Public Act 099-0725
 
HB6213 EnrolledLRB099 19222 KTG 45140 b


  
    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 and  by adding Section 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. 
    (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 
    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.
        (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.
        (1) The Department shall:
            (A) ensure that an adequate  provider network is in 
        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. require 
        MCOs to maintain an updated and public list of network 
        providers.
    (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.
        (4) The Department may establish a process for MCOs to 
    expedite payments to providers based on criteria 
    established 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.

(Source: P.A. 98-651, eff. 6-16-14.)
 
    (305 ILCS 5/5-30.3 new)
    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, 
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.
        (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 
        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.
        (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 
        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. 
    (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.
        (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 
    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 
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 
    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. 
            (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 
        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.
            (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 
    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. 
  
 
    Section 99. Effective date. This Act takes effect upon 
becoming law.