Illinois General Assembly - Full Text of HR0100
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Full Text of HR0100  100th General Assembly




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2    WHEREAS, The Medicaid program in Illinois has an immense,
3and growing, impact, both in terms of taxpayer dollars and the
4effect it has on citizens across the State; and
5    WHEREAS, State resources for healthcare services are
6currently so scarce that many healthcare providers are
7discontinuing services, leading to a profoundly detrimental
8impact on our communities; and
9    WHEREAS, Enrollment under the Illinois Department of
10Healthcare and Family Services' Medical Assistance Programs
11(Medicaid) exceeds three million; and
12    WHEREAS, A sizable portion of the Medicaid population is
13currently enrolled, often mandatorily, in Managed Care
14Organizations (MCOs), making outlays to MCOS, measured in
15billions of dollars, one of the largest resource uses in the
16State; and
17    WHEREAS, There has been little information disseminated to
18the General Assembly in terms of how State resources are being
19spent on MCOs and on the overall healthcare outcomes for
20individuals enrolled in these MCOs; and



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1    WHEREAS, In this quickly evolving environment, the General
2Assembly must stay engaged in Medicaid funding and
3corresponding healthcare outcome issues and must be prepared to
4make legislative and administrative recommendations;
5therefore, be it
8Auditor General is directed to conduct an audit of Medicaid
9MCOs, which includes a comparison of State expenditures between
10MCOs and the Medicaid fee-for-service program; and be it
12    RESOLVED, That the audit shall examine capitation rate
13setting and reimbursement issues for Medicaid MCOs for fiscal
14year 2016 with respect to the following issues:
15        (1) Compare the total dollar amount of all reported MCO
16    encounter data submitted to the Illinois Department of
17    Healthcare and Family Services (DHFS) during SFY 2016 to
18    the total dollar amount of reported claims payments made on
19    behalf of Illinois Medicaid individuals by MCOs as reported
20    to DHFS during SFY 2016;
21        (2) Whether MCO encounter data is used by the
22    Department of Healthcare and Family Services (DHFS) to set



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1    capitation rates;
2        (3) Calculate the aggregate amount of MCO capitation
3    payments made by DHFS during SFY2016 (exclude payments
4    authorized under 305 ILCS Sections 5/5A-12.2, 5/5A-12.4,
5    and 5/5A-12 from this calculation);
6        (4) Determine the amount of payments made by DHFS to
7    reimburse for-profit MCOs for the ACA Health Insurance Fee
8    (HIF); determine if reimbursement by the State to
9    for-profit MCOs for this HIF payment is mandated by federal
10    CMS;
11        (5) Determine the amount of payments made by DHFS to
12    reimburse for-profit MCOs for "gross-ups" related to the
13    HIF payment; determine the purpose of the "gross-up"
14    payments;
15        (6) The incidence to which the MCO capitation rates
16    contain supplemental, GRF-based payments to providers; for
17    these payments, determine the amount of the supplemental,
18    which providers received these payments, and whether these
19    monies were directly tied to services actually provided (do
20    not include payments authorized under 305 ILCS Sections
21    5/5A-12.2, 5/5A-12.4, and 5/5A-12);



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1        (7) What administrative costs are paid to MCOs in terms
2    of total dollars and percent of overall MCO medical
3    based-payments;
4        (8) What is the average payout ratio for all MCOs in
5    aggregate and for each MCO individually; for the purposes
6    of this audit, payout ratio is defined as all paid claims
7    to Medicaid providers made by MCOs as reported to HFS for
8    state fiscal year 2016 divided by aggregate MCO capitation
9    payments made by DHFS for State fiscal year 2016; and
10        (9) What the denial rates are for MCOs and for
11    fee-for-service providers billing the DHFS; determine
12    whether there is a higher denial rate for services paid by
13    MCOs; and be it further
14    RESOLVED, That the Illinois Department of Healthcare and
15Family Services and any other State agency having information
16relevant to this audit cooperate fully and promptly with the
17Auditor General's Office in its conduct; and be it further
18    RESOLVED, That the Auditor General commence this audit as
19soon as possible and report his findings and recommendations
20upon completion in accordance with the provisions of Section
213-14 of the Illinois State Auditing Act.