Bill Amendment: IL SB2552 | 2017-2018 | 100th General Assembly

NOTE: For additional amemendments please see the Bill Drafting List

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Bill Title: MEDICAL ASSISTANCE-RATES-MCO

Status: 2019-01-09 - Session Sine Die [SB2552 Detail]

Download: Illinois-2017-SB2552-Senate_Amendment_001.html

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Sen. Heather A. Steans

Filed: 3/20/2018

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AMENDMENT TO SENATE BILL 2552
AMENDMENT NO. ______. Amend Senate Bill 2552 by replacing
everything after the enacting clause with the following:
"Section 5. The Illinois Public Aid Code is amended by
adding Section 5-30.8 as follows:
(305 ILCS 5/5-30.8 new)
Sec. 5-30.8. Managed care organization rate transparency.
(a) For the establishment of Managed Care Organization
(MCO) capitated rate payments from the State, including, but
not limited to, (i) hospital fee schedule reforms and updates,
(ii) rates related to a single State-mandated preferred drug
list, (iii) rate updates related to the State's preferred drug
list, (iv) inclusion of coverage for children with special
needs, (v) inclusion of coverage for children within the child
welfare system, (vi) annual MCO capitated rates, and (vii) any
retroactive provider fee schedule adjustments or other changes

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required by legislation or other actions, the Department of
Healthcare and Family Services shall implement a base rate
setting process beginning on the effective date of this
amendatory Act of the 100th General Assembly which shall
include all of the following elements of transparency:
(1) The Department shall include participating MCOs
and a statewide trade association representing a majority
of participating MCOs in work groups to discuss the
development of any new or updated hospital fee schedules or
other provider fee schedules. Additionally, the Department
shall share any data or reports used to develop MCO rates
with participating MCOs. This data shall be comprehensive
enough for MCO actuaries to recreate and verify the
accuracy of the rate build-up.
(2) The Department shall not limit the number of
experts that each MCO is allowed to bring to the draft rate
meeting or the final rate review meeting.
(3) The Department and its contracted actuary shall
meet with all participating MCOs simultaneously and
together along with consulting actuaries contracted with
statewide trade association representing a majority of
Medicaid health plans at the request of the plans.
Participating MCOs shall additionally, at their request,
be granted individual rate development meetings with the
Department.
(4) When a dispute remains between the MCOs and the

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State's actuaries about the base capitation rates, an MCO
or MCOs shall have the option to seek an arbitration by a
third party actuary to settle the dispute. The third party
actuary shall be selected by the Department from a list of
3 actuary firms produced by the participating and
complaining MCOs to the Department, and the arbitration
costs shall be funded by the participating and complaining
MCOs. The decision of the third party actuary shall be
binding and shall apply to the base rates of the entire
program retroactively.
(5) Any quality incentive or other incentive
withholding of any portion of the actuarially certified
rates must be budget-neutral; the entirety of any aggregate
withheld amounts must be returned to the MCOs in proportion
to their performance on the relevant performance metric. No
amounts shall be returned to the Department in the event
all performance measures are not achieved.
(6) Upon request, the Department shall provide written
responses to questions regarding MCO base rates, the rate
development methodology, MCO rate data, and all other
requests regarding rates from MCOs. Upon request, the
Department shall also provide to the MCOs materials used in
the development of provider fee schedules.
(b) For the development of rates for new rate years:
(1) the Department shall take into account emerging
experience in the development of the annual MCO base rates,

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including, but not limited to, current-year cost and
utilization trends observed by MCOs;
(2) no less than 6 months prior to submission of the
new rates to the Centers for Medicare and Medicaid
Services, the Department shall meet with MCOs to review
data and the Department's written draft assumptions to be
used in the development of base rates for the following
year, and shall provide opportunities for questions to be
asked and answered;
(3) no less than 2 months prior to the submission of
the new rates to the Centers for Medicare and Medicaid
Services, the Department shall provide the MCOs with draft
capitated base rates and shall also conduct a draft rate
meeting with MCOs to discuss, review, and seek feedback
regarding the draft rates; and
(4) prior to the submission of final rates to the
Centers for Medicare and Medicaid Services, the Department
shall provide the MCOs with a final actuarial report
regarding the final base rates for the following year and
subsequently conduct a final rate review meeting; final
rates shall be marked final.
(c) For the development of rates reflecting policy changes:
(1) the Department must provide advance notice to MCOs
of any significant policy change no later than 90 days
prior to the effective date of the policy change. A
significant policy change is defined as a change to covered

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benefits, payment methodology, new member population, or
new service area made at the discretion of the Department
and not required by legislation with a retroactive
effective date;
(2) prior to the effective date of the policy change or
program implementation, the Department shall meet with the
MCOs regarding the initial data collection needed to
establish base rates for the policy change. Additionally,
the Department shall share with the participating MCOs what
other data and the processes for collection shall be
utilized to develop base rates;
(3) prior to the effective date of the policy change or
program implementation, the Department shall meet with
MCOs to review data and the Department's written draft
assumptions to be used in the development of rates for the
following year, and shall provide opportunities for
questions to be asked and answered; and
(4) prior to the effective date of the policy change or
program implementation, the Department shall provide the
MCOs with draft capitated base rates and shall also conduct
a draft rate meeting with MCOs to discuss, review, and seek
feedback regarding the draft rates.
(d) For the development of rates for retroactive policy or
rate changes:
(1) the Department shall meet with the MCOs regarding
the initial data collection needed to establish rates for

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the policy change. Additionally, the Department shall
share with the participating MCOs what other data and the
processes for collection shall be utilized to develop
rates;
(2) the Department shall meet with MCOs to review data
and the Department's written draft assumptions to be used
in the development of rates for the following year; and
shall provide opportunities for questions to be asked and
answered; and
(3) the Department shall provide the MCOs with draft
capitated rates and shall also conduct a draft rate meeting
with MCOs to discuss, review, and seek feedback regarding
the draft rates.".