SB0054 EnrolledLRB099 03946 MLM 23963 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    For purposes of this Section, "low-dose mammography" means
7the x-ray examination of the breast using equipment dedicated
8specifically for mammography, including the x-ray tube,
9filter, compression device, and image receptor, with radiation
10exposure delivery of less than 1 rad per breast for 2 views of
11an average size breast. The term also includes digital
12mammography and includes breast tomosynthesis. As used in this
13Section, the term "breast tomosynthesis" means a radiologic
14procedure that involves the acquisition of projection images
15over the stationary breast to produce cross-sectional digital
16three-dimensional images of the breast.
17    (a-5) Coverage as described by subsection (a) shall be
18provided at no cost to the insured and shall not be applied to
19an annual or lifetime maximum benefit.
20    (a-10) When health care services are available through
21contracted providers and a person does not comply with plan
22provisions specific to the use of contracted providers, the
23requirements of subsection (a-5) are not applicable. When a
24person does not comply with plan provisions specific to the use
25of contracted providers, plan provisions specific to the use of
26non-contracted providers must be applied without distinction

 

 

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1for coverage required by this Section and shall be at least as
2favorable as for other radiological examinations covered by the
3policy or contract.
4    (b) No policy of accident or health insurance that provides
5for the surgical procedure known as a mastectomy shall be
6issued, amended, delivered, or renewed in this State unless
7that coverage also provides for prosthetic devices or
8reconstructive surgery incident to the mastectomy. Coverage
9for breast reconstruction in connection with a mastectomy shall
10include:
11        (1) reconstruction of the breast upon which the
12    mastectomy has been performed;
13        (2) surgery and reconstruction of the other breast to
14    produce a symmetrical appearance; and
15        (3) prostheses and treatment for physical
16    complications at all stages of mastectomy, including
17    lymphedemas.
18Care shall be determined in consultation with the attending
19physician and the patient. The offered coverage for prosthetic
20devices and reconstructive surgery shall be subject to the
21deductible and coinsurance conditions applied to the
22mastectomy, and all other terms and conditions applicable to
23other benefits. When a mastectomy is performed and there is no
24evidence of malignancy then the offered coverage may be limited
25to the provision of prosthetic devices and reconstructive
26surgery to within 2 years after the date of the mastectomy. As

 

 

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1used in this Section, "mastectomy" means the removal of all or
2part of the breast for medically necessary reasons, as
3determined by a licensed physician.
4    Written notice of the availability of coverage under this
5Section shall be delivered to the insured upon enrollment and
6annually thereafter. An insurer may not deny to an insured
7eligibility, or continued eligibility, to enroll or to renew
8coverage under the terms of the plan solely for the purpose of
9avoiding the requirements of this Section. An insurer may not
10penalize or reduce or limit the reimbursement of an attending
11provider or provide incentives (monetary or otherwise) to an
12attending provider to induce the provider to provide care to an
13insured in a manner inconsistent with this Section.
14    (c) Rulemaking authority to implement this amendatory Act
15of the 95th General Assembly, if any, is conditioned on the
16rules being adopted in accordance with all provisions of the
17Illinois Administrative Procedure Act and all rules and
18procedures of the Joint Committee on Administrative Rules; any
19purported rule not so adopted, for whatever reason, is
20unauthorized.
21(Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07;
2295-1045, eff. 3-27-09.)
 
23    Section 10. The Health Maintenance Organization Act is
24amended by changing Section 4-6.1 as follows:
 

 

 

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1    (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)
2    Sec. 4-6.1. Mammograms; mastectomies.
3    (a) Every contract or evidence of coverage issued by a
4Health Maintenance Organization for persons who are residents
5of this State shall contain coverage for screening by low-dose
6mammography for all women 35 years of age or older for the
7presence of occult breast cancer. The coverage shall be as
8follows:
9        (1) A baseline mammogram for women 35 to 39 years of
10    age.
11        (2) An annual mammogram for women 40 years of age or
12    older.
13        (3) A mammogram at the age and intervals considered
14    medically necessary by the woman's health care provider for
15    women under 40 years of age and having a family history of
16    breast cancer, prior personal history of breast cancer,
17    positive genetic testing, or other risk factors.
18        (4) A comprehensive ultrasound screening of an entire
19    breast or breasts if a mammogram demonstrates
20    heterogeneous or dense breast tissue, when medically
21    necessary as determined by a physician licensed to practice
22    medicine in all of its branches.
23    For purposes of this Section, "low-dose mammography" means
24the x-ray examination of the breast using equipment dedicated
25specifically for mammography, including the x-ray tube,
26filter, compression device, and image receptor, with radiation

 

 

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1exposure delivery of less than 1 rad per breast for 2 views of
2an average size breast. The term also includes digital
3mammography and includes breast tomosynthesis. As used in this
4Section, the term "breast tomosynthesis" means a radiologic
5procedure that involves the acquisition of projection images
6over the stationary breast to produce cross-sectional digital
7three-dimensional images of the breast.
8    (a-5) Coverage as described in subsection (a) shall be
9provided at no cost to the enrollee and shall not be applied to
10an annual or lifetime maximum benefit.
11    (b) No contract or evidence of coverage issued by a health
12maintenance organization that provides for the surgical
13procedure known as a mastectomy shall be issued, amended,
14delivered, or renewed in this State on or after the effective
15date of this amendatory Act of the 92nd General Assembly unless
16that coverage also provides for prosthetic devices or
17reconstructive surgery incident to the mastectomy, providing
18that the mastectomy is performed after the effective date of
19this amendatory Act. Coverage for breast reconstruction in
20connection with a mastectomy shall include:
21        (1) reconstruction of the breast upon which the
22    mastectomy has been performed;
23        (2) surgery and reconstruction of the other breast to
24    produce a symmetrical appearance; and
25        (3) prostheses and treatment for physical
26    complications at all stages of mastectomy, including

 

 

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1    lymphedemas.
2Care shall be determined in consultation with the attending
3physician and the patient. The offered coverage for prosthetic
4devices and reconstructive surgery shall be subject to the
5deductible and coinsurance conditions applied to the
6mastectomy and all other terms and conditions applicable to
7other benefits. When a mastectomy is performed and there is no
8evidence of malignancy, then the offered coverage may be
9limited to the provision of prosthetic devices and
10reconstructive surgery to within 2 years after the date of the
11mastectomy. As used in this Section, "mastectomy" means the
12removal of all or part of the breast for medically necessary
13reasons, as determined by a licensed physician.
14    Written notice of the availability of coverage under this
15Section shall be delivered to the enrollee upon enrollment and
16annually thereafter. A health maintenance organization may not
17deny to an enrollee eligibility, or continued eligibility, to
18enroll or to renew coverage under the terms of the plan solely
19for the purpose of avoiding the requirements of this Section. A
20health maintenance organization may not penalize or reduce or
21limit the reimbursement of an attending provider or provide
22incentives (monetary or otherwise) to an attending provider to
23induce the provider to provide care to an insured in a manner
24inconsistent with this Section.
25    (c) Rulemaking authority to implement this amendatory Act
26of the 95th General Assembly, if any, is conditioned on the

 

 

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1rules being adopted in accordance with all provisions of the
2Illinois Administrative Procedure Act and all rules and
3procedures of the Joint Committee on Administrative Rules; any
4purported rule not so adopted, for whatever reason, is
5unauthorized.
6(Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07;
795-1045, eff. 3-27-09.)
 
8    Section 15. The Illinois Public Aid Code is amended by
9changing Section 5-5 as follows:
 
10    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
11    Sec. 5-5. Medical services. The Illinois Department, by
12rule, shall determine the quantity and quality of and the rate
13of reimbursement for the medical assistance for which payment
14will be authorized, and the medical services to be provided,
15which may include all or part of the following: (1) inpatient
16hospital services; (2) outpatient hospital services; (3) other
17laboratory and X-ray services; (4) skilled nursing home
18services; (5) physicians' services whether furnished in the
19office, the patient's home, a hospital, a skilled nursing home,
20or elsewhere; (6) medical care, or any other type of remedial
21care furnished by licensed practitioners; (7) home health care
22services; (8) private duty nursing service; (9) clinic
23services; (10) dental services, including prevention and
24treatment of periodontal disease and dental caries disease for

 

 

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

 

 

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

 

 

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1Illinois Department may not require, as a condition of payment
2for any laboratory test authorized under this Article, that a
3physician's handwritten signature appear on the laboratory
4test order form. The Illinois Department may, however, impose
5other appropriate requirements regarding laboratory test order
6documentation.
7    Upon receipt of federal approval of an amendment to the
8Illinois Title XIX State Plan for this purpose, the Department
9shall authorize the Chicago Public Schools (CPS) to procure a
10vendor or vendors to manufacture eyeglasses for individuals
11enrolled in a school within the CPS system. CPS shall ensure
12that its vendor or vendors are enrolled as providers in the
13medical assistance program and in any capitated Medicaid
14managed care entity (MCE) serving individuals enrolled in a
15school within the CPS system. Under any contract procured under
16this provision, the vendor or vendors must serve only
17individuals enrolled in a school within the CPS system. Claims
18for services provided by CPS's vendor or vendors to recipients
19of benefits in the medical assistance program under this Code,
20the Children's Health Insurance Program, or the Covering ALL
21KIDS Health Insurance Program shall be submitted to the
22Department or the MCE in which the individual is enrolled for
23payment and shall be reimbursed at the Department's or the
24MCE's established rates or rate methodologies for eyeglasses.
25    On and after July 1, 2012, the Department of Healthcare and
26Family Services may provide the following services to persons

 

 

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1eligible for assistance under this Article who are
2participating in education, training or employment programs
3operated by the Department of Human Services as successor to
4the Department of Public Aid:
5        (1) dental services provided by or under the
6    supervision of a dentist; and
7        (2) eyeglasses prescribed by a physician skilled in the
8    diseases of the eye, or by an optometrist, whichever the
9    person may select.
10    Notwithstanding any other provision of this Code and
11subject to federal approval, the Department may adopt rules to
12allow a dentist who is volunteering his or her service at no
13cost to render dental services through an enrolled
14not-for-profit health clinic without the dentist personally
15enrolling as a participating provider in the medical assistance
16program. A not-for-profit health clinic shall include a public
17health clinic or Federally Qualified Health Center or other
18enrolled provider, as determined by the Department, through
19which dental services covered under this Section are performed.
20The Department shall establish a process for payment of claims
21for reimbursement for covered dental services rendered under
22this provision.
23    The Illinois Department, by rule, may distinguish and
24classify the medical services to be provided only in accordance
25with the classes of persons designated in Section 5-2.
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 for
18    women under 40 years of age and having a family history of
19    breast cancer, prior personal history of breast cancer,
20    positive genetic testing, or other risk factors.
21        (D) A comprehensive ultrasound screening of an entire
22    breast or breasts if a mammogram demonstrates
23    heterogeneous or dense breast tissue, when medically
24    necessary as determined by a physician licensed to practice
25    medicine in all of its branches.
26    All screenings shall include a physical breast exam,

 

 

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1instruction on self-examination and information regarding the
2frequency of self-examination and its value as a preventative
3tool. For purposes of this Section, "low-dose mammography"
4means the x-ray examination of the breast using equipment
5dedicated specifically for mammography, including the x-ray
6tube, filter, compression device, and image receptor, with an
7average radiation exposure delivery of less than one rad per
8breast for 2 views of an average size breast. The term also
9includes digital mammography and includes breast
10tomosynthesis. As used in this Section, the term "breast
11tomosynthesis" means a radiologic procedure that involves the
12acquisition of projection images over the stationary breast to
13produce cross-sectional digital three-dimensional images of
14the breast.
15    On and after January 1, 2012, providers participating in a
16quality improvement program approved by the Department shall be
17reimbursed for screening and diagnostic mammography at the same
18rate as the Medicare program's rates, including the increased
19reimbursement for digital mammography.
20    The Department shall convene an expert panel including
21representatives of hospitals, free-standing mammography
22facilities, and doctors, including radiologists, to establish
23quality standards.
24    Subject to federal approval, the Department shall
25establish a rate methodology for mammography at federally
26qualified health centers and other encounter-rate clinics.

 

 

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1These clinics or centers may also collaborate with other
2hospital-based mammography facilities.
3    The Department shall establish a methodology to remind
4women who are age-appropriate for screening mammography, but
5who have not received a mammogram within the previous 18
6months, of the importance and benefit of screening mammography.
7    The Department shall establish a performance goal for
8primary care providers with respect to their female patients
9over age 40 receiving an annual mammogram. This performance
10goal shall be used to provide additional reimbursement in the
11form of a quality performance bonus to primary care providers
12who meet that goal.
13    The Department shall devise a means of case-managing or
14patient navigation for beneficiaries diagnosed with breast
15cancer. This program shall initially operate as a pilot program
16in areas of the State with the highest incidence of mortality
17related to breast cancer. At least one pilot program site shall
18be in the metropolitan Chicago area and at least one site shall
19be outside the metropolitan Chicago area. An evaluation of the
20pilot program shall be carried out measuring health outcomes
21and cost of care for those served by the pilot program compared
22to similarly situated patients who are not served by the pilot
23program.
24    Any medical or health care provider shall immediately
25recommend, to any pregnant woman who is being provided prenatal
26services and is suspected of drug abuse or is addicted as

 

 

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1defined in the Alcoholism and Other Drug Abuse and Dependency
2Act, referral to a local substance abuse treatment provider
3licensed by the Department of Human Services or to a licensed
4hospital which provides substance abuse treatment services.
5The Department of Healthcare and Family Services shall assure
6coverage for the cost of treatment of the drug abuse or
7addiction for pregnant recipients in accordance with the
8Illinois Medicaid Program in conjunction with the Department of
9Human Services.
10    All medical providers providing medical assistance to
11pregnant women under this Code shall receive information from
12the Department on the availability of services under the Drug
13Free Families with a Future or any comparable program providing
14case management services for addicted women, including
15information on appropriate referrals for other social services
16that may be needed by addicted women in addition to treatment
17for addiction.
18    The Illinois Department, in cooperation with the
19Departments of Human Services (as successor to the Department
20of Alcoholism and Substance Abuse) and Public Health, through a
21public awareness campaign, may provide information concerning
22treatment for alcoholism and drug abuse and addiction, prenatal
23health care, and other pertinent programs directed at reducing
24the number of drug-affected infants born to recipients of
25medical assistance.
26    Neither the Department of Healthcare and Family Services

 

 

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1nor the Department of Human Services shall sanction the
2recipient solely on the basis of her substance abuse.
3    The Illinois Department shall establish such regulations
4governing the dispensing of health services under this Article
5as it shall deem appropriate. The Department should seek the
6advice of formal professional advisory committees appointed by
7the Director of the Illinois Department for the purpose of
8providing regular advice on policy and administrative matters,
9information dissemination and educational activities for
10medical and health care providers, and consistency in
11procedures to the Illinois Department.
12    The Illinois Department may develop and contract with
13Partnerships of medical providers to arrange medical services
14for persons eligible under Section 5-2 of this Code.
15Implementation of this Section may be by demonstration projects
16in certain geographic areas. The Partnership shall be
17represented by a sponsor organization. The Department, by rule,
18shall develop qualifications for sponsors of Partnerships.
19Nothing in this Section shall be construed to require that the
20sponsor organization be a medical organization.
21    The sponsor must negotiate formal written contracts with
22medical providers for physician services, inpatient and
23outpatient hospital care, home health services, treatment for
24alcoholism and substance abuse, and other services determined
25necessary by the Illinois Department by rule for delivery by
26Partnerships. Physician services must include prenatal and

 

 

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

 

 

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

 

 

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1sufficient to fully and accurately document the nature, scope,
2details and receipt of the health care provided to persons
3eligible for medical assistance under this Code, in accordance
4with regulations promulgated by the Illinois Department. The
5rules and regulations shall require that proof of the receipt
6of prescription drugs, dentures, prosthetic devices and
7eyeglasses by eligible persons under this Section accompany
8each claim for reimbursement submitted by the dispenser of such
9medical services. No such claims for reimbursement shall be
10approved for payment by the Illinois Department without such
11proof of receipt, unless the Illinois Department shall have put
12into effect and shall be operating a system of post-payment
13audit and review which shall, on a sampling basis, be deemed
14adequate by the Illinois Department to assure that such drugs,
15dentures, prosthetic devices and eyeglasses for which payment
16is being made are actually being received by eligible
17recipients. Within 90 days after the effective date of this
18amendatory Act of 1984, the Illinois Department shall establish
19a current list of acquisition costs for all prosthetic devices
20and any other items recognized as medical equipment and
21supplies reimbursable under this Article and shall update such
22list on a quarterly basis, except that the acquisition costs of
23all prescription drugs shall be updated no less frequently than
24every 30 days as required by Section 5-5.12.
25    The rules and regulations of the Illinois Department shall
26require that a written statement including the required opinion

 

 

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1of a physician shall accompany any claim for reimbursement for
2abortions, or induced miscarriages or premature births. This
3statement shall indicate what procedures were used in providing
4such medical services.
5    Notwithstanding any other law to the contrary, the Illinois
6Department shall, within 365 days after July 22, 2013, (the
7effective date of Public Act 98-104), establish procedures to
8permit skilled care facilities licensed under the Nursing Home
9Care Act to submit monthly billing claims for reimbursement
10purposes. Following development of these procedures, the
11Department shall have an additional 365 days to test the
12viability of the new system and to ensure that any necessary
13operational or structural changes to its information
14technology platforms are implemented.
15    Notwithstanding any other law to the contrary, the Illinois
16Department shall, within 365 days after August 15, 2014 (the
17effective date of Public Act 98-963) this amendatory Act of the
1898th General Assembly, establish procedures to permit ID/DD
19facilities licensed under the ID/DD Community Care Act to
20submit monthly billing claims for reimbursement purposes.
21Following development of these procedures, the Department
22shall have an additional 365 days to test the viability of the
23new system and to ensure that any necessary operational or
24structural changes to its information technology platforms are
25implemented.
26    The Illinois Department shall require all dispensers of

 

 

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

 

 

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1enrollment period for vendors based upon category of risk of
2the vendor.
3    Prior to enrollment and during the conditional enrollment
4period in the medical assistance program, all vendors shall be
5subject to enhanced oversight, screening, and review based on
6the risk of fraud, waste, and abuse that is posed by the
7category of risk of the vendor. The Illinois Department shall
8establish the procedures for oversight, screening, and review,
9which may include, but need not be limited to: criminal and
10financial background checks; fingerprinting; license,
11certification, and authorization verifications; unscheduled or
12unannounced site visits; database checks; prepayment audit
13reviews; audits; payment caps; payment suspensions; and other
14screening as required by federal or State law.
15    The Department shall define or specify the following: (i)
16by provider notice, the "category of risk of the vendor" for
17each type of vendor, which shall take into account the level of
18screening applicable to a particular category of vendor under
19federal law and regulations; (ii) by rule or provider notice,
20the maximum length of the conditional enrollment period for
21each category of risk of the vendor; and (iii) by rule, the
22hearing rights, if any, afforded to a vendor in each category
23of risk of the vendor that is terminated or disenrolled during
24the conditional enrollment period.
25    To be eligible for payment consideration, a vendor's
26payment claim or bill, either as an initial claim or as a

 

 

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

 

 

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

 

 

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1access to confidential and other information and data necessary
2to perform eligibility and payment verifications and other
3Illinois Department functions. This includes, but is not
4limited to: information pertaining to licensure;
5certification; earnings; immigration status; citizenship; wage
6reporting; unearned and earned income; pension income;
7employment; supplemental security income; social security
8numbers; National Provider Identifier (NPI) numbers; the
9National Practitioner Data Bank (NPDB); program and agency
10exclusions; taxpayer identification numbers; tax delinquency;
11corporate information; and death records.
12    The Illinois Department shall enter into agreements with
13State agencies and departments, and is authorized to enter into
14agreements with federal agencies and departments, under which
15such agencies and departments shall share data necessary for
16medical assistance program integrity functions and oversight.
17The Illinois Department shall develop, in cooperation with
18other State departments and agencies, and in compliance with
19applicable federal laws and regulations, appropriate and
20effective methods to share such data. At a minimum, and to the
21extent necessary to provide data sharing, the Illinois
22Department shall enter into agreements with State agencies and
23departments, and is authorized to enter into agreements with
24federal agencies and departments, including but not limited to:
25the Secretary of State; the Department of Revenue; the
26Department of Public Health; the Department of Human Services;

 

 

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

 

 

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1recipient to temporarily acquire and use alternative or
2substitute devices or equipment pending repairs or
3replacements of any device or equipment previously authorized
4for such recipient by the Department.
5    The Department shall execute, relative to the nursing home
6prescreening project, written inter-agency agreements with the
7Department of Human Services and the Department on Aging, to
8effect the following: (i) intake procedures and common
9eligibility criteria for those persons who are receiving
10non-institutional services; and (ii) the establishment and
11development of non-institutional services in areas of the State
12where they are not currently available or are undeveloped; and
13(iii) notwithstanding any other provision of law, subject to
14federal approval, on and after July 1, 2012, an increase in the
15determination of need (DON) scores from 29 to 37 for applicants
16for institutional and home and community-based long term care;
17if and only if federal approval is not granted, the Department
18may, in conjunction with other affected agencies, implement
19utilization controls or changes in benefit packages to
20effectuate a similar savings amount for this population; and
21(iv) no later than July 1, 2013, minimum level of care
22eligibility criteria for institutional and home and
23community-based long term care; and (v) no later than October
241, 2013, establish procedures to permit long term care
25providers access to eligibility scores for individuals with an
26admission date who are seeking or receiving services from the

 

 

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1long term care provider. In order to select the minimum level
2of care eligibility criteria, the Governor shall establish a
3workgroup that includes affected agency representatives and
4stakeholders representing the institutional and home and
5community-based long term care interests. This Section shall
6not restrict the Department from implementing lower level of
7care eligibility criteria for community-based services in
8circumstances where federal approval has been granted.
9    The Illinois Department shall develop and operate, in
10cooperation with other State Departments and agencies and in
11compliance with applicable federal laws and regulations,
12appropriate and effective systems of health care evaluation and
13programs for monitoring of utilization of health care services
14and facilities, as it affects persons eligible for medical
15assistance under this Code.
16    The Illinois Department shall report annually to the
17General Assembly, no later than the second Friday in April of
181979 and each year thereafter, in regard to:
19        (a) actual statistics and trends in utilization of
20    medical services by public aid recipients;
21        (b) actual statistics and trends in the provision of
22    the various medical services by medical vendors;
23        (c) current rate structures and proposed changes in
24    those rate structures for the various medical vendors; and
25        (d) efforts at utilization review and control by the
26    Illinois Department.

 

 

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

 

 

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1necessary and notwithstanding the provisions of Section 1-11 of
2this Code, beginning October 1, 2014, the Department shall
3cover kidney transplantation for noncitizens with end-stage
4renal disease who are not eligible for comprehensive medical
5benefits, who meet the residency requirements of Section 5-3 of
6this Code, and who would otherwise meet the financial
7requirements of the appropriate class of eligible persons under
8Section 5-2 of this Code. To qualify for coverage of kidney
9transplantation, such person must be receiving emergency renal
10dialysis services covered by the Department. Providers under
11this Section shall be prior approved and certified by the
12Department to perform kidney transplantation and the services
13under this Section shall be limited to services associated with
14kidney transplantation.
15(Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689,
16eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section
179-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff.
187-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; 98-651,
19eff. 6-16-14; 98-756, eff. 7-16-14; 98-963, eff. 8-15-14;
20revised 10-2-14.)
 
21    Section 99. Effective date. This Act takes effect on July
221, 2016, if and only if on or before July 1, 2016:
23     (1) the Secretary of the United States Department of
24Health and Human Services, or its successor agency, promulgates
25rules or regulations published in the Federal Register or
26publishes a comment in the Federal Register:

 

 

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1         (A) repealing, amending, or reinterpreting 45 CFR
2    155.170 to eliminate the State's responsibility to defray
3    the cost of a state-mandated benefit enacted on or after
4    January 1, 2012;
5        (B) requiring qualified health plans, as defined in the
6    federal Patient Protection and Affordable Care Act, as
7    amended by the Health Care and Education Reconciliation Act
8    of 2010 and any subsequent amendatory Acts, rules, or
9    regulations issued pursuant thereto, to cover breast
10    tomosynthesis as an essential health benefit; or
11        (C) including breast tomosynthesis as a standard as
12    part of the essential health benefits required of benchmark
13    plans under 45 CFR 156.110; or
14    (2) the federal Patient Protection and Affordable Care Act
15is repealed by an Act of Congress or is invalidated by a
16decision of the U.S. Supreme Court.