2023 Illinois Compiled Statutes › Chapter 305 - PUBLIC AID › 305 ILCS 5/ - Illinois Public Aid Code. › Article V-H - Managed Care Organization Provider Assessment

(305 ILCS 5/Art. V-H heading)
ARTICLE V-H.  MANAGED CARE ORGANIZATION PROVIDER ASSESSMENT
(Source: P.A. 103-154, eff. 6-30-23.)
(305 ILCS 5/5H-1)
Sec. 5H-1. Definitions.  As used in this Article:
"Base year" means the 12-month period from January 1, 2018 to December 31, 2018.
"Department" means the Department of Healthcare and Family Services.
"Federal employee health benefit" means the program of health benefits plans, as defined in 5 U.S.C. 8901, available to federal employees under 5 U.S.C. 8901 to 8914.
"Fund" means the Healthcare Provider Relief Fund.
"Managed care organization" means an entity operating  under a certificate of authority issued pursuant to the Health Maintenance Organization Act or as a Managed Care Community Network pursuant to Section 5-11 of this Code.
"Medicaid managed care organization" means a managed care organization under contract with the Department to provide services to recipients of benefits in the medical assistance program pursuant to Article V of this Code, the Children's Health Insurance Program Act, or the Covering ALL KIDS Health Insurance Act. It does not include contracts the same entity or an affiliated entity has for other business.
"Medicare" means the federal Medicare program established under Title XVIII of the federal Social Security Act.
"Member months" means the aggregate total number of months all individuals are enrolled for coverage in a Managed Care Organization during the base year. Member months are determined by the Department for Medicaid Managed Care Organizations based on enrollment data in its Medicaid Management Information System and by the Department of Insurance for other Managed Care Organizations based on required filings with the Department of Insurance.  Member months do not include months individuals are enrolled in a Limited Health Services Organization, including stand-alone dental or vision plans, a Medicare Advantage Plan, a Medicare Supplement Plan, a Medicaid Medicare Alignment Initiate Plan pursuant to a Memorandum of Understanding between the Department and the Federal Centers for Medicare and Medicaid Services or a Federal Employee Health Benefits Plan.
(Source: P.A. 101-9, eff. 6-5-19; 102-558, eff. 8-20-21.)
(305 ILCS 5/5H-2)
Sec. 5H-2. Federal waivers.  The Department shall request a waiver from the federal Centers for Medicare and Medicaid Services of the broad-based and uniformity provisions of Section 1903(w)(3)(B) and (C) of Title XIX of the Social Security Act, 42 U.S.C. 1396b, relating to the assessment imposed under this Article. The assessment required pursuant to Section 5H-3 shall not be due and payable until such waiver has been approved and all other federal requirements necessary to obtain federal financial participation have been approved by the Centers for Medicare and Medicaid Services.
(Source: P.A. 101-9, eff. 6-5-19.)
(305 ILCS 5/5H-3)
Sec. 5H-3. Managed care assessment.
(a)  For State Fiscal year 2020 through State Fiscal Year 2025, there is imposed upon managed care organization member months an assessment, calculated on base year data, as set forth below for the appropriate tier:
(1)  Tier 1: $60.20 per member month.
(2)  Tier 2: $1.20 per member month.
(3)  Tier 3: $2.40 per member month.
(b)   The tiers are established as follows:
(1) Tier 1 includes the first 4,195,000 member months     in a Medicaid managed care organization for the base year;
(ii) Tier 2 includes member months over 4,195,000 in     a Medicaid managed care organization during the base year; and
(iv)  Tier 3 includes member months during the base     year in a managed care organization that is not a Medicaid managed care organization.
(c)   For State fiscal year 2020 through State fiscal year 2025, the Department may by rule adjust rates or tier parameters or both in order to maximize the revenue generated by the assessment consistent with federal regulations and to meet federal statistical tests necessary for federal financial participation. Any upward adjustment to the Tier 3 rate shall be the minimum necessary to meet federal statistical tests.
(Source: P.A. 101-9, eff. 6-5-19.)
(305 ILCS 5/5H-4)
Sec. 5H-4. Payment of assessment.
(a)  The assessment payable pursuant to Section 5H-3 shall be due and payable in monthly installments, each equaling one-twelfth of the assessment for the year, on the first State business day of each month.
(b) If the approval of the waivers required under Section 5H-2 is delayed beyond the start of State fiscal year 2020, then the first installment shall be due on the first business day of the first month that begins more than 15 days after the date of such approval.  In the event approval results in installments beginning after July 1, 2019, the amount of each installment for that fiscal year shall equal the full amount of the annual assessment divided by the number of payments that will be paid in fiscal year 2020.
(c)  The Department shall notify each managed care organization of its annual fiscal year 2020 assessment and the installment due dates no later than 30 days prior to the first installment due date and the annual assessment and due dates for each subsequent year at least 30 days prior to the start of each fiscal year.
(d)  Proceeds from the assessment levied pursuant to Section 5H-3 shall be deposited into the Fund; provided, however, that proceeds from the assessment levied pursuant to Section 5H-3 upon a county provider as defined in Section 15-1 of this Code shall instead be deposited directly into the County Provider Trust Fund.
(Source: P.A. 101-9, eff. 6-5-19; 101-636, eff. 6-10-20.)
(305 ILCS 5/5H-5)
Sec. 5H-5. Liability or resultant entities.  In the event of a merger, acquisition, or any similar transaction involving entities subject to the assessment under this Article, the resultant entity shall be responsible for the full amount of the assessment for all entities involved in the transaction with the member months allotted to tiers as they were prior to the transaction and no member months shall change tiers as a result of any transaction. A managed care organization that ceases doing business in the State during any fiscal year shall be liable only for the monthly installments due in months that it operated in the State. The Department shall by rule establish a methodology to set the assessment base member months for a managed care organization that begins operating in the State at any time after 2018.  Nothing in this Section shall be construed to limit authority granted in subsection (c) of Section 5H-3.
(Source: P.A. 101-9, eff. 6-5-19; 102-558, eff. 8-20-21.)
(305 ILCS 5/5H-6)
Sec. 5H-6. Recordkeeping; penalties.
(a)  A managed care organization that is liable for the assessment under this Article shall keep accurate and complete records and pertinent documents as may be required by the Department. Records required by the Department shall be retained for a period of 4 years after the assessment imposed under this Act to which the records apply is due or as otherwise provided by law. The Department or the Department of Insurance may audit all records necessary to ensure compliance with this Article and make adjustments to assessment amounts previously calculated based on the results of any such audit.
(b)  If a managed care organization fails to make a payment due under this Article in a timely fashion, it shall pay an additional penalty of 5% of the amount of the installment not paid on or before the due date, or any grace period granted, plus 5% of the portion thereof remaining unpaid on the last day of each 30-day period thereafter. The Department is authorized to grant grace periods of up to 30 days upon request of a managed care organization for good cause due to financial or other difficulties, as determined by the Department. If a managed care organization fails to make a payment within 60 days after the due date the Department shall additionally impose a contractual sanction allowed against a Medicaid managed care organization and may terminate any such contract.  The Department of Insurance shall take action against the certificate of authority of a non-Medicaid managed care organization that fails to pay an installment within 60 days after the due date.
(Source: P.A. 101-9, eff. 6-5-19; 102-558, eff. 8-20-21.)
(305 ILCS 5/5H-7)
Sec. 5H-7. Rulemaking.  The Department may by rule modify or make adjustments to any methodology, assessment amount, assessment  tier, or other similar provision specified in this Article, including broadening the tax base in subsection (a) of Section 5H-3, to the extent necessary to meet the requirements of federal law or regulations, obtain federal approval, or to ensure federal financial participation is available.  However, upward adjustments to Tier 3 rates shall be the minimum necessary to meet federal statistical tests to receive federal financial participation. The Department shall adopt rules to implement this Article under the Illinois Administrative Procedure Act.
(Source: P.A. 101-9, eff. 6-5-19.)
(305 ILCS 5/5H-8)
Sec. 5H-8. Duties of the Department.
(a)  The Department shall ensure that rates to Medicaid managed care organizations are actuarially sound including appropriate incorporation of assessments under this Article, other taxes and administrative expenses, including standardization of processes, and cost of medical care.
(b)  The Department shall pay to each Medicaid managed care organization the amount required to be included in its rates due to the assessment under this Article in order to ensure actuarial soundness within 10 business days of receipt of each assessment payment from the Medicaid managed care organization.  The Department shall extend the deadline for any assessment payment due after the initial assessment payment if the payment to the managed care organizations under this subsection for the previous assessment payment has not been paid.  Such extension shall extend until 7 business days after receipt by the managed care organization of the late payment under this subsection.
(c)  Reimbursement of assessments paid under this Article shall not be required to count as revenue towards any calculation of the managed care organization's medical loss ratio, net worth, risk based capital or other deposit requirements as may otherwise be required under the Insurance Code. Such  reimbursements will be considered revenue in calculating the 6% limit under 42 U.S.C. 433.68(f)(3).
(d)  The Department shall include in its annual report, beginning with its fiscal year 2020 report, and every year thereafter, information on the revenues collected from this assessment, the federal funds drawn based on those revenues, the rates set in Section 5H-3 or any alterations thereof by administrative rule, and other impacts this gross revenue has had on the Medicaid program.
(Source: P.A. 101-9, eff. 6-5-19.)