Sen. Laura Fine

Filed: 5/13/2021

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 2589

2    AMENDMENT NO. ______. Amend House Bill 2589 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Substance Use Disorder Act is amended by
5changing Sections 5-23 and 20-10 as follows:
 
6    (20 ILCS 301/5-23)
7    Sec. 5-23. Drug Overdose Prevention Program.
8    (a) Reports.
9        (1) The Department may publish annually a report on
10    drug overdose trends statewide that reviews State death
11    rates from available data to ascertain changes in the
12    causes or rates of fatal and nonfatal drug overdose. The
13    report shall also provide information on interventions
14    that would be effective in reducing the rate of fatal or
15    nonfatal drug overdose and on the current substance use
16    disorder treatment capacity within the State. The report

 

 

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1    shall include an analysis of drug overdose information
2    reported to the Department of Public Health pursuant to
3    subsection (e) of Section 3-3013 of the Counties Code,
4    Section 6.14g of the Hospital Licensing Act, and
5    subsection (j) of Section 22-30 of the School Code.
6        (2) The report may include:
7            (A) Trends in drug overdose death rates.
8            (B) Trends in emergency room utilization related
9        to drug overdose and the cost impact of emergency room
10        utilization.
11            (C) Trends in utilization of pre-hospital and
12        emergency services and the cost impact of emergency
13        services utilization.
14            (D) Suggested improvements in data collection.
15            (E) A description of other interventions effective
16        in reducing the rate of fatal or nonfatal drug
17        overdose.
18            (F) A description of efforts undertaken to educate
19        the public about unused medication and about how to
20        properly dispose of unused medication, including the
21        number of registered collection receptacles in this
22        State, mail-back programs, and drug take-back events.
23            (G) An inventory of the State's substance use
24        disorder treatment capacity, including, but not
25        limited to:
26                (i) The number and type of licensed treatment

 

 

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1            programs in each geographic area of the State.
2                (ii) The availability of medication-assisted
3            treatment at each licensed program and which types
4            of medication-assisted treatment are available.
5                (iii) The number of recovery homes that accept
6            individuals using medication-assisted treatment in
7            their recovery.
8                (iv) The number of medical professionals
9            currently authorized to prescribe buprenorphine
10            and the number of individuals who fill
11            prescriptions for that medication at retail
12            pharmacies as prescribed.
13                (v) Any partnerships between programs licensed
14            by the Department and other providers of
15            medication-assisted treatment.
16                (vi) Any challenges in providing
17            medication-assisted treatment reported by programs
18            licensed by the Department and any potential
19            solutions.
20    (b) Programs; drug overdose prevention.
21        (1) The Department may establish a program to provide
22    for the production and publication, in electronic and
23    other formats, of drug overdose prevention, recognition,
24    and response literature. The Department may develop and
25    disseminate curricula for use by professionals,
26    organizations, individuals, or committees interested in

 

 

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1    the prevention of fatal and nonfatal drug overdose,
2    including, but not limited to, drug users, jail and prison
3    personnel, jail and prison inmates, drug treatment
4    professionals, emergency medical personnel, hospital
5    staff, families and associates of drug users, peace
6    officers, firefighters, public safety officers, needle
7    exchange program staff, and other persons. In addition to
8    information regarding drug overdose prevention,
9    recognition, and response, literature produced by the
10    Department shall stress that drug use remains illegal and
11    highly dangerous and that complete abstinence from illegal
12    drug use is the healthiest choice. The literature shall
13    provide information and resources for substance use
14    disorder treatment.
15        The Department may establish or authorize programs for
16    prescribing, dispensing, or distributing opioid
17    antagonists for the treatment of drug overdose. Such
18    programs may include the prescribing of opioid antagonists
19    for the treatment of drug overdose to a person who is not
20    at risk of opioid overdose but who, in the judgment of the
21    health care professional, may be in a position to assist
22    another individual during an opioid-related drug overdose
23    and who has received basic instruction on how to
24    administer an opioid antagonist.
25        (2) The Department may provide advice to State and
26    local officials on the growing drug overdose crisis,

 

 

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1    including the prevalence of drug overdose incidents,
2    programs promoting the disposal of unused prescription
3    drugs, trends in drug overdose incidents, and solutions to
4    the drug overdose crisis.
5        (3) The Department may support drug overdose
6    prevention, recognition, and response projects by
7    facilitating the acquisition of opioid antagonist
8    medication approved for opioid overdose reversal,
9    facilitating the acquisition of opioid antagonist
10    medication approved for opioid overdose reversal,
11    providing trainings in overdose prevention best practices,
12    connecting programs to medical resources, establishing a
13    statewide standing order for the acquisition of needed
14    medication, establishing learning collaboratives between
15    localities and programs, and assisting programs in
16    navigating any regulatory requirements for establishing or
17    expanding such programs.
18        (4) In supporting best practices in drug overdose
19    prevention programming, the Department may promote the
20    following programmatic elements:
21            (A) Training individuals who currently use drugs
22        in the administration of opioid antagonists approved
23        for the reversal of an opioid overdose.
24            (B) Directly distributing opioid antagonists
25        approved for the reversal of an opioid overdose rather
26        than providing prescriptions to be filled at a

 

 

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1        pharmacy.
2            (C) Conducting street and community outreach to
3        work directly with individuals who are using drugs.
4            (D) Employing community health workers or peer
5        recovery specialists who are familiar with the
6        communities served and can provide culturally
7        competent services.
8            (E) Collaborating with other community-based
9        organizations, substance use disorder treatment
10        centers, or other health care providers engaged in
11        treating individuals who are using drugs.
12            (F) Providing linkages for individuals to obtain
13        evidence-based substance use disorder treatment.
14            (G) Engaging individuals exiting jails or prisons
15        who are at a high risk of overdose.
16            (H) Providing education and training to
17        community-based organizations who work directly with
18        individuals who are using drugs and those individuals'
19        families and communities.
20            (I) Providing education and training on drug
21        overdose prevention and response to emergency
22        personnel and law enforcement.
23            (J) Informing communities of the important role
24        emergency personnel play in responding to accidental
25        overdose.
26            (K) Producing and distributing targeted mass media

 

 

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1        materials on drug overdose prevention and response,
2        the potential dangers of leaving unused prescription
3        drugs in the home, and the proper methods for
4        disposing of unused prescription drugs.
5    (c) Grants.
6        (1) The Department may award grants, in accordance
7    with this subsection, to create or support local drug
8    overdose prevention, recognition, and response projects.
9    Local health departments, correctional institutions,
10    hospitals, universities, community-based organizations,
11    and faith-based organizations may apply to the Department
12    for a grant under this subsection at the time and in the
13    manner the Department prescribes. Eligible grant
14    activities include, but are not limited to, purchasing and
15    distributing opioid antagonists, hiring peer recovery
16    specialists or other community members to conduct
17    community outreach, and hosting public health fairs or
18    events to distribute opioid antagonists, promote harm
19    reduction activities, and provide linkages to community
20    partners.
21        (2) In awarding grants, the Department shall consider
22    the overall rate of opioid overdose, the rate of increase
23    in opioid overdose, and racial disparities in opioid
24    overdose experienced by the communities to be served by
25    grantees. The Department necessity for overdose prevention
26    projects in various settings and shall encourage all grant

 

 

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1    applicants to develop interventions that will be effective
2    and viable in their local areas.
3        (3) (Blank).
4        (3.5) Any hospital licensed under the Hospital
5    Licensing Act or organized under the University of
6    Illinois Hospital Act shall be deemed to have met the
7    standards and requirements set forth in this Section to
8    enroll in the drug overdose prevention program upon
9    completion of the enrollment process except that proof of
10    a standing order and attestation of programmatic
11    requirements shall be waived for enrollment purposes.
12    Reporting mandated by enrollment shall be necessary to
13    carry out or attain eligibility for associated resources
14    under this Section for drug overdose prevention projects
15    operated on the licensed premises of the hospital and
16    operated by the hospital or its designated agent. The
17    Department shall streamline hospital enrollment for drug
18    overdose prevention programs by accepting such deemed
19    status under this Section in order to reduce barriers to
20    hospital participation in drug overdose prevention,
21    recognition, or response projects.
22        (4) In addition to moneys appropriated by the General
23    Assembly, the Department may seek grants from private
24    foundations, the federal government, and other sources to
25    fund the grants under this Section and to fund an
26    evaluation of the programs supported by the grants.

 

 

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1    (d) Health care professional prescription of opioid
2antagonists.
3        (1) A health care professional who, acting in good
4    faith, directly or by standing order, prescribes or
5    dispenses an opioid antagonist to: (a) a patient who, in
6    the judgment of the health care professional, is capable
7    of administering the drug in an emergency, or (b) a person
8    who is not at risk of opioid overdose but who, in the
9    judgment of the health care professional, may be in a
10    position to assist another individual during an
11    opioid-related drug overdose and who has received basic
12    instruction on how to administer an opioid antagonist
13    shall not, as a result of his or her acts or omissions, be
14    subject to: (i) any disciplinary or other adverse action
15    under the Medical Practice Act of 1987, the Physician
16    Assistant Practice Act of 1987, the Nurse Practice Act,
17    the Pharmacy Practice Act, or any other professional
18    licensing statute or (ii) any criminal liability, except
19    for willful and wanton misconduct.
20        (1.5) Notwithstanding any provision of or requirement
21    otherwise imposed by the Pharmacy Practice Act, the
22    Medical Practice Act of 1987, or any other law or rule,
23    including, but not limited to, any requirement related to
24    labeling, storage, or recordkeeping, a health care
25    professional or other person acting under the direction of
26    a health care professional may, directly or by standing

 

 

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1    order, obtain, store, and dispense an opioid antagonist to
2    a patient in a facility that includes, but is not limited
3    to, a hospital, a hospital affiliate, or a federally
4    qualified health center if the patient information
5    specified in paragraph (4) of this subsection is provided
6    to the patient. A person acting in accordance with this
7    paragraph shall not, as a result of his or her acts or
8    omissions, be subject to: (i) any disciplinary or other
9    adverse action under the Medical Practice Act of 1987, the
10    Physician Assistant Practice Act of 1987, the Nurse
11    Practice Act, the Pharmacy Practice Act, or any other
12    professional licensing statute; or (ii) any criminal
13    liability, except for willful and wanton misconduct.
14        (2) A person who is not otherwise licensed to
15    administer an opioid antagonist may in an emergency
16    administer without fee an opioid antagonist if the person
17    has received the patient information specified in
18    paragraph (4) of this subsection and believes in good
19    faith that another person is experiencing a drug overdose.
20    The person shall not, as a result of his or her acts or
21    omissions, be (i) liable for any violation of the Medical
22    Practice Act of 1987, the Physician Assistant Practice Act
23    of 1987, the Nurse Practice Act, the Pharmacy Practice
24    Act, or any other professional licensing statute, or (ii)
25    subject to any criminal prosecution or civil liability,
26    except for willful and wanton misconduct.

 

 

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1        (3) A health care professional prescribing an opioid
2    antagonist to a patient shall ensure that the patient
3    receives the patient information specified in paragraph
4    (4) of this subsection. Patient information may be
5    provided by the health care professional or a
6    community-based organization, substance use disorder
7    program, or other organization with which the health care
8    professional establishes a written agreement that includes
9    a description of how the organization will provide patient
10    information, how employees or volunteers providing
11    information will be trained, and standards for documenting
12    the provision of patient information to patients.
13    Provision of patient information shall be documented in
14    the patient's medical record or through similar means as
15    determined by agreement between the health care
16    professional and the organization. The Department, in
17    consultation with statewide organizations representing
18    physicians, pharmacists, advanced practice registered
19    nurses, physician assistants, substance use disorder
20    programs, and other interested groups, shall develop and
21    disseminate to health care professionals, community-based
22    organizations, substance use disorder programs, and other
23    organizations training materials in video, electronic, or
24    other formats to facilitate the provision of such patient
25    information.
26        (4) For the purposes of this subsection:

 

 

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1        "Opioid antagonist" means a drug that binds to opioid
2    receptors and blocks or inhibits the effect of opioids
3    acting on those receptors, including, but not limited to,
4    naloxone hydrochloride or any other similarly acting drug
5    approved by the U.S. Food and Drug Administration.
6        "Health care professional" means a physician licensed
7    to practice medicine in all its branches, a licensed
8    physician assistant with prescriptive authority, a
9    licensed advanced practice registered nurse with
10    prescriptive authority, an advanced practice registered
11    nurse or physician assistant who practices in a hospital,
12    hospital affiliate, or ambulatory surgical treatment
13    center and possesses appropriate clinical privileges in
14    accordance with the Nurse Practice Act, or a pharmacist
15    licensed to practice pharmacy under the Pharmacy Practice
16    Act.
17        "Patient" includes a person who is not at risk of
18    opioid overdose but who, in the judgment of the physician,
19    advanced practice registered nurse, or physician
20    assistant, may be in a position to assist another
21    individual during an overdose and who has received patient
22    information as required in paragraph (2) of this
23    subsection on the indications for and administration of an
24    opioid antagonist.
25        "Patient information" includes information provided to
26    the patient on drug overdose prevention and recognition;

 

 

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1    how to perform rescue breathing and resuscitation; opioid
2    antagonist dosage and administration; the importance of
3    calling 911; care for the overdose victim after
4    administration of the overdose antagonist; and other
5    issues as necessary.
6    (e) Drug overdose response policy.
7        (1) Every State and local government agency that
8    employs a law enforcement officer or fireman as those
9    terms are defined in the Line of Duty Compensation Act
10    must possess opioid antagonists and must establish a
11    policy to control the acquisition, storage,
12    transportation, and administration of such opioid
13    antagonists and to provide training in the administration
14    of opioid antagonists. A State or local government agency
15    that employs a fireman as defined in the Line of Duty
16    Compensation Act but does not respond to emergency medical
17    calls or provide medical services shall be exempt from
18    this subsection.
19        (2) Every publicly or privately owned ambulance,
20    special emergency medical services vehicle, non-transport
21    vehicle, or ambulance assist vehicle, as described in the
22    Emergency Medical Services (EMS) Systems Act, that
23    responds to requests for emergency services or transports
24    patients between hospitals in emergency situations must
25    possess opioid antagonists.
26        (3) Entities that are required under paragraphs (1)

 

 

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1    and (2) to possess opioid antagonists may also apply to
2    the Department for a grant to fund the acquisition of
3    opioid antagonists and training programs on the
4    administration of opioid antagonists.
5(Source: P.A. 100-201, eff. 8-18-17; 100-513, eff. 1-1-18;
6100-759, eff. 1-1-19; 101-356, eff. 8-9-19.)
 
7    (20 ILCS 301/20-10)
8    Sec. 20-10. Screening, Brief Intervention, and Referral to
9Treatment. As used in this Section, "SBIRT" means a
10comprehensive, integrated, public health approach to the
11delivery of early intervention and treatment services for
12persons who are at risk of developing substance use disorders
13or have substance use disorders including, but not limited to,
14an addiction to alcohol, opioids, tobacco, or cannabis. SBIRT
15services include all of the following:
16        (1) Screening to quickly assess the severity of
17    substance use and to identify the appropriate level of
18    treatment.
19        (2) Brief intervention focused on increasing insight
20    and awareness regarding substance use and motivation
21    toward behavioral change.
22        (3) Referral to treatment provided to those identified
23    as needing more extensive treatment with access to
24    specialty care.
25    SBIRT services may include, but are not limited to, the

 

 

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1following settings and programs: primary care centers,
2hospital emergency rooms, hospital in-patient units, trauma
3centers, community behavioral health programs, and other
4community settings that provide opportunities for early
5intervention with at-risk substance users before more severe
6consequences occur.
7    (a) As used in this Section, "SBIRT" means the
8identification of individuals, within primary care settings,
9who need substance use disorder treatment. Primary care
10providers will screen and, based on the results of the screen,
11deliver a brief intervention or make referral to a licensed
12treatment provider as appropriate. SBIRT is not a licensed
13category of service.
14    (b) The Department may develop policy or best practice
15guidelines for identification of at-risk individuals through
16SBIRT and contract or billing requirements for SBIRT.
17(Source: P.A. 100-759, eff. 1-1-19.)
 
18    Section 10. The Illinois Public Aid Code is amended by
19changing Section 5-5 and by adding Section 5-41 as follows:
 
20    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
21    Sec. 5-5. Medical services. The Illinois Department, by
22rule, shall determine the quantity and quality of and the rate
23of reimbursement for the medical assistance for which payment
24will be authorized, and the medical services to be provided,

 

 

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

 

 

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1assessment, and evaluation process refers to a process that
2includes an appropriate evaluation and, as warranted, a
3referral; "uniform" does not mean the use of a singular
4instrument, tool, or process that all must utilize; (14)
5transportation and such other expenses as may be necessary;
6(15) medical treatment of sexual assault survivors, as defined
7in Section 1a of the Sexual Assault Survivors Emergency
8Treatment Act, for injuries sustained as a result of the
9sexual assault, including examinations and laboratory tests to
10discover evidence which may be used in criminal proceedings
11arising from the sexual assault; (16) the diagnosis and
12treatment of sickle cell anemia; and (17) any other medical
13care, and any other type of remedial care recognized under the
14laws of this State. The term "any other type of remedial care"
15shall include nursing care and nursing home service for
16persons who rely on treatment by spiritual means alone through
17prayer for healing.
18    Notwithstanding any other provision of this Section, a
19comprehensive tobacco use cessation program that includes
20purchasing prescription drugs or prescription medical devices
21approved by the Food and Drug Administration shall be covered
22under the medical assistance program under this Article for
23persons who are otherwise eligible for assistance under this
24Article.
25    Notwithstanding any other provision of this Code,
26reproductive health care that is otherwise legal in Illinois

 

 

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1shall be covered under the medical assistance program for
2persons who are otherwise eligible for medical assistance
3under this Article.
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
20under this 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
4and Family Services may provide the following services to
5persons eligible 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
12    the diseases of the eye, or by an optometrist, whichever
13    the person may select.
14    On and after July 1, 2018, the Department of Healthcare
15and Family Services shall provide dental services to any adult
16who is otherwise eligible for assistance under the medical
17assistance program. As used in this paragraph, "dental
18services" means diagnostic, preventative, restorative, or
19corrective procedures, including procedures and services for
20the prevention and treatment of periodontal disease and dental
21caries disease, provided by an individual who is licensed to
22practice dentistry or dental surgery or who is under the
23supervision of a dentist in the practice of his or her
24profession.
25    On and after July 1, 2018, targeted dental services, as
26set forth in Exhibit D of the Consent Decree entered by the

 

 

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1United States District Court for the Northern District of
2Illinois, Eastern Division, in the matter of Memisovski v.
3Maram, Case No. 92 C 1982, that are provided to adults under
4the medical assistance program shall be established at no less
5than the rates set forth in the "New Rate" column in Exhibit D
6of the Consent Decree for targeted dental services that are
7provided to persons under the age of 18 under the medical
8assistance program.
9    Notwithstanding any other provision of this Code and
10subject to federal approval, the Department may adopt rules to
11allow a dentist who is volunteering his or her service at no
12cost to render dental services through an enrolled
13not-for-profit health clinic without the dentist personally
14enrolling as a participating provider in the medical
15assistance program. A not-for-profit health clinic shall
16include a public health clinic or Federally Qualified Health
17Center or other enrolled provider, as determined by the
18Department, through which dental services covered under this
19Section are performed. The Department shall establish a
20process for payment of claims for reimbursement for covered
21dental services rendered under this provision.
22    The Illinois Department, by rule, may distinguish and
23classify the medical services to be provided only in
24accordance with the classes of persons designated in Section
255-2.
26    The Department of Healthcare and Family Services must

 

 

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1provide coverage and reimbursement for amino acid-based
2elemental formulas, regardless of delivery method, for the
3diagnosis and treatment of (i) eosinophilic disorders and (ii)
4short bowel syndrome when the prescribing physician has issued
5a written order stating that the amino acid-based elemental
6formula is medically necessary.
7    The Illinois Department shall authorize the provision of,
8and shall authorize payment for, screening by low-dose
9mammography for the presence of occult breast cancer for women
1035 years of age or older who are eligible for medical
11assistance under this Article, as follows:
12        (A) A baseline mammogram for women 35 to 39 years of
13    age.
14        (B) An annual mammogram for women 40 years of age or
15    older.
16        (C) A mammogram at the age and intervals considered
17    medically necessary by the woman's health care provider
18    for women under 40 years of age and having a family history
19    of breast cancer, prior personal history of breast cancer,
20    positive genetic testing, or other risk factors.
21        (D) A comprehensive ultrasound screening and MRI of an
22    entire breast or breasts if a mammogram demonstrates
23    heterogeneous or dense breast tissue or when medically
24    necessary as determined by a physician licensed to
25    practice medicine in all of its branches.
26        (E) A screening MRI when medically necessary, as

 

 

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1    determined by a physician licensed to practice medicine in
2    all of its branches.
3        (F) A diagnostic mammogram when medically necessary,
4    as determined by a physician licensed to practice medicine
5    in all its branches, advanced practice registered nurse,
6    or physician assistant.
7    The Department shall not impose a deductible, coinsurance,
8copayment, or any other cost-sharing requirement on the
9coverage provided under this paragraph; except that this
10sentence does not apply to coverage of diagnostic mammograms
11to the extent such coverage would disqualify a high-deductible
12health plan from eligibility for a health savings account
13pursuant to Section 223 of the Internal Revenue Code (26
14U.S.C. 223).
15    All screenings shall include a physical breast exam,
16instruction on self-examination and information regarding the
17frequency of self-examination and its value as a preventative
18tool.
19     For purposes of this Section:
20    "Diagnostic mammogram" means a mammogram obtained using
21diagnostic mammography.
22    "Diagnostic mammography" means a method of screening that
23is designed to evaluate an abnormality in a breast, including
24an abnormality seen or suspected on a screening mammogram or a
25subjective or objective abnormality otherwise detected in the
26breast.

 

 

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1    "Low-dose mammography" means the x-ray examination of the
2breast using equipment dedicated specifically for mammography,
3including the x-ray tube, filter, compression device, and
4image receptor, with an average radiation exposure delivery of
5less than one rad per breast for 2 views of an average size
6breast. The term also includes digital mammography and
7includes breast tomosynthesis.
8    "Breast tomosynthesis" means a radiologic procedure that
9involves the acquisition of projection images over the
10stationary breast to produce cross-sectional digital
11three-dimensional images of the breast.
12    If, at any time, the Secretary of the United States
13Department of Health and Human Services, or its successor
14agency, promulgates rules or regulations to be published in
15the Federal Register or publishes a comment in the Federal
16Register or issues an opinion, guidance, or other action that
17would require the State, pursuant to any provision of the
18Patient Protection and Affordable Care Act (Public Law
19111-148), including, but not limited to, 42 U.S.C.
2018031(d)(3)(B) or any successor provision, to defray the cost
21of any coverage for breast tomosynthesis outlined in this
22paragraph, then the requirement that an insurer cover breast
23tomosynthesis is inoperative other than any such coverage
24authorized under Section 1902 of the Social Security Act, 42
25U.S.C. 1396a, and the State shall not assume any obligation
26for the cost of coverage for breast tomosynthesis set forth in

 

 

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1this paragraph.
2    On and after January 1, 2016, the Department shall ensure
3that all networks of care for adult clients of the Department
4include access to at least one breast imaging Center of
5Imaging Excellence as certified by the American College of
6Radiology.
7    On and after January 1, 2012, providers participating in a
8quality improvement program approved by the Department shall
9be reimbursed for screening and diagnostic mammography at the
10same rate as the Medicare program's rates, including the
11increased reimbursement for digital mammography.
12    The Department shall convene an expert panel including
13representatives of hospitals, free-standing mammography
14facilities, and doctors, including radiologists, to establish
15quality standards for mammography.
16    On and after January 1, 2017, providers participating in a
17breast cancer treatment quality improvement program approved
18by the Department shall be reimbursed for breast cancer
19treatment at a rate that is no lower than 95% of the Medicare
20program's rates for the data elements included in the breast
21cancer treatment quality program.
22    The Department shall convene an expert panel, including
23representatives of hospitals, free-standing breast cancer
24treatment centers, breast cancer quality organizations, and
25doctors, including breast surgeons, reconstructive breast
26surgeons, oncologists, and primary care providers to establish

 

 

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1quality standards for breast cancer treatment.
2    Subject to federal approval, the Department shall
3establish a rate methodology for mammography at federally
4qualified health centers and other encounter-rate clinics.
5These clinics or centers may also collaborate with other
6hospital-based mammography facilities. By January 1, 2016, the
7Department shall report to the General Assembly on the status
8of the provision set forth in this paragraph.
9    The Department shall establish a methodology to remind
10women who are age-appropriate for screening mammography, but
11who have not received a mammogram within the previous 18
12months, of the importance and benefit of screening
13mammography. The Department shall work with experts in breast
14cancer outreach and patient navigation to optimize these
15reminders and shall establish a methodology for evaluating
16their effectiveness and modifying the methodology based on the
17evaluation.
18    The Department shall establish a performance goal for
19primary care providers with respect to their female patients
20over age 40 receiving an annual mammogram. This performance
21goal shall be used to provide additional reimbursement in the
22form of a quality performance bonus to primary care providers
23who meet that goal.
24    The Department shall devise a means of case-managing or
25patient navigation for beneficiaries diagnosed with breast
26cancer. This program shall initially operate as a pilot

 

 

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1program in areas of the State with the highest incidence of
2mortality related to breast cancer. At least one pilot program
3site shall be in the metropolitan Chicago area and at least one
4site shall be outside the metropolitan Chicago area. On or
5after July 1, 2016, the pilot program shall be expanded to
6include one site in western Illinois, one site in southern
7Illinois, one site in central Illinois, and 4 sites within
8metropolitan Chicago. An evaluation of the pilot program shall
9be carried out measuring health outcomes and cost of care for
10those served by the pilot program compared to similarly
11situated patients who are not served by the pilot program.
12    The Department shall require all networks of care to
13develop a means either internally or by contract with experts
14in navigation and community outreach to navigate cancer
15patients to comprehensive care in a timely fashion. The
16Department shall require all networks of care to include
17access for patients diagnosed with cancer to at least one
18academic commission on cancer-accredited cancer program as an
19in-network covered benefit.
20    Any medical or health care provider shall immediately
21recommend, to any pregnant woman who is being provided
22prenatal services and is suspected of having a substance use
23disorder as defined in the Substance Use Disorder Act,
24referral to a local substance use disorder treatment program
25licensed by the Department of Human Services or to a licensed
26hospital which provides substance abuse treatment services.

 

 

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1The Department of Healthcare and Family Services shall assure
2coverage for the cost of treatment of the drug abuse or
3addiction for pregnant recipients in accordance with the
4Illinois Medicaid Program in conjunction with the Department
5of Human Services.
6    All medical providers providing medical assistance to
7pregnant women under this Code shall receive information from
8the Department on the availability of services under any
9program providing case management services for addicted women,
10including information on appropriate referrals for other
11social services that may be needed by addicted women in
12addition to treatment for addiction.
13    The Illinois Department, in cooperation with the
14Departments of Human Services (as successor to the Department
15of Alcoholism and Substance Abuse) and Public Health, through
16a public awareness campaign, may provide information
17concerning treatment for alcoholism and drug abuse and
18addiction, prenatal health care, and other pertinent programs
19directed at reducing the number of drug-affected infants born
20to recipients of medical assistance.
21    Neither the Department of Healthcare and Family Services
22nor the Department of Human Services shall sanction the
23recipient solely on the basis of her substance abuse.
24    The Illinois Department shall establish such regulations
25governing the dispensing of health services under this Article
26as it shall deem appropriate. The Department should seek the

 

 

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1advice of formal professional advisory committees appointed by
2the Director of the Illinois Department for the purpose of
3providing regular advice on policy and administrative matters,
4information dissemination and educational activities for
5medical and health care providers, and consistency in
6procedures to the Illinois Department.
7    The Illinois Department may develop and contract with
8Partnerships of medical providers to arrange medical services
9for persons eligible under Section 5-2 of this Code.
10Implementation of this Section may be by demonstration
11projects in certain geographic areas. The Partnership shall be
12represented by a sponsor organization. The Department, by
13rule, shall develop qualifications for sponsors of
14Partnerships. Nothing in this Section shall be construed to
15require that the sponsor organization be a medical
16organization.
17    The sponsor must negotiate formal written contracts with
18medical providers for physician services, inpatient and
19outpatient hospital care, home health services, treatment for
20alcoholism and substance abuse, and other services determined
21necessary by the Illinois Department by rule for delivery by
22Partnerships. Physician services must include prenatal and
23obstetrical care. The Illinois Department shall reimburse
24medical services delivered by Partnership providers to clients
25in target areas according to provisions of this Article and
26the Illinois Health Finance Reform Act, except that:

 

 

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1        (1) Physicians participating in a Partnership and
2    providing certain services, which shall be determined by
3    the Illinois Department, to persons in areas covered by
4    the Partnership may receive an additional surcharge for
5    such services.
6        (2) The Department may elect to consider and negotiate
7    financial incentives to encourage the development of
8    Partnerships and the efficient delivery of medical care.
9        (3) Persons receiving medical services through
10    Partnerships may receive medical and case management
11    services above the level usually offered through the
12    medical assistance program.
13    Medical providers shall be required to meet certain
14qualifications to participate in Partnerships to ensure the
15delivery of high quality medical services. These
16qualifications shall be determined by rule of the Illinois
17Department and may be higher than qualifications for
18participation in the medical assistance program. Partnership
19sponsors may prescribe reasonable additional qualifications
20for participation by medical providers, only with the prior
21written approval of the Illinois Department.
22    Nothing in this Section shall limit the free choice of
23practitioners, hospitals, and other providers of medical
24services by clients. In order to ensure patient freedom of
25choice, the Illinois Department shall immediately promulgate
26all rules and take all other necessary actions so that

 

 

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1provided services may be accessed from therapeutically
2certified optometrists to the full extent of the Illinois
3Optometric Practice Act of 1987 without discriminating between
4service providers.
5    The Department shall apply for a waiver from the United
6States Health Care Financing Administration to allow for the
7implementation of Partnerships under this Section.
8    The Illinois Department shall require health care
9providers to maintain records that document the medical care
10and services provided to recipients of Medical Assistance
11under this Article. Such records must be retained for a period
12of not less than 6 years from the date of service or as
13provided by applicable State law, whichever period is longer,
14except that if an audit is initiated within the required
15retention period then the records must be retained until the
16audit is completed and every exception is resolved. The
17Illinois Department shall require health care providers to
18make available, when authorized by the patient, in writing,
19the medical records in a timely fashion to other health care
20providers who are treating or serving persons eligible for
21Medical Assistance under this Article. All dispensers of
22medical services shall be required to maintain and retain
23business and professional records sufficient to fully and
24accurately document the nature, scope, details and receipt of
25the health care provided to persons eligible for medical
26assistance under this Code, in accordance with regulations

 

 

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1promulgated by the Illinois Department. The rules and
2regulations shall require that proof of the receipt of
3prescription drugs, dentures, prosthetic devices and
4eyeglasses by eligible persons under this Section accompany
5each claim for reimbursement submitted by the dispenser of
6such medical services. No such claims for reimbursement shall
7be approved for payment by the Illinois Department without
8such proof of receipt, unless the Illinois Department shall
9have put into effect and shall be operating a system of
10post-payment audit and review which shall, on a sampling
11basis, be deemed adequate by the Illinois Department to assure
12that such drugs, dentures, prosthetic devices and eyeglasses
13for which payment is being made are actually being received by
14eligible recipients. Within 90 days after September 16, 1984
15(the effective date of Public Act 83-1439), the Illinois
16Department shall establish a current list of acquisition costs
17for all prosthetic devices and any other items recognized as
18medical equipment and supplies reimbursable under this Article
19and shall update such list on a quarterly basis, except that
20the acquisition costs of all prescription drugs shall be
21updated no less frequently than every 30 days as required by
22Section 5-5.12.
23    Notwithstanding any other law to the contrary, the
24Illinois Department shall, within 365 days after July 22, 2013
25(the effective date of Public Act 98-104), establish
26procedures to permit skilled care facilities licensed under

 

 

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1the Nursing Home Care Act to submit monthly billing claims for
2reimbursement purposes. Following development of these
3procedures, the Department shall, by July 1, 2016, test the
4viability of the new system and implement any necessary
5operational or structural changes to its information
6technology platforms in order to allow for the direct
7acceptance and payment of nursing home claims.
8    Notwithstanding any other law to the contrary, the
9Illinois Department shall, within 365 days after August 15,
102014 (the effective date of Public Act 98-963), establish
11procedures to permit ID/DD facilities licensed under the ID/DD
12Community Care Act and MC/DD facilities licensed under the
13MC/DD Act to submit monthly billing claims for reimbursement
14purposes. Following development of these procedures, the
15Department shall have an additional 365 days to test the
16viability of the new system and to ensure that any necessary
17operational or structural changes to its information
18technology platforms are implemented.
19    The Illinois Department shall require all dispensers of
20medical services, other than an individual practitioner or
21group of practitioners, desiring to participate in the Medical
22Assistance program established under this Article to disclose
23all financial, beneficial, ownership, equity, surety or other
24interests in any and all firms, corporations, partnerships,
25associations, business enterprises, joint ventures, agencies,
26institutions or other legal entities providing any form of

 

 

10200HB2589sam001- 33 -LRB102 15983 KTG 26491 a

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

 

 

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

 

 

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1    shall not begin until the date on the written notice from
2    the Illinois Department that the provider enrollment is
3    complete.
4        (2) In the case of errors attributable to the Illinois
5    Department or any of its claims processing intermediaries
6    which result in an inability to receive, process, or
7    adjudicate a claim, the 180-day period shall not begin
8    until the provider has been notified of the error.
9        (3) In the case of a provider for whom the Illinois
10    Department initiates the monthly billing process.
11        (4) In the case of a provider operated by a unit of
12    local government with a population exceeding 3,000,000
13    when local government funds finance federal participation
14    for claims payments.
15    For claims for services rendered during a period for which
16a recipient received retroactive eligibility, claims must be
17filed within 180 days after the Department determines the
18applicant is eligible. For claims for which the Illinois
19Department is not the primary payer, claims must be submitted
20to the Illinois Department within 180 days after the final
21adjudication by the primary payer.
22    In the case of long term care facilities, within 45
23calendar days of receipt by the facility of required
24prescreening information, new admissions with associated
25admission documents shall be submitted through the Medical
26Electronic Data Interchange (MEDI) or the Recipient

 

 

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

 

 

10200HB2589sam001- 37 -LRB102 15983 KTG 26491 a

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

 

 

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

 

 

10200HB2589sam001- 39 -LRB102 15983 KTG 26491 a

1and positioning items, determine the wholesale price by
2methods other than actual acquisition costs.
3    The Department shall require, by rule, all providers of
4durable medical equipment to be accredited by an accreditation
5organization approved by the federal Centers for Medicare and
6Medicaid Services and recognized by the Department in order to
7bill the Department for providing durable medical equipment to
8recipients. No later than 15 months after the effective date
9of the rule adopted pursuant to this paragraph, all providers
10must meet the accreditation requirement.
11    In order to promote environmental responsibility, meet the
12needs of recipients and enrollees, and achieve significant
13cost savings, the Department, or a managed care organization
14under contract with the Department, may provide recipients or
15managed care enrollees who have a prescription or Certificate
16of Medical Necessity access to refurbished durable medical
17equipment under this Section (excluding prosthetic and
18orthotic devices as defined in the Orthotics, Prosthetics, and
19Pedorthics Practice Act and complex rehabilitation technology
20products and associated services) through the State's
21assistive technology program's reutilization program, using
22staff with the Assistive Technology Professional (ATP)
23Certification if the refurbished durable medical equipment:
24(i) is available; (ii) is less expensive, including shipping
25costs, than new durable medical equipment of the same type;
26(iii) is able to withstand at least 3 years of use; (iv) is

 

 

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1cleaned, disinfected, sterilized, and safe in accordance with
2federal Food and Drug Administration regulations and guidance
3governing the reprocessing of medical devices in health care
4settings; and (v) equally meets the needs of the recipient or
5enrollee. The reutilization program shall confirm that the
6recipient or enrollee is not already in receipt of same or
7similar equipment from another service provider, and that the
8refurbished durable medical equipment equally meets the needs
9of the recipient or enrollee. Nothing in this paragraph shall
10be construed to limit recipient or enrollee choice to obtain
11new durable medical equipment or place any additional prior
12authorization conditions on enrollees of managed care
13organizations.
14    The Department shall execute, relative to the nursing home
15prescreening project, written inter-agency agreements with the
16Department of Human Services and the Department on Aging, to
17effect the following: (i) intake procedures and common
18eligibility criteria for those persons who are receiving
19non-institutional services; and (ii) the establishment and
20development of non-institutional services in areas of the
21State where they are not currently available or are
22undeveloped; and (iii) notwithstanding any other provision of
23law, subject to federal approval, on and after July 1, 2012, an
24increase in the determination of need (DON) scores from 29 to
2537 for applicants for institutional and home and
26community-based long term care; if and only if federal

 

 

10200HB2589sam001- 41 -LRB102 15983 KTG 26491 a

1approval is not granted, the Department may, in conjunction
2with other affected agencies, implement utilization controls
3or changes in benefit packages to effectuate a similar savings
4amount for this population; and (iv) no later than July 1,
52013, minimum level of care eligibility criteria for
6institutional and home and community-based long term care; and
7(v) no later than October 1, 2013, establish procedures to
8permit long term care providers access to eligibility scores
9for individuals with an admission date who are seeking or
10receiving services from the long term care provider. In order
11to select the minimum level of care eligibility criteria, the
12Governor shall establish a workgroup that includes affected
13agency representatives and stakeholders representing the
14institutional and home and community-based long term care
15interests. This Section shall not restrict the Department from
16implementing lower level of care eligibility criteria for
17community-based services in circumstances where federal
18approval has been granted.
19    The Illinois Department shall develop and operate, in
20cooperation with other State Departments and agencies and in
21compliance with applicable federal laws and regulations,
22appropriate and effective systems of health care evaluation
23and programs for monitoring of utilization of health care
24services and facilities, as it affects persons eligible for
25medical assistance under this Code.
26    The Illinois Department shall report annually to the

 

 

10200HB2589sam001- 42 -LRB102 15983 KTG 26491 a

1General Assembly, no later than the second Friday in April of
21979 and each year thereafter, in regard to:
3        (a) actual statistics and trends in utilization of
4    medical services by public aid recipients;
5        (b) actual statistics and trends in the provision of
6    the various medical services by medical vendors;
7        (c) current rate structures and proposed changes in
8    those rate structures for the various medical vendors; and
9        (d) efforts at utilization review and control by the
10    Illinois Department.
11    The period covered by each report shall be the 3 years
12ending on the June 30 prior to the report. The report shall
13include suggested legislation for consideration by the General
14Assembly. The requirement for reporting to the General
15Assembly shall be satisfied by filing copies of the report as
16required by Section 3.1 of the General Assembly Organization
17Act, and filing such additional copies with the State
18Government Report Distribution Center for the General Assembly
19as is required under paragraph (t) of Section 7 of the State
20Library Act.
21    Rulemaking authority to implement Public Act 95-1045, if
22any, is conditioned on the rules being adopted in accordance
23with all provisions of the Illinois Administrative Procedure
24Act and all rules and procedures of the Joint Committee on
25Administrative Rules; any purported rule not so adopted, for
26whatever reason, is unauthorized.

 

 

10200HB2589sam001- 43 -LRB102 15983 KTG 26491 a

1    On and after July 1, 2012, the Department shall reduce any
2rate of reimbursement for services or other payments or alter
3any methodologies authorized by this Code to reduce any rate
4of reimbursement for services or other payments in accordance
5with Section 5-5e.
6    Because kidney transplantation can be an appropriate,
7cost-effective alternative to renal dialysis when medically
8necessary and notwithstanding the provisions of Section 1-11
9of this Code, beginning October 1, 2014, the Department shall
10cover kidney transplantation for noncitizens with end-stage
11renal disease who are not eligible for comprehensive medical
12benefits, who meet the residency requirements of Section 5-3
13of this Code, and who would otherwise meet the financial
14requirements of the appropriate class of eligible persons
15under Section 5-2 of this Code. To qualify for coverage of
16kidney transplantation, such person must be receiving
17emergency renal dialysis services covered by the Department.
18Providers under this Section shall be prior approved and
19certified by the Department to perform kidney transplantation
20and the services under this Section shall be limited to
21services associated with kidney transplantation.
22    Notwithstanding any other provision of this Code to the
23contrary, on or after July 1, 2015, all FDA approved forms of
24medication assisted treatment prescribed for the treatment of
25alcohol dependence or treatment of opioid dependence shall be
26covered under both fee for service and managed care medical

 

 

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

 

 

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1transmitted infections, medical monitoring, assorted labs, and
2counseling to reduce the likelihood of HIV infection among
3individuals who are not infected with HIV but who are at high
4risk of HIV infection.
5    A federally qualified health center, as defined in Section
61905(l)(2)(B) of the federal Social Security Act, shall be
7reimbursed by the Department in accordance with the federally
8qualified health center's encounter rate for services provided
9to medical assistance recipients that are performed by a
10dental hygienist, as defined under the Illinois Dental
11Practice Act, working under the general supervision of a
12dentist and employed by a federally qualified health center.
13(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
14100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
156-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
16eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
17100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
181-1-20; revised 9-18-19.)
 
19    (305 ILCS 5/5-41 new)
20    Sec. 5-41. Screening, Brief Intervention, and Referral to
21Treatment.
22    As used in this Section, "SBIRT" means a comprehensive,
23integrated, public health approach to the delivery of early
24intervention and treatment services for persons who are at
25risk of developing substance use disorders or have substance

 

 

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1use disorders including, but not limited to, an addiction to
2alcohol, opioids, tobacco, or cannabis. SBIRT services include
3all of the following:
4        (1) Screening to quickly assess the severity of
5    substance use and to identify the appropriate level of
6    treatment.
7        (2) Brief intervention focused on increasing insight
8    and awareness regarding substance use and motivation
9    toward behavioral change.
10        (3) Referral to treatment provided to those identified
11    as needing more extensive treatment with access to
12    specialty care.
13    SBIRT services may include, but are not limited to, the
14following settings and programs: primary care centers,
15hospital emergency rooms, hospital in-patient units, trauma
16centers, community behavioral health programs, and other
17community settings that provide opportunities for early
18intervention with at-risk substance users before more severe
19consequences occur.
20    The Department of Healthcare and Family Services shall
21develop and seek federal approval of a SBIRT benefit for which
22qualified providers shall be reimbursed under the medical
23assistance program.
24    In conjunction with the Department of Human Services'
25Division of Substance Use Prevention and Recovery, the
26Department of Healthcare and Family Services may develop a

 

 

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1methodology and reimbursement rate for SBIRT services provided
2by qualified providers in approved settings.
3    For opioid specific SBIRT services provided in a hospital
4emergency department, the Department of Healthcare and Family
5Services shall develop a bundled reimbursement methodology and
6rate for a package of opioid treatment services, which include
7initiation of medication for the treatment of opioid use
8disorder in the emergency department setting, including
9assessment, referral to ongoing care, and arranging access to
10supportive services when necessary. This package of opioid
11related services shall be billed on a separate claim and shall
12be reimbursed outside of the Enhanced Ambulatory Patient
13Grouping system.".