IL
Illinois House Bill HB4979

Illinois 2023-2024 Regular Session

Illinois House Bill HB4979 Compare Versions

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11 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4979 Introduced , by Rep. Robyn Gabel SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-30.18 new Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to adopt rules, by no later than January 1, 2025, to establish a process under which any provider meeting certain performance standards outlined in the amendatory Act shall be certified for a service authorization exemption from all service authorization programs for a period of no less than one year. Provides that qualification for a service authorization exemption shall be determined by the Department, or its contracted utilization review organization (URO), and shall be binding on a managed care organization (MCO) or the MCO's contracted URO. Provides that a provider shall be eligible for a service authorization exemption if the provider submitted at least 25 service authorization requests to a service authorization program in the preceding calendar year and the service authorization program approved at least 80% of the service authorization requests. Provides that no later than December 1 of each calendar year, each service authorization program shall provide written notification to all providers who qualify for a service authorization exemption for the subsequent calendar year. Requires the Department to adopt rules by January 1, 2025 to establish: (i) a standard method the Department, or its contracted URO, shall use to evaluate whether a provider meets the criteria to qualify for a service authorization exemption; (ii) a standard method the Department, or its contracted URO, shall use to accept and process provider appeals of denied or rescinded exemptions; and (iii) a standard method the MCOs shall use to accept and process professional claims and facility claims, as billed by the provider, for a health care service that is rendered, prescribed, or ordered by a provider granted a service authorization exemption, except in cases of fraud. Contains provisions concerning annual reviews by the Department of service authorization denials made under each service authorization program; quarterly reports issued by the Department that detail the performance of each service authorization program; sanctions on MCOs for noncompliance with any provision of the amendatory Act. Effective immediately. LRB103 37685 KTG 67812 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4979 Introduced , by Rep. Robyn Gabel SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-30.18 new 305 ILCS 5/5-30.18 new Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to adopt rules, by no later than January 1, 2025, to establish a process under which any provider meeting certain performance standards outlined in the amendatory Act shall be certified for a service authorization exemption from all service authorization programs for a period of no less than one year. Provides that qualification for a service authorization exemption shall be determined by the Department, or its contracted utilization review organization (URO), and shall be binding on a managed care organization (MCO) or the MCO's contracted URO. Provides that a provider shall be eligible for a service authorization exemption if the provider submitted at least 25 service authorization requests to a service authorization program in the preceding calendar year and the service authorization program approved at least 80% of the service authorization requests. Provides that no later than December 1 of each calendar year, each service authorization program shall provide written notification to all providers who qualify for a service authorization exemption for the subsequent calendar year. Requires the Department to adopt rules by January 1, 2025 to establish: (i) a standard method the Department, or its contracted URO, shall use to evaluate whether a provider meets the criteria to qualify for a service authorization exemption; (ii) a standard method the Department, or its contracted URO, shall use to accept and process provider appeals of denied or rescinded exemptions; and (iii) a standard method the MCOs shall use to accept and process professional claims and facility claims, as billed by the provider, for a health care service that is rendered, prescribed, or ordered by a provider granted a service authorization exemption, except in cases of fraud. Contains provisions concerning annual reviews by the Department of service authorization denials made under each service authorization program; quarterly reports issued by the Department that detail the performance of each service authorization program; sanctions on MCOs for noncompliance with any provision of the amendatory Act. Effective immediately. LRB103 37685 KTG 67812 b LRB103 37685 KTG 67812 b A BILL FOR
22 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4979 Introduced , by Rep. Robyn Gabel SYNOPSIS AS INTRODUCED:
33 305 ILCS 5/5-30.18 new 305 ILCS 5/5-30.18 new
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55 Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to adopt rules, by no later than January 1, 2025, to establish a process under which any provider meeting certain performance standards outlined in the amendatory Act shall be certified for a service authorization exemption from all service authorization programs for a period of no less than one year. Provides that qualification for a service authorization exemption shall be determined by the Department, or its contracted utilization review organization (URO), and shall be binding on a managed care organization (MCO) or the MCO's contracted URO. Provides that a provider shall be eligible for a service authorization exemption if the provider submitted at least 25 service authorization requests to a service authorization program in the preceding calendar year and the service authorization program approved at least 80% of the service authorization requests. Provides that no later than December 1 of each calendar year, each service authorization program shall provide written notification to all providers who qualify for a service authorization exemption for the subsequent calendar year. Requires the Department to adopt rules by January 1, 2025 to establish: (i) a standard method the Department, or its contracted URO, shall use to evaluate whether a provider meets the criteria to qualify for a service authorization exemption; (ii) a standard method the Department, or its contracted URO, shall use to accept and process provider appeals of denied or rescinded exemptions; and (iii) a standard method the MCOs shall use to accept and process professional claims and facility claims, as billed by the provider, for a health care service that is rendered, prescribed, or ordered by a provider granted a service authorization exemption, except in cases of fraud. Contains provisions concerning annual reviews by the Department of service authorization denials made under each service authorization program; quarterly reports issued by the Department that detail the performance of each service authorization program; sanctions on MCOs for noncompliance with any provision of the amendatory Act. Effective immediately.
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1111 1 AN ACT concerning public aid.
1212 2 Be it enacted by the People of the State of Illinois,
1313 3 represented in the General Assembly:
1414 4 Section 5. The Illinois Public Aid Code is amended by
1515 5 adding Section 5-30.18 as follows:
1616 6 (305 ILCS 5/5-30.18 new)
1717 7 Sec. 5-30.18. Service authorization program performance.
1818 8 (a) Definitions. As used in this Section:
1919 9 "Health care service" means any medical or behavioral
2020 10 health service covered under the medical assistance program
2121 11 that is rendered in the inpatient or outpatient hospital
2222 12 setting and subject to review under a service authorization
2323 13 program.
2424 14 "Provider" means a facility or individual, or group of
2525 15 individuals operating under the same tax identification
2626 16 number, actively enrolled in the medical assistance program
2727 17 and licensed or otherwise authorized to order, prescribe,
2828 18 refer, or render health care services in this State.
2929 19 "Service authorization determination" means a decision
3030 20 made by a service authorization program to approve, change the
3131 21 level of care, partially deny, or deny coverage and
3232 22 reimbursement for a health care service upon review of a
3333 23 service authorization request submitted by a provider.
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3737 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4979 Introduced , by Rep. Robyn Gabel SYNOPSIS AS INTRODUCED:
3838 305 ILCS 5/5-30.18 new 305 ILCS 5/5-30.18 new
3939 305 ILCS 5/5-30.18 new
4040 Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to adopt rules, by no later than January 1, 2025, to establish a process under which any provider meeting certain performance standards outlined in the amendatory Act shall be certified for a service authorization exemption from all service authorization programs for a period of no less than one year. Provides that qualification for a service authorization exemption shall be determined by the Department, or its contracted utilization review organization (URO), and shall be binding on a managed care organization (MCO) or the MCO's contracted URO. Provides that a provider shall be eligible for a service authorization exemption if the provider submitted at least 25 service authorization requests to a service authorization program in the preceding calendar year and the service authorization program approved at least 80% of the service authorization requests. Provides that no later than December 1 of each calendar year, each service authorization program shall provide written notification to all providers who qualify for a service authorization exemption for the subsequent calendar year. Requires the Department to adopt rules by January 1, 2025 to establish: (i) a standard method the Department, or its contracted URO, shall use to evaluate whether a provider meets the criteria to qualify for a service authorization exemption; (ii) a standard method the Department, or its contracted URO, shall use to accept and process provider appeals of denied or rescinded exemptions; and (iii) a standard method the MCOs shall use to accept and process professional claims and facility claims, as billed by the provider, for a health care service that is rendered, prescribed, or ordered by a provider granted a service authorization exemption, except in cases of fraud. Contains provisions concerning annual reviews by the Department of service authorization denials made under each service authorization program; quarterly reports issued by the Department that detail the performance of each service authorization program; sanctions on MCOs for noncompliance with any provision of the amendatory Act. Effective immediately.
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6868 1 "Service authorization exemption" means an exception
6969 2 granted by a service authorization program to a provider under
7070 3 which all service authorization requests for covered health
7171 4 care services are automatically deemed to be medically
7272 5 necessary, clinically appropriate, and approved for
7373 6 reimbursement as ordered.
7474 7 "Service authorization program" means any utilization
7575 8 review, utilization management, peer review, quality review,
7676 9 or other medical management activity conducted in advance of,
7777 10 concurrent to, or after the provision of a health care service
7878 11 by a Medicaid managed care organization, either directly or
7979 12 through a contracted utilization review organization (URO),
8080 13 including, but not limited to, prior authorization,
8181 14 pre-certification, certification of admission, concurrent
8282 15 review, and retrospective review of health care services.
8383 16 "Service authorization request" means a request by a
8484 17 provider to a service authorization program to determine
8585 18 whether a health care service that is otherwise covered under
8686 19 the medical assistance program meets the reimbursement
8787 20 requirements established by the managed care organization
8888 21 (MCO), or its contracted URO, for medically necessary,
8989 22 clinically appropriate care and to issue a service
9090 23 authorization determination.
9191 24 "Utilization review organization" or "URO" means a managed
9292 25 care organization or other entity that has established or
9393 26 administers one or more service authorization programs.
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104104 1 (b) By no later than January 1, 2025, the Department shall
105105 2 adopt rules to establish a process under which any provider
106106 3 meeting the performance standards outlined in subsection (c)
107107 4 shall be certified for a service authorization exemption from
108108 5 all service authorization programs for a period of no less
109109 6 than one year. Qualification for a service authorization
110110 7 exemption shall be determined by the Department, or its
111111 8 contracted URO, and shall be binding on the MCO or the MCO's
112112 9 contracted URO.
113113 10 (c) A provider shall be eligible for a service
114114 11 authorization exemption if the provider submitted at least 25
115115 12 service authorization requests to a service authorization
116116 13 program in the preceding calendar year and the service
117117 14 authorization program approved at least 80% of the service
118118 15 authorization requests. A provider shall not be required to
119119 16 request a service authorization exemption to qualify for such
120120 17 exemption.
121121 18 (d) No later than December 1 of each calendar year, each
122122 19 service authorization program shall provide written
123123 20 notification to all providers who qualify for a service
124124 21 authorization exemption, as determined by the Department, for
125125 22 the subsequent calendar year.
126126 23 (e) A service authorization program shall not deny,
127127 24 partially deny, reduce the level of care, or otherwise limit
128128 25 reimbursement to the rendering or supervising provider,
129129 26 including the rendering facility, for health care services
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140140 1 ordered by a provider who qualifies for a service
141141 2 authorization exemption, except in cases of fraud.
142142 3 (f) In consultation with the Medicaid managed care
143143 4 organizations, a statewide association representing managed
144144 5 care organizations, a statewide association representing the
145145 6 majority of Illinois hospitals, a statewide association
146146 7 representing physicians, and a statewide association
147147 8 representing nursing homes, the Department shall by January 1,
148148 9 2025 adopt administrative rules to establish:
149149 10 (1) a standard method the Department, or its
150150 11 contracted URO, shall use to evaluate whether a provider
151151 12 meets the criteria to qualify for a service authorization
152152 13 exemption under subsection (c) and to determine the
153153 14 conditions under which a service authorization exemption
154154 15 may be rescinded, including review of the provider's
155155 16 utilization during the preceding calendar year.
156156 17 (2) a standard method the Department, or its
157157 18 contracted URO, shall use to accept and process provider
158158 19 appeals of denied or rescinded exemptions;
159159 20 (3) a standard method the MCOs shall use to accept and
160160 21 process professional claims and facility claims, as billed
161161 22 by the provider, for a health care service that is
162162 23 rendered, prescribed, or ordered by a provider granted a
163163 24 service authorization exemption, except in cases of fraud.
164164 25 (g) To ensure covered services furnished to individuals
165165 26 enrolled in an MCO are no less in amount, duration, and scope
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176176 1 than the same services furnished to individuals enrolled in
177177 2 the State's fee-for-service medical assistance program,
178178 3 beginning January 1, 2026, the Department, or its external
179179 4 quality review organization, shall conduct and make publicly
180180 5 available the results of an annual review of a sample of
181181 6 service authorization denials made under each service
182182 7 authorization program, stratified by MCO during the preceding
183183 8 calendar year, including denials based on initial review of a
184184 9 service authorization request and denials overturned on appeal
185185 10 to the service authorization program's internal process. The
186186 11 review shall, at a minimum, evaluate whether the
187187 12 determinations were made:
188188 13 (1) using consistent application of established,
189189 14 evidence-based, and professionally recognized medical
190190 15 necessity criteria that is no more restrictive that the
191191 16 criteria used in the State's fee-for-service medical
192192 17 assistance program; and
193193 18 (2) in compliance with the Department's administrative
194194 19 rules, the terms of the contract between the Department
195195 20 and the MCOs, and other applicable federal and State laws,
196196 21 regulations, and policies.
197197 22 (h) The Department shall publish quarterly reports
198198 23 detailing the performance of each service authorization
199199 24 program, stratified by MCO, including concurrent review and
200200 25 continued stay review requests, that details, at a minimum,
201201 26 the number of service authorization requests received, the
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212212 1 number of requests approved based on review of the initial
213213 2 request, the number of requests denied based on review of the
214214 3 initial request and the reasons for the denials, the number of
215215 4 requests downgraded to a lower level of care and the reasons
216216 5 for the change in level of care, and the number of denied
217217 6 requests overturned on appeal and the reasons the requests
218218 7 were overturned.
219219 8 (i) The Department shall impose sanctions on a managed
220220 9 care organization for violating provisions of this Section
221221 10 that include, but are not limited to, financial penalties,
222222 11 suspension of enrollment of new enrollees, and termination of
223223 12 the MCO's contract with the Department.
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