99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
SB3080
 
Introduced 2/19/2016, by Sen. Donne E. Trotter
 
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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1 AN ACT concerning public aid.


2 Be it enacted by the People of the State of Illinois,

3represented in the General Assembly:



4 Section 5. The Illinois Public Aid Code is amended by 
5changing Section 5-30.1 as follows:

6 (305 ILCS 5/5-30.1)
7 Sec. 5-30.1. Managed care protections.
8 (a) As used in this Section:
9 "Managed care organization" or "MCO" means any entity which 
10contracts with the Department to provide services where payment 
11for medical services is made on a capitated basis.
12 "Emergency services" include:
13  (1) emergency services, as defined by Section 10 of the 
14 Managed Care Reform and Patient Rights Act;
15  (2) emergency medical screening examinations, as 
16 defined by Section 10 of the Managed Care Reform and 
17 Patient Rights Act;
18  (3) post-stabilization medical services, as defined by 
19 Section 10 of the Managed Care Reform and Patient Rights 
20 Act; and
21  (4) emergency medical conditions, as defined by

22 Section 10 of the Managed Care Reform and Patient Rights

23 Act. 
 
 
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1 (b) As provided by Section 5-16.12, managed care 
2organizations are subject to the provisions of the Managed Care 
3Reform and Patient Rights Act.
4 (c) An MCO shall pay any provider of emergency services 
5that does not have in effect a contract with the contracted 
6Medicaid MCO. The default rate of reimbursement shall be the 
7rate paid under Illinois Medicaid fee-for-service program 
8methodology, including all policy adjusters, including but not 
9limited to Medicaid High Volume Adjustments, Medicaid 
10Percentage Adjustments, Outpatient High Volume Adjustments, 
11and all outlier add-on adjustments to the extent such 
12adjustments are incorporated in the development of the 
13applicable MCO capitated rates.
14 (d) An MCO shall pay for all post-stabilization services as 
15a covered service in any of the following situations:
16  (1) the MCO authorized such services;
17  (2) such services were administered to maintain the 
18 enrollee's stabilized condition within one hour after a 
19 request to the MCO for authorization of further 
20 post-stabilization services;
21  (3) the MCO did not respond to a request to authorize 
22 such services within one hour;
23  (4) the MCO could not be contacted; or
24  (5) the MCO and the treating provider, if the treating 
25 provider is a non-affiliated provider, could not reach an 
26 agreement concerning the enrollee's care and an affiliated 
 
 
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1 provider was unavailable for a consultation, in which case 
2 the MCO
must pay for such services rendered by the treating 
3 non-affiliated provider until an affiliated provider was 
4 reached and either concurred with the treating 
5 non-affiliated provider's plan of care or assumed 
6 responsibility for the enrollee's care. Such payment shall 
7 be made at the default rate of reimbursement paid under 
8 Illinois Medicaid fee-for-service program methodology, 
9 including all policy adjusters, including but not limited 
10 to Medicaid High Volume Adjustments, Medicaid Percentage 
11 Adjustments, Outpatient High Volume Adjustments and all 
12 outlier add-on adjustments to the extent that such 
13 adjustments are incorporated in the development of the 
14 applicable MCO capitated rates.
15 (e) The following requirements apply to MCOs in determining 
16payment for all emergency services:
17  (1) MCOs shall not impose any requirements for prior 
18 approval of emergency services.
19  (2) The MCO shall cover emergency services provided to 
20 enrollees who are temporarily away from their residence and 
21 outside the contracting area to the extent that the 
22 enrollees would be entitled to the emergency services if 
23 they still were within the contracting area.
24  (3) The MCO shall have no obligation to cover medical 
25 services provided on an emergency basis that are not 
26 covered services under the contract.
 
 
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1  (4) The MCO shall not condition coverage for emergency 
2 services on the treating provider notifying the MCO of the 
3 enrollee's screening and treatment within 10 days after 
4 presentation for emergency services.
5  (5) The determination of the attending emergency 
6 physician, or the provider actually treating the enrollee, 
7 of whether an enrollee is sufficiently stabilized for 
8 discharge or transfer to another facility, shall be binding 
9 on the MCO. The MCO shall cover emergency services for all 
10 enrollees whether the emergency services are provided by an 
11 affiliated or non-affiliated provider.
12  (6) The MCO's financial responsibility for 
13 post-stabilization care services it has not pre-approved 
14 ends when: 
15   (A) a plan physician with privileges at the 
16 treating hospital assumes responsibility for the 
17 enrollee's care; 
18   (B) a plan physician assumes responsibility for 
19 the enrollee's care through transfer; 
20   (C) a contracting entity representative and the 
21 treating physician reach an agreement concerning the 
22 enrollee's care; or 
23   (D) the enrollee is discharged. 
24 (f) Network adequacy and transparency.
25  (1) The Department shall:
26   (A) ensure that an adequate provider network is in 
 
 
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1 place, taking into consideration health professional 
2 shortage areas and medically underserved areas;
3   (B) publicly release an explanation of its process 
4 for analyzing network adequacy;
5   (C) periodically ensure that an MCO continues to 
6 have an adequate network in place; and
7   (D) require MCOs to maintain an updated and public 
8 list of network providers.
9  (2) Each MCO shall:
10   (A) on a monthly basis, jointly validate with 
11 contracted providers, including contracted provider 
12 groups, any changes in provider information, 
13 including, but not limited to, changes concerning new 
14 providers, terminated providers, updated address 
15 information, hours of operation, or other information 
16 that is material to a Medicaid beneficiary in the 
17 enrollment and provider selection process; and
18   (B) be required to produce system reports that 
19 validate that all MCO systems reflect updated provider 
20 information.
21 (g) Timely payment of claims.
22  (1) The MCO shall pay a claim within 30 days of 
23 receiving a claim that contains all the essential 
24 information needed to adjudicate the claim.
25  (2) The MCO shall notify the billing party of its 
26 inability to adjudicate a claim within 30 days of receiving 
 
 
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1 that claim.
2  (3) The MCO shall pay a penalty that is at least equal 
3 to the penalty imposed under the Illinois Insurance Code 
4 for any claims not timely paid.
5  (4) The Department may establish a process for MCOs to 
6 expedite payments to providers based on criteria 
7 established by the Department.
8 (g-5) In situations in which an enrolled Medicaid provider 
9renders services based on information obtained after verifying 
10a patient's eligibility and coverage plan through either the 
11Department's current enrollment system or the coverage plan 
12identified by the patient presenting for services, such 
13services shall be considered rendered in good faith. In no 
14instance shall a service rendered in good faith be denied 
15coverage or payment if the information available at the time 
16the service was rendered is later found to be inaccurate.
17  (1) The provider of services shall be reimbursed by the 
18 MCO identified at the time services were rendered and based 
19 either on the current contract between the provider and the 
20 MCO or, when a contract does not exist, at the current 
21 Medicaid fee-for-service rate, including all applicable 
22 adjustors.
23  (2) The MCO as identified in paragraph (1) of this 
24 subsection, which pays the provider of services, shall be 
25 responsible for contacting either the Department or the 
26 appropriate MCO to request reimbursement for expenses 
 
 
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1 incurred to reimburse the provider of services.
2  (3) The responsible MCO may not attempt any collection 
3 efforts through subrogation on the provider of services if 
4 the provider can document that the services were provided 
5 based on information obtained at the time the services were 
6 rendered.
7 (g-6) MCO Performance Metrics Comparison Tool.
8  (1) The Department shall create and maintain a MCO 
9 Performance Metrics Comparison Tool that provides periodic 
10 reporting, on at least a quarterly basis, of each MCO's 
11 performance in various administrative measures, including, 
12 but not limited to, the following:
13   (A) Timely payment of claims, which shall mean the 
14 number of days between the date upon which the MCO 
15 receives a clean claim, as provided in Section 368a of 
16 the Illinois Insurance Code, and the date upon which 
17 payment from the MCO is received by the provider.
18   (B) Accuracy of the payment of claims, which shall 
19 mean the expected amount of reimbursement as defined in 
20 the provider's contract or the Medicaid 
21 fee-for-service rate, whichever is applicable, 
22 compared to the actual reimbursement amount received 
23 by the provider.
24   (C) Total number of provider denials.
25   (D) Total number of provider denials appealed and 
26 overturned.
 
 
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1   (E) Total number of patient complaints and 
2 grievances.
3   (F) Total timeframe average for completion of 
4 provider credentialing, which shall mean the 
5 difference between the date upon which a clean 
6 application is submitted to the MCO and the date upon 
7 which the MCO gives final approval and assigns an 
8 effective date for participation in the MCO's network, 
9 for the applicable reporting period.
10   (G) Total timeframe average for loading provider 
11 information into the MCO's approved provider 
12 directory, which shall mean the date upon which the 
13 provider is approved to the time in which the MCO 
14 validates loading in its directory system.
15   (H) Total timeframe average for loading provider 
16 information into the MCO's claims system, which shall 
17 mean the date upon which the provider is approved to 
18 the time in which the provider appears in the MCO's 
19 claim system.
20   (I) Total timeframe average for response times 
21 from MCO staff, which shall mean the length of time 
22 from initial contact by the provider to the time in 
23 which an identified issue is officially documented as 
24 resolved.
25   (J) Total timeframe average for responses from the 
26 MCO that approve the provider's request to render care 
 
 
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1 to the patient.
2  (2) The Department shall ensure that the tool shall be 
3 accessible in both a print and online format, with the 
4 online format allowing for Medicaid beneficiaries and 
5 providers to access additional detailed MCO performance 
6 information.
7  (3) At a minimum, the print version of the tool shall 
8 be provided by the Department on an annual basis to 
9 providers and to Medicaid beneficiaries who are required by 
10 the Department to enroll in a MCO during an enrollees open 
11 enrollment period.
12 (h) The Department shall not expand mandatory MCO 
13enrollment into new counties beyond those counties already 
14designated by the Department as of June 1, 2014 for the 
15individuals whose eligibility for medical assistance is not the 
16seniors or people with disabilities population until the 
17Department provides an opportunity for accountable care 
18entities and MCOs to participate in such newly designated 
19counties.
20 (i) The requirements of this Section apply to contracts 
21with accountable care entities and MCOs entered into, amended, 
22or renewed after the effective date of this amendatory Act of 
23the 98th General Assembly.

24(Source: P.A. 98-651, eff. 6-16-14.)


25 Section 99. Effective date. This Act takes effect upon 
26becoming law.