Bill Title: Reinserts the provisions of the engrossed bill with the following changes: Further amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that a managed care organization must pay for preventative prenatal services, perinatal healthcare services, and postpartum services rendered by a non-affiliated provider, for which the health plan would pay if rendered by an affiliated provider, at the rate paid (rather than at no less than the rate paid) under the Illinois Medicaid fee-for-service program methodology for such services. Provides that, in cases where a managed care organization must pay for preventive prenatal services, perinatal healthcare services, and postpartum services rendered by a non-affiliated provider, the payment rate requirements under the amendatory Act shall not apply if the services were not emergency services, as defined in a specified provision of the Code, and: (1) the non-affiliated provider is a perinatal hospital and has, within the 12 months preceding the date of service, rejected a contract that was offered in good faith by the health plan as determined by the Department of Healthcare and Family Services; or (2) the health plan has terminated a contract with the non-affiliated provider for cause, and the Department has not deemed the termination to have been without merit. Provides that the Department may deem that a determination for cause has merit if: (i) an institutional provider has repeatedly failed to conduct discharge planning; or (ii) the provider's conduct adversely and substantially impacts the health of Medicaid patients; or (iii) the provider's conduct constitutes fraud, waste, or abuse; or (iv) the provider's conduct violates the code of ethics governing his or her profession. Effective January 1, 2023.
Spectrum: Moderate Partisan Bill (Democrat 51-15)
Status: (Passed) 2022-05-27 - Public Act . . . . . . . . . 102-0964
[HB5013 Detail]Download: Illinois-2021-HB5013-Chaptered.html
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| Public Act 102-0964
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| HB5013 Enrolled | LRB102 25451 KTG 34737 b |
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AN ACT concerning public aid.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Birth Center Licensing Act is amended by |
changing Sections 5 and 25 as follows:
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(210 ILCS 170/5)
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Sec. 5. Definitions. In this Act: |
"Birth center" means a designated site, other than a |
hospital: |
(1) in which births are planned to occur following a |
normal, uncomplicated, and low-risk pregnancy; |
(2) that is not the pregnant person's usual place of |
residence; |
(3) that is exclusively dedicated to serving the |
childbirth-related needs of pregnant persons and their |
newborns, and has no more than 10 beds; |
(4) that offers prenatal care and community education |
services and coordinates these services with other health |
care services available in the community; and |
(5) that does not provide general anesthesia or |
surgery. |
"Certified nurse midwife" means an advanced practice |
registered nurse licensed in Illinois under the Nurse Practice |
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Act with full practice authority or who is delegated such |
authority as part of a written collaborative agreement with a |
physician who is associated with the birthing center or who |
has privileges at a nearby birthing hospital. |
"Department" means the Illinois Department of Public |
Health. |
"Hospital" does not include places where pregnant females |
are received, cared for, or treated during delivery if it is in |
a licensed birth center, nor include any facility required to |
be licensed as a birth center. |
"Licensed certified professional midwife" means a person |
who has successfully met the requirements under Section 45 of |
the Licensed Certified Professional Midwife Practice Act and |
holds an active license to practice as a licensed certified |
professional midwife in Illinois. |
"Physician" means a physician licensed to practice |
medicine in all its branches in Illinois.
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(Source: P.A. 102-518, eff. 8-20-21.)
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(210 ILCS 170/25)
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Sec. 25. Staffing. |
(a) A birth center shall have a clinical director, who may |
be: |
(1) a physician who is either certified or eligible |
for certification by the American College of Obstetricians
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and Gynecologists or the American Board of Osteopathic
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Obstetricians and Gynecologists or has hospital
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obstetrical privileges; or |
(2)
a certified nurse midwife.
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(b) The clinical director shall be responsible for: |
(1) the development of policies and procedures for |
services as provided by Department rules; |
(2) coordinating the clinical staff and overall |
provision of patient care; |
(3) developing and approving policies defining the |
criteria to determine which pregnancies are accepted as |
normal, uncomplicated, and low-risk; and |
(4) developing and approving policing regarding the |
anesthesia services available at the center.
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(c) An obstetrician, family practitioner, or certified |
nurse midwife, or licensed certified professional midwife |
shall attend each person in labor from the time of admission |
through birth and throughout the immediate postpartum period. |
Attendance may be delegated only to another physician, or a |
certified nurse midwife, or a licensed certified professional |
midwife. |
(d) A second staff person shall be present at each birth |
who: |
(1) is licensed or certified in Illinois in a |
health-related field and under the supervision of a |
physician, or a certified nurse midwife, or a licensed |
certified professional midwife who is in attendance; |
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(2) has specialized training in labor and delivery |
techniques and care of newborns; and |
(3) receives planned and ongoing training as needed to |
perform assigned duties effectively.
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(Source: P.A. 102-518, eff. 8-20-21.)
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Section 10. The Illinois Public Aid Code is amended by |
changing Section 5-5.24 as follows:
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(305 ILCS 5/5-5.24)
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Sec. 5-5.24. Prenatal and perinatal care. |
(a) The Department of
Healthcare and Family Services may |
provide reimbursement under this Article for all prenatal and
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perinatal health care services that are provided for the |
purpose of preventing
low-birthweight infants, reducing the |
need for neonatal intensive care hospital
services, and |
promoting perinatal and maternal health. These services may |
include
comprehensive risk assessments for pregnant |
individuals, individuals with infants, and
infants, lactation |
counseling, nutrition counseling, childbirth support,
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psychosocial counseling, treatment and prevention of |
periodontal disease, language translation, nurse home |
visitation, and
other support
services
that have been proven |
to improve birth and maternal health outcomes.
The Department
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shall
maximize the use of preventive prenatal and perinatal |
health care services
consistent with
federal statutes, rules, |
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and regulations.
The Department of Public Aid (now Department |
of Healthcare and Family Services)
shall develop a plan for |
prenatal and perinatal preventive
health care and
shall |
present the plan to the General Assembly by January 1, 2004.
On |
or before January 1, 2006 and
every 2 years
thereafter, the |
Department shall report to the General Assembly concerning the
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effectiveness of prenatal and perinatal health care services |
reimbursed under
this Section
in preventing low-birthweight |
infants and reducing the need for neonatal
intensive care
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hospital services. Each such report shall include an |
evaluation of how the
ratio of
expenditures for treating
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low-birthweight infants compared with the investment in |
promoting healthy
births and
infants in local community areas |
throughout Illinois relates to healthy infant
development
in |
those areas.
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On and after July 1, 2012, the Department shall reduce any |
rate of reimbursement for services or other payments or alter |
any methodologies authorized by this Code to reduce any rate |
of reimbursement for services or other payments in accordance |
with Section 5-5e. |
(b)(1) As used in this subsection: |
"Affiliated provider" means a provider who is enrolled in |
the medical assistance program and has an active contract with |
a managed care organization. |
"Non-affiliated provider" means a provider who is enrolled |
in the medical assistance program but does not have a contract |
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with an MCO. |
"Preventive prenatal and perinatal health care services" |
means services described in subsection (a) including the |
following non-emergent diagnostic and ancillary services: |
(i) Diagnostic labs and imaging, including level II |
ultrasounds. |
(ii) RhoGAM injections. |
(iii) Injectable 17-alpha-hydroxyprogesterone |
caproate (commonly called 17P). |
(iv) Intrapartum (labor and delivery) services. |
(v) Any other outpatient or inpatient service relating |
to pregnancy or the 12 months following childbirth or |
fetal loss. |
(2) In order to maximize the accessibility of preventive |
prenatal and perinatal health care services, the Department of |
Healthcare and Family Services shall amend its managed care |
contracts such that an MCO must pay for preventive prenatal |
services, perinatal healthcare services, and postpartum |
services rendered by a non-affiliated provider, for which the |
health plan would pay if rendered by an affiliated provider, |
at the rate paid under the Illinois Medicaid fee-for-service |
program methodology for such services, including all policy |
adjusters, including, but not limited to, Medicaid High Volume |
Adjustments, Medicaid Percentage Adjustments, Outpatient High |
Volume Adjustments, and all outlier add-on adjustments to the |
extent such adjustments are incorporated in the development of |
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the applicable MCO capitated rates, unless a different rate |
was agreed upon by the health plan and the non-affiliated |
provider. |
(3) In cases where a managed care organization must pay |
for preventive prenatal services, perinatal healthcare |
services, and postpartum services rendered by a non-affiliated |
provider, the requirements under paragraph (2) shall not apply |
if the services were not emergency services, as defined in |
Section 5-30.1, and: |
(A) the non-affiliated provider is a perinatal |
hospital and has, within the 12 months preceding the date |
of service, rejected a contract that was offered in good |
faith by the health plan as determined by the Department; |
or |
(B) the health plan has terminated a contract with the |
non-affiliated provider for cause, and the Department has |
not deemed the termination to have been without merit. The |
Department may deem that a determination for cause has |
merit if: |
(i) an institutional provider has repeatedly |
failed to conduct discharge planning; or |
(ii) the provider's conduct adversely and |
substantially impacts the health of Medicaid patients; |
or |
(iii) the provider's conduct constitutes fraud, |
waste, or abuse; or |
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(iv) the provider's conduct violates the code of |
ethics governing his or her profession. |
(Source: P.A. 102-665, eff. 10-8-21.)
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