100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
HB4189

 

Introduced , by Rep. David B. Reis

 

SYNOPSIS AS INTRODUCED:
 
5 ILCS 375/6  from Ch. 127, par. 526
5 ILCS 375/6.1  from Ch. 127, par. 526.1
305 ILCS 5/5-5  from Ch. 23, par. 5-5
305 ILCS 5/5-8  from Ch. 23, par. 5-8
305 ILCS 5/5-9  from Ch. 23, par. 5-9
305 ILCS 5/6-1  from Ch. 23, par. 6-1
410 ILCS 230/4-100  from Ch. 111 1/2, par. 4604-100
720 ILCS 510/1  from Ch. 38, par. 81-21

    Amends the State Employees Group Insurance Act of 1971, the Illinois Public Aid Code, the Problem Pregnancy Health Services and Care Act, and the Illinois Abortion Law of 1975. Restores the provisions that were amended by Public Act 100-538 to the form in which they existed before their amendment by Public Act 100-538.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB4189LRB100 15874 KTG 30985 b

1    AN ACT concerning abortion.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The State Employees Group Insurance Act of 1971
5is amended by changing Sections 6 and 6.1 as follows:
 
6    (5 ILCS 375/6)  (from Ch. 127, par. 526)
7    Sec. 6. Program of health benefits.
8    (a) The program of health benefits shall provide for
9protection against the financial costs of health care expenses
10incurred in and out of hospital including basic
11hospital-surgical-medical coverages. The program may include,
12but shall not be limited to, such supplemental coverages as
13out-patient diagnostic X-ray and laboratory expenses,
14prescription drugs, dental services, hearing evaluations,
15hearing aids, the dispensing and fitting of hearing aids, and
16similar group benefits as are now or may become available.
17However, nothing in this Act shall be construed to permit the
18non-contributory portion of any such program to include the
19expenses of obtaining an abortion, induced miscarriage or
20induced premature birth unless, in the opinion of a physician,
21such procedures are necessary for the preservation of the life
22of the woman seeking such treatment, or except an induced
23premature birth intended to produce a live viable child and

 

 

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

 

 

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

 

 

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1program on or after July 1, 1992; or (3) remain eligible for,
2but no longer receive Medicare coverage which they had been
3receiving on or after the effective date of this amendatory Act
4of 1992. Premiums may be adjusted, where applicable, to an
5amount deemed by the Director to be reasonably consistent with
6any reduction of benefits.
7    (b) A member, not otherwise covered by this Act, who has
8retired as a participating member under Article 2 of the
9Illinois Pension Code but is ineligible for the retirement
10annuity under Section 2-119 of the Illinois Pension Code, shall
11pay the premiums for coverage, not exceeding the amount paid by
12the State for the non-contributory coverage for other members,
13under the group health benefits program under this Act. The
14Director shall determine the premiums to be paid by a member
15under this subsection (b).
16(Source: P.A. 100-538, eff. 1-1-18.)
 
17    (5 ILCS 375/6.1)  (from Ch. 127, par. 526.1)
18    Sec. 6.1. The program of health benefits may offer as an
19alternative, available on an optional basis, coverage through
20health maintenance organizations. That part of the premium for
21such coverage which is in excess of the amount which would
22otherwise be paid by the State for the program of health
23benefits shall be paid by the member who elects such
24alternative coverage and shall be collected as provided for
25premiums for other optional coverages.

 

 

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1    However, nothing in this Act shall be construed to permit
2the noncontributory portion of any such program to include the
3expenses of obtaining an abortion, induced miscarriage or
4induced premature birth unless, in the opinion of a physician,
5such procedures are necessary for the preservation of the life
6of the woman seeking such treatment, or except an induced
7premature birth intended to produce a live viable child and
8such procedure is necessary for the health of the mother or her
9unborn child.
10(Source: P.A. 100-538, eff. 1-1-18.)
 
11    Section 10. 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    Sec. 5-5. Medical services. The Illinois Department, by
15rule, shall determine the quantity and quality of and the rate
16of reimbursement for the medical assistance for which payment
17will be authorized, and the medical services to be provided,
18which may include all or part of the following: (1) inpatient
19hospital services; (2) outpatient hospital services; (3) other
20laboratory and X-ray services; (4) skilled nursing home
21services; (5) physicians' services whether furnished in the
22office, the patient's home, a hospital, a skilled nursing home,
23or elsewhere; (6) medical care, or any other type of remedial
24care furnished by licensed practitioners; (7) home health care

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1which dental services covered under this Section are performed.
2The Department shall establish a process for payment of claims
3for reimbursement for covered dental services rendered under
4this provision.
5    The Illinois Department, by rule, may distinguish and
6classify the medical services to be provided only in accordance
7with the classes of persons designated in Section 5-2.
8    The Department of Healthcare and Family Services must
9provide coverage and reimbursement for amino acid-based
10elemental formulas, regardless of delivery method, for the
11diagnosis and treatment of (i) eosinophilic disorders and (ii)
12short bowel syndrome when the prescribing physician has issued
13a written order stating that the amino acid-based elemental
14formula is medically necessary.
15    The Illinois Department shall authorize the provision of,
16and shall authorize payment for, screening by low-dose
17mammography for the presence of occult breast cancer for women
1835 years of age or older who are eligible for medical
19assistance under this Article, as follows:
20        (A) A baseline mammogram for women 35 to 39 years of
21    age.
22        (B) An annual mammogram for women 40 years of age or
23    older.
24        (C) A mammogram at the age and intervals considered
25    medically necessary by the woman's health care provider for
26    women under 40 years of age and having a family history of

 

 

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

 

 

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

 

 

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

 

 

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1effectiveness and modifying the methodology based on the
2evaluation.
3    The Department shall establish a performance goal for
4primary care providers with respect to their female patients
5over age 40 receiving an annual mammogram. This performance
6goal shall be used to provide additional reimbursement in the
7form of a quality performance bonus to primary care providers
8who meet that goal.
9    The Department shall devise a means of case-managing or
10patient navigation for beneficiaries diagnosed with breast
11cancer. This program shall initially operate as a pilot program
12in areas of the State with the highest incidence of mortality
13related to breast cancer. At least one pilot program site shall
14be in the metropolitan Chicago area and at least one site shall
15be outside the metropolitan Chicago area. On or after July 1,
162016, the pilot program shall be expanded to include one site
17in western Illinois, one site in southern Illinois, one site in
18central Illinois, and 4 sites within metropolitan Chicago. An
19evaluation of the pilot program shall be carried out measuring
20health outcomes and cost of care for those served by the pilot
21program compared to similarly situated patients who are not
22served by the pilot program.
23    The Department shall require all networks of care to
24develop a means either internally or by contract with experts
25in navigation and community outreach to navigate cancer
26patients to comprehensive care in a timely fashion. The

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1prosthetic devices and any other items recognized as medical
2equipment and supplies reimbursable under this Article and
3shall update such list on a quarterly basis, except that the
4acquisition costs of all prescription drugs shall be updated no
5less frequently than every 30 days as required by Section
65-5.12.
7    The rules and regulations of the Illinois Department shall
8require that a written statement including the required opinion
9of a physician shall accompany any claim for reimbursement for
10abortions, or induced miscarriages or premature births. This
11statement shall indicate what procedures were used in providing
12such medical services.
13    Notwithstanding any other law to the contrary, the Illinois
14Department shall, within 365 days after July 22, 2013 (the
15effective date of Public Act 98-104), establish procedures to
16permit skilled care facilities licensed under the Nursing Home
17Care Act to submit monthly billing claims for reimbursement
18purposes. Following development of these procedures, the
19Department shall, by July 1, 2016, test the viability of the
20new system and implement any necessary operational or
21structural changes to its information technology platforms in
22order to allow for the direct acceptance and payment of nursing
23home claims.
24    Notwithstanding any other law to the contrary, the Illinois
25Department shall, within 365 days after August 15, 2014 (the
26effective date of Public Act 98-963), establish procedures to

 

 

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

 

 

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

 

 

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

 

 

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1    local government with a population exceeding 3,000,000
2    when local government funds finance federal participation
3    for claims payments.
4    For claims for services rendered during a period for which
5a recipient received retroactive eligibility, claims must be
6filed within 180 days after the Department determines the
7applicant is eligible. For claims for which the Illinois
8Department is not the primary payer, claims must be submitted
9to the Illinois Department within 180 days after the final
10adjudication by the primary payer.
11    In the case of long term care facilities, within 45
12calendar days of receipt by the facility of required
13prescreening information, new admissions with associated
14admission documents shall be submitted through the Medical
15Electronic Data Interchange (MEDI) or the Recipient
16Eligibility Verification (REV) System or shall be submitted
17directly to the Department of Human Services using required
18admission forms. Effective September 1, 2014, admission
19documents, including all prescreening information, must be
20submitted through MEDI or REV. Confirmation numbers assigned to
21an accepted transaction shall be retained by a facility to
22verify timely submittal. Once an admission transaction has been
23completed, all resubmitted claims following prior rejection
24are subject to receipt no later than 180 days after the
25admission transaction has been completed.
26    Claims that are not submitted and received in compliance

 

 

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

 

 

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

 

 

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

 

 

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1Department of Human Services and the Department on Aging, to
2effect the following: (i) intake procedures and common
3eligibility criteria for those persons who are receiving
4non-institutional services; and (ii) the establishment and
5development of non-institutional services in areas of the State
6where they are not currently available or are undeveloped; and
7(iii) notwithstanding any other provision of law, subject to
8federal approval, on and after July 1, 2012, an increase in the
9determination of need (DON) scores from 29 to 37 for applicants
10for institutional and home and community-based long term care;
11if and only if federal approval is not granted, the Department
12may, in conjunction with other affected agencies, implement
13utilization controls or changes in benefit packages to
14effectuate a similar savings amount for this population; and
15(iv) no later than July 1, 2013, minimum level of care
16eligibility criteria for institutional and home and
17community-based long term care; and (v) no later than October
181, 2013, establish procedures to permit long term care
19providers access to eligibility scores for individuals with an
20admission date who are seeking or receiving services from the
21long term care provider. In order to select the minimum level
22of care eligibility criteria, the Governor shall establish a
23workgroup that includes affected agency representatives and
24stakeholders representing the institutional and home and
25community-based long term care interests. This Section shall
26not restrict the Department from implementing lower level of

 

 

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1care eligibility criteria for community-based services in
2circumstances where federal approval has been granted.
3    The Illinois Department shall develop and operate, in
4cooperation with other State Departments and agencies and in
5compliance with applicable federal laws and regulations,
6appropriate and effective systems of health care evaluation and
7programs for monitoring of utilization of health care services
8and facilities, as it affects persons eligible for medical
9assistance under this Code.
10    The Illinois Department shall report annually to the
11General Assembly, no later than the second Friday in April of
121979 and each year thereafter, in regard to:
13        (a) actual statistics and trends in utilization of
14    medical services by public aid recipients;
15        (b) actual statistics and trends in the provision of
16    the various medical services by medical vendors;
17        (c) current rate structures and proposed changes in
18    those rate structures for the various medical vendors; and
19        (d) efforts at utilization review and control by the
20    Illinois Department.
21    The period covered by each report shall be the 3 years
22ending on the June 30 prior to the report. The report shall
23include suggested legislation for consideration by the General
24Assembly. The filing of one copy of the report with the
25Speaker, one copy with the Minority Leader and one copy with
26the Clerk of the House of Representatives, one copy with the

 

 

HB4189- 30 -LRB100 15874 KTG 30985 b

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

 

 

HB4189- 31 -LRB100 15874 KTG 30985 b

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

 

 

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1means a drug that binds to opioid receptors and blocks or
2inhibits the effect of opioids acting on those receptors,
3including, but not limited to, naloxone hydrochloride or any
4other similarly acting drug approved by the U.S. Food and Drug
5Administration.
6    Upon federal approval, the Department shall provide
7coverage and reimbursement for all drugs that are approved for
8marketing by the federal Food and Drug Administration and that
9are recommended by the federal Public Health Service or the
10United States Centers for Disease Control and Prevention for
11pre-exposure prophylaxis and related pre-exposure prophylaxis
12services, including, but not limited to, HIV and sexually
13transmitted infection screening, treatment for sexually
14transmitted infections, medical monitoring, assorted labs, and
15counseling to reduce the likelihood of HIV infection among
16individuals who are not infected with HIV but who are at high
17risk of HIV infection.
18(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
1999-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
20the effective date of P.A. 99-407); 99-433, eff. 8-21-15;
2199-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
227-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
23eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
24100-538, eff. 1-1-18; revised 10-26-17.)
 
25    (305 ILCS 5/5-8)  (from Ch. 23, par. 5-8)

 

 

HB4189- 33 -LRB100 15874 KTG 30985 b

1    Sec. 5-8. Practitioners. In supplying medical assistance,
2the Illinois Department may provide for the legally authorized
3services of (i) persons licensed under the Medical Practice Act
4of 1987, as amended, except as hereafter in this Section
5stated, whether under a general or limited license, (ii)
6persons licensed under the Nurse Practice Act as advanced
7practice registered nurses, regardless of whether or not the
8persons have written collaborative agreements, (iii) persons
9licensed or registered under other laws of this State to
10provide dental, medical, pharmaceutical, optometric,
11podiatric, or nursing services, or other remedial care
12recognized under State law, (iv) persons licensed under other
13laws of this State as a clinical social worker, and (v) persons
14licensed under other laws of this State as physician
15assistants. The Department shall adopt rules, no later than 90
16days after January 1, 2017 (the effective date of Public Act
1799-621) this amendatory Act of the 99th General Assembly, for
18the legally authorized services of persons licensed under other
19laws of this State as a clinical social worker. The Department
20may not provide for legally authorized services of any
21physician who has been convicted of having performed an
22abortion procedure in a wilful and wanton manner on a woman who
23was not pregnant at the time such abortion procedure was
24performed. The utilization of the services of persons engaged
25in the treatment or care of the sick, which persons are not
26required to be licensed or registered under the laws of this

 

 

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1State, is not prohibited by this Section.
2(Source: P.A. 99-173, eff. 7-29-15; 99-621, eff. 1-1-17;
3100-453, eff. 8-25-17; 100-513, eff. 1-1-18; 100-538, eff.
41-1-18; revised 10-26-17.)
 
5    (305 ILCS 5/5-9)  (from Ch. 23, par. 5-9)
6    Sec. 5-9. Choice of Medical Dispensers. Applicants and
7recipients shall be entitled to free choice of those qualified
8practitioners, hospitals, nursing homes, and other dispensers
9of medical services meeting the requirements and complying with
10the rules and regulations of the Illinois Department. However,
11the Director of Healthcare and Family Services may, after
12providing reasonable notice and opportunity for hearing, deny,
13suspend or terminate any otherwise qualified person, firm,
14corporation, association, agency, institution, or other legal
15entity, from participation as a vendor of goods or services
16under the medical assistance program authorized by this Article
17if the Director finds such vendor of medical services in
18violation of this Act or the policy or rules and regulations
19issued pursuant to this Act. Any physician who has been
20convicted of performing an abortion procedure in a wilful and
21wanton manner upon a woman who was not pregnant at the time
22such abortion procedure was performed shall be automatically
23removed from the list of physicians qualified to participate as
24a vendor of medical services under the medical assistance
25program authorized by this Article.

 

 

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1(Source: P.A. 100-538, eff. 1-1-18.)
 
2    (305 ILCS 5/6-1)  (from Ch. 23, par. 6-1)
3    Sec. 6-1. Eligibility requirements. Financial aid in
4meeting basic maintenance requirements shall be given under
5this Article to or in behalf of persons who meet the
6eligibility conditions of Sections 6-1.1 through 6-1.10. In
7addition, each unit of local government subject to this Article
8shall provide persons receiving financial aid in meeting basic
9maintenance requirements with financial aid for either (a)
10necessary treatment, care, and supplies required because of
11illness or disability, or (b) acute medical treatment, care,
12and supplies only. If a local governmental unit elects to
13provide financial aid for acute medical treatment, care, and
14supplies only, the general types of acute medical treatment,
15care, and supplies for which financial aid is provided shall be
16specified in the general assistance rules of the local
17governmental unit, which rules shall provide that financial aid
18is provided, at a minimum, for acute medical treatment, care,
19or supplies necessitated by a medical condition for which prior
20approval or authorization of medical treatment, care, or
21supplies is not required by the general assistance rules of the
22Illinois Department. Nothing in this Article shall be construed
23to permit the granting of financial aid where the purpose of
24such aid is to obtain an abortion, induced miscarriage or
25induced premature birth unless, in the opinion of a physician,

 

 

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1such procedures are necessary for the preservation of the life
2of the woman seeking such treatment, or except an induced
3premature birth intended to produce a live viable child and
4such procedure is necessary for the health of the mother or her
5unborn child.
6(Source: P.A. 100-538, eff. 1-1-18.)
 
7    Section 15. The Problem Pregnancy Health Services and Care
8Act is amended by changing Section 4-100 as follows:
 
9    (410 ILCS 230/4-100)  (from Ch. 111 1/2, par. 4604-100)
10    Sec. 4-100. The Department may make grants to nonprofit
11agencies and organizations which do not use such grants to
12refer or counsel for, or perform, abortions and which
13coordinate and establish linkages among services that will
14further the purposes of this Act and, where appropriate, will
15provide, supplement, or improve the quality of such services.
16(Source: P.A. 100-538, eff. 1-1-18.)
 
17    Section 20. The Illinois Abortion Law of 1975 is amended by
18changing Section 1 as follows:
 
19    (720 ILCS 510/1)  (from Ch. 38, par. 81-21)
20    Sec. 1. It is the intention of the General Assembly of the
21State of Illinois to reasonably regulate abortion in
22conformance with the legal standards set forth in the decisions

 

 

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

 

 

HB4189- 38 -LRB100 15874 KTG 30985 b

1participate in such relations, and to gather data for
2establishing criteria for medical decisions. The General
3Assembly finds as fact, upon hearings and public disclosures,
4that these rights and interests are not secure in the economic
5and social context in which abortion is presently performed.
6(Source: P.A. 100-538, eff. 1-1-18.)