Public Act 099-0751
 
SB3080 EnrolledLRB099 20371 KTG 44853 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 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 and transparency.
        (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 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.
        (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 
        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;
            (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.

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