Illinois 2023-2024 Regular Session

Illinois Senate Bill SB3374 Compare Versions

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

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1	1	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB3374 Introduced 2/7/2024, by Sen. Ann Gillespie SYNOPSIS AS INTRODUCED: 305 ILCS 5/14-13 Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to by rule implement a methodology to reimburse hospitals for inpatient stays extended beyond medical necessity due to the inability of the Department, the managed care organization (MCO) in which a medical assistance recipient is enrolled in, or the hospital discharge planner to find an appropriate placement after discharge from the hospital to the next level of care. Requires the Department to by rule implement a methodology effective for dates of service January 1, 2025 and later to reimburse hospitals for emergency department stays extended beyond medical necessity due to the inability of the Department, the MCO, or the hospital discharge planner to find an appropriate placement after discharge from the hospital setting to the next appropriate level of care. Provides that both methodologies shall provide reasonable compensation for the services provided attributable to the hours of the extended stay for which the prevailing rate methodology provides no reimbursement. Contains provisions concerning the rate for inpatient days of care; hourly rates of reimbursement for emergency department stays; a prohibition on MCOs restricting coverage due to delays caused by the Department or the MCOs in completing the pre-admission screening and resident review process; a prohibition on MCOs imposing authorization or documentation requirements and other conditions of reimbursement that are more restrictive than standards under the fee-for-service medical assistance program; sanctions on MCOs for noncompliance; and administrative rules. Effective immediately. LRB103 37681 KTG 67808 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB3374 Introduced 2/7/2024, by Sen. Ann Gillespie SYNOPSIS AS INTRODUCED: 305 ILCS 5/14-13 305 ILCS 5/14-13 Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to by rule implement a methodology to reimburse hospitals for inpatient stays extended beyond medical necessity due to the inability of the Department, the managed care organization (MCO) in which a medical assistance recipient is enrolled in, or the hospital discharge planner to find an appropriate placement after discharge from the hospital to the next level of care. Requires the Department to by rule implement a methodology effective for dates of service January 1, 2025 and later to reimburse hospitals for emergency department stays extended beyond medical necessity due to the inability of the Department, the MCO, or the hospital discharge planner to find an appropriate placement after discharge from the hospital setting to the next appropriate level of care. Provides that both methodologies shall provide reasonable compensation for the services provided attributable to the hours of the extended stay for which the prevailing rate methodology provides no reimbursement. Contains provisions concerning the rate for inpatient days of care; hourly rates of reimbursement for emergency department stays; a prohibition on MCOs restricting coverage due to delays caused by the Department or the MCOs in completing the pre-admission screening and resident review process; a prohibition on MCOs imposing authorization or documentation requirements and other conditions of reimbursement that are more restrictive than standards under the fee-for-service medical assistance program; sanctions on MCOs for noncompliance; and administrative rules. Effective immediately. LRB103 37681 KTG 67808 b LRB103 37681 KTG 67808 b A BILL FOR
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB3374 Introduced 2/7/2024, by Sen. Ann Gillespie SYNOPSIS AS INTRODUCED:
3	3	305 ILCS 5/14-13 305 ILCS 5/14-13
4	4	305 ILCS 5/14-13
5	5	Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to by rule implement a methodology to reimburse hospitals for inpatient stays extended beyond medical necessity due to the inability of the Department, the managed care organization (MCO) in which a medical assistance recipient is enrolled in, or the hospital discharge planner to find an appropriate placement after discharge from the hospital to the next level of care. Requires the Department to by rule implement a methodology effective for dates of service January 1, 2025 and later to reimburse hospitals for emergency department stays extended beyond medical necessity due to the inability of the Department, the MCO, or the hospital discharge planner to find an appropriate placement after discharge from the hospital setting to the next appropriate level of care. Provides that both methodologies shall provide reasonable compensation for the services provided attributable to the hours of the extended stay for which the prevailing rate methodology provides no reimbursement. Contains provisions concerning the rate for inpatient days of care; hourly rates of reimbursement for emergency department stays; a prohibition on MCOs restricting coverage due to delays caused by the Department or the MCOs in completing the pre-admission screening and resident review process; a prohibition on MCOs imposing authorization or documentation requirements and other conditions of reimbursement that are more restrictive than standards under the fee-for-service medical assistance program; sanctions on MCOs for noncompliance; and administrative rules. Effective immediately.
6	6	LRB103 37681 KTG 67808 b LRB103 37681 KTG 67808 b
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9	9	SB3374LRB103 37681 KTG 67808 b SB3374 LRB103 37681 KTG 67808 b
10	10	SB3374 LRB103 37681 KTG 67808 b
11	11	1 AN ACT concerning public aid.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 5. The Illinois Public Aid Code is amended by
15	15	5 changing Section 14-13 as follows:
16	16	6 (305 ILCS 5/14-13)
17	17	7 Sec. 14-13. Reimbursement for hospital inpatient stays
18	18	8 extended beyond medical necessity.
19	19	9 (a) The By October 1, 2019, the Department shall by rule
20	20	10 implement a methodology effective for dates of service July 1,
21	21	11 2019 and later to reimburse hospitals for inpatient stays
22	22	12 extended beyond medical necessity due to the inability of the
23	23	13 Department or the managed care organization in which a
24	24	14 recipient is enrolled or the hospital discharge planner to
25	25	15 find an appropriate placement after discharge from the
26	26	16 hospital to the next level of care, including, but not limited
27	27	17 to, care provided in a nursing facility, ICF/DD facility,
28	28	18 MC/DD facility, rehabilitation hospital or rehabilitation
29	29	19 unit, psychiatric hospital or psychiatric unit, long-term
30	30	20 acute care hospital, long-term services and supports waiver
31	31	21 setting, residence when home health care services are
32	32	22 required, or other post-acute or sub-acute care setting. The
33	33	23 Department shall evaluate the effectiveness of the current
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37	37	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB3374 Introduced 2/7/2024, by Sen. Ann Gillespie SYNOPSIS AS INTRODUCED:
38	38	305 ILCS 5/14-13 305 ILCS 5/14-13
39	39	305 ILCS 5/14-13
40	40	Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to by rule implement a methodology to reimburse hospitals for inpatient stays extended beyond medical necessity due to the inability of the Department, the managed care organization (MCO) in which a medical assistance recipient is enrolled in, or the hospital discharge planner to find an appropriate placement after discharge from the hospital to the next level of care. Requires the Department to by rule implement a methodology effective for dates of service January 1, 2025 and later to reimburse hospitals for emergency department stays extended beyond medical necessity due to the inability of the Department, the MCO, or the hospital discharge planner to find an appropriate placement after discharge from the hospital setting to the next appropriate level of care. Provides that both methodologies shall provide reasonable compensation for the services provided attributable to the hours of the extended stay for which the prevailing rate methodology provides no reimbursement. Contains provisions concerning the rate for inpatient days of care; hourly rates of reimbursement for emergency department stays; a prohibition on MCOs restricting coverage due to delays caused by the Department or the MCOs in completing the pre-admission screening and resident review process; a prohibition on MCOs imposing authorization or documentation requirements and other conditions of reimbursement that are more restrictive than standards under the fee-for-service medical assistance program; sanctions on MCOs for noncompliance; and administrative rules. Effective immediately.
41	41	LRB103 37681 KTG 67808 b LRB103 37681 KTG 67808 b
42	42	LRB103 37681 KTG 67808 b
43	43	A BILL FOR
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49	49	305 ILCS 5/14-13
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68	68	1 reimbursement rate for inpatient hospital stays beyond medical
69	69	2 necessity.
70	70	3 (a-2) By October 1, 2024, the Department shall by rule
71	71	4 implement a methodology effective for dates of service January
72	72	5 1, 2025 and later to reimburse hospitals for emergency
73	73	6 department stays extended beyond medical necessity due to the
74	74	7 inability of the Department or the managed care organization
75	75	8 in which a recipient is enrolled or the hospital discharge
76	76	9 planner to find an appropriate placement after discharge from
77	77	10 the hospital setting to the next appropriate level of care,
78	78	11 including, but not limited to, care provided in a nursing
79	79	12 facility, ICF/DD facility, MC/DD facility, rehabilitation
80	80	13 hospital or rehabilitation unit, psychiatric hospital or
81	81	14 psychiatric unit, long-term acute care hospital, long-term
82	82	15 services and supports waiver setting, residence when home
83	83	16 health care services are required, or other post-acute or
84	84	17 sub-acute care setting.
85	85	18 (b) The methodology developed under subsection (a) shall
86	86	19 provide reasonable compensation for the services provided
87	87	20 attributable to the days of the extended stay for which the
88	88	21 prevailing rate methodology provides no reimbursement. The
89	89	22 Department may use a day outlier program to satisfy this
90	90	23 requirement. The methodology developed under subsection (a-2)
91	91	24 shall provide reasonable compensation for the services
92	92	25 provided attributable to the hours of the extended stay for
93	93	26 which the prevailing rate methodology provides no
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104	104	1 reimbursement. The reimbursement rate shall be set at a level
105	105	2 so as not to act as an incentive to avoid transfer to the
106	106	3 appropriate level of care needed or placement, after
107	107	4 discharge.
108	108	5 (b-5) Effective January 1, 2025, the Department shall set
109	109	6 the rate for inpatient days of care, referenced in subsection
110	110	7 (a), equal to the statewide average rate paid per day
111	111	8 including Medicaid High Volume Adjustment (MHVA) and the
112	112	9 Medicaid Percentage Adjustment (MPA), for inpatient services,
113	113	10 specific to each category of services, provided by all
114	114	11 Illinois hospitals, based on dates of service in State Fiscal
115	115	12 Year 2023. Effective January 1, 2026, the Department shall
116	116	13 update this rate for dates of service on or after January 1 of
117	117	14 each calendar year, based on dates of service from the State
118	118	15 fiscal year ending 18 months before the beginning of the new
119	119	16 calendar year.
120	120	17 (b-6) Effective January 1, 2025, and each January 1
121	121	18 thereafter, the Department shall set the hourly rate of
122	122	19 reimbursement for emergency department stays, referenced
123	123	20 subsection (a-2), equal to the inpatient rate established in
124	124	21 subsection (b-5) divided by 24, and shall pay for each hour the
125	125	22 patient is unable to be transferred to the next appropriate
126	126	23 level of care. Effective January 1, 2026, the Department shall
127	127	24 update this rate for dates of service on or after January 1 of
128	128	25 each calendar year, coinciding with the update required in
129	129	26 subsection (b-5).
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140	140	1 (c) For recipients who require a level of care described
141	141	2 in subsection (a) and subsection (a-2), the The Department
142	142	3 shall require managed care organizations to adopt this
143	143	4 methodology or an alternative methodology that pays at least
144	144	5 as much as the Department's adopted methodology unless
145	145	6 otherwise mutually agreed upon contractual language is
146	146	7 developed by the provider and the managed care organization
147	147	8 for a risk-based or innovative payment methodology.
148	148	9 (d) Days beyond medical necessity shall not be separately
149	149	10 eligible for per diem add-on payments under the MHVA or MPA
150	150	11 Medicaid High Volume Adjustment (MHVA) or the Medicaid
151	151	12 Percentage Adjustment (MPA) programs.
152	152	13 (e) For services covered by the fee-for-service program,
153	153	14 reimbursement under this Section shall only be made for stays
154	154	15 days beyond medical necessity that occur after the hospital
155	155	16 has notified the Department of the need for post-discharge
156	156	17 placement. The Department shall not restrict coverage under
157	157	18 this Section due to delays caused by the Department, or its
158	158	19 designated contractor, in completing the Pre-Admission
159	159	20 Screening and Resident Review process.
160	160	21 (f) For services covered by a managed care organization,
161	161	22 hospitals shall notify the appropriate managed care
162	162	23 organization of an admission within 24 hours of admission. For
163	163	24 every 24-hour period beyond the initial 24 hours after
164	164	25 admission that the hospital fails to notify the managed care
165	165	26 organization of the admission, reimbursement under this
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176	176	1 subsection shall be reduced by one day. Managed care
177	177	2 organizations (MCOs) shall not restrict coverage under this
178	178	3 Section due to delays caused by:
179	179	4 (1) The MCO or its designated contractor, or the
180	180	5 Department or its designated contractor, in completing the
181	181	6 Pre-Admission Screening and Resident Review process.
182	182	7 (2) Processing authorization requests, as submitted by
183	183	8 the provider, for post-acute care for enrollees who are
184	184	9 approved for discharge, including, but not limited to any
185	185	10 MCO action to extend the timeframe for issuing a
186	186	11 determination by changing the provider's request from
187	187	12 urgent to routine.
188	188	13 (g) The Department shall, by contract, prohibit the MCOs
189	189	14 from imposing authorization or documentation requirements,
190	190	15 exclusionary criteria, or other conditions of reimbursement
191	191	16 that are more restrictive than the standards adopted by the
192	192	17 Department for the fee-for-service program.
193	193	18 (h) The Department shall impose sanctions on an MCO for
194	194	19 violating provisions of this Section, including, but not
195	195	20 limited to, financial penalties, suspension of enrollment, or
196	196	21 termination of the MCO's contract with the Department.
197	197	22 (i) The Department shall adopt or amend administrative
198	198	23 rules, as necessary, to implement the provisions of this
199	199	24 Section.
200	200	25 (Source: P.A. 101-209, eff. 8-5-19; 102-4, eff. 4-27-21.)
201	201	26 Section 99. Effective date. This Act takes effect upon
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