HR0100 LRB100 10418 MST 20616 r
1		HOUSE RESOLUTION
2		WHEREAS, The Medicaid program in Illinois has an immense,
3		and growing, impact, both in terms of taxpayer dollars and the
4		effect it has on citizens across the State; and
5		WHEREAS, State resources for healthcare services are
6		currently so scarce that many healthcare providers are
7		discontinuing services, leading to a profoundly detrimental
8		impact on our communities; and
9		WHEREAS, Enrollment under the Illinois Department of
10		Healthcare and Family Services' Medical Assistance Programs
11		(Medicaid) exceeds three million; and
12		WHEREAS, A sizable portion of the Medicaid population is
13		currently enrolled, often mandatorily, in Managed Care
14		Organizations (MCOs), making outlays to MCOS, measured in
15		billions of dollars, one of the largest resource uses in the
16		State; and
17		WHEREAS, There has been little information disseminated to
18		the General Assembly in terms of how State resources are being
19		spent on MCOs and on the overall healthcare outcomes for
20		individuals enrolled in these MCOs; and

HR0100 - 2 - LRB100 10418 MST 20616 r
1		WHEREAS, In this quickly evolving environment, the General
2		Assembly must stay engaged in Medicaid funding and
3		corresponding healthcare outcome issues and must be prepared to
4		make legislative and administrative recommendations;
5		therefore, be it
6		RESOLVED, BY THE HOUSE OF REPRESENTATIVES OF THE ONE
7		HUNDREDTH GENERAL ASSEMBLY OF THE STATE OF ILLINOIS, that the
8		Auditor General is directed to conduct an audit of Medicaid
9		MCOs, which includes a comparison of State expenditures between
10		MCOs and fee-for-service entities; and be it further
11		RESOLVED, That the audit shall examine capitation rate
12		setting and reimbursement issues for Medicaid MCOs for fiscal
13		year 2015 with respect to the following issues:
14		(1) Compare the total dollar amount of all reported
15		encounter data submitted to the Illinois Department of
16		Family Services (DHFS) during SFY 2015 to the total dollar
17		amount of reported claims payments made on behalf of
18		Illinois Medicaid individuals by MCOs as reported to DHFS
19		during SPY 2015;
20		(2) Whether encounter data is used by the Department of
21		Healthcare and Family Services (DHFS) to set capitation
22		rates;

HR0100 - 3 - LRB100 10418 MST 20616 r
1		(3) Calculate the aggregate amount of MCO capitation
2		payments made by DHFS during SFY2015 (exclude Hospital
3		Assessment pass-through payments from this calculation);
4		(4) The amount of payments made by DHFS to reimburse
5		for-profit MCOs for the ACA Health Insurance Fee (HIP);
6		determine if this HIP payment is mandated by federal CMS;
7		(5) The amount of payments made by DHFS to reimburse
8		for-profit MCOs for "gros-sup" related to the HIP payment;
9		determine the purpose of the "gross-up" payments;
10		(6) The incidence to which the MCO capitation rates
11		contain supplemental, ORF-based payments to providers; for
12		these payments, determine the amount of the supplemental,
13		which providers received these payments, and whether these
14		monies were directly tied to services actually provided (do
15		not include payments associated with the Hospital
16		Assessment Program);
17		(7) What administrative costs are paid to MCOs in terms
18		of total dollars and percent of overall MCO medical
19		based-payments;
20		(8) What is the overall average medical loss ratio

HR0100 - 4 - LRB100 10418 MST 20616 r
1		(MLR) for all MCOs in aggregate and for each MCO
2		individually; for the purposes of this audit, MLR is
3		defined as all paid claims made by MCOs as reported to HFS
4		for state fiscal year 2015 divided by aggregate MCO
5		capitation payments made by DHFS during the fiscal year;
6		(9) What the denial rates are for MCOs and for
7		fee-for-service providers billing the DHFS; determine
8		whether there is a higher denial rate for services paid by
9		MCOs; and
10		(10) To the extent information is available, determine
11		how Illinois' rate setting methodology compares to other
12		comparable states; and be it further
13		RESOLVED, That the Illinois Department of Healthcare and
14		Family Services and any other State agency having information
15		relevant to this audit cooperate fully and promptly with the
16		Auditor General's Office in its conduct; and be it further
17		RESOLVED, That the Auditor General commence this audit as
18		soon as possible and report his findings and recommendations
19		upon completion in accordance with the provisions of Section
20		3-14 of the Illinois State Auditing Act.