98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
SB1438

 

Introduced 2/6/2013, by Sen. David Koehler

 

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

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that one preventive dental visit a year shall be covered under the medical assistance program for pregnant women who are eligible for assistance. Provides that the Department of Healthcare and Family Services may (rather than shall) limit adult dental services to emergencies, except that this limitation shall not apply to pregnant women. Effective July 1, 2013.


LRB098 09557 KTG 39702 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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

 

 

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

 

 

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

 

 

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1    Notwithstanding any other provision of this Code, the
2Illinois Department may not require, as a condition of payment
3for any laboratory test authorized under this Article, that a
4physician's handwritten signature appear on the laboratory
5test order form. The Illinois Department may, however, impose
6other appropriate requirements regarding laboratory test order
7documentation.
8    On and after July 1, 2012, the Department of Healthcare and
9Family Services may provide the following services to persons
10eligible for assistance under this Article who are
11participating in education, training or employment programs
12operated by the Department of Human Services as successor to
13the Department of Public Aid:
14        (1) dental services provided by or under the
15    supervision of a dentist; and
16        (2) eyeglasses prescribed by a physician skilled in the
17    diseases of the eye, or by an optometrist, whichever the
18    person may select.
19    Notwithstanding any other provision of this Code and
20subject to federal approval, the Department may adopt rules to
21allow a dentist who is volunteering his or her service at no
22cost to render dental services through an enrolled
23not-for-profit health clinic without the dentist personally
24enrolling as a participating provider in the medical assistance
25program. A not-for-profit health clinic shall include a public
26health clinic or Federally Qualified Health Center or other

 

 

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1enrolled provider, as determined by the Department, through
2which dental services covered under this Section are performed.
3The Department shall establish a process for payment of claims
4for reimbursement for covered dental services rendered under
5this provision.
6    The Illinois Department, by rule, may distinguish and
7classify the medical services to be provided only in accordance
8with the classes of persons designated in Section 5-2.
9    The Department of Healthcare and Family Services must
10provide coverage and reimbursement for amino acid-based
11elemental formulas, regardless of delivery method, for the
12diagnosis and treatment of (i) eosinophilic disorders and (ii)
13short bowel syndrome when the prescribing physician has issued
14a written order stating that the amino acid-based elemental
15formula is medically necessary.
16    The Illinois Department shall authorize the provision of,
17and shall authorize payment for, screening by low-dose
18mammography for the presence of occult breast cancer for women
1935 years of age or older who are eligible for medical
20assistance under this Article, as follows:
21        (A) A baseline mammogram for women 35 to 39 years of
22    age.
23        (B) An annual mammogram for women 40 years of age or
24    older.
25        (C) A mammogram at the age and intervals considered
26    medically necessary by the woman's health care provider for

 

 

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1    women under 40 years of age and having a family history of
2    breast cancer, prior personal history of breast cancer,
3    positive genetic testing, or other risk factors.
4        (D) A comprehensive ultrasound screening of an entire
5    breast or breasts if a mammogram demonstrates
6    heterogeneous or dense breast tissue, when medically
7    necessary as determined by a physician licensed to practice
8    medicine in all of its branches.
9    All screenings shall include a physical breast exam,
10instruction on self-examination and information regarding the
11frequency of self-examination and its value as a preventative
12tool. For purposes of this Section, "low-dose mammography"
13means the x-ray examination of the breast using equipment
14dedicated specifically for mammography, including the x-ray
15tube, filter, compression device, and image receptor, with an
16average radiation exposure delivery of less than one rad per
17breast for 2 views of an average size breast. The term also
18includes digital mammography.
19    On and after January 1, 2012, providers participating in a
20quality improvement program approved by the Department shall be
21reimbursed for screening and diagnostic mammography at the same
22rate as the Medicare program's rates, including the increased
23reimbursement for digital mammography.
24    The Department shall convene an expert panel including
25representatives of hospitals, free-standing mammography
26facilities, and doctors, including radiologists, to establish

 

 

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1quality standards.
2    Subject to federal approval, the Department shall
3establish a rate methodology for mammography at federally
4qualified health centers and other encounter-rate clinics.
5These clinics or centers may also collaborate with other
6hospital-based mammography facilities.
7    The Department shall establish a methodology to remind
8women who are age-appropriate for screening mammography, but
9who have not received a mammogram within the previous 18
10months, of the importance and benefit of screening mammography.
11    The Department shall establish a performance goal for
12primary care providers with respect to their female patients
13over age 40 receiving an annual mammogram. This performance
14goal shall be used to provide additional reimbursement in the
15form of a quality performance bonus to primary care providers
16who meet that goal.
17    The Department shall devise a means of case-managing or
18patient navigation for beneficiaries diagnosed with breast
19cancer. This program shall initially operate as a pilot program
20in areas of the State with the highest incidence of mortality
21related to breast cancer. At least one pilot program site shall
22be in the metropolitan Chicago area and at least one site shall
23be outside the metropolitan Chicago area. An evaluation of the
24pilot program shall be carried out measuring health outcomes
25and cost of care for those served by the pilot program compared
26to similarly situated patients who are not served by the pilot

 

 

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1program.
2    Any medical or health care provider shall immediately
3recommend, to any pregnant woman who is being provided prenatal
4services and is suspected of drug abuse or is addicted as
5defined in the Alcoholism and Other Drug Abuse and Dependency
6Act, referral to a local substance abuse treatment provider
7licensed by the Department of Human Services or to a licensed
8hospital which provides substance abuse treatment services.
9The Department of Healthcare and Family Services shall assure
10coverage for the cost of treatment of the drug abuse or
11addiction for pregnant recipients in accordance with the
12Illinois Medicaid Program in conjunction with the Department of
13Human Services.
14    All medical providers providing medical assistance to
15pregnant women under this Code shall receive information from
16the Department on the availability of services under the Drug
17Free Families with a Future or any comparable program providing
18case management services for addicted women, including
19information on appropriate referrals for other social services
20that may be needed by addicted women in addition to treatment
21for addiction.
22    The Illinois Department, in cooperation with the
23Departments of Human Services (as successor to the Department
24of Alcoholism and Substance Abuse) and Public Health, through a
25public awareness campaign, may provide information concerning
26treatment for alcoholism and drug abuse and addiction, prenatal

 

 

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1health care, and other pertinent programs directed at reducing
2the number of drug-affected infants born to recipients of
3medical assistance.
4    Neither the Department of Healthcare and Family Services
5nor the Department of Human Services shall sanction the
6recipient solely on the basis of her substance abuse.
7    The Illinois Department shall establish such regulations
8governing the dispensing of health services under this Article
9as it shall deem appropriate. The Department should seek the
10advice of formal professional advisory committees appointed by
11the Director of the Illinois Department for the purpose of
12providing regular advice on policy and administrative matters,
13information dissemination and educational activities for
14medical and health care providers, and consistency in
15procedures to the Illinois Department.
16    The Illinois Department may develop and contract with
17Partnerships of medical providers to arrange medical services
18for persons eligible under Section 5-2 of this Code.
19Implementation of this Section may be by demonstration projects
20in certain geographic areas. The Partnership shall be
21represented by a sponsor organization. The Department, by rule,
22shall develop qualifications for sponsors of Partnerships.
23Nothing in this Section shall be construed to require that the
24sponsor organization be a medical organization.
25    The sponsor must negotiate formal written contracts with
26medical providers for physician services, inpatient and

 

 

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1outpatient hospital care, home health services, treatment for
2alcoholism and substance abuse, and other services determined
3necessary by the Illinois Department by rule for delivery by
4Partnerships. Physician services must include prenatal and
5obstetrical care. The Illinois Department shall reimburse
6medical services delivered by Partnership providers to clients
7in target areas according to provisions of this Article and the
8Illinois Health Finance Reform Act, except that:
9        (1) Physicians participating in a Partnership and
10    providing certain services, which shall be determined by
11    the Illinois Department, to persons in areas covered by the
12    Partnership may receive an additional surcharge for such
13    services.
14        (2) The Department may elect to consider and negotiate
15    financial incentives to encourage the development of
16    Partnerships and the efficient delivery of medical care.
17        (3) Persons receiving medical services through
18    Partnerships may receive medical and case management
19    services above the level usually offered through the
20    medical assistance program.
21    Medical providers shall be required to meet certain
22qualifications to participate in Partnerships to ensure the
23delivery of high quality medical services. These
24qualifications shall be determined by rule of the Illinois
25Department and may be higher than qualifications for
26participation in the medical assistance program. Partnership

 

 

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

 

 

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1timely fashion to other health care providers who are treating
2or serving persons eligible for Medical Assistance under this
3Article. All dispensers of medical services shall be required
4to maintain and retain business and professional records
5sufficient to fully and accurately document the nature, scope,
6details and receipt of the health care provided to persons
7eligible for medical assistance under this Code, in accordance
8with regulations promulgated by the Illinois Department. The
9rules and regulations shall require that proof of the receipt
10of prescription drugs, dentures, prosthetic devices and
11eyeglasses by eligible persons under this Section accompany
12each claim for reimbursement submitted by the dispenser of such
13medical services. No such claims for reimbursement shall be
14approved for payment by the Illinois Department without such
15proof of receipt, unless the Illinois Department shall have put
16into effect and shall be operating a system of post-payment
17audit and review which shall, on a sampling basis, be deemed
18adequate by the Illinois Department to assure that such drugs,
19dentures, prosthetic devices and eyeglasses for which payment
20is being made are actually being received by eligible
21recipients. Within 90 days after the effective date of this
22amendatory Act of 1984, the Illinois Department shall establish
23a current list of acquisition costs for all prosthetic devices
24and any other items recognized as medical equipment and
25supplies reimbursable under this Article and shall update such
26list on a quarterly basis, except that the acquisition costs of

 

 

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1all prescription drugs shall be updated no less frequently than
2every 30 days as required by Section 5-5.12.
3    The rules and regulations of the Illinois Department shall
4require that a written statement including the required opinion
5of a physician shall accompany any claim for reimbursement for
6abortions, or induced miscarriages or premature births. This
7statement shall indicate what procedures were used in providing
8such medical services.
9    The Illinois Department shall require all dispensers of
10medical services, other than an individual practitioner or
11group of practitioners, desiring to participate in the Medical
12Assistance program established under this Article to disclose
13all financial, beneficial, ownership, equity, surety or other
14interests in any and all firms, corporations, partnerships,
15associations, business enterprises, joint ventures, agencies,
16institutions or other legal entities providing any form of
17health care services in this State under this Article.
18    The Illinois Department may require that all dispensers of
19medical services desiring to participate in the medical
20assistance program established under this Article disclose,
21under such terms and conditions as the Illinois Department may
22by rule establish, all inquiries from clients and attorneys
23regarding medical bills paid by the Illinois Department, which
24inquiries could indicate potential existence of claims or liens
25for the Illinois Department.
26    Enrollment of a vendor shall be subject to a provisional

 

 

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

 

 

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

 

 

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1    For claims for services rendered during a period for which
2a recipient received retroactive eligibility, claims must be
3filed within 180 days after the Department determines the
4applicant is eligible. For claims for which the Illinois
5Department is not the primary payer, claims must be submitted
6to the Illinois Department within 180 days after the final
7adjudication by the primary payer.
8    In the case of long term care facilities, admission
9documents shall be submitted within 30 days of an admission to
10the facility through the Medical Electronic Data Interchange
11(MEDI) or the Recipient Eligibility Verification (REV) System,
12or shall be submitted directly to the Department of Human
13Services using required admission forms. Confirmation numbers
14assigned to an accepted transaction shall be retained by a
15facility to verify timely submittal. Once an admission
16transaction has been completed, all resubmitted claims
17following prior rejection are subject to receipt no later than
18180 days after the admission transaction has been completed.
19    Claims that are not submitted and received in compliance
20with the foregoing requirements shall not be eligible for
21payment under the medical assistance program, and the State
22shall have no liability for payment of those claims.
23    To the extent consistent with applicable information and
24privacy, security, and disclosure laws, State and federal
25agencies and departments shall provide the Illinois Department
26access to confidential and other information and data necessary

 

 

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1to perform eligibility and payment verifications and other
2Illinois Department functions. This includes, but is not
3limited to: information pertaining to licensure;
4certification; earnings; immigration status; citizenship; wage
5reporting; unearned and earned income; pension income;
6employment; supplemental security income; social security
7numbers; National Provider Identifier (NPI) numbers; the
8National Practitioner Data Bank (NPDB); program and agency
9exclusions; taxpayer identification numbers; tax delinquency;
10corporate information; and death records.
11    The Illinois Department shall enter into agreements with
12State agencies and departments, and is authorized to enter into
13agreements with federal agencies and departments, under which
14such agencies and departments shall share data necessary for
15medical assistance program integrity functions and oversight.
16The Illinois Department shall develop, in cooperation with
17other State departments and agencies, and in compliance with
18applicable federal laws and regulations, appropriate and
19effective methods to share such data. At a minimum, and to the
20extent necessary to provide data sharing, the Illinois
21Department shall enter into agreements with State agencies and
22departments, and is authorized to enter into agreements with
23federal agencies and departments, including but not limited to:
24the Secretary of State; the Department of Revenue; the
25Department of Public Health; the Department of Human Services;
26and the Department of Financial and Professional Regulation.

 

 

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1    Beginning in fiscal year 2013, the Illinois Department
2shall set forth a request for information to identify the
3benefits of a pre-payment, post-adjudication, and post-edit
4claims system with the goals of streamlining claims processing
5and provider reimbursement, reducing the number of pending or
6rejected claims, and helping to ensure a more transparent
7adjudication process through the utilization of: (i) provider
8data verification and provider screening technology; and (ii)
9clinical code editing; and (iii) pre-pay, pre- or
10post-adjudicated predictive modeling with an integrated case
11management system with link analysis. Such a request for
12information shall not be considered as a request for proposal
13or as an obligation on the part of the Illinois Department to
14take any action or acquire any products or services.
15    The Illinois Department shall establish policies,
16procedures, standards and criteria by rule for the acquisition,
17repair and replacement of orthotic and prosthetic devices and
18durable medical equipment. Such rules shall provide, but not be
19limited to, the following services: (1) immediate repair or
20replacement of such devices by recipients; and (2) rental,
21lease, purchase or lease-purchase of durable medical equipment
22in a cost-effective manner, taking into consideration the
23recipient's medical prognosis, the extent of the recipient's
24needs, and the requirements and costs for maintaining such
25equipment. Subject to prior approval, such rules shall enable a
26recipient to temporarily acquire and use alternative or

 

 

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1substitute devices or equipment pending repairs or
2replacements of any device or equipment previously authorized
3for such recipient by the Department.
4    The Department shall execute, relative to the nursing home
5prescreening project, written inter-agency agreements with the
6Department of Human Services and the Department on Aging, to
7effect the following: (i) intake procedures and common
8eligibility criteria for those persons who are receiving
9non-institutional services; and (ii) the establishment and
10development of non-institutional services in areas of the State
11where they are not currently available or are undeveloped; and
12(iii) notwithstanding any other provision of law, subject to
13federal approval, on and after July 1, 2012, an increase in the
14determination of need (DON) scores from 29 to 37 for applicants
15for institutional and home and community-based long term care;
16if and only if federal approval is not granted, the Department
17may, in conjunction with other affected agencies, implement
18utilization controls or changes in benefit packages to
19effectuate a similar savings amount for this population; and
20(iv) no later than July 1, 2013, minimum level of care
21eligibility criteria for institutional and home and
22community-based long term care. In order to select the minimum
23level of care eligibility criteria, the Governor shall
24establish a workgroup that includes affected agency
25representatives and stakeholders representing the
26institutional and home and community-based long term care

 

 

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1interests. This Section shall not restrict the Department from
2implementing lower level of care eligibility criteria for
3community-based services in circumstances where federal
4approval has been granted.
5    The Illinois Department shall develop and operate, in
6cooperation with other State Departments and agencies and in
7compliance with applicable federal laws and regulations,
8appropriate and effective systems of health care evaluation and
9programs for monitoring of utilization of health care services
10and facilities, as it affects persons eligible for medical
11assistance under this Code.
12    The Illinois Department shall report annually to the
13General Assembly, no later than the second Friday in April of
141979 and each year thereafter, in regard to:
15        (a) actual statistics and trends in utilization of
16    medical services by public aid recipients;
17        (b) actual statistics and trends in the provision of
18    the various medical services by medical vendors;
19        (c) current rate structures and proposed changes in
20    those rate structures for the various medical vendors; and
21        (d) efforts at utilization review and control by the
22    Illinois Department.
23    The period covered by each report shall be the 3 years
24ending on the June 30 prior to the report. The report shall
25include suggested legislation for consideration by the General
26Assembly. The filing of one copy of the report with the

 

 

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1Speaker, one copy with the Minority Leader and one copy with
2the Clerk of the House of Representatives, one copy with the
3President, one copy with the Minority Leader and one copy with
4the Secretary of the Senate, one copy with the Legislative
5Research Unit, and such additional copies with the State
6Government Report Distribution Center for the General Assembly
7as is required under paragraph (t) of Section 7 of the State
8Library Act shall be deemed sufficient to comply with this
9Section.
10    Rulemaking authority to implement Public Act 95-1045, if
11any, is conditioned on the rules being adopted in accordance
12with all provisions of the Illinois Administrative Procedure
13Act and all rules and procedures of the Joint Committee on
14Administrative Rules; any purported rule not so adopted, for
15whatever reason, is unauthorized.
16    On and after July 1, 2012, the Department shall reduce any
17rate of reimbursement for services or other payments or alter
18any methodologies authorized by this Code to reduce any rate of
19reimbursement for services or other payments in accordance with
20Section 5-5e.
21(Source: P.A. 96-156, eff. 1-1-10; 96-806, eff. 7-1-10; 96-926,
22eff. 1-1-11; 96-1000, eff. 7-2-10; 97-48, eff. 6-28-11; 97-638,
23eff. 1-1-12; 97-689, eff. 6-14-12; 97-1061, eff. 8-24-12;
24revised 9-20-12.)
 
25    (305 ILCS 5/5-5f)

 

 

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1    Sec. 5-5f. Elimination and limitations of medical
2assistance services. Notwithstanding any other provision of
3this Code to the contrary, on and after July 1, 2012:
4    (a) The following services shall no longer be a covered
5service available under this Code: group psychotherapy for
6residents of any facility licensed under the Nursing Home Care
7Act or the Specialized Mental Health Rehabilitation Act; and
8adult chiropractic services.
9    (b) The Department shall place the following limitations on
10services: (i) the Department shall limit adult eyeglasses to
11one pair every 2 years; (ii) the Department shall set an annual
12limit of a maximum of 20 visits for each of the following
13services: adult speech, hearing, and language therapy
14services, adult occupational therapy services, and physical
15therapy services; (iii) the Department shall limit podiatry
16services to individuals with diabetes; (iv) the Department
17shall pay for caesarean sections at the normal vaginal delivery
18rate unless a caesarean section was medically necessary; (v)
19the Department may shall limit adult dental services to
20emergencies, except that this limitation shall not apply to
21pregnant women; and (vi) effective July 1, 2012, the Department
22shall place limitations and require concurrent review on every
23inpatient detoxification stay to prevent repeat admissions to
24any hospital for detoxification within 60 days of a previous
25inpatient detoxification stay. The Department shall convene a
26workgroup of hospitals, substance abuse providers, care

 

 

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1coordination entities, managed care plans, and other
2stakeholders to develop recommendations for quality standards,
3diversion to other settings, and admission criteria for
4patients who need inpatient detoxification.
5    (c) The Department shall require prior approval of the
6following services: wheelchair repairs, regardless of the cost
7of the repairs, coronary artery bypass graft, and bariatric
8surgery consistent with Medicare standards concerning patient
9responsibility. The wholesale cost of power wheelchairs shall
10be actual acquisition cost including all discounts.
11    (d) The Department shall establish benchmarks for
12hospitals to measure and align payments to reduce potentially
13preventable hospital readmissions, inpatient complications,
14and unnecessary emergency room visits. In doing so, the
15Department shall consider items, including, but not limited to,
16historic and current acuity of care and historic and current
17trends in readmission. The Department shall publish
18provider-specific historical readmission data and anticipated
19potentially preventable targets 60 days prior to the start of
20the program. In the instance of readmissions, the Department
21shall adopt policies and rates of reimbursement for services
22and other payments provided under this Code to ensure that, by
23June 30, 2013, expenditures to hospitals are reduced by, at a
24minimum, $40,000,000.
25    (e) The Department shall establish utilization controls
26for the hospice program such that it shall not pay for other

 

 

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1care services when an individual is in hospice.
2    (f) For home health services, the Department shall require
3Medicare certification of providers participating in the
4program, implement the Medicare face-to-face encounter rule,
5and limit services to post-hospitalization. The Department
6shall require providers to implement auditable electronic
7service verification based on global positioning systems or
8other cost-effective technology.
9    (g) For the Home Services Program operated by the
10Department of Human Services and the Community Care Program
11operated by the Department on Aging, the Department of Human
12Services, in cooperation with the Department on Aging, shall
13implement an electronic service verification based on global
14positioning systems or other cost-effective technology.
15    (h) The Department shall not pay for hospital admissions
16when the claim indicates a hospital acquired condition that
17would cause Medicare to reduce its payment on the claim had the
18claim been submitted to Medicare, nor shall the Department pay
19for hospital admissions where a Medicare identified "never
20event" occurred.
21    (i) The Department shall implement cost savings
22initiatives for advanced imaging services, cardiac imaging
23services, pain management services, and back surgery. Such
24initiatives shall be designed to achieve annual costs savings.
25(Source: P.A. 97-689, eff. 6-14-12.)
 
26    Section 99. Effective date. This Act takes effect July 1,

 

 

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12013.