Illinois Compiled Statutes 305 ILCS 5/5F-20 – Network adequacy
Current as of: 2024 | Check for updates
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(a) Every managed care organization shall allow every nursing home in its service area an opportunity to be a network contracted facility at the plan’s standard terms, conditions, and rates. Either party may opt to limit the contract to existing residents only.
(b) With the exception of subsection (c) of this Section, a managed care organization shall only terminate or refuse to renew a contract with a nursing home if the nursing home fails to meet quality standards if the following conditions are met:
(1) the quality standards are made known to the
(b) With the exception of subsection (c) of this Section, a managed care organization shall only terminate or refuse to renew a contract with a nursing home if the nursing home fails to meet quality standards if the following conditions are met:
Terms Used In Illinois Compiled Statutes 305 ILCS 5/5F-20
- Contract: A legal written agreement that becomes binding when signed.
- Department: means the Department of Healthcare and Family Services. See Illinois Compiled Statutes 305 ILCS 5/5F-15
- MCO: means an entity that meets the definition of health maintenance organization as defined in the Health Maintenance Organization Act, is licensed, regulated and in good standing with the Department of Insurance, and is authorized to participate in the nursing home component of the Medicare-Medicaid Alignment Initiative Demonstration Project by a 3-way contract with the Department of Healthcare and Family Services and the Centers for Medicare and Medicaid Services. See Illinois Compiled Statutes 305 ILCS 5/5F-15
- Nursing home: means a facility licensed under the Nursing Home Care Act. See Illinois Compiled Statutes 305 ILCS 5/5F-15
(1) the quality standards are made known to the
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nursing home;
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(2) the quality standards can be objectively
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measured through data;
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(3) the nursing home is measured on at least a
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year’s worth of performance;
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(4) a nursing home that the MCO has determined did
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not meet a quality standard has the opportunity to contest that determination by challenging the accuracy or the measurement of the data through an arbitration process agreed to by contract; and
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(5) the Department may attempt to mediate a dispute
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prior to arbitration.
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(c) A managed care organization may terminate or refuse to renew a contract with a nursing home for a material breach of the contract, including, but not limited to, failure to grant reasonable and timely access to the MCO’s care coordinators, SNFists and other providers, termination from the Medicare or Medicaid program, or revocation of license.