(305 ILCS 5/5-5)
(from Ch. 23, par. 5-5)
The Illinois Department, by rule, shall
determine the quantity and quality of and the rate of reimbursement for the
medical assistance for which
payment will be authorized, and the medical services to be provided,
which may include all or part of the following: (1) inpatient hospital
services; (2) outpatient hospital services; (3) other laboratory and
X-ray services; (4) skilled nursing home services; (5) physicians'
services whether furnished in the office, the patient's home, a
hospital, a skilled nursing home, or elsewhere; (6) medical care, or any
other type of remedial care furnished by licensed practitioners; (7)
home health care services; (8) private duty nursing service; (9) clinic
services; (10) dental services, including prevention and treatment of periodontal disease and dental caries disease for pregnant women, provided by an individual licensed to practice dentistry or dental surgery; for purposes of this item (10), "dental services" means diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession; (11) physical therapy and related
services; (12) prescribed drugs, dentures, and prosthetic devices; and
eyeglasses prescribed by a physician skilled in the diseases of the eye,
or by an optometrist, whichever the person may select; (13) other
diagnostic, screening, preventive, and rehabilitative services, including to ensure that the individual's need for intervention or treatment of mental disorders or substance use disorders or co-occurring mental health and substance use disorders is determined using a uniform screening, assessment, and evaluation process inclusive of criteria, for children and adults; for purposes of this item (13), a uniform screening, assessment, and evaluation process refers to a process that includes an appropriate evaluation and, as warranted, a referral; "uniform" does not mean the use of a singular instrument, tool, or process that all must utilize; (14)
transportation and such other expenses as may be necessary; (15) medical
treatment of sexual assault survivors, as defined in
Section 1a of the Sexual Assault Survivors Emergency Treatment Act, for
injuries sustained as a result of the sexual assault, including
examinations and laboratory tests to discover evidence which may be used in
criminal proceedings arising from the sexual assault; (16) the
diagnosis and treatment of sickle cell anemia; and (17)
any other medical care, and any other type of remedial care recognized
under the laws of this State. The term "any other type of remedial care" shall
include nursing care and nursing home service for persons who rely on
treatment by spiritual means alone through prayer for healing.
Notwithstanding any other provision of this Section, a comprehensive
tobacco use cessation program that includes purchasing prescription drugs or
prescription medical devices approved by the Food and Drug Administration shall
be covered under the medical assistance
program under this Article for persons who are otherwise eligible for
assistance under this Article.
Notwithstanding any other provision of this Code, reproductive health care that is otherwise legal in Illinois shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article.
Notwithstanding any other provision of this Code, the Illinois
Department may not require, as a condition of payment for any laboratory
test authorized under this Article, that a physician's handwritten signature
appear on the laboratory test order form. The Illinois Department may,
however, impose other appropriate requirements regarding laboratory test
Upon receipt of federal approval of an amendment to the Illinois Title XIX State Plan for this purpose, the Department shall authorize the Chicago Public Schools (CPS) to procure a vendor or vendors to manufacture eyeglasses for individuals enrolled in a school within the CPS system. CPS shall ensure that its vendor or vendors are enrolled as providers in the medical assistance program and in any capitated Medicaid managed care entity (MCE) serving individuals enrolled in a school within the CPS system. Under any contract procured under this provision, the vendor or vendors must serve only individuals enrolled in a school within the CPS system. Claims for services provided by CPS's vendor or vendors to recipients of benefits in the medical assistance program under this Code, the Children's Health Insurance Program, or the Covering ALL KIDS Health Insurance Program shall be submitted to the Department or the MCE in which the individual is enrolled for payment and shall be reimbursed at the Department's or the MCE's established rates or rate methodologies for eyeglasses.
On and after July 1, 2012, the Department of Healthcare and Family Services may provide the following services to
eligible for assistance under this Article who are participating in
education, training or employment programs operated by the Department of Human
Services as successor to the Department of Public Aid:
(1) dental services provided by or under the
supervision of a dentist; and
(2) eyeglasses prescribed by a physician skilled in
the diseases of the eye, or by an optometrist, whichever the person may select.
On and after July 1, 2018, the Department of Healthcare and Family Services shall provide dental services to any adult who is otherwise eligible for assistance under the medical assistance program. As used in this paragraph, "dental services" means diagnostic, preventative, restorative, or corrective procedures, including procedures and services for the prevention and treatment of periodontal disease and dental caries disease, provided by an individual who is licensed to practice dentistry or dental surgery or who is under the supervision of a dentist in the practice of his or her profession.
On and after July 1, 2018, targeted dental services, as set forth in Exhibit D of the Consent Decree entered by the United States District Court for the Northern District of Illinois, Eastern Division, in the matter of Memisovski v. Maram, Case No. 92 C 1982, that are provided to adults under the medical assistance program shall be established at no less than the rates set forth in the "New Rate" column in Exhibit D of the Consent Decree for targeted dental services that are provided to persons under the age of 18 under the medical assistance program.
Notwithstanding any other provision of this Code and subject to federal approval, the Department may adopt rules to allow a dentist who is volunteering his or her service at no cost to render dental services through an enrolled not-for-profit health clinic without the dentist personally enrolling as a participating provider in the medical assistance program. A not-for-profit health clinic shall include a public health clinic or Federally Qualified Health Center or other enrolled provider, as determined by the Department, through which dental services covered under this Section are performed. The Department shall establish a process for payment of claims for reimbursement for covered dental services rendered under this provision.
The Illinois Department, by rule, may distinguish and classify the
medical services to be provided only in accordance with the classes of
persons designated in Section 5-2.
The Department of Healthcare and Family Services must provide coverage and reimbursement for amino acid-based elemental formulas, regardless of delivery method, for the diagnosis and treatment of (i) eosinophilic disorders and (ii) short bowel syndrome when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary.
The Illinois Department shall authorize the provision of, and shall
authorize payment for, screening by low-dose mammography for the presence of
occult breast cancer for women 35 years of age or older who are eligible
for medical assistance under this Article, as follows:
(A) A baseline mammogram for women 35 to 39 years of
(B) An annual mammogram for women 40 years of age or
(C) A mammogram at the age and intervals considered
medically necessary by the woman's health care provider for women under 40 years of age and having a family history of breast cancer, prior personal history of breast cancer, positive genetic testing, or other risk factors.
(D) A comprehensive ultrasound screening and MRI of
an entire breast or breasts if a mammogram demonstrates heterogeneous or dense breast tissue, when medically necessary as determined by a physician licensed to practice medicine in all of its branches.
(E) A screening MRI when medically necessary, as
determined by a physician licensed to practice medicine in all of its branches.
include a physical breast exam, instruction on self-examination and
information regarding the frequency of self-examination and its value as a
preventative tool. For purposes of this Section, "low-dose mammography" means
the x-ray examination of the breast using equipment dedicated specifically
for mammography, including the x-ray tube, filter, compression device,
and image receptor, with an average radiation exposure delivery
of less than one rad per breast for 2 views of an average size breast.
The term also includes digital mammography and includes breast tomosynthesis. As used in this Section, the term "breast tomosynthesis" means a radiologic procedure that involves the acquisition of projection images over the stationary breast to produce cross-sectional digital three-dimensional images of the breast. If, at any time, the Secretary of the United States Department of Health and Human Services, or its successor agency, promulgates rules or regulations to be published in the Federal Register or publishes a comment in the Federal Register or issues an opinion, guidance, or other action that would require the State, pursuant to any provision of the Patient Protection and Affordable Care Act (Public Law 111-148), including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any successor provision, to defray the cost of any coverage for breast tomosynthesis outlined in this paragraph, then the requirement that an insurer cover breast tomosynthesis is inoperative other than any such coverage authorized under Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and the State shall not assume any obligation for the cost of coverage for breast tomosynthesis set forth in this paragraph.
On and after January 1, 2016, the Department shall ensure that all networks of care for adult clients of the Department include access to at least one breast imaging Center of Imaging Excellence as certified by the American College of Radiology.
On and after January 1, 2012, providers participating in a quality improvement program approved by the Department shall be reimbursed for screening and diagnostic mammography at the same rate as the Medicare program's rates, including the increased reimbursement for digital mammography.
The Department shall convene an expert panel including representatives of hospitals, free-standing mammography facilities, and doctors, including radiologists, to establish quality standards for mammography.
On and after January 1, 2017, providers participating in a breast cancer treatment quality improvement program approved by the Department shall be reimbursed for breast cancer treatment at a rate that is no lower than 95% of the Medicare program's rates for the data elements included in the breast cancer treatment quality program.
The Department shall convene an expert panel, including representatives of hospitals, free-standing breast cancer treatment centers, breast cancer quality organizations, and doctors, including breast surgeons, reconstructive breast surgeons, oncologists, and primary care providers to establish quality standards for breast cancer treatment.
Subject to federal approval, the Department shall establish a rate methodology for mammography at federally qualified health centers and other encounter-rate clinics. These clinics or centers may also collaborate with other hospital-based mammography facilities. By January 1, 2016, the Department shall report to the General Assembly on the status of the provision set forth in this paragraph.
The Department shall establish a methodology to remind women who are age-appropriate for screening mammography, but who have not received a mammogram within the previous 18 months, of the importance and benefit of screening mammography. The Department shall work with experts in breast cancer outreach and patient navigation to optimize these reminders and shall establish a methodology for evaluating their effectiveness and modifying the methodology based on the evaluation.
The Department shall establish a performance goal for primary care providers with respect to their female patients over age 40 receiving an annual mammogram. This performance goal shall be used to provide additional reimbursement in the form of a quality performance bonus to primary care providers who meet that goal.
The Department shall devise a means of case-managing or patient navigation for beneficiaries diagnosed with breast cancer. This program shall initially operate as a pilot program in areas of the State with the highest incidence of mortality related to breast cancer. At least one pilot program site shall be in the metropolitan Chicago area and at least one site shall be outside the metropolitan Chicago area. On or after July 1, 2016, the pilot program shall be expanded to include one site in western Illinois, one site in southern Illinois, one site in central Illinois, and 4 sites within metropolitan Chicago. An evaluation of the pilot program shall be carried out measuring health outcomes and cost of care for those served by the pilot program compared to similarly situated patients who are not served by the pilot program.
The Department shall require all networks of care to develop a means either internally or by contract with experts in navigation and community outreach to navigate cancer patients to comprehensive care in a timely fashion. The Department shall require all networks of care to include access for patients diagnosed with cancer to at least one academic commission on cancer-accredited cancer program as an in-network covered benefit.
Any medical or health care provider shall immediately recommend, to
any pregnant woman who is being provided prenatal services and is suspected
of having a substance use disorder as defined in the Substance Use Disorder Act, referral to a local substance use disorder treatment program licensed by the Department of Human Services or to a licensed
hospital which provides substance abuse treatment services. The Department of Healthcare and Family Services
shall assure coverage for the cost of treatment of the drug abuse or
addiction for pregnant recipients in accordance with the Illinois Medicaid
Program in conjunction with the Department of Human Services.
All medical providers providing medical assistance to pregnant women
under this Code shall receive information from the Department on the
availability of services under any
program providing case management services for addicted women,
including information on appropriate referrals for other social services
that may be needed by addicted women in addition to treatment for addiction.
The Illinois Department, in cooperation with the Departments of Human
Services (as successor to the Department of Alcoholism and Substance
Abuse) and Public Health, through a public awareness campaign, may
provide information concerning treatment for alcoholism and drug abuse and
addiction, prenatal health care, and other pertinent programs directed at
reducing the number of drug-affected infants born to recipients of medical
Neither the Department of Healthcare and Family Services nor the Department of Human
Services shall sanction the recipient solely on the basis of
her substance abuse.
The Illinois Department shall establish such regulations governing
the dispensing of health services under this Article as it shall deem
appropriate. The Department
seek the advice of formal professional advisory committees appointed by
the Director of the Illinois Department for the purpose of providing regular
advice on policy and administrative matters, information dissemination and
educational activities for medical and health care providers, and
consistency in procedures to the Illinois Department.
The Illinois Department may develop and contract with Partnerships of
medical providers to arrange medical services for persons eligible under
Section 5-2 of this Code. Implementation of this Section may be by
demonstration projects in certain geographic areas. The Partnership shall
be represented by a sponsor organization. The Department, by rule, shall
develop qualifications for sponsors of Partnerships. Nothing in this
Section shall be construed to require that the sponsor organization be a
The sponsor must negotiate formal written contracts with medical
providers for physician services, inpatient and outpatient hospital care,
home health services, treatment for alcoholism and substance abuse, and
other services determined necessary by the Illinois Department by rule for
delivery by Partnerships. Physician services must include prenatal and
obstetrical care. The Illinois Department shall reimburse medical services
delivered by Partnership providers to clients in target areas according to
provisions of this Article and the Illinois Health Finance Reform Act,
(1) Physicians participating in a Partnership and
providing certain services, which shall be determined by the Illinois Department, to persons in areas covered by the Partnership may receive an additional surcharge for such services.
(2) The Department may elect to consider and
negotiate financial incentives to encourage the development of Partnerships and the efficient delivery of medical care.
(3) Persons receiving medical services through
Partnerships may receive medical and case management services above the level usually offered through the medical assistance program.
Medical providers shall be required to meet certain qualifications to
participate in Partnerships to ensure the delivery of high quality medical
services. These qualifications shall be determined by rule of the Illinois
Department and may be higher than qualifications for participation in the
medical assistance program. Partnership sponsors may prescribe reasonable
additional qualifications for participation by medical providers, only with
the prior written approval of the Illinois Department.
Nothing in this Section shall limit the free choice of practitioners,
hospitals, and other providers of medical services by clients.
In order to ensure patient freedom of choice, the Illinois Department shall
immediately promulgate all rules and take all other necessary actions so that
provided services may be accessed from therapeutically certified optometrists
to the full extent of the Illinois Optometric Practice Act of 1987 without
discriminating between service providers.
The Department shall apply for a waiver from the United States Health
Care Financing Administration to allow for the implementation of
Partnerships under this Section.
The Illinois Department shall require health care providers to maintain
records that document the medical care and services provided to recipients
of Medical Assistance under this Article. Such records must be retained for a period of not less than 6 years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period then the records must be retained until the audit is completed and every exception is resolved. The Illinois Department shall
require health care providers to make available, when authorized by the
patient, in writing, the medical records in a timely fashion to other
health care providers who are treating or serving persons eligible for
Medical Assistance under this Article. All dispensers of medical services
shall be required to maintain and retain business and professional records
sufficient to fully and accurately document the nature, scope, details and
receipt of the health care provided to persons eligible for medical
assistance under this Code, in accordance with regulations promulgated by
the Illinois Department. The rules and regulations shall require that proof
of the receipt of prescription drugs, dentures, prosthetic devices and
eyeglasses by eligible persons under this Section accompany each claim
for reimbursement submitted by the dispenser of such medical services.
No such claims for reimbursement shall be approved for payment by the Illinois
Department without such proof of receipt, unless the Illinois Department
shall have put into effect and shall be operating a system of post-payment
audit and review which shall, on a sampling basis, be deemed adequate by
the Illinois Department to assure that such drugs, dentures, prosthetic
devices and eyeglasses for which payment is being made are actually being
received by eligible recipients. Within 90 days after September 16, 1984 (the effective date of Public Act 83-1439), the Illinois Department shall establish a
current list of acquisition costs for all prosthetic devices and any
other items recognized as medical equipment and supplies reimbursable under
this Article and shall update such list on a quarterly basis, except that
the acquisition costs of all prescription drugs shall be updated no
less frequently than every 30 days as required by Section 5-5.12.
Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after July 22, 2013 (the effective date of Public Act 98-104), establish procedures to permit skilled care facilities licensed under the Nursing Home Care Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall, by July 1, 2016, test the viability of the new system and implement any necessary operational or structural changes to its information technology platforms in order to allow for the direct acceptance and payment of nursing home claims.
Notwithstanding any other law to the contrary, the Illinois Department shall, within 365 days after August 15, 2014 (the effective date of Public Act 98-963), establish procedures to permit ID/DD facilities licensed under the ID/DD Community Care Act and MC/DD facilities licensed under the MC/DD Act to submit monthly billing claims for reimbursement purposes. Following development of these procedures, the Department shall have an additional 365 days to test the viability of the new system and to ensure that any necessary operational or structural changes to its information technology platforms are implemented.
The Illinois Department shall require all dispensers of medical
services, other than an individual practitioner or group of practitioners,
desiring to participate in the Medical Assistance program
established under this Article to disclose all financial, beneficial,
ownership, equity, surety or other interests in any and all firms,
corporations, partnerships, associations, business enterprises, joint
ventures, agencies, institutions or other legal entities providing any
form of health care services in this State under this Article.
The Illinois Department may require that all dispensers of medical
services desiring to participate in the medical assistance program
established under this Article disclose, under such terms and conditions as
the Illinois Department may by rule establish, all inquiries from clients
and attorneys regarding medical bills paid by the Illinois Department, which
inquiries could indicate potential existence of claims or liens for the
Enrollment of a vendor
subject to a provisional period and shall be conditional for one year. During the period of conditional enrollment, the Department may
terminate the vendor's eligibility to participate in, or may disenroll the vendor from, the medical assistance
program without cause. Unless otherwise specified, such termination of eligibility or disenrollment is not subject to the
Department's hearing process.
However, a disenrolled vendor may reapply without penalty.
The Department has the discretion to limit the conditional enrollment period for vendors based upon category of risk of the vendor.
Prior to enrollment and during the conditional enrollment period in the medical assistance program, all vendors shall be subject to enhanced oversight, screening, and review based on the risk of fraud, waste, and abuse that is posed by the category of risk of the vendor. The Illinois Department shall establish the procedures for oversight, screening, and review, which may include, but need not be limited to: criminal and financial background checks; fingerprinting; license, certification, and authorization verifications; unscheduled or unannounced site visits; database checks; prepayment audit reviews; audits; payment caps; payment suspensions; and other screening as required by federal or State law.
The Department shall define or specify the following: (i) by provider notice, the "category of risk of the vendor" for each type of vendor, which shall take into account the level of screening applicable to a particular category of vendor under federal law and regulations; (ii) by rule or provider notice, the maximum length of the conditional enrollment period for each category of risk of the vendor; and (iii) by rule, the hearing rights, if any, afforded to a vendor in each category of risk of the vendor that is terminated or disenrolled during the conditional enrollment period.
To be eligible for payment consideration, a vendor's payment claim or bill, either as an initial claim or as a resubmitted claim following prior rejection, must be received by the Illinois Department, or its fiscal intermediary, no later than 180 days after the latest date on the claim on which medical goods or services were provided, with the following exceptions:
(1) In the case of a provider whose enrollment is in
process by the Illinois Department, the 180-day period shall not begin until the date on the written notice from the Illinois Department that the provider enrollment is complete.
(2) In the case of errors attributable to the
Illinois Department or any of its claims processing intermediaries which result in an inability to receive, process, or adjudicate a claim, the 180-day period shall not begin until the provider has been notified of the error.
(3) In the case of a provider for whom the Illinois
Department initiates the monthly billing process.
(4) In the case of a provider operated by a unit of
local government with a population exceeding 3,000,000 when local government funds finance federal participation for claims payments.
For claims for services rendered during a period for which a recipient received retroactive eligibility, claims must be filed within 180 days after the Department determines the applicant is eligible. For claims for which the Illinois Department is not the primary payer, claims must be submitted to the Illinois Department within 180 days after the final adjudication by the primary payer.
In the case of long term care facilities, within 45 calendar days of receipt by the facility of required prescreening information, new admissions with associated admission documents shall be submitted through the Medical Electronic Data Interchange (MEDI) or the Recipient Eligibility Verification (REV) System or shall be submitted directly to the Department of Human Services using required admission forms. Effective September
1, 2014, admission documents, including all prescreening
information, must be submitted through MEDI or REV. Confirmation numbers assigned to an accepted transaction shall be retained by a facility to verify timely submittal. Once an admission transaction has been completed, all resubmitted claims following prior rejection are subject to receipt no later than 180 days after the admission transaction has been completed.
Claims that are not submitted and received in compliance with the foregoing requirements shall not be eligible for payment under the medical assistance program, and the State shall have no liability for payment of those claims.
To the extent consistent with applicable information and privacy, security, and disclosure laws, State and federal agencies and departments shall provide the Illinois Department access to confidential and other information and data necessary to perform eligibility and payment verifications and other Illinois Department functions. This includes, but is not limited to: information pertaining to licensure; certification; earnings; immigration status; citizenship; wage reporting; unearned and earned income; pension income; employment; supplemental security income; social security numbers; National Provider Identifier (NPI) numbers; the National Practitioner Data Bank (NPDB); program and agency exclusions; taxpayer identification numbers; tax delinquency; corporate information; and death records.
The Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, under which such agencies and departments shall share data necessary for medical assistance program integrity functions and oversight. The Illinois Department shall develop, in cooperation with other State departments and agencies, and in compliance with applicable federal laws and regulations, appropriate and effective methods to share such data. At a minimum, and to the extent necessary to provide data sharing, the Illinois Department shall enter into agreements with State agencies and departments, and is authorized to enter into agreements with federal agencies and departments, including but not limited to: the Secretary of State; the Department of Revenue; the Department of Public Health; the Department of Human Services; and the Department of Financial and Professional Regulation.
Beginning in fiscal year 2013, the Illinois Department shall set forth a request for information to identify the benefits of a pre-payment, post-adjudication, and post-edit claims system with the goals of streamlining claims processing and provider reimbursement, reducing the number of pending or rejected claims, and helping to ensure a more transparent adjudication process through the utilization of: (i) provider data verification and provider screening technology; and (ii) clinical code editing; and (iii) pre-pay, pre- or post-adjudicated predictive modeling with an integrated case management system with link analysis. Such a request for information shall not be considered as a request for proposal or as an obligation on the part of the Illinois Department to take any action or acquire any products or services.
The Illinois Department shall establish policies, procedures,
standards and criteria by rule for the acquisition, repair and replacement
of orthotic and prosthetic devices and durable medical equipment. Such
rules shall provide, but not be limited to, the following services: (1)
immediate repair or replacement of such devices by recipients; and (2) rental, lease, purchase or lease-purchase of
durable medical equipment in a cost-effective manner, taking into
consideration the recipient's medical prognosis, the extent of the
recipient's needs, and the requirements and costs for maintaining such
equipment. Subject to prior approval, such rules shall enable a recipient to temporarily acquire and
use alternative or substitute devices or equipment pending repairs or
replacements of any device or equipment previously authorized for such
recipient by the Department. Notwithstanding any provision of Section 5-5f to the contrary, the Department may, by rule, exempt certain replacement wheelchair parts from prior approval and, for wheelchairs, wheelchair parts, wheelchair accessories, and related seating and positioning items, determine the wholesale price by methods other than actual acquisition costs.
The Department shall require, by rule, all providers of durable medical equipment to be accredited by an accreditation organization approved by the federal Centers for Medicare and Medicaid Services and recognized by the Department in order to bill the Department for providing durable medical equipment to recipients. No later than 15 months after the effective date of the rule adopted pursuant to this paragraph, all providers must meet the accreditation requirement.
In order to promote environmental responsibility, meet the needs of recipients and enrollees, and achieve significant cost savings, the Department, or a managed care organization under contract with the Department, may provide recipients or managed care enrollees who have a prescription or Certificate of Medical Necessity access to refurbished durable medical equipment under this Section (excluding prosthetic and orthotic devices as defined in the Orthotics, Prosthetics, and Pedorthics Practice Act and complex rehabilitation technology products and associated services) through the State's assistive technology program's reutilization program, using staff with the Assistive Technology Professional (ATP) Certification if the refurbished durable medical equipment: (i) is available; (ii) is less expensive, including shipping costs, than new durable medical equipment of the same type; (iii) is able to withstand at least 3 years of use; (iv) is cleaned, disinfected, sterilized, and safe in accordance with federal Food and Drug Administration regulations and guidance governing the reprocessing of medical devices in health care settings; and (v) equally meets the needs of the recipient or enrollee. The reutilization program shall confirm that the recipient or enrollee is not already in receipt of same or similar equipment from another service provider, and that the refurbished durable medical equipment equally meets the needs of the recipient or enrollee. Nothing in this paragraph shall be construed to limit recipient or enrollee choice to obtain new durable medical equipment or place any additional prior authorization conditions on enrollees of managed care organizations.
The Department shall execute, relative to the nursing home prescreening
project, written inter-agency agreements with the Department of Human
Services and the Department on Aging, to effect the following: (i) intake
procedures and common eligibility criteria for those persons who are receiving
non-institutional services; and (ii) the establishment and development of
non-institutional services in areas of the State where they are not currently
available or are undeveloped; and (iii) notwithstanding any other provision of law, subject to federal approval, on and after July 1, 2012, an increase in the determination of need (DON) scores from 29 to 37 for applicants for institutional and home and community-based long term care; if and only if federal approval is not granted, the Department may, in conjunction with other affected agencies, implement utilization controls or changes in benefit packages to effectuate a similar savings amount for this population; and (iv) no later than July 1, 2013, minimum level of care eligibility criteria for institutional and home and community-based long term care; and (v) no later than October 1, 2013, establish procedures to permit long term care providers access to eligibility scores for individuals with an admission date who are seeking or receiving services from the long term care provider. In order to select the minimum level of care eligibility criteria, the Governor shall establish a workgroup that includes affected agency representatives and stakeholders representing the institutional and home and community-based long term care interests. This Section shall not restrict the Department from implementing lower level of care eligibility criteria for community-based services in circumstances where federal approval has been granted.
The Illinois Department shall develop and operate, in cooperation
with other State Departments and agencies and in compliance with
applicable federal laws and regulations, appropriate and effective
systems of health care evaluation and programs for monitoring of
utilization of health care services and facilities, as it affects
persons eligible for medical assistance under this Code.
The Illinois Department shall report annually to the General Assembly,
no later than the second Friday in April of 1979 and each year
thereafter, in regard to:
(a) actual statistics and trends in utilization of
medical services by public aid recipients;
(b) actual statistics and trends in the provision of
the various medical services by medical vendors;
(c) current rate structures and proposed changes in
those rate structures for the various medical vendors; and
(d) efforts at utilization review and control by the
The period covered by each report shall be the 3 years ending on the June
30 prior to the report. The report shall include suggested legislation
for consideration by the General Assembly. The requirement for reporting to the General Assembly shall be satisfied
by filing copies of the report as required by Section 3.1 of the General Assembly Organization Act, and filing such additional
with the State Government Report Distribution Center for the General
Assembly as is required under paragraph (t) of Section 7 of the State
Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.
On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.
Because kidney transplantation can be an appropriate, cost-effective
alternative to renal dialysis when medically necessary and notwithstanding the provisions of Section 1-11 of this Code, beginning October 1, 2014, the Department shall cover kidney transplantation for noncitizens with end-stage renal disease who are not eligible for comprehensive medical benefits, who meet the residency requirements of Section 5-3 of this Code, and who would otherwise meet the financial requirements of the appropriate class of eligible persons under Section 5-2 of this Code. To qualify for coverage of kidney transplantation, such person must be receiving emergency renal dialysis services covered by the Department. Providers under this Section shall be prior approved and certified by the Department to perform kidney transplantation and the services under this Section shall be limited to services associated with kidney transplantation.
Notwithstanding any other provision of this Code to the contrary, on or after July 1, 2015, all FDA approved forms of medication assisted treatment prescribed for the treatment of alcohol dependence or treatment of opioid dependence shall be covered under both fee for service and managed care medical assistance programs for persons who are otherwise eligible for medical assistance under this Article and shall not be subject to any (1) utilization control, other than those established under the American Society of Addiction Medicine patient placement criteria,
(2) prior authorization mandate, or (3) lifetime restriction limit
On or after July 1, 2015, opioid antagonists prescribed for the treatment of an opioid overdose, including the medication product, administration devices, and any pharmacy fees related to the dispensing and administration of the opioid antagonist, shall be covered under the medical assistance program for persons who are otherwise eligible for medical assistance under this Article. As used in this Section, "opioid antagonist" means a drug that binds to opioid receptors and blocks or inhibits the effect of opioids acting on those receptors, including, but not limited to, naloxone hydrochloride or any other similarly acting drug approved by the U.S. Food and Drug Administration.
Upon federal approval, the Department shall provide coverage and reimbursement for all drugs that are approved for marketing by the federal Food and Drug Administration and that are recommended by the federal Public Health Service or the United States Centers for Disease Control and Prevention for pre-exposure prophylaxis and related pre-exposure prophylaxis services, including, but not limited to, HIV and sexually transmitted infection screening, treatment for sexually transmitted infections, medical monitoring, assorted labs, and counseling to reduce the likelihood of HIV infection among individuals who are not infected with HIV but who are at high risk of HIV infection.
A federally qualified health center, as defined in Section 1905(l)(2)(B) of the federal
Social Security Act, shall be reimbursed by the Department in accordance with the federally qualified health center's encounter rate for services provided to medical assistance recipients that are performed by a dental hygienist, as defined under the Illinois Dental Practice Act, working under the general supervision of a dentist and employed by a federally qualified health center.
Notwithstanding any other provision of this Code, the Illinois Department shall authorize licensed dietitian nutritionists and certified diabetes educators to counsel senior diabetes patients in the senior diabetes patients' homes to remove the hurdle of transportation for senior diabetes patients to receive treatment.
(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for the effective date of P.A. 99-407); 99-433, eff. 8-21-15; 99-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff. 7-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201, eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff. 6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974, eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; 100-1148, eff. 12-10-18.)