Illinois 2023-2024 Regular Session

Illinois House Bill HB4980 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 HB4980 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. Requires the Department of Healthcare and Family Services to: (1) adopt a single, uniform service authorization program under which service authorization determinations for all individuals enrolled in a managed care organization (MCO) shall be made by the Department's contracted utilization review organization (URO), as defined; (2) require all service authorization determinations made by the URO to be binding upon the MCO; (3) prohibit an MCO from denying or reducing payment of a claim, or recouping payment of a paid claim, for health care services approved by the URO, except in cases of fraud; (4) adopt certain rules concerning service authorization determinations; (5) seek approval from the federal Centers for Medicare and Medicaid Services for enhanced federal matching funds for such improvements to the Department's Medicaid Management Information System to implement the single, uniform service authorization program; and other matters. Makes these changes applicable to managed care contracts issued, amended, delivered, or renewed on or after January 1, 2025. Makes changes to provisions on when an MCO is required to pay for post-stabilization services as a covered service. Prohibits MCOs and the URO from imposing any requirements for prior approval of emergency services. Provides that MCOs are not obligated to cover health care services, as defined, that are provided on an emergency basis but are not covered services under its contract with the Department. 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 37674 KTG 67801 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4980 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. Requires the Department of Healthcare and Family Services to: (1) adopt a single, uniform service authorization program under which service authorization determinations for all individuals enrolled in a managed care organization (MCO) shall be made by the Department's contracted utilization review organization (URO), as defined; (2) require all service authorization determinations made by the URO to be binding upon the MCO; (3) prohibit an MCO from denying or reducing payment of a claim, or recouping payment of a paid claim, for health care services approved by the URO, except in cases of fraud; (4) adopt certain rules concerning service authorization determinations; (5) seek approval from the federal Centers for Medicare and Medicaid Services for enhanced federal matching funds for such improvements to the Department's Medicaid Management Information System to implement the single, uniform service authorization program; and other matters. Makes these changes applicable to managed care contracts issued, amended, delivered, or renewed on or after January 1, 2025. Makes changes to provisions on when an MCO is required to pay for post-stabilization services as a covered service. Prohibits MCOs and the URO from imposing any requirements for prior approval of emergency services. Provides that MCOs are not obligated to cover health care services, as defined, that are provided on an emergency basis but are not covered services under its contract with the Department. 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 37674 KTG 67801 b LRB103 37674 KTG 67801 b A BILL FOR
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4980 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. Requires the Department of Healthcare and Family Services to: (1) adopt a single, uniform service authorization program under which service authorization determinations for all individuals enrolled in a managed care organization (MCO) shall be made by the Department's contracted utilization review organization (URO), as defined; (2) require all service authorization determinations made by the URO to be binding upon the MCO; (3) prohibit an MCO from denying or reducing payment of a claim, or recouping payment of a paid claim, for health care services approved by the URO, except in cases of fraud; (4) adopt certain rules concerning service authorization determinations; (5) seek approval from the federal Centers for Medicare and Medicaid Services for enhanced federal matching funds for such improvements to the Department's Medicaid Management Information System to implement the single, uniform service authorization program; and other matters. Makes these changes applicable to managed care contracts issued, amended, delivered, or renewed on or after January 1, 2025. Makes changes to provisions on when an MCO is required to pay for post-stabilization services as a covered service. Prohibits MCOs and the URO from imposing any requirements for prior approval of emergency services. Provides that MCOs are not obligated to cover health care services, as defined, that are provided on an emergency basis but are not covered services under its contract with the Department. 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
9	9	HB4980LRB103 37674 KTG 67801 b HB4980 LRB103 37674 KTG 67801 b
10	10	HB4980 LRB103 37674 KTG 67801 b
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, including health care services
22	22	12 as defined in this Section, is made on a capitated basis.
23	23	13 "Emergency services" include:
24	24	14 (1) emergency services, as defined by Section 10 of
25	25	15 the Managed Care Reform and Patient Rights Act;
26	26	16 (2) emergency medical screening examinations, as
27	27	17 defined by Section 10 of the Managed Care Reform and
28	28	18 Patient Rights Act;
29	29	19 (3) post-stabilization medical services, as defined by
30	30	20 Section 10 of the Managed Care Reform and Patient Rights
31	31	21 Act, and health care services; and
32	32	22 (4) emergency medical conditions, as defined by
33	33	23 Section 10 of the Managed Care Reform and Patient Rights
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37	37	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4980 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. Requires the Department of Healthcare and Family Services to: (1) adopt a single, uniform service authorization program under which service authorization determinations for all individuals enrolled in a managed care organization (MCO) shall be made by the Department's contracted utilization review organization (URO), as defined; (2) require all service authorization determinations made by the URO to be binding upon the MCO; (3) prohibit an MCO from denying or reducing payment of a claim, or recouping payment of a paid claim, for health care services approved by the URO, except in cases of fraud; (4) adopt certain rules concerning service authorization determinations; (5) seek approval from the federal Centers for Medicare and Medicaid Services for enhanced federal matching funds for such improvements to the Department's Medicaid Management Information System to implement the single, uniform service authorization program; and other matters. Makes these changes applicable to managed care contracts issued, amended, delivered, or renewed on or after January 1, 2025. Makes changes to provisions on when an MCO is required to pay for post-stabilization services as a covered service. Prohibits MCOs and the URO from imposing any requirements for prior approval of emergency services. Provides that MCOs are not obligated to cover health care services, as defined, that are provided on an emergency basis but are not covered services under its contract with the Department. 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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49	49	305 ILCS 5/5-30.1
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68	68	1 Act.
69	69	2 "Health care services" mean any medical or behavioral
70	70	3 health services covered under the medical assistance program
71	71	4 that are rendered in the inpatient or outpatient hospital
72	72	5 setting and subject to review under a service authorization
73	73	6 program.
74	74	7 "Provider" means a facility or individual who is actively
75	75	8 enrolled in the medical assistance program and licensed or
76	76	9 otherwise authorized to order, prescribe, refer, or render
77	77	10 health care services in this State.
78	78	11 "Service authorization determination" means a decision
79	79	12 made by a service authorization program in advance of,
80	80	13 concurrent to, or after the provision of a health care service
81	81	14 to approve, change the level of care, partially deny, deny, or
82	82	15 otherwise limit coverage and reimbursement for a health care
83	83	16 service upon review of a service authorization request.
84	84	17 "Service authorization program" means any utilization
85	85	18 review, utilization management, peer review, quality review,
86	86	19 or other medical management activity conducted by the
87	87	20 Department's contracted utilization review organization,
88	88	21 including, but not limited to, prior authorization,
89	89	22 pre-certification, certification of admission, concurrent
90	90	23 review, and retrospective review, of health care services.
91	91	24 "Service authorization request" means a request by a
92	92	25 provider to a service authorization program to determine
93	93	26 whether an otherwise covered health care service meets the
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104	104	1 reimbursement requirements established by the Department by
105	105	2 rule for medically necessary, clinically appropriate care and
106	106	3 to issue a service authorization determination.
107	107	4 "Utilization review organization" or "URO" means a peer
108	108	5 review organization or quality improvement organization that
109	109	6 contracts with the Department to administer a service
110	110	7 authorization program and make service authorization
111	111	8 determinations.
112	112	9 (b) As provided by Section 5-16.12, managed care
113	113	10 organizations are subject to the provisions of the Managed
114	114	11 Care Reform and Patient Rights Act.
115	115	12 (c) An MCO shall pay any provider of emergency services
116	116	13 that does not have in effect a contract with the contracted
117	117	14 Medicaid MCO. The default rate of reimbursement shall be the
118	118	15 rate paid under Illinois Medicaid fee-for-service program
119	119	16 methodology, including all policy adjusters, including but not
120	120	17 limited to Medicaid High Volume Adjustments, Medicaid
121	121	18 Percentage Adjustments, Outpatient High Volume Adjustments,
122	122	19 and all outlier add-on adjustments to the extent such
123	123	20 adjustments are incorporated in the development of the
124	124	21 applicable MCO capitated rates.
125	125	22 (d) An MCO shall pay for all post-stabilization services
126	126	23 as a covered service in any of the following situations:
127	127	24 (1) the URO MCO authorized such services;
128	128	25 (2) such services were administered to maintain the
129	129	26 enrollee's stabilized condition within one hour after a
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140	140	1 request to the URO MCO for authorization of further
141	141	2 post-stabilization services;
142	142	3 (3) the URO MCO did not respond to a request to
143	143	4 authorize such services within one hour;
144	144	5 (4) the URO MCO could not be contacted; or
145	145	6 (5) the URO MCO and the treating provider, if the
146	146	7 treating provider is a non-affiliated provider, could not
147	147	8 reach an agreement concerning the enrollee's care and an
148	148	9 affiliated provider was unavailable for a consultation, in
149	149	10 which case the MCO must pay for such services rendered by
150	150	11 the treating non-affiliated provider until an affiliated
151	151	12 provider was reached and either concurred with the
152	152	13 treating non-affiliated provider's plan of care or assumed
153	153	14 responsibility for the enrollee's care. Such payment shall
154	154	15 be made at the default rate of reimbursement paid under
155	155	16 Illinois Medicaid fee-for-service program methodology,
156	156	17 including all policy adjusters, including but not limited
157	157	18 to Medicaid High Volume Adjustments, Medicaid Percentage
158	158	19 Adjustments, Outpatient High Volume Adjustments and all
159	159	20 outlier add-on adjustments to the extent that such
160	160	21 adjustments are incorporated in the development of the
161	161	22 applicable MCO capitated rates.
162	162	23 (e) The following requirements apply to MCOs in
163	163	24 determining payment for all emergency services:
164	164	25 (1) Neither the MCOs nor the URO shall not impose any
165	165	26 requirements for prior approval of emergency services.
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176	176	1 (2) The MCO shall cover emergency services provided to
177	177	2 enrollees who are temporarily away from their residence
178	178	3 and outside the contracting area to the extent that the
179	179	4 enrollees would be entitled to the emergency services if
180	180	5 they still were within the contracting area.
181	181	6 (3) The MCO shall have no obligation to cover medical
182	182	7 services, including health care services, provided on an
183	183	8 emergency basis that are not covered services under the
184	184	9 contract.
185	185	10 (4) The MCO shall not condition coverage for emergency
186	186	11 services on the treating provider notifying the MCO of the
187	187	12 enrollee's screening and treatment within 10 days after
188	188	13 presentation for emergency services.
189	189	14 (5) The determination of the attending emergency
190	190	15 physician, or the provider actually treating the enrollee,
191	191	16 of whether an enrollee is sufficiently stabilized for
192	192	17 discharge or transfer to another facility, shall be
193	193	18 binding on the URO MCO. The MCO shall cover emergency
194	194	19 services for all enrollees whether the emergency services
195	195	20 are provided by an affiliated or non-affiliated provider.
196	196	21 (6) The MCO's financial responsibility for
197	197	22 post-stabilization care services the URO it has not
198	198	23 pre-approved ends when:
199	199	24 (A) a plan physician with privileges at the
200	200	25 treating hospital assumes responsibility for the
201	201	26 enrollee's care;
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212	212	1 (B) a plan physician assumes responsibility for
213	213	2 the enrollee's care through transfer;
214	214	3 (C) a contracting entity representative and the
215	215	4 treating physician reach an agreement concerning the
216	216	5 enrollee's care; or
217	217	6 (D) the enrollee is discharged.
218	218	7 (f) Network adequacy and transparency.
219	219	8 (1) The Department shall:
220	220	9 (A) ensure that an adequate provider network is in
221	221	10 place, taking into consideration health professional
222	222	11 shortage areas and medically underserved areas;
223	223	12 (B) publicly release an explanation of its process
224	224	13 for analyzing network adequacy;
225	225	14 (C) periodically ensure that an MCO continues to
226	226	15 have an adequate network in place;
227	227	16 (D) require MCOs, including Medicaid Managed Care
228	228	17 Entities as defined in Section 5-30.2, to meet
229	229	18 provider directory requirements under Section 5-30.3;
230	230	19 (E) require MCOs to ensure that any
231	231	20 Medicaid-certified provider under contract with an MCO
232	232	21 and previously submitted on a roster on the date of
233	233	22 service is paid for any medically necessary,
234	234	23 Medicaid-covered, and authorized service rendered to
235	235	24 any of the MCO's enrollees, regardless of inclusion on
236	236	25 the MCO's published and publicly available directory
237	237	26 of available providers; and
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248	248	1 (F) require MCOs, including Medicaid Managed Care
249	249	2 Entities as defined in Section 5-30.2, to meet each of
250	250	3 the requirements under subsection (d-5) of Section 10
251	251	4 of the Network Adequacy and Transparency Act; with
252	252	5 necessary exceptions to the MCO's network to ensure
253	253	6 that admission and treatment with a provider or at a
254	254	7 treatment facility in accordance with the network
255	255	8 adequacy standards in paragraph (3) of subsection
256	256	9 (d-5) of Section 10 of the Network Adequacy and
257	257	10 Transparency Act is limited to providers or facilities
258	258	11 that are Medicaid certified.
259	259	12 (2) Each MCO shall confirm its receipt of information
260	260	13 submitted specific to physician or dentist additions or
261	261	14 physician or dentist deletions from the MCO's provider
262	262	15 network within 3 days after receiving all required
263	263	16 information from contracted physicians or dentists, and
264	264	17 electronic physician and dental directories must be
265	265	18 updated consistent with current rules as published by the
266	266	19 Centers for Medicare and Medicaid Services or its
267	267	20 successor agency.
268	268	21 (g) Timely payment of claims.
269	269	22 (1) The MCO shall pay a claim within 30 days of
270	270	23 receiving a claim that contains all the essential
271	271	24 information needed to adjudicate the claim.
272	272	25 (2) The MCO shall notify the billing party of its
273	273	26 inability to adjudicate a claim within 30 days of
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284	284	1 receiving that claim.
285	285	2 (3) The MCO shall pay a penalty that is at least equal
286	286	3 to the timely payment interest penalty imposed under
287	287	4 Section 368a of the Illinois Insurance Code for any claims
288	288	5 not timely paid.
289	289	6 (A) When an MCO is required to pay a timely payment
290	290	7 interest penalty to a provider, the MCO must calculate
291	291	8 and pay the timely payment interest penalty that is
292	292	9 due to the provider within 30 days after the payment of
293	293	10 the claim. In no event shall a provider be required to
294	294	11 request or apply for payment of any owed timely
295	295	12 payment interest penalties.
296	296	13 (B) Such payments shall be reported separately
297	297	14 from the claim payment for services rendered to the
298	298	15 MCO's enrollee and clearly identified as interest
299	299	16 payments.
300	300	17 (4)(A) The Department shall require MCOs to expedite
301	301	18 payments to providers identified on the Department's
302	302	19 expedited provider list, determined in accordance with 89
303	303	20 Ill. Adm. Code 140.71(b), on a schedule at least as
304	304	21 frequently as the providers are paid under the
305	305	22 Department's fee-for-service expedited provider schedule.
306	306	23 (B) Compliance with the expedited provider requirement
307	307	24 may be satisfied by an MCO through the use of a Periodic
308	308	25 Interim Payment (PIP) program that has been mutually
309	309	26 agreed to and documented between the MCO and the provider,
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320	320	1 if the PIP program ensures that any expedited provider
321	321	2 receives regular and periodic payments based on prior
322	322	3 period payment experience from that MCO. Total payments
323	323	4 under the PIP program may be reconciled against future PIP
324	324	5 payments on a schedule mutually agreed to between the MCO
325	325	6 and the provider.
326	326	7 (C) The Department shall share at least monthly its
327	327	8 expedited provider list and the frequency with which it
328	328	9 pays providers on the expedited list.
329	329	10 (g-4) Effective for dates of service on or after January
330	330	11 1, 2025 for any contracts between the Department and a managed
331	331	12 care organization issued, amended, delivered, or renewed on or
332	332	13 after January 1, 2025, the Department shall:
333	333	14 (1) adopt a single, uniform service authorization
334	334	15 program under which service authorization determinations
335	335	16 for all individuals enrolled in a managed care
336	336	17 organization shall be made by the Department's contracted
337	337	18 URO, or its successor organization;
338	338	19 (2) require all service authorization determinations
339	339	20 made by the URO under the service authorization program to
340	340	21 be binding upon the managed care organization;
341	341	22 (3) prohibit a managed care organization from denying
342	342	23 or reducing payment of a claim, or recouping payment of a
343	343	24 paid claim, for health care services approved by the URO
344	344	25 under the service authorization program, except in cases
345	345	26 of fraud;
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356	356	1 (4) require the URO to accept and process a dispute
357	357	2 submitted by the provider to the URO's internal dispute
358	358	3 resolution process of a service authorization
359	359	4 determination;
360	360	5 (5) require the MCOs to accept and process a dispute
361	361	6 submitted by the provider to the MCO's internal dispute
362	362	7 resolution process of the final claim reimbursement amount
363	363	8 paid for a health care service subject to the service
364	364	9 authorization program;
365	365	10 (6) prohibit a managed care organization from making
366	366	11 service authorization determinations or implementing a
367	367	12 service authorization program other than, or in addition
368	368	13 to, the Department's single, uniform service authorization
369	369	14 program administered by the Department's contracted URO;
370	370	15 (7) in consultation with the managed care
371	371	16 organizations, a statewide association representing the
372	372	17 managed care organizations, a statewide association
373	373	18 representing the majority of Illinois hospitals, a
374	374	19 statewide association representing physicians, and a
375	375	20 statewide association representing nursing homes, adopt
376	376	21 administrative rules to:
377	377	22 (A) establish and make publicly available the
378	378	23 medical policies and guidelines used by the URO to
379	379	24 inform service authorization determinations;
380	380	25 (B) select one evidence-based,
381	381	26 nationally-recognized clinical decision support tool,
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392	392	1 such as InterQual or MCG, to inform service
393	393	2 authorization determinations;
394	394	3 (C) establish a standard list of health care
395	395	4 services that, due to their medical complexity, shall
396	396	5 only be reimbursed when performed in the hospital
397	397	6 inpatient setting, including, at a minimum, all
398	398	7 services designated as "inpatient only" by Medicare
399	399	8 under 42 CFR 419.22(n);
400	400	9 (D) establish standard timeframes for providers to
401	401	10 submit service authorization requests and the URO to
402	402	11 make a service authorization determination; and
403	403	12 (E) adopt a standard Appointment of Representative
404	404	13 form that shall be accepted by all managed care
405	405	14 organizations when signed by an enrollee,
406	406	15 electronically or in writing, in advance of,
407	407	16 concurrent to, or after the provision of a health care
408	408	17 service to appoint a provider as the enrollee's
409	409	18 representative for purposes of filing a member appeal
410	410	19 in accordance with 42 CFR 438 and the Illinois Health
411	411	20 Carrier External Review Act;
412	412	21 (8) allow a managed care organization to conduct
413	413	22 retrospective review of health care services approved by
414	414	23 the URO for education, training, quality assurance, or
415	415	24 purposes other than the recoupment of a paid claim; and
416	416	25 (9) seek approval from the federal Centers for
417	417	26 Medicare and Medicaid Services for enhanced federal
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428	428	1 matching funds for such improvements to the Department's
429	429	2 Medicaid Management Information System to implement the
430	430	3 single, uniform service authorization program. Approval of
431	431	4 enhanced federal matching funds shall not be a condition
432	432	5 of the requirements of this subsection.
433	433	6 (g-5) Recognizing that the rapid transformation of the
434	434	7 Illinois Medicaid program may have unintended operational
435	435	8 challenges for both payers and providers:
436	436	9 (1) in no instance shall a medically necessary covered
437	437	10 service rendered in good faith, based upon eligibility
438	438	11 information documented by the provider, be denied coverage
439	439	12 or diminished in payment amount if the eligibility or
440	440	13 coverage information available at the time the service was
441	441	14 rendered is later found to be inaccurate in the assignment
442	442	15 of coverage responsibility between MCOs or the
443	443	16 fee-for-service system, except for instances when an
444	444	17 individual is deemed to have not been eligible for
445	445	18 coverage under the Illinois Medicaid program; and
446	446	19 (2) the Department shall, by December 31, 2016, adopt
447	447	20 rules establishing policies that shall be included in the
448	448	21 Medicaid managed care policy and procedures manual
449	449	22 addressing payment resolutions in situations in which a
450	450	23 provider renders services based upon information obtained
451	451	24 after verifying a patient's eligibility and coverage plan
452	452	25 through either the Department's current enrollment system
453	453	26 or a system operated by the coverage plan identified by
454	454
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456	456
457	457
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464	464	1 the patient presenting for services:
465	465	2 (A) such medically necessary covered services
466	466	3 shall be considered rendered in good faith;
467	467	4 (B) such policies and procedures shall be
468	468	5 developed in consultation with industry
469	469	6 representatives of the Medicaid managed care health
470	470	7 plans and representatives of provider associations
471	471	8 representing the majority of providers within the
472	472	9 identified provider industry; and
473	473	10 (C) such rules shall be published for a review and
474	474	11 comment period of no less than 30 days on the
475	475	12 Department's website with final rules remaining
476	476	13 available on the Department's website.
477	477	14 The rules on payment resolutions shall include, but
478	478	15 not be limited to:
479	479	16 (A) the extension of the timely filing period;
480	480	17 (B) retroactive prior authorizations; and
481	481	18 (C) guaranteed minimum payment rate of no less
482	482	19 than the current, as of the date of service,
483	483	20 fee-for-service rate, plus all applicable add-ons,
484	484	21 when the resulting service relationship is out of
485	485	22 network.
486	486	23 The rules shall be applicable for both MCO coverage
487	487	24 and fee-for-service coverage.
488	488	25 If the fee-for-service system is ultimately determined to
489	489	26 have been responsible for coverage on the date of service, the
490	490
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500	500	1 Department shall provide for an extended period for claims
501	501	2 submission outside the standard timely filing requirements.
502	502	3 (g-6) MCO Performance Metrics Report.
503	503	4 (1) The Department shall publish, on at least a
504	504	5 quarterly basis, each MCO's operational performance,
505	505	6 including, but not limited to, the following categories of
506	506	7 metrics:
507	507	8 (A) claims payment, including timeliness and
508	508	9 accuracy;
509	509	10 (B) prior authorizations;
510	510	11 (C) grievance and appeals;
511	511	12 (D) utilization statistics;
512	512	13 (E) provider disputes;
513	513	14 (F) provider credentialing; and
514	514	15 (G) member and provider customer service.
515	515	16 (2) The Department shall ensure that the metrics
516	516	17 report is accessible to providers online by January 1,
517	517	18 2017.
518	518	19 (3) The metrics shall be developed in consultation
519	519	20 with industry representatives of the Medicaid managed care
520	520	21 health plans and representatives of associations
521	521	22 representing the majority of providers within the
522	522	23 identified industry.
523	523	24 (4) Metrics shall be defined and incorporated into the
524	524	25 applicable Managed Care Policy Manual issued by the
525	525	26 Department.
526	526
527	527
528	528
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536	536	1 (g-7) MCO claims processing and performance analysis. In
537	537	2 order to monitor MCO payments to hospital providers, pursuant
538	538	3 to Public Act 100-580, the Department shall post an analysis
539	539	4 of MCO claims processing and payment performance on its
540	540	5 website every 6 months. Such analysis shall include a review
541	541	6 and evaluation of a representative sample of hospital claims
542	542	7 that are rejected and denied for clean and unclean claims and
543	543	8 the top 5 reasons for such actions and timeliness of claims
544	544	9 adjudication, which identifies the percentage of claims
545	545	10 adjudicated within 30, 60, 90, and over 90 days, and the dollar
546	546	11 amounts associated with those claims.
547	547	12 (g-8) Dispute resolution process. The Department shall
548	548	13 maintain a provider complaint portal through which a provider
549	549	14 can submit to the Department unresolved disputes with an MCO.
550	550	15 An unresolved dispute means an MCO's decision that denies in
551	551	16 whole or in part a claim for reimbursement to a provider for
552	552	17 health care services rendered by the provider to an enrollee
553	553	18 of the MCO with which the provider disagrees. Disputes shall
554	554	19 not be submitted to the portal until the provider has availed
555	555	20 itself of the MCO's internal dispute resolution process.
556	556	21 Disputes that are submitted to the MCO internal dispute
557	557	22 resolution process may be submitted to the Department of
558	558	23 Healthcare and Family Services' complaint portal no sooner
559	559	24 than 30 days after submitting to the MCO's internal process
560	560	25 and not later than 30 days after the unsatisfactory resolution
561	561	26 of the internal MCO process or 60 days after submitting the
562	562
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572	572	1 dispute to the MCO internal process. Multiple claim disputes
573	573	2 involving the same MCO may be submitted in one complaint,
574	574	3 regardless of whether the claims are for different enrollees,
575	575	4 when the specific reason for non-payment of the claims
576	576	5 involves a common question of fact or policy. Within 10
577	577	6 business days of receipt of a complaint, the Department shall
578	578	7 present such disputes to the appropriate MCO, which shall then
579	579	8 have 30 days to issue its written proposal to resolve the
580	580	9 dispute. The Department may grant one 30-day extension of this
581	581	10 time frame to one of the parties to resolve the dispute. If the
582	582	11 dispute remains unresolved at the end of this time frame or the
583	583	12 provider is not satisfied with the MCO's written proposal to
584	584	13 resolve the dispute, the provider may, within 30 days, request
585	585	14 the Department to review the dispute and make a final
586	586	15 determination. Within 30 days of the request for Department
587	587	16 review of the dispute, both the provider and the MCO shall
588	588	17 present all relevant information to the Department for
589	589	18 resolution and make individuals with knowledge of the issues
590	590	19 available to the Department for further inquiry if needed.
591	591	20 Within 30 days of receiving the relevant information on the
592	592	21 dispute, or the lapse of the period for submitting such
593	593	22 information, the Department shall issue a written decision on
594	594	23 the dispute based on contractual terms between the provider
595	595	24 and the MCO, contractual terms between the MCO and the
596	596	25 Department of Healthcare and Family Services and applicable
597	597	26 Medicaid policy. The decision of the Department shall be
598	598
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608	608	1 final. By January 1, 2020, the Department shall establish by
609	609	2 rule further details of this dispute resolution process.
610	610	3 Disputes between MCOs and providers presented to the
611	611	4 Department for resolution are not contested cases, as defined
612	612	5 in Section 1-30 of the Illinois Administrative Procedure Act,
613	613	6 conferring any right to an administrative hearing.
614	614	7 (g-9)(1) The Department shall publish annually on its
615	615	8 website a report on the calculation of each managed care
616	616	9 organization's medical loss ratio showing the following:
617	617	10 (A) Premium revenue, with appropriate adjustments.
618	618	11 (B) Benefit expense, setting forth the aggregate
619	619	12 amount spent for the following:
620	620	13 (i) Direct paid claims.
621	621	14 (ii) Subcapitation payments.
622	622	15 (iii) Other claim payments.
623	623	16 (iv) Direct reserves.
624	624	17 (v) Gross recoveries.
625	625	18 (vi) Expenses for activities that improve health
626	626	19 care quality as allowed by the Department.
627	627	20 (2) The medical loss ratio shall be calculated consistent
628	628	21 with federal law and regulation following a claims runout
629	629	22 period determined by the Department.
630	630	23 (g-10)(1) "Liability effective date" means the date on
631	631	24 which an MCO becomes responsible for payment for medically
632	632	25 necessary and covered services rendered by a provider to one
633	633	26 of its enrollees in accordance with the contract terms between
634	634
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644	644	1 the MCO and the provider. The liability effective date shall
645	645	2 be the later of:
646	646	3 (A) The execution date of a network participation
647	647	4 contract agreement.
648	648	5 (B) The date the provider or its representative
649	649	6 submits to the MCO the complete and accurate standardized
650	650	7 roster form for the provider in the format approved by the
651	651	8 Department.
652	652	9 (C) The provider effective date contained within the
653	653	10 Department's provider enrollment subsystem within the
654	654	11 Illinois Medicaid Program Advanced Cloud Technology
655	655	12 (IMPACT) System.
656	656	13 (2) The standardized roster form may be submitted to the
657	657	14 MCO at the same time that the provider submits an enrollment
658	658	15 application to the Department through IMPACT.
659	659	16 (3) By October 1, 2019, the Department shall require all
660	660	17 MCOs to update their provider directory with information for
661	661	18 new practitioners of existing contracted providers within 30
662	662	19 days of receipt of a complete and accurate standardized roster
663	663	20 template in the format approved by the Department provided
664	664	21 that the provider is effective in the Department's provider
665	665	22 enrollment subsystem within the IMPACT system. Such provider
666	666	23 directory shall be readily accessible for purposes of
667	667	24 selecting an approved health care provider and comply with all
668	668	25 other federal and State requirements.
669	669	26 (g-11) The Department shall work with relevant
670	670
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673	673
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680	680	1 stakeholders on the development of operational guidelines to
681	681	2 enhance and improve operational performance of Illinois'
682	682	3 Medicaid managed care program, including, but not limited to,
683	683	4 improving provider billing practices, reducing claim
684	684	5 rejections and inappropriate payment denials, and
685	685	6 standardizing processes, procedures, definitions, and response
686	686	7 timelines, with the goal of reducing provider and MCO
687	687	8 administrative burdens and conflict. The Department shall
688	688	9 include a report on the progress of these program improvements
689	689	10 and other topics in its Fiscal Year 2020 annual report to the
690	690	11 General Assembly.
691	691	12 (g-12) Notwithstanding any other provision of law, if the
692	692	13 Department or an MCO requires submission of a claim for
693	693	14 payment in a non-electronic format, a provider shall always be
694	694	15 afforded a period of no less than 90 business days, as a
695	695	16 correction period, following any notification of rejection by
696	696	17 either the Department or the MCO to correct errors or
697	697	18 omissions in the original submission.
698	698	19 Under no circumstances, either by an MCO or under the
699	699	20 State's fee-for-service system, shall a provider be denied
700	700	21 payment for failure to comply with any timely submission
701	701	22 requirements under this Code or under any existing contract,
702	702	23 unless the non-electronic format claim submission occurs after
703	703	24 the initial 180 days following the latest date of service on
704	704	25 the claim, or after the 90 business days correction period
705	705	26 following notification to the provider of rejection or denial
706	706
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716	716	1 of payment.
717	717	2 (h) The Department shall not expand mandatory MCO
718	718	3 enrollment into new counties beyond those counties already
719	719	4 designated by the Department as of June 1, 2014 for the
720	720	5 individuals whose eligibility for medical assistance is not
721	721	6 the seniors or people with disabilities population until the
722	722	7 Department provides an opportunity for accountable care
723	723	8 entities and MCOs to participate in such newly designated
724	724	9 counties.
725	725	10 (h-5) Leading indicator data sharing. By January 1, 2024,
726	726	11 the Department shall obtain input from the Department of Human
727	727	12 Services, the Department of Juvenile Justice, the Department
728	728	13 of Children and Family Services, the State Board of Education,
729	729	14 managed care organizations, providers, and clinical experts to
730	730	15 identify and analyze key indicators from assessments and data
731	731	16 sets available to the Department that can be shared with
732	732	17 managed care organizations and similar care coordination
733	733	18 entities contracted with the Department as leading indicators
734	734	19 for elevated behavioral health crisis risk for children. To
735	735	20 the extent permitted by State and federal law, the identified
736	736	21 leading indicators shall be shared with managed care
737	737	22 organizations and similar care coordination entities
738	738	23 contracted with the Department within 6 months of
739	739	24 identification for the purpose of improving care coordination
740	740	25 with the early detection of elevated risk. Leading indicators
741	741	26 shall be reassessed annually with stakeholder input.
742	742
743	743
744	744
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752	752	1 (i) The requirements of this Section apply to contracts
753	753	2 with accountable care entities and MCOs entered into, amended,
754	754	3 or renewed after June 16, 2014 (the effective date of Public
755	755	4 Act 98-651).
756	756	5 (j) Health care information released to managed care
757	757	6 organizations. A health care provider shall release to a
758	758	7 Medicaid managed care organization, upon request, and subject
759	759	8 to the Health Insurance Portability and Accountability Act of
760	760	9 1996 and any other law applicable to the release of health
761	761	10 information, the health care information of the MCO's
762	762	11 enrollee, if the enrollee has completed and signed a general
763	763	12 release form that grants to the health care provider
764	764	13 permission to release the recipient's health care information
765	765	14 to the recipient's insurance carrier.
766	766	15 (k) The Department of Healthcare and Family Services,
767	767	16 managed care organizations, a statewide organization
768	768	17 representing hospitals, and a statewide organization
769	769	18 representing safety-net hospitals shall explore ways to
770	770	19 support billing departments in safety-net hospitals.
771	771	20 (l) The requirements of this Section added by Public Act
772	772	21 102-4 shall apply to services provided on or after the first
773	773	22 day of the month that begins 60 days after April 27, 2021 (the
774	774	23 effective date of Public Act 102-4).
775	775	24 (m) The Department shall impose sanctions on a managed
776	776	25 care organization for violating any provision under this
777	777	26 Section, including, but not limited to, financial penalties,
778	778
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788	788	1 suspension of enrollment of new enrollees, and termination of
789	789	2 the MCO's contract with the Department.
790	790	3 (Source: P.A. 102-4, eff. 4-27-21; 102-43, eff. 7-6-21;
791	791	4 102-144, eff. 1-1-22; 102-454, eff. 8-20-21; 102-813, eff.
792	792	5 5-13-22; 103-546, eff. 8-11-23.)
793	793
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