Current through Register Vol. 48, No. 12, March 22, 2024
a) The
Department shall enter into contracts with MCCNs for the provision of medical
care to eligible enrollees in accordance with Section 5-11 of the Illinois
Public Aid Code [305
ILCS 5/5-11 ].
b) The Department may limit the number of
MCCNs with which it contracts and shall specify a maximum enrollment capacity
per MCCN.
c) Covered services to be
provided or arranged by an MCCN shall be established in each MCCN's
contract.
d) The Department shall
include, in every contract with an MCCN, language describing the sanctions that
the Department may impose upon the MCCN for failure to comply with this Part or
the terms and conditions of that contract.
1)
The contract shall provide for sanctions including, but not limited to, one or
more of the following:
A) Monetary sanctions
established and assessed by the Department against the MCCN;
B) Freezing enrollment for a period to be
determined by the Department;
C)
Liquidated damages;
D)
Disenrollment of enrollees;
E)
Withholding all payments or any portion of a payment due the MCCN;
and
F) Any other sanctions that are
deemed appropriate by the Department.
2) In addition to any sanctions, the
Department shall have the right to terminate the contract with or without
cause.
e) To be
certified as an MCCN by the Department, an MCCN must meet each of the following
requirements:
1) An MCCN must execute a
written contract with the Department.
2) An MCCN must meet each of the requirements
set forth in the applicable federal and State statutes, regulations and rules,
this Part and the contract.
3) An
MCCN must maintain procedures for enrollee complaints as established in the
contract with the Department. The procedures shall, at a minimum, meet the
standards set forth in the Health Maintenance Organization Act [215 ILCS 125 ],
applicable rules, applicable federal law and the contract. Those requirements
shall include, but are not limited to, requirements that MCCNs maintain:
A) Procedures for registering and responding
to complaints and grievances in a specified time;
B) Procedures for recording the substance of
the complaints;
C) A method for
monitoring complaints against providers and coordinating this function with
established grievance procedures; and
D) A method for tracking minor but regular
complaints about specific providers that may be indicative of
problems.
4) An MCCN
must maintain a quality assurance and utilization review program. The
procedures shall, at a minimum, meet the standards set forth in the Health
Maintenance Organization Act [215 ILCS 125], applicable federal law, and the
contract. Requirements shall include, but are not limited to:
A) The establishment of a quality assurance
plan that satisfies any and all applicable State and federal statutory,
regulatory, administrative, and policy requirements that address quality of
care oversight in managed care;
B)
Utilization and quality assurance monitoring and reporting;
C) The establishment of a peer review
committee that is responsible for reviewing medical care provided, including
issues involving conflicts of interest, and making recommendations for changes
when problems are identified; and
D) Other quality assurance requirements that
are established by the Department.
f) The rates to be paid to MCCNs shall be
established by the Department through its actuary and included in contracts.
Rates shall be certified as actuarially sound in accordance with federal
regulations.
g) If the MCCN's
enrollment exceeds the maximum enrollment capacity set forth in the contract or
its monthly total capitation amount to be paid exceeds $10,000,000, the
Department may limit further enrollment capacity set forth in the contract so
that the monthly total capitation amount does not exceed $10,000,000. If the
MCCN receives a certificate of authority to operate a health maintenance
organization (HMO) from the Department of Insurance, then the Department may
open enrollment to a level commensurate with the HMO's ability to serve the
enrollees.