103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB2088 Introduced 2/9/2023, by Sen. Celina Villanueva SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-30.1305 ILCS 5/5A-12.7 Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires managed care organizations (MCOs) to pay a clean claim (rather than claim) within 30 days of receiving a claim. Defines "clean claim" as a claim that contains all the essential information needed to adjudicate the claim or a claim for which a managed care organization does not request within 30 days of receipt any additional information to adjudicate the claim. Contains provisions concerning MCO reports to providers on the receipt and payment of claims; MCO data collection requirements; providers' right to file suit to recover outstanding payments; quarterly audits of each MCO's requests for provider information to adjudicate claims; MCO claims processing and performance analysis; quarterly audits of MCOs payments to hospitals; the segregation of State-issued Medicaid funds received by MCOs for payments to providers; and other matters. Amends the Hospital Provider Funding Article of the Code. Requires the Department of Healthcare and Family Services to calculate, at least quarterly, all Hospital Assessment Program-related funds paid to each hospital, whether paid by the Department or an MCO, including the amounts integrated into rate increases and distributed as provided under the Code. LRB103 28984 KTG 55370 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB2088 Introduced 2/9/2023, by Sen. Celina Villanueva SYNOPSIS AS INTRODUCED: 305 ILCS 5/5-30.1305 ILCS 5/5A-12.7 305 ILCS 5/5-30.1 305 ILCS 5/5A-12.7 Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires managed care organizations (MCOs) to pay a clean claim (rather than claim) within 30 days of receiving a claim. Defines "clean claim" as a claim that contains all the essential information needed to adjudicate the claim or a claim for which a managed care organization does not request within 30 days of receipt any additional information to adjudicate the claim. Contains provisions concerning MCO reports to providers on the receipt and payment of claims; MCO data collection requirements; providers' right to file suit to recover outstanding payments; quarterly audits of each MCO's requests for provider information to adjudicate claims; MCO claims processing and performance analysis; quarterly audits of MCOs payments to hospitals; the segregation of State-issued Medicaid funds received by MCOs for payments to providers; and other matters. Amends the Hospital Provider Funding Article of the Code. Requires the Department of Healthcare and Family Services to calculate, at least quarterly, all Hospital Assessment Program-related funds paid to each hospital, whether paid by the Department or an MCO, including the amounts integrated into rate increases and distributed as provided under the Code. LRB103 28984 KTG 55370 b LRB103 28984 KTG 55370 b A BILL FOR
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB2088 Introduced 2/9/2023, by Sen. Celina Villanueva SYNOPSIS AS INTRODUCED:
305 ILCS 5/5-30.1305 ILCS 5/5A-12.7 305 ILCS 5/5-30.1 305 ILCS 5/5A-12.7
305 ILCS 5/5-30.1
305 ILCS 5/5A-12.7
Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires managed care organizations (MCOs) to pay a clean claim (rather than claim) within 30 days of receiving a claim. Defines "clean claim" as a claim that contains all the essential information needed to adjudicate the claim or a claim for which a managed care organization does not request within 30 days of receipt any additional information to adjudicate the claim. Contains provisions concerning MCO reports to providers on the receipt and payment of claims; MCO data collection requirements; providers' right to file suit to recover outstanding payments; quarterly audits of each MCO's requests for provider information to adjudicate claims; MCO claims processing and performance analysis; quarterly audits of MCOs payments to hospitals; the segregation of State-issued Medicaid funds received by MCOs for payments to providers; and other matters. Amends the Hospital Provider Funding Article of the Code. Requires the Department of Healthcare and Family Services to calculate, at least quarterly, all Hospital Assessment Program-related funds paid to each hospital, whether paid by the Department or an MCO, including the amounts integrated into rate increases and distributed as provided under the Code.
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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 Sections 5-30.1 and 5A-12.7 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 "Clean claim" means: (i) a claim that contains all the
10 essential information needed to adjudicate the claim or (ii) a
11 claim for which a managed care organization does not request
12 within 30 days of receipt any additional information to
13 adjudicate the claim. A resubmitted claim shall be considered
14 a clean claim on the resubmission date if it meets the
15 foregoing criteria.
16 "Managed care organization" or "MCO" means any entity
17 which contracts with the Department to provide services where
18 payment for medical services is made on a capitated basis.
19 "Emergency services" include:
20 (1) emergency services, as defined by Section 10 of
21 the Managed Care Reform and Patient Rights Act;
22 (2) emergency medical screening examinations, as
23 defined by Section 10 of the Managed Care Reform and
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB2088 Introduced 2/9/2023, by Sen. Celina Villanueva SYNOPSIS AS INTRODUCED:
305 ILCS 5/5-30.1305 ILCS 5/5A-12.7 305 ILCS 5/5-30.1 305 ILCS 5/5A-12.7
305 ILCS 5/5-30.1
305 ILCS 5/5A-12.7
Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires managed care organizations (MCOs) to pay a clean claim (rather than claim) within 30 days of receiving a claim. Defines "clean claim" as a claim that contains all the essential information needed to adjudicate the claim or a claim for which a managed care organization does not request within 30 days of receipt any additional information to adjudicate the claim. Contains provisions concerning MCO reports to providers on the receipt and payment of claims; MCO data collection requirements; providers' right to file suit to recover outstanding payments; quarterly audits of each MCO's requests for provider information to adjudicate claims; MCO claims processing and performance analysis; quarterly audits of MCOs payments to hospitals; the segregation of State-issued Medicaid funds received by MCOs for payments to providers; and other matters. Amends the Hospital Provider Funding Article of the Code. Requires the Department of Healthcare and Family Services to calculate, at least quarterly, all Hospital Assessment Program-related funds paid to each hospital, whether paid by the Department or an MCO, including the amounts integrated into rate increases and distributed as provided under the Code.
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A BILL FOR
305 ILCS 5/5-30.1
305 ILCS 5/5A-12.7
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1 Patient Rights Act;
2 (3) post-stabilization medical services, as defined by
3 Section 10 of the Managed Care Reform and Patient Rights
4 Act; and
5 (4) emergency medical conditions, as defined by
6 Section 10 of the Managed Care Reform and Patient Rights
7 Act.
8 (b) As provided by Section 5-16.12, managed care
9 organizations are subject to the provisions of the Managed
10 Care Reform and Patient Rights Act.
11 (c) An MCO shall pay any provider of emergency services
12 that does not have in effect a contract with the contracted
13 Medicaid MCO. The default rate of reimbursement shall be the
14 rate paid under Illinois Medicaid fee-for-service program
15 methodology, including all policy adjusters, including but not
16 limited to Medicaid High Volume Adjustments, Medicaid
17 Percentage Adjustments, Outpatient High Volume Adjustments,
18 and all outlier add-on adjustments to the extent such
19 adjustments are incorporated in the development of the
20 applicable MCO capitated rates.
21 (d) An MCO shall pay for all post-stabilization services
22 as a covered service in any of the following situations:
23 (1) the MCO authorized such services;
24 (2) such services were administered to maintain the
25 enrollee's stabilized condition within one hour after a
26 request to the MCO for authorization of further
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1 post-stabilization services;
2 (3) the MCO did not respond to a request to authorize
3 such services within one hour;
4 (4) the MCO could not be contacted; or
5 (5) the MCO and the treating provider, if the treating
6 provider is a non-affiliated provider, could not reach an
7 agreement concerning the enrollee's care and an affiliated
8 provider was unavailable for a consultation, in which case
9 the MCO must pay for such services rendered by the
10 treating non-affiliated provider until an affiliated
11 provider was reached and either concurred with the
12 treating non-affiliated provider's plan of care or assumed
13 responsibility for the enrollee's care. Such payment shall
14 be made at the default rate of reimbursement paid under
15 Illinois Medicaid fee-for-service program methodology,
16 including all policy adjusters, including but not limited
17 to Medicaid High Volume Adjustments, Medicaid Percentage
18 Adjustments, Outpatient High Volume Adjustments and all
19 outlier add-on adjustments to the extent that such
20 adjustments are incorporated in the development of the
21 applicable MCO capitated rates.
22 (e) The following requirements apply to MCOs in
23 determining payment for all emergency services:
24 (1) MCOs shall not impose any requirements for prior
25 approval of emergency services.
26 (2) The MCO shall cover emergency services provided to
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1 enrollees who are temporarily away from their residence
2 and outside the contracting area to the extent that the
3 enrollees would be entitled to the emergency services if
4 they still were within the contracting area.
5 (3) The MCO shall have no obligation to cover medical
6 services provided on an emergency basis that are not
7 covered services under the contract.
8 (4) The MCO shall not condition coverage for emergency
9 services on the treating provider notifying the MCO of the
10 enrollee's screening and treatment within 10 days after
11 presentation for emergency services.
12 (5) The determination of the attending emergency
13 physician, or the provider actually treating the enrollee,
14 of whether an enrollee is sufficiently stabilized for
15 discharge or transfer to another facility, shall be
16 binding on the MCO. The MCO shall cover emergency services
17 for all enrollees whether the emergency services are
18 provided by an affiliated or non-affiliated provider.
19 (6) The MCO's financial responsibility for
20 post-stabilization care services it has not pre-approved
21 ends when:
22 (A) a plan physician with privileges at the
23 treating hospital assumes responsibility for the
24 enrollee's care;
25 (B) a plan physician assumes responsibility for
26 the enrollee's care through transfer;
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1 (C) a contracting entity representative and the
2 treating physician reach an agreement concerning the
3 enrollee's care; or
4 (D) the enrollee is discharged.
5 (f) Network adequacy and transparency.
6 (1) The Department shall:
7 (A) ensure that an adequate provider network is in
8 place, taking into consideration health professional
9 shortage areas and medically underserved areas;
10 (B) publicly release an explanation of its process
11 for analyzing network adequacy;
12 (C) periodically ensure that an MCO continues to
13 have an adequate network in place;
14 (D) require MCOs, including Medicaid Managed Care
15 Entities as defined in Section 5-30.2, to meet
16 provider directory requirements under Section 5-30.3;
17 (E) require MCOs to ensure that any
18 Medicaid-certified provider under contract with an MCO
19 and previously submitted on a roster on the date of
20 service is paid for any medically necessary,
21 Medicaid-covered, and authorized service rendered to
22 any of the MCO's enrollees, regardless of inclusion on
23 the MCO's published and publicly available directory
24 of available providers; and
25 (F) require MCOs, including Medicaid Managed Care
26 Entities as defined in Section 5-30.2, to meet each of
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1 the requirements under subsection (d-5) of Section 10
2 of the Network Adequacy and Transparency Act; with
3 necessary exceptions to the MCO's network to ensure
4 that admission and treatment with a provider or at a
5 treatment facility in accordance with the network
6 adequacy standards in paragraph (3) of subsection
7 (d-5) of Section 10 of the Network Adequacy and
8 Transparency Act is limited to providers or facilities
9 that are Medicaid certified.
10 (2) Each MCO shall confirm its receipt of information
11 submitted specific to physician or dentist additions or
12 physician or dentist deletions from the MCO's provider
13 network within 3 days after receiving all required
14 information from contracted physicians or dentists, and
15 electronic physician and dental directories must be
16 updated consistent with current rules as published by the
17 Centers for Medicare and Medicaid Services or its
18 successor agency.
19 (g) Timely payment of claims.
20 (1) The MCO shall pay a clean claim within 30 days of
21 receiving a claim that contains all the essential
22 information needed to adjudicate the claim.
23 (2) The MCO shall notify the billing party of its
24 inability to adjudicate a claim within 30 days of
25 receiving that claim.
26 (2.5) At the time of payment for a claim, MCOs shall
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1 report to the provider (i) the date of receipt of the claim
2 by the MCO; (ii) the date of payment of the claim; and
3 (iii) whether the MCO considers the claim to have been a
4 clean claim.
5 (2.6) MCOs shall provide to safety-net hospitals on a
6 monthly basis a report of all claims paid the preceding
7 month stating (i) the dates of receipt and payment of each
8 of the claims and (ii) whether the MCO considers the claim
9 to have been a clean claim. The reports shall be provided
10 in both portable document format (PDF) and Excel
11 spreadsheet formats.
12 (2.7) MCOs shall collect and maintain the following
13 data for each claim submitted by a provider:
14 (A) the date the claim was received by the MCO;
15 (B) if applicable, the date any additional
16 information was requested by the MCO;
17 (C) if applicable, the date additional information
18 was received by the MCO;
19 (D) the date the claim was adjudicated; and
20 (E) the date the claim was denied or paid. MCOs
21 shall provide this data to any individual provider
22 that requests it, within 30 days after receiving the
23 provider's written request.
24 (3) The MCO shall pay a penalty that is at least equal
25 to the timely payment interest penalty imposed under
26 Section 368a of the Illinois Insurance Code for any claims
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1 not timely paid.
2 (A) When an MCO is required to pay a timely payment
3 interest penalty to a provider, the MCO must calculate
4 and pay the timely payment interest penalty that is
5 due to the provider within 30 days after the payment of
6 the claim. In no event shall a provider be required to
7 request or apply for payment of any owed timely
8 payment interest penalties.
9 (B) Such payments shall be reported separately
10 from the claim payment for services rendered to the
11 MCO's enrollee and clearly identified as interest
12 payments.
13 (C) Each MCO, including any owned, operated, or
14 controlled by any governmental agency, shall pay
15 interest for untimely payment of claims in accordance
16 with this subsection.
17 (3.1) On a quarterly basis, and within 30 days after
18 the end of each calendar quarter, each MCO shall report to
19 the Department the following information on a
20 provider-by-provider basis for each provider that
21 submitted 20 or more Medicaid claims to the MCO in the
22 quarter:
23 (A) the total number of claims received from the
24 provider during the prior quarter;
25 (B) the percentage of all such claims that were
26 clean claims;
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1 (C) the percentage of all claims the MCO paid
2 within 30 days of receiving the claim;
3 (D) the percentage of all claims the MCO paid
4 within 90 days of receiving the claim;
5 (E) the percentage of all clean claims the MCO
6 paid within 30 days of receiving the claim; and
7 (F) the percentage of all clean claims the MCO
8 paid within 90 days of receiving the claim.
9 Such information shall be provided by the Department
10 to the provider to whom the data applies within 14 days of
11 request by the provider.
12 (3.2) The provisions of this subsection, and others
13 dealing with timely payment of claims, are intended for
14 the benefit of the Department and of the providers. The
15 Department and each provider shall have the right to bring
16 suit in any court of competent jurisdiction to enforce
17 these provisions, including recovery of payments due to
18 providers, and to obtain any information related to
19 individual providers required to be provided under this
20 subsection. The court may enter any appropriate
21 compensatory, declaratory, or injunctive relief. In any
22 action or proceeding to enforce this subsection, the court
23 shall have the authority to award the prevailing party all
24 fees and costs incurred, including attorneys' fees.
25 (3.3) On a quarterly basis, the Department shall audit
26 a representative sample of each MCO's requests for
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1 information from providers to determine whether the
2 requested information is necessary to adjudicate the
3 claim. If the Department determines that the MCO requested
4 information that was not necessary to adjudicate the
5 claim, the MCO shall be required to pay a penalty to the
6 Department and interest to the provider computed from the
7 date of the submission of the claim to the MCO.
8 (4)(A) The Department shall require MCOs to expedite
9 payments to providers identified on the Department's
10 expedited provider list, determined in accordance with 89
11 Ill. Adm. Code 140.71(b), on a schedule at least as
12 frequently as the providers are paid under the
13 Department's fee-for-service expedited provider schedule.
14 (B) Compliance with the expedited provider requirement
15 may be satisfied by an MCO through the use of a Periodic
16 Interim Payment (PIP) program that has been mutually
17 agreed to and documented between the MCO and the provider,
18 if the PIP program ensures that any expedited provider
19 receives regular and periodic payments based on prior
20 period payment experience from that MCO. Total payments
21 under the PIP program may be reconciled against future PIP
22 payments on a schedule mutually agreed to between the MCO
23 and the provider.
24 (C) The Department shall share at least monthly its
25 expedited provider list and the frequency with which it
26 pays providers on the expedited list.
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1 (g-5) Recognizing that the rapid transformation of the
2 Illinois Medicaid program may have unintended operational
3 challenges for both payers and providers:
4 (1) in no instance shall a medically necessary covered
5 service rendered in good faith, based upon eligibility
6 information documented by the provider, be denied coverage
7 or diminished in payment amount if the eligibility or
8 coverage information available at the time the service was
9 rendered is later found to be inaccurate in the assignment
10 of coverage responsibility between MCOs or the
11 fee-for-service system, except for instances when an
12 individual is deemed to have not been eligible for
13 coverage under the Illinois Medicaid program; and
14 (2) the Department shall, by December 31, 2016, adopt
15 rules establishing policies that shall be included in the
16 Medicaid managed care policy and procedures manual
17 addressing payment resolutions in situations in which a
18 provider renders services based upon information obtained
19 after verifying a patient's eligibility and coverage plan
20 through either the Department's current enrollment system
21 or a system operated by the coverage plan identified by
22 the patient presenting for services:
23 (A) such medically necessary covered services
24 shall be considered rendered in good faith;
25 (B) such policies and procedures shall be
26 developed in consultation with industry
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1 representatives of the Medicaid managed care health
2 plans and representatives of provider associations
3 representing the majority of providers within the
4 identified provider industry; and
5 (C) such rules shall be published for a review and
6 comment period of no less than 30 days on the
7 Department's website with final rules remaining
8 available on the Department's website.
9 The rules on payment resolutions shall include, but
10 not be limited to:
11 (A) the extension of the timely filing period;
12 (B) retroactive prior authorizations; and
13 (C) guaranteed minimum payment rate of no less
14 than the current, as of the date of service,
15 fee-for-service rate, plus all applicable add-ons,
16 when the resulting service relationship is out of
17 network.
18 The rules shall be applicable for both MCO coverage
19 and fee-for-service coverage.
20 If the fee-for-service system is ultimately determined to
21 have been responsible for coverage on the date of service, the
22 Department shall provide for an extended period for claims
23 submission outside the standard timely filing requirements.
24 (g-6) MCO Performance Metrics Report.
25 (1) The Department shall publish, on at least a
26 quarterly basis, each MCO's operational performance,
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1 including, but not limited to, the following categories of
2 metrics:
3 (A) claims payment, including timeliness and
4 accuracy;
5 (B) prior authorizations;
6 (C) grievance and appeals;
7 (D) utilization statistics;
8 (E) provider disputes;
9 (F) provider credentialing; and
10 (G) member and provider customer service.
11 (2) The Department shall ensure that the metrics
12 report is accessible to providers online by January 1,
13 2017.
14 (3) The metrics shall be developed in consultation
15 with industry representatives of the Medicaid managed care
16 health plans and representatives of associations
17 representing the majority of providers within the
18 identified industry.
19 (4) Metrics shall be defined and incorporated into the
20 applicable Managed Care Policy Manual issued by the
21 Department.
22 (g-7) MCO claims processing and performance analysis. In
23 order to monitor MCO payments to hospital providers, pursuant
24 to Public Act 100-580, the Department shall post an analysis
25 of MCO claims processing and payment performance on its
26 website every 3 6 months. Such analysis shall include a review
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1 and evaluation of all Medicaid claims that were paid, denied,
2 rejected, or otherwise adjudicated by each MCO in the
3 preceding 3 months and were submitted to an MCO by a provider
4 that submitted at least 20 Medicaid claims to that MCO during
5 the period. The review and evaluation shall state a
6 representative sample of hospital claims that are rejected and
7 denied for clean and unclean claims and the top 5 reasons for
8 the rejection or denial of clean and unclean claims and the
9 time required for claim adjudication and payment, including
10 identifying: such actions and timeliness of claims
11 adjudication
12 (1) the total number of claims, by MCO, in the review
13 and evaluation;
14 (2) the percentage of all such claims, by MCO, that
15 were clean claims;
16 (3) the percentage of all claims, by MCO, that the MCO
17 paid within 30 days of receiving the claim, and the
18 percentage of all claims the MCO paid within 90 days of
19 receiving the claim;
20 (4) the percentage of clean claims the MCO paid within
21 30 days of receiving the claim, and the percentage of
22 clean claims the MCO paid within 90 days of receiving the
23 claim;
24 (5) the aggregate dollar amounts of those claims
25 identified in paragraphs (3) and (4).
26 Individual providers that submitted claims that are
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1 included in any Department review and evaluation required by
2 this subsection may request, and the Department shall provide
3 to such provider within 14 days thereafter, the data used by
4 the Department in its review and analysis that pertains to
5 claims submitted by that provider. The Department shall post
6 the contracted claims report required by HealthChoice Illinois
7 on its website every 3 months.
8 , which identifies the percentage of claims adjudicated within
9 30, 60, 90, and over 90 days, and the dollar amounts associated
10 with those claims.
11 (g-8) Dispute resolution process. The Department shall
12 maintain a provider complaint portal through which a provider
13 can submit to the Department unresolved disputes with an MCO.
14 An unresolved dispute means an MCO's decision that denies in
15 whole or in part a claim for reimbursement to a provider for
16 health care services rendered by the provider to an enrollee
17 of the MCO with which the provider disagrees. Disputes shall
18 not be submitted to the portal until the provider has availed
19 itself of the MCO's internal dispute resolution process.
20 Disputes that are submitted to the MCO internal dispute
21 resolution process may be submitted to the Department of
22 Healthcare and Family Services' complaint portal no sooner
23 than 30 days after submitting to the MCO's internal process
24 and not later than 30 days after the unsatisfactory resolution
25 of the internal MCO process or 60 days after submitting the
26 dispute to the MCO internal process. Multiple claim disputes
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1 involving the same MCO may be submitted in one complaint,
2 regardless of whether the claims are for different enrollees,
3 when the specific reason for non-payment of the claims
4 involves a common question of fact or policy. Within 10
5 business days of receipt of a complaint, the Department shall
6 present such disputes to the appropriate MCO, which shall then
7 have 30 days to issue its written proposal to resolve the
8 dispute. The Department may grant one 30-day extension of this
9 time frame to one of the parties to resolve the dispute. If the
10 dispute remains unresolved at the end of this time frame or the
11 provider is not satisfied with the MCO's written proposal to
12 resolve the dispute, the provider may, within 30 days, request
13 the Department to review the dispute and make a final
14 determination. Within 30 days of the request for Department
15 review of the dispute, both the provider and the MCO shall
16 present all relevant information to the Department for
17 resolution and make individuals with knowledge of the issues
18 available to the Department for further inquiry if needed.
19 Within 30 days of receiving the relevant information on the
20 dispute, or the lapse of the period for submitting such
21 information, the Department shall issue a written decision on
22 the dispute based on contractual terms between the provider
23 and the MCO, contractual terms between the MCO and the
24 Department of Healthcare and Family Services and applicable
25 Medicaid policy. The decision of the Department shall be
26 final. By January 1, 2020, the Department shall establish by
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1 rule further details of this dispute resolution process.
2 Disputes between MCOs and providers presented to the
3 Department for resolution are not contested cases, as defined
4 in Section 1-30 of the Illinois Administrative Procedure Act,
5 conferring any right to an administrative hearing.
6 (g-9)(1) The Department shall publish annually on its
7 website a report on the calculation of each managed care
8 organization's medical loss ratio showing the following:
9 (A) Premium revenue, with appropriate adjustments.
10 (B) Benefit expense, setting forth the aggregate
11 amount spent for the following:
12 (i) Direct paid claims.
13 (ii) Subcapitation payments.
14 (iii) Other claim payments.
15 (iv) Direct reserves.
16 (v) Gross recoveries.
17 (vi) Expenses for activities that improve health
18 care quality as allowed by the Department.
19 (3) The report shall also include the total amounts of all
20 Hospital Assessment Program-related payments made to the MCO,
21 and whether such amounts exceed the actual increased amounts
22 paid by the MCO to providers as a result of HAP-associated rate
23 increases.
24 (2) The medical loss ratio shall be calculated consistent
25 with federal law and regulation following a claims runout
26 period determined by the Department.
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1 (g-10)(1) "Liability effective date" means the date on
2 which an MCO becomes responsible for payment for medically
3 necessary and covered services rendered by a provider to one
4 of its enrollees in accordance with the contract terms between
5 the MCO and the provider. The liability effective date shall
6 be the later of:
7 (A) The execution date of a network participation
8 contract agreement.
9 (B) The date the provider or its representative
10 submits to the MCO the complete and accurate standardized
11 roster form for the provider in the format approved by the
12 Department.
13 (C) The provider effective date contained within the
14 Department's provider enrollment subsystem within the
15 Illinois Medicaid Program Advanced Cloud Technology
16 (IMPACT) System.
17 (2) The standardized roster form may be submitted to the
18 MCO at the same time that the provider submits an enrollment
19 application to the Department through IMPACT.
20 (3) By October 1, 2019, the Department shall require all
21 MCOs to update their provider directory with information for
22 new practitioners of existing contracted providers within 30
23 days of receipt of a complete and accurate standardized roster
24 template in the format approved by the Department provided
25 that the provider is effective in the Department's provider
26 enrollment subsystem within the IMPACT system. Such provider
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1 directory shall be readily accessible for purposes of
2 selecting an approved health care provider and comply with all
3 other federal and State requirements.
4 (g-11) The Department shall work with relevant
5 stakeholders on the development of operational guidelines to
6 enhance and improve operational performance of Illinois'
7 Medicaid managed care program, including, but not limited to,
8 improving provider billing practices, reducing claim
9 rejections and inappropriate payment denials, and
10 standardizing processes, procedures, definitions, and response
11 timelines, with the goal of reducing provider and MCO
12 administrative burdens and conflict. The Department shall
13 include a report on the progress of these program improvements
14 and other topics in its Fiscal Year 2020 annual report to the
15 General Assembly.
16 (g-12) Notwithstanding any other provision of law, if the
17 Department or an MCO requires submission of a claim for
18 payment in a non-electronic format, a provider shall always be
19 afforded a period of no less than 90 business days, as a
20 correction period, following any notification of rejection by
21 either the Department or the MCO to correct errors or
22 omissions in the original submission.
23 Under no circumstances, either by an MCO or under the
24 State's fee-for-service system, shall a provider be denied
25 payment for failure to comply with any timely submission
26 requirements under this Code or under any existing contract,
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1 unless the non-electronic format claim submission occurs after
2 the initial 180 days following the latest date of service on
3 the claim, or after the 90 business days correction period
4 following notification to the provider of rejection or denial
5 of payment.
6 At the time of payment for a claim, an MCO shall report to
7 the provider the payment components applicable to the payment,
8 including the base rate, the Diagnosis-Related Group (DRG) or
9 Enhanced Ambulatory Procedure Grouping (EAPG) group and
10 weight, any add-ons or adjustors, and any interest.
11 (g-13) The Department shall audit on a quarterly basis a
12 representative sample of claims that each MCO pays to a
13 representative sample of hospitals to determine if the MCOs
14 are accurately paying claims, including the base rate, the DRG
15 or EAPG group and weight, any add-ons or adjustors, and any
16 interest.
17 (1) If the Department finds that an MCO has improperly
18 denied or underpaid on a claim, the Department shall
19 promptly communicate the underpayment to the MCO and
20 provider, and take such steps as necessary to see that the
21 amount due is paid.
22 (2) The Department shall also investigate whether the
23 error affected other providers, and if so, notify affected
24 providers.
25 (3) The findings of the audits shall be included in
26 the quarterly MCO Performance Metrics Report under
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1 subsection (g-6).
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 (i) The requirements of this Section apply to contracts
11 with accountable care entities and MCOs entered into, amended,
12 or renewed after June 16, 2014 (the effective date of Public
13 Act 98-651).
14 (j) Health care information released to managed care
15 organizations. A health care provider shall release to a
16 Medicaid managed care organization, upon request, and subject
17 to the Health Insurance Portability and Accountability Act of
18 1996 and any other law applicable to the release of health
19 information, the health care information of the MCO's
20 enrollee, if the enrollee has completed and signed a general
21 release form that grants to the health care provider
22 permission to release the recipient's health care information
23 to the recipient's insurance carrier.
24 (k) The Department of Healthcare and Family Services,
25 managed care organizations, a statewide organization
26 representing hospitals, and a statewide organization
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1 representing safety-net hospitals shall explore ways to
2 support billing departments in safety-net hospitals.
3 (l) The requirements of this Section added by Public Act
4 102-4 shall apply to services provided on or after the first
5 day of the month that begins 60 days after April 27, 2021 (the
6 effective date of Public Act 102-4).
7 (m) MCOs operated as part of or by any unit of State or
8 local government shall segregate any Medicaid funds received
9 from the State or any State agency for payments to providers
10 separately from the governmental entity's general operating
11 and other funds and shall use such Medicaid funds only for the
12 Medicaid purposes for which the funds were paid to it by the
13 State or State agency.
14 (Source: P.A. 101-209, eff. 8-5-19; 102-4, eff. 4-27-21;
15 102-43, eff. 7-6-21; 102-144, eff. 1-1-22; 102-454, eff.
16 8-20-21; 102-813, eff. 5-13-22.)
17 (305 ILCS 5/5A-12.7)
18 (Section scheduled to be repealed on December 31, 2026)
19 Sec. 5A-12.7. Continuation of hospital access payments on
20 and after July 1, 2020.
21 (a) To preserve and improve access to hospital services,
22 for hospital services rendered on and after July 1, 2020, the
23 Department shall, except for hospitals described in subsection
24 (b) of Section 5A-3, make payments to hospitals or require
25 capitated managed care organizations to make payments as set
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1 forth in this Section. Payments under this Section are not due
2 and payable, however, until: (i) the methodologies described
3 in this Section are approved by the federal government in an
4 appropriate State Plan amendment or directed payment preprint;
5 and (ii) the assessment imposed under this Article is
6 determined to be a permissible tax under Title XIX of the
7 Social Security Act. In determining the hospital access
8 payments authorized under subsection (g) of this Section, if a
9 hospital ceases to qualify for payments from the pool, the
10 payments for all hospitals continuing to qualify for payments
11 from such pool shall be uniformly adjusted to fully expend the
12 aggregate net amount of the pool, with such adjustment being
13 effective on the first day of the second month following the
14 date the hospital ceases to receive payments from such pool.
15 (b) Amounts moved into claims-based rates and distributed
16 in accordance with Section 14-12 shall remain in those
17 claims-based rates.
18 (c) Graduate medical education.
19 (1) The calculation of graduate medical education
20 payments shall be based on the hospital's Medicare cost
21 report ending in Calendar Year 2018, as reported in the
22 Healthcare Cost Report Information System file, release
23 date September 30, 2019. An Illinois hospital reporting
24 intern and resident cost on its Medicare cost report shall
25 be eligible for graduate medical education payments.
26 (2) Each hospital's annualized Medicaid Intern
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1 Resident Cost is calculated using annualized intern and
2 resident total costs obtained from Worksheet B Part I,
3 Columns 21 and 22 the sum of Lines 30-43, 50-76, 90-93,
4 96-98, and 105-112 multiplied by the percentage that the
5 hospital's Medicaid days (Worksheet S3 Part I, Column 7,
6 Lines 2, 3, 4, 14, 16-18, and 32) comprise of the
7 hospital's total days (Worksheet S3 Part I, Column 8,
8 Lines 14, 16-18, and 32).
9 (3) An annualized Medicaid indirect medical education
10 (IME) payment is calculated for each hospital using its
11 IME payments (Worksheet E Part A, Line 29, Column 1)
12 multiplied by the percentage that its Medicaid days
13 (Worksheet S3 Part I, Column 7, Lines 2, 3, 4, 14, 16-18,
14 and 32) comprise of its Medicare days (Worksheet S3 Part
15 I, Column 6, Lines 2, 3, 4, 14, and 16-18).
16 (4) For each hospital, its annualized Medicaid Intern
17 Resident Cost and its annualized Medicaid IME payment are
18 summed, and, except as capped at 120% of the average cost
19 per intern and resident for all qualifying hospitals as
20 calculated under this paragraph, is multiplied by the
21 applicable reimbursement factor as described in this
22 paragraph, to determine the hospital's final graduate
23 medical education payment. Each hospital's average cost
24 per intern and resident shall be calculated by summing its
25 total annualized Medicaid Intern Resident Cost plus its
26 annualized Medicaid IME payment and dividing that amount
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1 by the hospital's total Full Time Equivalent Residents and
2 Interns. If the hospital's average per intern and resident
3 cost is greater than 120% of the same calculation for all
4 qualifying hospitals, the hospital's per intern and
5 resident cost shall be capped at 120% of the average cost
6 for all qualifying hospitals.
7 (A) For the period of July 1, 2020 through
8 December 31, 2022, the applicable reimbursement factor
9 shall be 22.6%.
10 (B) For the period of January 1, 2023 through
11 December 31, 2026, the applicable reimbursement factor
12 shall be 35% for all qualified safety-net hospitals,
13 as defined in Section 5-5e.1 of this Code, and all
14 hospitals with 100 or more Full Time Equivalent
15 Residents and Interns, as reported on the hospital's
16 Medicare cost report ending in Calendar Year 2018, and
17 for all other qualified hospitals the applicable
18 reimbursement factor shall be 30%.
19 (d) Fee-for-service supplemental payments. For the period
20 of July 1, 2020 through December 31, 2022, each Illinois
21 hospital shall receive an annual payment equal to the amounts
22 below, to be paid in 12 equal installments on or before the
23 seventh State business day of each month, except that no
24 payment shall be due within 30 days after the later of the date
25 of notification of federal approval of the payment
26 methodologies required under this Section or any waiver
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1 required under 42 CFR 433.68, at which time the sum of amounts
2 required under this Section prior to the date of notification
3 is due and payable.
4 (1) For critical access hospitals, $385 per covered
5 inpatient day contained in paid fee-for-service claims and
6 $530 per paid fee-for-service outpatient claim for dates
7 of service in Calendar Year 2019 in the Department's
8 Enterprise Data Warehouse as of May 11, 2020.
9 (2) For safety-net hospitals, $960 per covered
10 inpatient day contained in paid fee-for-service claims and
11 $625 per paid fee-for-service outpatient claim for dates
12 of service in Calendar Year 2019 in the Department's
13 Enterprise Data Warehouse as of May 11, 2020.
14 (3) For long term acute care hospitals, $295 per
15 covered inpatient day contained in paid fee-for-service
16 claims for dates of service in Calendar Year 2019 in the
17 Department's Enterprise Data Warehouse as of May 11, 2020.
18 (4) For freestanding psychiatric hospitals, $125 per
19 covered inpatient day contained in paid fee-for-service
20 claims and $130 per paid fee-for-service outpatient claim
21 for dates of service in Calendar Year 2019 in the
22 Department's Enterprise Data Warehouse as of May 11, 2020.
23 (5) For freestanding rehabilitation hospitals, $355
24 per covered inpatient day contained in paid
25 fee-for-service claims for dates of service in Calendar
26 Year 2019 in the Department's Enterprise Data Warehouse as
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1 of May 11, 2020.
2 (6) For all general acute care hospitals and high
3 Medicaid hospitals as defined in subsection (f), $350 per
4 covered inpatient day for dates of service in Calendar
5 Year 2019 contained in paid fee-for-service claims and
6 $620 per paid fee-for-service outpatient claim in the
7 Department's Enterprise Data Warehouse as of May 11, 2020.
8 (7) Alzheimer's treatment access payment. Each
9 Illinois academic medical center or teaching hospital, as
10 defined in Section 5-5e.2 of this Code, that is identified
11 as the primary hospital affiliate of one of the Regional
12 Alzheimer's Disease Assistance Centers, as designated by
13 the Alzheimer's Disease Assistance Act and identified in
14 the Department of Public Health's Alzheimer's Disease
15 State Plan dated December 2016, shall be paid an
16 Alzheimer's treatment access payment equal to the product
17 of the qualifying hospital's State Fiscal Year 2018 total
18 inpatient fee-for-service days multiplied by the
19 applicable Alzheimer's treatment rate of $226.30 for
20 hospitals located in Cook County and $116.21 for hospitals
21 located outside Cook County.
22 (d-2) Fee-for-service supplemental payments. Beginning
23 January 1, 2023, each Illinois hospital shall receive an
24 annual payment equal to the amounts listed below, to be paid in
25 12 equal installments on or before the seventh State business
26 day of each month, except that no payment shall be due within
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1 30 days after the later of the date of notification of federal
2 approval of the payment methodologies required under this
3 Section or any waiver required under 42 CFR 433.68, at which
4 time the sum of amounts required under this Section prior to
5 the date of notification is due and payable. The Department
6 may adjust the rates in paragraphs (1) through (7) to comply
7 with the federal upper payment limits, with such adjustments
8 being determined so that the total estimated spending by
9 hospital class, under such adjusted rates, remains
10 substantially similar to the total estimated spending under
11 the original rates set forth in this subsection.
12 (1) For critical access hospitals, as defined in
13 subsection (f), $750 per covered inpatient day contained
14 in paid fee-for-service claims and $750 per paid
15 fee-for-service outpatient claim for dates of service in
16 Calendar Year 2019 in the Department's Enterprise Data
17 Warehouse as of August 6, 2021.
18 (2) For safety-net hospitals, as described in
19 subsection (f), $1,350 per inpatient day contained in paid
20 fee-for-service claims and $1,350 per paid fee-for-service
21 outpatient claim for dates of service in Calendar Year
22 2019 in the Department's Enterprise Data Warehouse as of
23 August 6, 2021.
24 (3) For long term acute care hospitals, $550 per
25 covered inpatient day contained in paid fee-for-service
26 claims for dates of service in Calendar Year 2019 in the
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1 Department's Enterprise Data Warehouse as of August 6,
2 2021.
3 (4) For freestanding psychiatric hospitals, $200 per
4 covered inpatient day contained in paid fee-for-service
5 claims and $200 per paid fee-for-service outpatient claim
6 for dates of service in Calendar Year 2019 in the
7 Department's Enterprise Data Warehouse as of August 6,
8 2021.
9 (5) For freestanding rehabilitation hospitals, $550
10 per covered inpatient day contained in paid
11 fee-for-service claims and $125 per paid fee-for-service
12 outpatient claim for dates of service in Calendar Year
13 2019 in the Department's Enterprise Data Warehouse as of
14 August 6, 2021.
15 (6) For all general acute care hospitals and high
16 Medicaid hospitals as defined in subsection (f), $500 per
17 covered inpatient day for dates of service in Calendar
18 Year 2019 contained in paid fee-for-service claims and
19 $500 per paid fee-for-service outpatient claim in the
20 Department's Enterprise Data Warehouse as of August 6,
21 2021.
22 (7) For public hospitals, as defined in subsection
23 (f), $275 per covered inpatient day contained in paid
24 fee-for-service claims and $275 per paid fee-for-service
25 outpatient claim for dates of service in Calendar Year
26 2019 in the Department's Enterprise Data Warehouse as of
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1 August 6, 2021.
2 (8) Alzheimer's treatment access payment. Each
3 Illinois academic medical center or teaching hospital, as
4 defined in Section 5-5e.2 of this Code, that is identified
5 as the primary hospital affiliate of one of the Regional
6 Alzheimer's Disease Assistance Centers, as designated by
7 the Alzheimer's Disease Assistance Act and identified in
8 the Department of Public Health's Alzheimer's Disease
9 State Plan dated December 2016, shall be paid an
10 Alzheimer's treatment access payment equal to the product
11 of the qualifying hospital's Calendar Year 2019 total
12 inpatient fee-for-service days, in the Department's
13 Enterprise Data Warehouse as of August 6, 2021, multiplied
14 by the applicable Alzheimer's treatment rate of $244.37
15 for hospitals located in Cook County and $312.03 for
16 hospitals located outside Cook County.
17 (e) The Department shall require managed care
18 organizations (MCOs) to make directed payments and
19 pass-through payments according to this Section. Each calendar
20 year, the Department shall require MCOs to pay the maximum
21 amount out of these funds as allowed as pass-through payments
22 under federal regulations. The Department shall require MCOs
23 to make such pass-through payments as specified in this
24 Section. The Department shall require the MCOs to pay the
25 remaining amounts as directed Payments as specified in this
26 Section. The Department shall issue payments to the
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1 Comptroller by the seventh business day of each month for all
2 MCOs that are sufficient for MCOs to make the directed
3 payments and pass-through payments according to this Section.
4 The Department shall require the MCOs to make pass-through
5 payments and directed payments using electronic funds
6 transfers (EFT), if the hospital provides the information
7 necessary to process such EFTs, in accordance with directions
8 provided monthly by the Department, within 7 business days of
9 the date the funds are paid to the MCOs, as indicated by the
10 "Paid Date" on the website of the Office of the Comptroller if
11 the funds are paid by EFT and the MCOs have received directed
12 payment instructions. If funds are not paid through the
13 Comptroller by EFT, payment must be made within 7 business
14 days of the date actually received by the MCO. The MCO will be
15 considered to have paid the pass-through payments when the
16 payment remittance number is generated or the date the MCO
17 sends the check to the hospital, if EFT information is not
18 supplied. If an MCO is late in paying a pass-through payment or
19 directed payment as required under this Section (including any
20 extensions granted by the Department), it shall pay a penalty,
21 unless waived by the Department for reasonable cause, to the
22 Department equal to 5% of the amount of the pass-through
23 payment or directed payment not paid on or before the due date
24 plus 5% of the portion thereof remaining unpaid on the last day
25 of each 30-day period thereafter. Payments to MCOs that would
26 be paid consistent with actuarial certification and enrollment
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1 in the absence of the increased capitation payments under this
2 Section shall not be reduced as a consequence of payments made
3 under this subsection. The Department shall publish and
4 maintain on its website for a period of no less than 8 calendar
5 quarters, the quarterly calculation of directed payments and
6 pass-through payments owed to each hospital from each MCO. All
7 calculations and reports shall be posted no later than the
8 first day of the quarter for which the payments are to be
9 issued.
10 (f)(1) For purposes of allocating the funds included in
11 capitation payments to MCOs, Illinois hospitals shall be
12 divided into the following classes as defined in
13 administrative rules:
14 (A) Beginning July 1, 2020 through December 31, 2022,
15 critical access hospitals. Beginning January 1, 2023,
16 "critical access hospital" means a hospital designated by
17 the Department of Public Health as a critical access
18 hospital, excluding any hospital meeting the definition of
19 a public hospital in subparagraph (F).
20 (B) Safety-net hospitals, except that stand-alone
21 children's hospitals that are not specialty children's
22 hospitals will not be included. For the calendar year
23 beginning January 1, 2023, and each calendar year
24 thereafter, assignment to the safety-net class shall be
25 based on the annual safety-net rate year beginning 15
26 months before the beginning of the first Payout Quarter of
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1 the calendar year.
2 (C) Long term acute care hospitals.
3 (D) Freestanding psychiatric hospitals.
4 (E) Freestanding rehabilitation hospitals.
5 (F) Beginning January 1, 2023, "public hospital" means
6 a hospital that is owned or operated by an Illinois
7 Government body or municipality, excluding a hospital
8 provider that is a State agency, a State university, or a
9 county with a population of 3,000,000 or more.
10 (G) High Medicaid hospitals.
11 (i) As used in this Section, "high Medicaid
12 hospital" means a general acute care hospital that:
13 (I) For the payout periods July 1, 2020
14 through December 31, 2022, is not a safety-net
15 hospital or critical access hospital and that has
16 a Medicaid Inpatient Utilization Rate above 30% or
17 a hospital that had over 35,000 inpatient Medicaid
18 days during the applicable period. For the period
19 July 1, 2020 through December 31, 2020, the
20 applicable period for the Medicaid Inpatient
21 Utilization Rate (MIUR) is the rate year 2020 MIUR
22 and for the number of inpatient days it is State
23 fiscal year 2018. Beginning in calendar year 2021,
24 the Department shall use the most recently
25 determined MIUR, as defined in subsection (h) of
26 Section 5-5.02, and for the inpatient day
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1 threshold, the State fiscal year ending 18 months
2 prior to the beginning of the calendar year. For
3 purposes of calculating MIUR under this Section,
4 children's hospitals and affiliated general acute
5 care hospitals shall be considered a single
6 hospital.
7 (II) For the calendar year beginning January
8 1, 2023, and each calendar year thereafter, is not
9 a public hospital, safety-net hospital, or
10 critical access hospital and that qualifies as a
11 regional high volume hospital or is a hospital
12 that has a Medicaid Inpatient Utilization Rate
13 (MIUR) above 30%. As used in this item, "regional
14 high volume hospital" means a hospital which ranks
15 in the top 2 quartiles based on total hospital
16 services volume, of all eligible general acute
17 care hospitals, when ranked in descending order
18 based on total hospital services volume, within
19 the same Medicaid managed care region, as
20 designated by the Department, as of January 1,
21 2022. As used in this item, "total hospital
22 services volume" means the total of all Medical
23 Assistance hospital inpatient admissions plus all
24 Medical Assistance hospital outpatient visits. For
25 purposes of determining regional high volume
26 hospital inpatient admissions and outpatient
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1 visits, the Department shall use dates of service
2 provided during State Fiscal Year 2020 for the
3 Payout Quarter beginning January 1, 2023. The
4 Department shall use dates of service from the
5 State fiscal year ending 18 month before the
6 beginning of the first Payout Quarter of the
7 subsequent annual determination period.
8 (ii) For the calendar year beginning January 1,
9 2023, the Department shall use the Rate Year 2022
10 Medicaid inpatient utilization rate (MIUR), as defined
11 in subsection (h) of Section 5-5.02. For each
12 subsequent annual determination, the Department shall
13 use the MIUR applicable to the rate year ending
14 September 30 of the year preceding the beginning of
15 the calendar year.
16 (H) General acute care hospitals. As used under this
17 Section, "general acute care hospitals" means all other
18 Illinois hospitals not identified in subparagraphs (A)
19 through (G).
20 (2) Hospitals' qualification for each class shall be
21 assessed prior to the beginning of each calendar year and the
22 new class designation shall be effective January 1 of the next
23 year. The Department shall publish by rule the process for
24 establishing class determination.
25 (g) Fixed pool directed payments. Beginning July 1, 2020,
26 the Department shall issue payments to MCOs which shall be
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1 used to issue directed payments to qualified Illinois
2 safety-net hospitals and critical access hospitals on a
3 monthly basis in accordance with this subsection. Prior to the
4 beginning of each Payout Quarter beginning July 1, 2020, the
5 Department shall use encounter claims data from the
6 Determination Quarter, accepted by the Department's Medicaid
7 Management Information System for inpatient and outpatient
8 services rendered by safety-net hospitals and critical access
9 hospitals to determine a quarterly uniform per unit add-on for
10 each hospital class.
11 (1) Inpatient per unit add-on. A quarterly uniform per
12 diem add-on shall be derived by dividing the quarterly
13 Inpatient Directed Payments Pool amount allocated to the
14 applicable hospital class by the total inpatient days
15 contained on all encounter claims received during the
16 Determination Quarter, for all hospitals in the class.
17 (A) Each hospital in the class shall have a
18 quarterly inpatient directed payment calculated that
19 is equal to the product of the number of inpatient days
20 attributable to the hospital used in the calculation
21 of the quarterly uniform class per diem add-on,
22 multiplied by the calculated applicable quarterly
23 uniform class per diem add-on of the hospital class.
24 (B) Each hospital shall be paid 1/3 of its
25 quarterly inpatient directed payment in each of the 3
26 months of the Payout Quarter, in accordance with
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1 directions provided to each MCO by the Department.
2 (2) Outpatient per unit add-on. A quarterly uniform
3 per claim add-on shall be derived by dividing the
4 quarterly Outpatient Directed Payments Pool amount
5 allocated to the applicable hospital class by the total
6 outpatient encounter claims received during the
7 Determination Quarter, for all hospitals in the class.
8 (A) Each hospital in the class shall have a
9 quarterly outpatient directed payment calculated that
10 is equal to the product of the number of outpatient
11 encounter claims attributable to the hospital used in
12 the calculation of the quarterly uniform class per
13 claim add-on, multiplied by the calculated applicable
14 quarterly uniform class per claim add-on of the
15 hospital class.
16 (B) Each hospital shall be paid 1/3 of its
17 quarterly outpatient directed payment in each of the 3
18 months of the Payout Quarter, in accordance with
19 directions provided to each MCO by the Department.
20 (3) Each MCO shall pay each hospital the Monthly
21 Directed Payment as identified by the Department on its
22 quarterly determination report.
23 (4) Definitions. As used in this subsection:
24 (A) "Payout Quarter" means each 3 month calendar
25 quarter, beginning July 1, 2020.
26 (B) "Determination Quarter" means each 3 month
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1 calendar quarter, which ends 3 months prior to the
2 first day of each Payout Quarter.
3 (5) For the period July 1, 2020 through December 2020,
4 the following amounts shall be allocated to the following
5 hospital class directed payment pools for the quarterly
6 development of a uniform per unit add-on:
7 (A) $2,894,500 for hospital inpatient services for
8 critical access hospitals.
9 (B) $4,294,374 for hospital outpatient services
10 for critical access hospitals.
11 (C) $29,109,330 for hospital inpatient services
12 for safety-net hospitals.
13 (D) $35,041,218 for hospital outpatient services
14 for safety-net hospitals.
15 (6) For the period January 1, 2023 through December
16 31, 2023, the Department shall establish the amounts that
17 shall be allocated to the hospital class directed payment
18 fixed pools identified in this paragraph for the quarterly
19 development of a uniform per unit add-on. The Department
20 shall establish such amounts so that the total amount of
21 payments to each hospital under this Section in calendar
22 year 2023 is projected to be substantially similar to the
23 total amount of such payments received by the hospital
24 under this Section in calendar year 2021, adjusted for
25 increased funding provided for fixed pool directed
26 payments under subsection (g) in calendar year 2022,
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1 assuming that the volume and acuity of claims are held
2 constant. The Department shall publish the directed
3 payment fixed pool amounts to be established under this
4 paragraph on its website by November 15, 2022.
5 (A) Hospital inpatient services for critical
6 access hospitals.
7 (B) Hospital outpatient services for critical
8 access hospitals.
9 (C) Hospital inpatient services for public
10 hospitals.
11 (D) Hospital outpatient services for public
12 hospitals.
13 (E) Hospital inpatient services for safety-net
14 hospitals.
15 (F) Hospital outpatient services for safety-net
16 hospitals.
17 (7) Semi-annual rate maintenance review. The
18 Department shall ensure that hospitals assigned to the
19 fixed pools in paragraph (6) are paid no less than 95% of
20 the annual initial rate for each 6-month period of each
21 annual payout period. For each calendar year, the
22 Department shall calculate the annual initial rate per day
23 and per visit for each fixed pool hospital class listed in
24 paragraph (6), by dividing the total of all applicable
25 inpatient or outpatient directed payments issued in the
26 preceding calendar year to the hospitals in each fixed
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1 pool class for the calendar year, plus any increase
2 resulting from the annual adjustments described in
3 subsection (i), by the actual applicable total service
4 units for the preceding calendar year which were the basis
5 of the total applicable inpatient or outpatient directed
6 payments issued to the hospitals in each fixed pool class
7 in the calendar year, except that for calendar year 2023,
8 the service units from calendar year 2021 shall be used.
9 (A) The Department shall calculate the effective
10 rate, per day and per visit, for the payout periods of
11 January to June and July to December of each year, for
12 each fixed pool listed in paragraph (6), by dividing
13 50% of the annual pool by the total applicable
14 reported service units for the 2 applicable
15 determination quarters.
16 (B) If the effective rate calculated in
17 subparagraph (A) is less than 95% of the annual
18 initial rate assigned to the class for each pool under
19 paragraph (6), the Department shall adjust the payment
20 for each hospital to a level equal to no less than 95%
21 of the annual initial rate, by issuing a retroactive
22 adjustment payment for the 6-month period under review
23 as identified in subparagraph (A).
24 (h) Fixed rate directed payments. Effective July 1, 2020,
25 the Department shall issue payments to MCOs which shall be
26 used to issue directed payments to Illinois hospitals not
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1 identified in paragraph (g) on a monthly basis. Prior to the
2 beginning of each Payout Quarter beginning July 1, 2020, the
3 Department shall use encounter claims data from the
4 Determination Quarter, accepted by the Department's Medicaid
5 Management Information System for inpatient and outpatient
6 services rendered by hospitals in each hospital class
7 identified in paragraph (f) and not identified in paragraph
8 (g). For the period July 1, 2020 through December 2020, the
9 Department shall direct MCOs to make payments as follows:
10 (1) For general acute care hospitals an amount equal
11 to $1,750 multiplied by the hospital's category of service
12 20 case mix index for the determination quarter multiplied
13 by the hospital's total number of inpatient admissions for
14 category of service 20 for the determination quarter.
15 (2) For general acute care hospitals an amount equal
16 to $160 multiplied by the hospital's category of service
17 21 case mix index for the determination quarter multiplied
18 by the hospital's total number of inpatient admissions for
19 category of service 21 for the determination quarter.
20 (3) For general acute care hospitals an amount equal
21 to $80 multiplied by the hospital's category of service 22
22 case mix index for the determination quarter multiplied by
23 the hospital's total number of inpatient admissions for
24 category of service 22 for the determination quarter.
25 (4) For general acute care hospitals an amount equal
26 to $375 multiplied by the hospital's category of service
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1 24 case mix index for the determination quarter multiplied
2 by the hospital's total number of category of service 24
3 paid EAPG (EAPGs) for the determination quarter.
4 (5) For general acute care hospitals an amount equal
5 to $240 multiplied by the hospital's category of service
6 27 and 28 case mix index for the determination quarter
7 multiplied by the hospital's total number of category of
8 service 27 and 28 paid EAPGs for the determination
9 quarter.
10 (6) For general acute care hospitals an amount equal
11 to $290 multiplied by the hospital's category of service
12 29 case mix index for the determination quarter multiplied
13 by the hospital's total number of category of service 29
14 paid EAPGs for the determination quarter.
15 (7) For high Medicaid hospitals an amount equal to
16 $1,800 multiplied by the hospital's category of service 20
17 case mix index for the determination quarter multiplied by
18 the hospital's total number of inpatient admissions for
19 category of service 20 for the determination quarter.
20 (8) For high Medicaid hospitals an amount equal to
21 $160 multiplied by the hospital's category of service 21
22 case mix index for the determination quarter multiplied by
23 the hospital's total number of inpatient admissions for
24 category of service 21 for the determination quarter.
25 (9) For high Medicaid hospitals an amount equal to $80
26 multiplied by the hospital's category of service 22 case
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1 mix index for the determination quarter multiplied by the
2 hospital's total number of inpatient admissions for
3 category of service 22 for the determination quarter.
4 (10) For high Medicaid hospitals an amount equal to
5 $400 multiplied by the hospital's category of service 24
6 case mix index for the determination quarter multiplied by
7 the hospital's total number of category of service 24 paid
8 EAPG outpatient claims for the determination quarter.
9 (11) For high Medicaid hospitals an amount equal to
10 $240 multiplied by the hospital's category of service 27
11 and 28 case mix index for the determination quarter
12 multiplied by the hospital's total number of category of
13 service 27 and 28 paid EAPGs for the determination
14 quarter.
15 (12) For high Medicaid hospitals an amount equal to
16 $290 multiplied by the hospital's category of service 29
17 case mix index for the determination quarter multiplied by
18 the hospital's total number of category of service 29 paid
19 EAPGs for the determination quarter.
20 (13) For long term acute care hospitals the amount of
21 $495 multiplied by the hospital's total number of
22 inpatient days for the determination quarter.
23 (14) For psychiatric hospitals the amount of $210
24 multiplied by the hospital's total number of inpatient
25 days for category of service 21 for the determination
26 quarter.
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1 (15) For psychiatric hospitals the amount of $250
2 multiplied by the hospital's total number of outpatient
3 claims for category of service 27 and 28 for the
4 determination quarter.
5 (16) For rehabilitation hospitals the amount of $410
6 multiplied by the hospital's total number of inpatient
7 days for category of service 22 for the determination
8 quarter.
9 (17) For rehabilitation hospitals the amount of $100
10 multiplied by the hospital's total number of outpatient
11 claims for category of service 29 for the determination
12 quarter.
13 (18) Effective for the Payout Quarter beginning
14 January 1, 2023, for the directed payments to hospitals
15 required under this subsection, the Department shall
16 establish the amounts that shall be used to calculate such
17 directed payments using the methodologies specified in
18 this paragraph. The Department shall use a single, uniform
19 rate, adjusted for acuity as specified in paragraphs (1)
20 through (12), for all categories of inpatient services
21 provided by each class of hospitals and a single uniform
22 rate, adjusted for acuity as specified in paragraphs (1)
23 through (12), for all categories of outpatient services
24 provided by each class of hospitals. The Department shall
25 establish such amounts so that the total amount of
26 payments to each hospital under this Section in calendar
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1 year 2023 is projected to be substantially similar to the
2 total amount of such payments received by the hospital
3 under this Section in calendar year 2021, adjusted for
4 increased funding provided for fixed pool directed
5 payments under subsection (g) in calendar year 2022,
6 assuming that the volume and acuity of claims are held
7 constant. The Department shall publish the directed
8 payment amounts to be established under this subsection on
9 its website by November 15, 2022.
10 (19) Each hospital shall be paid 1/3 of their
11 quarterly inpatient and outpatient directed payment in
12 each of the 3 months of the Payout Quarter, in accordance
13 with directions provided to each MCO by the Department.
14 20 Each MCO shall pay each hospital the Monthly
15 Directed Payment amount as identified by the Department on
16 its quarterly determination report.
17 Notwithstanding any other provision of this subsection, if
18 the Department determines that the actual total hospital
19 utilization data that is used to calculate the fixed rate
20 directed payments is substantially different than anticipated
21 when the rates in this subsection were initially determined
22 for unforeseeable circumstances (such as the COVID-19 pandemic
23 or some other public health emergency), the Department may
24 adjust the rates specified in this subsection so that the
25 total directed payments approximate the total spending amount
26 anticipated when the rates were initially established.
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1 Definitions. As used in this subsection:
2 (A) "Payout Quarter" means each calendar quarter,
3 beginning July 1, 2020.
4 (B) "Determination Quarter" means each calendar
5 quarter which ends 3 months prior to the first day of
6 each Payout Quarter.
7 (C) "Case mix index" means a hospital specific
8 calculation. For inpatient claims the case mix index
9 is calculated each quarter by summing the relative
10 weight of all inpatient Diagnosis-Related Group (DRG)
11 claims for a category of service in the applicable
12 Determination Quarter and dividing the sum by the
13 number of sum total of all inpatient DRG admissions
14 for the category of service for the associated claims.
15 The case mix index for outpatient claims is calculated
16 each quarter by summing the relative weight of all
17 paid EAPGs in the applicable Determination Quarter and
18 dividing the sum by the sum total of paid EAPGs for the
19 associated claims.
20 (i) Beginning January 1, 2021, the rates for directed
21 payments shall be recalculated in order to spend the
22 additional funds for directed payments that result from
23 reduction in the amount of pass-through payments allowed under
24 federal regulations. The additional funds for directed
25 payments shall be allocated proportionally to each class of
26 hospitals based on that class' proportion of services.
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1 (1) Beginning January 1, 2024, the fixed pool directed
2 payment amounts and the associated annual initial rates
3 referenced in paragraph (6) of subsection (f) for each
4 hospital class shall be uniformly increased by a ratio of
5 not less than, the ratio of the total pass-through
6 reduction amount pursuant to paragraph (4) of subsection
7 (j), for the hospitals comprising the hospital fixed pool
8 directed payment class for the next calendar year, to the
9 total inpatient and outpatient directed payments for the
10 hospitals comprising the hospital fixed pool directed
11 payment class paid during the preceding calendar year.
12 (2) Beginning January 1, 2024, the fixed rates for the
13 directed payments referenced in paragraph (18) of
14 subsection (h) for each hospital class shall be uniformly
15 increased by a ratio of not less than, the ratio of the
16 total pass-through reduction amount pursuant to paragraph
17 (4) of subsection (j), for the hospitals comprising the
18 hospital directed payment class for the next calendar
19 year, to the total inpatient and outpatient directed
20 payments for the hospitals comprising the hospital fixed
21 rate directed payment class paid during the preceding
22 calendar year.
23 (j) Pass-through payments.
24 (1) For the period July 1, 2020 through December 31,
25 2020, the Department shall assign quarterly pass-through
26 payments to each class of hospitals equal to one-fourth of
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1 the following annual allocations:
2 (A) $390,487,095 to safety-net hospitals.
3 (B) $62,553,886 to critical access hospitals.
4 (C) $345,021,438 to high Medicaid hospitals.
5 (D) $551,429,071 to general acute care hospitals.
6 (E) $27,283,870 to long term acute care hospitals.
7 (F) $40,825,444 to freestanding psychiatric
8 hospitals.
9 (G) $9,652,108 to freestanding rehabilitation
10 hospitals.
11 (2) For the period of July 1, 2020 through December
12 31, 2020, the pass-through payments shall at a minimum
13 ensure hospitals receive a total amount of monthly
14 payments under this Section as received in calendar year
15 2019 in accordance with this Article and paragraph (1) of
16 subsection (d-5) of Section 14-12, exclusive of amounts
17 received through payments referenced in subsection (b).
18 (3) For the calendar year beginning January 1, 2023,
19 the Department shall establish the annual pass-through
20 allocation to each class of hospitals and the pass-through
21 payments to each hospital so that the total amount of
22 payments to each hospital under this Section in calendar
23 year 2023 is projected to be substantially similar to the
24 total amount of such payments received by the hospital
25 under this Section in calendar year 2021, adjusted for
26 increased funding provided for fixed pool directed
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1 payments under subsection (g) in calendar year 2022,
2 assuming that the volume and acuity of claims are held
3 constant. The Department shall publish the pass-through
4 allocation to each class and the pass-through payments to
5 each hospital to be established under this subsection on
6 its website by November 15, 2022.
7 (4) For the calendar years beginning January 1, 2021,
8 January 1, 2022, and January 1, 2024, and each calendar
9 year thereafter, each hospital's pass-through payment
10 amount shall be reduced proportionally to the reduction of
11 all pass-through payments required by federal regulations.
12 (k) At least 30 days prior to each calendar year, the
13 Department shall notify each hospital of changes to the
14 payment methodologies in this Section, including, but not
15 limited to, changes in the fixed rate directed payment rates,
16 the aggregate pass-through payment amount for all hospitals,
17 and the hospital's pass-through payment amount for the
18 upcoming calendar year.
19 (l) Notwithstanding any other provisions of this Section,
20 the Department may adopt rules to change the methodology for
21 directed and pass-through payments as set forth in this
22 Section, but only to the extent necessary to obtain federal
23 approval of a necessary State Plan amendment or Directed
24 Payment Preprint or to otherwise conform to federal law or
25 federal regulation.
26 (m) As used in this subsection, "managed care
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1 organization" or "MCO" means an entity which contracts with
2 the Department to provide services where payment for medical
3 services is made on a capitated basis, excluding contracted
4 entities for dual eligible or Department of Children and
5 Family Services youth populations.
6 (n) In order to address the escalating infant mortality
7 rates among minority communities in Illinois, the State shall,
8 subject to appropriation, create a pool of funding of at least
9 $50,000,000 annually to be disbursed among safety-net
10 hospitals that maintain perinatal designation from the
11 Department of Public Health. The funding shall be used to
12 preserve or enhance OB/GYN services or other specialty
13 services at the receiving hospital, with the distribution of
14 funding to be established by rule and with consideration to
15 perinatal hospitals with safe birthing levels and quality
16 metrics for healthy mothers and babies.
17 The Department shall calculate, at least quarterly, all
18 Hospital Assessment Program-related funds paid to each
19 hospital, whether paid by the Department or an MCO, including
20 the amounts integrated into rate increases and distributed in
21 accordance with Section 14-12 as provided under subsection (b)
22 of Section 5A-12.7, and shall provide a report to each
23 hospital stating the total payments made in the preceding
24 quarter and including the data and mathematical formulas
25 supporting its calculation.
26 (o) In order to address the growing challenges of
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1 providing stable access to healthcare in rural Illinois,
2 including perinatal services, behavioral healthcare including
3 substance use disorder services (SUDs) and other specialty
4 services, and to expand access to telehealth services among
5 rural communities in Illinois, the Department of Healthcare
6 and Family Services, subject to appropriation, shall
7 administer a program to provide at least $10,000,000 in
8 financial support annually to critical access hospitals for
9 delivery of perinatal and OB/GYN services, behavioral
10 healthcare including SUDS, other specialty services and
11 telehealth services. The funding shall be used to preserve or
12 enhance perinatal and OB/GYN services, behavioral healthcare
13 including SUDS, other specialty services, as well as the
14 explanation of telehealth services by the receiving hospital,
15 with the distribution of funding to be established by rule.
16 (p) For calendar year 2023, the final amounts, rates, and
17 payments under subsections (c), (d-2), (g), (h), and (j) shall
18 be established by the Department, so that the sum of the total
19 estimated annual payments under subsections (c), (d-2), (g),
20 (h), and (j) for each hospital class for calendar year 2023, is
21 no less than:
22 (1) $858,260,000 to safety-net hospitals.
23 (2) $86,200,000 to critical access hospitals.
24 (3) $1,765,000,000 to high Medicaid hospitals.
25 (4) $673,860,000 to general acute care hospitals.
26 (5) $48,330,000 to long term acute care hospitals.
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1 (6) $89,110,000 to freestanding psychiatric hospitals.
2 (7) $24,300,000 to freestanding rehabilitation
3 hospitals.
4 (8) $32,570,000 to public hospitals.
5 (q) Hospital Pandemic Recovery Stabilization Payments. The
6 Department shall disburse a pool of $460,000,000 in stability
7 payments to hospitals prior to April 1, 2023. The allocation
8 of the pool shall be based on the hospital directed payment
9 classes and directed payments issued, during Calendar Year
10 2022 with added consideration to safety net hospitals, as
11 defined in subdivision (f)(1)(B) of this Section, and critical
12 access hospitals.
13 (Source: P.A. 101-650, eff. 7-7-20; 102-4, eff. 4-27-21;
14 102-16, eff. 6-17-21; 102-886, eff. 5-17-22; 102-1115, eff.
15 1-9-23.)
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