Illinois General Assembly - Full Text of Public Act 102-0454
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Public Act 102-0454


Public Act 0454 102ND GENERAL ASSEMBLY



Public Act 102-0454
HB3069 EnrolledLRB102 13330 KTG 18674 b

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

Effective Date: 8/20/2021