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



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2    AMENDMENT NO. ___. Amend House Resolution 100 by deleting
3everything and replacing it with the following:
4    "WHEREAS, The Medicaid program in Illinois has an immense,
5and growing, impact, both in terms of taxpayer dollars and the
6effect it has on citizens across the State; and
7    WHEREAS, State resources for healthcare services are
8currently so scarce that many healthcare providers are
9discontinuing services, leading to a profoundly detrimental
10impact on our communities; and
11    WHEREAS, Enrollment under the Illinois Department of
12Healthcare and Family Services' Medical Assistance Programs
13(Medicaid) exceeds three million; and
14    WHEREAS, A sizable portion of the Medicaid population is



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1currently enrolled, often mandatorily, in Managed Care
2Organizations (MCOs), making outlays to MCOS, measured in
3billions of dollars, one of the largest resource uses in the
4State; and
5    WHEREAS, There has been little information disseminated to
6the General Assembly in terms of how State resources are being
7spent on MCOs and on the overall healthcare outcomes for
8individuals enrolled in these MCOs; and
9    WHEREAS, In this quickly evolving environment, the General
10Assembly must stay engaged in Medicaid funding and
11corresponding healthcare outcome issues and must be prepared to
12make legislative and administrative recommendations;
13therefore, be it
16Auditor General is directed to conduct an audit of Medicaid
17MCOs, which includes a comparison of State expenditures between
18MCOs and the Medicaid fee-for-service program; and be it
20    RESOLVED, That the audit shall examine capitation rate
21setting and reimbursement issues for Medicaid MCOs for fiscal
22year 2016 with respect to the following issues:



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1        (1) Compare the total dollar amount of all reported MCO
2    encounter data submitted to the Illinois Department of
3    Healthcare and Family Services (DHFS) during SFY 2016 to
4    the total dollar amount of reported claims payments made on
5    behalf of Illinois Medicaid individuals by MCOs as reported
6    to DHFS during SFY 2016;
7        (2) Whether MCO encounter data is used by the
8    Department of Healthcare and Family Services (DHFS) to set
9    capitation rates;
10        (3) Calculate the aggregate amount of MCO capitation
11    payments made by DHFS during SFY2016 (exclude payments
12    authorized under 305 ILCS Sections 5/5A-12.2, 5/5A-12.4,
13    and 5/5A-12 from this calculation);
14        (4) Determine the amount of payments made by DHFS to
15    reimburse for-profit MCOs for the ACA Health Insurance Fee
16    (HIF); determine if reimbursement by the State to
17    for-profit MCOs for this HIF payment is mandated by federal
18    CMS;
19        (5) Determine the amount of payments made by DHFS to
20    reimburse for-profit MCOs for "gross-ups" related to the
21    HIF payment; determine the purpose of the "gross-up"



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1    payments;
2        (6) The incidence to which the MCO capitation rates
3    contain supplemental, GRF-based payments to providers; for
4    these payments, determine the amount of the supplemental,
5    which providers received these payments, and whether these
6    monies were directly tied to services actually provided (do
7    not include payments authorized under 305 ILCS Sections
8    5/5A-12.2, 5/5A-12.4, and 5/5A-12);
9        (7) What administrative costs are paid to MCOs in terms
10    of total dollars and percent of overall MCO medical
11    based-payments;
12        (8) What is the average payout ratio for all MCOs in
13    aggregate and for each MCO individually; for the purposes
14    of this audit, payout ratio is defined as all paid claims
15    to Medicaid providers made by MCOs as reported to HFS for
16    state fiscal year 2016 divided by aggregate MCO capitation
17    payments made by DHFS for State fiscal year 2016; and
18        (9) What the denial rates are for MCOs and for
19    fee-for-service providers billing the DHFS; determine
20    whether there is a higher denial rate for services paid by
21    MCOs; and be it further



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1    RESOLVED, That the Illinois Department of Healthcare and
2Family Services and any other State agency having information
3relevant to this audit cooperate fully and promptly with the
4Auditor General's Office in its conduct; and be it further
5    RESOLVED, That the Auditor General commence this audit as
6soon as possible and report his findings and recommendations
7upon completion in accordance with the provisions of Section
83-14 of the Illinois State Auditing Act."