100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
HB3844

 

Introduced , by Rep. Tim Butler

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to provide medical assistance coverage for diabetes education provided by a certified diabetes education provider for children with Type 1 diabetes who are under the age of 18. Defines "certified diabetes education provider" to mean a professional who has undergone training and certification under conditions approved by the American Association of Diabetes Educators or a successor association of professionals. Defines "Type 1 diabetes" to have the meaning ascribed to it by the American Diabetes Association or any successor association. Effective immediately.


LRB100 09062 KTG 19211 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB3844LRB100 09062 KTG 19211 b

1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5 as follows:
 
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    Sec. 5-5. Medical services. The Illinois Department, by
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing home,
16or elsewhere; (6) medical care, or any other type of remedial
17care furnished by licensed practitioners; (7) home health care
18services; (8) private duty nursing service; (9) clinic
19services; (10) dental services, including prevention and
20treatment of periodontal disease and dental caries disease for
21pregnant women, provided by an individual licensed to practice
22dentistry or dental surgery; for purposes of this item (10),
23"dental services" means diagnostic, preventive, or corrective

 

 

HB3844- 2 -LRB100 09062 KTG 19211 b

1procedures provided by or under the supervision of a dentist in
2the practice of his or her profession; (11) physical therapy
3and related services; (12) prescribed drugs, dentures, and
4prosthetic devices; and eyeglasses prescribed by a physician
5skilled in the diseases of the eye, or by an optometrist,
6whichever the person may select; (13) other diagnostic,
7screening, preventive, and rehabilitative services, including
8to ensure that the individual's need for intervention or
9treatment of mental disorders or substance use disorders or
10co-occurring mental health and substance use disorders is
11determined using a uniform screening, assessment, and
12evaluation process inclusive of criteria, for children and
13adults; for purposes of this item (13), a uniform screening,
14assessment, and evaluation process refers to a process that
15includes an appropriate evaluation and, as warranted, a
16referral; "uniform" does not mean the use of a singular
17instrument, tool, or process that all must utilize; (14)
18transportation and such other expenses as may be necessary;
19(15) medical treatment of sexual assault survivors, as defined
20in Section 1a of the Sexual Assault Survivors Emergency
21Treatment Act, for injuries sustained as a result of the sexual
22assault, including examinations and laboratory tests to
23discover evidence which may be used in criminal proceedings
24arising from the sexual assault; (16) the diagnosis and
25treatment of sickle cell anemia; and (17) any other medical
26care, and any other type of remedial care recognized under the

 

 

HB3844- 3 -LRB100 09062 KTG 19211 b

1laws of this State, but not including abortions, or induced
2miscarriages or premature births, unless, in the opinion of a
3physician, such procedures are necessary for the preservation
4of the life of the woman seeking such treatment, or except an
5induced premature birth intended to produce a live viable child
6and such procedure is necessary for the health of the mother or
7her unborn child. The Illinois Department, by rule, shall
8prohibit any physician from providing medical assistance to
9anyone eligible therefor under this Code where such physician
10has been found guilty of performing an abortion procedure in a
11wilful and wanton manner upon a woman who was not pregnant at
12the time such abortion procedure was performed. The term "any
13other type of remedial care" shall include nursing care and
14nursing home service for persons who rely on treatment by
15spiritual means alone through prayer for healing.
16    Notwithstanding any other provision of this Section, a
17comprehensive tobacco use cessation program that includes
18purchasing prescription drugs or prescription medical devices
19approved by the Food and Drug Administration shall be covered
20under the medical assistance program under this Article for
21persons who are otherwise eligible for assistance under this
22Article.
23    Notwithstanding any other provision of this Code, the
24Illinois Department may not require, as a condition of payment
25for any laboratory test authorized under this Article, that a
26physician's handwritten signature appear on the laboratory

 

 

HB3844- 4 -LRB100 09062 KTG 19211 b

1test order form. The Illinois Department may, however, impose
2other appropriate requirements regarding laboratory test order
3documentation.
4    Notwithstanding any other provision of this Code, the
5Department shall provide medical assistance coverage for
6diabetes education provided by a certified diabetes education
7provider for children with Type 1 diabetes who are under the
8age of 18. For purposes of this paragraph:
9        "Certified diabetes education provider" means a
10    professional who has undergone training and certification
11    under conditions approved by the American Association of
12    Diabetes Educators or a successor association of
13    professionals.
14        "Type 1 diabetes" has the same meaning ascribed to it
15    by the American Diabetes Association or any successor
16    association.
17    Upon receipt of federal approval of an amendment to the
18Illinois Title XIX State Plan for this purpose, the Department
19shall authorize the Chicago Public Schools (CPS) to procure a
20vendor or vendors to manufacture eyeglasses for individuals
21enrolled in a school within the CPS system. CPS shall ensure
22that its vendor or vendors are enrolled as providers in the
23medical assistance program and in any capitated Medicaid
24managed care entity (MCE) serving individuals enrolled in a
25school within the CPS system. Under any contract procured under
26this provision, the vendor or vendors must serve only

 

 

HB3844- 5 -LRB100 09062 KTG 19211 b

1individuals enrolled in a school within the CPS system. Claims
2for services provided by CPS's vendor or vendors to recipients
3of benefits in the medical assistance program under this Code,
4the Children's Health Insurance Program, or the Covering ALL
5KIDS Health Insurance Program shall be submitted to the
6Department or the MCE in which the individual is enrolled for
7payment and shall be reimbursed at the Department's or the
8MCE's established rates or rate methodologies for eyeglasses.
9    On and after July 1, 2012, the Department of Healthcare and
10Family Services may provide the following services to persons
11eligible for assistance under this Article who are
12participating in education, training or employment programs
13operated by the Department of Human Services as successor to
14the Department of Public Aid:
15        (1) dental services provided by or under the
16    supervision of a dentist; and
17        (2) eyeglasses prescribed by a physician skilled in the
18    diseases of the eye, or by an optometrist, whichever the
19    person may select.
20    Notwithstanding any other provision of this Code and
21subject to federal approval, the Department may adopt rules to
22allow a dentist who is volunteering his or her service at no
23cost to render dental services through an enrolled
24not-for-profit health clinic without the dentist personally
25enrolling as a participating provider in the medical assistance
26program. A not-for-profit health clinic shall include a public

 

 

HB3844- 6 -LRB100 09062 KTG 19211 b

1health clinic or Federally Qualified Health Center or other
2enrolled provider, as determined by the Department, through
3which dental services covered under this Section are performed.
4The Department shall establish a process for payment of claims
5for reimbursement for covered dental services rendered under
6this provision.
7    The Illinois Department, by rule, may distinguish and
8classify the medical services to be provided only in accordance
9with the classes of persons designated in Section 5-2.
10    The Department of Healthcare and Family Services must
11provide coverage and reimbursement for amino acid-based
12elemental formulas, regardless of delivery method, for the
13diagnosis and treatment of (i) eosinophilic disorders and (ii)
14short bowel syndrome when the prescribing physician has issued
15a written order stating that the amino acid-based elemental
16formula is medically necessary.
17    The Illinois Department shall authorize the provision of,
18and shall authorize payment for, screening by low-dose
19mammography for the presence of occult breast cancer for women
2035 years of age or older who are eligible for medical
21assistance under this Article, as follows:
22        (A) A baseline mammogram for women 35 to 39 years of
23    age.
24        (B) An annual mammogram for women 40 years of age or
25    older.
26        (C) A mammogram at the age and intervals considered

 

 

HB3844- 7 -LRB100 09062 KTG 19211 b

1    medically necessary by the woman's health care provider for
2    women under 40 years of age and having a family history of
3    breast cancer, prior personal history of breast cancer,
4    positive genetic testing, or other risk factors.
5        (D) A comprehensive ultrasound screening of an entire
6    breast or breasts if a mammogram demonstrates
7    heterogeneous or dense breast tissue, when medically
8    necessary as determined by a physician licensed to practice
9    medicine in all of its branches.
10        (E) A screening MRI when medically necessary, as
11    determined by a physician licensed to practice medicine in
12    all of its branches.
13    All screenings shall include a physical breast exam,
14instruction on self-examination and information regarding the
15frequency of self-examination and its value as a preventative
16tool. For purposes of this Section, "low-dose mammography"
17means the x-ray examination of the breast using equipment
18dedicated specifically for mammography, including the x-ray
19tube, filter, compression device, and image receptor, with an
20average radiation exposure delivery of less than one rad per
21breast for 2 views of an average size breast. The term also
22includes digital mammography and includes breast
23tomosynthesis. As used in this Section, the term "breast
24tomosynthesis" means a radiologic procedure that involves the
25acquisition of projection images over the stationary breast to
26produce cross-sectional digital three-dimensional images of

 

 

HB3844- 8 -LRB100 09062 KTG 19211 b

1the breast. If, at any time, the Secretary of the United States
2Department of Health and Human Services, or its successor
3agency, promulgates rules or regulations to be published in the
4Federal Register or publishes a comment in the Federal Register
5or issues an opinion, guidance, or other action that would
6require the State, pursuant to any provision of the Patient
7Protection and Affordable Care Act (Public Law 111-148),
8including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
9successor provision, to defray the cost of any coverage for
10breast tomosynthesis outlined in this paragraph, then the
11requirement that an insurer cover breast tomosynthesis is
12inoperative other than any such coverage authorized under
13Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
14the State shall not assume any obligation for the cost of
15coverage for breast tomosynthesis set forth in this paragraph.
16    On and after January 1, 2016, the Department shall ensure
17that all networks of care for adult clients of the Department
18include access to at least one breast imaging Center of Imaging
19Excellence as certified by the American College of Radiology.
20    On and after January 1, 2012, providers participating in a
21quality improvement program approved by the Department shall be
22reimbursed for screening and diagnostic mammography at the same
23rate as the Medicare program's rates, including the increased
24reimbursement for digital mammography.
25    The Department shall convene an expert panel including
26representatives of hospitals, free-standing mammography

 

 

HB3844- 9 -LRB100 09062 KTG 19211 b

1facilities, and doctors, including radiologists, to establish
2quality standards for mammography.
3    On and after January 1, 2017, providers participating in a
4breast cancer treatment quality improvement program approved
5by the Department shall be reimbursed for breast cancer
6treatment at a rate that is no lower than 95% of the Medicare
7program's rates for the data elements included in the breast
8cancer treatment quality program.
9    The Department shall convene an expert panel, including
10representatives of hospitals, free standing breast cancer
11treatment centers, breast cancer quality organizations, and
12doctors, including breast surgeons, reconstructive breast
13surgeons, oncologists, and primary care providers to establish
14quality standards for breast cancer treatment.
15    Subject to federal approval, the Department shall
16establish a rate methodology for mammography at federally
17qualified health centers and other encounter-rate clinics.
18These clinics or centers may also collaborate with other
19hospital-based mammography facilities. By January 1, 2016, the
20Department shall report to the General Assembly on the status
21of the provision set forth in this paragraph.
22    The Department shall establish a methodology to remind
23women who are age-appropriate for screening mammography, but
24who have not received a mammogram within the previous 18
25months, of the importance and benefit of screening mammography.
26The Department shall work with experts in breast cancer

 

 

HB3844- 10 -LRB100 09062 KTG 19211 b

1outreach and patient navigation to optimize these reminders and
2shall establish a methodology for evaluating their
3effectiveness and modifying the methodology based on the
4evaluation.
5    The Department shall establish a performance goal for
6primary care providers with respect to their female patients
7over age 40 receiving an annual mammogram. This performance
8goal shall be used to provide additional reimbursement in the
9form of a quality performance bonus to primary care providers
10who meet that goal.
11    The Department shall devise a means of case-managing or
12patient navigation for beneficiaries diagnosed with breast
13cancer. This program shall initially operate as a pilot program
14in areas of the State with the highest incidence of mortality
15related to breast cancer. At least one pilot program site shall
16be in the metropolitan Chicago area and at least one site shall
17be outside the metropolitan Chicago area. On or after July 1,
182016, the pilot program shall be expanded to include one site
19in western Illinois, one site in southern Illinois, one site in
20central Illinois, and 4 sites within metropolitan Chicago. An
21evaluation of the pilot program shall be carried out measuring
22health outcomes and cost of care for those served by the pilot
23program compared to similarly situated patients who are not
24served by the pilot program.
25    The Department shall require all networks of care to
26develop a means either internally or by contract with experts

 

 

HB3844- 11 -LRB100 09062 KTG 19211 b

1in navigation and community outreach to navigate cancer
2patients to comprehensive care in a timely fashion. The
3Department shall require all networks of care to include access
4for patients diagnosed with cancer to at least one academic
5commission on cancer-accredited cancer program as an
6in-network covered benefit.
7    Any medical or health care provider shall immediately
8recommend, to any pregnant woman who is being provided prenatal
9services and is suspected of drug abuse or is addicted as
10defined in the Alcoholism and Other Drug Abuse and Dependency
11Act, referral to a local substance abuse treatment provider
12licensed by the Department of Human Services or to a licensed
13hospital which provides substance abuse treatment services.
14The Department of Healthcare and Family Services shall assure
15coverage for the cost of treatment of the drug abuse or
16addiction for pregnant recipients in accordance with the
17Illinois Medicaid Program in conjunction with the Department of
18Human Services.
19    All medical providers providing medical assistance to
20pregnant women under this Code shall receive information from
21the Department on the availability of services under the Drug
22Free Families with a Future or any comparable program providing
23case management services for addicted women, including
24information on appropriate referrals for other social services
25that may be needed by addicted women in addition to treatment
26for addiction.

 

 

HB3844- 12 -LRB100 09062 KTG 19211 b

1    The Illinois Department, in cooperation with the
2Departments of Human Services (as successor to the Department
3of Alcoholism and Substance Abuse) and Public Health, through a
4public awareness campaign, may provide information concerning
5treatment for alcoholism and drug abuse and addiction, prenatal
6health care, and other pertinent programs directed at reducing
7the number of drug-affected infants born to recipients of
8medical assistance.
9    Neither the Department of Healthcare and Family Services
10nor the Department of Human Services shall sanction the
11recipient solely on the basis of her substance abuse.
12    The Illinois Department shall establish such regulations
13governing the dispensing of health services under this Article
14as it shall deem appropriate. The Department should seek the
15advice of formal professional advisory committees appointed by
16the Director of the Illinois Department for the purpose of
17providing regular advice on policy and administrative matters,
18information dissemination and educational activities for
19medical and health care providers, and consistency in
20procedures to the Illinois Department.
21    The Illinois Department may develop and contract with
22Partnerships of medical providers to arrange medical services
23for persons eligible under Section 5-2 of this Code.
24Implementation of this Section may be by demonstration projects
25in certain geographic areas. The Partnership shall be
26represented by a sponsor organization. The Department, by rule,

 

 

HB3844- 13 -LRB100 09062 KTG 19211 b

1shall develop qualifications for sponsors of Partnerships.
2Nothing in this Section shall be construed to require that the
3sponsor organization be a medical organization.
4    The sponsor must negotiate formal written contracts with
5medical providers for physician services, inpatient and
6outpatient hospital care, home health services, treatment for
7alcoholism and substance abuse, and other services determined
8necessary by the Illinois Department by rule for delivery by
9Partnerships. Physician services must include prenatal and
10obstetrical care. The Illinois Department shall reimburse
11medical services delivered by Partnership providers to clients
12in target areas according to provisions of this Article and the
13Illinois Health Finance Reform Act, except that:
14        (1) Physicians participating in a Partnership and
15    providing certain services, which shall be determined by
16    the Illinois Department, to persons in areas covered by the
17    Partnership may receive an additional surcharge for such
18    services.
19        (2) The Department may elect to consider and negotiate
20    financial incentives to encourage the development of
21    Partnerships and the efficient delivery of medical care.
22        (3) Persons receiving medical services through
23    Partnerships may receive medical and case management
24    services above the level usually offered through the
25    medical assistance program.
26    Medical providers shall be required to meet certain

 

 

HB3844- 14 -LRB100 09062 KTG 19211 b

1qualifications to participate in Partnerships to ensure the
2delivery of high quality medical services. These
3qualifications shall be determined by rule of the Illinois
4Department and may be higher than qualifications for
5participation in the medical assistance program. Partnership
6sponsors may prescribe reasonable additional qualifications
7for participation by medical providers, only with the prior
8written approval of the Illinois Department.
9    Nothing in this Section shall limit the free choice of
10practitioners, hospitals, and other providers of medical
11services by clients. In order to ensure patient freedom of
12choice, the Illinois Department shall immediately promulgate
13all rules and take all other necessary actions so that provided
14services may be accessed from therapeutically certified
15optometrists to the full extent of the Illinois Optometric
16Practice Act of 1987 without discriminating between service
17providers.
18    The Department shall apply for a waiver from the United
19States Health Care Financing Administration to allow for the
20implementation of Partnerships under this Section.
21    The Illinois Department shall require health care
22providers to maintain records that document the medical care
23and services provided to recipients of Medical Assistance under
24this Article. Such records must be retained for a period of not
25less than 6 years from the date of service or as provided by
26applicable State law, whichever period is longer, except that

 

 

HB3844- 15 -LRB100 09062 KTG 19211 b

1if an audit is initiated within the required retention period
2then the records must be retained until the audit is completed
3and every exception is resolved. The Illinois Department shall
4require health care providers to make available, when
5authorized by the patient, in writing, the medical records in a
6timely fashion to other health care providers who are treating
7or serving persons eligible for Medical Assistance under this
8Article. All dispensers of medical services shall be required
9to maintain and retain business and professional records
10sufficient to fully and accurately document the nature, scope,
11details and receipt of the health care provided to persons
12eligible for medical assistance under this Code, in accordance
13with regulations promulgated by the Illinois Department. The
14rules and regulations shall require that proof of the receipt
15of prescription drugs, dentures, prosthetic devices and
16eyeglasses by eligible persons under this Section accompany
17each claim for reimbursement submitted by the dispenser of such
18medical services. No such claims for reimbursement shall be
19approved for payment by the Illinois Department without such
20proof of receipt, unless the Illinois Department shall have put
21into effect and shall be operating a system of post-payment
22audit and review which shall, on a sampling basis, be deemed
23adequate by the Illinois Department to assure that such drugs,
24dentures, prosthetic devices and eyeglasses for which payment
25is being made are actually being received by eligible
26recipients. Within 90 days after September 16, 1984 (the

 

 

HB3844- 16 -LRB100 09062 KTG 19211 b

1effective date of Public Act 83-1439), the Illinois Department
2shall establish a current list of acquisition costs for all
3prosthetic devices and any other items recognized as medical
4equipment and supplies reimbursable under this Article and
5shall update such list on a quarterly basis, except that the
6acquisition costs of all prescription drugs shall be updated no
7less frequently than every 30 days as required by Section
85-5.12.
9    The rules and regulations of the Illinois Department shall
10require that a written statement including the required opinion
11of a physician shall accompany any claim for reimbursement for
12abortions, or induced miscarriages or premature births. This
13statement shall indicate what procedures were used in providing
14such medical services.
15    Notwithstanding any other law to the contrary, the Illinois
16Department shall, within 365 days after July 22, 2013 (the
17effective date of Public Act 98-104), establish procedures to
18permit skilled care facilities licensed under the Nursing Home
19Care Act to submit monthly billing claims for reimbursement
20purposes. Following development of these procedures, the
21Department shall, by July 1, 2016, test the viability of the
22new system and implement any necessary operational or
23structural changes to its information technology platforms in
24order to allow for the direct acceptance and payment of nursing
25home claims.
26    Notwithstanding any other law to the contrary, the Illinois

 

 

HB3844- 17 -LRB100 09062 KTG 19211 b

1Department shall, within 365 days after August 15, 2014 (the
2effective date of Public Act 98-963), establish procedures to
3permit ID/DD facilities licensed under the ID/DD Community Care
4Act and MC/DD facilities licensed under the MC/DD Act to submit
5monthly billing claims for reimbursement purposes. Following
6development of these procedures, the Department shall have an
7additional 365 days to test the viability of the new system and
8to ensure that any necessary operational or structural changes
9to its information technology platforms are implemented.
10    The Illinois Department shall require all dispensers of
11medical services, other than an individual practitioner or
12group of practitioners, desiring to participate in the Medical
13Assistance program established under this Article to disclose
14all financial, beneficial, ownership, equity, surety or other
15interests in any and all firms, corporations, partnerships,
16associations, business enterprises, joint ventures, agencies,
17institutions or other legal entities providing any form of
18health care services in this State under this Article.
19    The Illinois Department may require that all dispensers of
20medical services desiring to participate in the medical
21assistance program established under this Article disclose,
22under such terms and conditions as the Illinois Department may
23by rule establish, all inquiries from clients and attorneys
24regarding medical bills paid by the Illinois Department, which
25inquiries could indicate potential existence of claims or liens
26for the Illinois Department.

 

 

HB3844- 18 -LRB100 09062 KTG 19211 b

1    Enrollment of a vendor shall be subject to a provisional
2period and shall be conditional for one year. During the period
3of conditional enrollment, the Department may terminate the
4vendor's eligibility to participate in, or may disenroll the
5vendor from, the medical assistance program without cause.
6Unless otherwise specified, such termination of eligibility or
7disenrollment is not subject to the Department's hearing
8process. However, a disenrolled vendor may reapply without
9penalty.
10    The Department has the discretion to limit the conditional
11enrollment period for vendors based upon category of risk of
12the vendor.
13    Prior to enrollment and during the conditional enrollment
14period in the medical assistance program, all vendors shall be
15subject to enhanced oversight, screening, and review based on
16the risk of fraud, waste, and abuse that is posed by the
17category of risk of the vendor. The Illinois Department shall
18establish the procedures for oversight, screening, and review,
19which may include, but need not be limited to: criminal and
20financial background checks; fingerprinting; license,
21certification, and authorization verifications; unscheduled or
22unannounced site visits; database checks; prepayment audit
23reviews; audits; payment caps; payment suspensions; and other
24screening as required by federal or State law.
25    The Department shall define or specify the following: (i)
26by provider notice, the "category of risk of the vendor" for

 

 

HB3844- 19 -LRB100 09062 KTG 19211 b

1each type of vendor, which shall take into account the level of
2screening applicable to a particular category of vendor under
3federal law and regulations; (ii) by rule or provider notice,
4the maximum length of the conditional enrollment period for
5each category of risk of the vendor; and (iii) by rule, the
6hearing rights, if any, afforded to a vendor in each category
7of risk of the vendor that is terminated or disenrolled during
8the conditional enrollment period.
9    To be eligible for payment consideration, a vendor's
10payment claim or bill, either as an initial claim or as a
11resubmitted claim following prior rejection, must be received
12by the Illinois Department, or its fiscal intermediary, no
13later than 180 days after the latest date on the claim on which
14medical goods or services were provided, with the following
15exceptions:
16        (1) In the case of a provider whose enrollment is in
17    process by the Illinois Department, the 180-day period
18    shall not begin until the date on the written notice from
19    the Illinois Department that the provider enrollment is
20    complete.
21        (2) In the case of errors attributable to the Illinois
22    Department or any of its claims processing intermediaries
23    which result in an inability to receive, process, or
24    adjudicate a claim, the 180-day period shall not begin
25    until the provider has been notified of the error.
26        (3) In the case of a provider for whom the Illinois

 

 

HB3844- 20 -LRB100 09062 KTG 19211 b

1    Department initiates the monthly billing process.
2        (4) In the case of a provider operated by a unit of
3    local government with a population exceeding 3,000,000
4    when local government funds finance federal participation
5    for claims payments.
6    For claims for services rendered during a period for which
7a recipient received retroactive eligibility, claims must be
8filed within 180 days after the Department determines the
9applicant is eligible. For claims for which the Illinois
10Department is not the primary payer, claims must be submitted
11to the Illinois Department within 180 days after the final
12adjudication by the primary payer.
13    In the case of long term care facilities, within 5 days of
14receipt by the facility of required prescreening information,
15data for new admissions shall be entered into the Medical
16Electronic Data Interchange (MEDI) or the Recipient
17Eligibility Verification (REV) System or successor system, and
18within 15 days of receipt by the facility of required
19prescreening information, admission documents shall be
20submitted through MEDI or REV or shall be submitted directly to
21the Department of Human Services using required admission
22forms. Effective September 1, 2014, admission documents,
23including all prescreening information, must be submitted
24through MEDI or REV. Confirmation numbers assigned to an
25accepted transaction shall be retained by a facility to verify
26timely submittal. Once an admission transaction has been

 

 

HB3844- 21 -LRB100 09062 KTG 19211 b

1completed, all resubmitted claims following prior rejection
2are subject to receipt no later than 180 days after the
3admission transaction has been completed.
4    Claims that are not submitted and received in compliance
5with the foregoing requirements shall not be eligible for
6payment under the medical assistance program, and the State
7shall have no liability for payment of those claims.
8    To the extent consistent with applicable information and
9privacy, security, and disclosure laws, State and federal
10agencies and departments shall provide the Illinois Department
11access to confidential and other information and data necessary
12to perform eligibility and payment verifications and other
13Illinois Department functions. This includes, but is not
14limited to: information pertaining to licensure;
15certification; earnings; immigration status; citizenship; wage
16reporting; unearned and earned income; pension income;
17employment; supplemental security income; social security
18numbers; National Provider Identifier (NPI) numbers; the
19National Practitioner Data Bank (NPDB); program and agency
20exclusions; taxpayer identification numbers; tax delinquency;
21corporate information; and death records.
22    The Illinois Department shall enter into agreements with
23State agencies and departments, and is authorized to enter into
24agreements with federal agencies and departments, under which
25such agencies and departments shall share data necessary for
26medical assistance program integrity functions and oversight.

 

 

HB3844- 22 -LRB100 09062 KTG 19211 b

1The Illinois Department shall develop, in cooperation with
2other State departments and agencies, and in compliance with
3applicable federal laws and regulations, appropriate and
4effective methods to share such data. At a minimum, and to the
5extent necessary to provide data sharing, the Illinois
6Department shall enter into agreements with State agencies and
7departments, and is authorized to enter into agreements with
8federal agencies and departments, including but not limited to:
9the Secretary of State; the Department of Revenue; the
10Department of Public Health; the Department of Human Services;
11and the Department of Financial and Professional Regulation.
12    Beginning in fiscal year 2013, the Illinois Department
13shall set forth a request for information to identify the
14benefits of a pre-payment, post-adjudication, and post-edit
15claims system with the goals of streamlining claims processing
16and provider reimbursement, reducing the number of pending or
17rejected claims, and helping to ensure a more transparent
18adjudication process through the utilization of: (i) provider
19data verification and provider screening technology; and (ii)
20clinical code editing; and (iii) pre-pay, pre- or
21post-adjudicated predictive modeling with an integrated case
22management system with link analysis. Such a request for
23information shall not be considered as a request for proposal
24or as an obligation on the part of the Illinois Department to
25take any action or acquire any products or services.
26    The Illinois Department shall establish policies,

 

 

HB3844- 23 -LRB100 09062 KTG 19211 b

1procedures, standards and criteria by rule for the acquisition,
2repair and replacement of orthotic and prosthetic devices and
3durable medical equipment. Such rules shall provide, but not be
4limited to, the following services: (1) immediate repair or
5replacement of such devices by recipients; and (2) rental,
6lease, purchase or lease-purchase of durable medical equipment
7in a cost-effective manner, taking into consideration the
8recipient's medical prognosis, the extent of the recipient's
9needs, and the requirements and costs for maintaining such
10equipment. Subject to prior approval, such rules shall enable a
11recipient to temporarily acquire and use alternative or
12substitute devices or equipment pending repairs or
13replacements of any device or equipment previously authorized
14for such recipient by the Department. Notwithstanding any
15provision of Section 5-5f to the contrary, the Department may,
16by rule, exempt certain replacement wheelchair parts from prior
17approval and, for wheelchairs, wheelchair parts, wheelchair
18accessories, and related seating and positioning items,
19determine the wholesale price by methods other than actual
20acquisition costs.
21    The Department shall require, by rule, all providers of
22durable medical equipment to be accredited by an accreditation
23organization approved by the federal Centers for Medicare and
24Medicaid Services and recognized by the Department in order to
25bill the Department for providing durable medical equipment to
26recipients. No later than 15 months after the effective date of

 

 

HB3844- 24 -LRB100 09062 KTG 19211 b

1the rule adopted pursuant to this paragraph, all providers must
2meet the accreditation requirement.
3    The Department shall execute, relative to the nursing home
4prescreening project, written inter-agency agreements with the
5Department of Human Services and the Department on Aging, to
6effect the following: (i) intake procedures and common
7eligibility criteria for those persons who are receiving
8non-institutional services; and (ii) the establishment and
9development of non-institutional services in areas of the State
10where they are not currently available or are undeveloped; and
11(iii) notwithstanding any other provision of law, subject to
12federal approval, on and after July 1, 2012, an increase in the
13determination of need (DON) scores from 29 to 37 for applicants
14for institutional and home and community-based long term care;
15if and only if federal approval is not granted, the Department
16may, in conjunction with other affected agencies, implement
17utilization controls or changes in benefit packages to
18effectuate a similar savings amount for this population; and
19(iv) no later than July 1, 2013, minimum level of care
20eligibility criteria for institutional and home and
21community-based long term care; and (v) no later than October
221, 2013, establish procedures to permit long term care
23providers access to eligibility scores for individuals with an
24admission date who are seeking or receiving services from the
25long term care provider. In order to select the minimum level
26of care eligibility criteria, the Governor shall establish a

 

 

HB3844- 25 -LRB100 09062 KTG 19211 b

1workgroup that includes affected agency representatives and
2stakeholders representing the institutional and home and
3community-based long term care interests. This Section shall
4not restrict the Department from implementing lower level of
5care eligibility criteria for community-based services in
6circumstances where federal approval has been granted.
7    The Illinois Department shall develop and operate, in
8cooperation with other State Departments and agencies and in
9compliance with applicable federal laws and regulations,
10appropriate and effective systems of health care evaluation and
11programs for monitoring of utilization of health care services
12and facilities, as it affects persons eligible for medical
13assistance under this Code.
14    The Illinois Department shall report annually to the
15General Assembly, no later than the second Friday in April of
161979 and each year thereafter, in regard to:
17        (a) actual statistics and trends in utilization of
18    medical services by public aid recipients;
19        (b) actual statistics and trends in the provision of
20    the various medical services by medical vendors;
21        (c) current rate structures and proposed changes in
22    those rate structures for the various medical vendors; and
23        (d) efforts at utilization review and control by the
24    Illinois Department.
25    The period covered by each report shall be the 3 years
26ending on the June 30 prior to the report. The report shall

 

 

HB3844- 26 -LRB100 09062 KTG 19211 b

1include suggested legislation for consideration by the General
2Assembly. The filing of one copy of the report with the
3Speaker, one copy with the Minority Leader and one copy with
4the Clerk of the House of Representatives, one copy with the
5President, one copy with the Minority Leader and one copy with
6the Secretary of the Senate, one copy with the Legislative
7Research Unit, and such additional copies with the State
8Government Report Distribution Center for the General Assembly
9as is required under paragraph (t) of Section 7 of the State
10Library Act shall be deemed sufficient to comply with this
11Section.
12    Rulemaking authority to implement Public Act 95-1045, if
13any, is conditioned on the rules being adopted in accordance
14with all provisions of the Illinois Administrative Procedure
15Act and all rules and procedures of the Joint Committee on
16Administrative Rules; any purported rule not so adopted, for
17whatever reason, is unauthorized.
18    On and after July 1, 2012, the Department shall reduce any
19rate of reimbursement for services or other payments or alter
20any methodologies authorized by this Code to reduce any rate of
21reimbursement for services or other payments in accordance with
22Section 5-5e.
23    Because kidney transplantation can be an appropriate, cost
24effective alternative to renal dialysis when medically
25necessary and notwithstanding the provisions of Section 1-11 of
26this Code, beginning October 1, 2014, the Department shall

 

 

HB3844- 27 -LRB100 09062 KTG 19211 b

1cover kidney transplantation for noncitizens with end-stage
2renal disease who are not eligible for comprehensive medical
3benefits, who meet the residency requirements of Section 5-3 of
4this Code, and who would otherwise meet the financial
5requirements of the appropriate class of eligible persons under
6Section 5-2 of this Code. To qualify for coverage of kidney
7transplantation, such person must be receiving emergency renal
8dialysis services covered by the Department. Providers under
9this Section shall be prior approved and certified by the
10Department to perform kidney transplantation and the services
11under this Section shall be limited to services associated with
12kidney transplantation.
13    Notwithstanding any other provision of this Code to the
14contrary, on or after July 1, 2015, all FDA approved forms of
15medication assisted treatment prescribed for the treatment of
16alcohol dependence or treatment of opioid dependence shall be
17covered under both fee for service and managed care medical
18assistance programs for persons who are otherwise eligible for
19medical assistance under this Article and shall not be subject
20to any (1) utilization control, other than those established
21under the American Society of Addiction Medicine patient
22placement criteria, (2) prior authorization mandate, or (3)
23lifetime restriction limit mandate.
24    On or after July 1, 2015, opioid antagonists prescribed for
25the treatment of an opioid overdose, including the medication
26product, administration devices, and any pharmacy fees related

 

 

HB3844- 28 -LRB100 09062 KTG 19211 b

1to the dispensing and administration of the opioid antagonist,
2shall be covered under the medical assistance program for
3persons who are otherwise eligible for medical assistance under
4this Article. As used in this Section, "opioid antagonist"
5means a drug that binds to opioid receptors and blocks or
6inhibits the effect of opioids acting on those receptors,
7including, but not limited to, naloxone hydrochloride or any
8other similarly acting drug approved by the U.S. Food and Drug
9Administration.
10    Upon federal approval, the Department shall provide
11coverage and reimbursement for all drugs that are approved for
12marketing by the federal Food and Drug Administration and that
13are recommended by the federal Public Health Service or the
14United States Centers for Disease Control and Prevention for
15pre-exposure prophylaxis and related pre-exposure prophylaxis
16services, including, but not limited to, HIV and sexually
17transmitted infection screening, treatment for sexually
18transmitted infections, medical monitoring, assorted labs, and
19counseling to reduce the likelihood of HIV infection among
20individuals who are not infected with HIV but who are at high
21risk of HIV infection.
22(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
2398-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
248-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
25eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
2699-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section

 

 

HB3844- 29 -LRB100 09062 KTG 19211 b

120 of P.A. 99-588 for the effective date of P.A. 99-407);
299-433, eff. 8-21-15; 99-480, eff. 9-9-15; 99-588, eff.
37-20-16; 99-642, eff. 7-28-16; 99-772, eff. 1-1-17; 99-895,
4eff. 1-1-17; revised 9-20-16.)
 
5    Section 99. Effective date. This Act takes effect upon
6becoming law.