Rep. Anna Moeller

Filed: 5/16/2023

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 1965

2    AMENDMENT NO. ______. Amend Senate Bill 1965 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-30.8 as follows:
 
6    (305 ILCS 5/5-30.8)
7    Sec. 5-30.8. Managed care organization rate transparency.
8    (a) For the establishment of managed care organization
9(MCO) capitation base rate payments from the State, including,
10but not limited to: (i) hospital fee schedule reforms and
11updates, (ii) rates related to a single State-mandated
12preferred drug list, (iii) rate updates related to the State's
13preferred drug list, (iv) inclusion of coverage for children
14with special needs, (v) inclusion of coverage for children
15within the child welfare system, (vi) annual MCO capitation
16rates, and (vii) any retroactive provider fee schedule

 

 

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1adjustments or other changes required by legislation or other
2actions, the Department of Healthcare and Family Services
3shall implement a capitation base rate setting process
4beginning on July 27, 2018 (the effective date of Public Act
5100-646) which shall include all of the following elements of
6transparency:
7        (1) The Department shall include participating MCOs
8    and a statewide trade association representing a majority
9    of participating MCOs in meetings to discuss the impact to
10    base capitation rates as a result of any new or updated
11    hospital fee schedules or other provider fee schedules.
12    Additionally, the Department shall share any data or
13    reports used to develop MCO capitation rates with
14    participating MCOs. This data shall be comprehensive
15    enough for MCO actuaries to recreate and verify the
16    accuracy of the capitation base rate build-up.
17        (2) The Department shall not limit the number of
18    experts that each MCO is allowed to bring to the draft
19    capitation base rate meeting or the final capitation base
20    rate review meeting. Draft and final capitation base rate
21    review meetings shall be held in at least 2 locations.
22        (3) The Department and its contracted actuary shall
23    meet with all participating MCOs simultaneously and
24    together along with consulting actuaries contracted with
25    statewide trade association representing a majority of
26    Medicaid health plans at the request of the plans.

 

 

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1    Participating MCOs shall additionally, at their request,
2    be granted individual capitation rate development meetings
3    with the Department.
4        (4) (Blank). Any quality incentive or other incentive
5    withholding of any portion of the actuarially certified
6    capitation rates must be budget-neutral. The entirety of
7    any aggregate withheld amounts must be returned to the
8    MCOs in proportion to their performance on the relevant
9    performance metric. No amounts shall be returned to the
10    Department if all performance measures are not achieved to
11    the extent allowable by federal law and regulations.
12        (4.5) Effective for calendar year 2024, a quality
13    withhold program may be established by the Department for
14    the HealthChoice Illinois Managed Care Program or any
15    successor program. If such program withholds a portion of
16    the actuarially certified capitation rates, the program
17    must meet the following criteria: (i) benchmarks must be
18    discussed publicly, based on predetermined quality
19    standards that align with the Department's federally
20    approved quality strategy, and set by publication on the
21    Department's website at least 4 months prior to the start
22    of the calendar year; (ii) incentive measures and
23    benchmarks must be reasonable and attainable within the
24    measurement year; and (iii) no less than 75% of the
25    metrics shall be tied to nationally recognized measures.
26    Any non-nationally recognized measures shall be in the

 

 

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1    reporting category for at least 2 years of experience and
2    evaluation for consistency among MCOs prior to setting a
3    performance baseline. The Department shall provide MCOs
4    with biannual industry average data on the quality
5    withhold measures. If all the money withheld is not earned
6    back by individual MCOs, the Department shall reallocate
7    unearned funds among the MCOs in one or both of the
8    following manners: based upon their quality performance or
9    for quality and equity improvement projects. Nothing in
10    this paragraph prohibits the Department and the MCOs from
11    establishing any other quality performance program.
12        (5) Upon request, the Department shall provide written
13    responses to questions regarding MCO capitation base
14    rates, the capitation base development methodology, and
15    MCO capitation rate data, and all other requests regarding
16    capitation rates from MCOs. Upon request, the Department
17    shall also provide to the MCOs materials used in
18    incorporating provider fee schedules into base capitation
19    rates.
20    (b) For the development of capitation base rates for new
21capitation rate years:
22        (1) The Department shall take into account emerging
23    experience in the development of the annual MCO capitation
24    base rates, including, but not limited to, current-year
25    cost and utilization trends observed by MCOs in an
26    actuarially sound manner and in accordance with federal

 

 

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1    law and regulations.
2        (2) No later than January 1 of each year, the
3    Department shall release an agreed upon annual calendar
4    that outlines dates for capitation rate setting meetings
5    for that year. The calendar shall include at least the
6    following meetings and deadlines:
7            (A) An initial meeting for the Department to
8        review MCO data and draft rate assumptions to be used
9        in the development of capitation base rates for the
10        following year.
11            (B) A draft rate meeting after the Department
12        provides the MCOs with the draft capitation base rates
13        to discuss, review, and seek feedback regarding the
14        draft capitation base rates.
15        (3) Prior to the submission of final capitation rates
16    to the federal Centers for Medicare and Medicaid Services,
17    the Department shall provide the MCOs with a final
18    actuarial report including the final capitation base rates
19    for the following year and subsequently conduct a final
20    capitation base review meeting. Final capitation rates
21    shall be marked final.
22    (c) For the development of capitation base rates
23reflecting policy changes:
24        (1) Unless contrary to federal law and regulation, the
25    Department must provide notice to MCOs of any significant
26    operational policy change no later than 60 days prior to

 

 

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1    the effective date of an operational policy change in
2    order to give MCOs time to prepare for and implement the
3    operational policy change and to ensure that the quality
4    and delivery of enrollee health care is not disrupted.
5    "Operational policy change" means a change to operational
6    requirements such as reporting formats, encounter
7    submission definitional changes, or required provider
8    interfaces made at the sole discretion of the Department
9    and not required by legislation with a retroactive
10    effective date. Nothing in this Section shall be construed
11    as a requirement to delay or prohibit implementation of
12    policy changes that impact enrollee benefits as determined
13    in the sole discretion of the Department.
14        (2) No later than 60 days after the effective date of
15    the policy change or program implementation, the
16    Department shall meet with the MCOs regarding the initial
17    data collection needed to establish capitation base rates
18    for the policy change. Additionally, the Department shall
19    share with the participating MCOs what other data is
20    needed to estimate the change and the processes for
21    collection of that data that shall be utilized to develop
22    capitation base rates.
23        (3) No later than 60 days after the effective date of
24    the policy change or program implementation, the
25    Department shall meet with MCOs to review data and the
26    Department's written draft assumptions to be used in

 

 

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1    development of capitation base rates for the policy
2    change, and shall provide opportunities for questions to
3    be asked and answered.
4        (4) No later than 60 days after the effective date of
5    the policy change or program implementation, the
6    Department shall provide the MCOs with draft capitation
7    base rates and shall also conduct a draft capitation base
8    rate meeting with MCOs to discuss, review, and seek
9    feedback regarding the draft capitation base rates.
10    (d) For the development of capitation base rates for
11retroactive policy or fee schedule changes:
12        (1) The Department shall meet with the MCOs regarding
13    the initial data collection needed to establish capitation
14    base rates for the policy change. Additionally, the
15    Department shall share with the participating MCOs what
16    other data is needed to estimate the change and the
17    processes for collection of the data that shall be
18    utilized to develop capitation base rates.
19        (2) The Department shall meet with MCOs to review data
20    and the Department's written draft assumptions to be used
21    in development of capitation base rates for the policy
22    change. The Department shall provide opportunities for
23    questions to be asked and answered.
24        (3) The Department shall provide the MCOs with draft
25    capitation rates and shall also conduct a draft rate
26    meeting with MCOs to discuss, review, and seek feedback

 

 

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1    regarding the draft capitation base rates.
2        (4) The Department shall inform MCOs no less than
3    quarterly of upcoming benefit and policy changes to the
4    Medicaid program.
5    (e) Meetings of the group established to discuss Medicaid
6capitation rates under this Section shall be closed to the
7public and shall not be subject to the Open Meetings Act.
8Records and information produced by the group established to
9discuss Medicaid capitation rates under this Section shall be
10confidential and not subject to the Freedom of Information
11Act.
12(Source: P.A. 100-646, eff. 7-27-18; 101-81, eff. 7-12-19.)".