305 ILCS 5/5-30.8
2021 Illinois Compiled Statutes|Chapter 305 - PUBLIC AID|305 ILCS 5/ - Illinois Public Aid Code.|Article V - Medical Assistance

Sec. 5-30.8. Managed care organization rate transparency.(a)     For the establishment of managed care  organization (MCO) capitation base rate payments from the State,  including, but not limited to: (i) hospital fee schedule  reforms and updates, (ii) rates related to a single  State-mandated preferred drug list, (iii) rate updates related  to the State's preferred drug list, (iv) inclusion of coverage  for children with special needs, (v) inclusion of coverage for  children within the child welfare system, (vi) annual MCO  capitation rates, and (vii) any retroactive provider fee  schedule adjustments or other changes required by legislation  or other actions, the Department of Healthcare and Family  Services shall implement a capitation base rate setting process beginning  on July 27, 2018 (the effective date of Public Act 100-646) which shall include all of the following  elements of transparency:(1)      The Department shall include participating     MCOs and a statewide trade association representing a majority of participating MCOs in meetings to discuss the impact to base capitation rates as a result  of any new or updated hospital fee schedules or     other provider fee schedules. Additionally, the Department     shall share any data or reports used to develop MCO capitation rates     with participating MCOs. This data shall be comprehensive     enough for MCO actuaries to recreate and verify the     accuracy of the capitation base rate build-up.(2) The Department shall not limit the number of         experts that each MCO is allowed to bring to the draft capitation base rate     meeting or the final capitation base rate review meeting. Draft and final capitation base rate review meetings shall be held in at least 2 locations.(3) The Department and its contracted actuary shall         meet with all participating MCOs simultaneously and     together along with consulting actuaries contracted with     statewide trade association representing a majority of Medicaid health plans at the request of the plans.     Participating MCOs shall additionally, at their request,     be granted individual capitation rate development meetings with the     Department.(4)         Any quality incentive or other incentive         withholding of any portion of the actuarially certified     capitation rates must be budget-neutral. The entirety of any aggregate     withheld amounts must be returned to the MCOs in proportion     to their performance on the relevant performance metric. No     amounts shall be returned to the Department if     all performance measures are not achieved to the extent allowable by federal law and regulations.(5)         Upon request, the Department shall     provide written responses to     questions regarding MCO capitation base rates, the capitation base  development     methodology, and MCO capitation rate data, and all other requests regarding     capitation rates from MCOs.  Upon request, the Department shall also provide to the MCOs materials used in incorporating provider fee schedules into base capitation rates.(b) For the development of capitation base rates for new capitation rate years:(1) The Department shall take into account emerging         experience in the development of the annual MCO capitation base rates,     including, but not limited to, current-year cost and     utilization trends observed by MCOs in an actuarially sound manner and in accordance with federal law and regulations.(2) No later than January 1 of each year, the     Department shall release an agreed upon annual calendar that outlines dates for capitation rate setting meetings for that year. The calendar shall include at least the following meetings and deadlines:(A) An initial meeting  for the Department to         review MCO data and draft rate assumptions to be used in the development of capitation base rates for the following year.(B) A draft rate meeting after the Department         provides the MCOs with the      draft capitation base     rates     to discuss, review, and seek feedback regarding the draft capitation base     rates.(3)     Prior to the submission of final capitation     rates to the federal Centers for     Medicare and Medicaid Services, the Department shall     provide the MCOs with a final actuarial report including     the final capitation base rates for the following year and     subsequently conduct a final capitation base  review meeting.     Final capitation rates shall be marked final.(c) For the development of capitation base rates reflecting policy changes:(1) Unless contrary to federal law and regulation,       the Department must provide notice to MCOs     of any significant operational policy change no later than 60 days     prior to the effective date of an operational policy change in order to give MCOs time to  prepare for and implement the operational policy change and to ensure that the quality and delivery of enrollee health care is not disrupted. "Operational policy change" means a change to operational requirements such as reporting formats, encounter submission definitional changes, or required provider interfaces  made at the sole discretion of the Department     and not required by legislation with a retroactive effective date. Nothing in this Section shall be construed as a requirement to delay or prohibit implementation of policy changes that impact enrollee benefits as determined in the sole discretion of the Department.(2)         No later than 60 days after the effective     date of the policy change or     program implementation, the Department shall meet with the     MCOs regarding the initial data collection needed to     establish capitation base rates for the policy change. Additionally,     the Department shall share with the participating MCOs what     other data is needed to estimate the change and the processes for collection of that data that shall be     utilized to develop capitation base rates.(3) No later than 60 days after the effective date of     the policy change or     program implementation, the Department shall meet with     MCOs to review data and the Department's written draft     assumptions to be used in development of capitation base rates for the policy change, and shall provide opportunities for     questions to be asked and answered.(4)         No later than 60 days after the effective     date of the policy change or     program implementation, the Department shall provide the     MCOs with draft capitation base rates and shall also conduct     a draft capitation base rate meeting with MCOs to discuss, review, and seek     feedback regarding the draft capitation base rates.(d) For the development of capitation base rates for retroactive policy or  fee schedule changes:(1) The Department shall meet with the MCOs regarding         the initial data collection needed to establish capitation base rates for     the policy change. Additionally, the Department shall     share with the participating MCOs what other data is needed to estimate the change and the     processes for collection of the data that shall be utilized to develop capitation base     rates.(2) The Department shall meet with MCOs to review     data     and the Department's written draft assumptions to be used     in development of capitation base rates for the policy change. The Department shall     provide opportunities for questions to be asked and     answered.(3) The Department shall provide the MCOs with draft         capitation rates and shall also conduct a draft rate meeting     with MCOs to discuss, review, and seek feedback regarding the draft capitation base rates.(4) The Department shall inform MCOs no less than     quarterly of upcoming benefit and policy changes to the Medicaid program.(e) Meetings of the group established to discuss Medicaid capitation rates under this Section shall be closed to the public and shall not be subject to the Open Meetings Act. Records and information produced by the group established to discuss Medicaid capitation rates under this Section shall be confidential and not subject to the Freedom of Information Act.  (Source: P.A. 100-646, eff. 7-27-18; 101-81, eff. 7-12-19.)