98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
HB6285

 

Introduced , by Rep. Mike Smiddy

 

SYNOPSIS AS INTRODUCED:
 
See Index

    Amends the Illinois Insurance Code and the Illinois Public Aid Code. With regard to the respective requirements concerning coverage and payment for screening by low-dose mammography for all women 35 years of age or older for the presence of occult breast cancer, includes a screening MRI when medically necessary, as determined by a physician licensed to practice medicine in all of its branches, and if the American Cancer Society's guidelines for appropriate use for women at high risk for breast cancer are met. Further amends the Illinois Public Aid Code. Provides that on and after January 1, 2015, the Department of Healthcare and Family Services shall ensure that all networks of care for adult clients of the Department include access to at least one breast imaging Center of Imaging Excellence as certified by the American College of Radiology. Provides that on and after January 1, 2016, providers participating in a breast cancer treatment quality improvement program approved by the Department shall be reimbursed for breast cancer treatment at a rate that is no lower than 95% of the Medicare program's rates for the data elements included in the breast cancer treatment quality program. Makes changes concerning the case-managing and patient navigation pilot program. Sets forth provisions concerning departmental requirements for networks of care. Provides that on and after January 1, 2015, the Department shall ensure that provider and hospital reimbursement for certain required post-mastectomy care benefits are no lower than the Medicare reimbursement rate. Provides that on and after January 1, 2015 and subject to funding availability, the Department shall administer a grant program to build the public infrastructure for breast cancer imaging and diagnostic services across the State. Effective immediately.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB6285LRB098 21659 RPM 60511 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 356g as follows:
 
6    (215 ILCS 5/356g)  (from Ch. 73, par. 968g)
7    Sec. 356g. Mammograms; mastectomies.
8    (a) Every insurer shall provide in each group or individual
9policy, contract, or certificate of insurance issued or renewed
10for persons who are residents of this State, coverage for
11screening by low-dose mammography for all women 35 years of age
12or older for the presence of occult breast cancer within the
13provisions of the policy, contract, or certificate. The
14coverage shall be as follows:
15         (1) A baseline mammogram for women 35 to 39 years of
16    age.
17         (2) An annual mammogram for women 40 years of age or
18    older.
19         (3) A mammogram at the age and intervals considered
20    medically necessary by the woman's health care provider for
21    women under 40 years of age and having a family history of
22    breast cancer, prior personal history of breast cancer,
23    positive genetic testing, or other risk factors.

 

 

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1        (4) A comprehensive ultrasound screening of an entire
2    breast or breasts if a mammogram demonstrates
3    heterogeneous or dense breast tissue, when medically
4    necessary as determined by a physician licensed to practice
5    medicine in all of its branches.
6        (5) A screening MRI when medically necessary, as
7    determined by a physician licensed to practice medicine in
8    all of its branches, and if the American Cancer Society's
9    guidelines for appropriate use for women at high risk for
10    breast cancer are met.
11    For purposes of this Section, "low-dose mammography" means
12the x-ray examination of the breast using equipment dedicated
13specifically for mammography, including the x-ray tube,
14filter, compression device, and image receptor, with radiation
15exposure delivery of less than 1 rad per breast for 2 views of
16an average size breast. The term also includes digital
17mammography.
18    (a-5) Coverage as described by subsection (a) shall be
19provided at no cost to the insured and shall not be applied to
20an annual or lifetime maximum benefit.
21    (a-10) When health care services are available through
22contracted providers and a person does not comply with plan
23provisions specific to the use of contracted providers, the
24requirements of subsection (a-5) are not applicable. When a
25person does not comply with plan provisions specific to the use
26of contracted providers, plan provisions specific to the use of

 

 

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1non-contracted providers must be applied without distinction
2for coverage required by this Section and shall be at least as
3favorable as for other radiological examinations covered by the
4policy or contract.
5    (b) No policy of accident or health insurance that provides
6for the surgical procedure known as a mastectomy shall be
7issued, amended, delivered, or renewed in this State unless
8that coverage also provides for prosthetic devices or
9reconstructive surgery incident to the mastectomy. Coverage
10for breast reconstruction in connection with a mastectomy shall
11include:
12        (1) reconstruction of the breast upon which the
13    mastectomy has been performed;
14        (2) surgery and reconstruction of the other breast to
15    produce a symmetrical appearance; and
16        (3) prostheses and treatment for physical
17    complications at all stages of mastectomy, including
18    lymphedemas.
19Care shall be determined in consultation with the attending
20physician and the patient. The offered coverage for prosthetic
21devices and reconstructive surgery shall be subject to the
22deductible and coinsurance conditions applied to the
23mastectomy, and all other terms and conditions applicable to
24other benefits. When a mastectomy is performed and there is no
25evidence of malignancy then the offered coverage may be limited
26to the provision of prosthetic devices and reconstructive

 

 

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1surgery to within 2 years after the date of the mastectomy. As
2used in this Section, "mastectomy" means the removal of all or
3part of the breast for medically necessary reasons, as
4determined by a licensed physician.
5    Written notice of the availability of coverage under this
6Section shall be delivered to the insured upon enrollment and
7annually thereafter. An insurer may not deny to an insured
8eligibility, or continued eligibility, to enroll or to renew
9coverage under the terms of the plan solely for the purpose of
10avoiding the requirements of this Section. An insurer may not
11penalize or reduce or limit the reimbursement of an attending
12provider or provide incentives (monetary or otherwise) to an
13attending provider to induce the provider to provide care to an
14insured in a manner inconsistent with this Section.
15    (c) Rulemaking authority to implement this amendatory Act
16of the 95th General Assembly, if any, is conditioned on the
17rules being adopted in accordance with all provisions of the
18Illinois Administrative Procedure Act and all rules and
19procedures of the Joint Committee on Administrative Rules; any
20purported rule not so adopted, for whatever reason, is
21unauthorized.
22(Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07;
2395-1045, eff. 3-27-09.)
 
24    Section 10. The Illinois Public Aid Code is amended by
25changing Sections 5-5 and 5-16.8 and by adding Section 12-4.47

 

 

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1as follows:
 
2    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
3    Sec. 5-5. Medical services. The Illinois Department, by
4rule, shall determine the quantity and quality of and the rate
5of reimbursement for the medical assistance for which payment
6will be authorized, and the medical services to be provided,
7which may include all or part of the following: (1) inpatient
8hospital services; (2) outpatient hospital services; (3) other
9laboratory and X-ray services; (4) skilled nursing home
10services; (5) physicians' services whether furnished in the
11office, the patient's home, a hospital, a skilled nursing home,
12or elsewhere; (6) medical care, or any other type of remedial
13care furnished by licensed practitioners; (7) home health care
14services; (8) private duty nursing service; (9) clinic
15services; (10) dental services, including prevention and
16treatment of periodontal disease and dental caries disease for
17pregnant women, provided by an individual licensed to practice
18dentistry or dental surgery; for purposes of this item (10),
19"dental services" means diagnostic, preventive, or corrective
20procedures provided by or under the supervision of a dentist in
21the practice of his or her profession; (11) physical therapy
22and related services; (12) prescribed drugs, dentures, and
23prosthetic devices; and eyeglasses prescribed by a physician
24skilled in the diseases of the eye, or by an optometrist,
25whichever the person may select; (13) other diagnostic,

 

 

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1screening, preventive, and rehabilitative services, including
2to ensure that the individual's need for intervention or
3treatment of mental disorders or substance use disorders or
4co-occurring mental health and substance use disorders is
5determined using a uniform screening, assessment, and
6evaluation process inclusive of criteria, for children and
7adults; for purposes of this item (13), a uniform screening,
8assessment, and evaluation process refers to a process that
9includes an appropriate evaluation and, as warranted, a
10referral; "uniform" does not mean the use of a singular
11instrument, tool, or process that all must utilize; (14)
12transportation and such other expenses as may be necessary;
13(15) medical treatment of sexual assault survivors, as defined
14in Section 1a of the Sexual Assault Survivors Emergency
15Treatment Act, for injuries sustained as a result of the sexual
16assault, including examinations and laboratory tests to
17discover evidence which may be used in criminal proceedings
18arising from the sexual assault; (16) the diagnosis and
19treatment of sickle cell anemia; and (17) any other medical
20care, and any other type of remedial care recognized under the
21laws of this State, but not including abortions, or induced
22miscarriages or premature births, unless, in the opinion of a
23physician, such procedures are necessary for the preservation
24of the life of the woman seeking such treatment, or except an
25induced premature birth intended to produce a live viable child
26and such procedure is necessary for the health of the mother or

 

 

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1her unborn child. The Illinois Department, by rule, shall
2prohibit any physician from providing medical assistance to
3anyone eligible therefor under this Code where such physician
4has been found guilty of performing an abortion procedure in a
5wilful and wanton manner upon a woman who was not pregnant at
6the time such abortion procedure was performed. The term "any
7other type of remedial care" shall include nursing care and
8nursing home service for persons who rely on treatment by
9spiritual means alone through prayer for healing.
10    Notwithstanding any other provision of this Section, a
11comprehensive tobacco use cessation program that includes
12purchasing prescription drugs or prescription medical devices
13approved by the Food and Drug Administration shall be covered
14under the medical assistance program under this Article for
15persons who are otherwise eligible for assistance under this
16Article.
17    Notwithstanding any other provision of this Code, the
18Illinois Department may not require, as a condition of payment
19for any laboratory test authorized under this Article, that a
20physician's handwritten signature appear on the laboratory
21test order form. The Illinois Department may, however, impose
22other appropriate requirements regarding laboratory test order
23documentation.
24    On and after July 1, 2012, the Department of Healthcare and
25Family Services may provide the following services to persons
26eligible for assistance under this Article who are

 

 

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1participating in education, training or employment programs
2operated by the Department of Human Services as successor to
3the Department of Public Aid:
4        (1) dental services provided by or under the
5    supervision of a dentist; and
6        (2) eyeglasses prescribed by a physician skilled in the
7    diseases of the eye, or by an optometrist, whichever the
8    person may select.
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 assistance
15program. A not-for-profit health clinic shall include a public
16health clinic or Federally Qualified Health Center or other
17enrolled provider, as determined by the Department, through
18which dental services covered under this Section are performed.
19The Department shall establish a process for payment of claims
20for reimbursement for covered dental services rendered under
21this provision.
22    The Illinois Department, by rule, may distinguish and
23classify the medical services to be provided only in accordance
24with the classes of persons designated in Section 5-2.
25    The Department of Healthcare and Family Services must
26provide coverage and reimbursement for amino acid-based

 

 

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1elemental formulas, regardless of delivery method, for the
2diagnosis and treatment of (i) eosinophilic disorders and (ii)
3short bowel syndrome when the prescribing physician has issued
4a written order stating that the amino acid-based elemental
5formula is medically necessary.
6    The Illinois Department shall authorize the provision of,
7and shall authorize payment for, screening by low-dose
8mammography for the presence of occult breast cancer for women
935 years of age or older who are eligible for medical
10assistance under this Article, as follows:
11        (A) A baseline mammogram for women 35 to 39 years of
12    age.
13        (B) An annual mammogram for women 40 years of age or
14    older.
15        (C) A mammogram at the age and intervals considered
16    medically necessary by the woman's health care provider for
17    women under 40 years of age and having a family history of
18    breast cancer, prior personal history of breast cancer,
19    positive genetic testing, or other risk factors.
20        (D) A comprehensive ultrasound screening of an entire
21    breast or breasts if a mammogram demonstrates
22    heterogeneous or dense breast tissue, when medically
23    necessary as determined by a physician licensed to practice
24    medicine in all of its branches.
25        (E) A screening MRI when medically necessary, as
26    determined by a physician licensed to practice medicine in

 

 

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1    all of its branches, and if the American Cancer Society's
2    guidelines for appropriate use for women at high risk for
3    breast cancer are met.
4    All screenings shall include a physical breast exam,
5instruction on self-examination and information regarding the
6frequency of self-examination and its value as a preventative
7tool. For purposes of this Section, "low-dose mammography"
8means the x-ray examination of the breast using equipment
9dedicated specifically for mammography, including the x-ray
10tube, filter, compression device, and image receptor, with an
11average radiation exposure delivery of less than one rad per
12breast for 2 views of an average size breast. The term also
13includes digital mammography.
14    On and after January 1, 2015, 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, 2016, 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, 2015, 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,
162015, 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 the effective date of this
25amendatory Act of 1984, the Illinois Department shall establish
26a current list of acquisition costs for all prosthetic devices

 

 

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1and any other items recognized as medical equipment and
2supplies reimbursable under this Article and shall update such
3list on a quarterly basis, except that the acquisition costs of
4all prescription drugs shall be updated no less frequently than
5every 30 days as required by Section 5-5.12.
6    The rules and regulations of the Illinois Department shall
7require that a written statement including the required opinion
8of a physician shall accompany any claim for reimbursement for
9abortions, or induced miscarriages or premature births. This
10statement shall indicate what procedures were used in providing
11such medical services.
12    Notwithstanding any other law to the contrary, the Illinois
13Department shall, within 365 days after July 22, 2013 (the
14effective date of Public Act 98-104) this amendatory Act of the
1598th General Assembly, establish procedures to permit skilled
16care facilities licensed under the Nursing Home Care Act to
17submit monthly billing claims for reimbursement purposes.
18Following development of these procedures, the Department
19shall have an additional 365 days to test the viability of the
20new system and to ensure that any necessary operational or
21structural changes to its information technology platforms are
22implemented.
23    The Illinois Department shall require all dispensers of
24medical services, other than an individual practitioner or
25group of practitioners, desiring to participate in the Medical
26Assistance program established under this Article to disclose

 

 

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1all financial, beneficial, ownership, equity, surety or other
2interests in any and all firms, corporations, partnerships,
3associations, business enterprises, joint ventures, agencies,
4institutions or other legal entities providing any form of
5health care services in this State under this Article.
6    The Illinois Department may require that all dispensers of
7medical services desiring to participate in the medical
8assistance program established under this Article disclose,
9under such terms and conditions as the Illinois Department may
10by rule establish, all inquiries from clients and attorneys
11regarding medical bills paid by the Illinois Department, which
12inquiries could indicate potential existence of claims or liens
13for the Illinois Department.
14    Enrollment of a vendor shall be subject to a provisional
15period and shall be conditional for one year. During the period
16of conditional enrollment, the Department may terminate the
17vendor's eligibility to participate in, or may disenroll the
18vendor from, the medical assistance program without cause.
19Unless otherwise specified, such termination of eligibility or
20disenrollment is not subject to the Department's hearing
21process. However, a disenrolled vendor may reapply without
22penalty.
23    The Department has the discretion to limit the conditional
24enrollment period for vendors based upon category of risk of
25the vendor.
26    Prior to enrollment and during the conditional enrollment

 

 

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

 

 

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

 

 

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1documents shall be submitted within 30 days of an admission to
2the facility through the Medical Electronic Data Interchange
3(MEDI) or the Recipient Eligibility Verification (REV) System,
4or shall be submitted directly to the Department of Human
5Services using required admission forms. Confirmation numbers
6assigned to an accepted transaction shall be retained by a
7facility to verify timely submittal. Once an admission
8transaction has been completed, all resubmitted claims
9following prior rejection are subject to receipt no later than
10180 days after the 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 necessary
19to perform eligibility and payment verifications and other
20Illinois 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

 

 

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

 

 

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1clinical code editing; and (iii) pre-pay, pre- or
2post-adjudicated predictive modeling with an integrated case
3management system with link analysis. Such a request for
4information shall not be considered as a request for proposal
5or as an obligation on the part of the Illinois Department to
6take any action or acquire any products or services.
7    The Illinois Department shall establish policies,
8procedures, standards and criteria by rule for the acquisition,
9repair and replacement of orthotic and prosthetic devices and
10durable medical equipment. Such rules shall provide, but not be
11limited to, the following services: (1) immediate repair or
12replacement of such devices by recipients; and (2) rental,
13lease, purchase or lease-purchase of durable medical equipment
14in a cost-effective manner, taking into consideration the
15recipient's medical prognosis, the extent of the recipient's
16needs, and the requirements and costs for maintaining such
17equipment. Subject to prior approval, such rules shall enable a
18recipient to temporarily acquire and use alternative or
19substitute devices or equipment pending repairs or
20replacements of any device or equipment previously authorized
21for such recipient by the Department.
22    The Department shall execute, relative to the nursing home
23prescreening project, written inter-agency agreements with the
24Department of Human Services and the Department on Aging, to
25effect the following: (i) intake procedures and common
26eligibility criteria for those persons who are receiving

 

 

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1non-institutional services; and (ii) the establishment and
2development of non-institutional services in areas of the State
3where they are not currently available or are undeveloped; and
4(iii) notwithstanding any other provision of law, subject to
5federal approval, on and after July 1, 2012, an increase in the
6determination of need (DON) scores from 29 to 37 for applicants
7for institutional and home and community-based long term care;
8if and only if federal approval is not granted, the Department
9may, in conjunction with other affected agencies, implement
10utilization controls or changes in benefit packages to
11effectuate a similar savings amount for this population; and
12(iv) no later than July 1, 2013, minimum level of care
13eligibility criteria for institutional and home and
14community-based long term care; and (v) no later than October
151, 2013, establish procedures to permit long term care
16providers access to eligibility scores for individuals with an
17admission date who are seeking or receiving services from the
18long term care provider. In order to select the minimum level
19of care eligibility criteria, the Governor shall establish a
20workgroup that includes affected agency representatives and
21stakeholders representing the institutional and home and
22community-based long term care interests. This Section shall
23not restrict the Department from implementing lower level of
24care eligibility criteria for community-based services in
25circumstances where federal approval has been granted.
26    The Illinois Department shall develop and operate, in

 

 

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1cooperation with other State Departments and agencies and in
2compliance with applicable federal laws and regulations,
3appropriate and effective systems of health care evaluation and
4programs for monitoring of utilization of health care services
5and facilities, as it affects persons eligible for medical
6assistance under this Code.
7    The Illinois Department shall report annually to the
8General Assembly, no later than the second Friday in April of
91979 and each year thereafter, in regard to:
10        (a) actual statistics and trends in utilization of
11    medical services by public aid recipients;
12        (b) actual statistics and trends in the provision of
13    the various medical services by medical vendors;
14        (c) current rate structures and proposed changes in
15    those rate structures for the various medical vendors; and
16        (d) efforts at utilization review and control by the
17    Illinois Department.
18    The period covered by each report shall be the 3 years
19ending on the June 30 prior to the report. The report shall
20include suggested legislation for consideration by the General
21Assembly. The filing of one copy of the report with the
22Speaker, one copy with the Minority Leader and one copy with
23the Clerk of the House of Representatives, one copy with the
24President, one copy with the Minority Leader and one copy with
25the Secretary of the Senate, one copy with the Legislative
26Research Unit, and such additional copies with the State

 

 

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1Government Report Distribution Center for the General Assembly
2as is required under paragraph (t) of Section 7 of the State
3Library Act shall be deemed sufficient to comply with this
4Section.
5    Rulemaking authority to implement Public Act 95-1045, if
6any, is conditioned on the rules being adopted in accordance
7with all provisions of the Illinois Administrative Procedure
8Act and all rules and procedures of the Joint Committee on
9Administrative Rules; any purported rule not so adopted, for
10whatever reason, is unauthorized.
11    On and after July 1, 2012, the Department shall reduce any
12rate of reimbursement for services or other payments or alter
13any methodologies authorized by this Code to reduce any rate of
14reimbursement for services or other payments in accordance with
15Section 5-5e.
16(Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689,
17eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section
189-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff.
197-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; revised
209-19-13.)
 
21    (305 ILCS 5/5-16.8)
22    Sec. 5-16.8. Required health benefits. The medical
23assistance program shall (i) provide the post-mastectomy care
24benefits required to be covered by a policy of accident and
25health insurance under Section 356t and the coverage required

 

 

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1under Sections 356g.5, 356u, 356w, 356x, and 356z.6 of the
2Illinois Insurance Code and (ii) be subject to the provisions
3of Sections 356z.19 and 364.01 of the Illinois Insurance Code.
4    On and after July 1, 2012, the Department shall reduce any
5rate of reimbursement for services or other payments or alter
6any methodologies authorized by this Code to reduce any rate of
7reimbursement for services or other payments in accordance with
8Section 5-5e.
9    To ensure full access to the benefits set forth in this
10Section, on and after January 1, 2015, the Department shall
11ensure that provider and hospital reimbursement for
12post-mastectomy care benefits required under this Section are
13no lower than the Medicare reimbursement rate.
14(Source: P.A. 97-282, eff. 8-9-11; 97-689, eff. 6-14-12.)
 
15    (305 ILCS 5/12-4.47 new)
16    Sec. 12-4.47. Breast cancer imaging and diagnostic
17equipment grant program.
18    (a) On and after January 1, 2015 and subject to funding
19availability, the Department of Healthcare and Family Services
20shall administer a grant program the purpose of which shall be
21to build the public infrastructure for breast cancer imaging
22and diagnostic services across the State, in particular in
23rural, medically underserved areas and in areas with high
24breast cancer mortality.
25    (b) In order to be eligible for the program, an applicant

 

 

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1must be a:
2        (1) disproportionate share hospital with high MIUR (as
3    set by the Department by rule);
4        (2) mammography facility in a rural area;
5        (3) federally qualified health center; or
6        (4) rural health clinic.
7    (c) The grants may be used to purchase new equipment for
8breast imaging, image-guided biopsies, or other equipment to
9enhance the detection and diagnosis of breast cancer.
10    (d) The primary purpose of these grants is to increase
11access for low-income and Department of Healthcare and Family
12Services clients to high quality breast cancer screening and
13diagnostics. Medically Underserved Areas (MUAs), areas with
14high breast cancer mortality rates, and Health Professional
15Shortage Areas (HPSAs) shall receive special priority for
16grants under this program.
17    (e) The Department shall establish procedures for applying
18for grant funds under this Section.
 
19    Section 99. Effective date. This Act takes effect upon
20becoming law.

 

 

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1 INDEX
2 Statutes amended in order of appearance
3    215 ILCS 5/356gfrom Ch. 73, par. 968g
4    305 ILCS 5/5-5from Ch. 23, par. 5-5
5    305 ILCS 5/5-16.8
6    305 ILCS 5/12-4.47 new