Bill Text: IL HB4979 | 2023-2024 | 103rd General Assembly | Introduced

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Bill Title: Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to adopt rules, by no later than January 1, 2025, to establish a process under which any provider meeting certain performance standards outlined in the amendatory Act shall be certified for a service authorization exemption from all service authorization programs for a period of no less than one year. Provides that qualification for a service authorization exemption shall be determined by the Department, or its contracted utilization review organization (URO), and shall be binding on a managed care organization (MCO) or the MCO's contracted URO. Provides that a provider shall be eligible for a service authorization exemption if the provider submitted at least 25 service authorization requests to a service authorization program in the preceding calendar year and the service authorization program approved at least 80% of the service authorization requests. Provides that no later than December 1 of each calendar year, each service authorization program shall provide written notification to all providers who qualify for a service authorization exemption for the subsequent calendar year. Requires the Department to adopt rules by January 1, 2025 to establish: (i) a standard method the Department, or its contracted URO, shall use to evaluate whether a provider meets the criteria to qualify for a service authorization exemption; (ii) a standard method the Department, or its contracted URO, shall use to accept and process provider appeals of denied or rescinded exemptions; and (iii) a standard method the MCOs shall use to accept and process professional claims and facility claims, as billed by the provider, for a health care service that is rendered, prescribed, or ordered by a provider granted a service authorization exemption, except in cases of fraud. Contains provisions concerning annual reviews by the Department of service authorization denials made under each service authorization program; quarterly reports issued by the Department that detail the performance of each service authorization program; sanctions on MCOs for noncompliance with any provision of the amendatory Act. Effective immediately.

Spectrum: Partisan Bill (Democrat 2-0)

Status: (Introduced) 2024-04-05 - Committee/3rd Reading Deadline Extended-Rule May 24, 2024 [HB4979 Detail]

Download: Illinois-2023-HB4979-Introduced.html

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103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4979 Introduced , by Rep. Robyn Gabel SYNOPSIS AS INTRODUCED:
305 ILCS 5/5-30.18 new
Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to adopt rules, by no later than January 1, 2025, to establish a process under which any provider meeting certain performance standards outlined in the amendatory Act shall be certified for a service authorization exemption from all service authorization programs for a period of no less than one year. Provides that qualification for a service authorization exemption shall be determined by the Department, or its contracted utilization review organization (URO), and shall be binding on a managed care organization (MCO) or the MCO's contracted URO. Provides that a provider shall be eligible for a service authorization exemption if the provider submitted at least 25 service authorization requests to a service authorization program in the preceding calendar year and the service authorization program approved at least 80% of the service authorization requests. Provides that no later than December 1 of each calendar year, each service authorization program shall provide written notification to all providers who qualify for a service authorization exemption for the subsequent calendar year. Requires the Department to adopt rules by January 1, 2025 to establish: (i) a standard method the Department, or its contracted URO, shall use to evaluate whether a provider meets the criteria to qualify for a service authorization exemption; (ii) a standard method the Department, or its contracted URO, shall use to accept and process provider appeals of denied or rescinded exemptions; and (iii) a standard method the MCOs shall use to accept and process professional claims and facility claims, as billed by the provider, for a health care service that is rendered, prescribed, or ordered by a provider granted a service authorization exemption, except in cases of fraud. Contains provisions concerning annual reviews by the Department of service authorization denials made under each service authorization program; quarterly reports issued by the Department that detail the performance of each service authorization program; sanctions on MCOs for noncompliance with any provision of the amendatory Act. Effective immediately.
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A BILL FOR
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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
adding Section 5-30.18 as follows:
(305 ILCS 5/5-30.18 new)
Sec. 5-30.18. Service authorization program performance.
(a) Definitions. As used in this Section:
"Health care service" means any medical or behavioral
health service covered under the medical assistance program
that is rendered in the inpatient or outpatient hospital
setting and subject to review under a service authorization
program.
"Provider" means a facility or individual, or group of
individuals operating under the same tax identification
number, actively enrolled in the medical assistance program
and licensed or otherwise authorized to order, prescribe,
refer, or render health care services in this State.
"Service authorization determination" means a decision
made by a service authorization program to approve, change the
level of care, partially deny, or deny coverage and
reimbursement for a health care service upon review of a
service authorization request submitted by a provider.

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"Service authorization exemption" means an exception
granted by a service authorization program to a provider under
which all service authorization requests for covered health
care services are automatically deemed to be medically
necessary, clinically appropriate, and approved for
reimbursement as ordered.
"Service authorization program" means any utilization
review, utilization management, peer review, quality review,
or other medical management activity conducted in advance of,
concurrent to, or after the provision of a health care service
by a Medicaid managed care organization, either directly or
through a contracted utilization review organization (URO),
including, but not limited to, prior authorization,
pre-certification, certification of admission, concurrent
review, and retrospective review of health care services.
"Service authorization request" means a request by a
provider to a service authorization program to determine
whether a health care service that is otherwise covered under
the medical assistance program meets the reimbursement
requirements established by the managed care organization
(MCO), or its contracted URO, for medically necessary,
clinically appropriate care and to issue a service
authorization determination.
"Utilization review organization" or "URO" means a managed
care organization or other entity that has established or
administers one or more service authorization programs.

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(b) By no later than January 1, 2025, the Department shall
adopt rules to establish a process under which any provider
meeting the performance standards outlined in subsection (c)
shall be certified for a service authorization exemption from
all service authorization programs for a period of no less
than one year. Qualification for a service authorization
exemption shall be determined by the Department, or its
contracted URO, and shall be binding on the MCO or the MCO's
contracted URO.
(c) A provider shall be eligible for a service
authorization exemption if the provider submitted at least 25
service authorization requests to a service authorization
program in the preceding calendar year and the service
authorization program approved at least 80% of the service
authorization requests. A provider shall not be required to
request a service authorization exemption to qualify for such
exemption.
(d) No later than December 1 of each calendar year, each
service authorization program shall provide written
notification to all providers who qualify for a service
authorization exemption, as determined by the Department, for
the subsequent calendar year.
(e) A service authorization program shall not deny,
partially deny, reduce the level of care, or otherwise limit
reimbursement to the rendering or supervising provider,
including the rendering facility, for health care services

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ordered by a provider who qualifies for a service
authorization exemption, except in cases of fraud.
(f) In consultation with the Medicaid managed care
organizations, a statewide association representing managed
care organizations, a statewide association representing the
majority of Illinois hospitals, a statewide association
representing physicians, and a statewide association
representing nursing homes, the Department shall by January 1,
2025 adopt administrative rules to establish:
(1) a standard method the Department, or its
contracted URO, shall use to evaluate whether a provider
meets the criteria to qualify for a service authorization
exemption under subsection (c) and to determine the
conditions under which a service authorization exemption
may be rescinded, including review of the provider's
utilization during the preceding calendar year.
(2) a standard method the Department, or its
contracted URO, shall use to accept and process provider
appeals of denied or rescinded exemptions;
(3) a standard method the MCOs shall use to accept and
process professional claims and facility claims, as billed
by the provider, for a health care service that is
rendered, prescribed, or ordered by a provider granted a
service authorization exemption, except in cases of fraud.
(g) To ensure covered services furnished to individuals
enrolled in an MCO are no less in amount, duration, and scope

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than the same services furnished to individuals enrolled in
the State's fee-for-service medical assistance program,
beginning January 1, 2026, the Department, or its external
quality review organization, shall conduct and make publicly
available the results of an annual review of a sample of
service authorization denials made under each service
authorization program, stratified by MCO during the preceding
calendar year, including denials based on initial review of a
service authorization request and denials overturned on appeal
to the service authorization program's internal process. The
review shall, at a minimum, evaluate whether the
determinations were made:
(1) using consistent application of established,
evidence-based, and professionally recognized medical
necessity criteria that is no more restrictive that the
criteria used in the State's fee-for-service medical
assistance program; and
(2) in compliance with the Department's administrative
rules, the terms of the contract between the Department
and the MCOs, and other applicable federal and State laws,
regulations, and policies.
(h) The Department shall publish quarterly reports
detailing the performance of each service authorization
program, stratified by MCO, including concurrent review and
continued stay review requests, that details, at a minimum,
the number of service authorization requests received, the

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number of requests approved based on review of the initial
request, the number of requests denied based on review of the
initial request and the reasons for the denials, the number of
requests downgraded to a lower level of care and the reasons
for the change in level of care, and the number of denied
requests overturned on appeal and the reasons the requests
were overturned.
(i) The Department shall impose sanctions on a managed
care organization for violating provisions of this Section
that include, but are not limited to, financial penalties,
suspension of enrollment of new enrollees, and termination of
the MCO's contract with the Department.