State of Illinois
2013 and 2014


Introduced , by Rep. Sara Feigenholtz


305 ILCS 5/5-5f

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Deletes provisions limiting adult dental services to emergencies. Effective July 1, 2014.

LRB098 14190 KTG 48784 b






HB3693LRB098 14190 KTG 48784 b

1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5f as follows:
6    (305 ILCS 5/5-5f)
7    Sec. 5-5f. Elimination and limitations of medical
8assistance services. Notwithstanding any other provision of
9this Code to the contrary, on and after July 1, 2012:
10    (a) The following services shall no longer be a covered
11service available under this Code: group psychotherapy for
12residents of any facility licensed under the Nursing Home Care
13Act or the Specialized Mental Health Rehabilitation Act of
142013; and adult chiropractic services.
15    (b) The Department shall place the following limitations on
16services: (i) the Department shall limit adult eyeglasses to
17one pair every 2 years; (ii) the Department shall set an annual
18limit of a maximum of 20 visits for each of the following
19services: adult speech, hearing, and language therapy
20services, adult occupational therapy services, and physical
21therapy services; (iii) the Department shall limit adult
22podiatry services to individuals with diabetes; (iv) the
23Department shall pay for caesarean sections at the normal



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1vaginal delivery rate unless a caesarean section was medically
2necessary; (v) (blank) the Department shall limit adult dental
3services to emergencies; beginning July 1, 2013, the Department
4shall ensure that the following conditions are recognized as
5emergencies: (A) dental services necessary for an individual in
6order for the individual to be cleared for a medical procedure,
7such as a transplant; (B) extractions and dentures necessary
8for a diabetic to receive proper nutrition; (C) extractions and
9dentures necessary as a result of cancer treatment; and (D)
10dental services necessary for the health of a pregnant woman
11prior to delivery of her baby; and (vi) effective July 1, 2012,
12the Department shall place limitations and require concurrent
13review on every inpatient detoxification stay to prevent repeat
14admissions to any hospital for detoxification within 60 days of
15a previous inpatient detoxification stay. The Department shall
16convene a workgroup of hospitals, substance abuse providers,
17care coordination entities, managed care plans, and other
18stakeholders to develop recommendations for quality standards,
19diversion to other settings, and admission criteria for
20patients who need inpatient detoxification, which shall be
21published on the Department's website no later than September
221, 2013.
23    (c) The Department shall require prior approval of the
24following services: wheelchair repairs costing more than $400,
25coronary artery bypass graft, and bariatric surgery consistent
26with Medicare standards concerning patient responsibility.



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1Wheelchair repair prior approval requests shall be adjudicated
2within one business day of receipt of complete supporting
3documentation. Providers may not break wheelchair repairs into
4separate claims for purposes of staying under the $400
5threshold for requiring prior approval. The wholesale price of
6manual and power wheelchairs, durable medical equipment and
7supplies, and complex rehabilitation technology products and
8services shall be defined as actual acquisition cost including
9all discounts.
10    (d) The Department shall establish benchmarks for
11hospitals to measure and align payments to reduce potentially
12preventable hospital readmissions, inpatient complications,
13and unnecessary emergency room visits. In doing so, the
14Department shall consider items, including, but not limited to,
15historic and current acuity of care and historic and current
16trends in readmission. The Department shall publish
17provider-specific historical readmission data and anticipated
18potentially preventable targets 60 days prior to the start of
19the program. In the instance of readmissions, the Department
20shall adopt policies and rates of reimbursement for services
21and other payments provided under this Code to ensure that, by
22June 30, 2013, expenditures to hospitals are reduced by, at a
23minimum, $40,000,000.
24    (e) The Department shall establish utilization controls
25for the hospice program such that it shall not pay for other
26care services when an individual is in hospice.



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1    (f) For home health services, the Department shall require
2Medicare certification of providers participating in the
3program and implement the Medicare face-to-face encounter
4rule. The Department shall require providers to implement
5auditable electronic service verification based on global
6positioning systems or other cost-effective technology.
7    (g) For the Home Services Program operated by the
8Department of Human Services and the Community Care Program
9operated by the Department on Aging, the Department of Human
10Services, in cooperation with the Department on Aging, shall
11implement an electronic service verification based on global
12positioning systems or other cost-effective technology.
13    (h) Effective with inpatient hospital admissions on or
14after July 1, 2012, the Department shall reduce the payment for
15a claim that indicates the occurrence of a provider-preventable
16condition during the admission as specified by the Department
17in rules. The Department shall not pay for services related to
18an other provider-preventable condition.
19    As used in this subsection (h):
20    "Provider-preventable condition" means a health care
21acquired condition as defined under the federal Medicaid
22regulation found at 42 CFR 447.26 or an other
23provider-preventable condition.
24    "Other provider-preventable condition" means a wrong
25surgical or other invasive procedure performed on a patient, a
26surgical or other invasive procedure performed on the wrong



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1body part, or a surgical procedure or other invasive procedure
2performed on the wrong patient.
3    (i) The Department shall implement cost savings
4initiatives for advanced imaging services, cardiac imaging
5services, pain management services, and back surgery. Such
6initiatives shall be designed to achieve annual costs savings.
7    (j) The Department shall ensure that beneficiaries with a
8diagnosis of epilepsy or seizure disorder in Department records
9will not require prior approval for anticonvulsants.
10(Source: P.A. 97-689, eff. 6-14-12; 98-104, Article 6, Section
116-240, eff. 7-22-13; 98-104, Article 9, Section 9-5, eff.
127-22-13; revised 9-19-13.)
13    Section 99. Effective date. This Act takes effect on July
141, 2014.