Bill Text: IL HB5671 | 2015-2016 | 99th General Assembly | Introduced

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Bill Title: Amends the Medical Assistance Article of the Illinois Public Aid Code. In a provision concerning network adequacy for managed care organizations (MCO) contracted with the Department of Healthcare and Family Services, provides that each MCO shall (i) on a monthly basis, jointly validate with contracted providers any changes in provider information, including, but not limited to, changes concerning new providers, terminated providers, updated address information, hours of operation, or other information that is material to a Medicaid beneficiary in the enrollment and provider selection process; and (ii) be required to produce system reports that validate that all MCO systems reflect updated provider information. Provides that in situations in which an enrolled Medicaid provider renders services based on information obtained after verifying a patient's eligibility and coverage plan through either the Department's current enrollment system or the coverage plan identified by the patient presenting for services, such services shall be considered rendered in good faith. Requires the Department to create and maintain a MCO Performance Metrics Comparison Tool that provides periodic reporting, on at least a quarterly basis, of each MCO's performance in various administrative measures. Requires the tool to be accessible in both a print and online format, with the online format allowing for Medicaid beneficiaries and providers to access additional detailed MCO performance information. Effective immediately.

Spectrum: Partisan Bill (Democrat 6-0)

Status: (Introduced - Dead) 2016-04-22 - Rule 19(a) / Re-referred to Rules Committee [HB5671 Detail]

Download: Illinois-2015-HB5671-Introduced.html

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99TH GENERAL ASSEMBLY State of Illinois 2015 and 2016 HB5671 Introduced , by Rep. Greg Harris SYNOPSIS AS INTRODUCED:
305 ILCS 5/5-30.1
Amends the Medical Assistance Article of the Illinois Public Aid Code. In a provision concerning network adequacy for managed care organizations (MCO) contracted with the Department of Healthcare and Family Services, provides that each MCO shall (i) on a monthly basis, jointly validate with contracted providers any changes in provider information, including, but not limited to, changes concerning new providers, terminated providers, updated address information, hours of operation, or other information that is material to a Medicaid beneficiary in the enrollment and provider selection process; and (ii) be required to produce system reports that validate that all MCO systems reflect updated provider information. Provides that in situations in which an enrolled Medicaid provider renders services based on information obtained after verifying a patient's eligibility and coverage plan through either the Department's current enrollment system or the coverage plan identified by the patient presenting for services, such services shall be considered rendered in good faith. Requires the Department to create and maintain a MCO Performance Metrics Comparison Tool that provides periodic reporting, on at least a quarterly basis, of each MCO's performance in various administrative measures. Requires the tool to be accessible in both a print and online format, with the online format allowing for Medicaid beneficiaries and providers to access additional detailed MCO performance information. 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 Section 5-30.1 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 to maintain an updated and public
list of network providers.
(2) Each MCO shall:
(A) on a monthly basis, jointly validate with
contracted providers, including contracted provider
groups, any changes in provider information,
including, but not limited to, changes concerning new
providers, terminated providers, updated address
information, hours of operation, or other information
that is material to a Medicaid beneficiary in the
enrollment and provider selection process; and
(B) be required to produce system reports that
validate that all MCO systems reflect updated provider
information.
(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

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that claim.
(3) The MCO shall pay a penalty that is at least equal
to the penalty imposed under the Illinois Insurance Code
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) In situations in which an enrolled Medicaid provider
renders services based on information obtained after verifying
a patient's eligibility and coverage plan through either the
Department's current enrollment system or the coverage plan
identified by the patient presenting for services, such
services shall be considered rendered in good faith. In no
instance shall a service rendered in good faith be denied
coverage or payment if the information available at the time
the service was rendered is later found to be inaccurate.
(1) The provider of services shall be reimbursed by the
MCO identified at the time services were rendered and based
either on the current contract between the provider and the
MCO or, when a contract does not exist, at the current
Medicaid fee-for-service rate, including all applicable
adjustors.
(2) The MCO as identified in paragraph (1) of this
subsection, which pays the provider of services, shall be
responsible for contacting either the Department or the
appropriate MCO to request reimbursement for expenses

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incurred to reimburse the provider of services.
(3) The responsible MCO may not attempt any collection
efforts through subrogation on the provider of services if
the provider can document that the services were provided
based on information obtained at the time the services were
rendered.
(g-6) MCO Performance Metrics Comparison Tool.
(1) The Department shall create and maintain a MCO
Performance Metrics Comparison Tool that provides periodic
reporting, on at least a quarterly basis, of each MCO's
performance in various administrative measures, including,
but not limited to, the following:
(A) Timely payment of claims, which shall mean the
number of days between the date upon which the MCO
receives a clean claim, as provided in Section 368a of
the Illinois Insurance Code, and the date upon which
payment from the MCO is received by the provider.
(B) Accuracy of the payment of claims, which shall
mean the expected amount of reimbursement as defined in
the provider's contract or the Medicaid
fee-for-service rate, whichever is applicable,
compared to the actual reimbursement amount received
by the provider.
(C) Total number of provider denials.
(D) Total number of provider denials appealed and
overturned.

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(E) Total number of patient complaints and
grievances.
(F) Total timeframe average for completion of
provider credentialing, which shall mean the
difference between the date upon which a clean
application is submitted to the MCO and the date upon
which the MCO gives final approval and assigns an
effective date for participation in the MCO's network,
for the applicable reporting period.
(G) Total timeframe average for loading provider
information into the MCO's approved provider
directory, which shall mean the date upon which the
provider is approved to the time in which the MCO
validates loading in its directory system.
(H) Total timeframe average for loading provider
information into the MCO's claims system, which shall
mean the date upon which the provider is approved to
the time in which the provider appears in the MCO's
claim system.
(I) Total timeframe average for response times
from MCO staff, which shall mean the length of time
from initial contact by the provider to the time in
which an identified issue is officially documented as
resolved.
(J) Total timeframe average for responses from the
MCO that approve the provider's request to render care

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to the patient.
(2) The Department shall ensure that the tool shall be
accessible in both a print and online format, with the
online format allowing for Medicaid beneficiaries and
providers to access additional detailed MCO performance
information.
(3) At a minimum, the print version of the tool shall
be provided by the Department on an annual basis to
providers and to Medicaid beneficiaries who are required by
the Department to enroll in a MCO during an enrollees open
enrollment period.
(h) The Department shall not expand mandatory MCO
enrollment into new counties beyond those counties already
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 the effective date of this amendatory Act of
the 98th General Assembly.
(Source: P.A. 98-651, eff. 6-16-14.)
Section 99. Effective date. This Act takes effect upon
becoming law.