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Full Text of HB0040  100th General Assembly

HB0040enr 100TH GENERAL ASSEMBLY

  
  
  

 


 
HB0040 EnrolledLRB100 04384 KTG 14390 b

1    AN ACT concerning abortion.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by 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.
17However, nothing in this Act shall be construed to permit, on
18or after July 1, 1980, the non-contributory portion of any such
19program to include the expenses of obtaining an abortion,
20induced miscarriage or induced premature birth unless, in the
21opinion of a physician, such procedures are necessary for the
22preservation of the life of the woman seeking such treatment,
23or except an induced premature birth intended to produce a live

 

 

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1viable child and such procedure is necessary for the health of
2the mother or the unborn child. The program may also include
3coverage for those who rely on treatment by prayer or spiritual
4means alone for healing in accordance with the tenets and
5practice of a recognized religious denomination.
6    The program of health benefits shall be designed by the
7Director (1) to provide a reasonable relationship between the
8benefits to be included and the expected distribution of
9expenses of each such type to be incurred by the covered
10members and dependents, (2) to specify, as covered benefits and
11as optional benefits, the medical services of practitioners in
12all categories licensed under the Medical Practice Act of 1987,
13(3) to include reasonable controls, which may include
14deductible and co-insurance provisions, applicable to some or
15all of the benefits, or a coordination of benefits provision,
16to prevent or minimize unnecessary utilization of the various
17hospital, surgical and medical expenses to be provided and to
18provide reasonable assurance of stability of the program, and
19(4) to provide benefits to the extent possible to members
20throughout the State, wherever located, on an equitable basis.
21Notwithstanding any other provision of this Section or Act, for
22all members or dependents who are eligible for benefits under
23Social Security or the Railroad Retirement system or who had
24sufficient Medicare-covered government employment, the
25Department shall reduce benefits which would otherwise be paid
26by Medicare, by the amount of benefits for which the member or

 

 

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

 

 

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1program on or after July 1, 1992; or (3) remain eligible for,
2but no longer receive Medicare coverage which they had been
3receiving on or after the effective date of this amendatory Act
4of 1992. Premiums may be adjusted, where applicable, to an
5amount deemed by the Director to be reasonably consistent with
6any reduction of benefits.
7    (b) A member, not otherwise covered by this Act, who has
8retired as a participating member under Article 2 of the
9Illinois Pension Code but is ineligible for the retirement
10annuity under Section 2-119 of the Illinois Pension Code, shall
11pay the premiums for coverage, not exceeding the amount paid by
12the State for the non-contributory coverage for other members,
13under the group health benefits program under this Act. The
14Director shall determine the premiums to be paid by a member
15under this subsection (b).
16(Source: P.A. 93-47, eff. 7-1-03.)
 
17    (5 ILCS 375/6.1)  (from Ch. 127, par. 526.1)
18    Sec. 6.1. The program of health benefits may offer as an
19alternative, available on an optional basis, coverage through
20health maintenance organizations. That part of the premium for
21such coverage which is in excess of the amount which would
22otherwise be paid by the State for the program of health
23benefits shall be paid by the member who elects such
24alternative coverage and shall be collected as provided for
25premiums for other optional coverages.

 

 

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1    However, nothing in this Act shall be construed to permit,
2after the effective date of this amendatory Act of 1983, the
3noncontributory portion of any such program to include the
4expenses of obtaining an abortion, induced miscarriage or
5induced premature birth unless, in the opinion of a physician,
6such procedures are necessary for the preservation of the life
7of the woman seeking such treatment, or except an induced
8premature birth intended to produce a live viable child and
9such procedure is necessary for the health of the mother or her
10unborn child.
11(Source: P.A. 85-848.)
 
12    Section 10. The Illinois Public Aid Code is amended by
13changing Sections 5-5, 5-8, 5-9, and 6-1 as follows:
 
14    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
15    Sec. 5-5. Medical services. The Illinois Department, by
16rule, shall determine the quantity and quality of and the rate
17of reimbursement for the medical assistance for which payment
18will be authorized, and the medical services to be provided,
19which may include all or part of the following: (1) inpatient
20hospital services; (2) outpatient hospital services; (3) other
21laboratory and X-ray services; (4) skilled nursing home
22services; (5) physicians' services whether furnished in the
23office, the patient's home, a hospital, a skilled nursing home,
24or elsewhere; (6) medical care, or any other type of remedial

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1shall establish a methodology for evaluating their
2effectiveness and modifying the methodology based on the
3evaluation.
4    The Department shall establish a performance goal for
5primary care providers with respect to their female patients
6over age 40 receiving an annual mammogram. This performance
7goal shall be used to provide additional reimbursement in the
8form of a quality performance bonus to primary care providers
9who meet that goal.
10    The Department shall devise a means of case-managing or
11patient navigation for beneficiaries diagnosed with breast
12cancer. This program shall initially operate as a pilot program
13in areas of the State with the highest incidence of mortality
14related to breast cancer. At least one pilot program site shall
15be in the metropolitan Chicago area and at least one site shall
16be outside the metropolitan Chicago area. On or after July 1,
172016, the pilot program shall be expanded to include one site
18in western Illinois, one site in southern Illinois, one site in
19central Illinois, and 4 sites within metropolitan Chicago. An
20evaluation of the pilot program shall be carried out measuring
21health outcomes and cost of care for those served by the pilot
22program compared to similarly situated patients who are not
23served by the pilot program.
24    The Department shall require all networks of care to
25develop a means either internally or by contract with experts
26in navigation and community outreach to navigate cancer

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1then the records must be retained until the audit is completed
2and every exception is resolved. The Illinois Department shall
3require health care providers to make available, when
4authorized by the patient, in writing, the medical records in a
5timely fashion to other health care providers who are treating
6or serving persons eligible for Medical Assistance under this
7Article. All dispensers of medical services shall be required
8to maintain and retain business and professional records
9sufficient to fully and accurately document the nature, scope,
10details and receipt of the health care provided to persons
11eligible for medical assistance under this Code, in accordance
12with regulations promulgated by the Illinois Department. The
13rules and regulations shall require that proof of the receipt
14of prescription drugs, dentures, prosthetic devices and
15eyeglasses by eligible persons under this Section accompany
16each claim for reimbursement submitted by the dispenser of such
17medical services. No such claims for reimbursement shall be
18approved for payment by the Illinois Department without such
19proof of receipt, unless the Illinois Department shall have put
20into effect and shall be operating a system of post-payment
21audit and review which shall, on a sampling basis, be deemed
22adequate by the Illinois Department to assure that such drugs,
23dentures, prosthetic devices and eyeglasses for which payment
24is being made are actually being received by eligible
25recipients. Within 90 days after September 16, 1984 (the
26effective date of Public Act 83-1439), the Illinois Department

 

 

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1shall establish a current list of acquisition costs for all
2prosthetic devices and any other items recognized as medical
3equipment and supplies reimbursable under this Article and
4shall update such list on a quarterly basis, except that the
5acquisition costs of all prescription drugs shall be updated no
6less frequently than every 30 days as required by Section
75-5.12.
8    The rules and regulations of the Illinois Department shall
9require that a written statement including the required opinion
10of a physician shall accompany any claim for reimbursement for
11abortions, or induced miscarriages or premature births. This
12statement shall indicate what procedures were used in providing
13such medical services.
14    Notwithstanding any other law to the contrary, the Illinois
15Department shall, within 365 days after July 22, 2013 (the
16effective date of Public Act 98-104), establish procedures to
17permit skilled care facilities licensed under the Nursing Home
18Care Act to submit monthly billing claims for reimbursement
19purposes. Following development of these procedures, the
20Department shall, by July 1, 2016, test the viability of the
21new system and implement any necessary operational or
22structural changes to its information technology platforms in
23order to allow for the direct acceptance and payment of nursing
24home claims.
25    Notwithstanding any other law to the contrary, the Illinois
26Department shall, within 365 days after August 15, 2014 (the

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1repair and replacement of orthotic and prosthetic devices and
2durable medical equipment. Such rules shall provide, but not be
3limited to, the following services: (1) immediate repair or
4replacement of such devices by recipients; and (2) rental,
5lease, purchase or lease-purchase of durable medical equipment
6in a cost-effective manner, taking into consideration the
7recipient's medical prognosis, the extent of the recipient's
8needs, and the requirements and costs for maintaining such
9equipment. Subject to prior approval, such rules shall enable a
10recipient to temporarily acquire and use alternative or
11substitute devices or equipment pending repairs or
12replacements of any device or equipment previously authorized
13for such recipient by the Department. Notwithstanding any
14provision of Section 5-5f to the contrary, the Department may,
15by rule, exempt certain replacement wheelchair parts from prior
16approval and, for wheelchairs, wheelchair parts, wheelchair
17accessories, and related seating and positioning items,
18determine the wholesale price by methods other than actual
19acquisition costs.
20    The Department shall require, by rule, all providers of
21durable medical equipment to be accredited by an accreditation
22organization approved by the federal Centers for Medicare and
23Medicaid Services and recognized by the Department in order to
24bill the Department for providing durable medical equipment to
25recipients. No later than 15 months after the effective date of
26the rule adopted pursuant to this paragraph, all providers must

 

 

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1meet the accreditation requirement.
2    The Department shall execute, relative to the nursing home
3prescreening project, written inter-agency agreements with the
4Department of Human Services and the Department on Aging, to
5effect the following: (i) intake procedures and common
6eligibility criteria for those persons who are receiving
7non-institutional services; and (ii) the establishment and
8development of non-institutional services in areas of the State
9where they are not currently available or are undeveloped; and
10(iii) notwithstanding any other provision of law, subject to
11federal approval, on and after July 1, 2012, an increase in the
12determination of need (DON) scores from 29 to 37 for applicants
13for institutional and home and community-based long term care;
14if and only if federal approval is not granted, the Department
15may, in conjunction with other affected agencies, implement
16utilization controls or changes in benefit packages to
17effectuate a similar savings amount for this population; and
18(iv) no later than July 1, 2013, minimum level of care
19eligibility criteria for institutional and home and
20community-based long term care; and (v) no later than October
211, 2013, establish procedures to permit long term care
22providers access to eligibility scores for individuals with an
23admission date who are seeking or receiving services from the
24long term care provider. In order to select the minimum level
25of care eligibility criteria, the Governor shall establish a
26workgroup that includes affected agency representatives and

 

 

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1stakeholders representing the institutional and home and
2community-based long term care interests. This Section shall
3not restrict the Department from implementing lower level of
4care eligibility criteria for community-based services in
5circumstances where federal approval has been granted.
6    The Illinois Department shall develop and operate, in
7cooperation with other State Departments and agencies and in
8compliance with applicable federal laws and regulations,
9appropriate and effective systems of health care evaluation and
10programs for monitoring of utilization of health care services
11and facilities, as it affects persons eligible for medical
12assistance under this Code.
13    The Illinois Department shall report annually to the
14General Assembly, no later than the second Friday in April of
151979 and each year thereafter, in regard to:
16        (a) actual statistics and trends in utilization of
17    medical services by public aid recipients;
18        (b) actual statistics and trends in the provision of
19    the various medical services by medical vendors;
20        (c) current rate structures and proposed changes in
21    those rate structures for the various medical vendors; and
22        (d) efforts at utilization review and control by the
23    Illinois Department.
24    The period covered by each report shall be the 3 years
25ending on the June 30 prior to the report. The report shall
26include suggested legislation for consideration by the General

 

 

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1Assembly. The filing of one copy of the report with the
2Speaker, one copy with the Minority Leader and one copy with
3the Clerk of the House of Representatives, one copy with the
4President, one copy with the Minority Leader and one copy with
5the Secretary of the Senate, one copy with the Legislative
6Research Unit, and such additional copies with the State
7Government Report Distribution Center for the General Assembly
8as is required under paragraph (t) of Section 7 of the State
9Library Act shall be deemed sufficient to comply with this
10Section.
11    Rulemaking authority to implement Public Act 95-1045, if
12any, is conditioned on the rules being adopted in accordance
13with all provisions of the Illinois Administrative Procedure
14Act and all rules and procedures of the Joint Committee on
15Administrative Rules; any purported rule not so adopted, for
16whatever reason, is unauthorized.
17    On and after July 1, 2012, the Department shall reduce any
18rate of reimbursement for services or other payments or alter
19any methodologies authorized by this Code to reduce any rate of
20reimbursement for services or other payments in accordance with
21Section 5-5e.
22    Because kidney transplantation can be an appropriate, cost
23effective alternative to renal dialysis when medically
24necessary and notwithstanding the provisions of Section 1-11 of
25this Code, beginning October 1, 2014, the Department shall
26cover kidney transplantation for noncitizens with end-stage

 

 

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

 

 

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1shall be covered under the medical assistance program for
2persons who are otherwise eligible for medical assistance under
3this Article. As used in this Section, "opioid antagonist"
4means a drug that binds to opioid receptors and blocks or
5inhibits the effect of opioids acting on those receptors,
6including, but not limited to, naloxone hydrochloride or any
7other similarly acting drug approved by the U.S. Food and Drug
8Administration.
9    Upon federal approval, the Department shall provide
10coverage and reimbursement for all drugs that are approved for
11marketing by the federal Food and Drug Administration and that
12are recommended by the federal Public Health Service or the
13United States Centers for Disease Control and Prevention for
14pre-exposure prophylaxis and related pre-exposure prophylaxis
15services, including, but not limited to, HIV and sexually
16transmitted infection screening, treatment for sexually
17transmitted infections, medical monitoring, assorted labs, and
18counseling to reduce the likelihood of HIV infection among
19individuals who are not infected with HIV but who are at high
20risk of HIV infection.
21(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
2298-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
238-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
24eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
2599-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
2620 of P.A. 99-588 for the effective date of P.A. 99-407);

 

 

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199-433, eff. 8-21-15; 99-480, eff. 9-9-15; 99-588, eff.
27-20-16; 99-642, eff. 7-28-16; 99-772, eff. 1-1-17; 99-895,
3eff. 1-1-17; revised 9-20-16.)
 
4    (305 ILCS 5/5-8)  (from Ch. 23, par. 5-8)
5    Sec. 5-8. Practitioners. In supplying medical assistance,
6the Illinois Department may provide for the legally authorized
7services of (i) persons licensed under the Medical Practice Act
8of 1987, as amended, except as hereafter in this Section
9stated, whether under a general or limited license, (ii)
10persons licensed under the Nurse Practice Act as advanced
11practice nurses, regardless of whether or not the persons have
12written collaborative agreements, (iii) persons licensed or
13registered under other laws of this State to provide dental,
14medical, pharmaceutical, optometric, podiatric, or nursing
15services, or other remedial care recognized under State law,
16and (iv) persons licensed under other laws of this State as a
17clinical social worker. The Department shall adopt rules, no
18later than 90 days after the effective date of this amendatory
19Act of the 99th General Assembly, for the legally authorized
20services of persons licensed under other laws of this State as
21a clinical social worker. The Department may not provide for
22legally authorized services of any physician who has been
23convicted of having performed an abortion procedure in a wilful
24and wanton manner on a woman who was not pregnant at the time
25such abortion procedure was performed. The utilization of the

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1 INDEX
2 Statutes amended in order of appearance
3    5 ILCS 375/6from Ch. 127, par. 526
4    5 ILCS 375/6.1from Ch. 127, par. 526.1
5    305 ILCS 5/5-5from Ch. 23, par. 5-5
6    305 ILCS 5/5-8from Ch. 23, par. 5-8
7    305 ILCS 5/5-9from Ch. 23, par. 5-9
8    305 ILCS 5/6-1from Ch. 23, par. 6-1
9    410 ILCS 230/4-100from Ch. 111 1/2, par. 4604-100
10    720 ILCS 510/1from Ch. 38, par. 81-21