(305 ILCS 5/Art. V-F heading)
(305 ILCS 5/5F-1)
Sec. 5F-1. Short title. This Article may be referred to as the Medicare-Medicaid Alignment Initiative (MMAI) Nursing Home Residents' Managed Care Rights Law.
(Source: P.A. 98-651, eff. 6-16-14.)
(305 ILCS 5/5F-5)
Sec. 5F-5. Findings. The General Assembly finds that elderly Illinoisans residing in a nursing home have the right to:
(Source: P.A. 98-651, eff. 6-16-14.)
(305 ILCS 5/5F-10)
Sec. 5F-10. Scope. This Article applies to policies and contracts amended, delivered, issued, or renewed on or after the effective date of this amendatory Act of the 98th General Assembly for the nursing home component of the Medicare-Medicaid Alignment Initiative and the Managed Long-Term Services and Support Program. This Article does not diminish a managed care organization's duties and responsibilities under other federal or State laws or rules adopted under those laws and the 3-way Medicare-Medicaid Alignment Initiative contract and the Managed Long-Term Services and Support Program contract.
(Source: P.A. 98-651, eff. 6-16-14; 99-719, eff. 1-1-17.)
(305 ILCS 5/5F-15)
Sec. 5F-15. Definitions. As used in this Article:
"Appeal" means any of the procedures that deal with the review of adverse organization determinations on the health care services the enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services, such that a delay would adversely affect the health of the enrollee or on any amounts the enrollee must pay for a service, as defined under 42 CFR 422.566(b). These procedures include reconsiderations by the managed care organization and, if necessary, an independent review entity as provided by the Health Carrier External Review Act, hearings before administrative law judges, review by the Medicare Appeals Council, and judicial review.
"Demonstration Project" means the nursing home component of the Medicare-Medicaid Alignment Initiative Demonstration Project.
"Department" means the Department of Healthcare and Family Services.
"Enrollee" means an individual who resides in a nursing home or is qualified to be admitted to a nursing home and is enrolled with a managed care organization participating in the Demonstration Project.
"Health care services" means the diagnosis, treatment, and prevention of disease and includes medication, primary care, nursing or medical care, mental health treatment, psychiatric rehabilitation, memory loss services, physical, occupational, and speech rehabilitation, enhanced care, medical supplies and equipment and the repair of such equipment, and assistance with activities of daily living.
"Managed care organization" or "MCO" means an entity that meets the definition of health maintenance organization as defined in the Health Maintenance Organization Act, is licensed, regulated and in good standing with the Department of Insurance, and is authorized to participate in the nursing home component of the Medicare-Medicaid Alignment Initiative Demonstration Project by a 3-way contract with the Department of Healthcare and Family Services and the Centers for Medicare and Medicaid Services.
"Medical professional" means a physician, physician assistant, or nurse practitioner.
"Medically necessary" means health care services that a medical professional, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, or disease or its symptoms, and that are: (i) in accordance with the generally accepted standards of medical practice; (ii) clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease; and (iii) not primarily for the convenience of the patient, a medical professional, other health care provider, caregiver, family member, or other interested party.
"Nursing home" means a facility licensed under the Nursing Home Care Act.
"Nurse practitioner" means an individual properly licensed as a nurse practitioner under the Nurse Practice Act.
"Physician" means an individual licensed to practice in all branches of medicine under the Medical Practice Act of 1987.
"Physician assistant" means an individual properly licensed under the Physician Assistant Practice Act of 1987.
"Resident" means an enrollee who is receiving personal or medical care, including, but not limited to, mental health treatment, psychiatric rehabilitation, physical rehabilitation, and assistance with activities of daily living, from a nursing home.
"RAI Manual" means the most recent Resident Assessment Instrument Manual, published by the Centers for Medicare and Medicaid Services.
"Resident's representative" means a person designated in writing by a resident to be the resident's representative or the resident's guardian, as described by the Nursing Home Care Act.
"SNFist" means a medical professional specializing in the care of individuals residing in nursing homes employed by or under contract with a MCO.
"Transition period" means a period of time immediately following enrollment into the Demonstration Project or an enrollee's movement from one managed care organization to another managed care organization or one care setting to another care setting.
(Source: P.A. 98-651, eff. 6-16-14.)
(305 ILCS 5/5F-20)
Sec. 5F-20. Network adequacy.
(a) Every managed care organization shall allow every nursing home in its service area an opportunity to be a network contracted facility at the plan's standard terms, conditions, and rates. Either party may opt to limit the contract to existing residents only.
(b) With the exception of subsection (c) of this Section, a managed care organization shall only terminate or refuse to renew a contract with a nursing home if the nursing home fails to meet quality standards if the following conditions are met:
(c) A managed care organization may terminate or refuse to renew a contract with a nursing home for a material breach of the contract, including, but not limited to, failure to grant reasonable and timely access to the MCO's care coordinators, SNFists and other providers, termination from the Medicare or Medicaid program, or revocation of license.
(Source: P.A. 98-651, eff. 6-16-14.)
(305 ILCS 5/5F-25)
Sec. 5F-25. Care coordination. Care coordination provided to all enrollees in the Demonstration Project shall conform to the following requirements:
(Source: P.A. 98-651, eff. 6-16-14.)
(305 ILCS 5/5F-30)
Sec. 5F-30. Continuity of care. When a nursing home resident first transitions to a managed care organization from the fee-for-service system or from another managed care organization, the managed care organization shall honor the existing care plan and any necessary changes to that care plan until the MCO has completed a comprehensive assessment and new care plan, to the extent such services are covered benefits under the contract, which shall be consistent with the requirements of the RAI Manual.
When an enrollee of a managed care organization is moving from a community setting to a nursing home, and the MCO is properly notified of the proposed admission by a network nursing home, and the managed care organization fails to participate in developing a care plan within the time frames required by nursing home regulations, the MCO must honor a care plan developed by the nursing home until the MCO has completed a comprehensive assessment and a new care plan to the extent such services are covered benefits under the contract, consistent with the requirements of the RAI Manual.
A nursing home shall have the ability to refuse admission of an enrollee for whom care is required that the nursing home determines is outside the scope of its license and healthcare capabilities.
(Source: P.A. 98-651, eff. 6-16-14.)
(305 ILCS 5/5F-31)
Sec. 5F-31. Patient credit files; denials of claims. To reduce the number of claim denials resulting from coverage plan errors, the Department shall provide each nursing home enrolled in one or more Medicaid managed care networks with the corresponding patient credit file at the same time the Department provides the files to the managed care organization.
(Source: P.A. 100-1085, eff. 1-1-19.)
(305 ILCS 5/5F-32)
Sec. 5F-32. Non-emergency prior approval and appeal.
(a) MCOs must have a method of receiving prior approval requests 24 hours a day, 7 days a week, 365 days a year from nursing home residents, physicians, or providers. If a response is not provided within 24 hours of the request and the nursing home is required by regulation to provide a service because a physician ordered it, the MCO must pay for the service if it is a covered service under the MCO's contract in the Demonstration Project, provided that the request is consistent with the policies and procedures of the MCO.
In a non-emergency situation, notwithstanding any provisions in State law to the contrary, in the event a resident's physician orders a service, treatment, or test that is not approved by the MCO, the enrollee, physician, or provider may utilize an expedited appeal to the MCO.
If an enrollee, physician, or provider requests an expedited appeal pursuant to 42 CFR 438.410, the MCO shall notify the individual filing the appeal, whether it is the enrollee, physician, or provider, within 24 hours after the submission of the appeal of all information from the enrollee, physician, or provider that the MCO requires to evaluate the appeal. The MCO shall notify the individual filing the appeal of the MCO's decision on an expedited appeal within 24 hours after receipt of the required information.
(b) While the appeal is pending or if the ordered service, treatment, or test is denied after appeal, the Department of Public Health may not cite the nursing home for failure to provide the ordered service, treatment, or test. The nursing home shall not be liable or responsible for an injury in any regulatory proceeding for the following:
(Source: P.A. 98-651, eff. 6-16-14; 99-719, eff. 1-1-17.)
(305 ILCS 5/5F-33)
Sec. 5F-33. Payment of claims.
(a) Clean claims, as defined by the Department, submitted by a provider to a managed care organization in the form and manner requested by the managed care organization shall be reviewed and paid within 30 days of receipt.
(b) A managed care organization must provide a status update within 60 days of the submission of a claim.
(c) A claim that is rejected or denied shall clearly state the reason for the rejection or denial in sufficient detail to permit the provider to understand the justification for the action.
(d) The Department shall work with stakeholders, including, but not limited to, managed care organizations and nursing home providers, to train them on the application of standardized codes for long-term care services.
(e) Managed care organizations shall provide a manual clearly explaining billing and claims payment procedures, including points of contact for provider services centers, within 15 days of a provider entering into a contract with a managed care organization. The manual shall include all necessary coding and documentation requirements. Providers under contract with a managed care organization on the effective date of this amendatory Act of the 99th General Assembly shall be provided with an electronic copy of these requirements within 30 days of the effective date of this amendatory Act of the 99th General Assembly. Any changes to these requirements shall be delivered electronically to all providers under contract with the managed care organization 30 days prior to the effective date of the change.
(Source: P.A. 99-719, eff. 1-1-17.)
(305 ILCS 5/5F-35)
Sec. 5F-35. Reimbursement. The Department shall provide each managed care organization with the quarterly facility-specific RUG-IV nursing component per diem along with any add-ons for enhanced care services, support component per diem, and capital component per diem effective for each nursing home under contract with the managed care organization.
(Source: P.A. 98-651, eff. 6-16-14.)
(305 ILCS 5/5F-40)
Sec. 5F-40. Contractual requirements.
(a) Every contract shall contain a clause for termination consistent with the Managed Care Reform and Patient Rights Act providing nursing homes the ability to terminate the contract.
(b) All changes to the contract by the MCO shall be preceded by 30 days' written notice sent to the nursing home.
(Source: P.A. 98-651, eff. 6-16-14.)
(305 ILCS 5/5F-45)
Sec. 5F-45. Prohibition. No managed care organization or contract shall contain any provision, policy, or procedure that limits, restricts, or waives any rights set forth in this Article or is expressly prohibited by this Article. Any such policy or procedure is void and unenforceable.
(Source: P.A. 98-651, eff. 6-16-14.)