Full Text of SB3080 99th General Assembly
SB3080sam001 99TH GENERAL ASSEMBLY | Sen. Donne E. Trotter Filed: 5/11/2016
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| 1 | | AMENDMENT TO SENATE BILL 3080
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 3080 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Illinois Public Aid Code is amended by | 5 | | changing 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 which | 10 | | contracts with the Department to provide services where payment | 11 | | for medical services is made on a capitated basis. | 12 | | "Emergency services" include: | 13 | | (1) emergency services, as defined by Section 10 of the | 14 | | Managed Care Reform and Patient Rights Act; | 15 | | (2) emergency medical screening examinations, as | 16 | | defined by Section 10 of the Managed Care Reform and |
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| 1 | | Patient Rights Act; | 2 | | (3) post-stabilization medical services, as defined by | 3 | | Section 10 of the Managed Care Reform and Patient Rights | 4 | | Act; and | 5 | | (4) emergency medical conditions, as defined by
| 6 | | Section 10 of the Managed Care Reform and Patient Rights
| 7 | | Act. | 8 | | (b) As provided by Section 5-16.12, managed care | 9 | | organizations are subject to the provisions of the Managed Care | 10 | | Reform and Patient Rights Act. | 11 | | (c) An MCO shall pay any provider of emergency services | 12 | | that does not have in effect a contract with the contracted | 13 | | Medicaid MCO. The default rate of reimbursement shall be the | 14 | | rate paid under Illinois Medicaid fee-for-service program | 15 | | methodology, including all policy adjusters, including but not | 16 | | limited to Medicaid High Volume Adjustments, Medicaid | 17 | | Percentage Adjustments, Outpatient High Volume Adjustments, | 18 | | and all outlier add-on adjustments to the extent such | 19 | | adjustments are incorporated in the development of the | 20 | | applicable MCO capitated rates. | 21 | | (d) An MCO shall pay for all post-stabilization services as | 22 | | a covered service in any of the following situations: | 23 | | (1) the MCO authorized such services; | 24 | | (2) such services were administered to maintain the | 25 | | enrollee's stabilized condition within one hour after a | 26 | | request to the MCO for authorization of further |
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| 1 | | post-stabilization services; | 2 | | (3) the MCO did not respond to a request to authorize | 3 | | such services within one hour; | 4 | | (4) the MCO could not be contacted; or | 5 | | (5) the MCO and the treating provider, if the treating | 6 | | provider is a non-affiliated provider, could not reach an | 7 | | agreement concerning the enrollee's care and an affiliated | 8 | | provider was unavailable for a consultation, in which case | 9 | | the MCO
must pay for such services rendered by the treating | 10 | | non-affiliated provider until an affiliated provider was | 11 | | reached and either concurred with the treating | 12 | | non-affiliated provider's plan of care or assumed | 13 | | responsibility for the enrollee's care. Such payment shall | 14 | | be made at the default rate of reimbursement paid under | 15 | | Illinois Medicaid fee-for-service program methodology, | 16 | | including all policy adjusters, including but not limited | 17 | | to Medicaid High Volume Adjustments, Medicaid Percentage | 18 | | Adjustments, Outpatient High Volume Adjustments and all | 19 | | outlier add-on adjustments to the extent that such | 20 | | adjustments are incorporated in the development of the | 21 | | applicable MCO capitated rates. | 22 | | (e) The following requirements apply to MCOs in determining | 23 | | payment for all emergency services: | 24 | | (1) MCOs shall not impose any requirements for prior | 25 | | approval of emergency services. | 26 | | (2) The MCO shall cover emergency services provided to |
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| 1 | | enrollees who are temporarily away from their residence and | 2 | | outside the contracting area to the extent that the | 3 | | enrollees would be entitled to the emergency services if | 4 | | they still were within the contracting area. | 5 | | (3) The MCO shall have no obligation to cover medical | 6 | | services provided on an emergency basis that are not | 7 | | covered services under the contract. | 8 | | (4) The MCO shall not condition coverage for emergency | 9 | | services on the treating provider notifying the MCO of the | 10 | | enrollee's screening and treatment within 10 days after | 11 | | presentation for emergency services. | 12 | | (5) The determination of the attending emergency | 13 | | physician, or the provider actually treating the enrollee, | 14 | | of whether an enrollee is sufficiently stabilized for | 15 | | discharge or transfer to another facility, shall be binding | 16 | | on the MCO. The MCO shall cover emergency services for all | 17 | | enrollees whether the emergency services are provided by an | 18 | | affiliated or non-affiliated provider. | 19 | | (6) The MCO's financial responsibility for | 20 | | post-stabilization care services it has not pre-approved | 21 | | ends when: | 22 | | (A) a plan physician with privileges at the | 23 | | treating hospital assumes responsibility for the | 24 | | enrollee's care; | 25 | | (B) a plan physician assumes responsibility for | 26 | | the enrollee's care through transfer; |
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| 1 | | (C) a contracting entity representative and the | 2 | | treating physician reach an agreement concerning the | 3 | | enrollee's care; or | 4 | | (D) the enrollee is discharged. | 5 | | (f) Network adequacy and transparency . | 6 | | (1) The Department shall: | 7 | | (A) ensure that an adequate provider network is in | 8 | | place, taking into consideration health professional | 9 | | shortage areas and medically underserved areas; | 10 | | (B) publicly release an explanation of its process | 11 | | for analyzing network adequacy; | 12 | | (C) periodically ensure that an MCO continues to | 13 | | have an adequate network in place; and | 14 | | (D) require MCOs to maintain an updated and public | 15 | | list of network providers. | 16 | | (2) Each MCO shall confirm its receipt of information | 17 | | submitted specific to physician additions or physician | 18 | | deletions from the MCO's provider network within 3 days | 19 | | after receiving all required information from contracted | 20 | | physicians, and electronic physician directories must be | 21 | | updated consistent with current rules as published by the | 22 | | Centers for Medicare and Medicaid Services or its successor | 23 | | agency. | 24 | | (g) Timely payment of claims. | 25 | | (1) The MCO shall pay a claim within 30 days of | 26 | | receiving a claim that contains all the essential |
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| 1 | | information needed to adjudicate the claim. | 2 | | (2) The MCO shall notify the billing party of its | 3 | | inability to adjudicate a claim within 30 days of receiving | 4 | | that claim. | 5 | | (3) The MCO shall pay a penalty that is at least equal | 6 | | to the penalty imposed under the Illinois Insurance Code | 7 | | for any claims not timely paid. | 8 | | (4) The Department may establish a process for MCOs to | 9 | | expedite payments to providers based on criteria | 10 | | established by the Department. | 11 | | (g-5) Recognizing that the rapid transformation of the | 12 | | Illinois Medicaid program may have unintended operational | 13 | | challenges for both payers and providers: | 14 | | (1) in no instance shall a medically necessary covered | 15 | | service rendered in good faith, based upon eligibility | 16 | | information documented by the provider, be denied coverage | 17 | | or diminished in payment amount if the eligibility or | 18 | | coverage information available at the time the service was | 19 | | rendered is later found to be inaccurate; and | 20 | | (2) the Department shall, by December 31, 2016, adopt | 21 | | rules establishing policies that shall be included in the | 22 | | Medicaid managed care policy and procedures manual | 23 | | addressing payment resolutions in situations in which a | 24 | | provider renders services based upon information obtained | 25 | | after verifying a patient's eligibility and coverage plan | 26 | | through either the Department's current enrollment system |
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| 1 | | or a system operated by the coverage plan identified by the | 2 | | patient presenting for services: | 3 | | (A) such medically necessary covered services | 4 | | shall be considered rendered in good faith; | 5 | | (B) such policies and procedures shall be | 6 | | developed in consultation with industry | 7 | | representatives of the Medicaid managed care health | 8 | | plans and representatives of provider associations | 9 | | representing the majority of providers within the | 10 | | identified provider industry; and | 11 | | (C) such rules shall be published for a review and | 12 | | comment period of no less than 30 days on the | 13 | | Department's website with final rules remaining | 14 | | available on the Department's website. | 15 | | (3) The rules on payment resolutions shall include, but | 16 | | not be limited to: | 17 | | (A) the extension of the timely filing period; | 18 | | (B) retroactive prior authorizations; and | 19 | | (C) guaranteed minimum payment rate of no less than | 20 | | the current, as of the date of service, fee-for-service | 21 | | rate, plus all applicable add-ons, when the resulting | 22 | | service relationship is out of network. | 23 | | (4) The rules shall be applicable for both MCO coverage | 24 | | and fee-for-service coverage. | 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 report | 13 | | is accessible to providers online by January 1, 2017. | 14 | | (3) The metrics shall be developed in consultation with | 15 | | industry representatives of the Medicaid managed care | 16 | | health plans and representatives of associations | 17 | | representing the majority of providers within the | 18 | | identified industry. | 19 | | (4) Metrics shall be defined and incorporated into the | 20 | | applicable Managed Care Policy Manual issued by the | 21 | | Department. | 22 | | (h) The Department shall not expand mandatory MCO | 23 | | enrollment into new counties beyond those counties already | 24 | | designated by the Department as of June 1, 2014 for the | 25 | | individuals whose eligibility for medical assistance is not the | 26 | | seniors or people with disabilities population until the |
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| 1 | | Department provides an opportunity for accountable care | 2 | | entities and MCOs to participate in such newly designated | 3 | | counties. | 4 | | (i) The requirements of this Section apply to contracts | 5 | | with accountable care entities and MCOs entered into, amended, | 6 | | or renewed after the effective date of this amendatory Act of | 7 | | the 98th General Assembly.
| 8 | | (Source: P.A. 98-651, eff. 6-16-14.)
| 9 | | Section 99. Effective date. This Act takes effect upon | 10 | | becoming law.".
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