HB 4980

Abstract

Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to: (1) adopt a single, uniform service authorization program under which service authorization determinations for all individuals enrolled in a managed care organization (MCO) shall be made by the Department's contracted utilization review organization (URO), as defined; (2) require all service authorization determinations made by the URO to be binding upon the MCO; (3) prohibit an MCO from denying or reducing payment of a claim, or recouping payment of a paid claim, for health care services approved by the URO, except in cases of fraud; (4) adopt certain rules concerning service authorization determinations; (5) seek approval from the federal Centers for Medicare and Medicaid Services for enhanced federal matching funds for such improvements to the Department's Medicaid Management Information System to implement the single, uniform service authorization program; and other matters. Makes these changes applicable to managed care contracts issued, amended, delivered, or renewed on or after January 1, 2025. Makes changes to provisions on when an MCO is required to pay for post-stabilization services as a covered service. Prohibits MCOs and the URO from imposing any requirements for prior approval of emergency services. Provides that MCOs are not obligated to cover health care services, as defined, that are provided on an emergency basis but are not covered services under its contract with the Department. Requires the Department to impose sanctions on an MCO for noncompliance, including, but not limited to, financial penalties, suspension of enrollment of new enrollees, and termination of the MCO's contract with the Department. Effective immediately.