Bill Amendment: IL HR0100 | 2017-2018 | 100th General Assembly

NOTE: For additional amemendments please see the Bill Drafting List

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Bill Title: MEDICAID MCOS AUDIT

Status: 2017-05-31 - Added Co-Sponsor Rep. Litesa E. Wallace [HR0100 Detail]

Download: Illinois-2017-HR0100-House_Amendment_001.html

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AMENDMENT TO HOUSE RESOLUTION 100
AMENDMENT NO. ___. Amend House Resolution 100 by deleting
everything and replacing it with the following:
"WHEREAS, The Medicaid program in Illinois has an immense,
and growing, impact, both in terms of taxpayer dollars and the
effect it has on citizens across the State; and
WHEREAS, State resources for healthcare services are
currently so scarce that many healthcare providers are
discontinuing services, leading to a profoundly detrimental
impact on our communities; and
WHEREAS, Enrollment under the Illinois Department of
Healthcare and Family Services' Medical Assistance Programs
(Medicaid) exceeds three million; and
WHEREAS, A sizable portion of the Medicaid population is

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currently enrolled, often mandatorily, in Managed Care
Organizations (MCOs), making outlays to MCOS, measured in
billions of dollars, one of the largest resource uses in the
State; and
WHEREAS, There has been little information disseminated to
the General Assembly in terms of how State resources are being
spent on MCOs and on the overall healthcare outcomes for
individuals enrolled in these MCOs; and
WHEREAS, In this quickly evolving environment, the General
Assembly must stay engaged in Medicaid funding and
corresponding healthcare outcome issues and must be prepared to
make legislative and administrative recommendations;
therefore, be it
RESOLVED, BY THE HOUSE OF REPRESENTATIVES OF THE ONE
HUNDREDTH GENERAL ASSEMBLY OF THE STATE OF ILLINOIS, that the
Auditor General is directed to conduct an audit of Medicaid
MCOs, which includes a comparison of State expenditures between
MCOs and the Medicaid fee-for-service program; and be it
further
RESOLVED, That the audit shall examine capitation rate
setting and reimbursement issues for Medicaid MCOs for fiscal
year 2016 with respect to the following issues:

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(1) Compare the total dollar amount of all reported MCO
encounter data submitted to the Illinois Department of
Healthcare and Family Services (DHFS) during SFY 2016 to
the total dollar amount of reported claims payments made on
behalf of Illinois Medicaid individuals by MCOs as reported
to DHFS during SFY 2016;
(2) Whether MCO encounter data is used by the
Department of Healthcare and Family Services (DHFS) to set
capitation rates;
(3) Calculate the aggregate amount of MCO capitation
payments made by DHFS during SFY2016 (exclude payments
authorized under 305 ILCS Sections 5/5A-12.2, 5/5A-12.4,
and 5/5A-12 from this calculation);
(4) Determine the amount of payments made by DHFS to
reimburse for-profit MCOs for the ACA Health Insurance Fee
(HIF); determine if reimbursement by the State to
for-profit MCOs for this HIF payment is mandated by federal
CMS;
(5) Determine the amount of payments made by DHFS to
reimburse for-profit MCOs for "gross-ups" related to the
HIF payment; determine the purpose of the "gross-up"

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payments;
(6) The incidence to which the MCO capitation rates
contain supplemental, GRF-based payments to providers; for
these payments, determine the amount of the supplemental,
which providers received these payments, and whether these
monies were directly tied to services actually provided (do
not include payments authorized under 305 ILCS Sections
5/5A-12.2, 5/5A-12.4, and 5/5A-12);
(7) What administrative costs are paid to MCOs in terms
of total dollars and percent of overall MCO medical
based-payments;
(8) What is the average payout ratio for all MCOs in
aggregate and for each MCO individually; for the purposes
of this audit, payout ratio is defined as all paid claims
to Medicaid providers made by MCOs as reported to HFS for
state fiscal year 2016 divided by aggregate MCO capitation
payments made by DHFS for State fiscal year 2016; and
(9) What the denial rates are for MCOs and for
fee-for-service providers billing the DHFS; determine
whether there is a higher denial rate for services paid by
MCOs; and be it further

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RESOLVED, That the Illinois Department of Healthcare and
Family Services and any other State agency having information
relevant to this audit cooperate fully and promptly with the
Auditor General's Office in its conduct; and be it further
RESOLVED, That the Auditor General commence this audit as
soon as possible and report his findings and recommendations
upon completion in accordance with the provisions of Section
3-14 of the Illinois State Auditing Act."