HB4635 Summary: Program Integrity for Medicaid and CHIP

• Creates the Program Integrity for Medicaid and the Children's Health Insurance Program Act to detect, prevent, and recover waste, fraud, and abuse in Illinois Medicaid and CHIP programs by shifting from retrospective "pay and chase" to prospective pre-payment models.

• Requires the State to implement five technology and service solutions: provider data verification and screening, clinical code editing, predictive modeling and analytics, fraud investigative services, and claims audit and recovery services.

• Mandates the State contract with The Cooperative Purchasing Network (TCPN) for a competitive request for proposals (RFP) process or use an alternative contractor selection process, with contractors required to demonstrate technical and analytical expertise and comply with conflict-of-interest standards.

• Requires the Department of Healthcare and Family Services to submit reports to the General Assembly within 3 months after years 1, 2, and 3 of implementation detailing savings achieved, waste and fraud prevention success, impacts on beneficiary access and quality, and effects on providers.

• Establishes intent that implementation savings exceed costs through a shared savings model where the State pays a percentage of actual savings achieved; allows a portion of achieved savings to fund program expenditures; effective immediately upon enactment.