101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB2159

 

Introduced , by Rep. Katie Stuart

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6.16 new
305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the State Employees Group Insurance Act of 1971. Requires coverage for breast pumps approved by the U.S. Food and Drug Administration. Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires coverage under the medical assistance program for breast pumps approved by the U.S. Food and Drug Administration. Effective January 1, 2020.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB2159LRB101 08525 KTG 53603 b

1    AN ACT concerning health care.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by adding Section 6.16 as follows:
 
6    (5 ILCS 375/6.16 new)
7    Sec. 6.16. Breast pumps. The program of health benefits
8provided under this Act shall provide coverage for breast pumps
9approved by the U.S. Food and Drug Administration.
 
10    Section 10. The Illinois Public Aid Code is amended by
11changing Section 5-5 as follows:
 
12    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
13    Sec. 5-5. Medical services. The Illinois Department, by
14rule, shall determine the quantity and quality of and the rate
15of reimbursement for the medical assistance for which payment
16will be authorized, and the medical services to be provided,
17which may include all or part of the following: (1) inpatient
18hospital services; (2) outpatient hospital services; (3) other
19laboratory and X-ray services; (4) skilled nursing home
20services; (5) physicians' services whether furnished in the
21office, the patient's home, a hospital, a skilled nursing home,

 

 

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1or elsewhere; (6) medical care, or any other type of remedial
2care furnished by licensed practitioners; (7) home health care
3services; (8) private duty nursing service; (9) clinic
4services; (10) dental services, including prevention and
5treatment of periodontal disease and dental caries disease for
6pregnant women, provided by an individual licensed to practice
7dentistry or dental surgery; for purposes of this item (10),
8"dental services" means diagnostic, preventive, or corrective
9procedures provided by or under the supervision of a dentist in
10the practice of his or her profession; (11) physical therapy
11and related services; (12) prescribed drugs, dentures, and
12prosthetic devices; and eyeglasses prescribed by a physician
13skilled in the diseases of the eye, or by an optometrist,
14whichever the person may select; (13) other diagnostic,
15screening, preventive, and rehabilitative services, including
16to ensure that the individual's need for intervention or
17treatment of mental disorders or substance use disorders or
18co-occurring mental health and substance use disorders is
19determined using a uniform screening, assessment, and
20evaluation process inclusive of criteria, for children and
21adults; for purposes of this item (13), a uniform screening,
22assessment, and evaluation process refers to a process that
23includes an appropriate evaluation and, as warranted, a
24referral; "uniform" does not mean the use of a singular
25instrument, tool, or process that all must utilize; (14)
26transportation and such other expenses as may be necessary;

 

 

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1(15) medical treatment of sexual assault survivors, as defined
2in Section 1a of the Sexual Assault Survivors Emergency
3Treatment Act, for injuries sustained as a result of the sexual
4assault, including examinations and laboratory tests to
5discover evidence which may be used in criminal proceedings
6arising from the sexual assault; (16) the diagnosis and
7treatment of sickle cell anemia; and (17) any other medical
8care, and any other type of remedial care recognized under the
9laws of this State. The term "any other type of remedial care"
10shall include nursing care and nursing home service for persons
11who rely on treatment by spiritual means alone through prayer
12for healing.
13    Notwithstanding any other provision of this Section, a
14comprehensive tobacco use cessation program that includes
15purchasing prescription drugs or prescription medical devices
16approved by the Food and Drug Administration shall be covered
17under the medical assistance program under this Article for
18persons who are otherwise eligible for assistance under this
19Article.
20    Notwithstanding any other provision of this Code,
21reproductive health care that is otherwise legal in Illinois
22shall be covered under the medical assistance program for
23persons who are otherwise eligible for medical assistance under
24this Article.
25    Notwithstanding any other provision of this Code, the
26Illinois Department may not require, as a condition of payment

 

 

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1for any laboratory test authorized under this Article, that a
2physician's handwritten signature appear on the laboratory
3test order form. The Illinois Department may, however, impose
4other appropriate requirements regarding laboratory test order
5documentation.
6    Upon receipt of federal approval of an amendment to the
7Illinois Title XIX State Plan for this purpose, the Department
8shall authorize the Chicago Public Schools (CPS) to procure a
9vendor or vendors to manufacture eyeglasses for individuals
10enrolled in a school within the CPS system. CPS shall ensure
11that its vendor or vendors are enrolled as providers in the
12medical assistance program and in any capitated Medicaid
13managed care entity (MCE) serving individuals enrolled in a
14school within the CPS system. Under any contract procured under
15this provision, the vendor or vendors must serve only
16individuals enrolled in a school within the CPS system. Claims
17for services provided by CPS's vendor or vendors to recipients
18of benefits in the medical assistance program under this Code,
19the Children's Health Insurance Program, or the Covering ALL
20KIDS Health Insurance Program shall be submitted to the
21Department or the MCE in which the individual is enrolled for
22payment and shall be reimbursed at the Department's or the
23MCE's established rates or rate methodologies for eyeglasses.
24    On and after July 1, 2012, the Department of Healthcare and
25Family Services may provide the following services to persons
26eligible for assistance under this Article who are

 

 

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1participating in education, training or employment programs
2operated by the Department of Human Services as successor to
3the Department of Public Aid:
4        (1) dental services provided by or under the
5    supervision of a dentist; and
6        (2) eyeglasses prescribed by a physician skilled in the
7    diseases of the eye, or by an optometrist, whichever the
8    person may select.
9    On and after July 1, 2018, the Department of Healthcare and
10Family Services shall provide dental services to any adult who
11is otherwise eligible for assistance under the medical
12assistance program. As used in this paragraph, "dental
13services" means diagnostic, preventative, restorative, or
14corrective procedures, including procedures and services for
15the prevention and treatment of periodontal disease and dental
16caries disease, provided by an individual who is licensed to
17practice dentistry or dental surgery or who is under the
18supervision of a dentist in the practice of his or her
19profession.
20    On and after July 1, 2018, targeted dental services, as set
21forth in Exhibit D of the Consent Decree entered by the United
22States District Court for the Northern District of Illinois,
23Eastern Division, in the matter of Memisovski v. Maram, Case
24No. 92 C 1982, that are provided to adults under the medical
25assistance program shall be established at no less than the
26rates set forth in the "New Rate" column in Exhibit D of the

 

 

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1Consent Decree for targeted dental services that are provided
2to persons under the age of 18 under the medical assistance
3program.
4    Notwithstanding any other provision of this Code and
5subject to federal approval, the Department may adopt rules to
6allow a dentist who is volunteering his or her service at no
7cost to render dental services through an enrolled
8not-for-profit health clinic without the dentist personally
9enrolling as a participating provider in the medical assistance
10program. A not-for-profit health clinic shall include a public
11health clinic or Federally Qualified Health Center or other
12enrolled provider, as determined by the Department, through
13which dental services covered under this Section are performed.
14The Department shall establish a process for payment of claims
15for reimbursement for covered dental services rendered under
16this provision.
17    The Illinois Department, by rule, may distinguish and
18classify the medical services to be provided only in accordance
19with the classes of persons designated in Section 5-2.
20    The Department of Healthcare and Family Services must
21provide coverage and reimbursement for amino acid-based
22elemental formulas, regardless of delivery method, for the
23diagnosis and treatment of (i) eosinophilic disorders and (ii)
24short bowel syndrome when the prescribing physician has issued
25a written order stating that the amino acid-based elemental
26formula is medically necessary.

 

 

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1    The Illinois Department shall authorize the provision of,
2and shall authorize payment for, screening by low-dose
3mammography for the presence of occult breast cancer for women
435 years of age or older who are eligible for medical
5assistance under this Article, as follows:
6        (A) A baseline mammogram for women 35 to 39 years of
7    age.
8        (B) An annual mammogram for women 40 years of age or
9    older.
10        (C) A mammogram at the age and intervals considered
11    medically necessary by the woman's health care provider for
12    women under 40 years of age and having a family history of
13    breast cancer, prior personal history of breast cancer,
14    positive genetic testing, or other risk factors.
15        (D) A comprehensive ultrasound screening and MRI of an
16    entire breast or breasts if a mammogram demonstrates
17    heterogeneous or dense breast tissue, when medically
18    necessary as determined by a physician licensed to practice
19    medicine in all of its branches.
20        (E) A screening MRI when medically necessary, as
21    determined by a physician licensed to practice medicine in
22    all of its branches.
23    All screenings shall include a physical breast exam,
24instruction on self-examination and information regarding the
25frequency of self-examination and its value as a preventative
26tool. For purposes of this Section, "low-dose mammography"

 

 

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1means the x-ray examination of the breast using equipment
2dedicated specifically for mammography, including the x-ray
3tube, filter, compression device, and image receptor, with an
4average radiation exposure delivery of less than one rad per
5breast for 2 views of an average size breast. The term also
6includes digital mammography and includes breast
7tomosynthesis. As used in this Section, the term "breast
8tomosynthesis" means a radiologic procedure that involves the
9acquisition of projection images over the stationary breast to
10produce cross-sectional digital three-dimensional images of
11the breast. If, at any time, the Secretary of the United States
12Department of Health and Human Services, or its successor
13agency, promulgates rules or regulations to be published in the
14Federal Register or publishes a comment in the Federal Register
15or issues an opinion, guidance, or other action that would
16require the State, pursuant to any provision of the Patient
17Protection and Affordable Care Act (Public Law 111-148),
18including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
19successor provision, to defray the cost of any coverage for
20breast tomosynthesis outlined in this paragraph, then the
21requirement that an insurer cover breast tomosynthesis is
22inoperative other than any such coverage authorized under
23Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
24the State shall not assume any obligation for the cost of
25coverage for breast tomosynthesis set forth in this paragraph.
26    On and after January 1, 2016, the Department shall ensure

 

 

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1that all networks of care for adult clients of the Department
2include access to at least one breast imaging Center of Imaging
3Excellence as certified by the American College of Radiology.
4    On and after January 1, 2012, providers participating in a
5quality improvement program approved by the Department shall be
6reimbursed for screening and diagnostic mammography at the same
7rate as the Medicare program's rates, including the increased
8reimbursement for digital mammography.
9    The Department shall convene an expert panel including
10representatives of hospitals, free-standing mammography
11facilities, and doctors, including radiologists, to establish
12quality standards for mammography.
13    On and after January 1, 2017, providers participating in a
14breast cancer treatment quality improvement program approved
15by the Department shall be reimbursed for breast cancer
16treatment at a rate that is no lower than 95% of the Medicare
17program's rates for the data elements included in the breast
18cancer treatment quality program.
19    The Department shall convene an expert panel, including
20representatives of hospitals, free-standing breast cancer
21treatment centers, breast cancer quality organizations, and
22doctors, including breast surgeons, reconstructive breast
23surgeons, oncologists, and primary care providers to establish
24quality standards for breast cancer treatment.
25    Subject to federal approval, the Department shall
26establish a rate methodology for mammography at federally

 

 

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1qualified health centers and other encounter-rate clinics.
2These clinics or centers may also collaborate with other
3hospital-based mammography facilities. By January 1, 2016, the
4Department shall report to the General Assembly on the status
5of the provision set forth in this paragraph.
6    The Department shall establish a methodology to remind
7women who are age-appropriate for screening mammography, but
8who have not received a mammogram within the previous 18
9months, of the importance and benefit of screening mammography.
10The Department shall work with experts in breast cancer
11outreach and patient navigation to optimize these reminders and
12shall establish a methodology for evaluating their
13effectiveness and modifying the methodology based on the
14evaluation.
15    The Department shall establish a performance goal for
16primary care providers with respect to their female patients
17over age 40 receiving an annual mammogram. This performance
18goal shall be used to provide additional reimbursement in the
19form of a quality performance bonus to primary care providers
20who meet that goal.
21    The Department shall devise a means of case-managing or
22patient navigation for beneficiaries diagnosed with breast
23cancer. This program shall initially operate as a pilot program
24in areas of the State with the highest incidence of mortality
25related to breast cancer. At least one pilot program site shall
26be in the metropolitan Chicago area and at least one site shall

 

 

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1be outside the metropolitan Chicago area. On or after July 1,
22016, the pilot program shall be expanded to include one site
3in western Illinois, one site in southern Illinois, one site in
4central Illinois, and 4 sites within metropolitan Chicago. An
5evaluation of the pilot program shall be carried out measuring
6health outcomes and cost of care for those served by the pilot
7program compared to similarly situated patients who are not
8served by the pilot program.
9    The Department shall require all networks of care to
10develop a means either internally or by contract with experts
11in navigation and community outreach to navigate cancer
12patients to comprehensive care in a timely fashion. The
13Department shall require all networks of care to include access
14for patients diagnosed with cancer to at least one academic
15commission on cancer-accredited cancer program as an
16in-network covered benefit.
17    Any medical or health care provider shall immediately
18recommend, to any pregnant woman who is being provided prenatal
19services and is suspected of having a substance use disorder as
20defined in the Substance Use Disorder Act, referral to a local
21substance use disorder treatment program licensed by the
22Department of Human Services or to a licensed hospital which
23provides substance abuse treatment services. The Department of
24Healthcare and Family Services shall assure coverage for the
25cost of treatment of the drug abuse or addiction for pregnant
26recipients in accordance with the Illinois Medicaid Program in

 

 

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

 

 

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

 

 

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

 

 

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1States Health Care Financing Administration to allow for the
2implementation of Partnerships under this Section.
3    The Illinois Department shall require health care
4providers to maintain records that document the medical care
5and services provided to recipients of Medical Assistance under
6this Article. Such records must be retained for a period of not
7less than 6 years from the date of service or as provided by
8applicable State law, whichever period is longer, except that
9if an audit is initiated within the required retention period
10then the records must be retained until the audit is completed
11and every exception is resolved. The Illinois Department shall
12require health care providers to make available, when
13authorized by the patient, in writing, the medical records in a
14timely fashion to other health care providers who are treating
15or serving persons eligible for Medical Assistance under this
16Article. All dispensers of medical services shall be required
17to maintain and retain business and professional records
18sufficient to fully and accurately document the nature, scope,
19details and receipt of the health care provided to persons
20eligible for medical assistance under this Code, in accordance
21with regulations promulgated by the Illinois Department. The
22rules and regulations shall require that proof of the receipt
23of prescription drugs, dentures, prosthetic devices and
24eyeglasses by eligible persons under this Section accompany
25each claim for reimbursement submitted by the dispenser of such
26medical services. No such claims for reimbursement shall be

 

 

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1approved for payment by the Illinois Department without such
2proof of receipt, unless the Illinois Department shall have put
3into effect and shall be operating a system of post-payment
4audit and review which shall, on a sampling basis, be deemed
5adequate by the Illinois Department to assure that such drugs,
6dentures, prosthetic devices and eyeglasses for which payment
7is being made are actually being received by eligible
8recipients. Within 90 days after September 16, 1984 (the
9effective date of Public Act 83-1439), the Illinois Department
10shall establish a current list of acquisition costs for all
11prosthetic devices and any other items recognized as medical
12equipment and supplies reimbursable under this Article and
13shall update such list on a quarterly basis, except that the
14acquisition costs of all prescription drugs shall be updated no
15less frequently than every 30 days as required by Section
165-5.12.
17    Notwithstanding any other law to the contrary, the Illinois
18Department shall, within 365 days after July 22, 2013 (the
19effective date of Public Act 98-104), establish procedures to
20permit skilled care facilities licensed under the Nursing Home
21Care Act to submit monthly billing claims for reimbursement
22purposes. Following development of these procedures, the
23Department shall, by July 1, 2016, test the viability of the
24new system and implement any necessary operational or
25structural changes to its information technology platforms in
26order to allow for the direct acceptance and payment of nursing

 

 

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

 

 

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

 

 

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

 

 

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1    until the provider has been notified of the error.
2        (3) In the case of a provider for whom the Illinois
3    Department initiates the monthly billing process.
4        (4) In the case of a provider operated by a unit of
5    local government with a population exceeding 3,000,000
6    when local government funds finance federal participation
7    for claims payments.
8    For claims for services rendered during a period for which
9a recipient received retroactive eligibility, claims must be
10filed within 180 days after the Department determines the
11applicant is eligible. For claims for which the Illinois
12Department is not the primary payer, claims must be submitted
13to the Illinois Department within 180 days after the final
14adjudication by the primary payer.
15    In the case of long term care facilities, within 45
16calendar days of receipt by the facility of required
17prescreening information, new admissions with associated
18admission documents shall be submitted through the Medical
19Electronic Data Interchange (MEDI) or the Recipient
20Eligibility Verification (REV) System or shall be submitted
21directly to the Department of Human Services using required
22admission forms. Effective September 1, 2014, admission
23documents, including all prescreening information, must be
24submitted through MEDI or REV. Confirmation numbers assigned to
25an accepted transaction shall be retained by a facility to
26verify timely submittal. Once an admission transaction has been

 

 

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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.

 

 

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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,

 

 

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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

 

 

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1the rule adopted pursuant to this paragraph, all providers must
2meet the accreditation requirement.
3    In order to promote environmental responsibility, meet the
4needs of recipients and enrollees, and achieve significant cost
5savings, the Department, or a managed care organization under
6contract with the Department, may provide recipients or managed
7care enrollees who have a prescription or Certificate of
8Medical Necessity access to refurbished durable medical
9equipment under this Section (excluding prosthetic and
10orthotic devices as defined in the Orthotics, Prosthetics, and
11Pedorthics Practice Act and complex rehabilitation technology
12products and associated services) through the State's
13assistive technology program's reutilization program, using
14staff with the Assistive Technology Professional (ATP)
15Certification if the refurbished durable medical equipment:
16(i) is available; (ii) is less expensive, including shipping
17costs, than new durable medical equipment of the same type;
18(iii) is able to withstand at least 3 years of use; (iv) is
19cleaned, disinfected, sterilized, and safe in accordance with
20federal Food and Drug Administration regulations and guidance
21governing the reprocessing of medical devices in health care
22settings; and (v) equally meets the needs of the recipient or
23enrollee. The reutilization program shall confirm that the
24recipient or enrollee is not already in receipt of same or
25similar equipment from another service provider, and that the
26refurbished durable medical equipment equally meets the needs

 

 

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1of the recipient or enrollee. Nothing in this paragraph shall
2be construed to limit recipient or enrollee choice to obtain
3new durable medical equipment or place any additional prior
4authorization conditions on enrollees of managed care
5organizations.
6    The Department shall execute, relative to the nursing home
7prescreening project, written inter-agency agreements with the
8Department of Human Services and the Department on Aging, to
9effect the following: (i) intake procedures and common
10eligibility criteria for those persons who are receiving
11non-institutional services; and (ii) the establishment and
12development of non-institutional services in areas of the State
13where they are not currently available or are undeveloped; and
14(iii) notwithstanding any other provision of law, subject to
15federal approval, on and after July 1, 2012, an increase in the
16determination of need (DON) scores from 29 to 37 for applicants
17for institutional and home and community-based long term care;
18if and only if federal approval is not granted, the Department
19may, in conjunction with other affected agencies, implement
20utilization controls or changes in benefit packages to
21effectuate a similar savings amount for this population; and
22(iv) no later than July 1, 2013, minimum level of care
23eligibility criteria for institutional and home and
24community-based long term care; and (v) no later than October
251, 2013, establish procedures to permit long term care
26providers access to eligibility scores for individuals with an

 

 

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1admission date who are seeking or receiving services from the
2long term care provider. In order to select the minimum level
3of care eligibility criteria, the Governor shall establish a
4workgroup that includes affected agency representatives and
5stakeholders representing the institutional and home and
6community-based long term care interests. This Section shall
7not restrict the Department from implementing lower level of
8care eligibility criteria for community-based services in
9circumstances where federal approval has been granted.
10    The Illinois Department shall develop and operate, in
11cooperation with other State Departments and agencies and in
12compliance with applicable federal laws and regulations,
13appropriate and effective systems of health care evaluation and
14programs for monitoring of utilization of health care services
15and facilities, as it affects persons eligible for medical
16assistance under this Code.
17    The Illinois Department shall report annually to the
18General Assembly, no later than the second Friday in April of
191979 and each year thereafter, in regard to:
20        (a) actual statistics and trends in utilization of
21    medical services by public aid recipients;
22        (b) actual statistics and trends in the provision of
23    the various medical services by medical vendors;
24        (c) current rate structures and proposed changes in
25    those rate structures for the various medical vendors; and
26        (d) efforts at utilization review and control by the

 

 

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1    Illinois Department.
2    The period covered by each report shall be the 3 years
3ending on the June 30 prior to the report. The report shall
4include suggested legislation for consideration by the General
5Assembly. The requirement for reporting to the General Assembly
6shall be satisfied by filing copies of the report as required
7by Section 3.1 of the General Assembly Organization Act, and
8filing such additional copies with the State Government Report
9Distribution Center for the General Assembly as is required
10under paragraph (t) of Section 7 of the State Library Act.
11    Rulemaking authority to implement Public Act 95-1045, if
12any, is conditioned on the rules being adopted in accordance
13with all provisions of the Illinois Administrative Procedure
14Act and all rules and procedures of the Joint Committee on
15Administrative Rules; any purported rule not so adopted, for
16whatever reason, is unauthorized.
17    On and after July 1, 2012, the Department shall reduce any
18rate of reimbursement for services or other payments or alter
19any methodologies authorized by this Code to reduce any rate of
20reimbursement for services or other payments in accordance with
21Section 5-5e.
22    Because kidney transplantation can be an appropriate,
23cost-effective alternative to renal dialysis when medically
24necessary and notwithstanding the provisions of Section 1-11 of
25this Code, beginning October 1, 2014, the Department shall
26cover kidney transplantation for noncitizens with end-stage

 

 

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

 

 

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1shall be covered under the medical assistance program for
2persons who are otherwise eligible for medical assistance under
3this Article. As used in this Section, "opioid antagonist"
4means a drug that binds to opioid receptors and blocks or
5inhibits the effect of opioids acting on those receptors,
6including, but not limited to, naloxone hydrochloride or any
7other similarly acting drug approved by the U.S. Food and Drug
8Administration.
9    Upon federal approval, the Department shall provide
10coverage and reimbursement for all drugs that are approved for
11marketing by the federal Food and Drug Administration and that
12are recommended by the federal Public Health Service or the
13United States Centers for Disease Control and Prevention for
14pre-exposure prophylaxis and related pre-exposure prophylaxis
15services, including, but not limited to, HIV and sexually
16transmitted infection screening, treatment for sexually
17transmitted infections, medical monitoring, assorted labs, and
18counseling to reduce the likelihood of HIV infection among
19individuals who are not infected with HIV but who are at high
20risk of HIV infection.
21    A federally qualified health center, as defined in Section
221905(l)(2)(B) of the federal Social Security Act, shall be
23reimbursed by the Department in accordance with the federally
24qualified health center's encounter rate for services provided
25to medical assistance recipients that are performed by a dental
26hygienist, as defined under the Illinois Dental Practice Act,

 

 

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1working under the general supervision of a dentist and employed
2by a federally qualified health center.
3    Notwithstanding any other provision of this Code, the
4Illinois Department shall authorize licensed dietitian
5nutritionists and certified diabetes educators to counsel
6senior diabetes patients in the senior diabetes patients' homes
7to remove the hurdle of transportation for senior diabetes
8patients to receive treatment.
9    Notwithstanding any other provision of this code, breast
10pumps approved by the U.S. Food and Drug Administration shall
11be covered under the medical assistance program for persons who
12are otherwise eligible for medical assistance under this
13Article.
14(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
1599-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
16the effective date of P.A. 99-407); 99-433, eff. 8-21-15;
1799-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
187-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
19eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
20100-538, eff. 1-1-18; 100-587, eff. 6-4-18; 100-759, eff.
211-1-19; 100-863, eff. 8-14-18; 100-974, eff. 8-19-18;
22100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; 100-1148, eff.
2312-10-18.)
 
24    Section 99. Effective date. This Act takes effect January
251, 2020.