305 Ill. Comp. Stat. § 5/5-30.1. Managed care protections: Medical Assistance – Illinois

Status: Enacted
Year Enacted: 2014
Year Amended: 2018
File: Download

An MCO shall pay any provider of emergency services that does not have in effect a contract with the contracted Medicaid MCO. The default rate of reimbursement shall be the rate paid under Illinois Medicaid fee-for-service program methodology, including all policy adjusters, including but not limited to Medicaid High Volume Adjustments, Medicaid Percentage Adjustments, Outpatient High Volume Adjustments, and all outlier add-on adjustments to the extent such adjustments are incorporated in the development of the applicable MCO capitated rates. The Department shall ensure that an adequate provider network is in place, taking into consideration health professional shortage areas and medically underserved areas; publicly release an explanation of its process for analyzing network adequacy;periodically ensure that an MCO continues to have an adequate network in place; and require MCOs, including Medicaid Managed Care Entities as defined in Section 5-30.2, to meet provider directory requirements under Section 5-30.3. MCOs shall not impose any requirements for prior approval of emergency services.

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