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
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
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.
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A BILL FOR
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1 AN ACT concerning public aid.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Public Aid Code is amended by
5 changing Section 5-30.1 as follows:
6 (305 ILCS 5/5-30.1)
7 Sec. 5-30.1. Managed care protections.
8 (a) As used in this Section:
9 "Managed care organization" or "MCO" means any entity
10 which contracts with the Department to provide services where
11 payment for medical services, including health care services
12 as defined in this Section, is made on a capitated basis.
13 "Emergency services" include:
14 (1) emergency services, as defined by Section 10 of
15 the Managed Care Reform and Patient Rights Act;
16 (2) emergency medical screening examinations, as
17 defined by Section 10 of the Managed Care Reform and
18 Patient Rights Act;
19 (3) post-stabilization medical services, as defined by
20 Section 10 of the Managed Care Reform and Patient Rights
21 Act, and health care services; and
22 (4) emergency medical conditions, as defined by
23 Section 10 of the Managed Care Reform and Patient Rights
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
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.
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A BILL FOR
305 ILCS 5/5-30.1
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1 Act.
2 "Health care services" mean any medical or behavioral
3 health services covered under the medical assistance program
4 that are rendered in the inpatient or outpatient hospital
5 setting and subject to review under a service authorization
6 program.
7 "Provider" means a facility or individual who is actively
8 enrolled in the medical assistance program and licensed or
9 otherwise authorized to order, prescribe, refer, or render
10 health care services in this State.
11 "Service authorization determination" means a decision
12 made by a service authorization program in advance of,
13 concurrent to, or after the provision of a health care service
14 to approve, change the level of care, partially deny, deny, or
15 otherwise limit coverage and reimbursement for a health care
16 service upon review of a service authorization request.
17 "Service authorization program" means any utilization
18 review, utilization management, peer review, quality review,
19 or other medical management activity conducted by the
20 Department's contracted utilization review organization,
21 including, but not limited to, prior authorization,
22 pre-certification, certification of admission, concurrent
23 review, and retrospective review, of health care services.
24 "Service authorization request" means a request by a
25 provider to a service authorization program to determine
26 whether an otherwise covered health care service meets the
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1 reimbursement requirements established by the Department by
2 rule for medically necessary, clinically appropriate care and
3 to issue a service authorization determination.
4 "Utilization review organization" or "URO" means a peer
5 review organization or quality improvement organization that
6 contracts with the Department to administer a service
7 authorization program and make service authorization
8 determinations.
9 (b) As provided by Section 5-16.12, managed care
10 organizations are subject to the provisions of the Managed
11 Care Reform and Patient Rights Act.
12 (c) An MCO shall pay any provider of emergency services
13 that does not have in effect a contract with the contracted
14 Medicaid MCO. The default rate of reimbursement shall be the
15 rate paid under Illinois Medicaid fee-for-service program
16 methodology, including all policy adjusters, including but not
17 limited to Medicaid High Volume Adjustments, Medicaid
18 Percentage Adjustments, Outpatient High Volume Adjustments,
19 and all outlier add-on adjustments to the extent such
20 adjustments are incorporated in the development of the
21 applicable MCO capitated rates.
22 (d) An MCO shall pay for all post-stabilization services
23 as a covered service in any of the following situations:
24 (1) the URO MCO authorized such services;
25 (2) such services were administered to maintain the
26 enrollee's stabilized condition within one hour after a
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1 request to the URO MCO for authorization of further
2 post-stabilization services;
3 (3) the URO MCO did not respond to a request to
4 authorize such services within one hour;
5 (4) the URO MCO could not be contacted; or
6 (5) the URO MCO and the treating provider, if the
7 treating provider is a non-affiliated provider, could not
8 reach an agreement concerning the enrollee's care and an
9 affiliated provider was unavailable for a consultation, in
10 which case the MCO must pay for such services rendered by
11 the treating non-affiliated provider until an affiliated
12 provider was reached and either concurred with the
13 treating non-affiliated provider's plan of care or assumed
14 responsibility for the enrollee's care. Such payment shall
15 be made at the default rate of reimbursement paid under
16 Illinois Medicaid fee-for-service program methodology,
17 including all policy adjusters, including but not limited
18 to Medicaid High Volume Adjustments, Medicaid Percentage
19 Adjustments, Outpatient High Volume Adjustments and all
20 outlier add-on adjustments to the extent that such
21 adjustments are incorporated in the development of the
22 applicable MCO capitated rates.
23 (e) The following requirements apply to MCOs in
24 determining payment for all emergency services:
25 (1) Neither the MCOs nor the URO shall not impose any
26 requirements for prior approval of emergency services.
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1 (2) The MCO shall cover emergency services provided to
2 enrollees who are temporarily away from their residence
3 and outside the contracting area to the extent that the
4 enrollees would be entitled to the emergency services if
5 they still were within the contracting area.
6 (3) The MCO shall have no obligation to cover medical
7 services, including health care services, provided on an
8 emergency basis that are not covered services under the
9 contract.
10 (4) The MCO shall not condition coverage for emergency
11 services on the treating provider notifying the MCO of the
12 enrollee's screening and treatment within 10 days after
13 presentation for emergency services.
14 (5) The determination of the attending emergency
15 physician, or the provider actually treating the enrollee,
16 of whether an enrollee is sufficiently stabilized for
17 discharge or transfer to another facility, shall be
18 binding on the URO MCO. The MCO shall cover emergency
19 services for all enrollees whether the emergency services
20 are provided by an affiliated or non-affiliated provider.
21 (6) The MCO's financial responsibility for
22 post-stabilization care services the URO it has not
23 pre-approved ends when:
24 (A) a plan physician with privileges at the
25 treating hospital assumes responsibility for the
26 enrollee's care;
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1 (B) a plan physician assumes responsibility for
2 the enrollee's care through transfer;
3 (C) a contracting entity representative and the
4 treating physician reach an agreement concerning the
5 enrollee's care; or
6 (D) the enrollee is discharged.
7 (f) Network adequacy and transparency.
8 (1) The Department shall:
9 (A) ensure that an adequate provider network is in
10 place, taking into consideration health professional
11 shortage areas and medically underserved areas;
12 (B) publicly release an explanation of its process
13 for analyzing network adequacy;
14 (C) periodically ensure that an MCO continues to
15 have an adequate network in place;
16 (D) require MCOs, including Medicaid Managed Care
17 Entities as defined in Section 5-30.2, to meet
18 provider directory requirements under Section 5-30.3;
19 (E) require MCOs to ensure that any
20 Medicaid-certified provider under contract with an MCO
21 and previously submitted on a roster on the date of
22 service is paid for any medically necessary,
23 Medicaid-covered, and authorized service rendered to
24 any of the MCO's enrollees, regardless of inclusion on
25 the MCO's published and publicly available directory
26 of available providers; and
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1 (F) require MCOs, including Medicaid Managed Care
2 Entities as defined in Section 5-30.2, to meet each of
3 the requirements under subsection (d-5) of Section 10
4 of the Network Adequacy and Transparency Act; with
5 necessary exceptions to the MCO's network to ensure
6 that admission and treatment with a provider or at a
7 treatment facility in accordance with the network
8 adequacy standards in paragraph (3) of subsection
9 (d-5) of Section 10 of the Network Adequacy and
10 Transparency Act is limited to providers or facilities
11 that are Medicaid certified.
12 (2) Each MCO shall confirm its receipt of information
13 submitted specific to physician or dentist additions or
14 physician or dentist deletions from the MCO's provider
15 network within 3 days after receiving all required
16 information from contracted physicians or dentists, and
17 electronic physician and dental directories must be
18 updated consistent with current rules as published by the
19 Centers for Medicare and Medicaid Services or its
20 successor agency.
21 (g) Timely payment of claims.
22 (1) The MCO shall pay a claim within 30 days of
23 receiving a claim that contains all the essential
24 information needed to adjudicate the claim.
25 (2) The MCO shall notify the billing party of its
26 inability to adjudicate a claim within 30 days of
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1 receiving that claim.
2 (3) The MCO shall pay a penalty that is at least equal
3 to the timely payment interest penalty imposed under
4 Section 368a of the Illinois Insurance Code for any claims
5 not timely paid.
6 (A) When an MCO is required to pay a timely payment
7 interest penalty to a provider, the MCO must calculate
8 and pay the timely payment interest penalty that is
9 due to the provider within 30 days after the payment of
10 the claim. In no event shall a provider be required to
11 request or apply for payment of any owed timely
12 payment interest penalties.
13 (B) Such payments shall be reported separately
14 from the claim payment for services rendered to the
15 MCO's enrollee and clearly identified as interest
16 payments.
17 (4)(A) The Department shall require MCOs to expedite
18 payments to providers identified on the Department's
19 expedited provider list, determined in accordance with 89
20 Ill. Adm. Code 140.71(b), on a schedule at least as
21 frequently as the providers are paid under the
22 Department's fee-for-service expedited provider schedule.
23 (B) Compliance with the expedited provider requirement
24 may be satisfied by an MCO through the use of a Periodic
25 Interim Payment (PIP) program that has been mutually
26 agreed to and documented between the MCO and the provider,
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1 if the PIP program ensures that any expedited provider
2 receives regular and periodic payments based on prior
3 period payment experience from that MCO. Total payments
4 under the PIP program may be reconciled against future PIP
5 payments on a schedule mutually agreed to between the MCO
6 and the provider.
7 (C) The Department shall share at least monthly its
8 expedited provider list and the frequency with which it
9 pays providers on the expedited list.
10 (g-4) Effective for dates of service on or after January
11 1, 2025 for any contracts between the Department and a managed
12 care organization issued, amended, delivered, or renewed on or
13 after January 1, 2025, the Department shall:
14 (1) adopt a single, uniform service authorization
15 program under which service authorization determinations
16 for all individuals enrolled in a managed care
17 organization shall be made by the Department's contracted
18 URO, or its successor organization;
19 (2) require all service authorization determinations
20 made by the URO under the service authorization program to
21 be binding upon the managed care organization;
22 (3) prohibit a managed care organization from denying
23 or reducing payment of a claim, or recouping payment of a
24 paid claim, for health care services approved by the URO
25 under the service authorization program, except in cases
26 of fraud;
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1 (4) require the URO to accept and process a dispute
2 submitted by the provider to the URO's internal dispute
3 resolution process of a service authorization
4 determination;
5 (5) require the MCOs to accept and process a dispute
6 submitted by the provider to the MCO's internal dispute
7 resolution process of the final claim reimbursement amount
8 paid for a health care service subject to the service
9 authorization program;
10 (6) prohibit a managed care organization from making
11 service authorization determinations or implementing a
12 service authorization program other than, or in addition
13 to, the Department's single, uniform service authorization
14 program administered by the Department's contracted URO;
15 (7) in consultation with the managed care
16 organizations, a statewide association representing the
17 managed care organizations, a statewide association
18 representing the majority of Illinois hospitals, a
19 statewide association representing physicians, and a
20 statewide association representing nursing homes, adopt
21 administrative rules to:
22 (A) establish and make publicly available the
23 medical policies and guidelines used by the URO to
24 inform service authorization determinations;
25 (B) select one evidence-based,
26 nationally-recognized clinical decision support tool,
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1 such as InterQual or MCG, to inform service
2 authorization determinations;
3 (C) establish a standard list of health care
4 services that, due to their medical complexity, shall
5 only be reimbursed when performed in the hospital
6 inpatient setting, including, at a minimum, all
7 services designated as "inpatient only" by Medicare
8 under 42 CFR 419.22(n);
9 (D) establish standard timeframes for providers to
10 submit service authorization requests and the URO to
11 make a service authorization determination; and
12 (E) adopt a standard Appointment of Representative
13 form that shall be accepted by all managed care
14 organizations when signed by an enrollee,
15 electronically or in writing, in advance of,
16 concurrent to, or after the provision of a health care
17 service to appoint a provider as the enrollee's
18 representative for purposes of filing a member appeal
19 in accordance with 42 CFR 438 and the Illinois Health
20 Carrier External Review Act;
21 (8) allow a managed care organization to conduct
22 retrospective review of health care services approved by
23 the URO for education, training, quality assurance, or
24 purposes other than the recoupment of a paid claim; and
25 (9) seek approval from the federal Centers for
26 Medicare and Medicaid Services for enhanced federal
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1 matching funds for such improvements to the Department's
2 Medicaid Management Information System to implement the
3 single, uniform service authorization program. Approval of
4 enhanced federal matching funds shall not be a condition
5 of the requirements of this subsection.
6 (g-5) Recognizing that the rapid transformation of the
7 Illinois Medicaid program may have unintended operational
8 challenges for both payers and providers:
9 (1) in no instance shall a medically necessary covered
10 service rendered in good faith, based upon eligibility
11 information documented by the provider, be denied coverage
12 or diminished in payment amount if the eligibility or
13 coverage information available at the time the service was
14 rendered is later found to be inaccurate in the assignment
15 of coverage responsibility between MCOs or the
16 fee-for-service system, except for instances when an
17 individual is deemed to have not been eligible for
18 coverage under the Illinois Medicaid program; and
19 (2) the Department shall, by December 31, 2016, adopt
20 rules establishing policies that shall be included in the
21 Medicaid managed care policy and procedures manual
22 addressing payment resolutions in situations in which a
23 provider renders services based upon information obtained
24 after verifying a patient's eligibility and coverage plan
25 through either the Department's current enrollment system
26 or a system operated by the coverage plan identified by
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1 the patient presenting for services:
2 (A) such medically necessary covered services
3 shall be considered rendered in good faith;
4 (B) such policies and procedures shall be
5 developed in consultation with industry
6 representatives of the Medicaid managed care health
7 plans and representatives of provider associations
8 representing the majority of providers within the
9 identified provider industry; and
10 (C) such rules shall be published for a review and
11 comment period of no less than 30 days on the
12 Department's website with final rules remaining
13 available on the Department's website.
14 The rules on payment resolutions shall include, but
15 not be limited to:
16 (A) the extension of the timely filing period;
17 (B) retroactive prior authorizations; and
18 (C) guaranteed minimum payment rate of no less
19 than the current, as of the date of service,
20 fee-for-service rate, plus all applicable add-ons,
21 when the resulting service relationship is out of
22 network.
23 The rules shall be applicable for both MCO coverage
24 and fee-for-service coverage.
25 If the fee-for-service system is ultimately determined to
26 have been responsible for coverage on the date of service, the
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1 Department shall provide for an extended period for claims
2 submission outside the standard timely filing requirements.
3 (g-6) MCO Performance Metrics Report.
4 (1) The Department shall publish, on at least a
5 quarterly basis, each MCO's operational performance,
6 including, but not limited to, the following categories of
7 metrics:
8 (A) claims payment, including timeliness and
9 accuracy;
10 (B) prior authorizations;
11 (C) grievance and appeals;
12 (D) utilization statistics;
13 (E) provider disputes;
14 (F) provider credentialing; and
15 (G) member and provider customer service.
16 (2) The Department shall ensure that the metrics
17 report is accessible to providers online by January 1,
18 2017.
19 (3) The metrics shall be developed in consultation
20 with industry representatives of the Medicaid managed care
21 health plans and representatives of associations
22 representing the majority of providers within the
23 identified industry.
24 (4) Metrics shall be defined and incorporated into the
25 applicable Managed Care Policy Manual issued by the
26 Department.
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1 (g-7) MCO claims processing and performance analysis. In
2 order to monitor MCO payments to hospital providers, pursuant
3 to Public Act 100-580, the Department shall post an analysis
4 of MCO claims processing and payment performance on its
5 website every 6 months. Such analysis shall include a review
6 and evaluation of a representative sample of hospital claims
7 that are rejected and denied for clean and unclean claims and
8 the top 5 reasons for such actions and timeliness of claims
9 adjudication, which identifies the percentage of claims
10 adjudicated within 30, 60, 90, and over 90 days, and the dollar
11 amounts associated with those claims.
12 (g-8) Dispute resolution process. The Department shall
13 maintain a provider complaint portal through which a provider
14 can submit to the Department unresolved disputes with an MCO.
15 An unresolved dispute means an MCO's decision that denies in
16 whole or in part a claim for reimbursement to a provider for
17 health care services rendered by the provider to an enrollee
18 of the MCO with which the provider disagrees. Disputes shall
19 not be submitted to the portal until the provider has availed
20 itself of the MCO's internal dispute resolution process.
21 Disputes that are submitted to the MCO internal dispute
22 resolution process may be submitted to the Department of
23 Healthcare and Family Services' complaint portal no sooner
24 than 30 days after submitting to the MCO's internal process
25 and not later than 30 days after the unsatisfactory resolution
26 of the internal MCO process or 60 days after submitting the
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1 dispute to the MCO internal process. Multiple claim disputes
2 involving the same MCO may be submitted in one complaint,
3 regardless of whether the claims are for different enrollees,
4 when the specific reason for non-payment of the claims
5 involves a common question of fact or policy. Within 10
6 business days of receipt of a complaint, the Department shall
7 present such disputes to the appropriate MCO, which shall then
8 have 30 days to issue its written proposal to resolve the
9 dispute. The Department may grant one 30-day extension of this
10 time frame to one of the parties to resolve the dispute. If the
11 dispute remains unresolved at the end of this time frame or the
12 provider is not satisfied with the MCO's written proposal to
13 resolve the dispute, the provider may, within 30 days, request
14 the Department to review the dispute and make a final
15 determination. Within 30 days of the request for Department
16 review of the dispute, both the provider and the MCO shall
17 present all relevant information to the Department for
18 resolution and make individuals with knowledge of the issues
19 available to the Department for further inquiry if needed.
20 Within 30 days of receiving the relevant information on the
21 dispute, or the lapse of the period for submitting such
22 information, the Department shall issue a written decision on
23 the dispute based on contractual terms between the provider
24 and the MCO, contractual terms between the MCO and the
25 Department of Healthcare and Family Services and applicable
26 Medicaid policy. The decision of the Department shall be
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1 final. By January 1, 2020, the Department shall establish by
2 rule further details of this dispute resolution process.
3 Disputes between MCOs and providers presented to the
4 Department for resolution are not contested cases, as defined
5 in Section 1-30 of the Illinois Administrative Procedure Act,
6 conferring any right to an administrative hearing.
7 (g-9)(1) The Department shall publish annually on its
8 website a report on the calculation of each managed care
9 organization's medical loss ratio showing the following:
10 (A) Premium revenue, with appropriate adjustments.
11 (B) Benefit expense, setting forth the aggregate
12 amount spent for the following:
13 (i) Direct paid claims.
14 (ii) Subcapitation payments.
15 (iii) Other claim payments.
16 (iv) Direct reserves.
17 (v) Gross recoveries.
18 (vi) Expenses for activities that improve health
19 care quality as allowed by the Department.
20 (2) The medical loss ratio shall be calculated consistent
21 with federal law and regulation following a claims runout
22 period determined by the Department.
23 (g-10)(1) "Liability effective date" means the date on
24 which an MCO becomes responsible for payment for medically
25 necessary and covered services rendered by a provider to one
26 of its enrollees in accordance with the contract terms between
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1 the MCO and the provider. The liability effective date shall
2 be the later of:
3 (A) The execution date of a network participation
4 contract agreement.
5 (B) The date the provider or its representative
6 submits to the MCO the complete and accurate standardized
7 roster form for the provider in the format approved by the
8 Department.
9 (C) The provider effective date contained within the
10 Department's provider enrollment subsystem within the
11 Illinois Medicaid Program Advanced Cloud Technology
12 (IMPACT) System.
13 (2) The standardized roster form may be submitted to the
14 MCO at the same time that the provider submits an enrollment
15 application to the Department through IMPACT.
16 (3) By October 1, 2019, the Department shall require all
17 MCOs to update their provider directory with information for
18 new practitioners of existing contracted providers within 30
19 days of receipt of a complete and accurate standardized roster
20 template in the format approved by the Department provided
21 that the provider is effective in the Department's provider
22 enrollment subsystem within the IMPACT system. Such provider
23 directory shall be readily accessible for purposes of
24 selecting an approved health care provider and comply with all
25 other federal and State requirements.
26 (g-11) The Department shall work with relevant
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1 stakeholders on the development of operational guidelines to
2 enhance and improve operational performance of Illinois'
3 Medicaid managed care program, including, but not limited to,
4 improving provider billing practices, reducing claim
5 rejections and inappropriate payment denials, and
6 standardizing processes, procedures, definitions, and response
7 timelines, with the goal of reducing provider and MCO
8 administrative burdens and conflict. The Department shall
9 include a report on the progress of these program improvements
10 and other topics in its Fiscal Year 2020 annual report to the
11 General Assembly.
12 (g-12) Notwithstanding any other provision of law, if the
13 Department or an MCO requires submission of a claim for
14 payment in a non-electronic format, a provider shall always be
15 afforded a period of no less than 90 business days, as a
16 correction period, following any notification of rejection by
17 either the Department or the MCO to correct errors or
18 omissions in the original submission.
19 Under no circumstances, either by an MCO or under the
20 State's fee-for-service system, shall a provider be denied
21 payment for failure to comply with any timely submission
22 requirements under this Code or under any existing contract,
23 unless the non-electronic format claim submission occurs after
24 the initial 180 days following the latest date of service on
25 the claim, or after the 90 business days correction period
26 following notification to the provider of rejection or denial
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1 of payment.
2 (h) The Department shall not expand mandatory MCO
3 enrollment into new counties beyond those counties already
4 designated by the Department as of June 1, 2014 for the
5 individuals whose eligibility for medical assistance is not
6 the seniors or people with disabilities population until the
7 Department provides an opportunity for accountable care
8 entities and MCOs to participate in such newly designated
9 counties.
10 (h-5) Leading indicator data sharing. By January 1, 2024,
11 the Department shall obtain input from the Department of Human
12 Services, the Department of Juvenile Justice, the Department
13 of Children and Family Services, the State Board of Education,
14 managed care organizations, providers, and clinical experts to
15 identify and analyze key indicators from assessments and data
16 sets available to the Department that can be shared with
17 managed care organizations and similar care coordination
18 entities contracted with the Department as leading indicators
19 for elevated behavioral health crisis risk for children. To
20 the extent permitted by State and federal law, the identified
21 leading indicators shall be shared with managed care
22 organizations and similar care coordination entities
23 contracted with the Department within 6 months of
24 identification for the purpose of improving care coordination
25 with the early detection of elevated risk. Leading indicators
26 shall be reassessed annually with stakeholder input.
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1 (i) The requirements of this Section apply to contracts
2 with accountable care entities and MCOs entered into, amended,
3 or renewed after June 16, 2014 (the effective date of Public
4 Act 98-651).
5 (j) Health care information released to managed care
6 organizations. A health care provider shall release to a
7 Medicaid managed care organization, upon request, and subject
8 to the Health Insurance Portability and Accountability Act of
9 1996 and any other law applicable to the release of health
10 information, the health care information of the MCO's
11 enrollee, if the enrollee has completed and signed a general
12 release form that grants to the health care provider
13 permission to release the recipient's health care information
14 to the recipient's insurance carrier.
15 (k) The Department of Healthcare and Family Services,
16 managed care organizations, a statewide organization
17 representing hospitals, and a statewide organization
18 representing safety-net hospitals shall explore ways to
19 support billing departments in safety-net hospitals.
20 (l) The requirements of this Section added by Public Act
21 102-4 shall apply to services provided on or after the first
22 day of the month that begins 60 days after April 27, 2021 (the
23 effective date of Public Act 102-4).
24 (m) The Department shall impose sanctions on a managed
25 care organization for violating any provision under this
26 Section, including, but not limited to, financial penalties,
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1 suspension of enrollment of new enrollees, and termination of
2 the MCO's contract with the Department.
3 (Source: P.A. 102-4, eff. 4-27-21; 102-43, eff. 7-6-21;
4 102-144, eff. 1-1-22; 102-454, eff. 8-20-21; 102-813, eff.
5 5-13-22; 103-546, eff. 8-11-23.)
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