Sen. John G. Mulroe

Filed: 3/16/2015

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 54

2    AMENDMENT NO. ______. Amend Senate Bill 54 by replacing
3everything after the enacting clause with the following:
 
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.

 

 

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1         (2) An annual mammogram for women 40 years of age or
2    older.
3         (3) A mammogram at the age and intervals considered
4    medically necessary by the woman's health care provider for
5    women under 40 years of age and having a family history of
6    breast cancer, prior personal history of breast cancer,
7    positive genetic testing, or other risk factors.
8        (4) A comprehensive ultrasound screening of an entire
9    breast or breasts if a mammogram demonstrates
10    heterogeneous or dense breast tissue, when medically
11    necessary as determined by a physician licensed to practice
12    medicine in all of its branches.
13    For purposes of this Section, "low-dose mammography" means
14the x-ray examination of the breast using equipment dedicated
15specifically for mammography, including the x-ray tube,
16filter, compression device, and image receptor, with radiation
17exposure delivery of less than 1 rad per breast for 2 views of
18an average size breast. The term also includes digital
19mammography and may include breast tomosynthesis. As used in
20this Section, the term "breast tomosynthesis" means a
21radiologic procedure that involves the acquisition of
22projection images over the stationary breast to produce
23cross-sectional digital three-dimensional images of the
24breast.
25    (a-5) Coverage as described by subsection (a) shall be
26provided at no cost to the insured and shall not be applied to

 

 

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1an annual or lifetime maximum benefit.
2    (a-10) When health care services are available through
3contracted providers and a person does not comply with plan
4provisions specific to the use of contracted providers, the
5requirements of subsection (a-5) are not applicable. When a
6person does not comply with plan provisions specific to the use
7of contracted providers, plan provisions specific to the use of
8non-contracted providers must be applied without distinction
9for coverage required by this Section and shall be at least as
10favorable as for other radiological examinations covered by the
11policy or contract.
12    (b) No policy of accident or health insurance that provides
13for the surgical procedure known as a mastectomy shall be
14issued, amended, delivered, or renewed in this State unless
15that coverage also provides for prosthetic devices or
16reconstructive surgery incident to the mastectomy. Coverage
17for breast reconstruction in connection with a mastectomy shall
18include:
19        (1) reconstruction of the breast upon which the
20    mastectomy has been performed;
21        (2) surgery and reconstruction of the other breast to
22    produce a symmetrical appearance; and
23        (3) prostheses and treatment for physical
24    complications at all stages of mastectomy, including
25    lymphedemas.
26Care shall be determined in consultation with the attending

 

 

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

 

 

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1purported rule not so adopted, for whatever reason, is
2unauthorized.
3(Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07;
495-1045, eff. 3-27-09.)
 
5    Section 10. The Health Maintenance Organization Act is
6amended by changing Section 4-6.1 as follows:
 
7    (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)
8    Sec. 4-6.1. Mammograms; mastectomies.
9    (a) Every contract or evidence of coverage issued by a
10Health Maintenance Organization for persons who are residents
11of this State shall contain coverage for screening by low-dose
12mammography for all women 35 years of age or older for the
13presence of occult breast cancer. The coverage shall be as
14follows:
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.
24        (4) A comprehensive ultrasound screening of an entire

 

 

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1    breast or breasts if a mammogram demonstrates
2    heterogeneous or dense breast tissue, when medically
3    necessary as determined by a physician licensed to practice
4    medicine in all of its branches.
5    For purposes of this Section, "low-dose mammography" means
6the x-ray examination of the breast using equipment dedicated
7specifically for mammography, including the x-ray tube,
8filter, compression device, and image receptor, with radiation
9exposure delivery of less than 1 rad per breast for 2 views of
10an average size breast. The term also includes digital
11mammography and may include breast tomosynthesis. As used in
12this Section, the term "breast tomosynthesis" means a
13radiologic procedure that involves the acquisition of
14projection images over the stationary breast to produce
15cross-sectional digital three-dimensional images of the
16breast.
17    (a-5) Coverage as described in subsection (a) shall be
18provided at no cost to the enrollee and shall not be applied to
19an annual or lifetime maximum benefit.
20    (b) No contract or evidence of coverage issued by a health
21maintenance organization that provides for the surgical
22procedure known as a mastectomy shall be issued, amended,
23delivered, or renewed in this State on or after the effective
24date of this amendatory Act of the 92nd General Assembly unless
25that coverage also provides for prosthetic devices or
26reconstructive surgery incident to the mastectomy, providing

 

 

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1that the mastectomy is performed after the effective date of
2this amendatory Act. Coverage for breast reconstruction in
3connection with a mastectomy shall include:
4        (1) reconstruction of the breast upon which the
5    mastectomy has been performed;
6        (2) surgery and reconstruction of the other breast to
7    produce a symmetrical appearance; and
8        (3) prostheses and treatment for physical
9    complications at all stages of mastectomy, including
10    lymphedemas.
11Care shall be determined in consultation with the attending
12physician and the patient. The offered coverage for prosthetic
13devices and reconstructive surgery shall be subject to the
14deductible and coinsurance conditions applied to the
15mastectomy and all other terms and conditions applicable to
16other benefits. When a mastectomy is performed and there is no
17evidence of malignancy, then the offered coverage may be
18limited to the provision of prosthetic devices and
19reconstructive surgery to within 2 years after the date of the
20mastectomy. As used in this Section, "mastectomy" means the
21removal of all or part of the breast for medically necessary
22reasons, as determined by a licensed physician.
23    Written notice of the availability of coverage under this
24Section shall be delivered to the enrollee upon enrollment and
25annually thereafter. A health maintenance organization may not
26deny to an enrollee eligibility, or continued eligibility, to

 

 

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1enroll or to renew coverage under the terms of the plan solely
2for the purpose of avoiding the requirements of this Section. A
3health maintenance organization may not penalize or reduce or
4limit the reimbursement of an attending provider or provide
5incentives (monetary or otherwise) to an attending provider to
6induce the provider to provide care to an insured in a manner
7inconsistent with this Section.
8    (c) Rulemaking authority to implement this amendatory Act
9of the 95th General Assembly, if any, is conditioned on the
10rules being adopted in accordance with all provisions of the
11Illinois Administrative Procedure Act and all rules and
12procedures of the Joint Committee on Administrative Rules; any
13purported rule not so adopted, for whatever reason, is
14unauthorized.
15(Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07;
1695-1045, eff. 3-27-09.)
 
17    Section 15. The Illinois Public Aid Code is amended by
18changing Section 5-5 as follows:
 
19    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
20    Sec. 5-5. Medical services. The Illinois Department, by
21rule, shall determine the quantity and quality of and the rate
22of reimbursement for the medical assistance for which payment
23will be authorized, and the medical services to be provided,
24which may include all or part of the following: (1) inpatient

 

 

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

 

 

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1includes an appropriate evaluation and, as warranted, a
2referral; "uniform" does not mean the use of a singular
3instrument, tool, or process that all must utilize; (14)
4transportation and such other expenses as may be necessary;
5(15) medical treatment of sexual assault survivors, as defined
6in Section 1a of the Sexual Assault Survivors Emergency
7Treatment Act, for injuries sustained as a result of the sexual
8assault, including examinations and laboratory tests to
9discover evidence which may be used in criminal proceedings
10arising from the sexual assault; (16) the diagnosis and
11treatment of sickle cell anemia; and (17) any other medical
12care, and any other type of remedial care recognized under the
13laws of this State, but not including abortions, or induced
14miscarriages or premature births, unless, in the opinion of a
15physician, such procedures are necessary for the preservation
16of the life of the woman seeking such treatment, or except an
17induced premature birth intended to produce a live viable child
18and such procedure is necessary for the health of the mother or
19her unborn child. The Illinois Department, by rule, shall
20prohibit any physician from providing medical assistance to
21anyone eligible therefor under this Code where such physician
22has been found guilty of performing an abortion procedure in a
23wilful and wanton manner upon a woman who was not pregnant at
24the time such abortion procedure was performed. The term "any
25other type of remedial care" shall include nursing care and
26nursing home service for persons who rely on treatment by

 

 

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

 

 

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

 

 

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1enrolled provider, as determined by the Department, through
2which dental services covered under this Section are performed.
3The Department shall establish a process for payment of claims
4for reimbursement for covered dental services rendered under
5this provision.
6    The Illinois Department, by rule, may distinguish and
7classify the medical services to be provided only in accordance
8with the classes of persons designated in Section 5-2.
9    The Department of Healthcare and Family Services must
10provide coverage and reimbursement for amino acid-based
11elemental formulas, regardless of delivery method, for the
12diagnosis and treatment of (i) eosinophilic disorders and (ii)
13short bowel syndrome when the prescribing physician has issued
14a written order stating that the amino acid-based elemental
15formula is medically necessary.
16    The Illinois Department shall authorize the provision of,
17and shall authorize payment for, screening by low-dose
18mammography for the presence of occult breast cancer for women
1935 years of age or older who are eligible for medical
20assistance under this Article, as follows:
21        (A) A baseline mammogram for women 35 to 39 years of
22    age.
23        (B) An annual mammogram for women 40 years of age or
24    older.
25        (C) A mammogram at the age and intervals considered
26    medically necessary by the woman's health care provider for

 

 

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1    women under 40 years of age and having a family history of
2    breast cancer, prior personal history of breast cancer,
3    positive genetic testing, or other risk factors.
4        (D) A comprehensive ultrasound screening of an entire
5    breast or breasts if a mammogram demonstrates
6    heterogeneous or dense breast tissue, when medically
7    necessary as determined by a physician licensed to practice
8    medicine in all of its branches.
9    All screenings shall include a physical breast exam,
10instruction on self-examination and information regarding the
11frequency of self-examination and its value as a preventative
12tool. For purposes of this Section, "low-dose mammography"
13means the x-ray examination of the breast using equipment
14dedicated specifically for mammography, including the x-ray
15tube, filter, compression device, and image receptor, with an
16average radiation exposure delivery of less than one rad per
17breast for 2 views of an average size breast. The term also
18includes digital mammography and may include breast
19tomosynthesis. As used in this Section, the term "breast
20tomosynthesis" means a radiologic procedure that involves the
21acquisition of projection images over the stationary breast to
22produce cross-sectional digital three-dimensional images of
23the breast.
24    On and after January 1, 2012, providers participating in a
25quality improvement program approved by the Department shall be
26reimbursed for screening and diagnostic mammography at the same

 

 

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1rate as the Medicare program's rates, including the increased
2reimbursement for digital mammography.
3    The Department shall convene an expert panel including
4representatives of hospitals, free-standing mammography
5facilities, and doctors, including radiologists, to establish
6quality standards.
7    Subject to federal approval, the Department shall
8establish a rate methodology for mammography at federally
9qualified health centers and other encounter-rate clinics.
10These clinics or centers may also collaborate with other
11hospital-based mammography facilities.
12    The Department shall establish a methodology to remind
13women who are age-appropriate for screening mammography, but
14who have not received a mammogram within the previous 18
15months, of the importance and benefit of screening mammography.
16    The Department shall establish a performance goal for
17primary care providers with respect to their female patients
18over age 40 receiving an annual mammogram. This performance
19goal shall be used to provide additional reimbursement in the
20form of a quality performance bonus to primary care providers
21who meet that goal.
22    The Department shall devise a means of case-managing or
23patient navigation for beneficiaries diagnosed with breast
24cancer. This program shall initially operate as a pilot program
25in areas of the State with the highest incidence of mortality
26related to breast cancer. At least one pilot program site shall

 

 

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1be in the metropolitan Chicago area and at least one site shall
2be outside the metropolitan Chicago area. An evaluation of the
3pilot program shall be carried out measuring health outcomes
4and cost of care for those served by the pilot program compared
5to similarly situated patients who are not served by the pilot
6program.
7    Any medical or health care provider shall immediately
8recommend, to any pregnant woman who is being provided prenatal
9services and is suspected of drug abuse or is addicted as
10defined in the Alcoholism and Other Drug Abuse and Dependency
11Act, referral to a local substance abuse treatment provider
12licensed by the Department of Human Services or to a licensed
13hospital which provides substance abuse treatment services.
14The Department of Healthcare and Family Services shall assure
15coverage for the cost of treatment of the drug abuse or
16addiction for pregnant recipients in accordance with the
17Illinois Medicaid Program in conjunction with the Department of
18Human Services.
19    All medical providers providing medical assistance to
20pregnant women under this Code shall receive information from
21the Department on the availability of services under the Drug
22Free Families with a Future or any comparable program providing
23case management services for addicted women, including
24information on appropriate referrals for other social services
25that may be needed by addicted women in addition to treatment
26for addiction.

 

 

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1    The Illinois Department, in cooperation with the
2Departments of Human Services (as successor to the Department
3of Alcoholism and Substance Abuse) and Public Health, through a
4public awareness campaign, may provide information concerning
5treatment for alcoholism and drug abuse and addiction, prenatal
6health care, and other pertinent programs directed at reducing
7the number of drug-affected infants born to recipients of
8medical assistance.
9    Neither the Department of Healthcare and Family Services
10nor the Department of Human Services shall sanction the
11recipient solely on the basis of her substance abuse.
12    The Illinois Department shall establish such regulations
13governing the dispensing of health services under this Article
14as it shall deem appropriate. The Department should seek the
15advice of formal professional advisory committees appointed by
16the Director of the Illinois Department for the purpose of
17providing regular advice on policy and administrative matters,
18information dissemination and educational activities for
19medical and health care providers, and consistency in
20procedures to the Illinois Department.
21    The Illinois Department may develop and contract with
22Partnerships of medical providers to arrange medical services
23for persons eligible under Section 5-2 of this Code.
24Implementation of this Section may be by demonstration projects
25in certain geographic areas. The Partnership shall be
26represented by a sponsor organization. The Department, by rule,

 

 

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1shall develop qualifications for sponsors of Partnerships.
2Nothing in this Section shall be construed to require that the
3sponsor organization be a medical organization.
4    The sponsor must negotiate formal written contracts with
5medical providers for physician services, inpatient and
6outpatient hospital care, home health services, treatment for
7alcoholism and substance abuse, and other services determined
8necessary by the Illinois Department by rule for delivery by
9Partnerships. Physician services must include prenatal and
10obstetrical care. The Illinois Department shall reimburse
11medical services delivered by Partnership providers to clients
12in target areas according to provisions of this Article and the
13Illinois Health Finance Reform Act, except that:
14        (1) Physicians participating in a Partnership and
15    providing certain services, which shall be determined by
16    the Illinois Department, to persons in areas covered by the
17    Partnership may receive an additional surcharge for such
18    services.
19        (2) The Department may elect to consider and negotiate
20    financial incentives to encourage the development of
21    Partnerships and the efficient delivery of medical care.
22        (3) Persons receiving medical services through
23    Partnerships may receive medical and case management
24    services above the level usually offered through the
25    medical assistance program.
26    Medical providers shall be required to meet certain

 

 

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

 

 

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

 

 

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1amendatory Act of 1984, the Illinois Department shall establish
2a current list of acquisition costs for all prosthetic devices
3and any other items recognized as medical equipment and
4supplies reimbursable under this Article and shall update such
5list on a quarterly basis, except that the acquisition costs of
6all prescription drugs shall be updated no less frequently than
7every 30 days as required by Section 5-5.12.
8    The rules and regulations of the Illinois Department shall
9require that a written statement including the required opinion
10of a physician shall accompany any claim for reimbursement for
11abortions, or induced miscarriages or premature births. This
12statement shall indicate what procedures were used in providing
13such medical services.
14    Notwithstanding any other law to the contrary, the Illinois
15Department shall, within 365 days after July 22, 2013, (the
16effective date of Public Act 98-104), establish procedures to
17permit skilled care facilities licensed under the Nursing Home
18Care Act to submit monthly billing claims for reimbursement
19purposes. Following development of these procedures, the
20Department shall have an additional 365 days to test the
21viability of the new system and to ensure that any necessary
22operational or structural changes to its information
23technology platforms are implemented.
24    Notwithstanding any other law to the contrary, the Illinois
25Department shall, within 365 days after August 15, 2014 (the
26effective date of Public Act 98-963) this amendatory Act of the

 

 

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198th General Assembly, establish procedures to permit ID/DD
2facilities licensed under the ID/DD Community Care Act to
3submit monthly billing claims for reimbursement purposes.
4Following development of these procedures, the Department
5shall have an additional 365 days to test the viability of the
6new system and to ensure that any necessary operational or
7structural changes to its information technology platforms are
8implemented.
9    The Illinois Department shall require all dispensers of
10medical services, other than an individual practitioner or
11group of practitioners, desiring to participate in the Medical
12Assistance program established under this Article to disclose
13all financial, beneficial, ownership, equity, surety or other
14interests in any and all firms, corporations, partnerships,
15associations, business enterprises, joint ventures, agencies,
16institutions or other legal entities providing any form of
17health care services in this State under this Article.
18    The Illinois Department may require that all dispensers of
19medical services desiring to participate in the medical
20assistance program established under this Article disclose,
21under such terms and conditions as the Illinois Department may
22by rule establish, all inquiries from clients and attorneys
23regarding medical bills paid by the Illinois Department, which
24inquiries could indicate potential existence of claims or liens
25for the Illinois Department.
26    Enrollment of a vendor shall be subject to a provisional

 

 

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

 

 

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

 

 

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1        (4) In the case of a provider operated by a unit of
2    local government with a population exceeding 3,000,000
3    when local government funds finance federal participation
4    for claims payments.
5    For claims for services rendered during a period for which
6a recipient received retroactive eligibility, claims must be
7filed within 180 days after the Department determines the
8applicant is eligible. For claims for which the Illinois
9Department is not the primary payer, claims must be submitted
10to the Illinois Department within 180 days after the final
11adjudication by the primary payer.
12    In the case of long term care facilities, within 5 days of
13receipt by the facility of required prescreening information,
14data for new admissions shall be entered into the Medical
15Electronic Data Interchange (MEDI) or the Recipient
16Eligibility Verification (REV) System or successor system, and
17within 15 days of receipt by the facility of required
18prescreening information, admission documents shall be
19submitted through MEDI or REV or shall be submitted directly to
20the Department of Human Services using required admission
21forms. Effective September 1, 2014, admission documents,
22including all prescreening information, must be submitted
23through MEDI or REV. Confirmation numbers assigned to an
24accepted transaction shall be retained by a facility to verify
25timely submittal. Once an admission transaction has been
26completed, all resubmitted claims following prior rejection

 

 

09900SB0054sam002- 26 -LRB099 03946 MLM 32638 a

1are subject to receipt no later than 180 days after the
2admission transaction has been completed.
3    Claims that are not submitted and received in compliance
4with the foregoing requirements shall not be eligible for
5payment under the medical assistance program, and the State
6shall have no liability for payment of those claims.
7    To the extent consistent with applicable information and
8privacy, security, and disclosure laws, State and federal
9agencies and departments shall provide the Illinois Department
10access to confidential and other information and data necessary
11to perform eligibility and payment verifications and other
12Illinois Department functions. This includes, but is not
13limited to: information pertaining to licensure;
14certification; earnings; immigration status; citizenship; wage
15reporting; unearned and earned income; pension income;
16employment; supplemental security income; social security
17numbers; National Provider Identifier (NPI) numbers; the
18National Practitioner Data Bank (NPDB); program and agency
19exclusions; taxpayer identification numbers; tax delinquency;
20corporate information; and death records.
21    The Illinois Department shall enter into agreements with
22State agencies and departments, and is authorized to enter into
23agreements with federal agencies and departments, under which
24such agencies and departments shall share data necessary for
25medical assistance program integrity functions and oversight.
26The Illinois Department shall develop, in cooperation with

 

 

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

 

 

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1repair and replacement of orthotic and prosthetic devices and
2durable medical equipment. Such rules shall provide, but not be
3limited to, the following services: (1) immediate repair or
4replacement of such devices by recipients; and (2) rental,
5lease, purchase or lease-purchase of durable medical equipment
6in a cost-effective manner, taking into consideration the
7recipient's medical prognosis, the extent of the recipient's
8needs, and the requirements and costs for maintaining such
9equipment. Subject to prior approval, such rules shall enable a
10recipient to temporarily acquire and use alternative or
11substitute devices or equipment pending repairs or
12replacements of any device or equipment previously authorized
13for such recipient by the Department.
14    The Department shall execute, relative to the nursing home
15prescreening project, written inter-agency agreements with the
16Department of Human Services and the Department on Aging, to
17effect the following: (i) intake procedures and common
18eligibility criteria for those persons who are receiving
19non-institutional services; and (ii) the establishment and
20development of non-institutional services in areas of the State
21where they are not currently available or are undeveloped; and
22(iii) notwithstanding any other provision of law, subject to
23federal approval, on and after July 1, 2012, an increase in the
24determination of need (DON) scores from 29 to 37 for applicants
25for institutional and home and community-based long term care;
26if and only if federal approval is not granted, the Department

 

 

09900SB0054sam002- 29 -LRB099 03946 MLM 32638 a

1may, in conjunction with other affected agencies, implement
2utilization controls or changes in benefit packages to
3effectuate a similar savings amount for this population; and
4(iv) no later than July 1, 2013, minimum level of care
5eligibility criteria for institutional and home and
6community-based long term care; and (v) no later than October
71, 2013, establish procedures to permit long term care
8providers access to eligibility scores for individuals with an
9admission date who are seeking or receiving services from the
10long term care provider. In order to select the minimum level
11of care eligibility criteria, the Governor shall establish a
12workgroup that includes affected agency representatives and
13stakeholders representing the institutional and home and
14community-based long term care interests. This Section shall
15not restrict the Department from implementing lower level of
16care eligibility criteria for community-based services in
17circumstances where federal approval has been granted.
18    The Illinois Department shall develop and operate, in
19cooperation with other State Departments and agencies and in
20compliance with applicable federal laws and regulations,
21appropriate and effective systems of health care evaluation and
22programs for monitoring of utilization of health care services
23and facilities, as it affects persons eligible for medical
24assistance under this Code.
25    The Illinois Department shall report annually to the
26General Assembly, no later than the second Friday in April of

 

 

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11979 and each year thereafter, in regard to:
2        (a) actual statistics and trends in utilization of
3    medical services by public aid recipients;
4        (b) actual statistics and trends in the provision of
5    the various medical services by medical vendors;
6        (c) current rate structures and proposed changes in
7    those rate structures for the various medical vendors; and
8        (d) efforts at utilization review and control by the
9    Illinois Department.
10    The period covered by each report shall be the 3 years
11ending on the June 30 prior to the report. The report shall
12include suggested legislation for consideration by the General
13Assembly. The filing of one copy of the report with the
14Speaker, one copy with the Minority Leader and one copy with
15the Clerk of the House of Representatives, one copy with the
16President, one copy with the Minority Leader and one copy with
17the Secretary of the Senate, one copy with the Legislative
18Research Unit, and such additional copies with the State
19Government Report Distribution Center for the General Assembly
20as is required under paragraph (t) of Section 7 of the State
21Library Act shall be deemed sufficient to comply with this
22Section.
23    Rulemaking authority to implement Public Act 95-1045, if
24any, is conditioned on the rules being adopted in accordance
25with all provisions of the Illinois Administrative Procedure
26Act and all rules and procedures of the Joint Committee on

 

 

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1Administrative Rules; any purported rule not so adopted, for
2whatever reason, is unauthorized.
3    On and after July 1, 2012, the Department shall reduce any
4rate of reimbursement for services or other payments or alter
5any methodologies authorized by this Code to reduce any rate of
6reimbursement for services or other payments in accordance with
7Section 5-5e.
8    Because kidney transplantation can be an appropriate, cost
9effective alternative to renal dialysis when medically
10necessary and notwithstanding the provisions of Section 1-11 of
11this Code, beginning October 1, 2014, the Department shall
12cover kidney transplantation for noncitizens with end-stage
13renal disease who are not eligible for comprehensive medical
14benefits, who meet the residency requirements of Section 5-3 of
15this Code, and who would otherwise meet the financial
16requirements of the appropriate class of eligible persons under
17Section 5-2 of this Code. To qualify for coverage of kidney
18transplantation, such person must be receiving emergency renal
19dialysis services covered by the Department. Providers under
20this Section shall be prior approved and certified by the
21Department to perform kidney transplantation and the services
22under this Section shall be limited to services associated with
23kidney transplantation.
24(Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689,
25eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section
269-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff.

 

 

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17-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; 98-651,
2eff. 6-16-14; 98-756, eff. 7-16-14; 98-963, eff. 8-15-14;
3revised 10-2-14.)
 
4    Section 99. Effective date. This Act takes effect upon
5becoming law.".