Bill Text: IL SB1962 | 2023-2024 | 103rd General Assembly | Introduced

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Bill Title: Amends the Illinois Public Aid. Makes a technical change in a Section concerning managed care protections.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced) 2024-04-15 - Chief Sponsor Changed to Sen. Don Harmon [SB1962 Detail]

Download: Illinois-2023-SB1962-Introduced.html

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103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB1962 Introduced 2/9/2023, by Sen. Ann Gillespie SYNOPSIS AS INTRODUCED:
305 ILCS 5/5-30.1
Amends the Illinois Public Aid. Makes a technical change in a Section concerning managed care protections.
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A BILL FOR
SB1962 LRB103 30582 KTG 57019 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 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

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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

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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

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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:

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(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;
(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;
(E) require MCOs to ensure that any
Medicaid-certified provider under contract with an MCO
and previously submitted on a roster on the date of
service is paid for any medically necessary,
Medicaid-covered, and authorized service rendered to
any of the MCO's enrollees, regardless of inclusion on
the MCO's published and publicly available directory
of available providers; and
(F) require MCOs, including Medicaid Managed Care
Entities as defined in Section 5-30.2, to meet each of
the requirements under subsection (d-5) of Section 10
of the Network Adequacy and Transparency Act; with
necessary exceptions to the MCO's network to ensure
that admission and treatment with a provider or at a
treatment facility in accordance with the network
adequacy standards in paragraph (3) of subsection

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(d-5) of Section 10 of the Network Adequacy and
Transparency Act is limited to providers or facilities
that are Medicaid certified.
(2) Each MCO shall confirm its receipt of information
submitted specific to physician or dentist additions or
physician or dentist deletions from the MCO's provider
network within 3 days after receiving all required
information from contracted physicians or dentists, and
electronic physician and dental 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 timely payment interest penalty imposed under
Section 368a of the Illinois Insurance Code for any claims
not timely paid.
(A) When an MCO is required to pay a timely payment
interest penalty to a provider, the MCO must calculate
and pay the timely payment interest penalty that is

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due to the provider within 30 days after the payment of
the claim. In no event shall a provider be required to
request or apply for payment of any owed timely
payment interest penalties.
(B) Such payments shall be reported separately
from the claim payment for services rendered to the
MCO's enrollee and clearly identified as interest
payments.
(4)(A) The Department shall require MCOs to expedite
payments to providers identified on the Department's
expedited provider list, determined in accordance with 89
Ill. Adm. Code 140.71(b), on a schedule at least as
frequently as the providers are paid under the
Department's fee-for-service expedited provider schedule.
(B) Compliance with the expedited provider requirement
may be satisfied by an MCO through the use of a Periodic
Interim Payment (PIP) program that has been mutually
agreed to and documented between the MCO and the provider,
if the PIP program ensures that any expedited provider
receives regular and periodic payments based on prior
period payment experience from that MCO. Total payments
under the PIP program may be reconciled against future PIP
payments on a schedule mutually agreed to between the MCO
and the provider.
(C) The Department shall share at least monthly its
expedited provider list and the frequency with which it

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pays providers on the expedited list.
(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 in the assignment
of coverage responsibility between MCOs or the
fee-for-service system, except for instances when an
individual is deemed to have not been eligible for
coverage under the Illinois Medicaid program; 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

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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.
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.
The rules shall be applicable for both MCO coverage
and fee-for-service coverage.
If the fee-for-service system is ultimately determined to
have been responsible for coverage on the date of service, the
Department shall provide for an extended period for claims
submission outside the standard timely filing requirements.
(g-6) MCO Performance Metrics Report.
(1) The Department shall publish, on at least a

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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.
(g-7) MCO claims processing and performance analysis. In
order to monitor MCO payments to hospital providers, pursuant
to Public Act 100-580, the Department shall post an analysis
of MCO claims processing and payment performance on its

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website every 6 months. Such analysis shall include a review
and evaluation of a representative sample of hospital claims
that are rejected and denied for clean and unclean claims and
the top 5 reasons for such actions and timeliness of claims
adjudication, which identifies the percentage of claims
adjudicated within 30, 60, 90, and over 90 days, and the dollar
amounts associated with those claims.
(g-8) Dispute resolution process. The Department shall
maintain a provider complaint portal through which a provider
can submit to the Department unresolved disputes with an MCO.
An unresolved dispute means an MCO's decision that denies in
whole or in part a claim for reimbursement to a provider for
health care services rendered by the provider to an enrollee
of the MCO with which the provider disagrees. Disputes shall
not be submitted to the portal until the provider has availed
itself of the MCO's internal dispute resolution process.
Disputes that are submitted to the MCO internal dispute
resolution process may be submitted to the Department of
Healthcare and Family Services' complaint portal no sooner
than 30 days after submitting to the MCO's internal process
and not later than 30 days after the unsatisfactory resolution
of the internal MCO process or 60 days after submitting the
dispute to the MCO internal process. Multiple claim disputes
involving the same MCO may be submitted in one complaint,
regardless of whether the claims are for different enrollees,
when the specific reason for non-payment of the claims

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involves a common question of fact or policy. Within 10
business days of receipt of a complaint, the Department shall
present such disputes to the appropriate MCO, which shall then
have 30 days to issue its written proposal to resolve the
dispute. The Department may grant one 30-day extension of this
time frame to one of the parties to resolve the dispute. If the
dispute remains unresolved at the end of this time frame or the
provider is not satisfied with the MCO's written proposal to
resolve the dispute, the provider may, within 30 days, request
the Department to review the dispute and make a final
determination. Within 30 days of the request for Department
review of the dispute, both the provider and the MCO shall
present all relevant information to the Department for
resolution and make individuals with knowledge of the issues
available to the Department for further inquiry if needed.
Within 30 days of receiving the relevant information on the
dispute, or the lapse of the period for submitting such
information, the Department shall issue a written decision on
the dispute based on contractual terms between the provider
and the MCO, contractual terms between the MCO and the
Department of Healthcare and Family Services and applicable
Medicaid policy. The decision of the Department shall be
final. By January 1, 2020, the Department shall establish by
rule further details of this dispute resolution process.
Disputes between MCOs and providers presented to the
Department for resolution are not contested cases, as defined

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in Section 1-30 of the Illinois Administrative Procedure Act,
conferring any right to an administrative hearing.
(g-9)(1) The Department shall publish annually on its
website a report on the calculation of each managed care
organization's medical loss ratio showing the following:
(A) Premium revenue, with appropriate adjustments.
(B) Benefit expense, setting forth the aggregate
amount spent for the following:
(i) Direct paid claims.
(ii) Subcapitation payments.
(iii) Other claim payments.
(iv) Direct reserves.
(v) Gross recoveries.
(vi) Expenses for activities that improve health
care quality as allowed by the Department.
(2) The medical loss ratio shall be calculated consistent
with federal law and regulation following a claims runout
period determined by the Department.
(g-10)(1) "Liability effective date" means the date on
which an MCO becomes responsible for payment for medically
necessary and covered services rendered by a provider to one
of its enrollees in accordance with the contract terms between
the MCO and the provider. The liability effective date shall
be the later of:
(A) The execution date of a network participation
contract agreement.

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(B) The date the provider or its representative
submits to the MCO the complete and accurate standardized
roster form for the provider in the format approved by the
Department.
(C) The provider effective date contained within the
Department's provider enrollment subsystem within the
Illinois Medicaid Program Advanced Cloud Technology
(IMPACT) System.
(2) The standardized roster form may be submitted to the
MCO at the same time that the provider submits an enrollment
application to the Department through IMPACT.
(3) By October 1, 2019, the Department shall require all
MCOs to update their provider directory with information for
new practitioners of existing contracted providers within 30
days of receipt of a complete and accurate standardized roster
template in the format approved by the Department provided
that the provider is effective in the Department's provider
enrollment subsystem within the IMPACT system. Such provider
directory shall be readily accessible for purposes of
selecting an approved health care provider and comply with all
other federal and State requirements.
(g-11) The Department shall work with relevant
stakeholders on the development of operational guidelines to
enhance and improve operational performance of Illinois'
Medicaid managed care program, including, but not limited to,
improving provider billing practices, reducing claim

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rejections and inappropriate payment denials, and
standardizing processes, procedures, definitions, and response
timelines, with the goal of reducing provider and MCO
administrative burdens and conflict. The Department shall
include a report on the progress of these program improvements
and other topics in its Fiscal Year 2020 annual report to the
General Assembly.
(g-12) Notwithstanding any other provision of law, if the
Department or an MCO requires submission of a claim for
payment in a non-electronic format, a provider shall always be
afforded a period of no less than 90 business days, as a
correction period, following any notification of rejection by
either the Department or the MCO to correct errors or
omissions in the original submission.
Under no circumstances, either by an MCO or under the
State's fee-for-service system, shall a provider be denied
payment for failure to comply with any timely submission
requirements under this Code or under any existing contract,
unless the non-electronic format claim submission occurs after
the initial 180 days following the latest date of service on
the claim, or after the 90 business days correction period
following notification to the provider of rejection or denial
of payment.
(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

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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 June 16, 2014 (the effective date of Public
Act 98-651).
(j) Health care information released to managed care
organizations. A health care provider shall release to a
Medicaid managed care organization, upon request, and subject
to the Health Insurance Portability and Accountability Act of
1996 and any other law applicable to the release of health
information, the health care information of the MCO's
enrollee, if the enrollee has completed and signed a general
release form that grants to the health care provider
permission to release the recipient's health care information
to the recipient's insurance carrier.
(k) The Department of Healthcare and Family Services,
managed care organizations, a statewide organization
representing hospitals, and a statewide organization
representing safety-net hospitals shall explore ways to
support billing departments in safety-net hospitals.
(l) The requirements of this Section added by Public Act
102-4 shall apply to services provided on or after the first

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day of the month that begins 60 days after April 27, 2021 (the
effective date of Public Act 102-4).
(Source: P.A. 101-209, eff. 8-5-19; 102-4, eff. 4-27-21;
102-43, eff. 7-6-21; 102-144, eff. 1-1-22; 102-454, eff.
8-20-21; 102-813, eff. 5-13-22.)