HB5013: DHFS-PRENATAL/PERINATAL CARE

Legislative Summary

Reinserts the provisions of the engrossed bill with the following changes: Further amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that a managed care organization must pay for preventative prenatal services, perinatal healthcare services, and postpartum services rendered by a non-affiliated provider, for which the health plan would pay if rendered by an affiliated provider, at the rate paid (rather than at no less than the rate paid) under the Illinois Medicaid fee-for-service program methodology for such services. Provides that, in cases where a managed care organization must pay for preventive prenatal services, perinatal healthcare services, and postpartum services rendered by a non-affiliated provider, the payment rate requirements under the amendatory Act shall not apply if the services were not emergency services, as defined in a specified provision of the Code, and: (1) the non-affiliated provider is a perinatal hospital and has, within the 12 months preceding the date of service, rejected a contract that was offered in good faith by the health plan as determined by the Department of Healthcare and Family Services; or (2) the health plan has terminated a contract with the non-affiliated provider for cause, and the Department has not deemed the termination to have been without merit. Provides that the Department may deem that a determination for cause has merit if: (i) an institutional provider has repeatedly failed to conduct discharge planning; or (ii) the provider's conduct adversely and substantially impacts the health of Medicaid patients; or (iii) the provider's conduct constitutes fraud, waste, or abuse; or (iv) the provider's conduct violates the code of ethics governing his or her profession. Effective January 1, 2023.