Bill Amendment: IL SB2830 | 2023-2024 | 103rd General Assembly
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: MEDICAID-MCO PROMPT PAYMENT
Status: 2024-05-03 - Senate Committee Amendment No. 2 Rule 3-9(a) / Re-referred to Assignments [SB2830 Detail]
Download: Illinois-2023-SB2830-Senate_Amendment_002.html
Bill Title: MEDICAID-MCO PROMPT PAYMENT
Status: 2024-05-03 - Senate Committee Amendment No. 2 Rule 3-9(a) / Re-referred to Assignments [SB2830 Detail]
Download: Illinois-2023-SB2830-Senate_Amendment_002.html
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1 | AMENDMENT TO SENATE BILL 2830 | ||||||
2 | AMENDMENT NO. ______. Amend Senate Bill 2830 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 5. The Illinois Public Aid Code is amended by | ||||||
5 | changing Sections 5-30.1 and 5F-35 as follows:
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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 | ||||||
10 | which contracts with the Department to provide services where | ||||||
11 | payment for medical services is made on a capitated basis. | ||||||
12 | "Emergency services" include: | ||||||
13 | (1) emergency services, as defined by Section 10 of | ||||||
14 | the 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 |
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1 | Patient Rights Act; | ||||||
2 | (3) post-stabilization medical services, as defined by | ||||||
3 | Section 10 of the Managed Care Reform and Patient Rights | ||||||
4 | Act; and | ||||||
5 | (4) emergency medical conditions, as defined by | ||||||
6 | Section 10 of the Managed Care Reform and Patient Rights | ||||||
7 | Act. | ||||||
8 | (b) As provided by Section 5-16.12, managed care | ||||||
9 | organizations are subject to the provisions of the Managed | ||||||
10 | Care Reform and Patient Rights Act. | ||||||
11 | (c) An MCO shall pay any provider of emergency services | ||||||
12 | that does not have in effect a contract with the contracted | ||||||
13 | Medicaid MCO. The default rate of reimbursement shall be the | ||||||
14 | rate paid under Illinois Medicaid fee-for-service program | ||||||
15 | methodology, including all policy adjusters, including but not | ||||||
16 | limited to Medicaid High Volume Adjustments, Medicaid | ||||||
17 | Percentage Adjustments, Outpatient High Volume Adjustments, | ||||||
18 | and all outlier add-on adjustments to the extent such | ||||||
19 | adjustments are incorporated in the development of the | ||||||
20 | applicable MCO capitated rates. | ||||||
21 | (d) An MCO shall pay for all post-stabilization services | ||||||
22 | as a covered service in any of the following situations: | ||||||
23 | (1) the MCO authorized such services; | ||||||
24 | (2) such services were administered to maintain the | ||||||
25 | enrollee's stabilized condition within one hour after a | ||||||
26 | request to the MCO for authorization of further |
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1 | post-stabilization services; | ||||||
2 | (3) the MCO did not respond to a request to authorize | ||||||
3 | such services within one hour; | ||||||
4 | (4) the MCO could not be contacted; or | ||||||
5 | (5) the MCO and the treating provider, if the treating | ||||||
6 | provider is a non-affiliated provider, could not reach an | ||||||
7 | agreement concerning the enrollee's care and an affiliated | ||||||
8 | provider was unavailable for a consultation, in which case | ||||||
9 | the MCO must pay for such services rendered by the | ||||||
10 | treating non-affiliated provider until an affiliated | ||||||
11 | provider was reached and either concurred with the | ||||||
12 | treating non-affiliated provider's plan of care or assumed | ||||||
13 | responsibility for the enrollee's care. Such payment shall | ||||||
14 | be made at the default rate of reimbursement paid under | ||||||
15 | Illinois Medicaid fee-for-service program methodology, | ||||||
16 | including all policy adjusters, including but not limited | ||||||
17 | to Medicaid High Volume Adjustments, Medicaid Percentage | ||||||
18 | Adjustments, Outpatient High Volume Adjustments and all | ||||||
19 | outlier add-on adjustments to the extent that such | ||||||
20 | adjustments are incorporated in the development of the | ||||||
21 | applicable MCO capitated rates. | ||||||
22 | (e) The following requirements apply to MCOs in | ||||||
23 | determining payment for all emergency services: | ||||||
24 | (1) MCOs shall not impose any requirements for prior | ||||||
25 | approval of emergency services. | ||||||
26 | (2) The MCO shall cover emergency services provided to |
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1 | enrollees who are temporarily away from their residence | ||||||
2 | and outside the contracting area to the extent that the | ||||||
3 | enrollees would be entitled to the emergency services if | ||||||
4 | they still were within the contracting area. | ||||||
5 | (3) The MCO shall have no obligation to cover medical | ||||||
6 | services provided on an emergency basis that are not | ||||||
7 | covered services under the contract. | ||||||
8 | (4) The MCO shall not condition coverage for emergency | ||||||
9 | services on the treating provider notifying the MCO of the | ||||||
10 | enrollee's screening and treatment within 10 days after | ||||||
11 | presentation for emergency services. | ||||||
12 | (5) The determination of the attending emergency | ||||||
13 | physician, or the provider actually treating the enrollee, | ||||||
14 | of whether an enrollee is sufficiently stabilized for | ||||||
15 | discharge or transfer to another facility, shall be | ||||||
16 | binding on the MCO. The MCO shall cover emergency services | ||||||
17 | for all enrollees whether the emergency services are | ||||||
18 | provided by an affiliated or non-affiliated provider. | ||||||
19 | (6) The MCO's financial responsibility for | ||||||
20 | post-stabilization care services it has not pre-approved | ||||||
21 | ends when: | ||||||
22 | (A) a plan physician with privileges at the | ||||||
23 | treating hospital assumes responsibility for the | ||||||
24 | enrollee's care; | ||||||
25 | (B) a plan physician assumes responsibility for | ||||||
26 | the enrollee's care through transfer; |
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1 | (C) a contracting entity representative and the | ||||||
2 | treating physician reach an agreement concerning the | ||||||
3 | enrollee's care; or | ||||||
4 | (D) the enrollee is discharged. | ||||||
5 | (f) Network adequacy and transparency. | ||||||
6 | (1) The Department shall: | ||||||
7 | (A) ensure that an adequate provider network is in | ||||||
8 | place, taking into consideration health professional | ||||||
9 | shortage areas and medically underserved areas; | ||||||
10 | (B) publicly release an explanation of its process | ||||||
11 | for analyzing network adequacy; | ||||||
12 | (C) periodically ensure that an MCO continues to | ||||||
13 | have an adequate network in place; | ||||||
14 | (D) require MCOs, including Medicaid Managed Care | ||||||
15 | Entities as defined in Section 5-30.2, to meet | ||||||
16 | provider directory requirements under Section 5-30.3; | ||||||
17 | (E) require MCOs to ensure that any | ||||||
18 | Medicaid-certified provider under contract with an MCO | ||||||
19 | and previously submitted on a roster on the date of | ||||||
20 | service is paid for any medically necessary, | ||||||
21 | Medicaid-covered, and authorized service rendered to | ||||||
22 | any of the MCO's enrollees, regardless of inclusion on | ||||||
23 | the MCO's published and publicly available directory | ||||||
24 | of available providers; and | ||||||
25 | (F) require MCOs, including Medicaid Managed Care | ||||||
26 | Entities as defined in Section 5-30.2, to meet each of |
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1 | the requirements under subsection (d-5) of Section 10 | ||||||
2 | of the Network Adequacy and Transparency Act; with | ||||||
3 | necessary exceptions to the MCO's network to ensure | ||||||
4 | that admission and treatment with a provider or at a | ||||||
5 | treatment facility in accordance with the network | ||||||
6 | adequacy standards in paragraph (3) of subsection | ||||||
7 | (d-5) of Section 10 of the Network Adequacy and | ||||||
8 | Transparency Act is limited to providers or facilities | ||||||
9 | that are Medicaid certified. | ||||||
10 | (2) Each MCO shall confirm its receipt of information | ||||||
11 | submitted specific to physician or dentist additions or | ||||||
12 | physician or dentist deletions from the MCO's provider | ||||||
13 | network within 3 days after receiving all required | ||||||
14 | information from contracted physicians or dentists, and | ||||||
15 | electronic physician and dental directories must be | ||||||
16 | updated consistent with current rules as published by the | ||||||
17 | Centers for Medicare and Medicaid Services or its | ||||||
18 | successor agency. | ||||||
19 | (g) Timely payment of claims. | ||||||
20 | (1) The MCO shall pay a claim within 30 days of | ||||||
21 | receiving a claim that contains all the essential | ||||||
22 | information needed to adjudicate the claim. | ||||||
23 | (2) The MCO shall notify the billing party of its | ||||||
24 | inability to adjudicate a claim within 30 days of | ||||||
25 | receiving that claim. | ||||||
26 | (3) The MCO shall pay a penalty that is at least equal |
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1 | to the timely payment interest penalty imposed under | ||||||
2 | Section 368a of the Illinois Insurance Code for any claims | ||||||
3 | not timely paid. | ||||||
4 | (A) When an MCO is required to pay a timely payment | ||||||
5 | interest penalty to a provider, the MCO must calculate | ||||||
6 | and pay the timely payment interest penalty that is | ||||||
7 | due to the provider within 30 days after the payment of | ||||||
8 | the claim. In no event shall a provider be required to | ||||||
9 | request or apply for payment of any owed timely | ||||||
10 | payment interest penalties. | ||||||
11 | (B) Such payments shall be reported separately | ||||||
12 | from the claim payment for services rendered to the | ||||||
13 | MCO's enrollee and clearly identified as interest | ||||||
14 | payments. | ||||||
15 | (4)(A) The Department shall require MCOs to expedite | ||||||
16 | payments to providers identified on the Department's | ||||||
17 | expedited provider list, determined in accordance with 89 | ||||||
18 | Ill. Adm. Code 140.71(b), on a schedule at least as | ||||||
19 | frequently as the providers are paid under the | ||||||
20 | Department's fee-for-service expedited provider schedule. | ||||||
21 | (B) Compliance with the expedited provider requirement | ||||||
22 | may be satisfied by an MCO through the use of a Periodic | ||||||
23 | Interim Payment (PIP) program that has been mutually | ||||||
24 | agreed to and documented between the MCO and the provider, | ||||||
25 | if the PIP program ensures that any expedited provider | ||||||
26 | receives regular and periodic payments based on prior |
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1 | period payment experience from that MCO. Total payments | ||||||
2 | under the PIP program may be reconciled against future PIP | ||||||
3 | payments on a schedule mutually agreed to between the MCO | ||||||
4 | and the provider. | ||||||
5 | (C) The Department shall share at least monthly its | ||||||
6 | expedited provider list and the frequency with which it | ||||||
7 | pays providers on the expedited list. | ||||||
8 | (g-1) Timely provider payments other than clean claims. | ||||||
9 | (1) The MCO shall pay to providers all incentive | ||||||
10 | payments, add-on payments, directed payments, and any | ||||||
11 | other Medicaid payment other than clean claims, within 30 | ||||||
12 | days of the posting from the Department. | ||||||
13 | (2) The MCO shall notify the billing party of its | ||||||
14 | inability to pay the payment within 30 days of the posting | ||||||
15 | by the Department. | ||||||
16 | (3) The MCO shall pay a penalty that is at least equal | ||||||
17 | to the timely payment interest penalty imposed under | ||||||
18 | Section 368a of the Illinois Insurance Code for any | ||||||
19 | payments not timely paid. | ||||||
20 | (A) When an MCO is required to pay a timely payment | ||||||
21 | interest penalty to a provider, the MCO must calculate | ||||||
22 | and pay the timely payment interest penalty that is | ||||||
23 | due to the provider within 30 days after the payment of | ||||||
24 | the claim. In no event shall a provider be required to | ||||||
25 | request or apply for payment of any owed timely | ||||||
26 | payment interest penalties. |
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1 | (B) Such payments shall be reported separately | ||||||
2 | from the claim payment for services rendered to the | ||||||
3 | MCO's enrollee and clearly identified as interest | ||||||
4 | payments. | ||||||
5 | (4)(A) The Department shall require MCOs to expedite | ||||||
6 | payments to providers identified on the Department's | ||||||
7 | expedited provider list, determined in accordance with 89 | ||||||
8 | Ill. Adm. Code 140.71(b), on a schedule at least as | ||||||
9 | frequently as the providers are paid under the | ||||||
10 | Department's fee-for-service expedited provider schedule. | ||||||
11 | (B) Compliance with the expedited provider requirement | ||||||
12 | may be satisfied by an MCO through the use of a Periodic | ||||||
13 | Interim Payment (PIP) program that has been mutually | ||||||
14 | agreed to and documented between the MCO and the provider, | ||||||
15 | if the PIP program ensures that any expedited provider | ||||||
16 | receives regular and periodic payments based on prior | ||||||
17 | periodic payment experience from that MCO. Total payments | ||||||
18 | under the PIP program may be reconciled against future PIP | ||||||
19 | payments on a schedule mutually agreed to between the MCO | ||||||
20 | and the provider. | ||||||
21 | (C) The Department shall share at least monthly its | ||||||
22 | expedited provider list and the frequency with which it | ||||||
23 | pays providers on the expedited list. | ||||||
24 | (g-5) Recognizing that the rapid transformation of the | ||||||
25 | Illinois Medicaid program may have unintended operational | ||||||
26 | challenges for both payers and providers: |
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1 | (1) in no instance shall a medically necessary covered | ||||||
2 | service rendered in good faith, based upon eligibility | ||||||
3 | information documented by the provider, be denied coverage | ||||||
4 | or diminished in payment amount if the eligibility or | ||||||
5 | coverage information available at the time the service was | ||||||
6 | rendered is later found to be inaccurate in the assignment | ||||||
7 | of coverage responsibility between MCOs or the | ||||||
8 | fee-for-service system, except for instances when an | ||||||
9 | individual is deemed to have not been eligible for | ||||||
10 | coverage under the Illinois Medicaid program; and | ||||||
11 | (2) the Department shall, by December 31, 2016, adopt | ||||||
12 | rules establishing policies that shall be included in the | ||||||
13 | Medicaid managed care policy and procedures manual | ||||||
14 | addressing payment resolutions in situations in which a | ||||||
15 | provider renders services based upon information obtained | ||||||
16 | after verifying a patient's eligibility and coverage plan | ||||||
17 | through either the Department's current enrollment system | ||||||
18 | or a system operated by the coverage plan identified by | ||||||
19 | the patient presenting for services: | ||||||
20 | (A) such medically necessary covered services | ||||||
21 | shall be considered rendered in good faith; | ||||||
22 | (B) such policies and procedures shall be | ||||||
23 | developed in consultation with industry | ||||||
24 | representatives of the Medicaid managed care health | ||||||
25 | plans and representatives of provider associations | ||||||
26 | representing the majority of providers within the |
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1 | identified provider industry; and | ||||||
2 | (C) such rules shall be published for a review and | ||||||
3 | comment period of no less than 30 days on the | ||||||
4 | Department's website with final rules remaining | ||||||
5 | available on the Department's website. | ||||||
6 | The rules on payment resolutions shall include, but | ||||||
7 | not be limited to: | ||||||
8 | (A) the extension of the timely filing period; | ||||||
9 | (B) retroactive prior authorizations; and | ||||||
10 | (C) guaranteed minimum payment rate of no less | ||||||
11 | than the current, as of the date of service, | ||||||
12 | fee-for-service rate, plus all applicable add-ons, | ||||||
13 | when the resulting service relationship is out of | ||||||
14 | network. | ||||||
15 | The rules shall be applicable for both MCO coverage | ||||||
16 | and fee-for-service coverage. | ||||||
17 | If the fee-for-service system is ultimately determined to | ||||||
18 | have been responsible for coverage on the date of service, the | ||||||
19 | Department shall provide for an extended period for claims | ||||||
20 | submission outside the standard timely filing requirements. | ||||||
21 | (g-6) MCO Performance Metrics Report. | ||||||
22 | (1) The Department shall publish, on at least a | ||||||
23 | quarterly basis, each MCO's operational performance, | ||||||
24 | including, but not limited to, the following categories of | ||||||
25 | metrics: | ||||||
26 | (A) claims payment, including timeliness and |
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1 | accuracy; | ||||||
2 | (B) prior authorizations; | ||||||
3 | (C) grievance and appeals; | ||||||
4 | (D) utilization statistics; | ||||||
5 | (E) provider disputes; | ||||||
6 | (F) provider credentialing; and | ||||||
7 | (G) member and provider customer service. | ||||||
8 | (2) The Department shall ensure that the metrics | ||||||
9 | report is accessible to providers online by January 1, | ||||||
10 | 2017. | ||||||
11 | (3) The metrics shall be developed in consultation | ||||||
12 | with industry representatives of the Medicaid managed care | ||||||
13 | health plans and representatives of associations | ||||||
14 | representing the majority of providers within the | ||||||
15 | identified industry. | ||||||
16 | (4) Metrics shall be defined and incorporated into the | ||||||
17 | applicable Managed Care Policy Manual issued by the | ||||||
18 | Department. | ||||||
19 | (g-7) MCO claims processing and performance analysis. In | ||||||
20 | order to monitor MCO payments to hospital providers, pursuant | ||||||
21 | to Public Act 100-580, the Department shall post an analysis | ||||||
22 | of MCO claims processing and payment performance on its | ||||||
23 | website every 6 months. Such analysis shall include a review | ||||||
24 | and evaluation of a representative sample of hospital claims | ||||||
25 | that are rejected and denied for clean and unclean claims and | ||||||
26 | the top 5 reasons for such actions and timeliness of claims |
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1 | adjudication, which identifies the percentage of claims | ||||||
2 | adjudicated within 30, 60, 90, and over 90 days, and the dollar | ||||||
3 | amounts associated with those claims. | ||||||
4 | (g-8) Dispute resolution process. The Department shall | ||||||
5 | maintain a provider complaint portal through which a provider | ||||||
6 | can submit to the Department unresolved disputes with an MCO. | ||||||
7 | An unresolved dispute means an MCO's decision that denies in | ||||||
8 | whole or in part a claim for reimbursement to a provider for | ||||||
9 | health care services rendered by the provider to an enrollee | ||||||
10 | of the MCO with which the provider disagrees. Disputes shall | ||||||
11 | not be submitted to the portal until the provider has availed | ||||||
12 | itself of the MCO's internal dispute resolution process. | ||||||
13 | Disputes that are submitted to the MCO internal dispute | ||||||
14 | resolution process may be submitted to the Department of | ||||||
15 | Healthcare and Family Services' complaint portal no sooner | ||||||
16 | than 30 days after submitting to the MCO's internal process | ||||||
17 | and not later than 30 days after the unsatisfactory resolution | ||||||
18 | of the internal MCO process or 60 days after submitting the | ||||||
19 | dispute to the MCO internal process. Multiple claim disputes | ||||||
20 | involving the same MCO may be submitted in one complaint, | ||||||
21 | regardless of whether the claims are for different enrollees, | ||||||
22 | when the specific reason for non-payment of the claims | ||||||
23 | involves a common question of fact or policy. Within 10 | ||||||
24 | business days of receipt of a complaint, the Department shall | ||||||
25 | present such disputes to the appropriate MCO, which shall then | ||||||
26 | have 30 days to issue its written proposal to resolve the |
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1 | dispute. The Department may grant one 30-day extension of this | ||||||
2 | time frame to one of the parties to resolve the dispute. If the | ||||||
3 | dispute remains unresolved at the end of this time frame or the | ||||||
4 | provider is not satisfied with the MCO's written proposal to | ||||||
5 | resolve the dispute, the provider may, within 30 days, request | ||||||
6 | the Department to review the dispute and make a final | ||||||
7 | determination. Within 30 days of the request for Department | ||||||
8 | review of the dispute, both the provider and the MCO shall | ||||||
9 | present all relevant information to the Department for | ||||||
10 | resolution and make individuals with knowledge of the issues | ||||||
11 | available to the Department for further inquiry if needed. | ||||||
12 | Within 30 days of receiving the relevant information on the | ||||||
13 | dispute, or the lapse of the period for submitting such | ||||||
14 | information, the Department shall issue a written decision on | ||||||
15 | the dispute based on contractual terms between the provider | ||||||
16 | and the MCO, contractual terms between the MCO and the | ||||||
17 | Department of Healthcare and Family Services and applicable | ||||||
18 | Medicaid policy. The decision of the Department shall be | ||||||
19 | final. By January 1, 2020, the Department shall establish by | ||||||
20 | rule further details of this dispute resolution process. | ||||||
21 | Disputes between MCOs and providers presented to the | ||||||
22 | Department for resolution are not contested cases, as defined | ||||||
23 | in Section 1-30 of the Illinois Administrative Procedure Act, | ||||||
24 | conferring any right to an administrative hearing. | ||||||
25 | (g-9)(1) The Department shall publish annually on its | ||||||
26 | website a report on the calculation of each managed care |
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1 | organization's medical loss ratio showing the following: | ||||||
2 | (A) Premium revenue, with appropriate adjustments. | ||||||
3 | (B) Benefit expense, setting forth the aggregate | ||||||
4 | amount spent for the following: | ||||||
5 | (i) Direct paid claims. | ||||||
6 | (ii) Subcapitation payments. | ||||||
7 | (iii) Other claim payments. | ||||||
8 | (iv) Direct reserves. | ||||||
9 | (v) Gross recoveries. | ||||||
10 | (vi) Expenses for activities that improve health | ||||||
11 | care quality as allowed by the Department. | ||||||
12 | (2) The medical loss ratio shall be calculated consistent | ||||||
13 | with federal law and regulation following a claims runout | ||||||
14 | period determined by the Department. | ||||||
15 | (g-10)(1) "Liability effective date" means the date on | ||||||
16 | which an MCO becomes responsible for payment for medically | ||||||
17 | necessary and covered services rendered by a provider to one | ||||||
18 | of its enrollees in accordance with the contract terms between | ||||||
19 | the MCO and the provider. The liability effective date shall | ||||||
20 | be the later of: | ||||||
21 | (A) The execution date of a network participation | ||||||
22 | contract agreement. | ||||||
23 | (B) The date the provider or its representative | ||||||
24 | submits to the MCO the complete and accurate standardized | ||||||
25 | roster form for the provider in the format approved by the | ||||||
26 | Department. |
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1 | (C) The provider effective date contained within the | ||||||
2 | Department's provider enrollment subsystem within the | ||||||
3 | Illinois Medicaid Program Advanced Cloud Technology | ||||||
4 | (IMPACT) System. | ||||||
5 | (2) The standardized roster form may be submitted to the | ||||||
6 | MCO at the same time that the provider submits an enrollment | ||||||
7 | application to the Department through IMPACT. | ||||||
8 | (3) By October 1, 2019, the Department shall require all | ||||||
9 | MCOs to update their provider directory with information for | ||||||
10 | new practitioners of existing contracted providers within 30 | ||||||
11 | days of receipt of a complete and accurate standardized roster | ||||||
12 | template in the format approved by the Department provided | ||||||
13 | that the provider is effective in the Department's provider | ||||||
14 | enrollment subsystem within the IMPACT system. Such provider | ||||||
15 | directory shall be readily accessible for purposes of | ||||||
16 | selecting an approved health care provider and comply with all | ||||||
17 | other federal and State requirements. | ||||||
18 | (g-11) The Department shall work with relevant | ||||||
19 | stakeholders on the development of operational guidelines to | ||||||
20 | enhance and improve operational performance of Illinois' | ||||||
21 | Medicaid managed care program, including, but not limited to, | ||||||
22 | improving provider billing practices, reducing claim | ||||||
23 | rejections and inappropriate payment denials, and | ||||||
24 | standardizing processes, procedures, definitions, and response | ||||||
25 | timelines, with the goal of reducing provider and MCO | ||||||
26 | administrative burdens and conflict. The Department shall |
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1 | include a report on the progress of these program improvements | ||||||
2 | and other topics in its Fiscal Year 2020 annual report to the | ||||||
3 | General Assembly. | ||||||
4 | (g-12) Notwithstanding any other provision of law, if the | ||||||
5 | Department or an MCO requires submission of a claim for | ||||||
6 | payment in a non-electronic format, a provider shall always be | ||||||
7 | afforded a period of no less than 90 business days, as a | ||||||
8 | correction period, following any notification of rejection by | ||||||
9 | either the Department or the MCO to correct errors or | ||||||
10 | omissions in the original submission. | ||||||
11 | Under no circumstances, either by an MCO or under the | ||||||
12 | State's fee-for-service system, shall a provider be denied | ||||||
13 | payment for failure to comply with any timely submission | ||||||
14 | requirements under this Code or under any existing contract, | ||||||
15 | unless the non-electronic format claim submission occurs after | ||||||
16 | the initial 180 days following the latest date of service on | ||||||
17 | the claim, or after the 90 business days correction period | ||||||
18 | following notification to the provider of rejection or denial | ||||||
19 | of payment. | ||||||
20 | (h) The Department shall not expand mandatory MCO | ||||||
21 | enrollment into new counties beyond those counties already | ||||||
22 | designated by the Department as of June 1, 2014 for the | ||||||
23 | individuals whose eligibility for medical assistance is not | ||||||
24 | the seniors or people with disabilities population until the | ||||||
25 | Department provides an opportunity for accountable care | ||||||
26 | entities and MCOs to participate in such newly designated |
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1 | counties. | ||||||
2 | (h-5) Leading indicator data sharing. By January 1, 2024, | ||||||
3 | the Department shall obtain input from the Department of Human | ||||||
4 | Services, the Department of Juvenile Justice, the Department | ||||||
5 | of Children and Family Services, the State Board of Education, | ||||||
6 | managed care organizations, providers, and clinical experts to | ||||||
7 | identify and analyze key indicators from assessments and data | ||||||
8 | sets available to the Department that can be shared with | ||||||
9 | managed care organizations and similar care coordination | ||||||
10 | entities contracted with the Department as leading indicators | ||||||
11 | for elevated behavioral health crisis risk for children. To | ||||||
12 | the extent permitted by State and federal law, the identified | ||||||
13 | leading indicators shall be shared with managed care | ||||||
14 | organizations and similar care coordination entities | ||||||
15 | contracted with the Department within 6 months of | ||||||
16 | identification for the purpose of improving care coordination | ||||||
17 | with the early detection of elevated risk. Leading indicators | ||||||
18 | shall be reassessed annually with stakeholder input. | ||||||
19 | (i) The requirements of this Section apply to contracts | ||||||
20 | with accountable care entities and MCOs entered into, amended, | ||||||
21 | or renewed after June 16, 2014 (the effective date of Public | ||||||
22 | Act 98-651). | ||||||
23 | (j) Health care information released to managed care | ||||||
24 | organizations. A health care provider shall release to a | ||||||
25 | Medicaid managed care organization, upon request, and subject | ||||||
26 | to the Health Insurance Portability and Accountability Act of |
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1 | 1996 and any other law applicable to the release of health | ||||||
2 | information, the health care information of the MCO's | ||||||
3 | enrollee, if the enrollee has completed and signed a general | ||||||
4 | release form that grants to the health care provider | ||||||
5 | permission to release the recipient's health care information | ||||||
6 | to the recipient's insurance carrier. | ||||||
7 | (k) The Department of Healthcare and Family Services, | ||||||
8 | managed care organizations, a statewide organization | ||||||
9 | representing hospitals, and a statewide organization | ||||||
10 | representing safety-net hospitals shall explore ways to | ||||||
11 | support billing departments in safety-net hospitals. | ||||||
12 | (l) The requirements of this Section added by Public Act | ||||||
13 | 102-4 shall apply to services provided on or after the first | ||||||
14 | day of the month that begins 60 days after April 27, 2021 (the | ||||||
15 | effective date of Public Act 102-4). | ||||||
16 | (Source: P.A. 102-4, eff. 4-27-21; 102-43, eff. 7-6-21; | ||||||
17 | 102-144, eff. 1-1-22; 102-454, eff. 8-20-21; 102-813, eff. | ||||||
18 | 5-13-22; 103-546, eff. 8-11-23.)
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19 | (305 ILCS 5/5F-35) | ||||||
20 | Sec. 5F-35. Reimbursement. The Department shall provide | ||||||
21 | each managed care organization with the quarterly | ||||||
22 | fee-for-service facility-specific RUG-IV nursing component per | ||||||
23 | diem along with any add-ons for enhanced care services, | ||||||
24 | support component per diem, and capital component per diem | ||||||
25 | effective for each nursing home under contract with the |
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