Rep. Sara Feigenholtz

Filed: 11/29/2016





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2    AMENDMENT NO. ______. Amend Senate Bill 1465 by replacing
3everything after the enacting clause with the following:
4    "Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Sections 6 and 6.1 as follows:
6    (5 ILCS 375/6)  (from Ch. 127, par. 526)
7    Sec. 6. Program of health benefits.
8    (a) The program of health benefits shall provide for
9protection against the financial costs of health care expenses
10incurred in and out of hospital including basic
11hospital-surgical-medical coverages. The program may include,
12but shall not be limited to, such supplemental coverages as
13out-patient diagnostic X-ray and laboratory expenses,
14prescription drugs, dental services, hearing evaluations,
15hearing aids, the dispensing and fitting of hearing aids, and
16similar group benefits as are now or may become available.



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1However, nothing in this Act shall be construed to permit, on
2or after July 1, 1980, the non-contributory portion of any such
3program to include the expenses of obtaining an abortion,
4induced miscarriage or induced premature birth unless, in the
5opinion of a physician, such procedures are necessary for the
6preservation of the life of the woman seeking such treatment,
7or except an induced premature birth intended to produce a live
8viable child and such procedure is necessary for the health of
9the mother or the unborn child. The program may also include
10coverage for those who rely on treatment by prayer or spiritual
11means alone for healing in accordance with the tenets and
12practice of a recognized religious denomination.
13    The program of health benefits shall be designed by the
14Director (1) to provide a reasonable relationship between the
15benefits to be included and the expected distribution of
16expenses of each such type to be incurred by the covered
17members and dependents, (2) to specify, as covered benefits and
18as optional benefits, the medical services of practitioners in
19all categories licensed under the Medical Practice Act of 1987,
20(3) to include reasonable controls, which may include
21deductible and co-insurance provisions, applicable to some or
22all of the benefits, or a coordination of benefits provision,
23to prevent or minimize unnecessary utilization of the various
24hospital, surgical and medical expenses to be provided and to
25provide reasonable assurance of stability of the program, and
26(4) to provide benefits to the extent possible to members



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1throughout the State, wherever located, on an equitable basis.
2Notwithstanding any other provision of this Section or Act, for
3all members or dependents who are eligible for benefits under
4Social Security or the Railroad Retirement system or who had
5sufficient Medicare-covered government employment, the
6Department shall reduce benefits which would otherwise be paid
7by Medicare, by the amount of benefits for which the member or
8dependents are eligible under Medicare, except that such
9reduction in benefits shall apply only to those members or
10dependents who (1) first become eligible for such medicare
11coverage on or after the effective date of this amendatory Act
12of 1992; or (2) are Medicare-eligible members or dependents of
13a local government unit which began participation in the
14program on or after July 1, 1992; or (3) remain eligible for
15but no longer receive Medicare coverage which they had been
16receiving on or after the effective date of this amendatory Act
17of 1992.
18    Notwithstanding any other provisions of this Act, where a
19covered member or dependents are eligible for benefits under
20the federal Medicare health insurance program (Title XVIII of
21the Social Security Act as added by Public Law 89-97, 89th
22Congress), benefits paid under the State of Illinois program or
23plan will be reduced by the amount of benefits paid by
24Medicare. For members or dependents who are eligible for
25benefits under Social Security or the Railroad Retirement
26system or who had sufficient Medicare-covered government



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1employment, benefits shall be reduced by the amount for which
2the member or dependent is eligible under Medicare, except that
3such reduction in benefits shall apply only to those members or
4dependents who (1) first become eligible for such Medicare
5coverage on or after the effective date of this amendatory Act
6of 1992; or (2) are Medicare-eligible members or dependents of
7a local government unit which began participation in the
8program on or after July 1, 1992; or (3) remain eligible for,
9but no longer receive Medicare coverage which they had been
10receiving on or after the effective date of this amendatory Act
11of 1992. Premiums may be adjusted, where applicable, to an
12amount deemed by the Director to be reasonably consistent with
13any reduction of benefits.
14    (b) A member, not otherwise covered by this Act, who has
15retired as a participating member under Article 2 of the
16Illinois Pension Code but is ineligible for the retirement
17annuity under Section 2-119 of the Illinois Pension Code, shall
18pay the premiums for coverage, not exceeding the amount paid by
19the State for the non-contributory coverage for other members,
20under the group health benefits program under this Act. The
21Director shall determine the premiums to be paid by a member
22under this subsection (b).
23(Source: P.A. 93-47, eff. 7-1-03.)
24    (5 ILCS 375/6.1)  (from Ch. 127, par. 526.1)
25    Sec. 6.1. The program of health benefits may offer as an



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1alternative, available on an optional basis, coverage through
2health maintenance organizations. That part of the premium for
3such coverage which is in excess of the amount which would
4otherwise be paid by the State for the program of health
5benefits shall be paid by the member who elects such
6alternative coverage and shall be collected as provided for
7premiums for other optional coverages.
8    However, nothing in this Act shall be construed to permit,
9after the effective date of this amendatory Act of 1983, the
10noncontributory portion of any such program to include the
11expenses of obtaining an abortion, induced miscarriage or
12induced premature birth unless, in the opinion of a physician,
13such procedures are necessary for the preservation of the life
14of the woman seeking such treatment, or except an induced
15premature birth intended to produce a live viable child and
16such procedure is necessary for the health of the mother or her
17unborn child.
18(Source: P.A. 85-848.)
19    Section 10. The Illinois Public Aid Code is amended by
20changing Sections 5-5, 5-8, 5-9, and 6-1 as follows:
21    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
22    Sec. 5-5. Medical services. The Illinois Department, by
23rule, shall determine the quantity and quality of and the rate
24of reimbursement for the medical assistance for which payment



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



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



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



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



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1program. A not-for-profit health clinic shall include a public
2health clinic or Federally Qualified Health Center or other
3enrolled provider, as determined by the Department, through
4which dental services covered under this Section are performed.
5The Department shall establish a process for payment of claims
6for reimbursement for covered dental services rendered under
7this provision.
8    The Illinois Department, by rule, may distinguish and
9classify the medical services to be provided only in accordance
10with the classes of persons designated in Section 5-2.
11    The Department of Healthcare and Family Services must
12provide coverage and reimbursement for amino acid-based
13elemental formulas, regardless of delivery method, for the
14diagnosis and treatment of (i) eosinophilic disorders and (ii)
15short bowel syndrome when the prescribing physician has issued
16a written order stating that the amino acid-based elemental
17formula is medically necessary.
18    The Illinois Department shall authorize the provision of,
19and shall authorize payment for, screening by low-dose
20mammography for the presence of occult breast cancer for women
2135 years of age or older who are eligible for medical
22assistance under this Article, as follows:
23        (A) A baseline mammogram for women 35 to 39 years of
24    age.
25        (B) An annual mammogram for women 40 years of age or
26    older.



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



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



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



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1The Department shall work with experts in breast cancer
2outreach and patient navigation to optimize these reminders and
3shall establish a methodology for evaluating their
4effectiveness and modifying the methodology based on the
6    The Department shall establish a performance goal for
7primary care providers with respect to their female patients
8over age 40 receiving an annual mammogram. This performance
9goal shall be used to provide additional reimbursement in the
10form of a quality performance bonus to primary care providers
11who meet that goal.
12    The Department shall devise a means of case-managing or
13patient navigation for beneficiaries diagnosed with breast
14cancer. This program shall initially operate as a pilot program
15in areas of the State with the highest incidence of mortality
16related to breast cancer. At least one pilot program site shall
17be in the metropolitan Chicago area and at least one site shall
18be outside the metropolitan Chicago area. On or after July 1,
192016, the pilot program shall be expanded to include one site
20in western Illinois, one site in southern Illinois, one site in
21central Illinois, and 4 sites within metropolitan Chicago. An
22evaluation of the pilot program shall be carried out measuring
23health outcomes and cost of care for those served by the pilot
24program compared to similarly situated patients who are not
25served by the pilot program.
26    The Department shall require all networks of care to



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



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



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



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



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



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1recipients. Within 90 days after September 16, 1984 (the
2effective date of Public Act 83-1439), the Illinois Department
3shall establish a current list of acquisition costs for all
4prosthetic devices and any other items recognized as medical
5equipment and supplies reimbursable under this Article and
6shall update such list on a quarterly basis, except that the
7acquisition costs of all prescription drugs shall be updated no
8less frequently than every 30 days as required by Section
10    The rules and regulations of the Illinois Department shall
11require that a written statement including the required opinion
12of a physician shall accompany any claim for reimbursement for
13abortions, or induced miscarriages or premature births. This
14statement shall indicate what procedures were used in providing
15such medical services.
16    Notwithstanding any other law to the contrary, the Illinois
17Department shall, within 365 days after July 22, 2013 (the
18effective date of Public Act 98-104), establish procedures to
19permit skilled care facilities licensed under the Nursing Home
20Care Act to submit monthly billing claims for reimbursement
21purposes. Following development of these procedures, the
22Department shall, by July 1, 2016, test the viability of the
23new system and implement any necessary operational or
24structural changes to its information technology platforms in
25order to allow for the direct acceptance and payment of nursing
26home claims.



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



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



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



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



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



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



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



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1recipients. No later than 15 months after the effective date of
2the rule adopted pursuant to this paragraph, all providers must
3meet the accreditation requirement.
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; and (v) no later than October
231, 2013, establish procedures to permit long term care
24providers access to eligibility scores for individuals with an
25admission date who are seeking or receiving services from the
26long term care provider. In order to select the minimum level



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1of care eligibility criteria, the Governor shall establish a
2workgroup that includes affected agency representatives and
3stakeholders representing the institutional and home and
4community-based long term care interests. This Section shall
5not restrict the Department from implementing lower level of
6care eligibility criteria for community-based services in
7circumstances where federal approval has been granted.
8    The Illinois Department shall develop and operate, in
9cooperation with other State Departments and agencies and in
10compliance with applicable federal laws and regulations,
11appropriate and effective systems of health care evaluation and
12programs for monitoring of utilization of health care services
13and facilities, as it affects persons eligible for medical
14assistance under this Code.
15    The Illinois Department shall report annually to the
16General Assembly, no later than the second Friday in April of
171979 and each year thereafter, in regard to:
18        (a) actual statistics and trends in utilization of
19    medical services by public aid recipients;
20        (b) actual statistics and trends in the provision of
21    the various medical services by medical vendors;
22        (c) current rate structures and proposed changes in
23    those rate structures for the various medical vendors; and
24        (d) efforts at utilization review and control by the
25    Illinois Department.
26    The period covered by each report shall be the 3 years



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



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



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1product, administration devices, and any pharmacy fees related
2to the dispensing and administration of the opioid antagonist,
3shall be covered under the medical assistance program for
4persons who are otherwise eligible for medical assistance under
5this Article. As used in this Section, "opioid antagonist"
6means a drug that binds to opioid receptors and blocks or
7inhibits the effect of opioids acting on those receptors,
8including, but not limited to, naloxone hydrochloride or any
9other similarly acting drug approved by the U.S. Food and Drug
11    Upon federal approval, the Department shall provide
12coverage and reimbursement for all drugs that are approved for
13marketing by the federal Food and Drug Administration and that
14are recommended by the federal Public Health Service or the
15United States Centers for Disease Control and Prevention for
16pre-exposure prophylaxis and related pre-exposure prophylaxis
17services, including, but not limited to, HIV and sexually
18transmitted infection screening, treatment for sexually
19transmitted infections, medical monitoring, assorted labs, and
20counseling to reduce the likelihood of HIV infection among
21individuals who are not infected with HIV but who are at high
22risk of HIV infection.
23(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
2498-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
258-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
26eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;



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199-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
220 of P.A. 99-588 for the effective date of P.A. 99-407);
399-433, eff. 8-21-15; 99-480, eff. 9-9-15; 99-588, eff.
47-20-16; 99-642, eff. 7-28-16; 99-772, eff. 1-1-17; 99-895,
5eff. 1-1-17; revised 9-20-16.)
6    (305 ILCS 5/5-8)  (from Ch. 23, par. 5-8)
7    Sec. 5-8. Practitioners. In supplying medical assistance,
8the Illinois Department may provide for the legally authorized
9services of (i) persons licensed under the Medical Practice Act
10of 1987, as amended, except as hereafter in this Section
11stated, whether under a general or limited license, (ii)
12persons licensed under the Nurse Practice Act as advanced
13practice nurses, regardless of whether or not the persons have
14written collaborative agreements, (iii) persons licensed or
15registered under other laws of this State to provide dental,
16medical, pharmaceutical, optometric, podiatric, or nursing
17services, or other remedial care recognized under State law,
18and (iv) persons licensed under other laws of this State as a
19clinical social worker. The Department shall adopt rules, no
20later than 90 days after the effective date of this amendatory
21Act of the 99th General Assembly, for the legally authorized
22services of persons licensed under other laws of this State as
23a clinical social worker. The Department may not provide for
24legally authorized services of any physician who has been
25convicted of having performed an abortion procedure in a wilful



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1and wanton manner on a woman who was not pregnant at the time
2such abortion procedure was performed. The utilization of the
3services of persons engaged in the treatment or care of the
4sick, which persons are not required to be licensed or
5registered under the laws of this State, is not prohibited by
6this Section.
7(Source: P.A. 99-173, eff. 7-29-15; 99-621, eff. 1-1-17.)
8    (305 ILCS 5/5-9)  (from Ch. 23, par. 5-9)
9    Sec. 5-9. Choice of Medical Dispensers. Applicants and
10recipients shall be entitled to free choice of those qualified
11practitioners, hospitals, nursing homes, and other dispensers
12of medical services meeting the requirements and complying with
13the rules and regulations of the Illinois Department. However,
14the Director of Healthcare and Family Services may, after
15providing reasonable notice and opportunity for hearing, deny,
16suspend or terminate any otherwise qualified person, firm,
17corporation, association, agency, institution, or other legal
18entity, from participation as a vendor of goods or services
19under the medical assistance program authorized by this Article
20if the Director finds such vendor of medical services in
21violation of this Act or the policy or rules and regulations
22issued pursuant to this Act. Any physician who has been
23convicted of performing an abortion procedure in a wilful and
24wanton manner upon a woman who was not pregnant at the time
25such abortion procedure was performed shall be automatically



09900SB1465ham001- 35 -LRB099 07911 KTG 51664 a

1removed from the list of physicians qualified to participate as
2a vendor of medical services under the medical assistance
3program authorized by this Article.
4(Source: P.A. 95-331, eff. 8-21-07.)
5    (305 ILCS 5/6-1)  (from Ch. 23, par. 6-1)
6    Sec. 6-1. Eligibility requirements. Financial aid in
7meeting basic maintenance requirements shall be given under
8this Article to or in behalf of persons who meet the
9eligibility conditions of Sections 6-1.1 through 6-1.10. In
10addition, each unit of local government subject to this Article
11shall provide persons receiving financial aid in meeting basic
12maintenance requirements with financial aid for either (a)
13necessary treatment, care, and supplies required because of
14illness or disability, or (b) acute medical treatment, care,
15and supplies only. If a local governmental unit elects to
16provide financial aid for acute medical treatment, care, and
17supplies only, the general types of acute medical treatment,
18care, and supplies for which financial aid is provided shall be
19specified in the general assistance rules of the local
20governmental unit, which rules shall provide that financial aid
21is provided, at a minimum, for acute medical treatment, care,
22or supplies necessitated by a medical condition for which prior
23approval or authorization of medical treatment, care, or
24supplies is not required by the general assistance rules of the
25Illinois Department. Nothing in this Article shall be construed



09900SB1465ham001- 36 -LRB099 07911 KTG 51664 a

1to permit the granting of financial aid where the purpose of
2such aid is to obtain an abortion, induced miscarriage or
3induced premature birth unless, in the opinion of a physician,
4such procedures are necessary for the preservation of the life
5of the woman seeking such treatment, or except an induced
6premature birth intended to produce a live viable child and
7such procedure is necessary for the health of the mother or her
8unborn child.
9(Source: P.A. 92-111, eff. 1-1-02.)
10    Section 15. The Problem Pregnancy Health Services and Care
11Act is amended by changing Section 4-100 as follows:
12    (410 ILCS 230/4-100)  (from Ch. 111 1/2, par. 4604-100)
13    Sec. 4-100. The Department may make grants to nonprofit
14agencies and organizations which do not use such grants to
15refer or counsel for, or perform, abortions and which
16coordinate and establish linkages among services that will
17further the purposes of this Act and, where appropriate, will
18provide, supplement, or improve the quality of such services.
19(Source: P.A. 83-51.)
20    Section 20. The Illinois Abortion Law of 1975 is amended by
21changing Section 1 as follows:
22    (720 ILCS 510/1)  (from Ch. 38, par. 81-21)



09900SB1465ham001- 37 -LRB099 07911 KTG 51664 a

1    Sec. 1. It is the intention of the General Assembly of the
2State of Illinois to reasonably regulate abortion in
3conformance with the legal standards set forth in the decisions
4of the United States Supreme Court of January 22, 1973. Without
5in any way restricting the right of privacy of a woman or the
6right of a woman to an abortion under those decisions, the
7General Assembly of the State of Illinois do solemnly declare
8and find in reaffirmation of the longstanding policy of this
9State, that the unborn child is a human being from the time of
10conception and is, therefore, a legal person for purposes of
11the unborn child's right to life and is entitled to the right
12to life from conception under the laws and Constitution of this
13State. Further, the General Assembly finds and declares that
14longstanding policy of this State to protect the right to life
15of the unborn child from conception by prohibiting abortion
16unless necessary to preserve the life of the mother is
17impermissible only because of the decisions of the United
18States Supreme Court and that, therefore, if those decisions of
19the United States Supreme Court are ever reversed or modified
20or the United States Constitution is amended to allow
21protection of the unborn then the former policy of this State
22to prohibit abortions unless necessary for the preservation of
23the mother's life shall be reinstated.
24    It is the further intention of the General Assembly to
25assure and protect the woman's health and the integrity of the
26woman's decision whether or not to continue to bear a child, to



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1protect the valid and compelling state interest in the infant
2and unborn child, to assure the integrity of marital and
3familial relations and the rights and interests of persons who
4participate in such relations, and to gather data for
5establishing criteria for medical decisions. The General
6Assembly finds as fact, upon hearings and public disclosures,
7that these rights and interests are not secure in the economic
8and social context in which abortion is presently performed.
9(Source: P.A. 81-1078.)".