Illinois 2023-2024 Regular Session

Illinois Senate Bill SB2088 Compare Versions

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

Old	New	Differences
1	1	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
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB2088 Introduced 2/9/2023, by Sen. Celina Villanueva SYNOPSIS AS INTRODUCED:
3	3	305 ILCS 5/5-30.1305 ILCS 5/5A-12.7 305 ILCS 5/5-30.1 305 ILCS 5/5A-12.7
4	4	305 ILCS 5/5-30.1
5	5	305 ILCS 5/5A-12.7
6	6	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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12	12	1 AN ACT concerning public aid.
13	13	2 Be it enacted by the People of the State of Illinois,
14	14	3 represented in the General Assembly:
15	15	4 Section 5. The Illinois Public Aid Code is amended by
16	16	5 changing Sections 5-30.1 and 5A-12.7 as follows:
17	17	6 (305 ILCS 5/5-30.1)
18	18	7 Sec. 5-30.1. Managed care protections.
19	19	8 (a) As used in this Section:
20	20	9 "Clean claim" means: (i) a claim that contains all the
21	21	10 essential information needed to adjudicate the claim or (ii) a
22	22	11 claim for which a managed care organization does not request
23	23	12 within 30 days of receipt any additional information to
24	24	13 adjudicate the claim. A resubmitted claim shall be considered
25	25	14 a clean claim on the resubmission date if it meets the
26	26	15 foregoing criteria.
27	27	16 "Managed care organization" or "MCO" means any entity
28	28	17 which contracts with the Department to provide services where
29	29	18 payment for medical services is made on a capitated basis.
30	30	19 "Emergency services" include:
31	31	20 (1) emergency services, as defined by Section 10 of
32	32	21 the Managed Care Reform and Patient Rights Act;
33	33	22 (2) emergency medical screening examinations, as
34	34	23 defined by Section 10 of the Managed Care Reform and
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38	38	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB2088 Introduced 2/9/2023, by Sen. Celina Villanueva SYNOPSIS AS INTRODUCED:
39	39	305 ILCS 5/5-30.1305 ILCS 5/5A-12.7 305 ILCS 5/5-30.1 305 ILCS 5/5A-12.7
40	40	305 ILCS 5/5-30.1
41	41	305 ILCS 5/5A-12.7
42	42	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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52	52	305 ILCS 5/5A-12.7
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71	71	1 Patient Rights Act;
72	72	2 (3) post-stabilization medical services, as defined by
73	73	3 Section 10 of the Managed Care Reform and Patient Rights
74	74	4 Act; and
75	75	5 (4) emergency medical conditions, as defined by
76	76	6 Section 10 of the Managed Care Reform and Patient Rights
77	77	7 Act.
78	78	8 (b) As provided by Section 5-16.12, managed care
79	79	9 organizations are subject to the provisions of the Managed
80	80	10 Care Reform and Patient Rights Act.
81	81	11 (c) An MCO shall pay any provider of emergency services
82	82	12 that does not have in effect a contract with the contracted
83	83	13 Medicaid MCO. The default rate of reimbursement shall be the
84	84	14 rate paid under Illinois Medicaid fee-for-service program
85	85	15 methodology, including all policy adjusters, including but not
86	86	16 limited to Medicaid High Volume Adjustments, Medicaid
87	87	17 Percentage Adjustments, Outpatient High Volume Adjustments,
88	88	18 and all outlier add-on adjustments to the extent such
89	89	19 adjustments are incorporated in the development of the
90	90	20 applicable MCO capitated rates.
91	91	21 (d) An MCO shall pay for all post-stabilization services
92	92	22 as a covered service in any of the following situations:
93	93	23 (1) the MCO authorized such services;
94	94	24 (2) such services were administered to maintain the
95	95	25 enrollee's stabilized condition within one hour after a
96	96	26 request to the MCO for authorization of further
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107	107	1 post-stabilization services;
108	108	2 (3) the MCO did not respond to a request to authorize
109	109	3 such services within one hour;
110	110	4 (4) the MCO could not be contacted; or
111	111	5 (5) the MCO and the treating provider, if the treating
112	112	6 provider is a non-affiliated provider, could not reach an
113	113	7 agreement concerning the enrollee's care and an affiliated
114	114	8 provider was unavailable for a consultation, in which case
115	115	9 the MCO must pay for such services rendered by the
116	116	10 treating non-affiliated provider until an affiliated
117	117	11 provider was reached and either concurred with the
118	118	12 treating non-affiliated provider's plan of care or assumed
119	119	13 responsibility for the enrollee's care. Such payment shall
120	120	14 be made at the default rate of reimbursement paid under
121	121	15 Illinois Medicaid fee-for-service program methodology,
122	122	16 including all policy adjusters, including but not limited
123	123	17 to Medicaid High Volume Adjustments, Medicaid Percentage
124	124	18 Adjustments, Outpatient High Volume Adjustments and all
125	125	19 outlier add-on adjustments to the extent that such
126	126	20 adjustments are incorporated in the development of the
127	127	21 applicable MCO capitated rates.
128	128	22 (e) The following requirements apply to MCOs in
129	129	23 determining payment for all emergency services:
130	130	24 (1) MCOs shall not impose any requirements for prior
131	131	25 approval of emergency services.
132	132	26 (2) The MCO shall cover emergency services provided to
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143	143	1 enrollees who are temporarily away from their residence
144	144	2 and outside the contracting area to the extent that the
145	145	3 enrollees would be entitled to the emergency services if
146	146	4 they still were within the contracting area.
147	147	5 (3) The MCO shall have no obligation to cover medical
148	148	6 services provided on an emergency basis that are not
149	149	7 covered services under the contract.
150	150	8 (4) The MCO shall not condition coverage for emergency
151	151	9 services on the treating provider notifying the MCO of the
152	152	10 enrollee's screening and treatment within 10 days after
153	153	11 presentation for emergency services.
154	154	12 (5) The determination of the attending emergency
155	155	13 physician, or the provider actually treating the enrollee,
156	156	14 of whether an enrollee is sufficiently stabilized for
157	157	15 discharge or transfer to another facility, shall be
158	158	16 binding on the MCO. The MCO shall cover emergency services
159	159	17 for all enrollees whether the emergency services are
160	160	18 provided by an affiliated or non-affiliated provider.
161	161	19 (6) The MCO's financial responsibility for
162	162	20 post-stabilization care services it has not pre-approved
163	163	21 ends when:
164	164	22 (A) a plan physician with privileges at the
165	165	23 treating hospital assumes responsibility for the
166	166	24 enrollee's care;
167	167	25 (B) a plan physician assumes responsibility for
168	168	26 the enrollee's care through transfer;
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179	179	1 (C) a contracting entity representative and the
180	180	2 treating physician reach an agreement concerning the
181	181	3 enrollee's care; or
182	182	4 (D) the enrollee is discharged.
183	183	5 (f) Network adequacy and transparency.
184	184	6 (1) The Department shall:
185	185	7 (A) ensure that an adequate provider network is in
186	186	8 place, taking into consideration health professional
187	187	9 shortage areas and medically underserved areas;
188	188	10 (B) publicly release an explanation of its process
189	189	11 for analyzing network adequacy;
190	190	12 (C) periodically ensure that an MCO continues to
191	191	13 have an adequate network in place;
192	192	14 (D) require MCOs, including Medicaid Managed Care
193	193	15 Entities as defined in Section 5-30.2, to meet
194	194	16 provider directory requirements under Section 5-30.3;
195	195	17 (E) require MCOs to ensure that any
196	196	18 Medicaid-certified provider under contract with an MCO
197	197	19 and previously submitted on a roster on the date of
198	198	20 service is paid for any medically necessary,
199	199	21 Medicaid-covered, and authorized service rendered to
200	200	22 any of the MCO's enrollees, regardless of inclusion on
201	201	23 the MCO's published and publicly available directory
202	202	24 of available providers; and
203	203	25 (F) require MCOs, including Medicaid Managed Care
204	204	26 Entities as defined in Section 5-30.2, to meet each of
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215	215	1 the requirements under subsection (d-5) of Section 10
216	216	2 of the Network Adequacy and Transparency Act; with
217	217	3 necessary exceptions to the MCO's network to ensure
218	218	4 that admission and treatment with a provider or at a
219	219	5 treatment facility in accordance with the network
220	220	6 adequacy standards in paragraph (3) of subsection
221	221	7 (d-5) of Section 10 of the Network Adequacy and
222	222	8 Transparency Act is limited to providers or facilities
223	223	9 that are Medicaid certified.
224	224	10 (2) Each MCO shall confirm its receipt of information
225	225	11 submitted specific to physician or dentist additions or
226	226	12 physician or dentist deletions from the MCO's provider
227	227	13 network within 3 days after receiving all required
228	228	14 information from contracted physicians or dentists, and
229	229	15 electronic physician and dental directories must be
230	230	16 updated consistent with current rules as published by the
231	231	17 Centers for Medicare and Medicaid Services or its
232	232	18 successor agency.
233	233	19 (g) Timely payment of claims.
234	234	20 (1) The MCO shall pay a clean claim within 30 days of
235	235	21 receiving a claim that contains all the essential
236	236	22 information needed to adjudicate the claim.
237	237	23 (2) The MCO shall notify the billing party of its
238	238	24 inability to adjudicate a claim within 30 days of
239	239	25 receiving that claim.
240	240	26 (2.5) At the time of payment for a claim, MCOs shall
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251	251	1 report to the provider (i) the date of receipt of the claim
252	252	2 by the MCO; (ii) the date of payment of the claim; and
253	253	3 (iii) whether the MCO considers the claim to have been a
254	254	4 clean claim.
255	255	5 (2.6) MCOs shall provide to safety-net hospitals on a
256	256	6 monthly basis a report of all claims paid the preceding
257	257	7 month stating (i) the dates of receipt and payment of each
258	258	8 of the claims and (ii) whether the MCO considers the claim
259	259	9 to have been a clean claim. The reports shall be provided
260	260	10 in both portable document format (PDF) and Excel
261	261	11 spreadsheet formats.
262	262	12 (2.7) MCOs shall collect and maintain the following
263	263	13 data for each claim submitted by a provider:
264	264	14 (A) the date the claim was received by the MCO;
265	265	15 (B) if applicable, the date any additional
266	266	16 information was requested by the MCO;
267	267	17 (C) if applicable, the date additional information
268	268	18 was received by the MCO;
269	269	19 (D) the date the claim was adjudicated; and
270	270	20 (E) the date the claim was denied or paid. MCOs
271	271	21 shall provide this data to any individual provider
272	272	22 that requests it, within 30 days after receiving the
273	273	23 provider's written request.
274	274	24 (3) The MCO shall pay a penalty that is at least equal
275	275	25 to the timely payment interest penalty imposed under
276	276	26 Section 368a of the Illinois Insurance Code for any claims
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287	287	1 not timely paid.
288	288	2 (A) When an MCO is required to pay a timely payment
289	289	3 interest penalty to a provider, the MCO must calculate
290	290	4 and pay the timely payment interest penalty that is
291	291	5 due to the provider within 30 days after the payment of
292	292	6 the claim. In no event shall a provider be required to
293	293	7 request or apply for payment of any owed timely
294	294	8 payment interest penalties.
295	295	9 (B) Such payments shall be reported separately
296	296	10 from the claim payment for services rendered to the
297	297	11 MCO's enrollee and clearly identified as interest
298	298	12 payments.
299	299	13 (C) Each MCO, including any owned, operated, or
300	300	14 controlled by any governmental agency, shall pay
301	301	15 interest for untimely payment of claims in accordance
302	302	16 with this subsection.
303	303	17 (3.1) On a quarterly basis, and within 30 days after
304	304	18 the end of each calendar quarter, each MCO shall report to
305	305	19 the Department the following information on a
306	306	20 provider-by-provider basis for each provider that
307	307	21 submitted 20 or more Medicaid claims to the MCO in the
308	308	22 quarter:
309	309	23 (A) the total number of claims received from the
310	310	24 provider during the prior quarter;
311	311	25 (B) the percentage of all such claims that were
312	312	26 clean claims;
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323	323	1 (C) the percentage of all claims the MCO paid
324	324	2 within 30 days of receiving the claim;
325	325	3 (D) the percentage of all claims the MCO paid
326	326	4 within 90 days of receiving the claim;
327	327	5 (E) the percentage of all clean claims the MCO
328	328	6 paid within 30 days of receiving the claim; and
329	329	7 (F) the percentage of all clean claims the MCO
330	330	8 paid within 90 days of receiving the claim.
331	331	9 Such information shall be provided by the Department
332	332	10 to the provider to whom the data applies within 14 days of
333	333	11 request by the provider.
334	334	12 (3.2) The provisions of this subsection, and others
335	335	13 dealing with timely payment of claims, are intended for
336	336	14 the benefit of the Department and of the providers. The
337	337	15 Department and each provider shall have the right to bring
338	338	16 suit in any court of competent jurisdiction to enforce
339	339	17 these provisions, including recovery of payments due to
340	340	18 providers, and to obtain any information related to
341	341	19 individual providers required to be provided under this
342	342	20 subsection. The court may enter any appropriate
343	343	21 compensatory, declaratory, or injunctive relief. In any
344	344	22 action or proceeding to enforce this subsection, the court
345	345	23 shall have the authority to award the prevailing party all
346	346	24 fees and costs incurred, including attorneys' fees.
347	347	25 (3.3) On a quarterly basis, the Department shall audit
348	348	26 a representative sample of each MCO's requests for
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359	359	1 information from providers to determine whether the
360	360	2 requested information is necessary to adjudicate the
361	361	3 claim. If the Department determines that the MCO requested
362	362	4 information that was not necessary to adjudicate the
363	363	5 claim, the MCO shall be required to pay a penalty to the
364	364	6 Department and interest to the provider computed from the
365	365	7 date of the submission of the claim to the MCO.
366	366	8 (4)(A) The Department shall require MCOs to expedite
367	367	9 payments to providers identified on the Department's
368	368	10 expedited provider list, determined in accordance with 89
369	369	11 Ill. Adm. Code 140.71(b), on a schedule at least as
370	370	12 frequently as the providers are paid under the
371	371	13 Department's fee-for-service expedited provider schedule.
372	372	14 (B) Compliance with the expedited provider requirement
373	373	15 may be satisfied by an MCO through the use of a Periodic
374	374	16 Interim Payment (PIP) program that has been mutually
375	375	17 agreed to and documented between the MCO and the provider,
376	376	18 if the PIP program ensures that any expedited provider
377	377	19 receives regular and periodic payments based on prior
378	378	20 period payment experience from that MCO. Total payments
379	379	21 under the PIP program may be reconciled against future PIP
380	380	22 payments on a schedule mutually agreed to between the MCO
381	381	23 and the provider.
382	382	24 (C) The Department shall share at least monthly its
383	383	25 expedited provider list and the frequency with which it
384	384	26 pays providers on the expedited list.
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395	395	1 (g-5) Recognizing that the rapid transformation of the
396	396	2 Illinois Medicaid program may have unintended operational
397	397	3 challenges for both payers and providers:
398	398	4 (1) in no instance shall a medically necessary covered
399	399	5 service rendered in good faith, based upon eligibility
400	400	6 information documented by the provider, be denied coverage
401	401	7 or diminished in payment amount if the eligibility or
402	402	8 coverage information available at the time the service was
403	403	9 rendered is later found to be inaccurate in the assignment
404	404	10 of coverage responsibility between MCOs or the
405	405	11 fee-for-service system, except for instances when an
406	406	12 individual is deemed to have not been eligible for
407	407	13 coverage under the Illinois Medicaid program; and
408	408	14 (2) the Department shall, by December 31, 2016, adopt
409	409	15 rules establishing policies that shall be included in the
410	410	16 Medicaid managed care policy and procedures manual
411	411	17 addressing payment resolutions in situations in which a
412	412	18 provider renders services based upon information obtained
413	413	19 after verifying a patient's eligibility and coverage plan
414	414	20 through either the Department's current enrollment system
415	415	21 or a system operated by the coverage plan identified by
416	416	22 the patient presenting for services:
417	417	23 (A) such medically necessary covered services
418	418	24 shall be considered rendered in good faith;
419	419	25 (B) such policies and procedures shall be
420	420	26 developed in consultation with industry
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431	431	1 representatives of the Medicaid managed care health
432	432	2 plans and representatives of provider associations
433	433	3 representing the majority of providers within the
434	434	4 identified provider industry; and
435	435	5 (C) such rules shall be published for a review and
436	436	6 comment period of no less than 30 days on the
437	437	7 Department's website with final rules remaining
438	438	8 available on the Department's website.
439	439	9 The rules on payment resolutions shall include, but
440	440	10 not be limited to:
441	441	11 (A) the extension of the timely filing period;
442	442	12 (B) retroactive prior authorizations; and
443	443	13 (C) guaranteed minimum payment rate of no less
444	444	14 than the current, as of the date of service,
445	445	15 fee-for-service rate, plus all applicable add-ons,
446	446	16 when the resulting service relationship is out of
447	447	17 network.
448	448	18 The rules shall be applicable for both MCO coverage
449	449	19 and fee-for-service coverage.
450	450	20 If the fee-for-service system is ultimately determined to
451	451	21 have been responsible for coverage on the date of service, the
452	452	22 Department shall provide for an extended period for claims
453	453	23 submission outside the standard timely filing requirements.
454	454	24 (g-6) MCO Performance Metrics Report.
455	455	25 (1) The Department shall publish, on at least a
456	456	26 quarterly basis, each MCO's operational performance,
457	457
458	458
459	459
460	460
461	461
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463	463
464	464
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467	467	1 including, but not limited to, the following categories of
468	468	2 metrics:
469	469	3 (A) claims payment, including timeliness and
470	470	4 accuracy;
471	471	5 (B) prior authorizations;
472	472	6 (C) grievance and appeals;
473	473	7 (D) utilization statistics;
474	474	8 (E) provider disputes;
475	475	9 (F) provider credentialing; and
476	476	10 (G) member and provider customer service.
477	477	11 (2) The Department shall ensure that the metrics
478	478	12 report is accessible to providers online by January 1,
479	479	13 2017.
480	480	14 (3) The metrics shall be developed in consultation
481	481	15 with industry representatives of the Medicaid managed care
482	482	16 health plans and representatives of associations
483	483	17 representing the majority of providers within the
484	484	18 identified industry.
485	485	19 (4) Metrics shall be defined and incorporated into the
486	486	20 applicable Managed Care Policy Manual issued by the
487	487	21 Department.
488	488	22 (g-7) MCO claims processing and performance analysis. In
489	489	23 order to monitor MCO payments to hospital providers, pursuant
490	490	24 to Public Act 100-580, the Department shall post an analysis
491	491	25 of MCO claims processing and payment performance on its
492	492	26 website every 3 6 months. Such analysis shall include a review
493	493
494	494
495	495
496	496
497	497
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499	499
500	500
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503	503	1 and evaluation of all Medicaid claims that were paid, denied,
504	504	2 rejected, or otherwise adjudicated by each MCO in the
505	505	3 preceding 3 months and were submitted to an MCO by a provider
506	506	4 that submitted at least 20 Medicaid claims to that MCO during
507	507	5 the period. The review and evaluation shall state a
508	508	6 representative sample of hospital claims that are rejected and
509	509	7 denied for clean and unclean claims and the top 5 reasons for
510	510	8 the rejection or denial of clean and unclean claims and the
511	511	9 time required for claim adjudication and payment, including
512	512	10 identifying: such actions and timeliness of claims
513	513	11 adjudication
514	514	12 (1) the total number of claims, by MCO, in the review
515	515	13 and evaluation;
516	516	14 (2) the percentage of all such claims, by MCO, that
517	517	15 were clean claims;
518	518	16 (3) the percentage of all claims, by MCO, that the MCO
519	519	17 paid within 30 days of receiving the claim, and the
520	520	18 percentage of all claims the MCO paid within 90 days of
521	521	19 receiving the claim;
522	522	20 (4) the percentage of clean claims the MCO paid within
523	523	21 30 days of receiving the claim, and the percentage of
524	524	22 clean claims the MCO paid within 90 days of receiving the
525	525	23 claim;
526	526	24 (5) the aggregate dollar amounts of those claims
527	527	25 identified in paragraphs (3) and (4).
528	528	26 Individual providers that submitted claims that are
529	529
530	530
531	531
532	532
533	533
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535	535
536	536
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539	539	1 included in any Department review and evaluation required by
540	540	2 this subsection may request, and the Department shall provide
541	541	3 to such provider within 14 days thereafter, the data used by
542	542	4 the Department in its review and analysis that pertains to
543	543	5 claims submitted by that provider. The Department shall post
544	544	6 the contracted claims report required by HealthChoice Illinois
545	545	7 on its website every 3 months.
546	546	8 , which identifies the percentage of claims adjudicated within
547	547	9 30, 60, 90, and over 90 days, and the dollar amounts associated
548	548	10 with those claims.
549	549	11 (g-8) Dispute resolution process. The Department shall
550	550	12 maintain a provider complaint portal through which a provider
551	551	13 can submit to the Department unresolved disputes with an MCO.
552	552	14 An unresolved dispute means an MCO's decision that denies in
553	553	15 whole or in part a claim for reimbursement to a provider for
554	554	16 health care services rendered by the provider to an enrollee
555	555	17 of the MCO with which the provider disagrees. Disputes shall
556	556	18 not be submitted to the portal until the provider has availed
557	557	19 itself of the MCO's internal dispute resolution process.
558	558	20 Disputes that are submitted to the MCO internal dispute
559	559	21 resolution process may be submitted to the Department of
560	560	22 Healthcare and Family Services' complaint portal no sooner
561	561	23 than 30 days after submitting to the MCO's internal process
562	562	24 and not later than 30 days after the unsatisfactory resolution
563	563	25 of the internal MCO process or 60 days after submitting the
564	564	26 dispute to the MCO internal process. Multiple claim disputes
565	565
566	566
567	567
568	568
569	569
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571	571
572	572
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574	574	SB2088 - 16 - LRB103 28984 KTG 55370 b
575	575	1 involving the same MCO may be submitted in one complaint,
576	576	2 regardless of whether the claims are for different enrollees,
577	577	3 when the specific reason for non-payment of the claims
578	578	4 involves a common question of fact or policy. Within 10
579	579	5 business days of receipt of a complaint, the Department shall
580	580	6 present such disputes to the appropriate MCO, which shall then
581	581	7 have 30 days to issue its written proposal to resolve the
582	582	8 dispute. The Department may grant one 30-day extension of this
583	583	9 time frame to one of the parties to resolve the dispute. If the
584	584	10 dispute remains unresolved at the end of this time frame or the
585	585	11 provider is not satisfied with the MCO's written proposal to
586	586	12 resolve the dispute, the provider may, within 30 days, request
587	587	13 the Department to review the dispute and make a final
588	588	14 determination. Within 30 days of the request for Department
589	589	15 review of the dispute, both the provider and the MCO shall
590	590	16 present all relevant information to the Department for
591	591	17 resolution and make individuals with knowledge of the issues
592	592	18 available to the Department for further inquiry if needed.
593	593	19 Within 30 days of receiving the relevant information on the
594	594	20 dispute, or the lapse of the period for submitting such
595	595	21 information, the Department shall issue a written decision on
596	596	22 the dispute based on contractual terms between the provider
597	597	23 and the MCO, contractual terms between the MCO and the
598	598	24 Department of Healthcare and Family Services and applicable
599	599	25 Medicaid policy. The decision of the Department shall be
600	600	26 final. By January 1, 2020, the Department shall establish by
601	601
602	602
603	603
604	604
605	605
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607	607
608	608
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610	610	SB2088 - 17 - LRB103 28984 KTG 55370 b
611	611	1 rule further details of this dispute resolution process.
612	612	2 Disputes between MCOs and providers presented to the
613	613	3 Department for resolution are not contested cases, as defined
614	614	4 in Section 1-30 of the Illinois Administrative Procedure Act,
615	615	5 conferring any right to an administrative hearing.
616	616	6 (g-9)(1) The Department shall publish annually on its
617	617	7 website a report on the calculation of each managed care
618	618	8 organization's medical loss ratio showing the following:
619	619	9 (A) Premium revenue, with appropriate adjustments.
620	620	10 (B) Benefit expense, setting forth the aggregate
621	621	11 amount spent for the following:
622	622	12 (i) Direct paid claims.
623	623	13 (ii) Subcapitation payments.
624	624	14 (iii) Other claim payments.
625	625	15 (iv) Direct reserves.
626	626	16 (v) Gross recoveries.
627	627	17 (vi) Expenses for activities that improve health
628	628	18 care quality as allowed by the Department.
629	629	19 (3) The report shall also include the total amounts of all
630	630	20 Hospital Assessment Program-related payments made to the MCO,
631	631	21 and whether such amounts exceed the actual increased amounts
632	632	22 paid by the MCO to providers as a result of HAP-associated rate
633	633	23 increases.
634	634	24 (2) The medical loss ratio shall be calculated consistent
635	635	25 with federal law and regulation following a claims runout
636	636	26 period determined by the Department.
637	637
638	638
639	639
640	640
641	641
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643	643
644	644
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646	646	SB2088 - 18 - LRB103 28984 KTG 55370 b
647	647	1 (g-10)(1) "Liability effective date" means the date on
648	648	2 which an MCO becomes responsible for payment for medically
649	649	3 necessary and covered services rendered by a provider to one
650	650	4 of its enrollees in accordance with the contract terms between
651	651	5 the MCO and the provider. The liability effective date shall
652	652	6 be the later of:
653	653	7 (A) The execution date of a network participation
654	654	8 contract agreement.
655	655	9 (B) The date the provider or its representative
656	656	10 submits to the MCO the complete and accurate standardized
657	657	11 roster form for the provider in the format approved by the
658	658	12 Department.
659	659	13 (C) The provider effective date contained within the
660	660	14 Department's provider enrollment subsystem within the
661	661	15 Illinois Medicaid Program Advanced Cloud Technology
662	662	16 (IMPACT) System.
663	663	17 (2) The standardized roster form may be submitted to the
664	664	18 MCO at the same time that the provider submits an enrollment
665	665	19 application to the Department through IMPACT.
666	666	20 (3) By October 1, 2019, the Department shall require all
667	667	21 MCOs to update their provider directory with information for
668	668	22 new practitioners of existing contracted providers within 30
669	669	23 days of receipt of a complete and accurate standardized roster
670	670	24 template in the format approved by the Department provided
671	671	25 that the provider is effective in the Department's provider
672	672	26 enrollment subsystem within the IMPACT system. Such provider
673	673
674	674
675	675
676	676
677	677
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679	679
680	680
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682	682	SB2088 - 19 - LRB103 28984 KTG 55370 b
683	683	1 directory shall be readily accessible for purposes of
684	684	2 selecting an approved health care provider and comply with all
685	685	3 other federal and State requirements.
686	686	4 (g-11) The Department shall work with relevant
687	687	5 stakeholders on the development of operational guidelines to
688	688	6 enhance and improve operational performance of Illinois'
689	689	7 Medicaid managed care program, including, but not limited to,
690	690	8 improving provider billing practices, reducing claim
691	691	9 rejections and inappropriate payment denials, and
692	692	10 standardizing processes, procedures, definitions, and response
693	693	11 timelines, with the goal of reducing provider and MCO
694	694	12 administrative burdens and conflict. The Department shall
695	695	13 include a report on the progress of these program improvements
696	696	14 and other topics in its Fiscal Year 2020 annual report to the
697	697	15 General Assembly.
698	698	16 (g-12) Notwithstanding any other provision of law, if the
699	699	17 Department or an MCO requires submission of a claim for
700	700	18 payment in a non-electronic format, a provider shall always be
701	701	19 afforded a period of no less than 90 business days, as a
702	702	20 correction period, following any notification of rejection by
703	703	21 either the Department or the MCO to correct errors or
704	704	22 omissions in the original submission.
705	705	23 Under no circumstances, either by an MCO or under the
706	706	24 State's fee-for-service system, shall a provider be denied
707	707	25 payment for failure to comply with any timely submission
708	708	26 requirements under this Code or under any existing contract,
709	709
710	710
711	711
712	712
713	713
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715	715
716	716
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719	719	1 unless the non-electronic format claim submission occurs after
720	720	2 the initial 180 days following the latest date of service on
721	721	3 the claim, or after the 90 business days correction period
722	722	4 following notification to the provider of rejection or denial
723	723	5 of payment.
724	724	6 At the time of payment for a claim, an MCO shall report to
725	725	7 the provider the payment components applicable to the payment,
726	726	8 including the base rate, the Diagnosis-Related Group (DRG) or
727	727	9 Enhanced Ambulatory Procedure Grouping (EAPG) group and
728	728	10 weight, any add-ons or adjustors, and any interest.
729	729	11 (g-13) The Department shall audit on a quarterly basis a
730	730	12 representative sample of claims that each MCO pays to a
731	731	13 representative sample of hospitals to determine if the MCOs
732	732	14 are accurately paying claims, including the base rate, the DRG
733	733	15 or EAPG group and weight, any add-ons or adjustors, and any
734	734	16 interest.
735	735	17 (1) If the Department finds that an MCO has improperly
736	736	18 denied or underpaid on a claim, the Department shall
737	737	19 promptly communicate the underpayment to the MCO and
738	738	20 provider, and take such steps as necessary to see that the
739	739	21 amount due is paid.
740	740	22 (2) The Department shall also investigate whether the
741	741	23 error affected other providers, and if so, notify affected
742	742	24 providers.
743	743	25 (3) The findings of the audits shall be included in
744	744	26 the quarterly MCO Performance Metrics Report under
745	745
746	746
747	747
748	748
749	749
750	750	SB2088 - 20 - LRB103 28984 KTG 55370 b
751	751
752	752
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754	754	SB2088 - 21 - LRB103 28984 KTG 55370 b
755	755	1 subsection (g-6).
756	756	2 (h) The Department shall not expand mandatory MCO
757	757	3 enrollment into new counties beyond those counties already
758	758	4 designated by the Department as of June 1, 2014 for the
759	759	5 individuals whose eligibility for medical assistance is not
760	760	6 the seniors or people with disabilities population until the
761	761	7 Department provides an opportunity for accountable care
762	762	8 entities and MCOs to participate in such newly designated
763	763	9 counties.
764	764	10 (i) The requirements of this Section apply to contracts
765	765	11 with accountable care entities and MCOs entered into, amended,
766	766	12 or renewed after June 16, 2014 (the effective date of Public
767	767	13 Act 98-651).
768	768	14 (j) Health care information released to managed care
769	769	15 organizations. A health care provider shall release to a
770	770	16 Medicaid managed care organization, upon request, and subject
771	771	17 to the Health Insurance Portability and Accountability Act of
772	772	18 1996 and any other law applicable to the release of health
773	773	19 information, the health care information of the MCO's
774	774	20 enrollee, if the enrollee has completed and signed a general
775	775	21 release form that grants to the health care provider
776	776	22 permission to release the recipient's health care information
777	777	23 to the recipient's insurance carrier.
778	778	24 (k) The Department of Healthcare and Family Services,
779	779	25 managed care organizations, a statewide organization
780	780	26 representing hospitals, and a statewide organization
781	781
782	782
783	783
784	784
785	785
786	786	SB2088 - 21 - LRB103 28984 KTG 55370 b
787	787
788	788
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790	790	SB2088 - 22 - LRB103 28984 KTG 55370 b
791	791	1 representing safety-net hospitals shall explore ways to
792	792	2 support billing departments in safety-net hospitals.
793	793	3 (l) The requirements of this Section added by Public Act
794	794	4 102-4 shall apply to services provided on or after the first
795	795	5 day of the month that begins 60 days after April 27, 2021 (the
796	796	6 effective date of Public Act 102-4).
797	797	7 (m) MCOs operated as part of or by any unit of State or
798	798	8 local government shall segregate any Medicaid funds received
799	799	9 from the State or any State agency for payments to providers
800	800	10 separately from the governmental entity's general operating
801	801	11 and other funds and shall use such Medicaid funds only for the
802	802	12 Medicaid purposes for which the funds were paid to it by the
803	803	13 State or State agency.
804	804	14 (Source: P.A. 101-209, eff. 8-5-19; 102-4, eff. 4-27-21;
805	805	15 102-43, eff. 7-6-21; 102-144, eff. 1-1-22; 102-454, eff.
806	806	16 8-20-21; 102-813, eff. 5-13-22.)
807	807	17 (305 ILCS 5/5A-12.7)
808	808	18 (Section scheduled to be repealed on December 31, 2026)
809	809	19 Sec. 5A-12.7. Continuation of hospital access payments on
810	810	20 and after July 1, 2020.
811	811	21 (a) To preserve and improve access to hospital services,
812	812	22 for hospital services rendered on and after July 1, 2020, the
813	813	23 Department shall, except for hospitals described in subsection
814	814	24 (b) of Section 5A-3, make payments to hospitals or require
815	815	25 capitated managed care organizations to make payments as set
816	816
817	817
818	818
819	819
820	820
821	821	SB2088 - 22 - LRB103 28984 KTG 55370 b
822	822
823	823
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825	825	SB2088 - 23 - LRB103 28984 KTG 55370 b
826	826	1 forth in this Section. Payments under this Section are not due
827	827	2 and payable, however, until: (i) the methodologies described
828	828	3 in this Section are approved by the federal government in an
829	829	4 appropriate State Plan amendment or directed payment preprint;
830	830	5 and (ii) the assessment imposed under this Article is
831	831	6 determined to be a permissible tax under Title XIX of the
832	832	7 Social Security Act. In determining the hospital access
833	833	8 payments authorized under subsection (g) of this Section, if a
834	834	9 hospital ceases to qualify for payments from the pool, the
835	835	10 payments for all hospitals continuing to qualify for payments
836	836	11 from such pool shall be uniformly adjusted to fully expend the
837	837	12 aggregate net amount of the pool, with such adjustment being
838	838	13 effective on the first day of the second month following the
839	839	14 date the hospital ceases to receive payments from such pool.
840	840	15 (b) Amounts moved into claims-based rates and distributed
841	841	16 in accordance with Section 14-12 shall remain in those
842	842	17 claims-based rates.
843	843	18 (c) Graduate medical education.
844	844	19 (1) The calculation of graduate medical education
845	845	20 payments shall be based on the hospital's Medicare cost
846	846	21 report ending in Calendar Year 2018, as reported in the
847	847	22 Healthcare Cost Report Information System file, release
848	848	23 date September 30, 2019. An Illinois hospital reporting
849	849	24 intern and resident cost on its Medicare cost report shall
850	850	25 be eligible for graduate medical education payments.
851	851	26 (2) Each hospital's annualized Medicaid Intern
852	852
853	853
854	854
855	855
856	856
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858	858
859	859
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861	861	SB2088 - 24 - LRB103 28984 KTG 55370 b
862	862	1 Resident Cost is calculated using annualized intern and
863	863	2 resident total costs obtained from Worksheet B Part I,
864	864	3 Columns 21 and 22 the sum of Lines 30-43, 50-76, 90-93,
865	865	4 96-98, and 105-112 multiplied by the percentage that the
866	866	5 hospital's Medicaid days (Worksheet S3 Part I, Column 7,
867	867	6 Lines 2, 3, 4, 14, 16-18, and 32) comprise of the
868	868	7 hospital's total days (Worksheet S3 Part I, Column 8,
869	869	8 Lines 14, 16-18, and 32).
870	870	9 (3) An annualized Medicaid indirect medical education
871	871	10 (IME) payment is calculated for each hospital using its
872	872	11 IME payments (Worksheet E Part A, Line 29, Column 1)
873	873	12 multiplied by the percentage that its Medicaid days
874	874	13 (Worksheet S3 Part I, Column 7, Lines 2, 3, 4, 14, 16-18,
875	875	14 and 32) comprise of its Medicare days (Worksheet S3 Part
876	876	15 I, Column 6, Lines 2, 3, 4, 14, and 16-18).
877	877	16 (4) For each hospital, its annualized Medicaid Intern
878	878	17 Resident Cost and its annualized Medicaid IME payment are
879	879	18 summed, and, except as capped at 120% of the average cost
880	880	19 per intern and resident for all qualifying hospitals as
881	881	20 calculated under this paragraph, is multiplied by the
882	882	21 applicable reimbursement factor as described in this
883	883	22 paragraph, to determine the hospital's final graduate
884	884	23 medical education payment. Each hospital's average cost
885	885	24 per intern and resident shall be calculated by summing its
886	886	25 total annualized Medicaid Intern Resident Cost plus its
887	887	26 annualized Medicaid IME payment and dividing that amount
888	888
889	889
890	890
891	891
892	892
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894	894
895	895
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897	897	SB2088 - 25 - LRB103 28984 KTG 55370 b
898	898	1 by the hospital's total Full Time Equivalent Residents and
899	899	2 Interns. If the hospital's average per intern and resident
900	900	3 cost is greater than 120% of the same calculation for all
901	901	4 qualifying hospitals, the hospital's per intern and
902	902	5 resident cost shall be capped at 120% of the average cost
903	903	6 for all qualifying hospitals.
904	904	7 (A) For the period of July 1, 2020 through
905	905	8 December 31, 2022, the applicable reimbursement factor
906	906	9 shall be 22.6%.
907	907	10 (B) For the period of January 1, 2023 through
908	908	11 December 31, 2026, the applicable reimbursement factor
909	909	12 shall be 35% for all qualified safety-net hospitals,
910	910	13 as defined in Section 5-5e.1 of this Code, and all
911	911	14 hospitals with 100 or more Full Time Equivalent
912	912	15 Residents and Interns, as reported on the hospital's
913	913	16 Medicare cost report ending in Calendar Year 2018, and
914	914	17 for all other qualified hospitals the applicable
915	915	18 reimbursement factor shall be 30%.
916	916	19 (d) Fee-for-service supplemental payments. For the period
917	917	20 of July 1, 2020 through December 31, 2022, each Illinois
918	918	21 hospital shall receive an annual payment equal to the amounts
919	919	22 below, to be paid in 12 equal installments on or before the
920	920	23 seventh State business day of each month, except that no
921	921	24 payment shall be due within 30 days after the later of the date
922	922	25 of notification of federal approval of the payment
923	923	26 methodologies required under this Section or any waiver
924	924
925	925
926	926
927	927
928	928
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930	930
931	931
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933	933	SB2088 - 26 - LRB103 28984 KTG 55370 b
934	934	1 required under 42 CFR 433.68, at which time the sum of amounts
935	935	2 required under this Section prior to the date of notification
936	936	3 is due and payable.
937	937	4 (1) For critical access hospitals, $385 per covered
938	938	5 inpatient day contained in paid fee-for-service claims and
939	939	6 $530 per paid fee-for-service outpatient claim for dates
940	940	7 of service in Calendar Year 2019 in the Department's
941	941	8 Enterprise Data Warehouse as of May 11, 2020.
942	942	9 (2) For safety-net hospitals, $960 per covered
943	943	10 inpatient day contained in paid fee-for-service claims and
944	944	11 $625 per paid fee-for-service outpatient claim for dates
945	945	12 of service in Calendar Year 2019 in the Department's
946	946	13 Enterprise Data Warehouse as of May 11, 2020.
947	947	14 (3) For long term acute care hospitals, $295 per
948	948	15 covered inpatient day contained in paid fee-for-service
949	949	16 claims for dates of service in Calendar Year 2019 in the
950	950	17 Department's Enterprise Data Warehouse as of May 11, 2020.
951	951	18 (4) For freestanding psychiatric hospitals, $125 per
952	952	19 covered inpatient day contained in paid fee-for-service
953	953	20 claims and $130 per paid fee-for-service outpatient claim
954	954	21 for dates of service in Calendar Year 2019 in the
955	955	22 Department's Enterprise Data Warehouse as of May 11, 2020.
956	956	23 (5) For freestanding rehabilitation hospitals, $355
957	957	24 per covered inpatient day contained in paid
958	958	25 fee-for-service claims for dates of service in Calendar
959	959	26 Year 2019 in the Department's Enterprise Data Warehouse as
960	960
961	961
962	962
963	963
964	964
965	965	SB2088 - 26 - LRB103 28984 KTG 55370 b
966	966
967	967
968	968	SB2088- 27 -LRB103 28984 KTG 55370 b SB2088 - 27 - LRB103 28984 KTG 55370 b
969	969	SB2088 - 27 - LRB103 28984 KTG 55370 b
970	970	1 of May 11, 2020.
971	971	2 (6) For all general acute care hospitals and high
972	972	3 Medicaid hospitals as defined in subsection (f), $350 per
973	973	4 covered inpatient day for dates of service in Calendar
974	974	5 Year 2019 contained in paid fee-for-service claims and
975	975	6 $620 per paid fee-for-service outpatient claim in the
976	976	7 Department's Enterprise Data Warehouse as of May 11, 2020.
977	977	8 (7) Alzheimer's treatment access payment. Each
978	978	9 Illinois academic medical center or teaching hospital, as
979	979	10 defined in Section 5-5e.2 of this Code, that is identified
980	980	11 as the primary hospital affiliate of one of the Regional
981	981	12 Alzheimer's Disease Assistance Centers, as designated by
982	982	13 the Alzheimer's Disease Assistance Act and identified in
983	983	14 the Department of Public Health's Alzheimer's Disease
984	984	15 State Plan dated December 2016, shall be paid an
985	985	16 Alzheimer's treatment access payment equal to the product
986	986	17 of the qualifying hospital's State Fiscal Year 2018 total
987	987	18 inpatient fee-for-service days multiplied by the
988	988	19 applicable Alzheimer's treatment rate of $226.30 for
989	989	20 hospitals located in Cook County and $116.21 for hospitals
990	990	21 located outside Cook County.
991	991	22 (d-2) Fee-for-service supplemental payments. Beginning
992	992	23 January 1, 2023, each Illinois hospital shall receive an
993	993	24 annual payment equal to the amounts listed below, to be paid in
994	994	25 12 equal installments on or before the seventh State business
995	995	26 day of each month, except that no payment shall be due within
996	996
997	997
998	998
999	999
1000	1000
1001	1001	SB2088 - 27 - LRB103 28984 KTG 55370 b
1002	1002
1003	1003
1004	1004	SB2088- 28 -LRB103 28984 KTG 55370 b SB2088 - 28 - LRB103 28984 KTG 55370 b
1005	1005	SB2088 - 28 - LRB103 28984 KTG 55370 b
1006	1006	1 30 days after the later of the date of notification of federal
1007	1007	2 approval of the payment methodologies required under this
1008	1008	3 Section or any waiver required under 42 CFR 433.68, at which
1009	1009	4 time the sum of amounts required under this Section prior to
1010	1010	5 the date of notification is due and payable. The Department
1011	1011	6 may adjust the rates in paragraphs (1) through (7) to comply
1012	1012	7 with the federal upper payment limits, with such adjustments
1013	1013	8 being determined so that the total estimated spending by
1014	1014	9 hospital class, under such adjusted rates, remains
1015	1015	10 substantially similar to the total estimated spending under
1016	1016	11 the original rates set forth in this subsection.
1017	1017	12 (1) For critical access hospitals, as defined in
1018	1018	13 subsection (f), $750 per covered inpatient day contained
1019	1019	14 in paid fee-for-service claims and $750 per paid
1020	1020	15 fee-for-service outpatient claim for dates of service in
1021	1021	16 Calendar Year 2019 in the Department's Enterprise Data
1022	1022	17 Warehouse as of August 6, 2021.
1023	1023	18 (2) For safety-net hospitals, as described in
1024	1024	19 subsection (f), $1,350 per inpatient day contained in paid
1025	1025	20 fee-for-service claims and $1,350 per paid fee-for-service
1026	1026	21 outpatient claim for dates of service in Calendar Year
1027	1027	22 2019 in the Department's Enterprise Data Warehouse as of
1028	1028	23 August 6, 2021.
1029	1029	24 (3) For long term acute care hospitals, $550 per
1030	1030	25 covered inpatient day contained in paid fee-for-service
1031	1031	26 claims for dates of service in Calendar Year 2019 in the
1032	1032
1033	1033
1034	1034
1035	1035
1036	1036
1037	1037	SB2088 - 28 - LRB103 28984 KTG 55370 b
1038	1038
1039	1039
1040	1040	SB2088- 29 -LRB103 28984 KTG 55370 b SB2088 - 29 - LRB103 28984 KTG 55370 b
1041	1041	SB2088 - 29 - LRB103 28984 KTG 55370 b
1042	1042	1 Department's Enterprise Data Warehouse as of August 6,
1043	1043	2 2021.
1044	1044	3 (4) For freestanding psychiatric hospitals, $200 per
1045	1045	4 covered inpatient day contained in paid fee-for-service
1046	1046	5 claims and $200 per paid fee-for-service outpatient claim
1047	1047	6 for dates of service in Calendar Year 2019 in the
1048	1048	7 Department's Enterprise Data Warehouse as of August 6,
1049	1049	8 2021.
1050	1050	9 (5) For freestanding rehabilitation hospitals, $550
1051	1051	10 per covered inpatient day contained in paid
1052	1052	11 fee-for-service claims and $125 per paid fee-for-service
1053	1053	12 outpatient claim for dates of service in Calendar Year
1054	1054	13 2019 in the Department's Enterprise Data Warehouse as of
1055	1055	14 August 6, 2021.
1056	1056	15 (6) For all general acute care hospitals and high
1057	1057	16 Medicaid hospitals as defined in subsection (f), $500 per
1058	1058	17 covered inpatient day for dates of service in Calendar
1059	1059	18 Year 2019 contained in paid fee-for-service claims and
1060	1060	19 $500 per paid fee-for-service outpatient claim in the
1061	1061	20 Department's Enterprise Data Warehouse as of August 6,
1062	1062	21 2021.
1063	1063	22 (7) For public hospitals, as defined in subsection
1064	1064	23 (f), $275 per covered inpatient day contained in paid
1065	1065	24 fee-for-service claims and $275 per paid fee-for-service
1066	1066	25 outpatient claim for dates of service in Calendar Year
1067	1067	26 2019 in the Department's Enterprise Data Warehouse as of
1068	1068
1069	1069
1070	1070
1071	1071
1072	1072
1073	1073	SB2088 - 29 - LRB103 28984 KTG 55370 b
1074	1074
1075	1075
1076	1076	SB2088- 30 -LRB103 28984 KTG 55370 b SB2088 - 30 - LRB103 28984 KTG 55370 b
1077	1077	SB2088 - 30 - LRB103 28984 KTG 55370 b
1078	1078	1 August 6, 2021.
1079	1079	2 (8) Alzheimer's treatment access payment. Each
1080	1080	3 Illinois academic medical center or teaching hospital, as
1081	1081	4 defined in Section 5-5e.2 of this Code, that is identified
1082	1082	5 as the primary hospital affiliate of one of the Regional
1083	1083	6 Alzheimer's Disease Assistance Centers, as designated by
1084	1084	7 the Alzheimer's Disease Assistance Act and identified in
1085	1085	8 the Department of Public Health's Alzheimer's Disease
1086	1086	9 State Plan dated December 2016, shall be paid an
1087	1087	10 Alzheimer's treatment access payment equal to the product
1088	1088	11 of the qualifying hospital's Calendar Year 2019 total
1089	1089	12 inpatient fee-for-service days, in the Department's
1090	1090	13 Enterprise Data Warehouse as of August 6, 2021, multiplied
1091	1091	14 by the applicable Alzheimer's treatment rate of $244.37
1092	1092	15 for hospitals located in Cook County and $312.03 for
1093	1093	16 hospitals located outside Cook County.
1094	1094	17 (e) The Department shall require managed care
1095	1095	18 organizations (MCOs) to make directed payments and
1096	1096	19 pass-through payments according to this Section. Each calendar
1097	1097	20 year, the Department shall require MCOs to pay the maximum
1098	1098	21 amount out of these funds as allowed as pass-through payments
1099	1099	22 under federal regulations. The Department shall require MCOs
1100	1100	23 to make such pass-through payments as specified in this
1101	1101	24 Section. The Department shall require the MCOs to pay the
1102	1102	25 remaining amounts as directed Payments as specified in this
1103	1103	26 Section. The Department shall issue payments to the
1104	1104
1105	1105
1106	1106
1107	1107
1108	1108
1109	1109	SB2088 - 30 - LRB103 28984 KTG 55370 b
1110	1110
1111	1111
1112	1112	SB2088- 31 -LRB103 28984 KTG 55370 b SB2088 - 31 - LRB103 28984 KTG 55370 b
1113	1113	SB2088 - 31 - LRB103 28984 KTG 55370 b
1114	1114	1 Comptroller by the seventh business day of each month for all
1115	1115	2 MCOs that are sufficient for MCOs to make the directed
1116	1116	3 payments and pass-through payments according to this Section.
1117	1117	4 The Department shall require the MCOs to make pass-through
1118	1118	5 payments and directed payments using electronic funds
1119	1119	6 transfers (EFT), if the hospital provides the information
1120	1120	7 necessary to process such EFTs, in accordance with directions
1121	1121	8 provided monthly by the Department, within 7 business days of
1122	1122	9 the date the funds are paid to the MCOs, as indicated by the
1123	1123	10 "Paid Date" on the website of the Office of the Comptroller if
1124	1124	11 the funds are paid by EFT and the MCOs have received directed
1125	1125	12 payment instructions. If funds are not paid through the
1126	1126	13 Comptroller by EFT, payment must be made within 7 business
1127	1127	14 days of the date actually received by the MCO. The MCO will be
1128	1128	15 considered to have paid the pass-through payments when the
1129	1129	16 payment remittance number is generated or the date the MCO
1130	1130	17 sends the check to the hospital, if EFT information is not
1131	1131	18 supplied. If an MCO is late in paying a pass-through payment or
1132	1132	19 directed payment as required under this Section (including any
1133	1133	20 extensions granted by the Department), it shall pay a penalty,
1134	1134	21 unless waived by the Department for reasonable cause, to the
1135	1135	22 Department equal to 5% of the amount of the pass-through
1136	1136	23 payment or directed payment not paid on or before the due date
1137	1137	24 plus 5% of the portion thereof remaining unpaid on the last day
1138	1138	25 of each 30-day period thereafter. Payments to MCOs that would
1139	1139	26 be paid consistent with actuarial certification and enrollment
1140	1140
1141	1141
1142	1142
1143	1143
1144	1144
1145	1145	SB2088 - 31 - LRB103 28984 KTG 55370 b
1146	1146
1147	1147
1148	1148	SB2088- 32 -LRB103 28984 KTG 55370 b SB2088 - 32 - LRB103 28984 KTG 55370 b
1149	1149	SB2088 - 32 - LRB103 28984 KTG 55370 b
1150	1150	1 in the absence of the increased capitation payments under this
1151	1151	2 Section shall not be reduced as a consequence of payments made
1152	1152	3 under this subsection. The Department shall publish and
1153	1153	4 maintain on its website for a period of no less than 8 calendar
1154	1154	5 quarters, the quarterly calculation of directed payments and
1155	1155	6 pass-through payments owed to each hospital from each MCO. All
1156	1156	7 calculations and reports shall be posted no later than the
1157	1157	8 first day of the quarter for which the payments are to be
1158	1158	9 issued.
1159	1159	10 (f)(1) For purposes of allocating the funds included in
1160	1160	11 capitation payments to MCOs, Illinois hospitals shall be
1161	1161	12 divided into the following classes as defined in
1162	1162	13 administrative rules:
1163	1163	14 (A) Beginning July 1, 2020 through December 31, 2022,
1164	1164	15 critical access hospitals. Beginning January 1, 2023,
1165	1165	16 "critical access hospital" means a hospital designated by
1166	1166	17 the Department of Public Health as a critical access
1167	1167	18 hospital, excluding any hospital meeting the definition of
1168	1168	19 a public hospital in subparagraph (F).
1169	1169	20 (B) Safety-net hospitals, except that stand-alone
1170	1170	21 children's hospitals that are not specialty children's
1171	1171	22 hospitals will not be included. For the calendar year
1172	1172	23 beginning January 1, 2023, and each calendar year
1173	1173	24 thereafter, assignment to the safety-net class shall be
1174	1174	25 based on the annual safety-net rate year beginning 15
1175	1175	26 months before the beginning of the first Payout Quarter of
1176	1176
1177	1177
1178	1178
1179	1179
1180	1180
1181	1181	SB2088 - 32 - LRB103 28984 KTG 55370 b
1182	1182
1183	1183
1184	1184	SB2088- 33 -LRB103 28984 KTG 55370 b SB2088 - 33 - LRB103 28984 KTG 55370 b
1185	1185	SB2088 - 33 - LRB103 28984 KTG 55370 b
1186	1186	1 the calendar year.
1187	1187	2 (C) Long term acute care hospitals.
1188	1188	3 (D) Freestanding psychiatric hospitals.
1189	1189	4 (E) Freestanding rehabilitation hospitals.
1190	1190	5 (F) Beginning January 1, 2023, "public hospital" means
1191	1191	6 a hospital that is owned or operated by an Illinois
1192	1192	7 Government body or municipality, excluding a hospital
1193	1193	8 provider that is a State agency, a State university, or a
1194	1194	9 county with a population of 3,000,000 or more.
1195	1195	10 (G) High Medicaid hospitals.
1196	1196	11 (i) As used in this Section, "high Medicaid
1197	1197	12 hospital" means a general acute care hospital that:
1198	1198	13 (I) For the payout periods July 1, 2020
1199	1199	14 through December 31, 2022, is not a safety-net
1200	1200	15 hospital or critical access hospital and that has
1201	1201	16 a Medicaid Inpatient Utilization Rate above 30% or
1202	1202	17 a hospital that had over 35,000 inpatient Medicaid
1203	1203	18 days during the applicable period. For the period
1204	1204	19 July 1, 2020 through December 31, 2020, the
1205	1205	20 applicable period for the Medicaid Inpatient
1206	1206	21 Utilization Rate (MIUR) is the rate year 2020 MIUR
1207	1207	22 and for the number of inpatient days it is State
1208	1208	23 fiscal year 2018. Beginning in calendar year 2021,
1209	1209	24 the Department shall use the most recently
1210	1210	25 determined MIUR, as defined in subsection (h) of
1211	1211	26 Section 5-5.02, and for the inpatient day
1212	1212
1213	1213
1214	1214
1215	1215
1216	1216
1217	1217	SB2088 - 33 - LRB103 28984 KTG 55370 b
1218	1218
1219	1219
1220	1220	SB2088- 34 -LRB103 28984 KTG 55370 b SB2088 - 34 - LRB103 28984 KTG 55370 b
1221	1221	SB2088 - 34 - LRB103 28984 KTG 55370 b
1222	1222	1 threshold, the State fiscal year ending 18 months
1223	1223	2 prior to the beginning of the calendar year. For
1224	1224	3 purposes of calculating MIUR under this Section,
1225	1225	4 children's hospitals and affiliated general acute
1226	1226	5 care hospitals shall be considered a single
1227	1227	6 hospital.
1228	1228	7 (II) For the calendar year beginning January
1229	1229	8 1, 2023, and each calendar year thereafter, is not
1230	1230	9 a public hospital, safety-net hospital, or
1231	1231	10 critical access hospital and that qualifies as a
1232	1232	11 regional high volume hospital or is a hospital
1233	1233	12 that has a Medicaid Inpatient Utilization Rate
1234	1234	13 (MIUR) above 30%. As used in this item, "regional
1235	1235	14 high volume hospital" means a hospital which ranks
1236	1236	15 in the top 2 quartiles based on total hospital
1237	1237	16 services volume, of all eligible general acute
1238	1238	17 care hospitals, when ranked in descending order
1239	1239	18 based on total hospital services volume, within
1240	1240	19 the same Medicaid managed care region, as
1241	1241	20 designated by the Department, as of January 1,
1242	1242	21 2022. As used in this item, "total hospital
1243	1243	22 services volume" means the total of all Medical
1244	1244	23 Assistance hospital inpatient admissions plus all
1245	1245	24 Medical Assistance hospital outpatient visits. For
1246	1246	25 purposes of determining regional high volume
1247	1247	26 hospital inpatient admissions and outpatient
1248	1248
1249	1249
1250	1250
1251	1251
1252	1252
1253	1253	SB2088 - 34 - LRB103 28984 KTG 55370 b
1254	1254
1255	1255
1256	1256	SB2088- 35 -LRB103 28984 KTG 55370 b SB2088 - 35 - LRB103 28984 KTG 55370 b
1257	1257	SB2088 - 35 - LRB103 28984 KTG 55370 b
1258	1258	1 visits, the Department shall use dates of service
1259	1259	2 provided during State Fiscal Year 2020 for the
1260	1260	3 Payout Quarter beginning January 1, 2023. The
1261	1261	4 Department shall use dates of service from the
1262	1262	5 State fiscal year ending 18 month before the
1263	1263	6 beginning of the first Payout Quarter of the
1264	1264	7 subsequent annual determination period.
1265	1265	8 (ii) For the calendar year beginning January 1,
1266	1266	9 2023, the Department shall use the Rate Year 2022
1267	1267	10 Medicaid inpatient utilization rate (MIUR), as defined
1268	1268	11 in subsection (h) of Section 5-5.02. For each
1269	1269	12 subsequent annual determination, the Department shall
1270	1270	13 use the MIUR applicable to the rate year ending
1271	1271	14 September 30 of the year preceding the beginning of
1272	1272	15 the calendar year.
1273	1273	16 (H) General acute care hospitals. As used under this
1274	1274	17 Section, "general acute care hospitals" means all other
1275	1275	18 Illinois hospitals not identified in subparagraphs (A)
1276	1276	19 through (G).
1277	1277	20 (2) Hospitals' qualification for each class shall be
1278	1278	21 assessed prior to the beginning of each calendar year and the
1279	1279	22 new class designation shall be effective January 1 of the next
1280	1280	23 year. The Department shall publish by rule the process for
1281	1281	24 establishing class determination.
1282	1282	25 (g) Fixed pool directed payments. Beginning July 1, 2020,
1283	1283	26 the Department shall issue payments to MCOs which shall be
1284	1284
1285	1285
1286	1286
1287	1287
1288	1288
1289	1289	SB2088 - 35 - LRB103 28984 KTG 55370 b
1290	1290
1291	1291
1292	1292	SB2088- 36 -LRB103 28984 KTG 55370 b SB2088 - 36 - LRB103 28984 KTG 55370 b
1293	1293	SB2088 - 36 - LRB103 28984 KTG 55370 b
1294	1294	1 used to issue directed payments to qualified Illinois
1295	1295	2 safety-net hospitals and critical access hospitals on a
1296	1296	3 monthly basis in accordance with this subsection. Prior to the
1297	1297	4 beginning of each Payout Quarter beginning July 1, 2020, the
1298	1298	5 Department shall use encounter claims data from the
1299	1299	6 Determination Quarter, accepted by the Department's Medicaid
1300	1300	7 Management Information System for inpatient and outpatient
1301	1301	8 services rendered by safety-net hospitals and critical access
1302	1302	9 hospitals to determine a quarterly uniform per unit add-on for
1303	1303	10 each hospital class.
1304	1304	11 (1) Inpatient per unit add-on. A quarterly uniform per
1305	1305	12 diem add-on shall be derived by dividing the quarterly
1306	1306	13 Inpatient Directed Payments Pool amount allocated to the
1307	1307	14 applicable hospital class by the total inpatient days
1308	1308	15 contained on all encounter claims received during the
1309	1309	16 Determination Quarter, for all hospitals in the class.
1310	1310	17 (A) Each hospital in the class shall have a
1311	1311	18 quarterly inpatient directed payment calculated that
1312	1312	19 is equal to the product of the number of inpatient days
1313	1313	20 attributable to the hospital used in the calculation
1314	1314	21 of the quarterly uniform class per diem add-on,
1315	1315	22 multiplied by the calculated applicable quarterly
1316	1316	23 uniform class per diem add-on of the hospital class.
1317	1317	24 (B) Each hospital shall be paid 1/3 of its
1318	1318	25 quarterly inpatient directed payment in each of the 3
1319	1319	26 months of the Payout Quarter, in accordance with
1320	1320
1321	1321
1322	1322
1323	1323
1324	1324
1325	1325	SB2088 - 36 - LRB103 28984 KTG 55370 b
1326	1326
1327	1327
1328	1328	SB2088- 37 -LRB103 28984 KTG 55370 b SB2088 - 37 - LRB103 28984 KTG 55370 b
1329	1329	SB2088 - 37 - LRB103 28984 KTG 55370 b
1330	1330	1 directions provided to each MCO by the Department.
1331	1331	2 (2) Outpatient per unit add-on. A quarterly uniform
1332	1332	3 per claim add-on shall be derived by dividing the
1333	1333	4 quarterly Outpatient Directed Payments Pool amount
1334	1334	5 allocated to the applicable hospital class by the total
1335	1335	6 outpatient encounter claims received during the
1336	1336	7 Determination Quarter, for all hospitals in the class.
1337	1337	8 (A) Each hospital in the class shall have a
1338	1338	9 quarterly outpatient directed payment calculated that
1339	1339	10 is equal to the product of the number of outpatient
1340	1340	11 encounter claims attributable to the hospital used in
1341	1341	12 the calculation of the quarterly uniform class per
1342	1342	13 claim add-on, multiplied by the calculated applicable
1343	1343	14 quarterly uniform class per claim add-on of the
1344	1344	15 hospital class.
1345	1345	16 (B) Each hospital shall be paid 1/3 of its
1346	1346	17 quarterly outpatient directed payment in each of the 3
1347	1347	18 months of the Payout Quarter, in accordance with
1348	1348	19 directions provided to each MCO by the Department.
1349	1349	20 (3) Each MCO shall pay each hospital the Monthly
1350	1350	21 Directed Payment as identified by the Department on its
1351	1351	22 quarterly determination report.
1352	1352	23 (4) Definitions. As used in this subsection:
1353	1353	24 (A) "Payout Quarter" means each 3 month calendar
1354	1354	25 quarter, beginning July 1, 2020.
1355	1355	26 (B) "Determination Quarter" means each 3 month
1356	1356
1357	1357
1358	1358
1359	1359
1360	1360
1361	1361	SB2088 - 37 - LRB103 28984 KTG 55370 b
1362	1362
1363	1363
1364	1364	SB2088- 38 -LRB103 28984 KTG 55370 b SB2088 - 38 - LRB103 28984 KTG 55370 b
1365	1365	SB2088 - 38 - LRB103 28984 KTG 55370 b
1366	1366	1 calendar quarter, which ends 3 months prior to the
1367	1367	2 first day of each Payout Quarter.
1368	1368	3 (5) For the period July 1, 2020 through December 2020,
1369	1369	4 the following amounts shall be allocated to the following
1370	1370	5 hospital class directed payment pools for the quarterly
1371	1371	6 development of a uniform per unit add-on:
1372	1372	7 (A) $2,894,500 for hospital inpatient services for
1373	1373	8 critical access hospitals.
1374	1374	9 (B) $4,294,374 for hospital outpatient services
1375	1375	10 for critical access hospitals.
1376	1376	11 (C) $29,109,330 for hospital inpatient services
1377	1377	12 for safety-net hospitals.
1378	1378	13 (D) $35,041,218 for hospital outpatient services
1379	1379	14 for safety-net hospitals.
1380	1380	15 (6) For the period January 1, 2023 through December
1381	1381	16 31, 2023, the Department shall establish the amounts that
1382	1382	17 shall be allocated to the hospital class directed payment
1383	1383	18 fixed pools identified in this paragraph for the quarterly
1384	1384	19 development of a uniform per unit add-on. The Department
1385	1385	20 shall establish such amounts so that the total amount of
1386	1386	21 payments to each hospital under this Section in calendar
1387	1387	22 year 2023 is projected to be substantially similar to the
1388	1388	23 total amount of such payments received by the hospital
1389	1389	24 under this Section in calendar year 2021, adjusted for
1390	1390	25 increased funding provided for fixed pool directed
1391	1391	26 payments under subsection (g) in calendar year 2022,
1392	1392
1393	1393
1394	1394
1395	1395
1396	1396
1397	1397	SB2088 - 38 - LRB103 28984 KTG 55370 b
1398	1398
1399	1399
1400	1400	SB2088- 39 -LRB103 28984 KTG 55370 b SB2088 - 39 - LRB103 28984 KTG 55370 b
1401	1401	SB2088 - 39 - LRB103 28984 KTG 55370 b
1402	1402	1 assuming that the volume and acuity of claims are held
1403	1403	2 constant. The Department shall publish the directed
1404	1404	3 payment fixed pool amounts to be established under this
1405	1405	4 paragraph on its website by November 15, 2022.
1406	1406	5 (A) Hospital inpatient services for critical
1407	1407	6 access hospitals.
1408	1408	7 (B) Hospital outpatient services for critical
1409	1409	8 access hospitals.
1410	1410	9 (C) Hospital inpatient services for public
1411	1411	10 hospitals.
1412	1412	11 (D) Hospital outpatient services for public
1413	1413	12 hospitals.
1414	1414	13 (E) Hospital inpatient services for safety-net
1415	1415	14 hospitals.
1416	1416	15 (F) Hospital outpatient services for safety-net
1417	1417	16 hospitals.
1418	1418	17 (7) Semi-annual rate maintenance review. The
1419	1419	18 Department shall ensure that hospitals assigned to the
1420	1420	19 fixed pools in paragraph (6) are paid no less than 95% of
1421	1421	20 the annual initial rate for each 6-month period of each
1422	1422	21 annual payout period. For each calendar year, the
1423	1423	22 Department shall calculate the annual initial rate per day
1424	1424	23 and per visit for each fixed pool hospital class listed in
1425	1425	24 paragraph (6), by dividing the total of all applicable
1426	1426	25 inpatient or outpatient directed payments issued in the
1427	1427	26 preceding calendar year to the hospitals in each fixed
1428	1428
1429	1429
1430	1430
1431	1431
1432	1432
1433	1433	SB2088 - 39 - LRB103 28984 KTG 55370 b
1434	1434
1435	1435
1436	1436	SB2088- 40 -LRB103 28984 KTG 55370 b SB2088 - 40 - LRB103 28984 KTG 55370 b
1437	1437	SB2088 - 40 - LRB103 28984 KTG 55370 b
1438	1438	1 pool class for the calendar year, plus any increase
1439	1439	2 resulting from the annual adjustments described in
1440	1440	3 subsection (i), by the actual applicable total service
1441	1441	4 units for the preceding calendar year which were the basis
1442	1442	5 of the total applicable inpatient or outpatient directed
1443	1443	6 payments issued to the hospitals in each fixed pool class
1444	1444	7 in the calendar year, except that for calendar year 2023,
1445	1445	8 the service units from calendar year 2021 shall be used.
1446	1446	9 (A) The Department shall calculate the effective
1447	1447	10 rate, per day and per visit, for the payout periods of
1448	1448	11 January to June and July to December of each year, for
1449	1449	12 each fixed pool listed in paragraph (6), by dividing
1450	1450	13 50% of the annual pool by the total applicable
1451	1451	14 reported service units for the 2 applicable
1452	1452	15 determination quarters.
1453	1453	16 (B) If the effective rate calculated in
1454	1454	17 subparagraph (A) is less than 95% of the annual
1455	1455	18 initial rate assigned to the class for each pool under
1456	1456	19 paragraph (6), the Department shall adjust the payment
1457	1457	20 for each hospital to a level equal to no less than 95%
1458	1458	21 of the annual initial rate, by issuing a retroactive
1459	1459	22 adjustment payment for the 6-month period under review
1460	1460	23 as identified in subparagraph (A).
1461	1461	24 (h) Fixed rate directed payments. Effective July 1, 2020,
1462	1462	25 the Department shall issue payments to MCOs which shall be
1463	1463	26 used to issue directed payments to Illinois hospitals not
1464	1464
1465	1465
1466	1466
1467	1467
1468	1468
1469	1469	SB2088 - 40 - LRB103 28984 KTG 55370 b
1470	1470
1471	1471
1472	1472	SB2088- 41 -LRB103 28984 KTG 55370 b SB2088 - 41 - LRB103 28984 KTG 55370 b
1473	1473	SB2088 - 41 - LRB103 28984 KTG 55370 b
1474	1474	1 identified in paragraph (g) on a monthly basis. Prior to the
1475	1475	2 beginning of each Payout Quarter beginning July 1, 2020, the
1476	1476	3 Department shall use encounter claims data from the
1477	1477	4 Determination Quarter, accepted by the Department's Medicaid
1478	1478	5 Management Information System for inpatient and outpatient
1479	1479	6 services rendered by hospitals in each hospital class
1480	1480	7 identified in paragraph (f) and not identified in paragraph
1481	1481	8 (g). For the period July 1, 2020 through December 2020, the
1482	1482	9 Department shall direct MCOs to make payments as follows:
1483	1483	10 (1) For general acute care hospitals an amount equal
1484	1484	11 to $1,750 multiplied by the hospital's category of service
1485	1485	12 20 case mix index for the determination quarter multiplied
1486	1486	13 by the hospital's total number of inpatient admissions for
1487	1487	14 category of service 20 for the determination quarter.
1488	1488	15 (2) For general acute care hospitals an amount equal
1489	1489	16 to $160 multiplied by the hospital's category of service
1490	1490	17 21 case mix index for the determination quarter multiplied
1491	1491	18 by the hospital's total number of inpatient admissions for
1492	1492	19 category of service 21 for the determination quarter.
1493	1493	20 (3) For general acute care hospitals an amount equal
1494	1494	21 to $80 multiplied by the hospital's category of service 22
1495	1495	22 case mix index for the determination quarter multiplied by
1496	1496	23 the hospital's total number of inpatient admissions for
1497	1497	24 category of service 22 for the determination quarter.
1498	1498	25 (4) For general acute care hospitals an amount equal
1499	1499	26 to $375 multiplied by the hospital's category of service
1500	1500
1501	1501
1502	1502
1503	1503
1504	1504
1505	1505	SB2088 - 41 - LRB103 28984 KTG 55370 b
1506	1506
1507	1507
1508	1508	SB2088- 42 -LRB103 28984 KTG 55370 b SB2088 - 42 - LRB103 28984 KTG 55370 b
1509	1509	SB2088 - 42 - LRB103 28984 KTG 55370 b
1510	1510	1 24 case mix index for the determination quarter multiplied
1511	1511	2 by the hospital's total number of category of service 24
1512	1512	3 paid EAPG (EAPGs) for the determination quarter.
1513	1513	4 (5) For general acute care hospitals an amount equal
1514	1514	5 to $240 multiplied by the hospital's category of service
1515	1515	6 27 and 28 case mix index for the determination quarter
1516	1516	7 multiplied by the hospital's total number of category of
1517	1517	8 service 27 and 28 paid EAPGs for the determination
1518	1518	9 quarter.
1519	1519	10 (6) For general acute care hospitals an amount equal
1520	1520	11 to $290 multiplied by the hospital's category of service
1521	1521	12 29 case mix index for the determination quarter multiplied
1522	1522	13 by the hospital's total number of category of service 29
1523	1523	14 paid EAPGs for the determination quarter.
1524	1524	15 (7) For high Medicaid hospitals an amount equal to
1525	1525	16 $1,800 multiplied by the hospital's category of service 20
1526	1526	17 case mix index for the determination quarter multiplied by
1527	1527	18 the hospital's total number of inpatient admissions for
1528	1528	19 category of service 20 for the determination quarter.
1529	1529	20 (8) For high Medicaid hospitals an amount equal to
1530	1530	21 $160 multiplied by the hospital's category of service 21
1531	1531	22 case mix index for the determination quarter multiplied by
1532	1532	23 the hospital's total number of inpatient admissions for
1533	1533	24 category of service 21 for the determination quarter.
1534	1534	25 (9) For high Medicaid hospitals an amount equal to $80
1535	1535	26 multiplied by the hospital's category of service 22 case
1536	1536
1537	1537
1538	1538
1539	1539
1540	1540
1541	1541	SB2088 - 42 - LRB103 28984 KTG 55370 b
1542	1542
1543	1543
1544	1544	SB2088- 43 -LRB103 28984 KTG 55370 b SB2088 - 43 - LRB103 28984 KTG 55370 b
1545	1545	SB2088 - 43 - LRB103 28984 KTG 55370 b
1546	1546	1 mix index for the determination quarter multiplied by the
1547	1547	2 hospital's total number of inpatient admissions for
1548	1548	3 category of service 22 for the determination quarter.
1549	1549	4 (10) For high Medicaid hospitals an amount equal to
1550	1550	5 $400 multiplied by the hospital's category of service 24
1551	1551	6 case mix index for the determination quarter multiplied by
1552	1552	7 the hospital's total number of category of service 24 paid
1553	1553	8 EAPG outpatient claims for the determination quarter.
1554	1554	9 (11) For high Medicaid hospitals an amount equal to
1555	1555	10 $240 multiplied by the hospital's category of service 27
1556	1556	11 and 28 case mix index for the determination quarter
1557	1557	12 multiplied by the hospital's total number of category of
1558	1558	13 service 27 and 28 paid EAPGs for the determination
1559	1559	14 quarter.
1560	1560	15 (12) For high Medicaid hospitals an amount equal to
1561	1561	16 $290 multiplied by the hospital's category of service 29
1562	1562	17 case mix index for the determination quarter multiplied by
1563	1563	18 the hospital's total number of category of service 29 paid
1564	1564	19 EAPGs for the determination quarter.
1565	1565	20 (13) For long term acute care hospitals the amount of
1566	1566	21 $495 multiplied by the hospital's total number of
1567	1567	22 inpatient days for the determination quarter.
1568	1568	23 (14) For psychiatric hospitals the amount of $210
1569	1569	24 multiplied by the hospital's total number of inpatient
1570	1570	25 days for category of service 21 for the determination
1571	1571	26 quarter.
1572	1572
1573	1573
1574	1574
1575	1575
1576	1576
1577	1577	SB2088 - 43 - LRB103 28984 KTG 55370 b
1578	1578
1579	1579
1580	1580	SB2088- 44 -LRB103 28984 KTG 55370 b SB2088 - 44 - LRB103 28984 KTG 55370 b
1581	1581	SB2088 - 44 - LRB103 28984 KTG 55370 b
1582	1582	1 (15) For psychiatric hospitals the amount of $250
1583	1583	2 multiplied by the hospital's total number of outpatient
1584	1584	3 claims for category of service 27 and 28 for the
1585	1585	4 determination quarter.
1586	1586	5 (16) For rehabilitation hospitals the amount of $410
1587	1587	6 multiplied by the hospital's total number of inpatient
1588	1588	7 days for category of service 22 for the determination
1589	1589	8 quarter.
1590	1590	9 (17) For rehabilitation hospitals the amount of $100
1591	1591	10 multiplied by the hospital's total number of outpatient
1592	1592	11 claims for category of service 29 for the determination
1593	1593	12 quarter.
1594	1594	13 (18) Effective for the Payout Quarter beginning
1595	1595	14 January 1, 2023, for the directed payments to hospitals
1596	1596	15 required under this subsection, the Department shall
1597	1597	16 establish the amounts that shall be used to calculate such
1598	1598	17 directed payments using the methodologies specified in
1599	1599	18 this paragraph. The Department shall use a single, uniform
1600	1600	19 rate, adjusted for acuity as specified in paragraphs (1)
1601	1601	20 through (12), for all categories of inpatient services
1602	1602	21 provided by each class of hospitals and a single uniform
1603	1603	22 rate, adjusted for acuity as specified in paragraphs (1)
1604	1604	23 through (12), for all categories of outpatient services
1605	1605	24 provided by each class of hospitals. The Department shall
1606	1606	25 establish such amounts so that the total amount of
1607	1607	26 payments to each hospital under this Section in calendar
1608	1608
1609	1609
1610	1610
1611	1611
1612	1612
1613	1613	SB2088 - 44 - LRB103 28984 KTG 55370 b
1614	1614
1615	1615
1616	1616	SB2088- 45 -LRB103 28984 KTG 55370 b SB2088 - 45 - LRB103 28984 KTG 55370 b
1617	1617	SB2088 - 45 - LRB103 28984 KTG 55370 b
1618	1618	1 year 2023 is projected to be substantially similar to the
1619	1619	2 total amount of such payments received by the hospital
1620	1620	3 under this Section in calendar year 2021, adjusted for
1621	1621	4 increased funding provided for fixed pool directed
1622	1622	5 payments under subsection (g) in calendar year 2022,
1623	1623	6 assuming that the volume and acuity of claims are held
1624	1624	7 constant. The Department shall publish the directed
1625	1625	8 payment amounts to be established under this subsection on
1626	1626	9 its website by November 15, 2022.
1627	1627	10 (19) Each hospital shall be paid 1/3 of their
1628	1628	11 quarterly inpatient and outpatient directed payment in
1629	1629	12 each of the 3 months of the Payout Quarter, in accordance
1630	1630	13 with directions provided to each MCO by the Department.
1631	1631	14 20 Each MCO shall pay each hospital the Monthly
1632	1632	15 Directed Payment amount as identified by the Department on
1633	1633	16 its quarterly determination report.
1634	1634	17 Notwithstanding any other provision of this subsection, if
1635	1635	18 the Department determines that the actual total hospital
1636	1636	19 utilization data that is used to calculate the fixed rate
1637	1637	20 directed payments is substantially different than anticipated
1638	1638	21 when the rates in this subsection were initially determined
1639	1639	22 for unforeseeable circumstances (such as the COVID-19 pandemic
1640	1640	23 or some other public health emergency), the Department may
1641	1641	24 adjust the rates specified in this subsection so that the
1642	1642	25 total directed payments approximate the total spending amount
1643	1643	26 anticipated when the rates were initially established.
1644	1644
1645	1645
1646	1646
1647	1647
1648	1648
1649	1649	SB2088 - 45 - LRB103 28984 KTG 55370 b
1650	1650
1651	1651
1652	1652	SB2088- 46 -LRB103 28984 KTG 55370 b SB2088 - 46 - LRB103 28984 KTG 55370 b
1653	1653	SB2088 - 46 - LRB103 28984 KTG 55370 b
1654	1654	1 Definitions. As used in this subsection:
1655	1655	2 (A) "Payout Quarter" means each calendar quarter,
1656	1656	3 beginning July 1, 2020.
1657	1657	4 (B) "Determination Quarter" means each calendar
1658	1658	5 quarter which ends 3 months prior to the first day of
1659	1659	6 each Payout Quarter.
1660	1660	7 (C) "Case mix index" means a hospital specific
1661	1661	8 calculation. For inpatient claims the case mix index
1662	1662	9 is calculated each quarter by summing the relative
1663	1663	10 weight of all inpatient Diagnosis-Related Group (DRG)
1664	1664	11 claims for a category of service in the applicable
1665	1665	12 Determination Quarter and dividing the sum by the
1666	1666	13 number of sum total of all inpatient DRG admissions
1667	1667	14 for the category of service for the associated claims.
1668	1668	15 The case mix index for outpatient claims is calculated
1669	1669	16 each quarter by summing the relative weight of all
1670	1670	17 paid EAPGs in the applicable Determination Quarter and
1671	1671	18 dividing the sum by the sum total of paid EAPGs for the
1672	1672	19 associated claims.
1673	1673	20 (i) Beginning January 1, 2021, the rates for directed
1674	1674	21 payments shall be recalculated in order to spend the
1675	1675	22 additional funds for directed payments that result from
1676	1676	23 reduction in the amount of pass-through payments allowed under
1677	1677	24 federal regulations. The additional funds for directed
1678	1678	25 payments shall be allocated proportionally to each class of
1679	1679	26 hospitals based on that class' proportion of services.
1680	1680
1681	1681
1682	1682
1683	1683
1684	1684
1685	1685	SB2088 - 46 - LRB103 28984 KTG 55370 b
1686	1686
1687	1687
1688	1688	SB2088- 47 -LRB103 28984 KTG 55370 b SB2088 - 47 - LRB103 28984 KTG 55370 b
1689	1689	SB2088 - 47 - LRB103 28984 KTG 55370 b
1690	1690	1 (1) Beginning January 1, 2024, the fixed pool directed
1691	1691	2 payment amounts and the associated annual initial rates
1692	1692	3 referenced in paragraph (6) of subsection (f) for each
1693	1693	4 hospital class shall be uniformly increased by a ratio of
1694	1694	5 not less than, the ratio of the total pass-through
1695	1695	6 reduction amount pursuant to paragraph (4) of subsection
1696	1696	7 (j), for the hospitals comprising the hospital fixed pool
1697	1697	8 directed payment class for the next calendar year, to the
1698	1698	9 total inpatient and outpatient directed payments for the
1699	1699	10 hospitals comprising the hospital fixed pool directed
1700	1700	11 payment class paid during the preceding calendar year.
1701	1701	12 (2) Beginning January 1, 2024, the fixed rates for the
1702	1702	13 directed payments referenced in paragraph (18) of
1703	1703	14 subsection (h) for each hospital class shall be uniformly
1704	1704	15 increased by a ratio of not less than, the ratio of the
1705	1705	16 total pass-through reduction amount pursuant to paragraph
1706	1706	17 (4) of subsection (j), for the hospitals comprising the
1707	1707	18 hospital directed payment class for the next calendar
1708	1708	19 year, to the total inpatient and outpatient directed
1709	1709	20 payments for the hospitals comprising the hospital fixed
1710	1710	21 rate directed payment class paid during the preceding
1711	1711	22 calendar year.
1712	1712	23 (j) Pass-through payments.
1713	1713	24 (1) For the period July 1, 2020 through December 31,
1714	1714	25 2020, the Department shall assign quarterly pass-through
1715	1715	26 payments to each class of hospitals equal to one-fourth of
1716	1716
1717	1717
1718	1718
1719	1719
1720	1720
1721	1721	SB2088 - 47 - LRB103 28984 KTG 55370 b
1722	1722
1723	1723
1724	1724	SB2088- 48 -LRB103 28984 KTG 55370 b SB2088 - 48 - LRB103 28984 KTG 55370 b
1725	1725	SB2088 - 48 - LRB103 28984 KTG 55370 b
1726	1726	1 the following annual allocations:
1727	1727	2 (A) $390,487,095 to safety-net hospitals.
1728	1728	3 (B) $62,553,886 to critical access hospitals.
1729	1729	4 (C) $345,021,438 to high Medicaid hospitals.
1730	1730	5 (D) $551,429,071 to general acute care hospitals.
1731	1731	6 (E) $27,283,870 to long term acute care hospitals.
1732	1732	7 (F) $40,825,444 to freestanding psychiatric
1733	1733	8 hospitals.
1734	1734	9 (G) $9,652,108 to freestanding rehabilitation
1735	1735	10 hospitals.
1736	1736	11 (2) For the period of July 1, 2020 through December
1737	1737	12 31, 2020, the pass-through payments shall at a minimum
1738	1738	13 ensure hospitals receive a total amount of monthly
1739	1739	14 payments under this Section as received in calendar year
1740	1740	15 2019 in accordance with this Article and paragraph (1) of
1741	1741	16 subsection (d-5) of Section 14-12, exclusive of amounts
1742	1742	17 received through payments referenced in subsection (b).
1743	1743	18 (3) For the calendar year beginning January 1, 2023,
1744	1744	19 the Department shall establish the annual pass-through
1745	1745	20 allocation to each class of hospitals and the pass-through
1746	1746	21 payments to each hospital so that the total amount of
1747	1747	22 payments to each hospital under this Section in calendar
1748	1748	23 year 2023 is projected to be substantially similar to the
1749	1749	24 total amount of such payments received by the hospital
1750	1750	25 under this Section in calendar year 2021, adjusted for
1751	1751	26 increased funding provided for fixed pool directed
1752	1752
1753	1753
1754	1754
1755	1755
1756	1756
1757	1757	SB2088 - 48 - LRB103 28984 KTG 55370 b
1758	1758
1759	1759
1760	1760	SB2088- 49 -LRB103 28984 KTG 55370 b SB2088 - 49 - LRB103 28984 KTG 55370 b
1761	1761	SB2088 - 49 - LRB103 28984 KTG 55370 b
1762	1762	1 payments under subsection (g) in calendar year 2022,
1763	1763	2 assuming that the volume and acuity of claims are held
1764	1764	3 constant. The Department shall publish the pass-through
1765	1765	4 allocation to each class and the pass-through payments to
1766	1766	5 each hospital to be established under this subsection on
1767	1767	6 its website by November 15, 2022.
1768	1768	7 (4) For the calendar years beginning January 1, 2021,
1769	1769	8 January 1, 2022, and January 1, 2024, and each calendar
1770	1770	9 year thereafter, each hospital's pass-through payment
1771	1771	10 amount shall be reduced proportionally to the reduction of
1772	1772	11 all pass-through payments required by federal regulations.
1773	1773	12 (k) At least 30 days prior to each calendar year, the
1774	1774	13 Department shall notify each hospital of changes to the
1775	1775	14 payment methodologies in this Section, including, but not
1776	1776	15 limited to, changes in the fixed rate directed payment rates,
1777	1777	16 the aggregate pass-through payment amount for all hospitals,
1778	1778	17 and the hospital's pass-through payment amount for the
1779	1779	18 upcoming calendar year.
1780	1780	19 (l) Notwithstanding any other provisions of this Section,
1781	1781	20 the Department may adopt rules to change the methodology for
1782	1782	21 directed and pass-through payments as set forth in this
1783	1783	22 Section, but only to the extent necessary to obtain federal
1784	1784	23 approval of a necessary State Plan amendment or Directed
1785	1785	24 Payment Preprint or to otherwise conform to federal law or
1786	1786	25 federal regulation.
1787	1787	26 (m) As used in this subsection, "managed care
1788	1788
1789	1789
1790	1790
1791	1791
1792	1792
1793	1793	SB2088 - 49 - LRB103 28984 KTG 55370 b
1794	1794
1795	1795
1796	1796	SB2088- 50 -LRB103 28984 KTG 55370 b SB2088 - 50 - LRB103 28984 KTG 55370 b
1797	1797	SB2088 - 50 - LRB103 28984 KTG 55370 b
1798	1798	1 organization" or "MCO" means an entity which contracts with
1799	1799	2 the Department to provide services where payment for medical
1800	1800	3 services is made on a capitated basis, excluding contracted
1801	1801	4 entities for dual eligible or Department of Children and
1802	1802	5 Family Services youth populations.
1803	1803	6 (n) In order to address the escalating infant mortality
1804	1804	7 rates among minority communities in Illinois, the State shall,
1805	1805	8 subject to appropriation, create a pool of funding of at least
1806	1806	9 $50,000,000 annually to be disbursed among safety-net
1807	1807	10 hospitals that maintain perinatal designation from the
1808	1808	11 Department of Public Health. The funding shall be used to
1809	1809	12 preserve or enhance OB/GYN services or other specialty
1810	1810	13 services at the receiving hospital, with the distribution of
1811	1811	14 funding to be established by rule and with consideration to
1812	1812	15 perinatal hospitals with safe birthing levels and quality
1813	1813	16 metrics for healthy mothers and babies.
1814	1814	17 The Department shall calculate, at least quarterly, all
1815	1815	18 Hospital Assessment Program-related funds paid to each
1816	1816	19 hospital, whether paid by the Department or an MCO, including
1817	1817	20 the amounts integrated into rate increases and distributed in
1818	1818	21 accordance with Section 14-12 as provided under subsection (b)
1819	1819	22 of Section 5A-12.7, and shall provide a report to each
1820	1820	23 hospital stating the total payments made in the preceding
1821	1821	24 quarter and including the data and mathematical formulas
1822	1822	25 supporting its calculation.
1823	1823	26 (o) In order to address the growing challenges of
1824	1824
1825	1825
1826	1826
1827	1827
1828	1828
1829	1829	SB2088 - 50 - LRB103 28984 KTG 55370 b
1830	1830
1831	1831
1832	1832	SB2088- 51 -LRB103 28984 KTG 55370 b SB2088 - 51 - LRB103 28984 KTG 55370 b
1833	1833	SB2088 - 51 - LRB103 28984 KTG 55370 b
1834	1834	1 providing stable access to healthcare in rural Illinois,
1835	1835	2 including perinatal services, behavioral healthcare including
1836	1836	3 substance use disorder services (SUDs) and other specialty
1837	1837	4 services, and to expand access to telehealth services among
1838	1838	5 rural communities in Illinois, the Department of Healthcare
1839	1839	6 and Family Services, subject to appropriation, shall
1840	1840	7 administer a program to provide at least $10,000,000 in
1841	1841	8 financial support annually to critical access hospitals for
1842	1842	9 delivery of perinatal and OB/GYN services, behavioral
1843	1843	10 healthcare including SUDS, other specialty services and
1844	1844	11 telehealth services. The funding shall be used to preserve or
1845	1845	12 enhance perinatal and OB/GYN services, behavioral healthcare
1846	1846	13 including SUDS, other specialty services, as well as the
1847	1847	14 explanation of telehealth services by the receiving hospital,
1848	1848	15 with the distribution of funding to be established by rule.
1849	1849	16 (p) For calendar year 2023, the final amounts, rates, and
1850	1850	17 payments under subsections (c), (d-2), (g), (h), and (j) shall
1851	1851	18 be established by the Department, so that the sum of the total
1852	1852	19 estimated annual payments under subsections (c), (d-2), (g),
1853	1853	20 (h), and (j) for each hospital class for calendar year 2023, is
1854	1854	21 no less than:
1855	1855	22 (1) $858,260,000 to safety-net hospitals.
1856	1856	23 (2) $86,200,000 to critical access hospitals.
1857	1857	24 (3) $1,765,000,000 to high Medicaid hospitals.
1858	1858	25 (4) $673,860,000 to general acute care hospitals.
1859	1859	26 (5) $48,330,000 to long term acute care hospitals.
1860	1860
1861	1861
1862	1862
1863	1863
1864	1864
1865	1865	SB2088 - 51 - LRB103 28984 KTG 55370 b
1866	1866
1867	1867
1868	1868	SB2088- 52 -LRB103 28984 KTG 55370 b SB2088 - 52 - LRB103 28984 KTG 55370 b
1869	1869	SB2088 - 52 - LRB103 28984 KTG 55370 b
1870	1870	1 (6) $89,110,000 to freestanding psychiatric hospitals.
1871	1871	2 (7) $24,300,000 to freestanding rehabilitation
1872	1872	3 hospitals.
1873	1873	4 (8) $32,570,000 to public hospitals.
1874	1874	5 (q) Hospital Pandemic Recovery Stabilization Payments. The
1875	1875	6 Department shall disburse a pool of $460,000,000 in stability
1876	1876	7 payments to hospitals prior to April 1, 2023. The allocation
1877	1877	8 of the pool shall be based on the hospital directed payment
1878	1878	9 classes and directed payments issued, during Calendar Year
1879	1879	10 2022 with added consideration to safety net hospitals, as
1880	1880	11 defined in subdivision (f)(1)(B) of this Section, and critical
1881	1881	12 access hospitals.
1882	1882	13 (Source: P.A. 101-650, eff. 7-7-20; 102-4, eff. 4-27-21;
1883	1883	14 102-16, eff. 6-17-21; 102-886, eff. 5-17-22; 102-1115, eff.
1884	1884	15 1-9-23.)
1885	1885
1886	1886
1887	1887
1888	1888
1889	1889
1890	1890	SB2088 - 52 - LRB103 28984 KTG 55370 b