Bill Text: IL HB5669 | 2017-2018 | 100th General Assembly | Introduced

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Bill Title: Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to report each managed care organization's operational performance concerning actual administrative costs incurred; the medical loss ratios for the previous 4 calendar years; all Medicaid provider payment data for all services; and the amount of denied claims. Requires each managed care entity to self-report the same information and publish it on a monthly basis on the managed care entity's website as soon as practical but no later than July 1, 2018. Requires the Department to: (i) regularly monitor the actual administrative costs incurred by Medicaid Managed Care Entities to ensure that the administrative costs do not exceed what is allowed by contract; (ii) annually calculate the medical loss ratios for the previous 4 calendar years, and beginning no later than July 1, 2018, annually determine whether the State should be reimbursed by the Medicaid Managed Care Entities due to overpayment; (iii) require all Medicaid Managed Care Entities to regularly submit all Medicaid provider payment data for all services; and other duties. Effective immediately.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Failed) 2019-01-08 - Session Sine Die [HB5669 Detail]

Download: Illinois-2017-HB5669-Introduced.html

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100TH GENERAL ASSEMBLY State of Illinois 2017 and 2018 HB5669 Introduced , by Rep. Robert Martwick SYNOPSIS AS INTRODUCED:
305 ILCS 5/5-30.1
305 ILCS 5/5-30.3
Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to report each managed care organization's operational performance concerning actual administrative costs incurred; the medical loss ratios for the previous 4 calendar years; all Medicaid provider payment data for all services; and the amount of denied claims. Requires each managed care entity to self-report the same information and publish it on a monthly basis on the managed care entity's website as soon as practical but no later than July 1, 2018. Requires the Department to: (i) regularly monitor the actual administrative costs incurred by Medicaid Managed Care Entities to ensure that the administrative costs do not exceed what is allowed by contract; (ii) annually calculate the medical loss ratios for the previous 4 calendar years, and beginning no later than July 1, 2018, annually determine whether the State should be reimbursed by the Medicaid Manage Care Entities due to overpayment; (iii) require all Medicaid Managed Care Entities to regularly submit all Medicaid provider payment data for all services; and other duties. Effective immediately.
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FISCAL NOTE ACT MAY APPLY
A BILL FOR
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AN ACT concerning public aid.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Public Aid Code is amended by
changing Sections 5-30.1 and 5-30.3 as follows:
(305 ILCS 5/5-30.1)
Sec. 5-30.1. Managed care protections.
(a) As used in this Section:
"Managed care organization" or "MCO" means any entity which
contracts with the Department to provide services where payment
for medical services is made on a capitated basis.
"Emergency services" include:
(1) emergency services, as defined by Section 10 of the
Managed Care Reform and Patient Rights Act;
(2) emergency medical screening examinations, as
defined by Section 10 of the Managed Care Reform and
Patient Rights Act;
(3) post-stabilization medical services, as defined by
Section 10 of the Managed Care Reform and Patient Rights
Act; and
(4) emergency medical conditions, as defined by
Section 10 of the Managed Care Reform and Patient Rights
Act.

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(b) As provided by Section 5-16.12, managed care
organizations are subject to the provisions of the Managed Care
Reform and Patient Rights Act.
(c) An MCO shall pay any provider of emergency services
that does not have in effect a contract with the contracted
Medicaid MCO. The default rate of reimbursement shall be the
rate paid under Illinois Medicaid fee-for-service program
methodology, 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 the
applicable MCO capitated rates.
(d) An MCO shall pay for all post-stabilization services as
a covered service in any of the following situations:
(1) the MCO authorized such services;
(2) such services were administered to maintain the
enrollee's stabilized condition within one hour after a
request to the MCO for authorization of further
post-stabilization services;
(3) the MCO did not respond to a request to authorize
such services within one hour;
(4) the MCO could not be contacted; or
(5) the MCO and the treating provider, if the treating
provider is a non-affiliated provider, could not reach an
agreement concerning the enrollee's care and an affiliated

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provider was unavailable for a consultation, in which case
the MCO must pay for such services rendered by the treating
non-affiliated provider until an affiliated provider was
reached and either concurred with the treating
non-affiliated provider's plan of care or assumed
responsibility for the enrollee's care. Such payment shall
be made at the default rate of reimbursement paid under
Illinois Medicaid fee-for-service program methodology,
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 that such
adjustments are incorporated in the development of the
applicable MCO capitated rates.
(e) The following requirements apply to MCOs in determining
payment for all emergency services:
(1) MCOs shall not impose any requirements for prior
approval of emergency services.
(2) The MCO shall cover emergency services provided to
enrollees who are temporarily away from their residence and
outside the contracting area to the extent that the
enrollees would be entitled to the emergency services if
they still were within the contracting area.
(3) The MCO shall have no obligation to cover medical
services provided on an emergency basis that are not
covered services under the contract.

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(4) The MCO shall not condition coverage for emergency
services on the treating provider notifying the MCO of the
enrollee's screening and treatment within 10 days after
presentation for emergency services.
(5) The determination of the attending emergency
physician, or the provider actually treating the enrollee,
of whether an enrollee is sufficiently stabilized for
discharge or transfer to another facility, shall be binding
on the MCO. The MCO shall cover emergency services for all
enrollees whether the emergency services are provided by an
affiliated or non-affiliated provider.
(6) The MCO's financial responsibility for
post-stabilization care services it has not pre-approved
ends when:
(A) a plan physician with privileges at the
treating hospital assumes responsibility for the
enrollee's care;
(B) a plan physician assumes responsibility for
the enrollee's care through transfer;
(C) a contracting entity representative and the
treating physician reach an agreement concerning the
enrollee's care; or
(D) the enrollee is discharged.
(f) Network adequacy and transparency.
(1) The Department shall:
(A) ensure that an adequate provider network is in

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place, taking into consideration health professional
shortage areas and medically underserved areas;
(B) publicly release an explanation of its process
for analyzing network adequacy;
(C) periodically ensure that an MCO continues to
have an adequate network in place; and
(D) require MCOs, including Medicaid Managed Care
Entities as defined in Section 5-30.2, to meet provider
directory requirements under Section 5-30.3.
(2) Each MCO shall confirm its receipt of information
submitted specific to physician additions or physician
deletions from the MCO's provider network within 3 days
after receiving all required information from contracted
physicians, and electronic physician directories must be
updated consistent with current rules as published by the
Centers for Medicare and Medicaid Services or its successor
agency.
(g) Timely payment of claims.
(1) The MCO shall pay a claim within 30 days of
receiving a claim that contains all the essential
information needed to adjudicate the claim.
(2) The MCO shall notify the billing party of its
inability to adjudicate a claim within 30 days of receiving
that claim.
(3) The MCO shall pay a penalty that is at least equal
to the penalty imposed under the Illinois Insurance Code

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for any claims not timely paid.
(4) The Department may establish a process for MCOs to
expedite payments to providers based on criteria
established by the Department.
(g-5) Recognizing that the rapid transformation of the
Illinois Medicaid program may have unintended operational
challenges for both payers and providers:
(1) in no instance shall a medically necessary covered
service rendered in good faith, based upon eligibility
information documented by the provider, be denied coverage
or diminished in payment amount if the eligibility or
coverage information available at the time the service was
rendered is later found to be inaccurate; and
(2) the Department shall, by December 31, 2016, adopt
rules establishing policies that shall be included in the
Medicaid managed care policy and procedures manual
addressing payment resolutions in situations in which a
provider renders services based upon information obtained
after verifying a patient's eligibility and coverage plan
through either the Department's current enrollment system
or a system operated by the coverage plan identified by the
patient presenting for services:
(A) such medically necessary covered services
shall be considered rendered in good faith;
(B) such policies and procedures shall be
developed in consultation with industry

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representatives of the Medicaid managed care health
plans and representatives of provider associations
representing the majority of providers within the
identified provider industry; and
(C) such rules shall be published for a review and
comment period of no less than 30 days on the
Department's website with final rules remaining
available on the Department's website.
(3) The rules on payment resolutions shall include, but
not be limited to:
(A) the extension of the timely filing period;
(B) retroactive prior authorizations; and
(C) guaranteed minimum payment rate of no less than
the current, as of the date of service, fee-for-service
rate, plus all applicable add-ons, when the resulting
service relationship is out of network.
(4) The rules shall be applicable for both MCO coverage
and fee-for-service coverage.
(g-6) MCO Performance Metrics Report.
(1) The Department shall publish, on at least a
quarterly basis, each MCO's operational performance,
including, but not limited to, the following categories of
metrics:
(A) claims payment, including timeliness and
accuracy;
(B) prior authorizations;

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(C) grievance and appeals;
(D) utilization statistics;
(E) provider disputes;
(F) provider credentialing; and
(G) member and provider customer service; .
(H) actual administrative costs incurred by the
MCO;
(I) the medical loss ratios for the previous 4
calendar years;
(J) all Medicaid provider payment data for all
services, including, but not limited to, alcohol and
substance abuse services, long-term care services, and
waiver services; and
(K) amount of denied claims.
(2) The Department shall ensure that the metrics report
is accessible to providers online by January 1, 2017.
(3) The metrics shall be developed in consultation with
industry representatives of the Medicaid managed care
health plans and representatives of associations
representing the majority of providers within the
identified industry.
(4) Metrics shall be defined and incorporated into the
applicable Managed Care Policy Manual issued by the
Department.
(h) The Department shall not expand mandatory MCO
enrollment into new counties beyond those counties already

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designated by the Department as of June 1, 2014 for the
individuals whose eligibility for medical assistance is not the
seniors or people with disabilities population until the
Department provides an opportunity for accountable care
entities and MCOs to participate in such newly designated
counties.
(i) The requirements of this Section apply to contracts
with accountable care entities and MCOs entered into, amended,
or renewed after June 16, 2014 (the effective date of Public
Act 98-651).
(Source: P.A. 99-725, eff. 8-5-16; 99-751, eff. 8-5-16;
100-201, eff. 8-18-17.)
(305 ILCS 5/5-30.3)
Sec. 5-30.3. Empowering meaningful patient choice in
Medicaid Managed Care.
(a) Definitions. As used in this Section:
"Client enrollment services broker" means a vendor the
Department contracts with to carry out activities related to
Medicaid recipients' enrollment, disenrollment, and renewal
with Medicaid Managed Care Entities.
"Composite domains" means the synthesized categories
reflecting the standardized quality performance measures
included in the consumer quality comparison tool. At a minimum,
these composite domains shall display Medicaid Managed Care
Entities' individual Plan performance on standardized quality,

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timeliness, and access measures.
"Consumer quality comparison tool" means an online and
paper tool developed by the Department with input from
interested stakeholders reflecting the performance of Medicaid
Managed Care Entity Plans on standardized quality performance
measures. This tool shall be designed in a consumer-friendly
and easily understandable format.
"Covered services" means those health care services to
which a covered person is entitled to under the terms of the
Medicaid Managed Care Entity Plan.
"Facilities" includes, but is not limited to, federally
qualified health centers, skilled nursing facilities, and
rehabilitation centers.
"Hospitals" includes, but is not limited to, acute care,
rehabilitation, children's, and cancer hospitals.
"Integrated provider directory" means a searchable
database bringing together network data from multiple Medicaid
Managed Care Entities that is available through client
enrollment services.
"Medicaid eligibility redetermination" means the process
by which the eligibility of a Medicaid recipient is reviewed by
the Department to determine if the recipient's medical benefits
will continue, be modified, or terminated.
"Medicaid Managed Care Entity" has the same meaning as
defined in Section 5-30.2 of this Code.
(b) Provider directory transparency.

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(1) Each Medicaid Managed Care Entity shall:
(A) Make available on the entity's website a
provider directory in a machine readable file and
format.
(B) Make provider directories publicly accessible
without the necessity of providing a password, a
username, or personally identifiable information.
(C) Comply with all federal and State statutes and
regulations, including 42 CFR 438.10, pertaining to
provider directories within Medicaid Managed Care.
(D) Request, at least annually, provider office
hours for each of the following provider types:
(i) Health care professionals, including
dental and vision providers.
(ii) Hospitals.
(iii) Facilities, other than hospitals.
(iv) Pharmacies, other than hospitals.
(v) Durable medical equipment suppliers, other
than hospitals.
Medicaid Managed Care Entities shall publish the
provider office hours in the provider directory upon
receipt.
(E) Confirm with the Medicaid Managed Care
Entity's contracted providers who have not submitted
claims within the past 6 months that the contracted
providers intend to remain in the network and correct

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any incorrect provider directory information as
necessary.
(F) Ensure that in situations in which a Medicaid
Managed Care Entity Plan enrollee receives covered
services from a non-participating provider due to a
material misrepresentation in a Medicaid Managed Care
Entity's online electronic provider directory, the
Medicaid Managed Care Entity Plan enrollee shall not be
held responsible for any costs resulting from that
material misrepresentation.
(G) Conspicuously display an e-mail address and a
toll-free telephone number to which any individual may
report any inaccuracy in the provider directory. If the
Medicaid Managed Care Entity receives a report from any
person who specifically identifies provider directory
information as inaccurate, the Medicaid Managed Care
Entity shall investigate the report and correct any
inaccurate information displayed in the electronic
directory.
(H) As soon as practical, but no later than July 1,
2018, make available on the entity's website a monthly
listing that includes, but is not limited to, the
following:
(i) actual administrative costs incurred;
(ii) medical loss ratios for the previous 4
calendar years;

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(iii) all Medicaid provider payment data for
all services, including, but not limited to,
alcohol and substance abuse services, long-term
care services, and waiver services; and
(iv) amount of denied claims.
(2) The Department shall:
(A) Regularly monitor Medicaid Managed Care
Entities to ensure that they are compliant with the
requirements under paragraph (1) of subsection (b).
(B) Require that the client enrollment services
broker use the Medicaid provider number for all
providers with a Medicaid Provider number to populate
the provider information in the integrated provider
directory.
(C) Ensure that each Medicaid Managed Care Entity
shall, at minimum, make the information in
subparagraph (D) of paragraph (1) of subsection (b)
available to the client enrollment services broker.
(D) Ensure that the client enrollment services
broker shall, at minimum, have the information in
subparagraph (D) of paragraph (1) of subsection (b)
available and searchable through the integrated
provider directory on its website as soon as possible
but no later than January 1, 2017.
(E) Require the client enrollment services broker
to conspicuously display near the integrated provider

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directory an email address and a toll-free telephone
number provided by the Department to which any
individual may report inaccuracies in the integrated
provider directory. If the Department receives a
report that identifies an inaccuracy in the integrated
provider directory, the Department shall provide the
information about the reported inaccuracy to the
appropriate Medicaid Managed Care Entity within 3
business days after the reported inaccuracy is
received.
(F) Regularly monitor the actual administrative
costs incurred by Medicaid Managed Care Entities to
ensure that the administrative costs do not exceed what
is allowed by contract.
(G) Annually calculate the medical loss ratios for
the previous 4 calendar years, and beginning no later
than July 1, 2018, annually determine whether the State
should be reimbursed by the Medicaid Managed Care
Entities due to overpayment.
(H) Require all Medicaid Managed Care Entities to
regularly submit all Medicaid provider payment data
for all services, including, but not limited to,
alcohol and substance abuse services, long-term care
services, and waiver services. The Department shall
perform on-site reviews of the Medicaid Managed Care
Entities' financial data systems and test the

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completeness and accuracy of the data reported to the
Department by the Medicaid Managed Care Entities that
is used to monitor the payments made to Medicaid
providers.
(I) Provide clear guidance to Medicaid Managed
Care Entities on reporting denied claims and ensure
that Medicaid Managed Care Entities provide the denied
claims to the Department as required by contract.
(J) Ensure multiple monthly capitation payments
are not being made for the same Medicaid recipients,
immediately identify and remove all duplicative
recipients from its eligibility data, and recoup any
overpayment of duplicate capitation payments.
(K) Ensure that the Department effectively
monitors the newly awarded Medicaid Managed Care
Entity contracts to ensure compliance with all
contractual provisions.
(c) Formulary transparency.
(1) Medicaid Managed Care Entities shall publish on
their respective websites a formulary for each Medicaid
Managed Care Entity Plan offered and make the formularies
easily understandable and publicly accessible without the
necessity of providing a password, a username, or
personally identifiable information.
(2) Medicaid Managed Care Entities shall provide
printed formularies upon request.

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(3) Electronic and print formularies shall display:
(A) the medications covered (both generic and name
brand);
(B) if the medication is preferred or not
preferred, and what each term means;
(C) what tier each medication is in and the meaning
of each tier;
(D) any utilization controls including, but not
limited to, step therapy, prior approval, dosage
limits, gender or age restrictions, quantity limits,
or other policies that affect access to medications;
(E) any required cost-sharing;
(F) a glossary of key terms and explanation of
utilization controls and cost-sharing requirements;
(G) a key or legend for all utilization controls
visible on every page in which specific medication
coverage information is displayed; and
(H) directions explaining the process or processes
a consumer may follow to obtain more information if a
medication the consumer requires is not covered or
listed in the formulary.
(4) Each Medicaid Managed Care Entity shall display
conspicuously with each electronic and printed medication
formulary an e-mail address and a toll-free telephone
number to which any individual may report any inaccuracy in
the formulary. If the Medicaid Managed Care Entity receives

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a report that the formulary information is inaccurate, the
Medicaid Managed Care Entity shall investigate the report
and correct any inaccurate information displayed in the
electronic formulary.
(5) Each Medicaid Managed Care Entity shall include a
disclosure in the electronic and requested print
formularies that provides the date of publication, a
statement that the formulary is up to date as of
publication, and contact information for questions and
requests to receive updated information.
(6) The client enrollment services broker's website
shall display prominently a website URL link to each
Medicaid Managed Care Entity's Plan formulary. If a
Medicaid enrollee calls the client enrollment services
broker with questions regarding formularies, the client
enrollment services broker shall offer a brief description
of what a formulary is and shall refer the Medicaid
enrollee to the appropriate Medicaid Managed Care Entity
regarding his or her questions about a specific entity's
formulary.
(d) Grievances and appeals. The Department shall display
prominently on its website consumer-oriented information
describing how a Medicaid enrollee can file a complaint or
grievance, request a fair hearing for any adverse action taken
by the Department or a Medicaid Managed Care Entity, and access
free legal assistance or other assistance made available by the

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State for Medicaid enrollees to pursue an action.
(e) Medicaid redetermination information. The Department
shall require the client enrollment services broker to display
prominently on the client enrollment services broker's website
a description of where a Medicaid enrollee can access
information regarding the Medicaid redetermination process.
(f) Medicaid care coordination information. The client
enrollment services broker shall display prominently on its
website, in an easily understandable format, consumer-oriented
information regarding the role of care coordination services
within Medicaid Managed Care. Such information shall include,
but shall not be limited to:
(1) a basic description of the role of care
coordination services and examples of specific care
coordination activities; and
(2) how a Medicaid enrollee may request care
coordination services from a Medicaid Managed Care Entity.
(g) Consumer quality comparison tool.
(1) The Department shall create a consumer quality
comparison tool to assist Medicaid enrollees with Medicaid
Managed Care Entity Plan selection. This tool shall provide
Medicaid Managed Care Entities' individual Plan
performance on a set of standardized quality performance
measures. The Department shall ensure that this tool shall
be accessible in both a print and online format, with the
online format allowing for individuals to access

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additional detailed Plan performance information.
(2) At a minimum, a printed version of the consumer
quality comparison tool shall be provided by the Department
on an annual basis to Medicaid enrollees who are required
by the Department to enroll in a Medicaid Managed Care
Entity Plan during an enrollee's open enrollment period.
The consumer quality comparison tool shall also meet all of
the following criteria:
(A) Display Medicaid Managed Care Entities'
individual Plan performance on at least 4 composite
domains that reflect Plan quality, timeliness, and
access. The composite domains shall draw from the most
current available performance data sets including, but
not limited to:
(i) Healthcare Effectiveness Data and
Information Set (HEDIS) measures.
(ii) Core Set of Children's Health Care
Quality measures as required under the Children's
Health Insurance Program Reauthorization Act
(CHIPRA).
(iii) Adult Core Set measures.
(iv) Consumer Assessment of Healthcare
Providers and Systems (CAHPS) survey results.
(v) Additional performance measures the
Department deems appropriate to populate the
composite domains.

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(B) Use a quality rating system developed by the
Department to reflect Medicaid Managed Care Entities'
individual Plan performance. The quality rating system
for each composite domain shall reflect the Medicaid
Managed Care Entities' individual Plan performance
and, when possible, plan performance relative to
national Medicaid percentiles.
(C) Be customized to reflect the specific Medicaid
Managed Care Entities' Plans available to the Medicaid
enrollee based on his or her geographic location and
Medicaid eligibility category.
(D) Include contact information for the client
enrollment services broker and contact information for
Medicaid Managed Care Entities available to the
Medicaid enrollee based on his or her geographic
location and Medicaid eligibility category.
(E) Include guiding questions designed to assist
individuals selecting a Medicaid Managed Care Entity
Plan.
(3) At a minimum, the online version of the consumer
quality comparison tool shall meet all of the following
criteria:
(A) Display Medicaid Managed Care Entities'
individual Plan performance for the same composite
domains selected by the Department in the printed
version of the consumer quality comparison tool. The

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Department may display additional composite domains in
the online version of the consumer quality comparison
tool as appropriate.
(B) Display Medicaid Managed Care Entities'
individual Plan performance on each of the
standardized performance measures that contribute to
each composite domain displayed on the online version
of the consumer quality comparison tool.
(C) Use a quality rating system developed by the
Department to reflect Medicaid Managed Care Entities'
individual Plan performance. The quality rating system
for each composite domain shall reflect the Medicaid
Managed Care Entities' individual Plan performance
and, when possible, plan performance relative to
national Medicaid percentiles.
(D) Include the specific Medicaid Managed Care
Entity Plans available to the Medicaid enrollee based
on his or her geographic location and Medicaid
eligibility category.
(E) Include a sort function to view Medicaid
Managed Care Entities' individual Plan performance by
quality rating and by standardized quality performance
measures.
(F) Include contact information for the client
enrollment services broker and for each Medicaid
Managed Care Entity.

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(G) Include guiding questions designed to assist
individuals in selecting a Medicaid Managed Care
Entity Plan.
(H) Prominently display current notice of quality
performance sanctions against Medicaid Managed Care
Entities. Notice of the sanctions shall remain present
on the online version of the consumer quality
comparison tool until the sanctions are lifted.
(4) The online version of the consumer quality
comparison tool shall be displayed prominently on the
client enrollment services broker's website.
(5) In the development of the consumer quality
comparison tool, the Department shall establish and
publicize a formal process to collect and consider written
and oral feedback from consumers, advocates, and
stakeholders on aspects of the consumer quality comparison
tool, including, but not limited to, the following:
(A) The standardized data sets and surveys,
specific performance measures, and composite domains
represented in the consumer quality comparison tool.
(B) The format and presentation of the consumer
quality comparison tool.
(C) The methods undertaken by the Department to
notify Medicaid enrollees of the availability of the
consumer quality comparison tool.
(6) The Department shall review and update as

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appropriate the composite domains and performance measures
represented in the print and online versions of the
consumer quality comparison tool at least once every 3
years. During the Department's review process, the
Department shall solicit engagement in the public feedback
process described in paragraph (5).
(7) The Department shall ensure that the consumer
quality comparison tool is available for consumer use as
soon as possible but no later than January 1, 2018.
(h) The Department may adopt rules and take any other
appropriate action necessary to implement its responsibilities
under this Section.
(Source: P.A. 99-725, eff. 8-5-16; 100-201, eff. 8-18-17.)
Section 99. Effective date. This Act takes effect upon
becoming law.