Full Text of HB2117 101st General Assembly
HB2117 101ST GENERAL ASSEMBLY |
| | 101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020 HB2117 Introduced , by Rep. David McSweeney SYNOPSIS AS INTRODUCED: |
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Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires managed care organizations (MCOs) to publish, at least
quarterly for the preceding quarter, on their websites: (1) the total number of claims received by the MCO;
(2) the number and monetary amount of claims payments
made to a service provider;
(3) the dates of services rendered for the claims
payments made under item (2); (4) the dates the claims were received by the MCO for
the claims payments made under item (2); and
(5) the dates on which claims payments under item
(2) were released. Effective July 1, 2019.
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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 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 | 17 | | Patient Rights Act; | 18 | | (3) post-stabilization medical services, as defined by | 19 | | Section 10 of the Managed Care Reform and Patient Rights | 20 | | Act; and | 21 | | (4) emergency medical conditions, as defined by
| 22 | | Section 10 of the Managed Care Reform and Patient Rights
| 23 | | Act. |
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| 1 | | (b) As provided by Section 5-16.12, managed care | 2 | | organizations are subject to the provisions of the Managed Care | 3 | | Reform and Patient Rights Act. | 4 | | (c) An MCO shall pay any provider of emergency services | 5 | | that does not have in effect a contract with the contracted | 6 | | Medicaid MCO. The default rate of reimbursement shall be the | 7 | | rate paid under Illinois Medicaid fee-for-service program | 8 | | methodology, including all policy adjusters, including but not | 9 | | limited to Medicaid High Volume Adjustments, Medicaid | 10 | | Percentage Adjustments, Outpatient High Volume Adjustments, | 11 | | and all outlier add-on adjustments to the extent such | 12 | | adjustments are incorporated in the development of the | 13 | | applicable MCO capitated rates. | 14 | | (d) An MCO shall pay for all post-stabilization services as | 15 | | a covered service in any of the following situations: | 16 | | (1) the MCO authorized such services; | 17 | | (2) such services were administered to maintain the | 18 | | enrollee's stabilized condition within one hour after a | 19 | | request to the MCO for authorization of further | 20 | | post-stabilization services; | 21 | | (3) the MCO did not respond to a request to authorize | 22 | | such services within one hour; | 23 | | (4) the MCO could not be contacted; or | 24 | | (5) the MCO and the treating provider, if the treating | 25 | | provider is a non-affiliated provider, could not reach an | 26 | | agreement concerning the enrollee's care and an affiliated |
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| 1 | | provider was unavailable for a consultation, in which case | 2 | | the MCO
must pay for such services rendered by the treating | 3 | | non-affiliated provider until an affiliated provider was | 4 | | reached and either concurred with the treating | 5 | | non-affiliated provider's plan of care or assumed | 6 | | responsibility for the enrollee's care. Such payment shall | 7 | | be made at the default rate of reimbursement paid under | 8 | | Illinois Medicaid fee-for-service program methodology, | 9 | | including all policy adjusters, including but not limited | 10 | | to Medicaid High Volume Adjustments, Medicaid Percentage | 11 | | Adjustments, Outpatient High Volume Adjustments and all | 12 | | outlier add-on adjustments to the extent that such | 13 | | adjustments are incorporated in the development of the | 14 | | applicable MCO capitated rates. | 15 | | (e) The following requirements apply to MCOs in determining | 16 | | payment for all emergency services: | 17 | | (1) MCOs shall not impose any requirements for prior | 18 | | approval of emergency services. | 19 | | (2) The MCO shall cover emergency services provided to | 20 | | enrollees who are temporarily away from their residence and | 21 | | outside the contracting area to the extent that the | 22 | | enrollees would be entitled to the emergency services if | 23 | | they still were within the contracting area. | 24 | | (3) The MCO shall have no obligation to cover medical | 25 | | services provided on an emergency basis that are not | 26 | | covered services under the contract. |
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| 1 | | (4) The MCO shall not condition coverage for emergency | 2 | | services on the treating provider notifying the MCO of the | 3 | | enrollee's screening and treatment within 10 days after | 4 | | presentation for emergency services. | 5 | | (5) The determination of the attending emergency | 6 | | physician, or the provider actually treating the enrollee, | 7 | | of whether an enrollee is sufficiently stabilized for | 8 | | discharge or transfer to another facility, shall be binding | 9 | | on the MCO. The MCO shall cover emergency services for all | 10 | | enrollees whether the emergency services are provided by an | 11 | | affiliated or non-affiliated provider. | 12 | | (6) The MCO's financial responsibility for | 13 | | post-stabilization care services it has not pre-approved | 14 | | ends when: | 15 | | (A) a plan physician with privileges at the | 16 | | treating hospital assumes responsibility for the | 17 | | enrollee's care; | 18 | | (B) a plan physician assumes responsibility for | 19 | | the enrollee's care through transfer; | 20 | | (C) a contracting entity representative and the | 21 | | treating physician reach an agreement concerning the | 22 | | enrollee's care; or | 23 | | (D) the enrollee is discharged. | 24 | | (f) Network adequacy and transparency. | 25 | | (1) The Department shall: | 26 | | (A) ensure that an adequate provider network is in |
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| 1 | | place, taking into consideration health professional | 2 | | shortage areas and medically underserved areas; | 3 | | (B) publicly release an explanation of its process | 4 | | for analyzing network adequacy; | 5 | | (C) periodically ensure that an MCO continues to | 6 | | have an adequate network in place; and | 7 | | (D) require MCOs, including Medicaid Managed Care | 8 | | Entities as defined in Section 5-30.2, to meet provider | 9 | | directory requirements under Section 5-30.3. | 10 | | (2) Each MCO shall confirm its receipt of information | 11 | | submitted specific to physician or dentist additions or | 12 | | physician or dentist deletions from the MCO's provider | 13 | | network within 3 days after receiving all required | 14 | | information from contracted physicians or dentists, and | 15 | | electronic physician and dental directories must be | 16 | | updated consistent with current rules as published by the | 17 | | Centers for Medicare and Medicaid Services or its successor | 18 | | agency. | 19 | | (g) Timely payment of claims. | 20 | | (1) The MCO shall pay a claim within 30 days of | 21 | | receiving a claim that contains all the essential | 22 | | information needed to adjudicate the claim. | 23 | | (2) The MCO shall notify the billing party of its | 24 | | inability to adjudicate a claim within 30 days of receiving | 25 | | that claim. | 26 | | (3) The MCO shall pay a penalty that is at least equal |
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| 1 | | to the penalty imposed under the Illinois Insurance Code | 2 | | for any claims not timely paid. | 3 | | (4) The Department may establish a process for MCOs to | 4 | | expedite payments to providers based on criteria | 5 | | established by the Department. | 6 | | (g-5) Recognizing that the rapid transformation of the | 7 | | Illinois Medicaid program may have unintended operational | 8 | | challenges for both payers and providers: | 9 | | (1) in no instance shall a medically necessary covered | 10 | | service rendered in good faith, based upon eligibility | 11 | | information documented by the provider, be denied coverage | 12 | | or diminished in payment amount if the eligibility or | 13 | | coverage information available at the time the service was | 14 | | rendered is later found to be inaccurate; 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 the | 23 | | 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 | | (3) 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 than | 15 | | the current, as of the date of service, fee-for-service | 16 | | rate, plus all applicable add-ons, when the resulting | 17 | | service relationship is out of network. | 18 | | (4) The rules shall be applicable for both MCO coverage | 19 | | and fee-for-service coverage. | 20 | | (g-6) MCO Performance Metrics Report. | 21 | | (1) The Department shall publish, on at least a | 22 | | quarterly basis, each MCO's operational performance, | 23 | | including, but not limited to, the following categories of | 24 | | metrics: | 25 | | (A) claims payment, including timeliness and | 26 | | accuracy; |
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| 1 | | (B) prior authorizations; | 2 | | (C) grievance and appeals; | 3 | | (D) utilization statistics; | 4 | | (E) provider disputes; | 5 | | (F) provider credentialing; and | 6 | | (G) member and provider customer service. | 7 | | (2) The Department shall ensure that the metrics report | 8 | | is accessible to providers online by January 1, 2017. | 9 | | (3) The metrics shall be developed in consultation with | 10 | | industry representatives of the Medicaid managed care | 11 | | health plans and representatives of associations | 12 | | representing the majority of providers within the | 13 | | identified industry. | 14 | | (4) Metrics shall be defined and incorporated into the | 15 | | applicable Managed Care Policy Manual issued by the | 16 | | Department. | 17 | | (g-7) MCO claims processing and performance analysis. In | 18 | | order to monitor MCO payments to hospital providers, pursuant | 19 | | to this amendatory Act of the 100th General Assembly, the | 20 | | Department shall post an analysis of MCO claims processing and | 21 | | payment performance on its website every 6 months. Such | 22 | | analysis shall include a review and evaluation of a | 23 | | representative sample of hospital claims that are rejected and | 24 | | denied for clean and unclean claims and the top 5 reasons for | 25 | | such actions and timeliness of claims adjudication, which | 26 | | identifies the percentage of claims adjudicated within 30, 60, |
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| 1 | | 90, and over 90 days, and the dollar amounts associated with | 2 | | those claims. The Department shall post the contracted claims | 3 | | report required by HealthChoice Illinois on its website every 3 | 4 | | months. | 5 | | (h) The Department shall not expand mandatory MCO | 6 | | enrollment into new counties beyond those counties already | 7 | | designated by the Department as of June 1, 2014 for the | 8 | | individuals whose eligibility for medical assistance is not the | 9 | | seniors or people with disabilities population until the | 10 | | Department provides an opportunity for accountable care | 11 | | entities and MCOs to participate in such newly designated | 12 | | counties. | 13 | | (h-5) MCOs shall be required to publish, at least quarterly | 14 | | for the preceding quarter, on their websites: | 15 | | (1) the total number of claims received by the MCO; | 16 | | (2) the number and monetary amount of claims payments | 17 | | made to a service provider as defined in Section 2-16 of | 18 | | this Code; | 19 | | (3) the dates of services rendered for the claims | 20 | | payments made under paragraph (2); | 21 | | (4) the dates the claims were received by the MCO for | 22 | | the claims payments made under paragraph (2); and | 23 | | (5) the dates on which claims payments under paragraph | 24 | | (2) were released. | 25 | | (i) The requirements of this Section apply to contracts | 26 | | with accountable care entities and MCOs entered into, amended, |
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| 1 | | or renewed after June 16, 2014 (the effective date of Public | 2 | | Act 98-651).
| 3 | | (Source: P.A. 99-725, eff. 8-5-16; 99-751, eff. 8-5-16; | 4 | | 100-201, eff. 8-18-17; 100-580, eff. 3-12-18; 100-587, eff. | 5 | | 6-4-18.)
| 6 | | Section 99. Effective date. This Act takes effect July 1, | 7 | | 2019.
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