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: Moderate Partisan Bill (Democrat 6-1)
Status: (Passed) 2016-08-05 - Public Act . . . . . . . . . 99-0751
[SB3080 Detail]Download: Illinois-2015-SB3080-Chaptered.html
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Public Act 099-0751
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SB3080 Enrolled | LRB099 20371 KTG 44853 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 Illinois Public Aid Code is amended by |
changing Section 5-30.1 as follows:
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(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
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Section 10 of the Managed Care Reform and Patient Rights
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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 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 |
for any claims not timely paid. |
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(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 |
representatives of the Medicaid managed care health |
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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; |
(C) grievance and appeals; |
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(D) utilization statistics; |
(E) provider disputes; |
(F) provider credentialing; and |
(G) member and provider customer service. |
(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 |
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.
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(Source: P.A. 98-651, eff. 6-16-14.)
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Section 99. Effective date. This Act takes effect upon |
becoming law.
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