Illinois 2023-2024 Regular Session

Illinois House Bill HB4977 Compare Versions

Only one version of the bill is available at this time.

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1	1	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4977 Introduced , by Rep. Robyn Gabel SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-30.1 Amends the Medical Assistance Article of the Illinois Public Aid Code. Makes changes to provisions requiring Medicaid managed care organizations (MCO) to make payments for emergency services. Requires an MCO to pay any provider of emergency services, including inpatient stabilization services provided during the inpatient stabilization period, that does not have in effect a contract with the MCO. Defines "inpatient stabilization period" to mean the initial 72 hours of inpatient stabilization services, beginning from the date and time of the order for inpatient admission to the hospital. Provides that when determining payment for all emergency services, including inpatient stabilization services provided during the inpatient stabilization period, the MCO shall: (i) not impose any service authorization requirements, including, but not limited to, prior authorization, prior approval, pre-certification, concurrent review, or certification of admission; (ii) have no obligation to cover emergency services provided on an emergency basis that are not covered services under the MCO's contract with the Department of Healthcare and Family Services; and (iii) not condition coverage for emergency services on the treating provider notifying the MCO of the enrollee's emergency medical screening examination and treatment within 10 days after presentation for emergency services. Provides that the determination of the attending emergency physician, or the practitioner responsible for the enrollee's care at the hospital, of whether an enrollee requires inpatient stabilization services, can be stabilized in the outpatient setting, or is sufficiently stabilized for discharge or transfer to another facility, shall be binding on the MCO. Provides that an MCO shall not reimburse inpatient stabilization services billed on an inpatient institutional claim under the outpatient reimbursement methodology and shall not reimburse providers for emergency services in cases of fraud. Requires the Department to impose sanctions on a MCO for noncompliance, including, but not limited to, financial penalties, suspension of enrollment of new enrollees, and termination of the MCO's contract with the Department. Effective immediately. LRB103 37679 KTG 67806 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4977 Introduced , by Rep. Robyn Gabel SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-30.1 305 ILCS 5/5-30.1 Amends the Medical Assistance Article of the Illinois Public Aid Code. Makes changes to provisions requiring Medicaid managed care organizations (MCO) to make payments for emergency services. Requires an MCO to pay any provider of emergency services, including inpatient stabilization services provided during the inpatient stabilization period, that does not have in effect a contract with the MCO. Defines "inpatient stabilization period" to mean the initial 72 hours of inpatient stabilization services, beginning from the date and time of the order for inpatient admission to the hospital. Provides that when determining payment for all emergency services, including inpatient stabilization services provided during the inpatient stabilization period, the MCO shall: (i) not impose any service authorization requirements, including, but not limited to, prior authorization, prior approval, pre-certification, concurrent review, or certification of admission; (ii) have no obligation to cover emergency services provided on an emergency basis that are not covered services under the MCO's contract with the Department of Healthcare and Family Services; and (iii) not condition coverage for emergency services on the treating provider notifying the MCO of the enrollee's emergency medical screening examination and treatment within 10 days after presentation for emergency services. Provides that the determination of the attending emergency physician, or the practitioner responsible for the enrollee's care at the hospital, of whether an enrollee requires inpatient stabilization services, can be stabilized in the outpatient setting, or is sufficiently stabilized for discharge or transfer to another facility, shall be binding on the MCO. Provides that an MCO shall not reimburse inpatient stabilization services billed on an inpatient institutional claim under the outpatient reimbursement methodology and shall not reimburse providers for emergency services in cases of fraud. Requires the Department to impose sanctions on a MCO for noncompliance, including, but not limited to, financial penalties, suspension of enrollment of new enrollees, and termination of the MCO's contract with the Department. Effective immediately. LRB103 37679 KTG 67806 b LRB103 37679 KTG 67806 b A BILL FOR
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4977 Introduced , by Rep. Robyn Gabel SYNOPSIS AS INTRODUCED:
3	3	305 ILCS 5/5-30.1 305 ILCS 5/5-30.1
4	4	305 ILCS 5/5-30.1
5	5	Amends the Medical Assistance Article of the Illinois Public Aid Code. Makes changes to provisions requiring Medicaid managed care organizations (MCO) to make payments for emergency services. Requires an MCO to pay any provider of emergency services, including inpatient stabilization services provided during the inpatient stabilization period, that does not have in effect a contract with the MCO. Defines "inpatient stabilization period" to mean the initial 72 hours of inpatient stabilization services, beginning from the date and time of the order for inpatient admission to the hospital. Provides that when determining payment for all emergency services, including inpatient stabilization services provided during the inpatient stabilization period, the MCO shall: (i) not impose any service authorization requirements, including, but not limited to, prior authorization, prior approval, pre-certification, concurrent review, or certification of admission; (ii) have no obligation to cover emergency services provided on an emergency basis that are not covered services under the MCO's contract with the Department of Healthcare and Family Services; and (iii) not condition coverage for emergency services on the treating provider notifying the MCO of the enrollee's emergency medical screening examination and treatment within 10 days after presentation for emergency services. Provides that the determination of the attending emergency physician, or the practitioner responsible for the enrollee's care at the hospital, of whether an enrollee requires inpatient stabilization services, can be stabilized in the outpatient setting, or is sufficiently stabilized for discharge or transfer to another facility, shall be binding on the MCO. Provides that an MCO shall not reimburse inpatient stabilization services billed on an inpatient institutional claim under the outpatient reimbursement methodology and shall not reimburse providers for emergency services in cases of fraud. Requires the Department to impose sanctions on a MCO for noncompliance, including, but not limited to, financial penalties, suspension of enrollment of new enrollees, and termination of the MCO's contract with the Department. Effective immediately.
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8	8	A BILL FOR
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11	11	1 AN ACT concerning public aid.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 5. The Illinois Public Aid Code is amended by
15	15	5 changing Section 5-30.1 as follows:
16	16	6 (305 ILCS 5/5-30.1)
17	17	7 Sec. 5-30.1. Managed care protections.
18	18	8 (a) As used in this Section:
19	19	9 "Managed care organization" or "MCO" means any entity
20	20	10 which contracts with the Department to provide services where
21	21	11 payment for medical services is made on a capitated basis.
22	22	12 "Emergency services" means health care items and services,
23	23	13 including inpatient and outpatient hospital services,
24	24	14 furnished or required to evaluate and stabilize an emergency
25	25	15 medical condition. "Emergency services" include inpatient
26	26	16 stabilization services furnished during the inpatient
27	27	17 stabilization period. "Emergency services" do not include
28	28	18 post-stabilization medical services. include:
29	29	19 (1) emergency services, as defined by Section 10 of
30	30	20 the Managed Care Reform and Patient Rights Act;
31	31	21 (2) emergency medical screening examinations, as
32	32	22 defined by Section 10 of the Managed Care Reform and
33	33	23 Patient Rights Act;
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37	37	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4977 Introduced , by Rep. Robyn Gabel SYNOPSIS AS INTRODUCED:
38	38	305 ILCS 5/5-30.1 305 ILCS 5/5-30.1
39	39	305 ILCS 5/5-30.1
40	40	Amends the Medical Assistance Article of the Illinois Public Aid Code. Makes changes to provisions requiring Medicaid managed care organizations (MCO) to make payments for emergency services. Requires an MCO to pay any provider of emergency services, including inpatient stabilization services provided during the inpatient stabilization period, that does not have in effect a contract with the MCO. Defines "inpatient stabilization period" to mean the initial 72 hours of inpatient stabilization services, beginning from the date and time of the order for inpatient admission to the hospital. Provides that when determining payment for all emergency services, including inpatient stabilization services provided during the inpatient stabilization period, the MCO shall: (i) not impose any service authorization requirements, including, but not limited to, prior authorization, prior approval, pre-certification, concurrent review, or certification of admission; (ii) have no obligation to cover emergency services provided on an emergency basis that are not covered services under the MCO's contract with the Department of Healthcare and Family Services; and (iii) not condition coverage for emergency services on the treating provider notifying the MCO of the enrollee's emergency medical screening examination and treatment within 10 days after presentation for emergency services. Provides that the determination of the attending emergency physician, or the practitioner responsible for the enrollee's care at the hospital, of whether an enrollee requires inpatient stabilization services, can be stabilized in the outpatient setting, or is sufficiently stabilized for discharge or transfer to another facility, shall be binding on the MCO. Provides that an MCO shall not reimburse inpatient stabilization services billed on an inpatient institutional claim under the outpatient reimbursement methodology and shall not reimburse providers for emergency services in cases of fraud. Requires the Department to impose sanctions on a MCO for noncompliance, including, but not limited to, financial penalties, suspension of enrollment of new enrollees, and termination of the MCO's contract with the Department. Effective immediately.
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43	43	A BILL FOR
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68	68	1 (3) post-stabilization medical services, as defined by
69	69	2 Section 10 of the Managed Care Reform and Patient Rights
70	70	3 Act; and
71	71	4 (4) emergency medical conditions, as defined by
72	72	5 Section 10 of the Managed Care Reform and Patient Rights
73	73	6 Act.
74	74	7 "Emergency medical condition" means a medical condition
75	75	8 manifesting itself by acute symptoms of sufficient severity,
76	76	9 regardless of the final diagnosis given, such that a prudent
77	77	10 layperson, who possesses an average knowledge of health and
78	78	11 medicine, could reasonably expect the absence of immediate
79	79	12 medical attention to result in:
80	80	13 (1) placing the health of the individual (or, with
81	81	14 respect to a pregnant woman, the health of the woman or her
82	82	15 unborn child) in serious jeopardy;
83	83	16 (2) serious impairment to bodily functions;
84	84	17 (3) serious dysfunction of any bodily organ or part;
85	85	18 (4) inadequately controlled pain; or
86	86	19 (5) with respect to a pregnant woman who is having
87	87	20 contractions:
88	88	21 (A) inadequate time to complete a safe transfer to
89	89	22 another hospital before delivery; or
90	90	23 (B) a transfer to another hospital may pose a
91	91	24 threat to the health or safety of the woman or unborn
92	92	25 child.
93	93	26 "Emergency medical screening examination" means a medical
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104	104	1 screening examination and evaluation by a physician licensed
105	105	2 to practice medicine in all its branches or, to the extent
106	106	3 permitted by applicable laws, by other appropriately licensed
107	107	4 personnel under the supervision of or in collaboration with a
108	108	5 physician licensed to practice medicine in all its branches to
109	109	6 determine whether the need for emergency services exists.
110	110	7 "Inpatient stabilization period" means the initial 72
111	111	8 hours of inpatient stabilization services, beginning from the
112	112	9 date and time of the order for inpatient admission to the
113	113	10 hospital.
114	114	11 "Inpatient stabilization services" mean emergency services
115	115	12 furnished in the inpatient setting at a licensed hospital
116	116	13 pursuant to an order for inpatient admission by a physician or
117	117	14 other qualified practitioner who has admitting privileges at
118	118	15 the hospital, as permitted by State law, to stabilize an
119	119	16 emergency medical condition following an emergency medical
120	120	17 screening examination.
121	121	18 "Post-stabilization medical services" means health care
122	122	19 services provided to an enrollee that are furnished in a
123	123	20 licensed hospital by a provider that is qualified to furnish
124	124	21 such services and determined to be medically necessary and
125	125	22 directly related to the emergency medical condition following
126	126	23 stabilization.
127	127	24 (b) As provided by Section 5-16.12, managed care
128	128	25 organizations are subject to the provisions of the Managed
129	129	26 Care Reform and Patient Rights Act.
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140	140	1 (c) An MCO shall pay any provider of emergency services,
141	141	2 including inpatient stabilization services provided during the
142	142	3 inpatient stabilization period, that does not have in effect a
143	143	4 contract with the contracted Medicaid MCO. The default rate of
144	144	5 reimbursement shall be the rate paid under Illinois Medicaid
145	145	6 fee-for-service program methodology, including all policy
146	146	7 adjusters, including but not limited to Medicaid High Volume
147	147	8 Adjustments, Medicaid Percentage Adjustments, Outpatient High
148	148	9 Volume Adjustments, and all outlier add-on adjustments to the
149	149	10 extent such adjustments are incorporated in the development of
150	150	11 the applicable MCO capitated rates.
151	151	12 (d) An MCO shall pay for all post-stabilization services
152	152	13 as a covered service in any of the following situations:
153	153	14 (1) the MCO authorized such services;
154	154	15 (2) such services were administered to maintain the
155	155	16 enrollee's stabilized condition within one hour after a
156	156	17 request to the MCO for authorization of further
157	157	18 post-stabilization services;
158	158	19 (3) the MCO did not respond to a request to authorize
159	159	20 such services within one hour;
160	160	21 (4) the MCO could not be contacted; or
161	161	22 (5) the MCO and the treating provider, if the treating
162	162	23 provider is a non-affiliated provider, could not reach an
163	163	24 agreement concerning the enrollee's care and an affiliated
164	164	25 provider was unavailable for a consultation, in which case
165	165	26 the MCO must pay for such services rendered by the
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176	176	1 treating non-affiliated provider until an affiliated
177	177	2 provider was reached and either concurred with the
178	178	3 treating non-affiliated provider's plan of care or assumed
179	179	4 responsibility for the enrollee's care. Such payment shall
180	180	5 be made at the default rate of reimbursement paid under
181	181	6 Illinois Medicaid fee-for-service program methodology,
182	182	7 including all policy adjusters, including but not limited
183	183	8 to Medicaid High Volume Adjustments, Medicaid Percentage
184	184	9 Adjustments, Outpatient High Volume Adjustments and all
185	185	10 outlier add-on adjustments to the extent that such
186	186	11 adjustments are incorporated in the development of the
187	187	12 applicable MCO capitated rates.
188	188	13 (d) Notwithstanding any other provision of law, the (e)
189	189	14 The following requirements apply to MCOs in determining
190	190	15 payment for all emergency services, including inpatient
191	191	16 stabilization services provided during the inpatient
192	192	17 stabilization period:
193	193	18 (1) The MCO MCOs shall not impose any service
194	194	19 authorization requirements for prior approval of emergency
195	195	20 services, including, but not limited to, prior
196	196	21 authorization, prior approval, pre-certification,
197	197	22 concurrent review, or certification of admission.
198	198	23 (2) The MCO shall cover emergency services provided to
199	199	24 enrollees who are temporarily away from their residence
200	200	25 and outside the contracting area to the extent that the
201	201	26 enrollees would be entitled to the emergency services if
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212	212	1 they still were within the contracting area.
213	213	2 (3) The MCO shall have no obligation to cover
214	214	3 emergency medical services provided on an emergency basis
215	215	4 that are not covered services under the contract.
216	216	5 (4) The MCO shall not condition coverage for emergency
217	217	6 services on the treating provider notifying the MCO of the
218	218	7 enrollee's emergency medical screening examination and
219	219	8 treatment within 10 days after presentation for emergency
220	220	9 services.
221	221	10 (5) The determination of the attending emergency
222	222	11 physician, or the practitioner responsible for the
223	223	12 enrollee's care at the hospital, the provider actually
224	224	13 treating the enrollee, of whether an enrollee requires
225	225	14 inpatient stabilization services, can be stabilized in the
226	226	15 outpatient setting, or is sufficiently stabilized for
227	227	16 discharge or transfer to another facility, shall be
228	228	17 binding on the MCO. The MCO shall cover and reimburse
229	229	18 providers for emergency services as billed by the provider
230	230	19 for all enrollees whether the emergency services are
231	231	20 provided by an affiliated or non-affiliated provider,
232	232	21 except in cases of fraud. The MCO shall not reimburse
233	233	22 inpatient stabilization services provided during the
234	234	23 inpatient stabilization period and billed on an inpatient
235	235	24 institutional claim under the outpatient reimbursement
236	236	25 methodology.
237	237	26 (6) The MCO's financial responsibility for
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248	248	1 post-stabilization medical care services it has not
249	249	2 pre-approved ends when:
250	250	3 (A) a plan physician with privileges at the
251	251	4 treating hospital assumes responsibility for the
252	252	5 enrollee's care;
253	253	6 (B) a plan physician assumes responsibility for
254	254	7 the enrollee's care through transfer;
255	255	8 (C) a contracting entity representative and the
256	256	9 treating physician reach an agreement concerning the
257	257	10 enrollee's care; or
258	258	11 (D) the enrollee is discharged.
259	259	12 (e) An MCO shall pay for all post-stabilization medical
260	260	13 services as a covered service in any of the following
261	261	14 situations:
262	262	15 (1) the MCO authorized such services;
263	263	16 (2) such services were administered to maintain the
264	264	17 enrollee's stabilized condition within one hour after a
265	265	18 request to the MCO for authorization of further
266	266	19 post-stabilization services;
267	267	20 (3) the MCO did not respond to a request to authorize
268	268	21 such services within one hour;
269	269	22 (4) the MCO could not be contacted; or
270	270	23 (5) the MCO and the treating provider, if the treating
271	271	24 provider is a non-affiliated provider, could not reach an
272	272	25 agreement concerning the enrollee's care and an affiliated
273	273	26 provider was unavailable for a consultation, in which case
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284	284	1 the MCO must pay for such services rendered by the
285	285	2 treating non-affiliated provider until an affiliated
286	286	3 provider was reached and either concurred with the
287	287	4 treating non-affiliated provider's plan of care or assumed
288	288	5 responsibility for the enrollee's care. Such payment shall
289	289	6 be made at the default rate of reimbursement paid under
290	290	7 the State's Medicaid fee-for-service program methodology,
291	291	8 including all policy adjusters, including, but not limited
292	292	9 to, Medicaid High Volume Adjustments, Medicaid Percentage
293	293	10 Adjustments, Outpatient High Volume Adjustments, and all
294	294	11 outlier add-on adjustments to the extent that such
295	295	12 adjustments are incorporated in the development of the
296	296	13 applicable MCO capitated rates.
297	297	14 (f) Network adequacy and transparency.
298	298	15 (1) The Department shall:
299	299	16 (A) ensure that an adequate provider network is in
300	300	17 place, taking into consideration health professional
301	301	18 shortage areas and medically underserved areas;
302	302	19 (B) publicly release an explanation of its process
303	303	20 for analyzing network adequacy;
304	304	21 (C) periodically ensure that an MCO continues to
305	305	22 have an adequate network in place;
306	306	23 (D) require MCOs, including Medicaid Managed Care
307	307	24 Entities as defined in Section 5-30.2, to meet
308	308	25 provider directory requirements under Section 5-30.3;
309	309	26 (E) require MCOs to ensure that any
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320	320	1 Medicaid-certified provider under contract with an MCO
321	321	2 and previously submitted on a roster on the date of
322	322	3 service is paid for any medically necessary,
323	323	4 Medicaid-covered, and authorized service rendered to
324	324	5 any of the MCO's enrollees, regardless of inclusion on
325	325	6 the MCO's published and publicly available directory
326	326	7 of available providers; and
327	327	8 (F) require MCOs, including Medicaid Managed Care
328	328	9 Entities as defined in Section 5-30.2, to meet each of
329	329	10 the requirements under subsection (d-5) of Section 10
330	330	11 of the Network Adequacy and Transparency Act; with
331	331	12 necessary exceptions to the MCO's network to ensure
332	332	13 that admission and treatment with a provider or at a
333	333	14 treatment facility in accordance with the network
334	334	15 adequacy standards in paragraph (3) of subsection
335	335	16 (d-5) of Section 10 of the Network Adequacy and
336	336	17 Transparency Act is limited to providers or facilities
337	337	18 that are Medicaid certified.
338	338	19 (2) Each MCO shall confirm its receipt of information
339	339	20 submitted specific to physician or dentist additions or
340	340	21 physician or dentist deletions from the MCO's provider
341	341	22 network within 3 days after receiving all required
342	342	23 information from contracted physicians or dentists, and
343	343	24 electronic physician and dental directories must be
344	344	25 updated consistent with current rules as published by the
345	345	26 Centers for Medicare and Medicaid Services or its
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356	356	1 successor agency.
357	357	2 (g) Timely payment of claims.
358	358	3 (1) The MCO shall pay a claim within 30 days of
359	359	4 receiving a claim that contains all the essential
360	360	5 information needed to adjudicate the claim.
361	361	6 (2) The MCO shall notify the billing party of its
362	362	7 inability to adjudicate a claim within 30 days of
363	363	8 receiving that claim.
364	364	9 (3) The MCO shall pay a penalty that is at least equal
365	365	10 to the timely payment interest penalty imposed under
366	366	11 Section 368a of the Illinois Insurance Code for any claims
367	367	12 not timely paid.
368	368	13 (A) When an MCO is required to pay a timely payment
369	369	14 interest penalty to a provider, the MCO must calculate
370	370	15 and pay the timely payment interest penalty that is
371	371	16 due to the provider within 30 days after the payment of
372	372	17 the claim. In no event shall a provider be required to
373	373	18 request or apply for payment of any owed timely
374	374	19 payment interest penalties.
375	375	20 (B) Such payments shall be reported separately
376	376	21 from the claim payment for services rendered to the
377	377	22 MCO's enrollee and clearly identified as interest
378	378	23 payments.
379	379	24 (4)(A) The Department shall require MCOs to expedite
380	380	25 payments to providers identified on the Department's
381	381	26 expedited provider list, determined in accordance with 89
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392	392	1 Ill. Adm. Code 140.71(b), on a schedule at least as
393	393	2 frequently as the providers are paid under the
394	394	3 Department's fee-for-service expedited provider schedule.
395	395	4 (B) Compliance with the expedited provider requirement
396	396	5 may be satisfied by an MCO through the use of a Periodic
397	397	6 Interim Payment (PIP) program that has been mutually
398	398	7 agreed to and documented between the MCO and the provider,
399	399	8 if the PIP program ensures that any expedited provider
400	400	9 receives regular and periodic payments based on prior
401	401	10 period payment experience from that MCO. Total payments
402	402	11 under the PIP program may be reconciled against future PIP
403	403	12 payments on a schedule mutually agreed to between the MCO
404	404	13 and the provider.
405	405	14 (C) The Department shall share at least monthly its
406	406	15 expedited provider list and the frequency with which it
407	407	16 pays providers on the expedited list.
408	408	17 (g-5) Recognizing that the rapid transformation of the
409	409	18 Illinois Medicaid program may have unintended operational
410	410	19 challenges for both payers and providers:
411	411	20 (1) in no instance shall a medically necessary covered
412	412	21 service rendered in good faith, based upon eligibility
413	413	22 information documented by the provider, be denied coverage
414	414	23 or diminished in payment amount if the eligibility or
415	415	24 coverage information available at the time the service was
416	416	25 rendered is later found to be inaccurate in the assignment
417	417	26 of coverage responsibility between MCOs or the
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428	428	1 fee-for-service system, except for instances when an
429	429	2 individual is deemed to have not been eligible for
430	430	3 coverage under the Illinois Medicaid program; and
431	431	4 (2) the Department shall, by December 31, 2016, adopt
432	432	5 rules establishing policies that shall be included in the
433	433	6 Medicaid managed care policy and procedures manual
434	434	7 addressing payment resolutions in situations in which a
435	435	8 provider renders services based upon information obtained
436	436	9 after verifying a patient's eligibility and coverage plan
437	437	10 through either the Department's current enrollment system
438	438	11 or a system operated by the coverage plan identified by
439	439	12 the patient presenting for services:
440	440	13 (A) such medically necessary covered services
441	441	14 shall be considered rendered in good faith;
442	442	15 (B) such policies and procedures shall be
443	443	16 developed in consultation with industry
444	444	17 representatives of the Medicaid managed care health
445	445	18 plans and representatives of provider associations
446	446	19 representing the majority of providers within the
447	447	20 identified provider industry; and
448	448	21 (C) such rules shall be published for a review and
449	449	22 comment period of no less than 30 days on the
450	450	23 Department's website with final rules remaining
451	451	24 available on the Department's website.
452	452	25 The rules on payment resolutions shall include, but
453	453	26 not be limited to:
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464	464	1 (A) the extension of the timely filing period;
465	465	2 (B) retroactive prior authorizations; and
466	466	3 (C) guaranteed minimum payment rate of no less
467	467	4 than the current, as of the date of service,
468	468	5 fee-for-service rate, plus all applicable add-ons,
469	469	6 when the resulting service relationship is out of
470	470	7 network.
471	471	8 The rules shall be applicable for both MCO coverage
472	472	9 and fee-for-service coverage.
473	473	10 If the fee-for-service system is ultimately determined to
474	474	11 have been responsible for coverage on the date of service, the
475	475	12 Department shall provide for an extended period for claims
476	476	13 submission outside the standard timely filing requirements.
477	477	14 (g-6) MCO Performance Metrics Report.
478	478	15 (1) The Department shall publish, on at least a
479	479	16 quarterly basis, each MCO's operational performance,
480	480	17 including, but not limited to, the following categories of
481	481	18 metrics:
482	482	19 (A) claims payment, including timeliness and
483	483	20 accuracy;
484	484	21 (B) prior authorizations;
485	485	22 (C) grievance and appeals;
486	486	23 (D) utilization statistics;
487	487	24 (E) provider disputes;
488	488	25 (F) provider credentialing; and
489	489	26 (G) member and provider customer service.
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500	500	1 (2) The Department shall ensure that the metrics
501	501	2 report is accessible to providers online by January 1,
502	502	3 2017.
503	503	4 (3) The metrics shall be developed in consultation
504	504	5 with industry representatives of the Medicaid managed care
505	505	6 health plans and representatives of associations
506	506	7 representing the majority of providers within the
507	507	8 identified industry.
508	508	9 (4) Metrics shall be defined and incorporated into the
509	509	10 applicable Managed Care Policy Manual issued by the
510	510	11 Department.
511	511	12 (g-7) MCO claims processing and performance analysis. In
512	512	13 order to monitor MCO payments to hospital providers, pursuant
513	513	14 to Public Act 100-580, the Department shall post an analysis
514	514	15 of MCO claims processing and payment performance on its
515	515	16 website every 6 months. Such analysis shall include a review
516	516	17 and evaluation of a representative sample of hospital claims
517	517	18 that are rejected and denied for clean and unclean claims and
518	518	19 the top 5 reasons for such actions and timeliness of claims
519	519	20 adjudication, which identifies the percentage of claims
520	520	21 adjudicated within 30, 60, 90, and over 90 days, and the dollar
521	521	22 amounts associated with those claims.
522	522	23 (g-8) Dispute resolution process. The Department shall
523	523	24 maintain a provider complaint portal through which a provider
524	524	25 can submit to the Department unresolved disputes with an MCO.
525	525	26 An unresolved dispute means an MCO's decision that denies in
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536	536	1 whole or in part a claim for reimbursement to a provider for
537	537	2 health care services rendered by the provider to an enrollee
538	538	3 of the MCO with which the provider disagrees. Disputes shall
539	539	4 not be submitted to the portal until the provider has availed
540	540	5 itself of the MCO's internal dispute resolution process.
541	541	6 Disputes that are submitted to the MCO internal dispute
542	542	7 resolution process may be submitted to the Department of
543	543	8 Healthcare and Family Services' complaint portal no sooner
544	544	9 than 30 days after submitting to the MCO's internal process
545	545	10 and not later than 30 days after the unsatisfactory resolution
546	546	11 of the internal MCO process or 60 days after submitting the
547	547	12 dispute to the MCO internal process. Multiple claim disputes
548	548	13 involving the same MCO may be submitted in one complaint,
549	549	14 regardless of whether the claims are for different enrollees,
550	550	15 when the specific reason for non-payment of the claims
551	551	16 involves a common question of fact or policy. Within 10
552	552	17 business days of receipt of a complaint, the Department shall
553	553	18 present such disputes to the appropriate MCO, which shall then
554	554	19 have 30 days to issue its written proposal to resolve the
555	555	20 dispute. The Department may grant one 30-day extension of this
556	556	21 time frame to one of the parties to resolve the dispute. If the
557	557	22 dispute remains unresolved at the end of this time frame or the
558	558	23 provider is not satisfied with the MCO's written proposal to
559	559	24 resolve the dispute, the provider may, within 30 days, request
560	560	25 the Department to review the dispute and make a final
561	561	26 determination. Within 30 days of the request for Department
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572	572	1 review of the dispute, both the provider and the MCO shall
573	573	2 present all relevant information to the Department for
574	574	3 resolution and make individuals with knowledge of the issues
575	575	4 available to the Department for further inquiry if needed.
576	576	5 Within 30 days of receiving the relevant information on the
577	577	6 dispute, or the lapse of the period for submitting such
578	578	7 information, the Department shall issue a written decision on
579	579	8 the dispute based on contractual terms between the provider
580	580	9 and the MCO, contractual terms between the MCO and the
581	581	10 Department of Healthcare and Family Services and applicable
582	582	11 Medicaid policy. The decision of the Department shall be
583	583	12 final. By January 1, 2020, the Department shall establish by
584	584	13 rule further details of this dispute resolution process.
585	585	14 Disputes between MCOs and providers presented to the
586	586	15 Department for resolution are not contested cases, as defined
587	587	16 in Section 1-30 of the Illinois Administrative Procedure Act,
588	588	17 conferring any right to an administrative hearing.
589	589	18 (g-9)(1) The Department shall publish annually on its
590	590	19 website a report on the calculation of each managed care
591	591	20 organization's medical loss ratio showing the following:
592	592	21 (A) Premium revenue, with appropriate adjustments.
593	593	22 (B) Benefit expense, setting forth the aggregate
594	594	23 amount spent for the following:
595	595	24 (i) Direct paid claims.
596	596	25 (ii) Subcapitation payments.
597	597	26 (iii) Other claim payments.
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608	608	1 (iv) Direct reserves.
609	609	2 (v) Gross recoveries.
610	610	3 (vi) Expenses for activities that improve health
611	611	4 care quality as allowed by the Department.
612	612	5 (2) The medical loss ratio shall be calculated consistent
613	613	6 with federal law and regulation following a claims runout
614	614	7 period determined by the Department.
615	615	8 (g-10)(1) "Liability effective date" means the date on
616	616	9 which an MCO becomes responsible for payment for medically
617	617	10 necessary and covered services rendered by a provider to one
618	618	11 of its enrollees in accordance with the contract terms between
619	619	12 the MCO and the provider. The liability effective date shall
620	620	13 be the later of:
621	621	14 (A) The execution date of a network participation
622	622	15 contract agreement.
623	623	16 (B) The date the provider or its representative
624	624	17 submits to the MCO the complete and accurate standardized
625	625	18 roster form for the provider in the format approved by the
626	626	19 Department.
627	627	20 (C) The provider effective date contained within the
628	628	21 Department's provider enrollment subsystem within the
629	629	22 Illinois Medicaid Program Advanced Cloud Technology
630	630	23 (IMPACT) System.
631	631	24 (2) The standardized roster form may be submitted to the
632	632	25 MCO at the same time that the provider submits an enrollment
633	633	26 application to the Department through IMPACT.
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644	644	1 (3) By October 1, 2019, the Department shall require all
645	645	2 MCOs to update their provider directory with information for
646	646	3 new practitioners of existing contracted providers within 30
647	647	4 days of receipt of a complete and accurate standardized roster
648	648	5 template in the format approved by the Department provided
649	649	6 that the provider is effective in the Department's provider
650	650	7 enrollment subsystem within the IMPACT system. Such provider
651	651	8 directory shall be readily accessible for purposes of
652	652	9 selecting an approved health care provider and comply with all
653	653	10 other federal and State requirements.
654	654	11 (g-11) The Department shall work with relevant
655	655	12 stakeholders on the development of operational guidelines to
656	656	13 enhance and improve operational performance of Illinois'
657	657	14 Medicaid managed care program, including, but not limited to,
658	658	15 improving provider billing practices, reducing claim
659	659	16 rejections and inappropriate payment denials, and
660	660	17 standardizing processes, procedures, definitions, and response
661	661	18 timelines, with the goal of reducing provider and MCO
662	662	19 administrative burdens and conflict. The Department shall
663	663	20 include a report on the progress of these program improvements
664	664	21 and other topics in its Fiscal Year 2020 annual report to the
665	665	22 General Assembly.
666	666	23 (g-12) Notwithstanding any other provision of law, if the
667	667	24 Department or an MCO requires submission of a claim for
668	668	25 payment in a non-electronic format, a provider shall always be
669	669	26 afforded a period of no less than 90 business days, as a
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680	680	1 correction period, following any notification of rejection by
681	681	2 either the Department or the MCO to correct errors or
682	682	3 omissions in the original submission.
683	683	4 Under no circumstances, either by an MCO or under the
684	684	5 State's fee-for-service system, shall a provider be denied
685	685	6 payment for failure to comply with any timely submission
686	686	7 requirements under this Code or under any existing contract,
687	687	8 unless the non-electronic format claim submission occurs after
688	688	9 the initial 180 days following the latest date of service on
689	689	10 the claim, or after the 90 business days correction period
690	690	11 following notification to the provider of rejection or denial
691	691	12 of payment.
692	692	13 (h) The Department shall not expand mandatory MCO
693	693	14 enrollment into new counties beyond those counties already
694	694	15 designated by the Department as of June 1, 2014 for the
695	695	16 individuals whose eligibility for medical assistance is not
696	696	17 the seniors or people with disabilities population until the
697	697	18 Department provides an opportunity for accountable care
698	698	19 entities and MCOs to participate in such newly designated
699	699	20 counties.
700	700	21 (h-5) Leading indicator data sharing. By January 1, 2024,
701	701	22 the Department shall obtain input from the Department of Human
702	702	23 Services, the Department of Juvenile Justice, the Department
703	703	24 of Children and Family Services, the State Board of Education,
704	704	25 managed care organizations, providers, and clinical experts to
705	705	26 identify and analyze key indicators from assessments and data
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716	716	1 sets available to the Department that can be shared with
717	717	2 managed care organizations and similar care coordination
718	718	3 entities contracted with the Department as leading indicators
719	719	4 for elevated behavioral health crisis risk for children. To
720	720	5 the extent permitted by State and federal law, the identified
721	721	6 leading indicators shall be shared with managed care
722	722	7 organizations and similar care coordination entities
723	723	8 contracted with the Department within 6 months of
724	724	9 identification for the purpose of improving care coordination
725	725	10 with the early detection of elevated risk. Leading indicators
726	726	11 shall be reassessed annually with stakeholder input.
727	727	12 (i) The requirements of this Section apply to contracts
728	728	13 with accountable care entities and MCOs entered into, amended,
729	729	14 or renewed after June 16, 2014 (the effective date of Public
730	730	15 Act 98-651).
731	731	16 (j) Health care information released to managed care
732	732	17 organizations. A health care provider shall release to a
733	733	18 Medicaid managed care organization, upon request, and subject
734	734	19 to the Health Insurance Portability and Accountability Act of
735	735	20 1996 and any other law applicable to the release of health
736	736	21 information, the health care information of the MCO's
737	737	22 enrollee, if the enrollee has completed and signed a general
738	738	23 release form that grants to the health care provider
739	739	24 permission to release the recipient's health care information
740	740	25 to the recipient's insurance carrier.
741	741	26 (k) The Department of Healthcare and Family Services,
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752	752	1 managed care organizations, a statewide organization
753	753	2 representing hospitals, and a statewide organization
754	754	3 representing safety-net hospitals shall explore ways to
755	755	4 support billing departments in safety-net hospitals.
756	756	5 (l) The requirements of this Section added by Public Act
757	757	6 102-4 shall apply to services provided on or after the first
758	758	7 day of the month that begins 60 days after April 27, 2021 (the
759	759	8 effective date of Public Act 102-4).
760	760	9 (m) The Department shall impose sanctions on a managed
761	761	10 care organization for violating any provision under this
762	762	11 Section, including, but not limited to, financial penalties,
763	763	12 suspension of enrollment of new enrollees, and termination of
764	764	13 the MCO's contract with the Department.
765	765	14 (Source: P.A. 102-4, eff. 4-27-21; 102-43, eff. 7-6-21;
766	766	15 102-144, eff. 1-1-22; 102-454, eff. 8-20-21; 102-813, eff.
767	767	16 5-13-22; 103-546, eff. 8-11-23.)
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