Illinois General Assembly - Full Text of SB2520
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Full Text of SB2520  101st General Assembly




State of Illinois
2019 and 2020


Introduced 1/28/2020, by Sen. Omar Aquino


305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that on and after July 1, 2020, the Department of Healthcare and Family Services shall administer a school-based dental program that allows for the out-of-office delivery of preventative dental services in a school setting to children under 19 years of age. Requires the Department to establish guidelines for participation by providers and set requirements for follow-up referral care based on each caries risk assessment code required for each student. Provides that every effort shall be made to ensure that children enrolled in the school-based dental program are assigned a primary dentist by allowing local dentists who practice within each school district the opportunity to participate in the school dental program prior to utilizing mobile dental services or dental providers outside the individual school boundaries. Provides that no provider shall be charged a fee by any unit of local government to participate in the school-based dental program administered by the Department. Effective immediately.

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SB2520LRB101 15492 KTG 64835 b

1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5 as follows:
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    Sec. 5-5. Medical services. The Illinois Department, by
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing home,
16or elsewhere; (6) medical care, or any other type of remedial
17care furnished by licensed practitioners; (7) home health care
18services; (8) private duty nursing service; (9) clinic
19services; (10) dental services, including prevention and
20treatment of periodontal disease and dental caries disease for
21pregnant women, provided by an individual licensed to practice
22dentistry or dental surgery; for purposes of this item (10),
23"dental services" means diagnostic, preventive, or corrective



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



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1laws of this State. The term "any other type of remedial care"
2shall include nursing care and nursing home service for persons
3who rely on treatment by spiritual means alone through prayer
4for healing.
5    Notwithstanding any other provision of this Section, a
6comprehensive tobacco use cessation program that includes
7purchasing prescription drugs or prescription medical devices
8approved by the Food and Drug Administration shall be covered
9under the medical assistance program under this Article for
10persons who are otherwise eligible for assistance under this
12    Notwithstanding any other provision of this Code,
13reproductive health care that is otherwise legal in Illinois
14shall be covered under the medical assistance program for
15persons who are otherwise eligible for medical assistance under
16this Article.
17    Notwithstanding any other provision of this Code, the
18Illinois Department may not require, as a condition of payment
19for any laboratory test authorized under this Article, that a
20physician's handwritten signature appear on the laboratory
21test order form. The Illinois Department may, however, impose
22other appropriate requirements regarding laboratory test order
24    Upon receipt of federal approval of an amendment to the
25Illinois Title XIX State Plan for this purpose, the Department
26shall authorize the Chicago Public Schools (CPS) to procure a



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1vendor or vendors to manufacture eyeglasses for individuals
2enrolled in a school within the CPS system. CPS shall ensure
3that its vendor or vendors are enrolled as providers in the
4medical assistance program and in any capitated Medicaid
5managed care entity (MCE) serving individuals enrolled in a
6school within the CPS system. Under any contract procured under
7this provision, the vendor or vendors must serve only
8individuals enrolled in a school within the CPS system. Claims
9for services provided by CPS's vendor or vendors to recipients
10of benefits in the medical assistance program under this Code,
11the Children's Health Insurance Program, or the Covering ALL
12KIDS Health Insurance Program shall be submitted to the
13Department or the MCE in which the individual is enrolled for
14payment and shall be reimbursed at the Department's or the
15MCE's established rates or rate methodologies for eyeglasses.
16    On and after July 1, 2012, the Department of Healthcare and
17Family Services may provide the following services to persons
18eligible for assistance under this Article who are
19participating in education, training or employment programs
20operated by the Department of Human Services as successor to
21the Department of Public Aid:
22        (1) dental services provided by or under the
23    supervision of a dentist; and
24        (2) eyeglasses prescribed by a physician skilled in the
25    diseases of the eye, or by an optometrist, whichever the
26    person may select.



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1    On and after July 1, 2018, the Department of Healthcare and
2Family Services shall provide dental services to any adult who
3is otherwise eligible for assistance under the medical
4assistance program. As used in this paragraph, "dental
5services" means diagnostic, preventative, restorative, or
6corrective procedures, including procedures and services for
7the prevention and treatment of periodontal disease and dental
8caries disease, provided by an individual who is licensed to
9practice dentistry or dental surgery or who is under the
10supervision of a dentist in the practice of his or her
12    On and after July 1, 2018, targeted dental services, as set
13forth in Exhibit D of the Consent Decree entered by the United
14States District Court for the Northern District of Illinois,
15Eastern Division, in the matter of Memisovski v. Maram, Case
16No. 92 C 1982, that are provided to adults under the medical
17assistance program shall be established at no less than the
18rates set forth in the "New Rate" column in Exhibit D of the
19Consent Decree for targeted dental services that are provided
20to persons under the age of 18 under the medical assistance
22    Notwithstanding any other provision of this Code and
23subject to federal approval, the Department may adopt rules to
24allow a dentist who is volunteering his or her service at no
25cost to render dental services through an enrolled
26not-for-profit health clinic without the dentist personally



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1enrolling as a participating provider in the medical assistance
2program. A not-for-profit health clinic shall include a public
3health clinic or Federally Qualified Health Center or other
4enrolled provider, as determined by the Department, through
5which dental services covered under this Section are performed.
6The Department shall establish a process for payment of claims
7for reimbursement for covered dental services rendered under
8this provision.
9    On and after July 1, 2020, the Department shall administer
10a school-based dental program that allows for the out-of-office
11delivery of preventative dental services in a school setting to
12children under 19 years of age. The Department shall establish
13guidelines for participation by providers and set requirements
14for follow-up referral care based on each caries risk
15assessment code required for each student.
16    Every effort shall be made to ensure that children enrolled
17in the school-based dental program are assigned a primary
18dentist by allowing local dentists who practice within each
19school district the opportunity to participate in the school
20dental program prior to utilizing mobile dental services or
21dental providers outside the individual school boundaries. No
22provider shall be charged a fee by any unit of local government
23to participate in the school-based dental program administered
24by the Department.
25    The Illinois Department, by rule, may distinguish and
26classify the medical services to be provided only in accordance



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1with the classes of persons designated in Section 5-2.
2    The Department of Healthcare and Family Services must
3provide coverage and reimbursement for amino acid-based
4elemental formulas, regardless of delivery method, for the
5diagnosis and treatment of (i) eosinophilic disorders and (ii)
6short bowel syndrome when the prescribing physician has issued
7a written order stating that the amino acid-based elemental
8formula is medically necessary.
9    The Illinois Department shall authorize the provision of,
10and shall authorize payment for, screening by low-dose
11mammography for the presence of occult breast cancer for women
1235 years of age or older who are eligible for medical
13assistance under this Article, as follows:
14        (A) A baseline mammogram for women 35 to 39 years of
15    age.
16        (B) An annual mammogram for women 40 years of age or
17    older.
18        (C) A mammogram at the age and intervals considered
19    medically necessary by the woman's health care provider for
20    women under 40 years of age and having a family history of
21    breast cancer, prior personal history of breast cancer,
22    positive genetic testing, or other risk factors.
23        (D) A comprehensive ultrasound screening and MRI of an
24    entire breast or breasts if a mammogram demonstrates
25    heterogeneous or dense breast tissue or when medically
26    necessary as determined by a physician licensed to practice



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



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1subjective or objective abnormality otherwise detected in the
3    "Low-dose mammography" means the x-ray examination of the
4breast using equipment dedicated specifically for mammography,
5including the x-ray tube, filter, compression device, and image
6receptor, with an average radiation exposure delivery of less
7than one rad per breast for 2 views of an average size breast.
8The term also includes digital mammography and includes breast
10    "Breast tomosynthesis" means a radiologic procedure that
11involves the acquisition of projection images over the
12stationary breast to produce cross-sectional digital
13three-dimensional images of the breast.
14    If, at any time, the Secretary of the United States
15Department of Health and Human Services, or its successor
16agency, promulgates rules or regulations to be published in the
17Federal Register or publishes a comment in the Federal Register
18or issues an opinion, guidance, or other action that would
19require the State, pursuant to any provision of the Patient
20Protection and Affordable Care Act (Public Law 111-148),
21including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
22successor provision, to defray the cost of any coverage for
23breast tomosynthesis outlined in this paragraph, then the
24requirement that an insurer cover breast tomosynthesis is
25inoperative other than any such coverage authorized under
26Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and



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1the State shall not assume any obligation for the cost of
2coverage for breast tomosynthesis set forth in this paragraph.
3    On and after January 1, 2016, the Department shall ensure
4that all networks of care for adult clients of the Department
5include access to at least one breast imaging Center of Imaging
6Excellence as certified by the American College of Radiology.
7    On and after January 1, 2012, providers participating in a
8quality improvement program approved by the Department shall be
9reimbursed for screening and diagnostic mammography at the same
10rate as the Medicare program's rates, including the increased
11reimbursement for digital mammography.
12    The Department shall convene an expert panel including
13representatives of hospitals, free-standing mammography
14facilities, and doctors, including radiologists, to establish
15quality standards for mammography.
16    On and after January 1, 2017, providers participating in a
17breast cancer treatment quality improvement program approved
18by the Department shall be reimbursed for breast cancer
19treatment at a rate that is no lower than 95% of the Medicare
20program's rates for the data elements included in the breast
21cancer treatment quality program.
22    The Department shall convene an expert panel, including
23representatives of hospitals, free-standing breast cancer
24treatment centers, breast cancer quality organizations, and
25doctors, including breast surgeons, reconstructive breast
26surgeons, oncologists, and primary care providers to establish



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



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1in areas of the State with the highest incidence of mortality
2related to breast cancer. At least one pilot program site shall
3be in the metropolitan Chicago area and at least one site shall
4be outside the metropolitan Chicago area. On or after July 1,
52016, the pilot program shall be expanded to include one site
6in western Illinois, one site in southern Illinois, one site in
7central Illinois, and 4 sites within metropolitan Chicago. An
8evaluation of the pilot program shall be carried out measuring
9health outcomes and cost of care for those served by the pilot
10program compared to similarly situated patients who are not
11served by the pilot program.
12    The Department shall require all networks of care to
13develop a means either internally or by contract with experts
14in navigation and community outreach to navigate cancer
15patients to comprehensive care in a timely fashion. The
16Department shall require all networks of care to include access
17for patients diagnosed with cancer to at least one academic
18commission on cancer-accredited cancer program as an
19in-network covered benefit.
20    Any medical or health care provider shall immediately
21recommend, to any pregnant woman who is being provided prenatal
22services and is suspected of having a substance use disorder as
23defined in the Substance Use Disorder Act, referral to a local
24substance use disorder treatment program licensed by the
25Department of Human Services or to a licensed hospital which
26provides substance abuse treatment services. The Department of



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



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



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



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



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1eyeglasses by eligible persons under this Section accompany
2each claim for reimbursement submitted by the dispenser of such
3medical services. No such claims for reimbursement shall be
4approved for payment by the Illinois Department without such
5proof of receipt, unless the Illinois Department shall have put
6into effect and shall be operating a system of post-payment
7audit and review which shall, on a sampling basis, be deemed
8adequate by the Illinois Department to assure that such drugs,
9dentures, prosthetic devices and eyeglasses for which payment
10is being made are actually being received by eligible
11recipients. Within 90 days after September 16, 1984 (the
12effective date of Public Act 83-1439), the Illinois Department
13shall establish a current list of acquisition costs for all
14prosthetic devices and any other items recognized as medical
15equipment and supplies reimbursable under this Article and
16shall update such list on a quarterly basis, except that the
17acquisition costs of all prescription drugs shall be updated no
18less frequently than every 30 days as required by Section
20    Notwithstanding any other law to the contrary, the Illinois
21Department shall, within 365 days after July 22, 2013 (the
22effective date of Public Act 98-104), establish procedures to
23permit skilled care facilities licensed under the Nursing Home
24Care Act to submit monthly billing claims for reimbursement
25purposes. Following development of these procedures, the
26Department shall, by July 1, 2016, test the viability of the



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1new system and implement any necessary operational or
2structural changes to its information technology platforms in
3order to allow for the direct acceptance and payment of nursing
4home claims.
5    Notwithstanding any other law to the contrary, the Illinois
6Department shall, within 365 days after August 15, 2014 (the
7effective date of Public Act 98-963), establish procedures to
8permit ID/DD facilities licensed under the ID/DD Community Care
9Act and MC/DD facilities licensed under the MC/DD Act to submit
10monthly billing claims for reimbursement purposes. Following
11development of these procedures, the Department shall have an
12additional 365 days to test the viability of the new system and
13to ensure that any necessary operational or structural changes
14to its information technology platforms are implemented.
15    The Illinois Department shall require all dispensers of
16medical services, other than an individual practitioner or
17group of practitioners, desiring to participate in the Medical
18Assistance program established under this Article to disclose
19all financial, beneficial, ownership, equity, surety or other
20interests in any and all firms, corporations, partnerships,
21associations, business enterprises, joint ventures, agencies,
22institutions or other legal entities providing any form of
23health care services in this State under this Article.
24    The Illinois Department may require that all dispensers of
25medical services desiring to participate in the medical
26assistance program established under this Article disclose,



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1under such terms and conditions as the Illinois Department may
2by rule establish, all inquiries from clients and attorneys
3regarding medical bills paid by the Illinois Department, which
4inquiries could indicate potential existence of claims or liens
5for the Illinois Department.
6    Enrollment of a vendor shall be subject to a provisional
7period and shall be conditional for one year. During the period
8of conditional enrollment, the Department may terminate the
9vendor's eligibility to participate in, or may disenroll the
10vendor from, the medical assistance program without cause.
11Unless otherwise specified, such termination of eligibility or
12disenrollment is not subject to the Department's hearing
13process. However, a disenrolled vendor may reapply without
15    The Department has the discretion to limit the conditional
16enrollment period for vendors based upon category of risk of
17the vendor.
18    Prior to enrollment and during the conditional enrollment
19period in the medical assistance program, all vendors shall be
20subject to enhanced oversight, screening, and review based on
21the risk of fraud, waste, and abuse that is posed by the
22category of risk of the vendor. The Illinois Department shall
23establish the procedures for oversight, screening, and review,
24which may include, but need not be limited to: criminal and
25financial background checks; fingerprinting; license,
26certification, and authorization verifications; unscheduled or



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



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1    Department or any of its claims processing intermediaries
2    which result in an inability to receive, process, or
3    adjudicate a claim, the 180-day period shall not begin
4    until the provider has been notified of the error.
5        (3) In the case of a provider for whom the Illinois
6    Department initiates the monthly billing process.
7        (4) In the case of a provider operated by a unit of
8    local government with a population exceeding 3,000,000
9    when local government funds finance federal participation
10    for claims payments.
11    For claims for services rendered during a period for which
12a recipient received retroactive eligibility, claims must be
13filed within 180 days after the Department determines the
14applicant is eligible. For claims for which the Illinois
15Department is not the primary payer, claims must be submitted
16to the Illinois Department within 180 days after the final
17adjudication by the primary payer.
18    In the case of long term care facilities, within 45
19calendar days of receipt by the facility of required
20prescreening information, new admissions with associated
21admission documents shall be submitted through the Medical
22Electronic Data Interchange (MEDI) or the Recipient
23Eligibility Verification (REV) System or shall be submitted
24directly to the Department of Human Services using required
25admission forms. Effective September 1, 2014, admission
26documents, including all prescreening information, must be



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



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



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1or as an obligation on the part of the Illinois Department to
2take any action or acquire any products or services.
3    The Illinois Department shall establish policies,
4procedures, standards and criteria by rule for the acquisition,
5repair and replacement of orthotic and prosthetic devices and
6durable medical equipment. Such rules shall provide, but not be
7limited to, the following services: (1) immediate repair or
8replacement of such devices by recipients; and (2) rental,
9lease, purchase or lease-purchase of durable medical equipment
10in a cost-effective manner, taking into consideration the
11recipient's medical prognosis, the extent of the recipient's
12needs, and the requirements and costs for maintaining such
13equipment. Subject to prior approval, such rules shall enable a
14recipient to temporarily acquire and use alternative or
15substitute devices or equipment pending repairs or
16replacements of any device or equipment previously authorized
17for such recipient by the Department. Notwithstanding any
18provision of Section 5-5f to the contrary, the Department may,
19by rule, exempt certain replacement wheelchair parts from prior
20approval and, for wheelchairs, wheelchair parts, wheelchair
21accessories, and related seating and positioning items,
22determine the wholesale price by methods other than actual
23acquisition costs.
24    The Department shall require, by rule, all providers of
25durable medical equipment to be accredited by an accreditation
26organization approved by the federal Centers for Medicare and



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



SB2520- 26 -LRB101 15492 KTG 64835 b

1recipient or enrollee is not already in receipt of same or
2similar equipment from another service provider, and that the
3refurbished durable medical equipment equally meets the needs
4of the recipient or enrollee. Nothing in this paragraph shall
5be construed to limit recipient or enrollee choice to obtain
6new durable medical equipment or place any additional prior
7authorization conditions on enrollees of managed care
9    The Department shall execute, relative to the nursing home
10prescreening project, written inter-agency agreements with the
11Department of Human Services and the Department on Aging, to
12effect the following: (i) intake procedures and common
13eligibility criteria for those persons who are receiving
14non-institutional services; and (ii) the establishment and
15development of non-institutional services in areas of the State
16where they are not currently available or are undeveloped; and
17(iii) notwithstanding any other provision of law, subject to
18federal approval, on and after July 1, 2012, an increase in the
19determination of need (DON) scores from 29 to 37 for applicants
20for institutional and home and community-based long term care;
21if and only if federal approval is not granted, the Department
22may, in conjunction with other affected agencies, implement
23utilization controls or changes in benefit packages to
24effectuate a similar savings amount for this population; and
25(iv) no later than July 1, 2013, minimum level of care
26eligibility criteria for institutional and home and



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1community-based long term care; and (v) no later than October
21, 2013, establish procedures to permit long term care
3providers access to eligibility scores for individuals with an
4admission date who are seeking or receiving services from the
5long term care provider. In order to select the minimum level
6of care eligibility criteria, the Governor shall establish a
7workgroup that includes affected agency representatives and
8stakeholders representing the institutional and home and
9community-based long term care interests. This Section shall
10not restrict the Department from implementing lower level of
11care eligibility criteria for community-based services in
12circumstances where federal approval has been granted.
13    The Illinois Department shall develop and operate, in
14cooperation with other State Departments and agencies and in
15compliance with applicable federal laws and regulations,
16appropriate and effective systems of health care evaluation and
17programs for monitoring of utilization of health care services
18and facilities, as it affects persons eligible for medical
19assistance under this Code.
20    The Illinois Department shall report annually to the
21General Assembly, no later than the second Friday in April of
221979 and each year thereafter, in regard to:
23        (a) actual statistics and trends in utilization of
24    medical services by public aid recipients;
25        (b) actual statistics and trends in the provision of
26    the various medical services by medical vendors;



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1        (c) current rate structures and proposed changes in
2    those rate structures for the various medical vendors; and
3        (d) efforts at utilization review and control by the
4    Illinois Department.
5    The period covered by each report shall be the 3 years
6ending on the June 30 prior to the report. The report shall
7include suggested legislation for consideration by the General
8Assembly. The requirement for reporting to the General Assembly
9shall be satisfied by filing copies of the report as required
10by Section 3.1 of the General Assembly Organization Act, and
11filing such additional copies with the State Government Report
12Distribution Center for the General Assembly as is required
13under paragraph (t) of Section 7 of the State Library Act.
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,
26cost-effective 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    Notwithstanding any other provision of this Code to the
16contrary, on or after July 1, 2015, all FDA approved forms of
17medication assisted treatment prescribed for the treatment of
18alcohol dependence or treatment of opioid dependence shall be
19covered under both fee for service and managed care medical
20assistance programs for persons who are otherwise eligible for
21medical assistance under this Article and shall not be subject
22to any (1) utilization control, other than those established
23under the American Society of Addiction Medicine patient
24placement criteria, (2) prior authorization mandate, or (3)
25lifetime restriction limit mandate.
26    On or after July 1, 2015, opioid antagonists prescribed for



SB2520- 30 -LRB101 15492 KTG 64835 b

1the treatment of an opioid overdose, including the medication
2product, administration devices, and any pharmacy fees related
3to the dispensing and administration of the opioid antagonist,
4shall be covered under the medical assistance program for
5persons who are otherwise eligible for medical assistance under
6this Article. As used in this Section, "opioid antagonist"
7means a drug that binds to opioid receptors and blocks or
8inhibits the effect of opioids acting on those receptors,
9including, but not limited to, naloxone hydrochloride or any
10other similarly acting drug approved by the U.S. Food and Drug
12    Upon federal approval, the Department shall provide
13coverage and reimbursement for all drugs that are approved for
14marketing by the federal Food and Drug Administration and that
15are recommended by the federal Public Health Service or the
16United States Centers for Disease Control and Prevention for
17pre-exposure prophylaxis and related pre-exposure prophylaxis
18services, including, but not limited to, HIV and sexually
19transmitted infection screening, treatment for sexually
20transmitted infections, medical monitoring, assorted labs, and
21counseling to reduce the likelihood of HIV infection among
22individuals who are not infected with HIV but who are at high
23risk of HIV infection.
24    A federally qualified health center, as defined in Section
251905(l)(2)(B) of the federal Social Security Act, shall be
26reimbursed by the Department in accordance with the federally



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1qualified health center's encounter rate for services provided
2to medical assistance recipients that are performed by a dental
3hygienist, as defined under the Illinois Dental Practice Act,
4working under the general supervision of a dentist and employed
5by a federally qualified health center.
6(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
7100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
86-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
9eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
10100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
111-1-20; revised 9-18-19.)
12    Section 99. Effective date. This Act takes effect upon
13becoming law.