjustments, Medicaid Percentage
12    Adjustments, Outpatient High Volume Adjustments and all
13    outlier add-on adjustments to the extent that such
14    adjustments are incorporated in the development of the
15    applicable MCO capitated rates.
16    (e) The following requirements apply to MCOs in
17determining payment for all emergency services:
18        (1) MCOs shall not impose any requirements for prior
19    approval of emergency services.
20        (2) The MCO shall cover emergency services provided to
21    enrollees who are temporarily away from their residence
22    and outside the contracting area to the extent that the
23    enrollees would be entitled to the emergency services if
24    they still were within the contracting area.
25        (3) The MCO shall have no obligation to cover medical
26    services provided on an emergency basis that are not

 

 

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1    covered services under the contract.
2        (4) The MCO shall not condition coverage for emergency
3    services on the treating provider notifying the MCO of the
4    enrollee's screening and treatment within 10 days after
5    presentation for emergency services.
6        (5) The determination of the attending emergency
7    physician, or the provider actually treating the enrollee,
8    of whether an enrollee is sufficiently stabilized for
9    discharge or transfer to another facility, shall be
10    binding on the MCO. The MCO shall cover emergency services
11    for all enrollees whether the emergency services are
12    provided by an affiliated or non-affiliated provider.
13        (6) The MCO's financial responsibility for
14    post-stabilization care services it has not pre-approved
15    ends when:
16            (A) a plan physician with privileges at the
17        treating hospital assumes responsibility for the
18        enrollee's care;
19            (B) a plan physician assumes responsibility for
20        the enrollee's care through transfer;
21            (C) a contracting entity representative and the
22        treating physician reach an agreement concerning the
23        enrollee's care; or
24            (D) the enrollee is discharged.
25    (f) Network adequacy and transparency.
26        (1) The Department shall:

 

 

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1            (A) ensure that an adequate provider network is in
2        place, taking into consideration health professional
3        shortage areas and medically underserved areas;
4            (B) publicly release an explanation of its process
5        for analyzing network adequacy;
6            (C) periodically ensure that an MCO continues to
7        have an adequate network in place;
8            (D) require MCOs, including Medicaid Managed Care
9        Entities as defined in Section 5-30.2, to meet
10        provider directory requirements under Section 5-30.3;
11            (E) require MCOs to ensure that any
12        Medicaid-certified provider under contract with an MCO
13        and previously submitted on a roster on the date of
14        service is paid for any medically necessary,
15        Medicaid-covered, and authorized service rendered to
16        any of the MCO's enrollees, regardless of inclusion on
17        the MCO's published and publicly available directory
18        of available providers; and
19            (F) require MCOs, including Medicaid Managed Care
20        Entities as defined in Section 5-30.2, to meet each of
21        the requirements under subsection (d-5) of Section 10
22        of the Network Adequacy and Transparency Act; with
23        necessary exceptions to the MCO's network to ensure
24        that admission and treatment with a provider or at a
25        treatment facility in accordance with the network
26        adequacy standards in paragraph (3) of subsection

 

 

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1        (d-5) of Section 10 of the Network Adequacy and
2        Transparency Act is limited to providers or facilities
3        that are Medicaid certified.
4        (2) Each MCO shall confirm its receipt of information
5    submitted specific to physician or dentist additions or
6    physician or dentist deletions from the MCO's provider
7    network within 3 days after receiving all required
8    information from contracted physicians or dentists, and
9    electronic physician and dental directories must be
10    updated consistent with current rules as published by the
11    Centers for Medicare and Medicaid Services or its
12    successor agency.
13    (g) Timely payment of claims.
14        (1) The MCO shall pay a claim within 30 days of
15    receiving a claim that contains all the essential
16    information needed to adjudicate the claim.
17        (2) The MCO shall notify the billing party of its
18    inability to adjudicate a claim within 30 days of
19    receiving that claim.
20        (3) The MCO shall pay a penalty that is at least equal
21    to the timely payment interest penalty imposed under
22    Section 368a of the Illinois Insurance Code for any claims
23    not timely paid.
24            (A) When an MCO is required to pay a timely payment
25        interest penalty to a provider, the MCO must calculate
26        and pay the timely payment interest penalty that is

 

 

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1        due to the provider within 30 days after the payment of
2        the claim. In no event shall a provider be required to
3        request or apply for payment of any owed timely
4        payment interest penalties.
5            (B) Such payments shall be reported separately
6        from the claim payment for services rendered to the
7        MCO's enrollee and clearly identified as interest
8        payments.
9        (4)(A) The Department shall require MCOs to expedite
10    payments to providers identified on the Department's
11    expedited provider list, determined in accordance with 89
12    Ill. Adm. Code 140.71(b), on a schedule at least as
13    frequently as the providers are paid under the
14    Department's fee-for-service expedited provider schedule.
15        (B) Compliance with the expedited provider requirement
16    may be satisfied by an MCO through the use of a Periodic
17    Interim Payment (PIP) program that has been mutually
18    agreed to and documented between the MCO and the provider,
19    if the PIP program ensures that any expedited provider
20    receives regular and periodic payments based on prior
21    period payment experience from that MCO. Total payments
22    under the PIP program may be reconciled against future PIP
23    payments on a schedule mutually agreed to between the MCO
24    and the provider.
25        (C) The Department shall share at least monthly its
26    expedited provider list and the frequency with which it

 

 

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1    pays providers on the expedited list.
2    (g-5) Recognizing that the rapid transformation of the
3Illinois Medicaid program may have unintended operational
4challenges for both payers and providers:
5        (1) in no instance shall a medically necessary covered
6    service rendered in good faith, based upon eligibility
7    information documented by the provider, be denied coverage
8    or diminished in payment amount if the eligibility or
9    coverage information available at the time the service was
10    rendered is later found to be inaccurate in the assignment
11    of coverage responsibility between MCOs or the
12    fee-for-service system, except for instances when an
13    individual is deemed to have not been eligible for
14    coverage under the Illinois Medicaid program; and
15        (2) the Department shall, by December 31, 2016, adopt
16    rules establishing policies that shall be included in the
17    Medicaid managed care policy and procedures manual
18    addressing payment resolutions in situations in which a
19    provider renders services based upon information obtained
20    after verifying a patient's eligibility and coverage plan
21    through either the Department's current enrollment system
22    or a system operated by the coverage plan identified by
23    the patient presenting for services:
24            (A) such medically necessary covered services
25        shall be considered rendered in good faith;
26            (B) such policies and procedures shall be

 

 

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1        developed in consultation with industry
2        representatives of the Medicaid managed care health
3        plans and representatives of provider associations
4        representing the majority of providers within the
5        identified provider industry; and
6            (C) such rules shall be published for a review and
7        comment period of no less than 30 days on the
8        Department's website with final rules remaining
9        available on the Department's website.
10        The rules on payment resolutions shall include, but
11    not be limited to:
12            (A) the extension of the timely filing period;
13            (B) retroactive prior authorizations; and
14            (C) guaranteed minimum payment rate of no less
15        than the current, as of the date of service,
16        fee-for-service rate, plus all applicable add-ons,
17        when the resulting service relationship is out of
18        network.
19        The rules shall be applicable for both MCO coverage
20    and fee-for-service coverage.
21    If the fee-for-service system is ultimately determined to
22have been responsible for coverage on the date of service, the
23Department shall provide for an extended period for claims
24submission outside the standard timely filing requirements.
25    (g-6) MCO Performance Metrics Report.
26        (1) The Department shall publish, on at least a

 

 

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1    quarterly basis, each MCO's operational performance,
2    including, but not limited to, the following categories of
3    metrics:
4            (A) claims payment, including timeliness and
5        accuracy;
6            (B) prior authorizations;
7            (C) grievance and appeals;
8            (D) utilization statistics;
9            (E) provider disputes;
10            (F) provider credentialing; and
11            (G) member and provider customer service.
12        (2) The Department shall ensure that the metrics
13    report is accessible to providers online by January 1,
14    2017.
15        (3) The metrics shall be developed in consultation
16    with industry representatives of the Medicaid managed care
17    health plans and representatives of associations
18    representing the majority of providers within the
19    identified industry.
20        (4) Metrics shall be defined and incorporated into the
21    applicable Managed Care Policy Manual issued by the
22    Department.
23    (g-7) MCO claims processing and performance analysis. In
24order to monitor MCO payments to hospital providers, pursuant
25to Public Act 100-580, the Department shall post an analysis
26of MCO claims processing and payment performance on its

 

 

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1website every 6 months. Such analysis shall include a review
2and evaluation of a representative sample of hospital claims
3that are rejected and denied for clean and unclean claims and
4the top 5 reasons for such actions and timeliness of claims
5adjudication, which identifies the percentage of claims
6adjudicated within 30, 60, 90, and over 90 days, and the dollar
7amounts associated with those claims.
8    (g-8) Dispute resolution process. The Department shall
9maintain a provider complaint portal through which a provider
10can submit to the Department unresolved disputes with an MCO.
11An unresolved dispute means an MCO's decision that denies in
12whole or in part a claim for reimbursement to a provider for
13health care services rendered by the provider to an enrollee
14of the MCO with which the provider disagrees. Disputes shall
15not be submitted to the portal until the provider has availed
16itself of the MCO's internal dispute resolution process.
17Disputes that are submitted to the MCO internal dispute
18resolution process may be submitted to the Department of
19Healthcare and Family Services' complaint portal no sooner
20than 30 days after submitting to the MCO's internal process
21and not later than 30 days after the unsatisfactory resolution
22of the internal MCO process or 60 days after submitting the
23dispute to the MCO internal process. Multiple claim disputes
24involving the same MCO may be submitted in one complaint,
25regardless of whether the claims are for different enrollees,
26when the specific reason for non-payment of the claims

 

 

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1involves a common question of fact or policy. Within 10
2business days of receipt of a complaint, the Department shall
3present such disputes to the appropriate MCO, which shall then
4have 30 days to issue its written proposal to resolve the
5dispute. The Department may grant one 30-day extension of this
6time frame to one of the parties to resolve the dispute. If the
7dispute remains unresolved at the end of this time frame or the
8provider is not satisfied with the MCO's written proposal to
9resolve the dispute, the provider may, within 30 days, request
10the Department to review the dispute and make a final
11determination. Within 30 days of the request for Department
12review of the dispute, both the provider and the MCO shall
13present all relevant information to the Department for
14resolution and make individuals with knowledge of the issues
15available to the Department for further inquiry if needed.
16Within 30 days of receiving the relevant information on the
17dispute, or the lapse of the period for submitting such
18information, the Department shall issue a written decision on
19the dispute based on contractual terms between the provider
20and the MCO, contractual terms between the MCO and the
21Department of Healthcare and Family Services and applicable
22Medicaid policy. The decision of the Department shall be
23final. By January 1, 2020, the Department shall establish by
24rule further details of this dispute resolution process.
25Disputes between MCOs and providers presented to the
26Department for resolution are not contested cases, as defined

 

 

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1in Section 1-30 of the Illinois Administrative Procedure Act,
2conferring any right to an administrative hearing.
3    (g-9)(1) The Department shall publish annually on its
4website a report on the calculation of each managed care
5organization's medical loss ratio showing the following:
6        (A) Premium revenue, with appropriate adjustments.
7        (B) Benefit expense, setting forth the aggregate
8    amount spent for the following:
9            (i) Direct paid claims.
10            (ii) Subcapitation payments.
11            (iii) Other claim payments.
12            (iv) Direct reserves.
13            (v) Gross recoveries.
14            (vi) Expenses for activities that improve health
15        care quality as allowed by the Department.
16    (2) The medical loss ratio shall be calculated consistent
17with federal law and regulation following a claims runout
18period determined by the Department.
19    (g-10)(1) "Liability effective date" means the date on
20which an MCO becomes responsible for payment for medically
21necessary and covered services rendered by a provider to one
22of its enrollees in accordance with the contract terms between
23the MCO and the provider. The liability effective date shall
24be the later of:
25        (A) The execution date of a network participation
26    contract agreement.

 

 

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1        (B) The date the provider or its representative
2    submits to the MCO the complete and accurate standardized
3    roster form for the provider in the format approved by the
4    Department.
5        (C) The provider effective date contained within the
6    Department's provider enrollment subsystem within the
7    Illinois Medicaid Program Advanced Cloud Technology
8    (IMPACT) System.
9    (2) The standardized roster form may be submitted to the
10MCO at the same time that the provider submits an enrollment
11application to the Department through IMPACT.
12    (3) By October 1, 2019, the Department shall require all
13MCOs to update their provider directory with information for
14new practitioners of existing contracted providers within 30
15days of receipt of a complete and accurate standardized roster
16template in the format approved by the Department provided
17that the provider is effective in the Department's provider
18enrollment subsystem within the IMPACT system. Such provider
19directory shall be readily accessible for purposes of
20selecting an approved health care provider and comply with all
21other federal and State requirements.
22    (g-11) The Department shall work with relevant
23stakeholders on the development of operational guidelines to
24enhance and improve operational performance of Illinois'
25Medicaid managed care program, including, but not limited to,
26improving provider billing practices, reducing claim

 

 

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1rejections and inappropriate payment denials, and
2standardizing processes, procedures, definitions, and response
3timelines, with the goal of reducing provider and MCO
4administrative burdens and conflict. The Department shall
5include a report on the progress of these program improvements
6and other topics in its Fiscal Year 2020 annual report to the
7General Assembly.
8    (g-12) Notwithstanding any other provision of law, if the
9Department or an MCO requires submission of a claim for
10payment in a non-electronic format, a provider shall always be
11afforded a period of no less than 90 business days, as a
12correction period, following any notification of rejection by
13either the Department or the MCO to correct errors or
14omissions in the original submission.
15    Under no circumstances, either by an MCO or under the
16State's fee-for-service system, shall a provider be denied
17payment for failure to comply with any timely submission
18requirements under this Code or under any existing contract,
19unless the non-electronic format claim submission occurs after
20the initial 180 days following the latest date of service on
21the claim, or after the 90 business days correction period
22following notification to the provider of rejection or denial
23of payment.
24    (h) The Department shall not expand mandatory MCO
25enrollment into new counties beyond those counties already
26designated by the Department as of June 1, 2014 for the

 

 

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1individuals whose eligibility for medical assistance is not
2the seniors or people with disabilities population until the
3Department provides an opportunity for accountable care
4entities and MCOs to participate in such newly designated
5counties.
6    (i) The requirements of this Section apply to contracts
7with accountable care entities and MCOs entered into, amended,
8or renewed after June 16, 2014 (the effective date of Public
9Act 98-651).
10    (j) Health care information released to managed care
11organizations. A health care provider shall release to a
12Medicaid managed care organization, upon request, and subject
13to the Health Insurance Portability and Accountability Act of
141996 and any other law applicable to the release of health
15information, the health care information of the MCO's
16enrollee, if the enrollee has completed and signed a general
17release form that grants to the health care provider
18permission to release the recipient's health care information
19to the recipient's insurance carrier.
20    (k) The Department of Healthcare and Family Services,
21managed care organizations, a statewide organization
22representing hospitals, and a statewide organization
23representing safety-net hospitals shall explore ways to
24support billing departments in safety-net hospitals.
25    (l) The requirements of this Section added by Public Act
26102-4 shall apply to services provided on or after the first

 

 

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1day of the month that begins 60 days after April 27, 2021 (the
2effective date of Public Act 102-4).
3(Source: P.A. 101-209, eff. 8-5-19; 102-4, eff. 4-27-21;
4102-43, eff. 7-6-21; 102-144, eff. 1-1-22; 102-454, eff.
58-20-21; 102-813, eff. 5-13-22.)