Sen. Laura M. Murphy

Filed: 3/30/2017

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 314

2    AMENDMENT NO. ______. Amend Senate Bill 314 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Insurance Code is amended by
5changing Section 356g as follows:
 
6    (215 ILCS 5/356g)  (from Ch. 73, par. 968g)
7    Sec. 356g. Mammograms; mastectomies.
8    (a) Every insurer shall provide in each group or individual
9policy, contract, or certificate of insurance issued or renewed
10for persons who are residents of this State, coverage for
11screening by low-dose mammography for all women 35 years of age
12or older for the presence of occult breast cancer within the
13provisions of the policy, contract, or certificate. The
14coverage shall be as follows:
15         (1) A baseline mammogram for women 35 to 39 years of
16    age.

 

 

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

 

 

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1    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 subsection, 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 subsection.
16    (a-5) Coverage as described by subsection (a) shall be
17provided at no cost to the insured and shall not be applied to
18an annual or lifetime maximum benefit.
19    (a-10) When health care services are available through
20contracted providers and a person does not comply with plan
21provisions specific to the use of contracted providers, the
22requirements of subsection (a-5) are not applicable. When a
23person does not comply with plan provisions specific to the use
24of contracted providers, plan provisions specific to the use of
25non-contracted providers must be applied without distinction
26for coverage required by this Section and shall be at least as

 

 

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1favorable as for other radiological examinations covered by the
2policy or contract.
3    (b) No policy of accident or health insurance that provides
4for the surgical procedure known as a mastectomy shall be
5issued, amended, delivered, or renewed in this State unless
6that coverage also provides for prosthetic devices or
7reconstructive surgery incident to the mastectomy. Coverage
8for breast reconstruction in connection with a mastectomy shall
9include:
10        (1) reconstruction of the breast upon which the
11    mastectomy has been performed;
12        (2) surgery and reconstruction of the other breast to
13    produce a symmetrical appearance; and
14        (3) prostheses and treatment for physical
15    complications at all stages of mastectomy, including
16    lymphedemas.
17Care shall be determined in consultation with the attending
18physician and the patient. The offered coverage for prosthetic
19devices and reconstructive surgery shall be subject to the
20deductible and coinsurance conditions applied to the
21mastectomy, and all other terms and conditions applicable to
22other benefits. When a mastectomy is performed and there is no
23evidence of malignancy then the offered coverage may be limited
24to the provision of prosthetic devices and reconstructive
25surgery to within 2 years after the date of the mastectomy. As
26used in this Section, "mastectomy" means the removal of all or

 

 

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1part of the breast for medically necessary reasons, as
2determined by a licensed physician.
3    Written notice of the availability of coverage under this
4Section shall be delivered to the insured upon enrollment and
5annually thereafter. An insurer may not deny to an insured
6eligibility, or continued eligibility, to enroll or to renew
7coverage under the terms of the plan solely for the purpose of
8avoiding the requirements of this Section. An insurer may not
9penalize or reduce or limit the reimbursement of an attending
10provider or provide incentives (monetary or otherwise) to an
11attending provider to induce the provider to provide care to an
12insured in a manner inconsistent with this Section.
13    (c) Rulemaking authority to implement Public Act 95-1045,
14if any, is conditioned on the rules being adopted in accordance
15with all provisions of the Illinois Administrative Procedure
16Act and all rules and procedures of the Joint Committee on
17Administrative Rules; any purported rule not so adopted, for
18whatever reason, is unauthorized.
19(Source: P.A. 99-407 (see Section 20 of P.A. 99-588 for the
20effective date of P.A. 99-407); 99-433, eff. 8-21-15; 99-588,
21eff. 7-20-16; 99-642, eff. 7-28-16.)
 
22    Section 10. The Health Maintenance Organization Act is
23amended by changing Section 4-6.1 as follows:
 
24    (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)

 

 

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1    Sec. 4-6.1. Mammograms; mastectomies.
2    (a) Every contract or evidence of coverage issued by a
3Health Maintenance Organization for persons who are residents
4of this State shall contain coverage for screening by low-dose
5mammography for all women 35 years of age or older for the
6presence of occult breast cancer. The coverage shall be as
7follows:
8        (1) A baseline mammogram for women 35 to 39 years of
9    age.
10        (2) An annual mammogram for women 40 years of age or
11    older.
12        (3) A mammogram at the age and intervals considered
13    medically necessary by the woman's health care provider for
14    women under 40 years of age and having a family history of
15    breast cancer, prior personal history of breast cancer,
16    positive genetic testing, or other risk factors.
17        (4) A comprehensive ultrasound screening and MRI of an
18    entire breast or breasts if a mammogram demonstrates
19    heterogeneous or dense breast tissue, when medically
20    necessary as determined by a physician licensed to practice
21    medicine in all of its branches.
22    For purposes of this Section, "low-dose mammography" means
23the x-ray examination of the breast using equipment dedicated
24specifically for mammography, including the x-ray tube,
25filter, compression device, and image receptor, with radiation
26exposure delivery of less than 1 rad per breast for 2 views of

 

 

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1an average size breast. The term also includes digital
2mammography and includes breast tomosynthesis. As used in this
3Section, the term "breast tomosynthesis" means a radiologic
4procedure that involves the acquisition of projection images
5over the stationary breast to produce cross-sectional digital
6three-dimensional images of the breast.
7    If, at any time, the Secretary of the United States
8Department of Health and Human Services, or its successor
9agency, promulgates rules or regulations to be published in the
10Federal Register or publishes a comment in the Federal Register
11or issues an opinion, guidance, or other action that would
12require the State, pursuant to any provision of the Patient
13Protection and Affordable Care Act (Public Law 111-148),
14including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
15successor provision, to defray the cost of any coverage for
16breast tomosynthesis outlined in this subsection, then the
17requirement that an insurer cover breast tomosynthesis is
18inoperative other than any such coverage authorized under
19Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
20the State shall not assume any obligation for the cost of
21coverage for breast tomosynthesis set forth in this subsection.
22    (a-5) Coverage as described in subsection (a) shall be
23provided at no cost to the enrollee and shall not be applied to
24an annual or lifetime maximum benefit.
25    (b) No contract or evidence of coverage issued by a health
26maintenance organization that provides for the surgical

 

 

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1procedure known as a mastectomy shall be issued, amended,
2delivered, or renewed in this State on or after the effective
3date of this amendatory Act of the 92nd General Assembly unless
4that coverage also provides for prosthetic devices or
5reconstructive surgery incident to the mastectomy, providing
6that the mastectomy is performed after the effective date of
7this amendatory Act. Coverage for breast reconstruction in
8connection with a mastectomy shall include:
9        (1) reconstruction of the breast upon which the
10    mastectomy has been performed;
11        (2) surgery and reconstruction of the other breast to
12    produce a symmetrical appearance; and
13        (3) prostheses and treatment for physical
14    complications at all stages of mastectomy, including
15    lymphedemas.
16Care shall be determined in consultation with the attending
17physician and the patient. The offered coverage for prosthetic
18devices and reconstructive surgery shall be subject to the
19deductible and coinsurance conditions applied to the
20mastectomy and all other terms and conditions applicable to
21other benefits. When a mastectomy is performed and there is no
22evidence of malignancy, then the offered coverage may be
23limited to the provision of prosthetic devices and
24reconstructive surgery to within 2 years after the date of the
25mastectomy. As used in this Section, "mastectomy" means the
26removal of all or part of the breast for medically necessary

 

 

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1reasons, as determined by a licensed physician.
2    Written notice of the availability of coverage under this
3Section shall be delivered to the enrollee upon enrollment and
4annually thereafter. A health maintenance organization may not
5deny to an enrollee eligibility, or continued eligibility, to
6enroll or to renew coverage under the terms of the plan solely
7for the purpose of avoiding the requirements of this Section. A
8health maintenance organization may not penalize or reduce or
9limit the reimbursement of an attending provider or provide
10incentives (monetary or otherwise) to an attending provider to
11induce the provider to provide care to an insured in a manner
12inconsistent with this Section.
13    (c) Rulemaking authority to implement this amendatory Act
14of the 95th General Assembly, if any, is conditioned on the
15rules being adopted in accordance with all provisions of the
16Illinois Administrative Procedure Act and all rules and
17procedures of the Joint Committee on Administrative Rules; any
18purported rule not so adopted, for whatever reason, is
19unauthorized.
20(Source: P.A. 99-407 (see Section 20 of P.A. 99-588 for the
21effective date of P.A. 99-407); 99-588, eff. 7-20-16.)
 
22    Section 15. The Illinois Public Aid Code is amended by
23changing Section 5-5 as follows:
 
24    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)

 

 

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1    Sec. 5-5. Medical services. The Illinois Department, by
2rule, shall determine the quantity and quality of and the rate
3of reimbursement for the medical assistance for which payment
4will be authorized, and the medical services to be provided,
5which may include all or part of the following: (1) inpatient
6hospital services; (2) outpatient hospital services; (3) other
7laboratory and X-ray services; (4) skilled nursing home
8services; (5) physicians' services whether furnished in the
9office, the patient's home, a hospital, a skilled nursing home,
10or elsewhere; (6) medical care, or any other type of remedial
11care furnished by licensed practitioners; (7) home health care
12services; (8) private duty nursing service; (9) clinic
13services; (10) dental services, including prevention and
14treatment of periodontal disease and dental caries disease for
15pregnant women, provided by an individual licensed to practice
16dentistry or dental surgery; for purposes of this item (10),
17"dental services" means diagnostic, preventive, or corrective
18procedures provided by or under the supervision of a dentist in
19the practice of his or her profession; (11) physical therapy
20and related services; (12) prescribed drugs, dentures, and
21prosthetic devices; and eyeglasses prescribed by a physician
22skilled in the diseases of the eye, or by an optometrist,
23whichever the person may select; (13) other diagnostic,
24screening, preventive, and rehabilitative services, including
25to ensure that the individual's need for intervention or
26treatment of mental disorders or substance use disorders or

 

 

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1co-occurring mental health and substance use disorders is
2determined using a uniform screening, assessment, and
3evaluation process inclusive of criteria, for children and
4adults; for purposes of this item (13), a uniform screening,
5assessment, and evaluation process refers to a process that
6includes an appropriate evaluation and, as warranted, a
7referral; "uniform" does not mean the use of a singular
8instrument, tool, or process that all must utilize; (14)
9transportation and such other expenses as may be necessary;
10(15) medical treatment of sexual assault survivors, as defined
11in Section 1a of the Sexual Assault Survivors Emergency
12Treatment Act, for injuries sustained as a result of the sexual
13assault, including examinations and laboratory tests to
14discover evidence which may be used in criminal proceedings
15arising from the sexual assault; (16) the diagnosis and
16treatment of sickle cell anemia; and (17) any other medical
17care, and any other type of remedial care recognized under the
18laws of this State, but not including abortions, or induced
19miscarriages or premature births, unless, in the opinion of a
20physician, such procedures are necessary for the preservation
21of the life of the woman seeking such treatment, or except an
22induced premature birth intended to produce a live viable child
23and such procedure is necessary for the health of the mother or
24her unborn child. The Illinois Department, by rule, shall
25prohibit any physician from providing medical assistance to
26anyone eligible therefor under this Code where such physician

 

 

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1has been found guilty of performing an abortion procedure in a
2wilful and wanton manner upon a woman who was not pregnant at
3the time such abortion procedure was performed. The term "any
4other type of remedial care" shall include nursing care and
5nursing home service for persons who rely on treatment by
6spiritual means alone through prayer for healing.
7    Notwithstanding any other provision of this Section, a
8comprehensive tobacco use cessation program that includes
9purchasing prescription drugs or prescription medical devices
10approved by the Food and Drug Administration shall be covered
11under the medical assistance program under this Article for
12persons who are otherwise eligible for assistance under this
13Article.
14    Notwithstanding any other provision of this Code, the
15Illinois Department may not require, as a condition of payment
16for any laboratory test authorized under this Article, that a
17physician's handwritten signature appear on the laboratory
18test order form. The Illinois Department may, however, impose
19other appropriate requirements regarding laboratory test order
20documentation.
21    Upon receipt of federal approval of an amendment to the
22Illinois Title XIX State Plan for this purpose, the Department
23shall authorize the Chicago Public Schools (CPS) to procure a
24vendor or vendors to manufacture eyeglasses for individuals
25enrolled in a school within the CPS system. CPS shall ensure
26that its vendor or vendors are enrolled as providers in the

 

 

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1medical assistance program and in any capitated Medicaid
2managed care entity (MCE) serving individuals enrolled in a
3school within the CPS system. Under any contract procured under
4this provision, the vendor or vendors must serve only
5individuals enrolled in a school within the CPS system. Claims
6for services provided by CPS's vendor or vendors to recipients
7of benefits in the medical assistance program under this Code,
8the Children's Health Insurance Program, or the Covering ALL
9KIDS Health Insurance Program shall be submitted to the
10Department or the MCE in which the individual is enrolled for
11payment and shall be reimbursed at the Department's or the
12MCE's established rates or rate methodologies for eyeglasses.
13    On and after July 1, 2012, the Department of Healthcare and
14Family Services may provide the following services to persons
15eligible for assistance under this Article who are
16participating in education, training or employment programs
17operated by the Department of Human Services as successor to
18the Department of Public Aid:
19        (1) dental services provided by or under the
20    supervision of a dentist; and
21        (2) eyeglasses prescribed by a physician skilled in the
22    diseases of the eye, or by an optometrist, whichever the
23    person may select.
24    Notwithstanding any other provision of this Code and
25subject to federal approval, the Department may adopt rules to
26allow a dentist who is volunteering his or her service at no

 

 

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1cost to render dental services through an enrolled
2not-for-profit health clinic without the dentist personally
3enrolling as a participating provider in the medical assistance
4program. A not-for-profit health clinic shall include a public
5health clinic or Federally Qualified Health Center or other
6enrolled provider, as determined by the Department, through
7which dental services covered under this Section are performed.
8The Department shall establish a process for payment of claims
9for reimbursement for covered dental services rendered under
10this provision.
11    The Illinois Department, by rule, may distinguish and
12classify the medical services to be provided only in accordance
13with the classes of persons designated in Section 5-2.
14    The Department of Healthcare and Family Services must
15provide coverage and reimbursement for amino acid-based
16elemental formulas, regardless of delivery method, for the
17diagnosis and treatment of (i) eosinophilic disorders and (ii)
18short bowel syndrome when the prescribing physician has issued
19a written order stating that the amino acid-based elemental
20formula is medically necessary.
21    The Illinois Department shall authorize the provision of,
22and shall authorize payment for, screening by low-dose
23mammography for the presence of occult breast cancer for women
2435 years of age or older who are eligible for medical
25assistance under this Article, as follows:
26        (A) A baseline mammogram for women 35 to 39 years of

 

 

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

 

 

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

 

 

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1rate as the Medicare program's rates, including the increased
2reimbursement for digital mammography.
3    The Department shall convene an expert panel including
4representatives of hospitals, free-standing mammography
5facilities, and doctors, including radiologists, to establish
6quality standards for mammography.
7    On and after January 1, 2017, providers participating in a
8breast cancer treatment quality improvement program approved
9by the Department shall be reimbursed for breast cancer
10treatment at a rate that is no lower than 95% of the Medicare
11program's rates for the data elements included in the breast
12cancer treatment quality program.
13    The Department shall convene an expert panel, including
14representatives of hospitals, free standing breast cancer
15treatment centers, breast cancer quality organizations, and
16doctors, including breast surgeons, reconstructive breast
17surgeons, oncologists, and primary care providers to establish
18quality standards for breast cancer treatment.
19    Subject to federal approval, the Department shall
20establish a rate methodology for mammography at federally
21qualified health centers and other encounter-rate clinics.
22These clinics or centers may also collaborate with other
23hospital-based mammography facilities. By January 1, 2016, the
24Department shall report to the General Assembly on the status
25of the provision set forth in this paragraph.
26    The Department shall establish a methodology to remind

 

 

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1women who are age-appropriate for screening mammography, but
2who have not received a mammogram within the previous 18
3months, of the importance and benefit of screening mammography.
4The Department shall work with experts in breast cancer
5outreach and patient navigation to optimize these reminders and
6shall establish a methodology for evaluating their
7effectiveness and modifying the methodology based on the
8evaluation.
9    The Department shall establish a performance goal for
10primary care providers with respect to their female patients
11over age 40 receiving an annual mammogram. This performance
12goal shall be used to provide additional reimbursement in the
13form of a quality performance bonus to primary care providers
14who meet that goal.
15    The Department shall devise a means of case-managing or
16patient navigation for beneficiaries diagnosed with breast
17cancer. This program shall initially operate as a pilot program
18in areas of the State with the highest incidence of mortality
19related to breast cancer. At least one pilot program site shall
20be in the metropolitan Chicago area and at least one site shall
21be outside the metropolitan Chicago area. On or after July 1,
222016, the pilot program shall be expanded to include one site
23in western Illinois, one site in southern Illinois, one site in
24central Illinois, and 4 sites within metropolitan Chicago. An
25evaluation of the pilot program shall be carried out measuring
26health outcomes and cost of care for those served by the pilot

 

 

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1program compared to similarly situated patients who are not
2served by the pilot program.
3    The Department shall require all networks of care to
4develop a means either internally or by contract with experts
5in navigation and community outreach to navigate cancer
6patients to comprehensive care in a timely fashion. The
7Department shall require all networks of care to include access
8for patients diagnosed with cancer to at least one academic
9commission on cancer-accredited cancer program as an
10in-network covered benefit.
11    Any medical or health care provider shall immediately
12recommend, to any pregnant woman who is being provided prenatal
13services and is suspected of drug abuse or is addicted as
14defined in the Alcoholism and Other Drug Abuse and Dependency
15Act, referral to a local substance abuse treatment provider
16licensed by the Department of Human Services or to a licensed
17hospital which provides substance abuse treatment services.
18The Department of Healthcare and Family Services shall assure
19coverage for the cost of treatment of the drug abuse or
20addiction for pregnant recipients in accordance with the
21Illinois Medicaid Program in conjunction with the Department of
22Human Services.
23    All medical providers providing medical assistance to
24pregnant women under this Code shall receive information from
25the Department on the availability of services under the Drug
26Free Families with a Future or any comparable program providing

 

 

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

 

 

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

 

 

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1    Partnerships may receive medical and case management
2    services above the level usually offered through the
3    medical assistance program.
4    Medical providers shall be required to meet certain
5qualifications to participate in Partnerships to ensure the
6delivery of high quality medical services. These
7qualifications shall be determined by rule of the Illinois
8Department and may be higher than qualifications for
9participation in the medical assistance program. Partnership
10sponsors may prescribe reasonable additional qualifications
11for participation by medical providers, only with the prior
12written approval of the Illinois Department.
13    Nothing in this Section shall limit the free choice of
14practitioners, hospitals, and other providers of medical
15services by clients. In order to ensure patient freedom of
16choice, the Illinois Department shall immediately promulgate
17all rules and take all other necessary actions so that provided
18services may be accessed from therapeutically certified
19optometrists to the full extent of the Illinois Optometric
20Practice Act of 1987 without discriminating between service
21providers.
22    The Department shall apply for a waiver from the United
23States Health Care Financing Administration to allow for the
24implementation of Partnerships under this Section.
25    The Illinois Department shall require health care
26providers to maintain records that document the medical care

 

 

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1and services provided to recipients of Medical Assistance under
2this Article. Such records must be retained for a period of not
3less than 6 years from the date of service or as provided by
4applicable State law, whichever period is longer, except that
5if an audit is initiated within the required retention period
6then the records must be retained until the audit is completed
7and every exception is resolved. The Illinois Department shall
8require health care providers to make available, when
9authorized by the patient, in writing, the medical records in a
10timely fashion to other health care providers who are treating
11or serving persons eligible for Medical Assistance under this
12Article. All dispensers of medical services shall be required
13to maintain and retain business and professional records
14sufficient to fully and accurately document the nature, scope,
15details and receipt of the health care provided to persons
16eligible for medical assistance under this Code, in accordance
17with regulations promulgated by the Illinois Department. The
18rules and regulations shall require that proof of the receipt
19of prescription drugs, dentures, prosthetic devices and
20eyeglasses by eligible persons under this Section accompany
21each claim for reimbursement submitted by the dispenser of such
22medical services. No such claims for reimbursement shall be
23approved for payment by the Illinois Department without such
24proof of receipt, unless the Illinois Department shall have put
25into effect and shall be operating a system of post-payment
26audit and review which shall, on a sampling basis, be deemed

 

 

10000SB0314sam001- 24 -LRB100 05099 SMS 24180 a

1adequate by the Illinois Department to assure that such drugs,
2dentures, prosthetic devices and eyeglasses for which payment
3is being made are actually being received by eligible
4recipients. Within 90 days after September 16, 1984 (the
5effective date of Public Act 83-1439), the Illinois Department
6shall establish a current list of acquisition costs for all
7prosthetic devices and any other items recognized as medical
8equipment and supplies reimbursable under this Article and
9shall update such list on a quarterly basis, except that the
10acquisition costs of all prescription drugs shall be updated no
11less frequently than every 30 days as required by Section
125-5.12.
13    The rules and regulations of the Illinois Department shall
14require that a written statement including the required opinion
15of a physician shall accompany any claim for reimbursement for
16abortions, or induced miscarriages or premature births. This
17statement shall indicate what procedures were used in providing
18such medical services.
19    Notwithstanding any other law to the contrary, the Illinois
20Department shall, within 365 days after July 22, 2013 (the
21effective date of Public Act 98-104), establish procedures to
22permit skilled care facilities licensed under the Nursing Home
23Care Act to submit monthly billing claims for reimbursement
24purposes. Following development of these procedures, the
25Department shall, by July 1, 2016, test the viability of the
26new system and implement any necessary operational or

 

 

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

 

 

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1by rule establish, all inquiries from clients and attorneys
2regarding medical bills paid by the Illinois Department, which
3inquiries could indicate potential existence of claims or liens
4for the Illinois Department.
5    Enrollment of a vendor shall be subject to a provisional
6period and shall be conditional for one year. During the period
7of conditional enrollment, the Department may terminate the
8vendor's eligibility to participate in, or may disenroll the
9vendor from, the medical assistance program without cause.
10Unless otherwise specified, such termination of eligibility or
11disenrollment is not subject to the Department's hearing
12process. However, a disenrolled vendor may reapply without
13penalty.
14    The Department has the discretion to limit the conditional
15enrollment period for vendors based upon category of risk of
16the vendor.
17    Prior to enrollment and during the conditional enrollment
18period in the medical assistance program, all vendors shall be
19subject to enhanced oversight, screening, and review based on
20the risk of fraud, waste, and abuse that is posed by the
21category of risk of the vendor. The Illinois Department shall
22establish the procedures for oversight, screening, and review,
23which may include, but need not be limited to: criminal and
24financial background checks; fingerprinting; license,
25certification, and authorization verifications; unscheduled or
26unannounced site visits; database checks; prepayment audit

 

 

10000SB0314sam001- 27 -LRB100 05099 SMS 24180 a

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

 

 

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

 

 

10000SB0314sam001- 29 -LRB100 05099 SMS 24180 a

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

 

 

10000SB0314sam001- 30 -LRB100 05099 SMS 24180 a

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

 

 

10000SB0314sam001- 31 -LRB100 05099 SMS 24180 a

1information shall not be considered as a request for proposal
2or as an obligation on the part of the Illinois Department to
3take any action or acquire any products or services.
4    The Illinois Department shall establish policies,
5procedures, standards and criteria by rule for the acquisition,
6repair and replacement of orthotic and prosthetic devices and
7durable medical equipment. Such rules shall provide, but not be
8limited to, the following services: (1) immediate repair or
9replacement of such devices by recipients; and (2) rental,
10lease, purchase or lease-purchase of durable medical equipment
11in a cost-effective manner, taking into consideration the
12recipient's medical prognosis, the extent of the recipient's
13needs, and the requirements and costs for maintaining such
14equipment. Subject to prior approval, such rules shall enable a
15recipient to temporarily acquire and use alternative or
16substitute devices or equipment pending repairs or
17replacements of any device or equipment previously authorized
18for such recipient by the Department. Notwithstanding any
19provision of Section 5-5f to the contrary, the Department may,
20by rule, exempt certain replacement wheelchair parts from prior
21approval and, for wheelchairs, wheelchair parts, wheelchair
22accessories, and related seating and positioning items,
23determine the wholesale price by methods other than actual
24acquisition costs.
25    The Department shall require, by rule, all providers of
26durable medical equipment to be accredited by an accreditation

 

 

10000SB0314sam001- 32 -LRB100 05099 SMS 24180 a

1organization approved by the federal Centers for Medicare and
2Medicaid Services and recognized by the Department in order to
3bill the Department for providing durable medical equipment to
4recipients. No later than 15 months after the effective date of
5the rule adopted pursuant to this paragraph, all providers must
6meet the accreditation requirement.
7    The Department shall execute, relative to the nursing home
8prescreening project, written inter-agency agreements with the
9Department of Human Services and the Department on Aging, to
10effect the following: (i) intake procedures and common
11eligibility criteria for those persons who are receiving
12non-institutional services; and (ii) the establishment and
13development of non-institutional services in areas of the State
14where they are not currently available or are undeveloped; and
15(iii) notwithstanding any other provision of law, subject to
16federal approval, on and after July 1, 2012, an increase in the
17determination of need (DON) scores from 29 to 37 for applicants
18for institutional and home and community-based long term care;
19if and only if federal approval is not granted, the Department
20may, in conjunction with other affected agencies, implement
21utilization controls or changes in benefit packages to
22effectuate a similar savings amount for this population; and
23(iv) no later than July 1, 2013, minimum level of care
24eligibility criteria for institutional and home and
25community-based long term care; and (v) no later than October
261, 2013, establish procedures to permit long term care

 

 

10000SB0314sam001- 33 -LRB100 05099 SMS 24180 a

1providers access to eligibility scores for individuals with an
2admission date who are seeking or receiving services from the
3long term care provider. In order to select the minimum level
4of care eligibility criteria, the Governor shall establish a
5workgroup that includes affected agency representatives and
6stakeholders representing the institutional and home and
7community-based long term care interests. This Section shall
8not restrict the Department from implementing lower level of
9care eligibility criteria for community-based services in
10circumstances where federal approval has been granted.
11    The Illinois Department shall develop and operate, in
12cooperation with other State Departments and agencies and in
13compliance with applicable federal laws and regulations,
14appropriate and effective systems of health care evaluation and
15programs for monitoring of utilization of health care services
16and facilities, as it affects persons eligible for medical
17assistance under this Code.
18    The Illinois Department shall report annually to the
19General Assembly, no later than the second Friday in April of
201979 and each year thereafter, in regard to:
21        (a) actual statistics and trends in utilization of
22    medical services by public aid recipients;
23        (b) actual statistics and trends in the provision of
24    the various medical services by medical vendors;
25        (c) current rate structures and proposed changes in
26    those rate structures for the various medical vendors; and

 

 

10000SB0314sam001- 34 -LRB100 05099 SMS 24180 a

1        (d) efforts at utilization review and control by the
2    Illinois Department.
3    The period covered by each report shall be the 3 years
4ending on the June 30 prior to the report. The report shall
5include suggested legislation for consideration by the General
6Assembly. The filing of one copy of the report with the
7Speaker, one copy with the Minority Leader and one copy with
8the Clerk of the House of Representatives, one copy with the
9President, one copy with the Minority Leader and one copy with
10the Secretary of the Senate, one copy with the Legislative
11Research Unit, and such additional copies with the State
12Government Report Distribution Center for the General Assembly
13as is required under paragraph (t) of Section 7 of the State
14Library Act shall be deemed sufficient to comply with this
15Section.
16    Rulemaking authority to implement Public Act 95-1045, if
17any, is conditioned on the rules being adopted in accordance
18with all provisions of the Illinois Administrative Procedure
19Act and all rules and procedures of the Joint Committee on
20Administrative Rules; any purported rule not so adopted, for
21whatever reason, is unauthorized.
22    On and after July 1, 2012, the Department shall reduce any
23rate of reimbursement for services or other payments or alter
24any methodologies authorized by this Code to reduce any rate of
25reimbursement for services or other payments in accordance with
26Section 5-5e.

 

 

10000SB0314sam001- 35 -LRB100 05099 SMS 24180 a

1    Because kidney transplantation can be an appropriate, cost
2effective alternative to renal dialysis when medically
3necessary and notwithstanding the provisions of Section 1-11 of
4this Code, beginning October 1, 2014, the Department shall
5cover kidney transplantation for noncitizens with end-stage
6renal disease who are not eligible for comprehensive medical
7benefits, who meet the residency requirements of Section 5-3 of
8this Code, and who would otherwise meet the financial
9requirements of the appropriate class of eligible persons under
10Section 5-2 of this Code. To qualify for coverage of kidney
11transplantation, such person must be receiving emergency renal
12dialysis services covered by the Department. Providers under
13this Section shall be prior approved and certified by the
14Department to perform kidney transplantation and the services
15under this Section shall be limited to services associated with
16kidney transplantation.
17    Notwithstanding any other provision of this Code to the
18contrary, on or after July 1, 2015, all FDA approved forms of
19medication assisted treatment prescribed for the treatment of
20alcohol dependence or treatment of opioid dependence shall be
21covered under both fee for service and managed care medical
22assistance programs for persons who are otherwise eligible for
23medical assistance under this Article and shall not be subject
24to any (1) utilization control, other than those established
25under the American Society of Addiction Medicine patient
26placement criteria, (2) prior authorization mandate, or (3)

 

 

10000SB0314sam001- 36 -LRB100 05099 SMS 24180 a

1lifetime restriction limit mandate.
2    On or after July 1, 2015, opioid antagonists prescribed for
3the treatment of an opioid overdose, including the medication
4product, administration devices, and any pharmacy fees related
5to the dispensing and administration of the opioid antagonist,
6shall be covered under the medical assistance program for
7persons who are otherwise eligible for medical assistance under
8this Article. As used in this Section, "opioid antagonist"
9means a drug that binds to opioid receptors and blocks or
10inhibits the effect of opioids acting on those receptors,
11including, but not limited to, naloxone hydrochloride or any
12other similarly acting drug approved by the U.S. Food and Drug
13Administration.
14    Upon federal approval, the Department shall provide
15coverage and reimbursement for all drugs that are approved for
16marketing by the federal Food and Drug Administration and that
17are recommended by the federal Public Health Service or the
18United States Centers for Disease Control and Prevention for
19pre-exposure prophylaxis and related pre-exposure prophylaxis
20services, including, but not limited to, HIV and sexually
21transmitted infection screening, treatment for sexually
22transmitted infections, medical monitoring, assorted labs, and
23counseling to reduce the likelihood of HIV infection among
24individuals who are not infected with HIV but who are at high
25risk of HIV infection.
26(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;

 

 

10000SB0314sam001- 37 -LRB100 05099 SMS 24180 a

198-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
28-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
3eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
499-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
520 of P.A. 99-588 for the effective date of P.A. 99-407);
699-433, eff. 8-21-15; 99-480, eff. 9-9-15; 99-588, eff.
77-20-16; 99-642, eff. 7-28-16; 99-772, eff. 1-1-17; 99-895,
8eff. 1-1-17; revised 9-20-16.)".