Full Text of HB2832 102nd General Assembly
HB2832ham001 102ND GENERAL ASSEMBLY | Rep. Jackie Haas Filed: 3/25/2021
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| 1 | | AMENDMENT TO HOUSE BILL 2832
| 2 | | AMENDMENT NO. ______. Amend House Bill 2832 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Illinois Public Aid Code is amended by | 5 | | adding Section 5-43 and by changing Section 5-30.1 and by | 6 | | adding Section 5-30.12a as follows: | 7 | | (305 ILCS 5/5-30.1) | 8 | | Sec. 5-30.1. Managed care protections. | 9 | | (a) As used in this Section: | 10 | | "Managed care organization" or "MCO" means any entity | 11 | | which contracts with the Department to provide services where | 12 | | payment for medical services is made on a capitated basis. | 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 |
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| 1 | | defined by Section 10 of the Managed Care Reform and | 2 | | Patient Rights Act; | 3 | | (3) post-stabilization medical services, as defined by | 4 | | Section 10 of the Managed Care Reform and Patient Rights | 5 | | Act; and | 6 | | (4) emergency medical conditions, as defined by
| 7 | | Section 10 of the Managed Care Reform and Patient Rights
| 8 | | Act. | 9 | | (b) As provided by Section 5-16.12, managed care | 10 | | organizations are subject to the provisions of the Managed | 11 | | Care Reform and Patient Rights Act. | 12 | | (c) An MCO shall pay any provider of emergency services | 13 | | that does not have in effect a contract with the contracted | 14 | | Medicaid MCO. The default rate of reimbursement shall be the | 15 | | rate paid under Illinois Medicaid fee-for-service program | 16 | | methodology, including all policy adjusters, including but not | 17 | | limited to Medicaid High Volume Adjustments, Medicaid | 18 | | Percentage Adjustments, Outpatient High Volume Adjustments, | 19 | | and all outlier add-on adjustments to the extent such | 20 | | adjustments are incorporated in the development of the | 21 | | applicable MCO capitated rates. | 22 | | (d) An MCO shall pay for all post-stabilization services | 23 | | as a covered service in any of the following situations: | 24 | | (1) the MCO authorized such services; | 25 | | (2) such services were administered to maintain the | 26 | | enrollee's stabilized condition within one hour after a |
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| 1 | | request to the MCO for authorization of further | 2 | | post-stabilization services; | 3 | | (3) the MCO did not respond to a request to authorize | 4 | | such services within one hour; | 5 | | (4) the MCO could not be contacted; or | 6 | | (5) the MCO and the treating provider, if the treating | 7 | | provider is a non-affiliated provider, could not reach an | 8 | | agreement concerning the enrollee's care and an affiliated | 9 | | provider was unavailable for a consultation, in which case | 10 | | the MCO
must pay for such services rendered by the | 11 | | treating non-affiliated provider until an affiliated | 12 | | provider was reached and either concurred with the | 13 | | treating non-affiliated provider's plan of care or assumed | 14 | | responsibility for the enrollee's care. Such payment shall | 15 | | be made at the default rate of reimbursement paid under | 16 | | Illinois Medicaid fee-for-service program methodology, | 17 | | including all policy adjusters, including but not limited | 18 | | to Medicaid High Volume Adjustments, Medicaid Percentage | 19 | | Adjustments, Outpatient High Volume Adjustments and all | 20 | | outlier add-on adjustments to the extent that such | 21 | | adjustments are incorporated in the development of the | 22 | | applicable MCO capitated rates. | 23 | | (e) The following requirements apply to MCOs in | 24 | | determining payment for all emergency services: | 25 | | (1) MCOs shall not impose any requirements for prior | 26 | | approval of emergency services. |
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| 1 | | (2) The MCO shall cover emergency services provided to | 2 | | enrollees who are temporarily away from their residence | 3 | | and outside the contracting area to the extent that the | 4 | | enrollees would be entitled to the emergency services if | 5 | | they still were within the contracting area. | 6 | | (3) The MCO shall have no obligation to cover medical | 7 | | services provided on an emergency basis that are not | 8 | | covered services under the contract. | 9 | | (4) The MCO shall not condition coverage for emergency | 10 | | services on the treating provider notifying the MCO of the | 11 | | enrollee's screening and treatment within 10 days after | 12 | | presentation for emergency services. | 13 | | (5) The determination of the attending emergency | 14 | | physician, or the provider actually treating the enrollee, | 15 | | of whether an enrollee is sufficiently stabilized for | 16 | | discharge or transfer to another facility, shall be | 17 | | binding on the MCO. The MCO shall cover emergency services | 18 | | for all enrollees whether the emergency services are | 19 | | provided by an affiliated or non-affiliated provider. | 20 | | (6) The MCO's financial responsibility for | 21 | | post-stabilization care services it has not pre-approved | 22 | | ends when: | 23 | | (A) a plan physician with privileges at the | 24 | | treating hospital assumes responsibility for the | 25 | | enrollee's care; | 26 | | (B) a plan physician assumes responsibility for |
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| 1 | | the enrollee's care through transfer; | 2 | | (C) a contracting entity representative and the | 3 | | treating physician reach an agreement concerning the | 4 | | enrollee's care; or | 5 | | (D) the enrollee is discharged. | 6 | | (f) Network adequacy and transparency. | 7 | | (1) The Department shall: | 8 | | (A) ensure that an adequate provider network is in | 9 | | place, taking into consideration health professional | 10 | | shortage areas and medically underserved areas; | 11 | | (B) publicly release an explanation of its process | 12 | | for analyzing network adequacy; | 13 | | (C) periodically ensure that an MCO continues to | 14 | | have an adequate network in place; and | 15 | | (D) require MCOs, including Medicaid Managed Care | 16 | | Entities as defined in Section 5-30.2, to meet | 17 | | provider directory requirements under Section 5-30.3. | 18 | | (2) Each MCO shall confirm its receipt of information | 19 | | submitted specific to physician or dentist additions or | 20 | | physician or dentist deletions from the MCO's provider | 21 | | network within 3 days after receiving all required | 22 | | information from contracted physicians or dentists, and | 23 | | electronic physician and dental directories must be | 24 | | updated consistent with current rules as published by the | 25 | | Centers for Medicare and Medicaid Services or its | 26 | | successor agency. |
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| 1 | | (g) Timely payment of claims. | 2 | | (1) The MCO shall pay a claim within 30 days of | 3 | | receiving a claim that contains all the essential | 4 | | information needed to adjudicate the claim. | 5 | | (2) The MCO shall notify the billing party of its | 6 | | inability to adjudicate a claim within 30 days of | 7 | | receiving that claim. | 8 | | (3) The MCO shall pay a penalty for any claims not | 9 | | timely paid at an interest rate of 9%, annually, | 10 | | compounded semiannually, from the date payment was | 11 | | required to be made to the date of the late payment that is | 12 | | at least equal to the timely payment interest penalty | 13 | | imposed under Section 368a of the Illinois Insurance Code | 14 | | for any claims not timely paid . | 15 | | (A) When an MCO is required to pay a timely payment | 16 | | interest penalty to a provider, the MCO must calculate | 17 | | and pay the timely payment interest penalty that is | 18 | | due to the provider within 30 days after the payment of | 19 | | the claim. In no event shall a provider be required to | 20 | | request or apply for payment of any owed timely | 21 | | payment interest penalties. | 22 | | (B) Such payments shall be reported separately | 23 | | from the claim payment for services rendered to the | 24 | | MCO's enrollee and clearly identified as interest | 25 | | payments. | 26 | | (4)(A) The Department shall require MCOs to expedite |
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| 1 | | payments to providers identified on the Department's | 2 | | expedited provider list, determined in accordance with 89 | 3 | | Ill. Adm. Code 140.71(b), on a schedule at least as | 4 | | frequently as the providers are paid under the | 5 | | Department's fee-for-service expedited provider schedule. | 6 | | (B) Compliance with the expedited provider requirement | 7 | | may be satisfied by an MCO through the use of a Periodic | 8 | | Interim Payment (PIP) program that has been mutually | 9 | | agreed to and documented between the MCO and the provider, | 10 | | and the PIP program ensures that any expedited provider | 11 | | receives regular and periodic payments based on prior | 12 | | period payment experience from that MCO. Total payments | 13 | | under the PIP program may be reconciled against future PIP | 14 | | payments on a schedule mutually agreed to between the MCO | 15 | | and the provider. | 16 | | (C) The Department shall share at least monthly its | 17 | | expedited provider list and the frequency with which it | 18 | | pays providers on the expedited list. | 19 | | (g-5) Recognizing that the rapid transformation of the | 20 | | Illinois Medicaid program may have unintended operational | 21 | | challenges for both payers and providers: | 22 | | (1) in no instance shall a medically necessary covered | 23 | | service rendered in good faith, based upon eligibility | 24 | | information documented by the provider, be denied coverage | 25 | | or diminished in payment amount if the eligibility or | 26 | | coverage information available at the time the service was |
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| 1 | | rendered is later found to be inaccurate in the assignment | 2 | | of coverage responsibility between MCOs or the | 3 | | fee-for-service system, except for instances when an | 4 | | individual is deemed to have not been eligible for | 5 | | coverage under the Illinois Medicaid program; and | 6 | | (2) the Department shall, by December 31, 2016, adopt | 7 | | rules establishing policies that shall be included in the | 8 | | Medicaid managed care policy and procedures manual | 9 | | addressing payment resolutions in situations in which a | 10 | | provider renders services based upon information obtained | 11 | | after verifying a patient's eligibility and coverage plan | 12 | | through either the Department's current enrollment system | 13 | | or a system operated by the coverage plan identified by | 14 | | the patient presenting for services: | 15 | | (A) such medically necessary covered services | 16 | | shall be considered rendered in good faith; | 17 | | (B) such policies and procedures shall be | 18 | | developed in consultation with industry | 19 | | representatives of the Medicaid managed care health | 20 | | plans and representatives of provider associations | 21 | | representing the majority of providers within the | 22 | | identified provider industry; and | 23 | | (C) such rules shall be published for a review and | 24 | | comment period of no less than 30 days on the | 25 | | Department's website with final rules remaining | 26 | | available on the Department's website. |
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| 1 | | The rules on payment resolutions shall include, but not be | 2 | | limited to: | 3 | | (A) the extension of the timely filing period; | 4 | | (B) retroactive prior authorizations; and | 5 | | (C) guaranteed minimum payment rate of no less than | 6 | | the current, as of the date of service, fee-for-service | 7 | | rate, plus all applicable add-ons, when the resulting | 8 | | service relationship is out of network. | 9 | | The rules shall be applicable for both MCO coverage and | 10 | | fee-for-service coverage. | 11 | | If the fee-for-service system is ultimately determined to | 12 | | have been responsible for coverage on the date of service, the | 13 | | Department shall provide for an extended period for claims | 14 | | submission outside the standard timely filing requirements. | 15 | | (g-6) MCO Performance Metrics Report. | 16 | | (1) The Department shall publish, on at least a | 17 | | quarterly basis, each MCO's operational performance, | 18 | | including, but not limited to, the following categories of | 19 | | metrics: | 20 | | (A) claims payment, including timeliness and | 21 | | accuracy; | 22 | | (B) prior authorizations; | 23 | | (C) grievance and appeals; | 24 | | (D) utilization statistics; | 25 | | (E) provider disputes; | 26 | | (F) provider credentialing; and |
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| 1 | | (G) member and provider customer service. | 2 | | (2) The Department shall ensure that the metrics | 3 | | report is accessible to providers online by January 1, | 4 | | 2017. | 5 | | (3) The metrics shall be developed in consultation | 6 | | with industry representatives of the Medicaid managed care | 7 | | health plans and representatives of associations | 8 | | representing the majority of providers within the | 9 | | identified industry. | 10 | | (4) Metrics shall be defined and incorporated into the | 11 | | applicable Managed Care Policy Manual issued by the | 12 | | Department. | 13 | | (g-7) MCO claims processing and performance analysis. In | 14 | | order to monitor MCO payments to hospital providers, pursuant | 15 | | to this amendatory Act of the 100th General Assembly, the | 16 | | Department shall post an analysis of MCO claims processing and | 17 | | payment performance on its website every 6 months. Such | 18 | | analysis shall include a review and evaluation of a | 19 | | representative sample of hospital claims that are rejected and | 20 | | denied for clean and unclean claims and the top 5 reasons for | 21 | | such actions and timeliness of claims adjudication, which | 22 | | identifies the percentage of claims adjudicated within 30, 60, | 23 | | 90, and over 90 days, and the dollar amounts associated with | 24 | | those claims. The Department shall post the contracted claims | 25 | | report required by HealthChoice Illinois on its website every | 26 | | 3 months. |
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| 1 | | (g-8) Dispute resolution process. The Department shall | 2 | | maintain a provider complaint portal through which a provider | 3 | | can submit to the Department unresolved disputes with an MCO. | 4 | | An unresolved dispute means an MCO's decision that denies in | 5 | | whole or in part a claim for reimbursement to a provider for | 6 | | health care services rendered by the provider to an enrollee | 7 | | of the MCO with which the provider disagrees. Disputes shall | 8 | | not be submitted to the portal until the provider has availed | 9 | | itself of the MCO's internal dispute resolution process. | 10 | | Disputes that are submitted to the MCO internal dispute | 11 | | resolution process may be submitted to the Department of | 12 | | Healthcare and Family Services' complaint portal no sooner | 13 | | than 30 days after submitting to the MCO's internal process | 14 | | and not later than 30 days after the unsatisfactory resolution | 15 | | of the internal MCO process or 60 days after submitting the | 16 | | dispute to the MCO internal process. Multiple claim disputes | 17 | | involving the same MCO may be submitted in one complaint, | 18 | | regardless of whether the claims are for different enrollees, | 19 | | when the specific reason for non-payment of the claims | 20 | | involves a common question of fact or policy. Within 10 | 21 | | business days of receipt of a complaint, the Department shall | 22 | | present such disputes to the appropriate MCO, which shall then | 23 | | have 30 days to issue its written proposal to resolve the | 24 | | dispute. The Department may grant one 30-day extension of this | 25 | | time frame to one of the parties to resolve the dispute. If the | 26 | | dispute remains unresolved at the end of this time frame or the |
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| 1 | | provider is not satisfied with the MCO's written proposal to | 2 | | resolve the dispute, the provider may, within 30 days, request | 3 | | the Department to review the dispute and make a final | 4 | | determination. Within 30 days of the request for Department | 5 | | review of the dispute, both the provider and the MCO shall | 6 | | present all relevant information to the Department for | 7 | | resolution and make individuals with knowledge of the issues | 8 | | available to the Department for further inquiry if needed. | 9 | | Within 30 days of receiving the relevant information on the | 10 | | dispute, or the lapse of the period for submitting such | 11 | | information, the Department shall issue a written decision on | 12 | | the dispute based on contractual terms between the provider | 13 | | and the MCO, contractual terms between the MCO and the | 14 | | Department of Healthcare and Family Services and applicable | 15 | | Medicaid policy. The decision of the Department shall be | 16 | | final. By January 1, 2020, the Department shall establish by | 17 | | rule further details of this dispute resolution process. | 18 | | Disputes between MCOs and providers presented to the | 19 | | Department for resolution are not contested cases, as defined | 20 | | in Section 1-30 of the Illinois Administrative Procedure Act, | 21 | | conferring any right to an administrative hearing. | 22 | | (g-9)(1) The Department shall publish annually on its | 23 | | website a report on the calculation of each managed care | 24 | | organization's medical loss ratio showing the following: | 25 | | (A) Premium revenue, with appropriate adjustments. | 26 | | (B) Benefit expense, setting forth the aggregate |
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| 1 | | amount spent for the following: | 2 | | (i) Direct paid claims. | 3 | | (ii) Subcapitation payments. | 4 | | (iii)
Other claim payments. | 5 | | (iv)
Direct reserves. | 6 | | (v)
Gross recoveries. | 7 | | (vi)
Expenses for activities that improve health | 8 | | care quality as allowed by the Department. | 9 | | (2) The medical loss ratio shall be calculated consistent | 10 | | with federal law and regulation following a claims runout | 11 | | period determined by the Department. | 12 | | (g-10)(1) "Liability effective date" means the date on | 13 | | which an MCO becomes responsible for payment for medically | 14 | | necessary and covered services rendered by a provider to one | 15 | | of its enrollees in accordance with the contract terms between | 16 | | the MCO and the provider. The liability effective date shall | 17 | | be the later of: | 18 | | (A) The execution date of a network participation | 19 | | contract agreement. | 20 | | (B) The date the provider or its representative | 21 | | submits to the MCO the complete and accurate standardized | 22 | | roster form for the provider in the format approved by the | 23 | | Department. | 24 | | (C) The provider effective date contained within the | 25 | | Department's provider enrollment subsystem within the | 26 | | Illinois Medicaid Program Advanced Cloud Technology |
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| 1 | | (IMPACT) System. | 2 | | (2) The standardized roster form may be submitted to the | 3 | | MCO at the same time that the provider submits an enrollment | 4 | | application to the Department through IMPACT. | 5 | | (3) By October 1, 2019, the Department shall require all | 6 | | MCOs to update their provider directory with information for | 7 | | new practitioners of existing contracted providers within 30 | 8 | | days of receipt of a complete and accurate standardized roster | 9 | | template in the format approved by the Department provided | 10 | | that the provider is effective in the Department's provider | 11 | | enrollment subsystem within the IMPACT system. Such provider | 12 | | directory shall be readily accessible for purposes of | 13 | | selecting an approved health care provider and comply with all | 14 | | other federal and State requirements. | 15 | | (g-11) The Department shall work with relevant | 16 | | stakeholders on the development of operational guidelines to | 17 | | enhance and improve operational performance of Illinois' | 18 | | Medicaid managed care program, including, but not limited to, | 19 | | improving provider billing practices, reducing claim | 20 | | rejections and inappropriate payment denials, and | 21 | | standardizing processes, procedures, definitions, and response | 22 | | timelines, with the goal of reducing provider and MCO | 23 | | administrative burdens and conflict. The Department shall | 24 | | include a report on the progress of these program improvements | 25 | | and other topics in its Fiscal Year 2020 annual report to the | 26 | | General Assembly. |
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| 1 | | (h) The Department shall not expand mandatory MCO | 2 | | enrollment into new counties beyond those counties already | 3 | | designated by the Department as of June 1, 2014 for the | 4 | | individuals whose eligibility for medical assistance is not | 5 | | the seniors or people with disabilities population until the | 6 | | Department provides an opportunity for accountable care | 7 | | entities and MCOs to participate in such newly designated | 8 | | counties. | 9 | | (i) The requirements of this Section apply to contracts | 10 | | with accountable care entities and MCOs entered into, amended, | 11 | | or renewed after June 16, 2014 (the effective date of Public | 12 | | Act 98-651).
| 13 | | (j) Health care information released to managed care | 14 | | organizations. A health care provider shall release to a | 15 | | Medicaid managed care organization, upon request, and subject | 16 | | to the Health Insurance Portability and Accountability Act of | 17 | | 1996 and any other law applicable to the release of health | 18 | | information, the health care information of the MCO's | 19 | | enrollee, if the enrollee has completed and signed a general | 20 | | release form that grants to the health care provider | 21 | | permission to release the recipient's health care information | 22 | | to the recipient's insurance carrier. | 23 | | (Source: P.A. 100-201, eff. 8-18-17; 100-580, eff. 3-12-18; | 24 | | 100-587, eff. 6-4-18; 101-209, eff. 8-5-19.) | 25 | | (305 ILCS 5/5-30.12a new) |
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| 1 | | Sec. 5-30.12a. Medical Electronic Data Interchange system | 2 | | upgrade. By July 1, 2022, the Department of Healthcare and | 3 | | Family Services shall explore the availability of and, if | 4 | | reasonably available, procure technology that: (i) allows the | 5 | | Department's Medical Electronic Data Interchange (MEDI) system | 6 | | to update recipient eligibility and coverage information for | 7 | | providers in real time; and (ii) allows the Department to | 8 | | transmit updated recipient eligibility and coverage | 9 | | information to managed care organizations under contract with | 10 | | the Department to ensure the information contained in the MEDI | 11 | | system corresponds with the information maintained by managed | 12 | | care organizations in their web-based provider portals. | 13 | | (305 ILCS 5/5-43 new) | 14 | | Sec. 5-43. MCO post-payment audit; time period limitation. | 15 | | Notwithstanding any provision of this Code to the contrary, in | 16 | | order to recover an overpayment by recoupment or offset of | 17 | | future payments, a managed care organization's post-payment | 18 | | audit of any claim submitted by a provider must be completed no | 19 | | later than 2 years after the claim's payment date. The 2-year | 20 | | time limit does not apply to claims that are (i) submitted | 21 | | fraudulently, (ii) known, or should have been known, by the | 22 | | provider to be a pattern of inappropriate billing according to | 23 | | standard provider billing practices, or (iii) subject to any | 24 | | federal law or regulation that permits post-payment audits | 25 | | beyond 2 years.
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| 1 | | Section 99. Effective date. This Act takes effect upon | 2 | | becoming law.".
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