SB0054 EngrossedLRB099 03946 MLM 23963 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
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.
17         (2) An annual mammogram for women 40 years of age or
18    older.
19         (3) A mammogram at the age and intervals considered
20    medically necessary by the woman's health care provider for
21    women under 40 years of age and having a family history of
22    breast cancer, prior personal history of breast cancer,
23    positive genetic testing, or other risk factors.

 

 

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1        (4) A comprehensive ultrasound screening of an entire
2    breast or breasts if a mammogram demonstrates
3    heterogeneous or dense breast tissue, when medically
4    necessary as determined by a physician licensed to practice
5    medicine in all of its branches.
6    For purposes of this Section, "low-dose mammography" means
7the x-ray examination of the breast using equipment dedicated
8specifically for mammography, including the x-ray tube,
9filter, compression device, and image receptor, with radiation
10exposure delivery of less than 1 rad per breast for 2 views of
11an average size breast. The term also includes digital
12mammography and may include breast tomosynthesis. As used in
13this Section, the term "breast tomosynthesis" means a
14radiologic procedure that involves the acquisition of
15projection images over the stationary breast to produce
16cross-sectional digital three-dimensional images of the
17breast.
18    (a-5) Coverage as described by subsection (a) shall be
19provided at no cost to the insured and shall not be applied to
20an annual or lifetime maximum benefit.
21    (a-10) When health care services are available through
22contracted providers and a person does not comply with plan
23provisions specific to the use of contracted providers, the
24requirements of subsection (a-5) are not applicable. When a
25person does not comply with plan provisions specific to the use
26of contracted providers, plan provisions specific to the use of

 

 

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1non-contracted providers must be applied without distinction
2for coverage required by this Section and shall be at least as
3favorable as for other radiological examinations covered by the
4policy or contract.
5    (b) No policy of accident or health insurance that provides
6for the surgical procedure known as a mastectomy shall be
7issued, amended, delivered, or renewed in this State unless
8that coverage also provides for prosthetic devices or
9reconstructive surgery incident to the mastectomy. Coverage
10for breast reconstruction in connection with a mastectomy shall
11include:
12        (1) reconstruction of the breast upon which the
13    mastectomy has been performed;
14        (2) surgery and reconstruction of the other breast to
15    produce a symmetrical appearance; and
16        (3) prostheses and treatment for physical
17    complications at all stages of mastectomy, including
18    lymphedemas.
19Care shall be determined in consultation with the attending
20physician and the patient. The offered coverage for prosthetic
21devices and reconstructive surgery shall be subject to the
22deductible and coinsurance conditions applied to the
23mastectomy, and all other terms and conditions applicable to
24other benefits. When a mastectomy is performed and there is no
25evidence of malignancy then the offered coverage may be limited
26to the provision of prosthetic devices and reconstructive

 

 

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1surgery to within 2 years after the date of the mastectomy. As
2used in this Section, "mastectomy" means the removal of all or
3part of the breast for medically necessary reasons, as
4determined by a licensed physician.
5    Written notice of the availability of coverage under this
6Section shall be delivered to the insured upon enrollment and
7annually thereafter. An insurer may not deny to an insured
8eligibility, or continued eligibility, to enroll or to renew
9coverage under the terms of the plan solely for the purpose of
10avoiding the requirements of this Section. An insurer may not
11penalize or reduce or limit the reimbursement of an attending
12provider or provide incentives (monetary or otherwise) to an
13attending provider to induce the provider to provide care to an
14insured in a manner inconsistent with this Section.
15    (c) Rulemaking authority to implement this amendatory Act
16of the 95th General Assembly, if any, is conditioned on the
17rules being adopted in accordance with all provisions of the
18Illinois Administrative Procedure Act and all rules and
19procedures of the Joint Committee on Administrative Rules; any
20purported rule not so adopted, for whatever reason, is
21unauthorized.
22(Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07;
2395-1045, eff. 3-27-09.)
 
24    Section 10. The Health Maintenance Organization Act is
25amended by changing Section 4-6.1 as follows:
 

 

 

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1    (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)
2    Sec. 4-6.1. Mammograms; mastectomies.
3    (a) Every contract or evidence of coverage issued by a
4Health Maintenance Organization for persons who are residents
5of this State shall contain coverage for screening by low-dose
6mammography for all women 35 years of age or older for the
7presence of occult breast cancer. The coverage shall be as
8follows:
9        (1) A baseline mammogram for women 35 to 39 years of
10    age.
11        (2) An annual mammogram for women 40 years of age or
12    older.
13        (3) A mammogram at the age and intervals considered
14    medically necessary by the woman's health care provider for
15    women under 40 years of age and having a family history of
16    breast cancer, prior personal history of breast cancer,
17    positive genetic testing, or other risk factors.
18        (4) A comprehensive ultrasound screening of an entire
19    breast or breasts if a mammogram demonstrates
20    heterogeneous or dense breast tissue, when medically
21    necessary as determined by a physician licensed to practice
22    medicine in all of its branches.
23    For purposes of this Section, "low-dose mammography" means
24the x-ray examination of the breast using equipment dedicated
25specifically for mammography, including the x-ray tube,

 

 

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1filter, compression device, and image receptor, with radiation
2exposure delivery of less than 1 rad per breast for 2 views of
3an average size breast. The term also includes digital
4mammography and may include breast tomosynthesis. As used in
5this Section, the term "breast tomosynthesis" means a
6radiologic procedure that involves the acquisition of
7projection images over the stationary breast to produce
8cross-sectional digital three-dimensional images of the
9breast.
10    (a-5) Coverage as described in subsection (a) shall be
11provided at no cost to the enrollee and shall not be applied to
12an annual or lifetime maximum benefit.
13    (b) No contract or evidence of coverage issued by a health
14maintenance organization that provides for the surgical
15procedure known as a mastectomy shall be issued, amended,
16delivered, or renewed in this State on or after the effective
17date of this amendatory Act of the 92nd General Assembly unless
18that coverage also provides for prosthetic devices or
19reconstructive surgery incident to the mastectomy, providing
20that the mastectomy is performed after the effective date of
21this amendatory Act. Coverage for breast reconstruction in
22connection with a mastectomy shall include:
23        (1) reconstruction of the breast upon which the
24    mastectomy has been performed;
25        (2) surgery and reconstruction of the other breast to
26    produce a symmetrical appearance; and

 

 

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1        (3) prostheses and treatment for physical
2    complications at all stages of mastectomy, including
3    lymphedemas.
4Care shall be determined in consultation with the attending
5physician and the patient. The offered coverage for prosthetic
6devices and reconstructive surgery shall be subject to the
7deductible and coinsurance conditions applied to the
8mastectomy and all other terms and conditions applicable to
9other benefits. When a mastectomy is performed and there is no
10evidence of malignancy, then the offered coverage may be
11limited to the provision of prosthetic devices and
12reconstructive surgery to within 2 years after the date of the
13mastectomy. As used in this Section, "mastectomy" means the
14removal of all or part of the breast for medically necessary
15reasons, as determined by a licensed physician.
16    Written notice of the availability of coverage under this
17Section shall be delivered to the enrollee upon enrollment and
18annually thereafter. A health maintenance organization may not
19deny to an enrollee eligibility, or continued eligibility, to
20enroll or to renew coverage under the terms of the plan solely
21for the purpose of avoiding the requirements of this Section. A
22health maintenance organization may not penalize or reduce or
23limit the reimbursement of an attending provider or provide
24incentives (monetary or otherwise) to an attending provider to
25induce the provider to provide care to an insured in a manner
26inconsistent with this Section.

 

 

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1    (c) Rulemaking authority to implement this amendatory Act
2of the 95th General Assembly, if any, is conditioned on the
3rules being adopted in accordance with all provisions of the
4Illinois Administrative Procedure Act and all rules and
5procedures of the Joint Committee on Administrative Rules; any
6purported rule not so adopted, for whatever reason, is
7unauthorized.
8(Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07;
995-1045, eff. 3-27-09.)
 
10    Section 15. 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,
22or elsewhere; (6) medical care, or any other type of remedial
23care furnished by licensed practitioners; (7) home health care
24services; (8) private duty nursing service; (9) clinic

 

 

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

 

 

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

 

 

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1Article.
2    Notwithstanding any other provision of this Code, the
3Illinois Department may not require, as a condition of payment
4for any laboratory test authorized under this Article, that a
5physician's handwritten signature appear on the laboratory
6test order form. The Illinois Department may, however, impose
7other appropriate requirements regarding laboratory test order
8documentation.
9    Upon receipt of federal approval of an amendment to the
10Illinois Title XIX State Plan for this purpose, the Department
11shall authorize the Chicago Public Schools (CPS) to procure a
12vendor or vendors to manufacture eyeglasses for individuals
13enrolled in a school within the CPS system. CPS shall ensure
14that its vendor or vendors are enrolled as providers in the
15medical assistance program and in any capitated Medicaid
16managed care entity (MCE) serving individuals enrolled in a
17school within the CPS system. Under any contract procured under
18this provision, the vendor or vendors must serve only
19individuals enrolled in a school within the CPS system. Claims
20for services provided by CPS's vendor or vendors to recipients
21of benefits in the medical assistance program under this Code,
22the Children's Health Insurance Program, or the Covering ALL
23KIDS Health Insurance Program shall be submitted to the
24Department or the MCE in which the individual is enrolled for
25payment and shall be reimbursed at the Department's or the
26MCE's established rates or rate methodologies for eyeglasses.

 

 

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1    On and after July 1, 2012, the Department of Healthcare and
2Family Services may provide the following services to persons
3eligible for assistance under this Article who are
4participating in education, training or employment programs
5operated by the Department of Human Services as successor to
6the Department of Public Aid:
7        (1) dental services provided by or under the
8    supervision of a dentist; and
9        (2) eyeglasses prescribed by a physician skilled in the
10    diseases of the eye, or by an optometrist, whichever the
11    person may select.
12    Notwithstanding any other provision of this Code and
13subject to federal approval, the Department may adopt rules to
14allow a dentist who is volunteering his or her service at no
15cost to render dental services through an enrolled
16not-for-profit health clinic without the dentist personally
17enrolling as a participating provider in the medical assistance
18program. A not-for-profit health clinic shall include a public
19health clinic or Federally Qualified Health Center or other
20enrolled provider, as determined by the Department, through
21which dental services covered under this Section are performed.
22The Department shall establish a process for payment of claims
23for reimbursement for covered dental services rendered under
24this provision.
25    The Illinois Department, by rule, may distinguish and
26classify the medical services to be provided only in accordance

 

 

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1with the classes of persons designated in Section 5-2.
2    The Department of Healthcare and Family Services must
3provide coverage and reimbursement for amino acid-based
4elemental formulas, regardless of delivery method, for the
5diagnosis and treatment of (i) eosinophilic disorders and (ii)
6short bowel syndrome when the prescribing physician has issued
7a written order stating that the amino acid-based elemental
8formula is medically necessary.
9    The Illinois Department shall authorize the provision of,
10and shall authorize payment for, screening by low-dose
11mammography for the presence of occult breast cancer for women
1235 years of age or older who are eligible for medical
13assistance under this Article, as follows:
14        (A) A baseline mammogram for women 35 to 39 years of
15    age.
16        (B) An annual mammogram for women 40 years of age or
17    older.
18        (C) A mammogram at the age and intervals considered
19    medically necessary by the woman's health care provider for
20    women under 40 years of age and having a family history of
21    breast cancer, prior personal history of breast cancer,
22    positive genetic testing, or other risk factors.
23        (D) A comprehensive ultrasound screening of an entire
24    breast or breasts if a mammogram demonstrates
25    heterogeneous or dense breast tissue, when medically
26    necessary as determined by a physician licensed to practice

 

 

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1    medicine in all of its branches.
2    All screenings shall include a physical breast exam,
3instruction on self-examination and information regarding the
4frequency of self-examination and its value as a preventative
5tool. For purposes of this Section, "low-dose mammography"
6means the x-ray examination of the breast using equipment
7dedicated specifically for mammography, including the x-ray
8tube, filter, compression device, and image receptor, with an
9average radiation exposure delivery of less than one rad per
10breast for 2 views of an average size breast. The term also
11includes digital mammography and may include breast
12tomosynthesis. As used in this Section, the term "breast
13tomosynthesis" means a radiologic procedure that involves the
14acquisition of projection images over the stationary breast to
15produce cross-sectional digital three-dimensional images of
16the breast.
17    On and after January 1, 2012, providers participating in a
18quality improvement program approved by the Department shall be
19reimbursed for screening and diagnostic mammography at the same
20rate as the Medicare program's rates, including the increased
21reimbursement for digital mammography.
22    The Department shall convene an expert panel including
23representatives of hospitals, free-standing mammography
24facilities, and doctors, including radiologists, to establish
25quality standards.
26    Subject to federal approval, the Department shall

 

 

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1establish a rate methodology for mammography at federally
2qualified health centers and other encounter-rate clinics.
3These clinics or centers may also collaborate with other
4hospital-based mammography facilities.
5    The Department shall establish a methodology to remind
6women who are age-appropriate for screening mammography, but
7who have not received a mammogram within the previous 18
8months, of the importance and benefit of screening mammography.
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. An evaluation of the
22pilot program shall be carried out measuring health outcomes
23and cost of care for those served by the pilot program compared
24to similarly situated patients who are not served by the pilot
25program.
26    Any medical or health care provider shall immediately

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1Article. All dispensers of medical services shall be required
2to maintain and retain business and professional records
3sufficient to fully and accurately document the nature, scope,
4details and receipt of the health care provided to persons
5eligible for medical assistance under this Code, in accordance
6with regulations promulgated by the Illinois Department. The
7rules and regulations shall require that proof of the receipt
8of prescription drugs, dentures, prosthetic devices and
9eyeglasses by eligible persons under this Section accompany
10each claim for reimbursement submitted by the dispenser of such
11medical services. No such claims for reimbursement shall be
12approved for payment by the Illinois Department without such
13proof of receipt, unless the Illinois Department shall have put
14into effect and shall be operating a system of post-payment
15audit and review which shall, on a sampling basis, be deemed
16adequate by the Illinois Department to assure that such drugs,
17dentures, prosthetic devices and eyeglasses for which payment
18is being made are actually being received by eligible
19recipients. Within 90 days after the effective date of this
20amendatory Act of 1984, the Illinois Department shall establish
21a current list of acquisition costs for all prosthetic devices
22and any other items recognized as medical equipment and
23supplies reimbursable under this Article and shall update such
24list on a quarterly basis, except that the acquisition costs of
25all prescription drugs shall be updated no less frequently than
26every 30 days as required by Section 5-5.12.

 

 

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1    The rules and regulations of the Illinois Department shall
2require that a written statement including the required opinion
3of a physician shall accompany any claim for reimbursement for
4abortions, or induced miscarriages or premature births. This
5statement shall indicate what procedures were used in providing
6such medical services.
7    Notwithstanding any other law to the contrary, the Illinois
8Department shall, within 365 days after July 22, 2013, (the
9effective date of Public Act 98-104), establish procedures to
10permit skilled care facilities licensed under the Nursing Home
11Care Act to submit monthly billing claims for reimbursement
12purposes. Following development of these procedures, the
13Department shall have an additional 365 days to test the
14viability of the new system and to ensure that any necessary
15operational or structural changes to its information
16technology platforms are implemented.
17    Notwithstanding any other law to the contrary, the Illinois
18Department shall, within 365 days after August 15, 2014 (the
19effective date of Public Act 98-963) this amendatory Act of the
2098th General Assembly, establish procedures to permit ID/DD
21facilities licensed under the ID/DD Community Care Act to
22submit monthly billing claims for reimbursement purposes.
23Following development of these procedures, the Department
24shall have an additional 365 days to test the viability of the
25new system and to ensure that any necessary operational or
26structural changes to its information technology platforms are

 

 

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1implemented.
2    The Illinois Department shall require all dispensers of
3medical services, other than an individual practitioner or
4group of practitioners, desiring to participate in the Medical
5Assistance program established under this Article to disclose
6all financial, beneficial, ownership, equity, surety or other
7interests in any and all firms, corporations, partnerships,
8associations, business enterprises, joint ventures, agencies,
9institutions or other legal entities providing any form of
10health care services in this State under this Article.
11    The Illinois Department may require that all dispensers of
12medical services desiring to participate in the medical
13assistance program established under this Article disclose,
14under such terms and conditions as the Illinois Department may
15by rule establish, all inquiries from clients and attorneys
16regarding medical bills paid by the Illinois Department, which
17inquiries could indicate potential existence of claims or liens
18for the Illinois Department.
19    Enrollment of a vendor shall be subject to a provisional
20period and shall be conditional for one year. During the period
21of conditional enrollment, the Department may terminate the
22vendor's eligibility to participate in, or may disenroll the
23vendor from, the medical assistance program without cause.
24Unless otherwise specified, such termination of eligibility or
25disenrollment is not subject to the Department's hearing
26process. However, a disenrolled vendor may reapply without

 

 

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1penalty.
2    The Department has the discretion to limit the conditional
3enrollment period for vendors based upon category of risk of
4the vendor.
5    Prior to enrollment and during the conditional enrollment
6period in the medical assistance program, all vendors shall be
7subject to enhanced oversight, screening, and review based on
8the risk of fraud, waste, and abuse that is posed by the
9category of risk of the vendor. The Illinois Department shall
10establish the procedures for oversight, screening, and review,
11which may include, but need not be limited to: criminal and
12financial background checks; fingerprinting; license,
13certification, and authorization verifications; unscheduled or
14unannounced site visits; database checks; prepayment audit
15reviews; audits; payment caps; payment suspensions; and other
16screening as required by federal or State law.
17    The Department shall define or specify the following: (i)
18by provider notice, the "category of risk of the vendor" for
19each type of vendor, which shall take into account the level of
20screening applicable to a particular category of vendor under
21federal law and regulations; (ii) by rule or provider notice,
22the maximum length of the conditional enrollment period for
23each category of risk of the vendor; and (iii) by rule, the
24hearing rights, if any, afforded to a vendor in each category
25of risk of the vendor that is terminated or disenrolled during
26the conditional enrollment period.

 

 

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1    To be eligible for payment consideration, a vendor's
2payment claim or bill, either as an initial claim or as a
3resubmitted claim following prior rejection, must be received
4by the Illinois Department, or its fiscal intermediary, no
5later than 180 days after the latest date on the claim on which
6medical goods or services were provided, with the following
7exceptions:
8        (1) In the case of a provider whose enrollment is in
9    process by the Illinois Department, the 180-day period
10    shall not begin until the date on the written notice from
11    the Illinois Department that the provider enrollment is
12    complete.
13        (2) In the case of errors attributable to the Illinois
14    Department or any of its claims processing intermediaries
15    which result in an inability to receive, process, or
16    adjudicate a claim, the 180-day period shall not begin
17    until the provider has been notified of the error.
18        (3) In the case of a provider for whom the Illinois
19    Department initiates the monthly billing process.
20        (4) In the case of a provider operated by a unit of
21    local government with a population exceeding 3,000,000
22    when local government funds finance federal participation
23    for claims payments.
24    For claims for services rendered during a period for which
25a recipient received retroactive eligibility, claims must be
26filed within 180 days after the Department determines the

 

 

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1applicant is eligible. For claims for which the Illinois
2Department is not the primary payer, claims must be submitted
3to the Illinois Department within 180 days after the final
4adjudication by the primary payer.
5    In the case of long term care facilities, within 5 days of
6receipt by the facility of required prescreening information,
7data for new admissions shall be entered into the Medical
8Electronic Data Interchange (MEDI) or the Recipient
9Eligibility Verification (REV) System or successor system, and
10within 15 days of receipt by the facility of required
11prescreening information, admission documents shall be
12submitted through MEDI or REV or shall be submitted directly to
13the Department of Human Services using required admission
14forms. Effective September 1, 2014, admission documents,
15including all prescreening information, must be submitted
16through MEDI or REV. Confirmation numbers assigned to an
17accepted transaction shall be retained by a facility to verify
18timely submittal. Once an admission transaction has been
19completed, all resubmitted claims following prior rejection
20are subject to receipt no later than 180 days after the
21admission transaction has been completed.
22    Claims that are not submitted and received in compliance
23with the foregoing requirements shall not be eligible for
24payment under the medical assistance program, and the State
25shall have no liability for payment of those claims.
26    To the extent consistent with applicable information and

 

 

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

 

 

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

 

 

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1needs, and the requirements and costs for maintaining such
2equipment. Subject to prior approval, such rules shall enable a
3recipient to temporarily acquire and use alternative or
4substitute devices or equipment pending repairs or
5replacements of any device or equipment previously authorized
6for such recipient by the Department.
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

 

 

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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

 

 

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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.

 

 

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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(Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689,
18eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section
199-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff.
207-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; 98-651,
21eff. 6-16-14; 98-756, eff. 7-16-14; 98-963, eff. 8-15-14;
22revised 10-2-14.)
 
23    Section 99. Effective date. This Act takes effect upon
24becoming law.