100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
HB4114

 

Introduced , by Rep. Peter Breen

 

SYNOPSIS AS INTRODUCED:
 
See Index

    Creates the No Taxpayer Funding for Abortion Act. Provides that neither the State nor any of its subdivisions may authorize the use of, appropriate, or expend funds to pay for an abortion or to cover any part of the costs of a health plan that includes coverage of abortion or to provide or refer for an abortion, unless a woman who suffers from a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the woman in danger of death if an abortion is not performed. Amends the State Employees Group Insurance Act of 1971 and the Illinois Public Aid Code. Excludes from the programs of health benefits and services authorized under those Acts coverage for elective abortions as provided in the No Taxpayer Funding for Abortion Act. Prohibits a physician who has been found guilty of performing an abortion procedure in a willful and wanton manner upon a woman who was not pregnant when the abortion procedure was performed from participating in the State's Medical Assistance Program. Provides that the Department of Healthcare and Family Services shall require a written statement, including the required opinion of a physician, to accompany a claim for reimbursement for abortions or induced miscarriages or premature births. Makes other changes. Amends the Problem Pregnancy Health Services and Care Act. Permits the Department of Human Services to make grants to nonprofit agencies and organizations that do not use those grants to refer or counsel for, or perform, abortions. Contains provisions regarding applicability and preempts home rule. Effective on the earlier of the effective date of Public Act 100-538 or June 1, 2018.


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FISCAL NOTE ACT MAY APPLY
HOME RULE NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB4114LRB100 15067 KTG 29910 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 1. Short title. This Act may be cited as the No
5Taxpayer Funding for Abortion Act.
 
6    Section 5. Public policy. It is the public policy of this
7State that the General Assembly of the State of Illinois does
8solemnly declare and find in reaffirmation of the longstanding
9policy of this State that the unborn child is a human being
10from the time of conception and has a right to life and, to the
11extent consistent with the United States Constitution,
12Illinois law should be interpreted to recognize that right to
13life and to protect unborn life.
14    The General Assembly further declares and finds that, while
15the people of Illinois hold a variety of positions on the issue
16of abortion, they generally oppose the use of tax dollars to
17pay for elective abortions and support the federal Hyde
18Amendment, named after the late Henry J. Hyde, whose memory is
19revered and service celebrated as a Congressman from the great
20State of Illinois. This Act honors the strong beliefs of the
21people of Illinois by prohibiting the taxpayer funding of
22abortion in this State.
 

 

 

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1    Section 10. Use of funds to pay for abortions prohibited;
2exceptions. Notwithstanding any other provision of law,
3neither the State nor any of its subdivisions may authorize the
4use of, appropriate, or expend any funds to pay for any
5abortion or to cover any part of the costs of any health plan
6that includes coverage of abortion or to provide or refer for
7any abortion, except in the case where a woman suffers from a
8physical disorder, physical injury, or physical illness that
9would, as certified by a physician, place the woman in danger
10of death unless an abortion is performed, including a
11life-endangering physical condition caused by or arising from
12the pregnancy itself, or in such other circumstances as
13required by federal law.
 
14    Section 900. The State Employees Group Insurance Act of
151971 is amended by changing Sections 6 and 6.1 as follows:
 
16    (5 ILCS 375/6)  (from Ch. 127, par. 526)
17    (Text of Section before amendment by P.A. 100-538)
18    Sec. 6. Program of health benefits.
19    (a) The program of health benefits shall provide for
20protection against the financial costs of health care expenses
21incurred in and out of hospital including basic
22hospital-surgical-medical coverages. The program may include,
23but shall not be limited to, such supplemental coverages as
24out-patient diagnostic X-ray and laboratory expenses,

 

 

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

 

 

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

 

 

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

 

 

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1    (Text of Section after amendment by P.A. 100-538)
2    Sec. 6. Program of health benefits.
3    (a) The program of health benefits shall provide for
4protection against the financial costs of health care expenses
5incurred in and out of hospital including basic
6hospital-surgical-medical coverages. The program may include,
7but shall not be limited to, such supplemental coverages as
8out-patient diagnostic X-ray and laboratory expenses,
9prescription drugs, dental services, hearing evaluations,
10hearing aids, the dispensing and fitting of hearing aids, and
11similar group benefits as are now or may become available,
12except as provided in the No Taxpayer Funding for Abortion Act.
13The program may also include coverage for those who rely on
14treatment by prayer or spiritual means alone for healing in
15accordance with the tenets and practice of a recognized
16religious denomination.
17    The program of health benefits shall be designed by the
18Director (1) to provide a reasonable relationship between the
19benefits to be included and the expected distribution of
20expenses of each such type to be incurred by the covered
21members and dependents, (2) to specify, as covered benefits and
22as optional benefits, the medical services of practitioners in
23all categories licensed under the Medical Practice Act of 1987,
24(3) to include reasonable controls, which may include
25deductible and co-insurance provisions, applicable to some or

 

 

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

 

 

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1Congress), benefits paid under the State of Illinois program or
2plan will be reduced by the amount of benefits paid by
3Medicare. For members or dependents who are eligible for
4benefits under Social Security or the Railroad Retirement
5system or who had sufficient Medicare-covered government
6employment, benefits shall be reduced by the amount for which
7the member or dependent is eligible under Medicare, except that
8such reduction in benefits shall apply only to those members or
9dependents who (1) first become eligible for such Medicare
10coverage on or after the effective date of this amendatory Act
11of 1992; or (2) are Medicare-eligible members or dependents of
12a local government unit which began participation in the
13program on or after July 1, 1992; or (3) remain eligible for,
14but no longer receive Medicare coverage which they had been
15receiving on or after the effective date of this amendatory Act
16of 1992. Premiums may be adjusted, where applicable, to an
17amount deemed by the Director to be reasonably consistent with
18any reduction of benefits.
19    (b) A member, not otherwise covered by this Act, who has
20retired as a participating member under Article 2 of the
21Illinois Pension Code but is ineligible for the retirement
22annuity under Section 2-119 of the Illinois Pension Code, shall
23pay the premiums for coverage, not exceeding the amount paid by
24the State for the non-contributory coverage for other members,
25under the group health benefits program under this Act. The
26Director shall determine the premiums to be paid by a member

 

 

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1under this subsection (b).
2(Source: P.A. 100-538, eff. 1-1-18.)
 
3    (5 ILCS 375/6.1)  (from Ch. 127, par. 526.1)
4    (Text of Section before amendment by P.A. 100-538)
5    Sec. 6.1. The program of health benefits may offer as an
6alternative, available on an optional basis, coverage through
7health maintenance organizations. That part of the premium for
8such coverage which is in excess of the amount which would
9otherwise be paid by the State for the program of health
10benefits shall be paid by the member who elects such
11alternative coverage and shall be collected as provided for
12premiums for other optional coverages.
13    However, nothing in this Act shall be construed to permit,
14after the effective date of this amendatory Act of 1983, the
15noncontributory portion of any such program to include the
16expenses of obtaining an abortion, induced miscarriage or
17induced premature birth unless, in the opinion of a physician,
18such procedures are necessary for the preservation of the life
19of the woman seeking such treatment, or except an induced
20premature birth intended to produce a live viable child and
21such procedure is necessary for the health of the mother or her
22unborn child.
23(Source: P.A. 85-848.)
 
24    (Text of Section after amendment by P.A. 100-538)

 

 

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1    Sec. 6.1. The program of health benefits may offer as an
2alternative, available on an optional basis, coverage through
3health maintenance organizations. That part of the premium for
4such coverage which is in excess of the amount which would
5otherwise be paid by the State for the program of health
6benefits shall be paid by the member who elects such
7alternative coverage and shall be collected as provided for
8premiums for other optional coverages, except as provided in
9the No Taxpayer Funding for Abortion Act.
10(Source: P.A. 100-538, eff. 1-1-18.)
 
11    Section 905. The Illinois Public Aid Code is amended by
12changing Sections 5-5, 5-8, 5-9, and 6-1 as follows:
 
13    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
14    (Text of Section before amendment by P.A. 100-538)
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, the
5Illinois Department may not require, as a condition of payment
6for any laboratory test authorized under this Article, that a
7physician's handwritten signature appear on the laboratory
8test order form. The Illinois Department may, however, impose
9other appropriate requirements regarding laboratory test order
10documentation.
11    Upon receipt of federal approval of an amendment to the
12Illinois Title XIX State Plan for this purpose, the Department
13shall authorize the Chicago Public Schools (CPS) to procure a
14vendor or vendors to manufacture eyeglasses for individuals
15enrolled in a school within the CPS system. CPS shall ensure
16that its vendor or vendors are enrolled as providers in the
17medical assistance program and in any capitated Medicaid
18managed care entity (MCE) serving individuals enrolled in a
19school within the CPS system. Under any contract procured under
20this provision, the vendor or vendors must serve only
21individuals enrolled in a school within the CPS system. Claims
22for services provided by CPS's vendor or vendors to recipients
23of benefits in the medical assistance program under this Code,
24the Children's Health Insurance Program, or the Covering ALL
25KIDS Health Insurance Program shall be submitted to the
26Department or the MCE in which the individual is enrolled for

 

 

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

 

 

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1    The Illinois Department, by rule, may distinguish and
2classify the medical services to be provided only in accordance
3with the classes of persons designated in Section 5-2.
4    The Department of Healthcare and Family Services must
5provide coverage and reimbursement for amino acid-based
6elemental formulas, regardless of delivery method, for the
7diagnosis and treatment of (i) eosinophilic disorders and (ii)
8short bowel syndrome when the prescribing physician has issued
9a written order stating that the amino acid-based elemental
10formula is medically necessary.
11    The Illinois Department shall authorize the provision of,
12and shall authorize payment for, screening by low-dose
13mammography for the presence of occult breast cancer for women
1435 years of age or older who are eligible for medical
15assistance under this Article, as follows:
16        (A) A baseline mammogram for women 35 to 39 years of
17    age.
18        (B) An annual mammogram for women 40 years of age or
19    older.
20        (C) A mammogram at the age and intervals considered
21    medically necessary by the woman's health care provider for
22    women under 40 years of age and having a family history of
23    breast cancer, prior personal history of breast cancer,
24    positive genetic testing, or other risk factors.
25        (D) A comprehensive ultrasound screening of an entire
26    breast or breasts if a mammogram demonstrates

 

 

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1    heterogeneous or dense breast tissue, when medically
2    necessary as determined by a physician licensed to practice
3    medicine in all of its branches.
4        (E) A screening MRI when medically necessary, as
5    determined by a physician licensed to practice medicine in
6    all of its branches.
7    All screenings shall include a physical breast exam,
8instruction on self-examination and information regarding the
9frequency of self-examination and its value as a preventative
10tool. For purposes of this Section, "low-dose mammography"
11means the x-ray examination of the breast using equipment
12dedicated specifically for mammography, including the x-ray
13tube, filter, compression device, and image receptor, with an
14average radiation exposure delivery of less than one rad per
15breast for 2 views of an average size breast. The term also
16includes digital mammography and includes breast
17tomosynthesis. As used in this Section, the term "breast
18tomosynthesis" means a radiologic procedure that involves the
19acquisition of projection images over the stationary breast to
20produce cross-sectional digital three-dimensional images of
21the breast. If, at any time, the Secretary of the United States
22Department of Health and Human Services, or its successor
23agency, promulgates rules or regulations to be published in the
24Federal Register or publishes a comment in the Federal Register
25or issues an opinion, guidance, or other action that would
26require the State, pursuant to any provision of the Patient

 

 

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1Protection and Affordable Care Act (Public Law 111-148),
2including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
3successor provision, to defray the cost of any coverage for
4breast tomosynthesis outlined in this paragraph, then the
5requirement that an insurer cover breast tomosynthesis is
6inoperative other than any such coverage authorized under
7Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
8the State shall not assume any obligation for the cost of
9coverage for breast tomosynthesis set forth in this paragraph.
10    On and after January 1, 2016, the Department shall ensure
11that all networks of care for adult clients of the Department
12include access to at least one breast imaging Center of Imaging
13Excellence as certified by the American College of Radiology.
14    On and after January 1, 2012, providers participating in a
15quality improvement program approved by the Department shall be
16reimbursed for screening and diagnostic mammography at the same
17rate as the Medicare program's rates, including the increased
18reimbursement for digital mammography.
19    The Department shall convene an expert panel including
20representatives of hospitals, free-standing mammography
21facilities, and doctors, including radiologists, to establish
22quality standards for mammography.
23    On and after January 1, 2017, providers participating in a
24breast cancer treatment quality improvement program approved
25by the Department shall be reimbursed for breast cancer
26treatment at a rate that is no lower than 95% of the Medicare

 

 

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1program's rates for the data elements included in the breast
2cancer treatment quality program.
3    The Department shall convene an expert panel, including
4representatives of hospitals, free standing breast cancer
5treatment centers, breast cancer quality organizations, and
6doctors, including breast surgeons, reconstructive breast
7surgeons, oncologists, and primary care providers to establish
8quality standards for breast cancer treatment.
9    Subject to federal approval, the Department shall
10establish a rate methodology for mammography at federally
11qualified health centers and other encounter-rate clinics.
12These clinics or centers may also collaborate with other
13hospital-based mammography facilities. By January 1, 2016, the
14Department shall report to the General Assembly on the status
15of the provision set forth in this paragraph.
16    The Department shall establish a methodology to remind
17women who are age-appropriate for screening mammography, but
18who have not received a mammogram within the previous 18
19months, of the importance and benefit of screening mammography.
20The Department shall work with experts in breast cancer
21outreach and patient navigation to optimize these reminders and
22shall establish a methodology for evaluating their
23effectiveness and modifying the methodology based on the
24evaluation.
25    The Department shall establish a performance goal for
26primary care providers with respect to their female patients

 

 

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1over age 40 receiving an annual mammogram. This performance
2goal shall be used to provide additional reimbursement in the
3form of a quality performance bonus to primary care providers
4who meet that goal.
5    The Department shall devise a means of case-managing or
6patient navigation for beneficiaries diagnosed with breast
7cancer. This program shall initially operate as a pilot program
8in areas of the State with the highest incidence of mortality
9related to breast cancer. At least one pilot program site shall
10be in the metropolitan Chicago area and at least one site shall
11be outside the metropolitan Chicago area. On or after July 1,
122016, the pilot program shall be expanded to include one site
13in western Illinois, one site in southern Illinois, one site in
14central Illinois, and 4 sites within metropolitan Chicago. An
15evaluation of the pilot program shall be carried out measuring
16health outcomes and cost of care for those served by the pilot
17program compared to similarly situated patients who are not
18served by the pilot program.
19    The Department shall require all networks of care to
20develop a means either internally or by contract with experts
21in navigation and community outreach to navigate cancer
22patients to comprehensive care in a timely fashion. The
23Department shall require all networks of care to include access
24for patients diagnosed with cancer to at least one academic
25commission on cancer-accredited cancer program as an
26in-network covered benefit.

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1or serving persons eligible for Medical Assistance under this
2Article. All dispensers of medical services shall be required
3to maintain and retain business and professional records
4sufficient to fully and accurately document the nature, scope,
5details and receipt of the health care provided to persons
6eligible for medical assistance under this Code, in accordance
7with regulations promulgated by the Illinois Department. The
8rules and regulations shall require that proof of the receipt
9of prescription drugs, dentures, prosthetic devices and
10eyeglasses by eligible persons under this Section accompany
11each claim for reimbursement submitted by the dispenser of such
12medical services. No such claims for reimbursement shall be
13approved for payment by the Illinois Department without such
14proof of receipt, unless the Illinois Department shall have put
15into effect and shall be operating a system of post-payment
16audit and review which shall, on a sampling basis, be deemed
17adequate by the Illinois Department to assure that such drugs,
18dentures, prosthetic devices and eyeglasses for which payment
19is being made are actually being received by eligible
20recipients. Within 90 days after September 16, 1984 (the
21effective date of Public Act 83-1439), the Illinois Department
22shall establish a current list of acquisition costs for all
23prosthetic devices and any other items recognized as medical
24equipment and supplies reimbursable under this Article and
25shall update such list on a quarterly basis, except that the
26acquisition costs of all prescription drugs shall be updated no

 

 

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1less frequently than every 30 days as required by Section
25-5.12.
3    The rules and regulations of the Illinois Department shall
4require that a written statement including the required opinion
5of a physician shall accompany any claim for reimbursement for
6abortions, or induced miscarriages or premature births. This
7statement shall indicate what procedures were used in providing
8such medical services.
9    Notwithstanding any other law to the contrary, the Illinois
10Department shall, within 365 days after July 22, 2013 (the
11effective date of Public Act 98-104), establish procedures to
12permit skilled care facilities licensed under the Nursing Home
13Care Act to submit monthly billing claims for reimbursement
14purposes. Following development of these procedures, the
15Department shall, by July 1, 2016, test the viability of the
16new system and implement any necessary operational or
17structural changes to its information technology platforms in
18order to allow for the direct acceptance and payment of nursing
19home claims.
20    Notwithstanding any other law to the contrary, the Illinois
21Department shall, within 365 days after August 15, 2014 (the
22effective date of Public Act 98-963), establish procedures to
23permit ID/DD facilities licensed under the ID/DD Community Care
24Act and MC/DD facilities licensed under the MC/DD Act to submit
25monthly billing claims for reimbursement purposes. Following
26development of these procedures, the Department shall have an

 

 

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1additional 365 days to test the viability of the new system and
2to ensure that any necessary operational or structural changes
3to its information technology platforms are implemented.
4    The Illinois Department shall require all dispensers of
5medical services, other than an individual practitioner or
6group of practitioners, desiring to participate in the Medical
7Assistance program established under this Article to disclose
8all financial, beneficial, ownership, equity, surety or other
9interests in any and all firms, corporations, partnerships,
10associations, business enterprises, joint ventures, agencies,
11institutions or other legal entities providing any form of
12health care services in this State under this Article.
13    The Illinois Department may require that all dispensers of
14medical services desiring to participate in the medical
15assistance program established under this Article disclose,
16under such terms and conditions as the Illinois Department may
17by rule establish, all inquiries from clients and attorneys
18regarding medical bills paid by the Illinois Department, which
19inquiries could indicate potential existence of claims or liens
20for the Illinois Department.
21    Enrollment of a vendor shall be subject to a provisional
22period and shall be conditional for one year. During the period
23of conditional enrollment, the Department may terminate the
24vendor's eligibility to participate in, or may disenroll the
25vendor from, the medical assistance program without cause.
26Unless otherwise specified, such termination of eligibility or

 

 

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

 

 

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

 

 

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

 

 

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

 

 

HB4114- 31 -LRB100 15067 KTG 29910 b

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

 

 

HB4114- 32 -LRB100 15067 KTG 29910 b

1in a cost-effective manner, taking into consideration the
2recipient's medical prognosis, the extent of the recipient's
3needs, and the requirements and costs for maintaining such
4equipment. Subject to prior approval, such rules shall enable a
5recipient to temporarily acquire and use alternative or
6substitute devices or equipment pending repairs or
7replacements of any device or equipment previously authorized
8for such recipient by the Department. Notwithstanding any
9provision of Section 5-5f to the contrary, the Department may,
10by rule, exempt certain replacement wheelchair parts from prior
11approval and, for wheelchairs, wheelchair parts, wheelchair
12accessories, and related seating and positioning items,
13determine the wholesale price by methods other than actual
14acquisition costs.
15    The Department shall require, by rule, all providers of
16durable medical equipment to be accredited by an accreditation
17organization approved by the federal Centers for Medicare and
18Medicaid Services and recognized by the Department in order to
19bill the Department for providing durable medical equipment to
20recipients. No later than 15 months after the effective date of
21the rule adopted pursuant to this paragraph, all providers must
22meet the accreditation requirement.
23    The Department shall execute, relative to the nursing home
24prescreening project, written inter-agency agreements with the
25Department of Human Services and the Department on Aging, to
26effect the following: (i) intake procedures and common

 

 

HB4114- 33 -LRB100 15067 KTG 29910 b

1eligibility criteria for those persons who are receiving
2non-institutional services; and (ii) the establishment and
3development of non-institutional services in areas of the State
4where they are not currently available or are undeveloped; and
5(iii) notwithstanding any other provision of law, subject to
6federal approval, on and after July 1, 2012, an increase in the
7determination of need (DON) scores from 29 to 37 for applicants
8for institutional and home and community-based long term care;
9if and only if federal approval is not granted, the Department
10may, in conjunction with other affected agencies, implement
11utilization controls or changes in benefit packages to
12effectuate a similar savings amount for this population; and
13(iv) no later than July 1, 2013, minimum level of care
14eligibility criteria for institutional and home and
15community-based long term care; and (v) no later than October
161, 2013, establish procedures to permit long term care
17providers access to eligibility scores for individuals with an
18admission date who are seeking or receiving services from the
19long term care provider. In order to select the minimum level
20of care eligibility criteria, the Governor shall establish a
21workgroup that includes affected agency representatives and
22stakeholders representing the institutional and home and
23community-based long term care interests. This Section shall
24not restrict the Department from implementing lower level of
25care eligibility criteria for community-based services in
26circumstances where federal approval has been granted.

 

 

HB4114- 34 -LRB100 15067 KTG 29910 b

1    The Illinois Department shall develop and operate, in
2cooperation with other State Departments and agencies and in
3compliance with applicable federal laws and regulations,
4appropriate and effective systems of health care evaluation and
5programs for monitoring of utilization of health care services
6and facilities, as it affects persons eligible for medical
7assistance under this Code.
8    The Illinois Department shall report annually to the
9General Assembly, no later than the second Friday in April of
101979 and each year thereafter, in regard to:
11        (a) actual statistics and trends in utilization of
12    medical services by public aid recipients;
13        (b) actual statistics and trends in the provision of
14    the various medical services by medical vendors;
15        (c) current rate structures and proposed changes in
16    those rate structures for the various medical vendors; and
17        (d) efforts at utilization review and control by the
18    Illinois Department.
19    The period covered by each report shall be the 3 years
20ending on the June 30 prior to the report. The report shall
21include suggested legislation for consideration by the General
22Assembly. The filing of one copy of the report with the
23Speaker, one copy with the Minority Leader and one copy with
24the Clerk of the House of Representatives, one copy with the
25President, one copy with the Minority Leader and one copy with
26the Secretary of the Senate, one copy with the Legislative

 

 

HB4114- 35 -LRB100 15067 KTG 29910 b

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

 

 

HB4114- 36 -LRB100 15067 KTG 29910 b

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

 

 

HB4114- 37 -LRB100 15067 KTG 29910 b

1including, but not limited to, naloxone hydrochloride or any
2other similarly acting drug approved by the U.S. Food and Drug
3Administration.
4    Upon federal approval, the Department shall provide
5coverage and reimbursement for all drugs that are approved for
6marketing by the federal Food and Drug Administration and that
7are recommended by the federal Public Health Service or the
8United States Centers for Disease Control and Prevention for
9pre-exposure prophylaxis and related pre-exposure prophylaxis
10services, including, but not limited to, HIV and sexually
11transmitted infection screening, treatment for sexually
12transmitted infections, medical monitoring, assorted labs, and
13counseling to reduce the likelihood of HIV infection among
14individuals who are not infected with HIV but who are at high
15risk of HIV infection.
16(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
1798-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
188-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
19eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
2099-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
2120 of P.A. 99-588 for the effective date of P.A. 99-407);
2299-433, eff. 8-21-15; 99-480, eff. 9-9-15; 99-588, eff.
237-20-16; 99-642, eff. 7-28-16; 99-772, eff. 1-1-17; 99-895,
24eff. 1-1-17; revised 9-20-16.)
 
25    (Text of Section after amendment by P.A. 100-538)

 

 

HB4114- 38 -LRB100 15067 KTG 29910 b

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

 

 

HB4114- 39 -LRB100 15067 KTG 29910 b

1co-occurring mental health and substance use disorders is
2determined using a uniform screening, assessment, and
3evaluation process inclusive of criteria, for children and
4adults; for purposes of this item (13), a uniform screening,
5assessment, and evaluation process refers to a process that
6includes an appropriate evaluation and, as warranted, a
7referral; "uniform" does not mean the use of a singular
8instrument, tool, or process that all must utilize; (14)
9transportation and such other expenses as may be necessary;
10(15) medical treatment of sexual assault survivors, as defined
11in Section 1a of the Sexual Assault Survivors Emergency
12Treatment Act, for injuries sustained as a result of the sexual
13assault, including examinations and laboratory tests to
14discover evidence which may be used in criminal proceedings
15arising from the sexual assault; (16) the diagnosis and
16treatment of sickle cell anemia; and (17) any other medical
17care, and any other type of remedial care recognized under the
18laws of this State, except as provided in the No Taxpayer
19Funding for Abortion Act. The Illinois Department, by rule,
20shall prohibit any physician from providing medical assistance
21to anyone eligible therefor under this Code where such
22physician has been found guilty of performing an abortion
23procedure in a willful and wanton manner upon a woman who was
24not pregnant at the time such abortion procedure was performed.
25The term "any other type of remedial care" shall include
26nursing care and nursing home service for persons who rely on

 

 

HB4114- 40 -LRB100 15067 KTG 29910 b

1treatment by spiritual means alone through prayer for healing.
2    Notwithstanding any other provision of this Section, a
3comprehensive tobacco use cessation program that includes
4purchasing prescription drugs or prescription medical devices
5approved by the Food and Drug Administration shall be covered
6under the medical assistance program under this Article for
7persons who are otherwise eligible for assistance under this
8Article.
9    Notwithstanding any other provision of this Code,
10reproductive health care that is otherwise legal in Illinois
11shall be covered under the medical assistance program for
12persons who are otherwise eligible for medical assistance under
13this Article, except as provided in the No Taxpayer Funding for
14Abortion Act.
15    Notwithstanding any other provision of this Code, the
16Illinois Department may not require, as a condition of payment
17for any laboratory test authorized under this Article, that a
18physician's handwritten signature appear on the laboratory
19test order form. The Illinois Department may, however, impose
20other appropriate requirements regarding laboratory test order
21documentation.
22    Upon receipt of federal approval of an amendment to the
23Illinois Title XIX State Plan for this purpose, the Department
24shall authorize the Chicago Public Schools (CPS) to procure a
25vendor or vendors to manufacture eyeglasses for individuals
26enrolled in a school within the CPS system. CPS shall ensure

 

 

HB4114- 41 -LRB100 15067 KTG 29910 b

1that its vendor or vendors are enrolled as providers in the
2medical assistance program and in any capitated Medicaid
3managed care entity (MCE) serving individuals enrolled in a
4school within the CPS system. Under any contract procured under
5this provision, the vendor or vendors must serve only
6individuals enrolled in a school within the CPS system. Claims
7for services provided by CPS's vendor or vendors to recipients
8of benefits in the medical assistance program under this Code,
9the Children's Health Insurance Program, or the Covering ALL
10KIDS Health Insurance Program shall be submitted to the
11Department or the MCE in which the individual is enrolled for
12payment and shall be reimbursed at the Department's or the
13MCE's established rates or rate methodologies for eyeglasses.
14    On and after July 1, 2012, the Department of Healthcare and
15Family Services may provide the following services to persons
16eligible for assistance under this Article who are
17participating in education, training or employment programs
18operated by the Department of Human Services as successor to
19the Department of Public Aid:
20        (1) dental services provided by or under the
21    supervision of a dentist; and
22        (2) eyeglasses prescribed by a physician skilled in the
23    diseases of the eye, or by an optometrist, whichever the
24    person may select.
25    Notwithstanding any other provision of this Code and
26subject to federal approval, the Department may adopt rules to

 

 

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1allow a dentist who is volunteering his or her service at no
2cost to render dental services through an enrolled
3not-for-profit health clinic without the dentist personally
4enrolling as a participating provider in the medical assistance
5program. A not-for-profit health clinic shall include a public
6health clinic or Federally Qualified Health Center or other
7enrolled provider, as determined by the Department, through
8which dental services covered under this Section are performed.
9The Department shall establish a process for payment of claims
10for reimbursement for covered dental services rendered under
11this provision.
12    The Illinois Department, by rule, may distinguish and
13classify the medical services to be provided only in accordance
14with the classes of persons designated in Section 5-2.
15    The Department of Healthcare and Family Services must
16provide coverage and reimbursement for amino acid-based
17elemental formulas, regardless of delivery method, for the
18diagnosis and treatment of (i) eosinophilic disorders and (ii)
19short bowel syndrome when the prescribing physician has issued
20a written order stating that the amino acid-based elemental
21formula is medically necessary.
22    The Illinois Department shall authorize the provision of,
23and shall authorize payment for, screening by low-dose
24mammography for the presence of occult breast cancer for women
2535 years of age or older who are eligible for medical
26assistance under this Article, as follows:

 

 

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1        (A) A baseline mammogram for women 35 to 39 years of
2    age.
3        (B) An annual mammogram for women 40 years of age or
4    older.
5        (C) A mammogram at the age and intervals considered
6    medically necessary by the woman's health care provider for
7    women under 40 years of age and having a family history of
8    breast cancer, prior personal history of breast cancer,
9    positive genetic testing, or other risk factors.
10        (D) A comprehensive ultrasound screening of an entire
11    breast or breasts if a mammogram demonstrates
12    heterogeneous or dense breast tissue, when medically
13    necessary as determined by a physician licensed to practice
14    medicine in all of its branches.
15        (E) A screening MRI when medically necessary, as
16    determined by a physician licensed to practice medicine in
17    all of its branches.
18    All screenings shall include a physical breast exam,
19instruction on self-examination and information regarding the
20frequency of self-examination and its value as a preventative
21tool. For purposes of this Section, "low-dose mammography"
22means the x-ray examination of the breast using equipment
23dedicated specifically for mammography, including the x-ray
24tube, filter, compression device, and image receptor, with an
25average radiation exposure delivery of less than one rad per
26breast for 2 views of an average size breast. The term also

 

 

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

 

 

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1reimbursed for screening and diagnostic mammography at the same
2rate as the Medicare program's rates, including the increased
3reimbursement for digital mammography.
4    The Department shall convene an expert panel including
5representatives of hospitals, free-standing mammography
6facilities, and doctors, including radiologists, to establish
7quality standards for mammography.
8    On and after January 1, 2017, providers participating in a
9breast cancer treatment quality improvement program approved
10by the Department shall be reimbursed for breast cancer
11treatment at a rate that is no lower than 95% of the Medicare
12program's rates for the data elements included in the breast
13cancer treatment quality program.
14    The Department shall convene an expert panel, including
15representatives of hospitals, free standing breast cancer
16treatment centers, breast cancer quality organizations, and
17doctors, including breast surgeons, reconstructive breast
18surgeons, oncologists, and primary care providers to establish
19quality standards for breast cancer treatment.
20    Subject to federal approval, the Department shall
21establish a rate methodology for mammography at federally
22qualified health centers and other encounter-rate clinics.
23These clinics or centers may also collaborate with other
24hospital-based mammography facilities. By January 1, 2016, the
25Department shall report to the General Assembly on the status
26of the provision set forth in this paragraph.

 

 

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1    The Department shall establish a methodology to remind
2women who are age-appropriate for screening mammography, but
3who have not received a mammogram within the previous 18
4months, of the importance and benefit of screening mammography.
5The Department shall work with experts in breast cancer
6outreach and patient navigation to optimize these reminders and
7shall establish a methodology for evaluating their
8effectiveness and modifying the methodology based on the
9evaluation.
10    The Department shall establish a performance goal for
11primary care providers with respect to their female patients
12over age 40 receiving an annual mammogram. This performance
13goal shall be used to provide additional reimbursement in the
14form of a quality performance bonus to primary care providers
15who meet that goal.
16    The Department shall devise a means of case-managing or
17patient navigation for beneficiaries diagnosed with breast
18cancer. This program shall initially operate as a pilot program
19in areas of the State with the highest incidence of mortality
20related to breast cancer. At least one pilot program site shall
21be in the metropolitan Chicago area and at least one site shall
22be outside the metropolitan Chicago area. On or after July 1,
232016, the pilot program shall be expanded to include one site
24in western Illinois, one site in southern Illinois, one site in
25central Illinois, and 4 sites within metropolitan Chicago. An
26evaluation of the pilot program shall be carried out measuring

 

 

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1health outcomes and cost of care for those served by the pilot
2program compared to similarly situated patients who are not
3served by the pilot program.
4    The Department shall require all networks of care to
5develop a means either internally or by contract with experts
6in navigation and community outreach to navigate cancer
7patients to comprehensive care in a timely fashion. The
8Department shall require all networks of care to include access
9for patients diagnosed with cancer to at least one academic
10commission on cancer-accredited cancer program as an
11in-network covered benefit.
12    Any medical or health care provider shall immediately
13recommend, to any pregnant woman who is being provided prenatal
14services and is suspected of drug abuse or is addicted as
15defined in the Alcoholism and Other Drug Abuse and Dependency
16Act, referral to a local substance abuse treatment provider
17licensed by the Department of Human Services or to a licensed
18hospital which provides substance abuse treatment services.
19The Department of Healthcare and Family Services shall assure
20coverage for the cost of treatment of the drug abuse or
21addiction for pregnant recipients in accordance with the
22Illinois Medicaid Program in conjunction with the Department of
23Human Services.
24    All medical providers providing medical assistance to
25pregnant women under this Code shall receive information from
26the Department on the availability of services under the Drug

 

 

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

 

 

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

 

 

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1        (3) Persons receiving medical services through
2    Partnerships may receive medical and case management
3    services above the level usually offered through the
4    medical assistance program.
5    Medical providers shall be required to meet certain
6qualifications to participate in Partnerships to ensure the
7delivery of high quality medical services. These
8qualifications shall be determined by rule of the Illinois
9Department and may be higher than qualifications for
10participation in the medical assistance program. Partnership
11sponsors may prescribe reasonable additional qualifications
12for participation by medical providers, only with the prior
13written approval of the Illinois Department.
14    Nothing in this Section shall limit the free choice of
15practitioners, hospitals, and other providers of medical
16services by clients. In order to ensure patient freedom of
17choice, the Illinois Department shall immediately promulgate
18all rules and take all other necessary actions so that provided
19services may be accessed from therapeutically certified
20optometrists to the full extent of the Illinois Optometric
21Practice Act of 1987 without discriminating between service
22providers.
23    The Department shall apply for a waiver from the United
24States Health Care Financing Administration to allow for the
25implementation of Partnerships under this Section.
26    The Illinois Department shall require health care

 

 

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1providers to maintain records that document the medical care
2and services provided to recipients of Medical Assistance under
3this Article. Such records must be retained for a period of not
4less than 6 years from the date of service or as provided by
5applicable State law, whichever period is longer, except that
6if an audit is initiated within the required retention period
7then the records must be retained until the audit is completed
8and every exception is resolved. The Illinois Department shall
9require health care providers to make available, when
10authorized by the patient, in writing, the medical records in a
11timely fashion to other health care providers who are treating
12or serving persons eligible for Medical Assistance under this
13Article. All dispensers of medical services shall be required
14to maintain and retain business and professional records
15sufficient to fully and accurately document the nature, scope,
16details and receipt of the health care provided to persons
17eligible for medical assistance under this Code, in accordance
18with regulations promulgated by the Illinois Department. The
19rules and regulations shall require that proof of the receipt
20of prescription drugs, dentures, prosthetic devices and
21eyeglasses by eligible persons under this Section accompany
22each claim for reimbursement submitted by the dispenser of such
23medical services. No such claims for reimbursement shall be
24approved for payment by the Illinois Department without such
25proof of receipt, unless the Illinois Department shall have put
26into effect and shall be operating a system of post-payment

 

 

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1audit and review which shall, on a sampling basis, be deemed
2adequate by the Illinois Department to assure that such drugs,
3dentures, prosthetic devices and eyeglasses for which payment
4is being made are actually being received by eligible
5recipients. Within 90 days after September 16, 1984 (the
6effective date of Public Act 83-1439), the Illinois Department
7shall establish a current list of acquisition costs for all
8prosthetic devices and any other items recognized as medical
9equipment and supplies reimbursable under this Article and
10shall update such list on a quarterly basis, except that the
11acquisition costs of all prescription drugs shall be updated no
12less frequently than every 30 days as required by Section
135-5.12.
14    The rules and regulations of the Illinois Department shall
15require that a written statement including the required opinion
16of a physician shall accompany any claim for reimbursement for
17abortions or induced miscarriages or premature births. This
18statement shall indicate what procedures were used in providing
19such medical services.
20    Notwithstanding any other law to the contrary, the Illinois
21Department shall, within 365 days after July 22, 2013 (the
22effective date of Public Act 98-104), establish procedures to
23permit skilled care facilities licensed under the Nursing Home
24Care Act to submit monthly billing claims for reimbursement
25purposes. Following development of these procedures, the
26Department shall, by July 1, 2016, test the viability of the

 

 

HB4114- 53 -LRB100 15067 KTG 29910 b

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

 

 

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1under such terms and conditions as the Illinois Department may
2by rule establish, all inquiries from clients and attorneys
3regarding medical bills paid by the Illinois Department, which
4inquiries could indicate potential existence of claims or liens
5for the Illinois Department.
6    Enrollment of a vendor shall be subject to a provisional
7period and shall be conditional for one year. During the period
8of conditional enrollment, the Department may terminate the
9vendor's eligibility to participate in, or may disenroll the
10vendor from, the medical assistance program without cause.
11Unless otherwise specified, such termination of eligibility or
12disenrollment is not subject to the Department's hearing
13process. However, a disenrolled vendor may reapply without
14penalty.
15    The Department has the discretion to limit the conditional
16enrollment period for vendors based upon category of risk of
17the vendor.
18    Prior to enrollment and during the conditional enrollment
19period in the medical assistance program, all vendors shall be
20subject to enhanced oversight, screening, and review based on
21the risk of fraud, waste, and abuse that is posed by the
22category of risk of the vendor. The Illinois Department shall
23establish the procedures for oversight, screening, and review,
24which may include, but need not be limited to: criminal and
25financial background checks; fingerprinting; license,
26certification, and authorization verifications; unscheduled or

 

 

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1unannounced site visits; database checks; prepayment audit
2reviews; audits; payment caps; payment suspensions; and other
3screening as required by federal or State law.
4    The Department shall define or specify the following: (i)
5by provider notice, the "category of risk of the vendor" for
6each type of vendor, which shall take into account the level of
7screening applicable to a particular category of vendor under
8federal law and regulations; (ii) by rule or provider notice,
9the maximum length of the conditional enrollment period for
10each category of risk of the vendor; and (iii) by rule, the
11hearing rights, if any, afforded to a vendor in each category
12of risk of the vendor that is terminated or disenrolled during
13the conditional enrollment period.
14    To be eligible for payment consideration, a vendor's
15payment claim or bill, either as an initial claim or as a
16resubmitted claim following prior rejection, must be received
17by the Illinois Department, or its fiscal intermediary, no
18later than 180 days after the latest date on the claim on which
19medical goods or services were provided, with the following
20exceptions:
21        (1) In the case of a provider whose enrollment is in
22    process by the Illinois Department, the 180-day period
23    shall not begin until the date on the written notice from
24    the Illinois Department that the provider enrollment is
25    complete.
26        (2) In the case of errors attributable to the Illinois

 

 

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

 

 

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1forms. Effective September 1, 2014, admission documents,
2including all prescreening information, must be submitted
3through MEDI or REV. Confirmation numbers assigned to an
4accepted transaction shall be retained by a facility to verify
5timely submittal. Once an admission transaction has been
6completed, all resubmitted claims following prior rejection
7are subject to receipt no later than 180 days after the
8admission transaction has been completed.
9    Claims that are not submitted and received in compliance
10with the foregoing requirements shall not be eligible for
11payment under the medical assistance program, and the State
12shall have no liability for payment of those claims.
13    To the extent consistent with applicable information and
14privacy, security, and disclosure laws, State and federal
15agencies and departments shall provide the Illinois Department
16access to confidential and other information and data necessary
17to perform eligibility and payment verifications and other
18Illinois Department functions. This includes, but is not
19limited to: information pertaining to licensure;
20certification; earnings; immigration status; citizenship; wage
21reporting; unearned and earned income; pension income;
22employment; supplemental security income; social security
23numbers; National Provider Identifier (NPI) numbers; the
24National Practitioner Data Bank (NPDB); program and agency
25exclusions; taxpayer identification numbers; tax delinquency;
26corporate information; and death records.

 

 

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

 

 

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

 

 

HB4114- 60 -LRB100 15067 KTG 29910 b

1durable medical equipment to be accredited by an accreditation
2organization approved by the federal Centers for Medicare and
3Medicaid Services and recognized by the Department in order to
4bill the Department for providing durable medical equipment to
5recipients. No later than 15 months after the effective date of
6the rule adopted pursuant to this paragraph, all providers must
7meet the accreditation requirement.
8    The Department shall execute, relative to the nursing home
9prescreening project, written inter-agency agreements with the
10Department of Human Services and the Department on Aging, to
11effect the following: (i) intake procedures and common
12eligibility criteria for those persons who are receiving
13non-institutional services; and (ii) the establishment and
14development of non-institutional services in areas of the State
15where they are not currently available or are undeveloped; and
16(iii) notwithstanding any other provision of law, subject to
17federal approval, on and after July 1, 2012, an increase in the
18determination of need (DON) scores from 29 to 37 for applicants
19for institutional and home and community-based long term care;
20if and only if federal approval is not granted, the Department
21may, in conjunction with other affected agencies, implement
22utilization controls or changes in benefit packages to
23effectuate a similar savings amount for this population; and
24(iv) no later than July 1, 2013, minimum level of care
25eligibility criteria for institutional and home and
26community-based long term care; and (v) no later than October

 

 

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11, 2013, establish procedures to permit long term care
2providers access to eligibility scores for individuals with an
3admission date who are seeking or receiving services from the
4long term care provider. In order to select the minimum level
5of care eligibility criteria, the Governor shall establish a
6workgroup that includes affected agency representatives and
7stakeholders representing the institutional and home and
8community-based long term care interests. This Section shall
9not restrict the Department from implementing lower level of
10care eligibility criteria for community-based services in
11circumstances where federal approval has been granted.
12    The Illinois Department shall develop and operate, in
13cooperation with other State Departments and agencies and in
14compliance with applicable federal laws and regulations,
15appropriate and effective systems of health care evaluation and
16programs for monitoring of utilization of health care services
17and facilities, as it affects persons eligible for medical
18assistance under this Code.
19    The Illinois Department shall report annually to the
20General Assembly, no later than the second Friday in April of
211979 and each year thereafter, in regard to:
22        (a) actual statistics and trends in utilization of
23    medical services by public aid recipients;
24        (b) actual statistics and trends in the provision of
25    the various medical services by medical vendors;
26        (c) current rate structures and proposed changes in

 

 

HB4114- 62 -LRB100 15067 KTG 29910 b

1    those rate structures for the various medical vendors; and
2        (d) efforts at utilization review and control by the
3    Illinois Department.
4    The period covered by each report shall be the 3 years
5ending on the June 30 prior to the report. The report shall
6include suggested legislation for consideration by the General
7Assembly. The filing of one copy of the report with the
8Speaker, one copy with the Minority Leader and one copy with
9the Clerk of the House of Representatives, one copy with the
10President, one copy with the Minority Leader and one copy with
11the Secretary of the Senate, one copy with the Legislative
12Research Unit, and such additional copies with the State
13Government Report Distribution Center for the General Assembly
14as is required under paragraph (t) of Section 7 of the State
15Library Act shall be deemed sufficient to comply with this
16Section.
17    Rulemaking authority to implement Public Act 95-1045, if
18any, is conditioned on the rules being adopted in accordance
19with all provisions of the Illinois Administrative Procedure
20Act and all rules and procedures of the Joint Committee on
21Administrative Rules; any purported rule not so adopted, for
22whatever reason, is unauthorized.
23    On and after July 1, 2012, the Department shall reduce any
24rate of reimbursement for services or other payments or alter
25any methodologies authorized by this Code to reduce any rate of
26reimbursement for services or other payments in accordance with

 

 

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

 

 

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1placement criteria, (2) prior authorization mandate, or (3)
2lifetime restriction limit mandate.
3    On or after July 1, 2015, opioid antagonists prescribed for
4the treatment of an opioid overdose, including the medication
5product, administration devices, and any pharmacy fees related
6to the dispensing and administration of the opioid antagonist,
7shall be covered under the medical assistance program for
8persons who are otherwise eligible for medical assistance under
9this Article. As used in this Section, "opioid antagonist"
10means a drug that binds to opioid receptors and blocks or
11inhibits the effect of opioids acting on those receptors,
12including, but not limited to, naloxone hydrochloride or any
13other similarly acting drug approved by the U.S. Food and Drug
14Administration.
15    Upon federal approval, the Department shall provide
16coverage and reimbursement for all drugs that are approved for
17marketing by the federal Food and Drug Administration and that
18are recommended by the federal Public Health Service or the
19United States Centers for Disease Control and Prevention for
20pre-exposure prophylaxis and related pre-exposure prophylaxis
21services, including, but not limited to, HIV and sexually
22transmitted infection screening, treatment for sexually
23transmitted infections, medical monitoring, assorted labs, and
24counseling to reduce the likelihood of HIV infection among
25individuals who are not infected with HIV but who are at high
26risk of HIV infection.

 

 

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1(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
298-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
38-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
4eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
599-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
620 of P.A. 99-588 for the effective date of P.A. 99-407);
799-433, eff. 8-21-15; 99-480, eff. 9-9-15; 99-588, eff.
87-20-16; 99-642, eff. 7-28-16; 99-772, eff. 1-1-17; 99-895,
9eff. 1-1-17; 100-538, eff. 1-1-18.)
 
10    (305 ILCS 5/5-8)  (from Ch. 23, par. 5-8)
11    (Text of Section before amendment by P.A. 100-538)
12    Sec. 5-8. Practitioners. In supplying medical assistance,
13the Illinois Department may provide for the legally authorized
14services of (i) persons licensed under the Medical Practice Act
15of 1987, as amended, except as hereafter in this Section
16stated, whether under a general or limited license, (ii)
17persons licensed under the Nurse Practice Act as advanced
18practice nurses, regardless of whether or not the persons have
19written collaborative agreements, (iii) persons licensed or
20registered under other laws of this State to provide dental,
21medical, pharmaceutical, optometric, podiatric, or nursing
22services, or other remedial care recognized under State law,
23and (iv) persons licensed under other laws of this State as a
24clinical social worker. The Department shall adopt rules, no
25later than 90 days after the effective date of this amendatory

 

 

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1Act of the 99th General Assembly, for the legally authorized
2services of persons licensed under other laws of this State as
3a clinical social worker. The Department may not provide for
4legally authorized services of any physician who has been
5convicted of having performed an abortion procedure in a wilful
6and wanton manner on a woman who was not pregnant at the time
7such abortion procedure was performed. The utilization of the
8services of persons engaged in the treatment or care of the
9sick, which persons are not required to be licensed or
10registered under the laws of this State, is not prohibited by
11this Section.
12(Source: P.A. 99-173, eff. 7-29-15; 99-621, eff. 1-1-17.)
 
13    (Text of Section after amendment by P.A. 100-538)
14    Sec. 5-8. Practitioners. In supplying medical assistance,
15the Illinois Department may provide for the legally authorized
16services of (i) persons licensed under the Medical Practice Act
17of 1987, as amended, except as hereafter in this Section
18stated, whether under a general or limited license, (ii)
19persons licensed under the Nurse Practice Act as advanced
20practice nurses, regardless of whether or not the persons have
21written collaborative agreements, (iii) persons licensed or
22registered under other laws of this State to provide dental,
23medical, pharmaceutical, optometric, podiatric, or nursing
24services, or other remedial care recognized under State law,
25and (iv) persons licensed under other laws of this State as a

 

 

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1clinical social worker. The Department shall adopt rules, no
2later than 90 days after the effective date of this amendatory
3Act of the 99th General Assembly, for the legally authorized
4services of persons licensed under other laws of this State as
5a clinical social worker. The Department may not provide for
6legally authorized services of any physician who has been
7convicted of having performed an abortion procedure in a
8willful and wanton manner on a woman who was not pregnant at
9the time such abortion procedure was performed. The utilization
10of the services of persons engaged in the treatment or care of
11the sick, which persons are not required to be licensed or
12registered under the laws of this State, is not prohibited by
13this Section.
14(Source: P.A. 99-173, eff. 7-29-15; 99-621, eff. 1-1-17;
15100-538, eff. 1-1-18.)
 
16    (305 ILCS 5/5-9)  (from Ch. 23, par. 5-9)
17    (Text of Section before amendment by P.A. 100-538)
18    Sec. 5-9. Choice of medical dispensers. Applicants and
19recipients shall be entitled to free choice of those qualified
20practitioners, hospitals, nursing homes, and other dispensers
21of medical services meeting the requirements and complying with
22the rules and regulations of the Illinois Department. However,
23the Director of Healthcare and Family Services may, after
24providing reasonable notice and opportunity for hearing, deny,
25suspend or terminate any otherwise qualified person, firm,

 

 

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1corporation, association, agency, institution, or other legal
2entity, from participation as a vendor of goods or services
3under the medical assistance program authorized by this Article
4if the Director finds such vendor of medical services in
5violation of this Act or the policy or rules and regulations
6issued pursuant to this Act. Any physician who has been
7convicted of performing an abortion procedure in a wilful and
8wanton manner upon a woman who was not pregnant at the time
9such abortion procedure was performed shall be automatically
10removed from the list of physicians qualified to participate as
11a vendor of medical services under the medical assistance
12program authorized by this Article.
13(Source: P.A. 95-331, eff. 8-21-07.)
 
14    (Text of Section after amendment by P.A. 100-538)
15    Sec. 5-9. Choice of medical dispensers. Applicants and
16recipients shall be entitled to free choice of those qualified
17practitioners, hospitals, nursing homes, and other dispensers
18of medical services meeting the requirements and complying with
19the rules and regulations of the Illinois Department. However,
20the Director of Healthcare and Family Services may, after
21providing reasonable notice and opportunity for hearing, deny,
22suspend or terminate any otherwise qualified person, firm,
23corporation, association, agency, institution, or other legal
24entity, from participation as a vendor of goods or services
25under the medical assistance program authorized by this Article

 

 

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1if the Director finds such vendor of medical services in
2violation of this Act or the policy or rules and regulations
3issued pursuant to this Act. Any physician who has been
4convicted of performing an abortion procedure in a willful and
5wanton manner upon a woman who was not pregnant at the time
6such abortion procedure was performed shall be automatically
7removed from the list of physicians qualified to participate as
8a vendor of medical services under the medical assistance
9program authorized by this Article.
10(Source: P.A. 100-538, eff. 1-1-18.)
 
11    (305 ILCS 5/6-1)  (from Ch. 23, par. 6-1)
12    (Text of Section before amendment by P.A. 100-538)
13    Sec. 6-1. Eligibility requirements. Financial aid in
14meeting basic maintenance requirements shall be given under
15this Article to or in behalf of persons who meet the
16eligibility conditions of Sections 6-1.1 through 6-1.10. In
17addition, each unit of local government subject to this Article
18shall provide persons receiving financial aid in meeting basic
19maintenance requirements with financial aid for either (a)
20necessary treatment, care, and supplies required because of
21illness or disability, or (b) acute medical treatment, care,
22and supplies only. If a local governmental unit elects to
23provide financial aid for acute medical treatment, care, and
24supplies only, the general types of acute medical treatment,
25care, and supplies for which financial aid is provided shall be

 

 

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1specified in the general assistance rules of the local
2governmental unit, which rules shall provide that financial aid
3is provided, at a minimum, for acute medical treatment, care,
4or supplies necessitated by a medical condition for which prior
5approval or authorization of medical treatment, care, or
6supplies is not required by the general assistance rules of the
7Illinois Department. Nothing in this Article shall be construed
8to permit the granting of financial aid where the purpose of
9such aid is to obtain an abortion, induced miscarriage or
10induced premature birth unless, in the opinion of a physician,
11such procedures are necessary for the preservation of the life
12of the woman seeking such treatment, or except an induced
13premature birth intended to produce a live viable child and
14such procedure is necessary for the health of the mother or her
15unborn child.
16(Source: P.A. 92-111, eff. 1-1-02.)
 
17    (Text of Section after amendment by P.A. 100-538)
18    Sec. 6-1. Eligibility requirements. Financial aid in
19meeting basic maintenance requirements shall be given under
20this Article to or in behalf of persons who meet the
21eligibility conditions of Sections 6-1.1 through 6-1.10,
22except as provided in the No Taxpayer Funding for Abortion Act.
23In addition, each unit of local government subject to this
24Article shall provide persons receiving financial aid in
25meeting basic maintenance requirements with financial aid for

 

 

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1either (a) necessary treatment, care, and supplies required
2because of illness or disability, or (b) acute medical
3treatment, care, and supplies only. If a local governmental
4unit elects to provide financial aid for acute medical
5treatment, care, and supplies only, the general types of acute
6medical treatment, care, and supplies for which financial aid
7is provided shall be specified in the general assistance rules
8of the local governmental unit, which rules shall provide that
9financial aid is provided, at a minimum, for acute medical
10treatment, care, or supplies necessitated by a medical
11condition for which prior approval or authorization of medical
12treatment, care, or supplies is not required by the general
13assistance rules of the Illinois Department.
14(Source: P.A. 100-538, eff. 1-1-18.)
 
15    Section 910. The Problem Pregnancy Health Services and Care
16Act is amended by changing Section 4-100 as follows:
 
17    (410 ILCS 230/4-100)  (from Ch. 111 1/2, par. 4604-100)
18    (Text of Section before amendment by P.A. 100-538)
19    Sec. 4-100. The Department may make grants to nonprofit
20agencies and organizations which do not use such grants to
21refer or counsel for, or perform, abortions and which
22coordinate and establish linkages among services that will
23further the purposes of this Act and, where appropriate, will
24provide, supplement, or improve the quality of such services.

 

 

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1(Source: P.A. 83-51.)
 
2    (Text of Section after amendment by P.A. 100-538)
3    Sec. 4-100. The Department may make grants to nonprofit
4agencies and organizations which do not use such grants to
5refer or counsel for, or perform, abortions and which
6coordinate and establish linkages among services that will
7further the purposes of this Act and, where appropriate, will
8provide, supplement, or improve the quality of such services.
9(Source: P.A. 100-538, eff. 1-1-18.)
 
10    Section 990. Application of Act; home rule powers.
11    (a) This Act applies to all State and local (including home
12rule unit) laws, ordinances, policies, procedures, practices,
13and governmental actions and their implementation, whether
14statutory or otherwise and whether adopted before or after the
15effective date of this Act.
16    (b) A home rule unit may not adopt any rule in a manner
17inconsistent with this Act. This Act is a limitation under
18subsection (i) of Section 6 of Article VII of the Illinois
19Constitution on the concurrent exercise by home rule units of
20powers and functions exercised by the State.
 
21    Section 995. No acceleration or delay. Where this Act makes
22changes in a statute that is represented in this Act by text
23that is not yet or no longer in effect (for example, a Section

 

 

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1represented by multiple versions), the use of that text does
2not accelerate or delay the taking effect of (i) the changes
3made by this Act or (ii) provisions derived from any other
4Public Act.
 
5    Section 999. Effective date. This Act takes effect on the
6earlier of the effective date of Public Act 100-538 or June 1,
72018.

 

 

HB4114- 74 -LRB100 15067 KTG 29910 b

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