Full Text of SB1962 103rd General Assembly
SB1962 103RD GENERAL ASSEMBLY |
| | 103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024 SB1962 Introduced 2/9/2023, by Sen. Ann Gillespie SYNOPSIS AS INTRODUCED: |
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Amends the Illinois Public Aid. Makes a technical change in a Section concerning managed care protections.
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| | A BILL FOR |
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| 1 | | AN ACT concerning public aid.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 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 | 10 | | which contracts with the the Department to provide services | 11 | | where payment for medical services is made on a capitated | 12 | | 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 | 17 | | defined by Section 10 of the Managed Care Reform and | 18 | | Patient Rights Act; | 19 | | (3) post-stabilization medical services, as defined by | 20 | | Section 10 of the Managed Care Reform and Patient Rights | 21 | | Act; and | 22 | | (4) emergency medical conditions, as defined by
| 23 | | Section 10 of the Managed Care Reform and Patient Rights
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| 1 | | Act. | 2 | | (b) As provided by Section 5-16.12, managed care | 3 | | organizations are subject to the provisions of the Managed | 4 | | Care Reform and Patient Rights Act. | 5 | | (c) An MCO shall pay any provider of emergency services | 6 | | that does not have in effect a contract with the contracted | 7 | | Medicaid MCO. The default rate of reimbursement shall be the | 8 | | rate paid under Illinois Medicaid fee-for-service program | 9 | | methodology, including all policy adjusters, including but not | 10 | | limited to Medicaid High Volume Adjustments, Medicaid | 11 | | Percentage Adjustments, Outpatient High Volume Adjustments, | 12 | | and all outlier add-on adjustments to the extent such | 13 | | adjustments are incorporated in the development of the | 14 | | applicable MCO capitated rates. | 15 | | (d) An MCO shall pay for all post-stabilization services | 16 | | as a covered service in any of the following situations: | 17 | | (1) the MCO authorized such services; | 18 | | (2) such services were administered to maintain the | 19 | | enrollee's stabilized condition within one hour after a | 20 | | request to the MCO for authorization of further | 21 | | post-stabilization services; | 22 | | (3) the MCO did not respond to a request to authorize | 23 | | such services within one hour; | 24 | | (4) the MCO could not be contacted; or | 25 | | (5) the MCO and the treating provider, if the treating | 26 | | provider is a non-affiliated provider, could not reach an |
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| 1 | | agreement concerning the enrollee's care and an affiliated | 2 | | provider was unavailable for a consultation, in which case | 3 | | the MCO
must pay for such services rendered by the | 4 | | treating non-affiliated provider until an affiliated | 5 | | provider was reached and either concurred with the | 6 | | treating non-affiliated provider's plan of care or assumed | 7 | | responsibility for the enrollee's care. Such payment shall | 8 | | be made at the default rate of reimbursement paid under | 9 | | Illinois Medicaid fee-for-service program methodology, | 10 | | including all policy adjusters, including but not limited | 11 | | to Medicaid High Volume Adjustments, Medicaid Percentage | 12 | | Adjustments, Outpatient High Volume Adjustments and all | 13 | | outlier add-on adjustments to the extent that such | 14 | | adjustments are incorporated in the development of the | 15 | | applicable MCO capitated rates. | 16 | | (e) The following requirements apply to MCOs in | 17 | | determining payment for all emergency services: | 18 | | (1) MCOs shall not impose any requirements for prior | 19 | | approval of emergency services. | 20 | | (2) The MCO shall cover emergency services provided to | 21 | | enrollees who are temporarily away from their residence | 22 | | and outside the contracting area to the extent that the | 23 | | enrollees would be entitled to the emergency services if | 24 | | they still were within the contracting area. | 25 | | (3) The MCO shall have no obligation to cover medical | 26 | | services provided on an emergency basis that are not |
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| 1 | | covered services under the contract. | 2 | | (4) The MCO shall not condition coverage for emergency | 3 | | services on the treating provider notifying the MCO of the | 4 | | enrollee's screening and treatment within 10 days after | 5 | | presentation for emergency services. | 6 | | (5) The determination of the attending emergency | 7 | | physician, or the provider actually treating the enrollee, | 8 | | of whether an enrollee is sufficiently stabilized for | 9 | | discharge or transfer to another facility, shall be | 10 | | binding on the MCO. The MCO shall cover emergency services | 11 | | for all enrollees whether the emergency services are | 12 | | provided by an affiliated or non-affiliated provider. | 13 | | (6) The MCO's financial responsibility for | 14 | | post-stabilization care services it has not pre-approved | 15 | | ends when: | 16 | | (A) a plan physician with privileges at the | 17 | | treating hospital assumes responsibility for the | 18 | | enrollee's care; | 19 | | (B) a plan physician assumes responsibility for | 20 | | the enrollee's care through transfer; | 21 | | (C) a contracting entity representative and the | 22 | | treating physician reach an agreement concerning the | 23 | | enrollee's care; or | 24 | | (D) the enrollee is discharged. | 25 | | (f) Network adequacy and transparency. | 26 | | (1) The Department shall: |
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| 1 | | (A) ensure that an adequate provider network is in | 2 | | place, taking into consideration health professional | 3 | | shortage areas and medically underserved areas; | 4 | | (B) publicly release an explanation of its process | 5 | | for analyzing network adequacy; | 6 | | (C) periodically ensure that an MCO continues to | 7 | | have an adequate network in place; | 8 | | (D) require MCOs, including Medicaid Managed Care | 9 | | Entities as defined in Section 5-30.2, to meet | 10 | | provider directory requirements under Section 5-30.3; | 11 | | (E) require MCOs to ensure that any | 12 | | Medicaid-certified provider
under contract with an MCO | 13 | | and previously submitted on a roster on the date of | 14 | | service is
paid for any medically necessary, | 15 | | Medicaid-covered, and authorized service rendered to
| 16 | | any of the MCO's enrollees, regardless of inclusion on
| 17 | | the MCO's published and publicly available directory | 18 | | of
available providers; and | 19 | | (F) require MCOs, including Medicaid Managed Care | 20 | | Entities as defined in Section 5-30.2, to meet each of | 21 | | the requirements under subsection (d-5) of Section 10 | 22 | | of the Network Adequacy and Transparency Act; with | 23 | | necessary exceptions to the MCO's network to ensure | 24 | | that admission and treatment with a provider or at a | 25 | | treatment facility in accordance with the network | 26 | | adequacy standards in paragraph (3) of subsection |
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| 1 | | (d-5) of Section 10 of the Network Adequacy and | 2 | | Transparency Act is limited to providers or facilities | 3 | | that are Medicaid certified. | 4 | | (2) Each MCO shall confirm its receipt of information | 5 | | submitted specific to physician or dentist additions or | 6 | | physician or dentist deletions from the MCO's provider | 7 | | network within 3 days after receiving all required | 8 | | information from contracted physicians or dentists, and | 9 | | electronic physician and dental directories must be | 10 | | updated consistent with current rules as published by the | 11 | | Centers for Medicare and Medicaid Services or its | 12 | | successor agency. | 13 | | (g) Timely payment of claims. | 14 | | (1) The MCO shall pay a claim within 30 days of | 15 | | receiving a claim that contains all the essential | 16 | | information needed to adjudicate the claim. | 17 | | (2) The MCO shall notify the billing party of its | 18 | | inability to adjudicate a claim within 30 days of | 19 | | receiving that claim. | 20 | | (3) The MCO shall pay a penalty that is at least equal | 21 | | to the timely payment interest penalty imposed under | 22 | | Section 368a of the Illinois Insurance Code for any claims | 23 | | not timely paid. | 24 | | (A) When an MCO is required to pay a timely payment | 25 | | interest penalty to a provider, the MCO must calculate | 26 | | and pay the timely payment interest penalty that is |
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| 1 | | due to the provider within 30 days after the payment of | 2 | | the claim. In no event shall a provider be required to | 3 | | request or apply for payment of any owed timely | 4 | | payment interest penalties. | 5 | | (B) Such payments shall be reported separately | 6 | | from the claim payment for services rendered to the | 7 | | MCO's enrollee and clearly identified as interest | 8 | | payments. | 9 | | (4)(A) The Department shall require MCOs to expedite | 10 | | payments to providers identified on the Department's | 11 | | expedited provider list, determined in accordance with 89 | 12 | | Ill. Adm. Code 140.71(b), on a schedule at least as | 13 | | frequently as the providers are paid under the | 14 | | Department's fee-for-service expedited provider schedule. | 15 | | (B) Compliance with the expedited provider requirement | 16 | | may be satisfied by an MCO through the use of a Periodic | 17 | | Interim Payment (PIP) program that has been mutually | 18 | | agreed to and documented between the MCO and the provider, | 19 | | if the PIP program ensures that any expedited provider | 20 | | receives regular and periodic payments based on prior | 21 | | period payment experience from that MCO. Total payments | 22 | | under the PIP program may be reconciled against future PIP | 23 | | payments on a schedule mutually agreed to between the MCO | 24 | | and the provider. | 25 | | (C) The Department shall share at least monthly its | 26 | | expedited provider list and the frequency with which it |
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| 1 | | pays providers on the expedited list. | 2 | | (g-5) Recognizing that the rapid transformation of the | 3 | | Illinois Medicaid program may have unintended operational | 4 | | challenges for both payers and providers: | 5 | | (1) in no instance shall a medically necessary covered | 6 | | service rendered in good faith, based upon eligibility | 7 | | information documented by the provider, be denied coverage | 8 | | or diminished in payment amount if the eligibility or | 9 | | coverage information available at the time the service was | 10 | | rendered is later found to be inaccurate in the assignment | 11 | | of coverage responsibility between MCOs or the | 12 | | fee-for-service system, except for instances when an | 13 | | individual is deemed to have not been eligible for | 14 | | coverage under the Illinois Medicaid program; and | 15 | | (2) the Department shall, by December 31, 2016, adopt | 16 | | rules establishing policies that shall be included in the | 17 | | Medicaid managed care policy and procedures manual | 18 | | addressing payment resolutions in situations in which a | 19 | | provider renders services based upon information obtained | 20 | | after verifying a patient's eligibility and coverage plan | 21 | | through either the Department's current enrollment system | 22 | | or a system operated by the coverage plan identified by | 23 | | the patient presenting for services: | 24 | | (A) such medically necessary covered services | 25 | | shall be considered rendered in good faith; | 26 | | (B) such policies and procedures shall be |
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| 1 | | developed in consultation with industry | 2 | | representatives of the Medicaid managed care health | 3 | | plans and representatives of provider associations | 4 | | representing the majority of providers within the | 5 | | identified provider industry; and | 6 | | (C) such rules shall be published for a review and | 7 | | comment period of no less than 30 days on the | 8 | | Department's website with final rules remaining | 9 | | available on the Department's website. | 10 | | The rules on payment resolutions shall include, but | 11 | | not be limited to: | 12 | | (A) the extension of the timely filing period; | 13 | | (B) retroactive prior authorizations; and | 14 | | (C) guaranteed minimum payment rate of no less | 15 | | than the current, as of the date of service, | 16 | | fee-for-service rate, plus all applicable add-ons, | 17 | | when the resulting service relationship is out of | 18 | | network. | 19 | | The rules shall be applicable for both MCO coverage | 20 | | and fee-for-service coverage. | 21 | | If the fee-for-service system is ultimately determined to | 22 | | have been responsible for coverage on the date of service, the | 23 | | Department shall provide for an extended period for claims | 24 | | submission outside the standard timely filing requirements. | 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 | 13 | | report is accessible to providers online by January 1, | 14 | | 2017. | 15 | | (3) The metrics shall be developed in consultation | 16 | | with industry representatives of the Medicaid managed care | 17 | | health plans and representatives of associations | 18 | | representing the majority of providers within the | 19 | | identified industry. | 20 | | (4) Metrics shall be defined and incorporated into the | 21 | | applicable Managed Care Policy Manual issued by the | 22 | | Department. | 23 | | (g-7) MCO claims processing and performance analysis. In | 24 | | order to monitor MCO payments to hospital providers, pursuant | 25 | | to Public Act 100-580, the Department shall post an analysis | 26 | | of MCO claims processing and payment performance on its |
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| 1 | | website every 6 months. Such analysis shall include a review | 2 | | and evaluation of a representative sample of hospital claims | 3 | | that are rejected and denied for clean and unclean claims and | 4 | | the top 5 reasons for such actions and timeliness of claims | 5 | | adjudication, which identifies the percentage of claims | 6 | | adjudicated within 30, 60, 90, and over 90 days, and the dollar | 7 | | amounts associated with those claims. | 8 | | (g-8) Dispute resolution process. The Department shall | 9 | | maintain a provider complaint portal through which a provider | 10 | | can submit to the Department unresolved disputes with an MCO. | 11 | | An unresolved dispute means an MCO's decision that denies in | 12 | | whole or in part a claim for reimbursement to a provider for | 13 | | health care services rendered by the provider to an enrollee | 14 | | of the MCO with which the provider disagrees. Disputes shall | 15 | | not be submitted to the portal until the provider has availed | 16 | | itself of the MCO's internal dispute resolution process. | 17 | | Disputes that are submitted to the MCO internal dispute | 18 | | resolution process may be submitted to the Department of | 19 | | Healthcare and Family Services' complaint portal no sooner | 20 | | than 30 days after submitting to the MCO's internal process | 21 | | and not later than 30 days after the unsatisfactory resolution | 22 | | of the internal MCO process or 60 days after submitting the | 23 | | dispute to the MCO internal process. Multiple claim disputes | 24 | | involving the same MCO may be submitted in one complaint, | 25 | | regardless of whether the claims are for different enrollees, | 26 | | when the specific reason for non-payment of the claims |
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| 1 | | involves a common question of fact or policy. Within 10 | 2 | | business days of receipt of a complaint, the Department shall | 3 | | present such disputes to the appropriate MCO, which shall then | 4 | | have 30 days to issue its written proposal to resolve the | 5 | | dispute. The Department may grant one 30-day extension of this | 6 | | time frame to one of the parties to resolve the dispute. If the | 7 | | dispute remains unresolved at the end of this time frame or the | 8 | | provider is not satisfied with the MCO's written proposal to | 9 | | resolve the dispute, the provider may, within 30 days, request | 10 | | the Department to review the dispute and make a final | 11 | | determination. Within 30 days of the request for Department | 12 | | review of the dispute, both the provider and the MCO shall | 13 | | present all relevant information to the Department for | 14 | | resolution and make individuals with knowledge of the issues | 15 | | available to the Department for further inquiry if needed. | 16 | | Within 30 days of receiving the relevant information on the | 17 | | dispute, or the lapse of the period for submitting such | 18 | | information, the Department shall issue a written decision on | 19 | | the dispute based on contractual terms between the provider | 20 | | and the MCO, contractual terms between the MCO and the | 21 | | Department of Healthcare and Family Services and applicable | 22 | | Medicaid policy. The decision of the Department shall be | 23 | | final. By January 1, 2020, the Department shall establish by | 24 | | rule further details of this dispute resolution process. | 25 | | Disputes between MCOs and providers presented to the | 26 | | Department for resolution are not contested cases, as defined |
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| 1 | | in Section 1-30 of the Illinois Administrative Procedure Act, | 2 | | conferring any right to an administrative hearing. | 3 | | (g-9)(1) The Department shall publish annually on its | 4 | | website a report on the calculation of each managed care | 5 | | organization's medical loss ratio showing the following: | 6 | | (A) Premium revenue, with appropriate adjustments. | 7 | | (B) Benefit expense, setting forth the aggregate | 8 | | amount spent for the following: | 9 | | (i) Direct paid claims. | 10 | | (ii) Subcapitation payments. | 11 | | (iii)
Other claim payments. | 12 | | (iv)
Direct reserves. | 13 | | (v)
Gross recoveries. | 14 | | (vi)
Expenses for activities that improve health | 15 | | care quality as allowed by the Department. | 16 | | (2) The medical loss ratio shall be calculated consistent | 17 | | with federal law and regulation following a claims runout | 18 | | period determined by the Department. | 19 | | (g-10)(1) "Liability effective date" means the date on | 20 | | which an MCO becomes responsible for payment for medically | 21 | | necessary and covered services rendered by a provider to one | 22 | | of its enrollees in accordance with the contract terms between | 23 | | the MCO and the provider. The liability effective date shall | 24 | | be the later of: | 25 | | (A) The execution date of a network participation | 26 | | contract agreement. |
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| 1 | | (B) The date the provider or its representative | 2 | | submits to the MCO the complete and accurate standardized | 3 | | roster form for the provider in the format approved by the | 4 | | Department. | 5 | | (C) The provider effective date contained within the | 6 | | Department's provider enrollment subsystem within the | 7 | | Illinois Medicaid Program Advanced Cloud Technology | 8 | | (IMPACT) System. | 9 | | (2) The standardized roster form may be submitted to the | 10 | | MCO at the same time that the provider submits an enrollment | 11 | | application to the Department through IMPACT. | 12 | | (3) By October 1, 2019, the Department shall require all | 13 | | MCOs to update their provider directory with information for | 14 | | new practitioners of existing contracted providers within 30 | 15 | | days of receipt of a complete and accurate standardized roster | 16 | | template in the format approved by the Department provided | 17 | | that the provider is effective in the Department's provider | 18 | | enrollment subsystem within the IMPACT system. Such provider | 19 | | directory shall be readily accessible for purposes of | 20 | | selecting an approved health care provider and comply with all | 21 | | other federal and State requirements. | 22 | | (g-11) The Department shall work with relevant | 23 | | stakeholders on the development of operational guidelines to | 24 | | enhance and improve operational performance of Illinois' | 25 | | Medicaid managed care program, including, but not limited to, | 26 | | improving provider billing practices, reducing claim |
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| 1 | | rejections and inappropriate payment denials, and | 2 | | standardizing processes, procedures, definitions, and response | 3 | | timelines, with the goal of reducing provider and MCO | 4 | | administrative burdens and conflict. The Department shall | 5 | | include a report on the progress of these program improvements | 6 | | and other topics in its Fiscal Year 2020 annual report to the | 7 | | General Assembly. | 8 | | (g-12) Notwithstanding any other provision of law, if the
| 9 | | Department or an MCO requires submission of a claim for | 10 | | payment
in a non-electronic format, a provider shall always be | 11 | | afforded
a period of no less than 90 business days, as a | 12 | | correction
period, following any notification of rejection by | 13 | | either the
Department or the MCO to correct errors or | 14 | | omissions in the
original submission. | 15 | | Under no circumstances, either by an MCO or under the
| 16 | | State's fee-for-service system, shall a provider be denied
| 17 | | payment for failure to comply with any timely submission
| 18 | | requirements under this Code or under any existing contract,
| 19 | | unless the non-electronic format claim submission occurs after
| 20 | | the initial 180 days following the latest date of service on
| 21 | | the claim, or after the 90 business days correction period
| 22 | | following notification to the provider of rejection or denial
| 23 | | of payment. | 24 | | (h) The Department shall not expand mandatory MCO | 25 | | enrollment into new counties beyond those counties already | 26 | | designated by the Department as of June 1, 2014 for the |
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| 1 | | individuals whose eligibility for medical assistance is not | 2 | | the seniors or people with disabilities population until the | 3 | | Department provides an opportunity for accountable care | 4 | | entities and MCOs to participate in such newly designated | 5 | | counties. | 6 | | (i) The requirements of this Section apply to contracts | 7 | | with accountable care entities and MCOs entered into, amended, | 8 | | or renewed after June 16, 2014 (the effective date of Public | 9 | | Act 98-651).
| 10 | | (j) Health care information released to managed care | 11 | | organizations. A health care provider shall release to a | 12 | | Medicaid managed care organization, upon request, and subject | 13 | | to the Health Insurance Portability and Accountability Act of | 14 | | 1996 and any other law applicable to the release of health | 15 | | information, the health care information of the MCO's | 16 | | enrollee, if the enrollee has completed and signed a general | 17 | | release form that grants to the health care provider | 18 | | permission to release the recipient's health care information | 19 | | to the recipient's insurance carrier. | 20 | | (k) The Department of Healthcare and Family Services, | 21 | | managed care organizations, a statewide organization | 22 | | representing hospitals, and a statewide organization | 23 | | representing safety-net hospitals shall explore ways to | 24 | | support billing departments in safety-net hospitals. | 25 | | (l) The requirements of this Section added by Public Act | 26 | | 102-4 shall apply to
services provided on or after the first |
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| 1 | | day of the month that
begins 60 days after April 27, 2021 (the | 2 | | effective date of Public Act 102-4). | 3 | | (Source: P.A. 101-209, eff. 8-5-19; 102-4, eff. 4-27-21; | 4 | | 102-43, eff. 7-6-21; 102-144, eff. 1-1-22; 102-454, eff. | 5 | | 8-20-21; 102-813, eff. 5-13-22.)
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