Illinois General Assembly - Full Text of SB3301
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Full Text of SB3301  101st General Assembly




State of Illinois
2019 and 2020


Introduced 2/11/2020, by Sen. Julie A. Morrison


305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that both individual and group tobacco cessation counseling shall be covered under the medical assistance program.

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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 Section, both
13individual and group tobacco cessation counseling shall be
14covered under the medical assistance program.
15    Notwithstanding any other provision of this Code,
16reproductive health care that is otherwise legal in Illinois
17shall be covered under the medical assistance program for
18persons who are otherwise eligible for medical assistance under
19this Article.
20    Notwithstanding any other provision of this Code, the
21Illinois Department may not require, as a condition of payment
22for any laboratory test authorized under this Article, that a
23physician's handwritten signature appear on the laboratory
24test order form. The Illinois Department may, however, impose
25other appropriate requirements regarding laboratory test order



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



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1        (2) eyeglasses prescribed by a physician skilled in the
2    diseases of the eye, or by an optometrist, whichever the
3    person may select.
4    On and after July 1, 2018, the Department of Healthcare and
5Family Services shall provide dental services to any adult who
6is otherwise eligible for assistance under the medical
7assistance program. As used in this paragraph, "dental
8services" means diagnostic, preventative, restorative, or
9corrective procedures, including procedures and services for
10the prevention and treatment of periodontal disease and dental
11caries disease, provided by an individual who is licensed to
12practice dentistry or dental surgery or who is under the
13supervision of a dentist in the practice of his or her
15    On and after July 1, 2018, targeted dental services, as set
16forth in Exhibit D of the Consent Decree entered by the United
17States District Court for the Northern District of Illinois,
18Eastern Division, in the matter of Memisovski v. Maram, Case
19No. 92 C 1982, that are provided to adults under the medical
20assistance program shall be established at no less than the
21rates set forth in the "New Rate" column in Exhibit D of the
22Consent Decree for targeted dental services that are provided
23to persons under the age of 18 under the medical assistance
25    Notwithstanding any other provision of this Code and
26subject to federal approval, the Department may adopt rules to



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1allow a dentist who is volunteering his or her service at no
2cost to render dental services through an enrolled
3not-for-profit health clinic without the dentist personally
4enrolling as a participating provider in the medical assistance
5program. A not-for-profit health clinic shall include a public
6health clinic or Federally Qualified Health Center or other
7enrolled provider, as determined by the Department, through
8which dental services covered under this Section are performed.
9The Department shall establish a process for payment of claims
10for reimbursement for covered dental services rendered under
11this provision.
12    The Illinois Department, by rule, may distinguish and
13classify the medical services to be provided only in accordance
14with the classes of persons designated in Section 5-2.
15    The Department of Healthcare and Family Services must
16provide coverage and reimbursement for amino acid-based
17elemental formulas, regardless of delivery method, for the
18diagnosis and treatment of (i) eosinophilic disorders and (ii)
19short bowel syndrome when the prescribing physician has issued
20a written order stating that the amino acid-based elemental
21formula is medically necessary.
22    The Illinois Department shall authorize the provision of,
23and shall authorize payment for, screening by low-dose
24mammography for the presence of occult breast cancer for women
2535 years of age or older who are eligible for medical
26assistance under this Article, as follows:



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1        (A) A baseline mammogram for women 35 to 39 years of
2    age.
3        (B) An annual mammogram for women 40 years of age or
4    older.
5        (C) A mammogram at the age and intervals considered
6    medically necessary by the woman's health care provider for
7    women under 40 years of age and having a family history of
8    breast cancer, prior personal history of breast cancer,
9    positive genetic testing, or other risk factors.
10        (D) A comprehensive ultrasound screening and MRI of an
11    entire breast or breasts if a mammogram demonstrates
12    heterogeneous or dense breast tissue or when medically
13    necessary as determined by a physician licensed to practice
14    medicine in all of its branches.
15        (E) A screening MRI when medically necessary, as
16    determined by a physician licensed to practice medicine in
17    all of its branches.
18        (F) A diagnostic mammogram when medically necessary,
19    as determined by a physician licensed to practice medicine
20    in all its branches, advanced practice registered nurse, or
21    physician assistant.
22    The Department shall not impose a deductible, coinsurance,
23copayment, or any other cost-sharing requirement on the
24coverage provided under this paragraph; except that this
25sentence does not apply to coverage of diagnostic mammograms to
26the extent such coverage would disqualify a high-deductible



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1health plan from eligibility for a health savings account
2pursuant to Section 223 of the Internal Revenue Code (26 U.S.C.
4    All screenings shall include a physical breast exam,
5instruction on self-examination and information regarding the
6frequency of self-examination and its value as a preventative
8     For purposes of this Section:
9    "Diagnostic mammogram" means a mammogram obtained using
10diagnostic mammography.
11    "Diagnostic mammography" means a method of screening that
12is designed to evaluate an abnormality in a breast, including
13an abnormality seen or suspected on a screening mammogram or a
14subjective or objective abnormality otherwise detected in the
16    "Low-dose mammography" means the x-ray examination of the
17breast using equipment dedicated specifically for mammography,
18including the x-ray tube, filter, compression device, and image
19receptor, with an average radiation exposure delivery of less
20than one rad per breast for 2 views of an average size breast.
21The term also includes digital mammography and includes breast
23    "Breast tomosynthesis" means a radiologic procedure that
24involves the acquisition of projection images over the
25stationary breast to produce cross-sectional digital
26three-dimensional images of the breast.



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1    If, at any time, the Secretary of the United States
2Department of Health and Human Services, or its successor
3agency, promulgates rules or regulations to be published in the
4Federal Register or publishes a comment in the Federal Register
5or issues an opinion, guidance, or other action that would
6require the State, pursuant to any provision of the Patient
7Protection and Affordable Care Act (Public Law 111-148),
8including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
9successor provision, to defray the cost of any coverage for
10breast tomosynthesis outlined in this paragraph, then the
11requirement that an insurer cover breast tomosynthesis is
12inoperative other than any such coverage authorized under
13Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
14the State shall not assume any obligation for the cost of
15coverage for breast tomosynthesis set forth in this paragraph.
16    On and after January 1, 2016, the Department shall ensure
17that all networks of care for adult clients of the Department
18include access to at least one breast imaging Center of Imaging
19Excellence as certified by the American College of Radiology.
20    On and after January 1, 2012, providers participating in a
21quality improvement program approved by the Department shall be
22reimbursed for screening and diagnostic mammography at the same
23rate as the Medicare program's rates, including the increased
24reimbursement for digital mammography.
25    The Department shall convene an expert panel including
26representatives of hospitals, free-standing mammography



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1facilities, and doctors, including radiologists, to establish
2quality standards for mammography.
3    On and after January 1, 2017, providers participating in a
4breast cancer treatment quality improvement program approved
5by the Department shall be reimbursed for breast cancer
6treatment at a rate that is no lower than 95% of the Medicare
7program's rates for the data elements included in the breast
8cancer treatment quality program.
9    The Department shall convene an expert panel, including
10representatives of hospitals, free-standing breast cancer
11treatment centers, breast cancer quality organizations, and
12doctors, including breast surgeons, reconstructive breast
13surgeons, oncologists, and primary care providers to establish
14quality standards for breast cancer treatment.
15    Subject to federal approval, the Department shall
16establish a rate methodology for mammography at federally
17qualified health centers and other encounter-rate clinics.
18These clinics or centers may also collaborate with other
19hospital-based mammography facilities. By January 1, 2016, the
20Department shall report to the General Assembly on the status
21of the provision set forth in this paragraph.
22    The Department shall establish a methodology to remind
23women who are age-appropriate for screening mammography, but
24who have not received a mammogram within the previous 18
25months, of the importance and benefit of screening mammography.
26The Department shall work with experts in breast cancer



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1outreach and patient navigation to optimize these reminders and
2shall establish a methodology for evaluating their
3effectiveness and modifying the methodology based on the
5    The Department shall establish a performance goal for
6primary care providers with respect to their female patients
7over age 40 receiving an annual mammogram. This performance
8goal shall be used to provide additional reimbursement in the
9form of a quality performance bonus to primary care providers
10who meet that goal.
11    The Department shall devise a means of case-managing or
12patient navigation for beneficiaries diagnosed with breast
13cancer. This program shall initially operate as a pilot program
14in areas of the State with the highest incidence of mortality
15related to breast cancer. At least one pilot program site shall
16be in the metropolitan Chicago area and at least one site shall
17be outside the metropolitan Chicago area. On or after July 1,
182016, the pilot program shall be expanded to include one site
19in western Illinois, one site in southern Illinois, one site in
20central Illinois, and 4 sites within metropolitan Chicago. An
21evaluation of the pilot program shall be carried out measuring
22health outcomes and cost of care for those served by the pilot
23program compared to similarly situated patients who are not
24served by the pilot program.
25    The Department shall require all networks of care to
26develop a means either internally or by contract with experts



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1in navigation and community outreach to navigate cancer
2patients to comprehensive care in a timely fashion. The
3Department shall require all networks of care to include access
4for patients diagnosed with cancer to at least one academic
5commission on cancer-accredited cancer program as an
6in-network covered benefit.
7    Any medical or health care provider shall immediately
8recommend, to any pregnant woman who is being provided prenatal
9services and is suspected of having a substance use disorder as
10defined in the Substance Use Disorder Act, referral to a local
11substance use disorder treatment program licensed by the
12Department of Human Services or to a licensed hospital which
13provides substance abuse treatment services. The Department of
14Healthcare and Family Services shall assure coverage for the
15cost of treatment of the drug abuse or addiction for pregnant
16recipients in accordance with the Illinois Medicaid Program in
17conjunction with the Department of Human Services.
18    All medical providers providing medical assistance to
19pregnant women under this Code shall receive information from
20the Department on the availability of services under any
21program providing case management services for addicted women,
22including information on appropriate referrals for other
23social services that may be needed by addicted women in
24addition to treatment for addiction.
25    The Illinois Department, in cooperation with the
26Departments of Human Services (as successor to the Department



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1of Alcoholism and Substance Abuse) and Public Health, through a
2public awareness campaign, may provide information concerning
3treatment for alcoholism and drug abuse and addiction, prenatal
4health care, and other pertinent programs directed at reducing
5the number of drug-affected infants born to recipients of
6medical assistance.
7    Neither the Department of Healthcare and Family Services
8nor the Department of Human Services shall sanction the
9recipient solely on the basis of her substance abuse.
10    The Illinois Department shall establish such regulations
11governing the dispensing of health services under this Article
12as it shall deem appropriate. The Department should seek the
13advice of formal professional advisory committees appointed by
14the Director of the Illinois Department for the purpose of
15providing regular advice on policy and administrative matters,
16information dissemination and educational activities for
17medical and health care providers, and consistency in
18procedures to the Illinois Department.
19    The Illinois Department may develop and contract with
20Partnerships of medical providers to arrange medical services
21for persons eligible under Section 5-2 of this Code.
22Implementation of this Section may be by demonstration projects
23in certain geographic areas. The Partnership shall be
24represented by a sponsor organization. The Department, by rule,
25shall develop qualifications for sponsors of Partnerships.
26Nothing in this Section shall be construed to require that the



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1sponsor organization be a medical organization.
2    The sponsor must negotiate formal written contracts with
3medical providers for physician services, inpatient and
4outpatient hospital care, home health services, treatment for
5alcoholism and substance abuse, and other services determined
6necessary by the Illinois Department by rule for delivery by
7Partnerships. Physician services must include prenatal and
8obstetrical care. The Illinois Department shall reimburse
9medical services delivered by Partnership providers to clients
10in target areas according to provisions of this Article and the
11Illinois Health Finance Reform Act, except that:
12        (1) Physicians participating in a Partnership and
13    providing certain services, which shall be determined by
14    the Illinois Department, to persons in areas covered by the
15    Partnership may receive an additional surcharge for such
16    services.
17        (2) The Department may elect to consider and negotiate
18    financial incentives to encourage the development of
19    Partnerships and the efficient delivery of medical care.
20        (3) Persons receiving medical services through
21    Partnerships may receive medical and case management
22    services above the level usually offered through the
23    medical assistance program.
24    Medical providers shall be required to meet certain
25qualifications to participate in Partnerships to ensure the
26delivery of high quality medical services. These



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



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1and every exception is resolved. The Illinois Department shall
2require health care providers to make available, when
3authorized by the patient, in writing, the medical records in a
4timely fashion to other health care providers who are treating
5or serving persons eligible for Medical Assistance under this
6Article. All dispensers of medical services shall be required
7to maintain and retain business and professional records
8sufficient to fully and accurately document the nature, scope,
9details and receipt of the health care provided to persons
10eligible for medical assistance under this Code, in accordance
11with regulations promulgated by the Illinois Department. The
12rules and regulations shall require that proof of the receipt
13of prescription drugs, dentures, prosthetic devices and
14eyeglasses by eligible persons under this Section accompany
15each claim for reimbursement submitted by the dispenser of such
16medical services. No such claims for reimbursement shall be
17approved for payment by the Illinois Department without such
18proof of receipt, unless the Illinois Department shall have put
19into effect and shall be operating a system of post-payment
20audit and review which shall, on a sampling basis, be deemed
21adequate by the Illinois Department to assure that such drugs,
22dentures, prosthetic devices and eyeglasses for which payment
23is being made are actually being received by eligible
24recipients. Within 90 days after September 16, 1984 (the
25effective date of Public Act 83-1439), the Illinois Department
26shall establish a current list of acquisition costs for all



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1prosthetic devices and any other items recognized as medical
2equipment and supplies reimbursable under this Article and
3shall update such list on a quarterly basis, except that the
4acquisition costs of all prescription drugs shall be updated no
5less frequently than every 30 days as required by Section
7    Notwithstanding any other law to the contrary, the Illinois
8Department shall, within 365 days after July 22, 2013 (the
9effective date of Public Act 98-104), establish procedures to
10permit skilled care facilities licensed under the Nursing Home
11Care Act to submit monthly billing claims for reimbursement
12purposes. Following development of these procedures, the
13Department shall, by July 1, 2016, test the viability of the
14new system and implement any necessary operational or
15structural changes to its information technology platforms in
16order to allow for the direct acceptance and payment of nursing
17home claims.
18    Notwithstanding any other law to the contrary, the Illinois
19Department shall, within 365 days after August 15, 2014 (the
20effective date of Public Act 98-963), establish procedures to
21permit ID/DD facilities licensed under the ID/DD Community Care
22Act and MC/DD facilities licensed under the MC/DD Act to submit
23monthly billing claims for reimbursement purposes. Following
24development of these procedures, the Department shall have an
25additional 365 days to test the viability of the new system and
26to ensure that any necessary operational or structural changes



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



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



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



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1applicant is eligible. For claims for which the Illinois
2Department is not the primary payer, claims must be submitted
3to the Illinois Department within 180 days after the final
4adjudication by the primary payer.
5    In the case of long term care facilities, within 45
6calendar days of receipt by the facility of required
7prescreening information, new admissions with associated
8admission documents shall be submitted through the Medical
9Electronic Data Interchange (MEDI) or the Recipient
10Eligibility Verification (REV) System or shall be submitted
11directly to the Department of Human Services using required
12admission forms. Effective September 1, 2014, admission
13documents, including all prescreening information, must be
14submitted through MEDI or REV. Confirmation numbers assigned to
15an accepted transaction shall be retained by a facility to
16verify timely submittal. Once an admission transaction has been
17completed, all resubmitted claims following prior rejection
18are subject to receipt no later than 180 days after the
19admission transaction has been completed.
20    Claims that are not submitted and received in compliance
21with the foregoing requirements shall not be eligible for
22payment under the medical assistance program, and the State
23shall have no liability for payment of those claims.
24    To the extent consistent with applicable information and
25privacy, security, and disclosure laws, State and federal
26agencies and departments shall provide the Illinois Department



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



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



SB3301- 24 -LRB101 18585 KTG 68040 b

1recipient to temporarily acquire and use alternative or
2substitute devices or equipment pending repairs or
3replacements of any device or equipment previously authorized
4for such recipient by the Department. Notwithstanding any
5provision of Section 5-5f to the contrary, the Department may,
6by rule, exempt certain replacement wheelchair parts from prior
7approval and, for wheelchairs, wheelchair parts, wheelchair
8accessories, and related seating and positioning items,
9determine the wholesale price by methods other than actual
10acquisition costs.
11    The Department shall require, by rule, all providers of
12durable medical equipment to be accredited by an accreditation
13organization approved by the federal Centers for Medicare and
14Medicaid Services and recognized by the Department in order to
15bill the Department for providing durable medical equipment to
16recipients. No later than 15 months after the effective date of
17the rule adopted pursuant to this paragraph, all providers must
18meet the accreditation requirement.
19    In order to promote environmental responsibility, meet the
20needs of recipients and enrollees, and achieve significant cost
21savings, the Department, or a managed care organization under
22contract with the Department, may provide recipients or managed
23care enrollees who have a prescription or Certificate of
24Medical Necessity access to refurbished durable medical
25equipment under this Section (excluding prosthetic and
26orthotic devices as defined in the Orthotics, Prosthetics, and



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1Pedorthics Practice Act and complex rehabilitation technology
2products and associated services) through the State's
3assistive technology program's reutilization program, using
4staff with the Assistive Technology Professional (ATP)
5Certification if the refurbished durable medical equipment:
6(i) is available; (ii) is less expensive, including shipping
7costs, than new durable medical equipment of the same type;
8(iii) is able to withstand at least 3 years of use; (iv) is
9cleaned, disinfected, sterilized, and safe in accordance with
10federal Food and Drug Administration regulations and guidance
11governing the reprocessing of medical devices in health care
12settings; and (v) equally meets the needs of the recipient or
13enrollee. The reutilization program shall confirm that the
14recipient or enrollee is not already in receipt of same or
15similar equipment from another service provider, and that the
16refurbished durable medical equipment equally meets the needs
17of the recipient or enrollee. Nothing in this paragraph shall
18be construed to limit recipient or enrollee choice to obtain
19new durable medical equipment or place any additional prior
20authorization conditions on enrollees of managed care
22    The Department shall execute, relative to the nursing home
23prescreening project, written inter-agency agreements with the
24Department of Human Services and the Department on Aging, to
25effect the following: (i) intake procedures and common
26eligibility criteria for those persons who are receiving



SB3301- 26 -LRB101 18585 KTG 68040 b

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



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1cooperation with other State Departments and agencies and in
2compliance with applicable federal laws and regulations,
3appropriate and effective systems of health care evaluation and
4programs for monitoring of utilization of health care services
5and facilities, as it affects persons eligible for medical
6assistance under this Code.
7    The Illinois Department shall report annually to the
8General Assembly, no later than the second Friday in April of
91979 and each year thereafter, in regard to:
10        (a) actual statistics and trends in utilization of
11    medical services by public aid recipients;
12        (b) actual statistics and trends in the provision of
13    the various medical services by medical vendors;
14        (c) current rate structures and proposed changes in
15    those rate structures for the various medical vendors; and
16        (d) efforts at utilization review and control by the
17    Illinois Department.
18    The period covered by each report shall be the 3 years
19ending on the June 30 prior to the report. The report shall
20include suggested legislation for consideration by the General
21Assembly. The requirement for reporting to the General Assembly
22shall be satisfied by filing copies of the report as required
23by Section 3.1 of the General Assembly Organization Act, and
24filing such additional copies with the State Government Report
25Distribution Center for the General Assembly as is required
26under paragraph (t) of Section 7 of the State Library Act.



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1    Rulemaking authority to implement Public Act 95-1045, if
2any, is conditioned on the rules being adopted in accordance
3with all provisions of the Illinois Administrative Procedure
4Act and all rules and procedures of the Joint Committee on
5Administrative Rules; any purported rule not so adopted, for
6whatever reason, is unauthorized.
7    On and after July 1, 2012, the Department shall reduce any
8rate of reimbursement for services or other payments or alter
9any methodologies authorized by this Code to reduce any rate of
10reimbursement for services or other payments in accordance with
11Section 5-5e.
12    Because kidney transplantation can be an appropriate,
13cost-effective alternative to renal dialysis when medically
14necessary and notwithstanding the provisions of Section 1-11 of
15this Code, beginning October 1, 2014, the Department shall
16cover kidney transplantation for noncitizens with end-stage
17renal disease who are not eligible for comprehensive medical
18benefits, who meet the residency requirements of Section 5-3 of
19this Code, and who would otherwise meet the financial
20requirements of the appropriate class of eligible persons under
21Section 5-2 of this Code. To qualify for coverage of kidney
22transplantation, such person must be receiving emergency renal
23dialysis services covered by the Department. Providers under
24this Section shall be prior approved and certified by the
25Department to perform kidney transplantation and the services
26under this Section shall be limited to services associated with



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1kidney transplantation.
2    Notwithstanding any other provision of this Code to the
3contrary, on or after July 1, 2015, all FDA approved forms of
4medication assisted treatment prescribed for the treatment of
5alcohol dependence or treatment of opioid dependence shall be
6covered under both fee for service and managed care medical
7assistance programs for persons who are otherwise eligible for
8medical assistance under this Article and shall not be subject
9to any (1) utilization control, other than those established
10under the American Society of Addiction Medicine patient
11placement criteria, (2) prior authorization mandate, or (3)
12lifetime restriction limit mandate.
13    On or after July 1, 2015, opioid antagonists prescribed for
14the treatment of an opioid overdose, including the medication
15product, administration devices, and any pharmacy fees related
16to the dispensing and administration of the opioid antagonist,
17shall be covered under the medical assistance program for
18persons who are otherwise eligible for medical assistance under
19this Article. As used in this Section, "opioid antagonist"
20means a drug that binds to opioid receptors and blocks or
21inhibits the effect of opioids acting on those receptors,
22including, but not limited to, naloxone hydrochloride or any
23other similarly acting drug approved by the U.S. Food and Drug
25    Upon federal approval, the Department shall provide
26coverage and reimbursement for all drugs that are approved for



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1marketing by the federal Food and Drug Administration and that
2are recommended by the federal Public Health Service or the
3United States Centers for Disease Control and Prevention for
4pre-exposure prophylaxis and related pre-exposure prophylaxis
5services, including, but not limited to, HIV and sexually
6transmitted infection screening, treatment for sexually
7transmitted infections, medical monitoring, assorted labs, and
8counseling to reduce the likelihood of HIV infection among
9individuals who are not infected with HIV but who are at high
10risk of HIV infection.
11    A federally qualified health center, as defined in Section
121905(l)(2)(B) of the federal Social Security Act, shall be
13reimbursed by the Department in accordance with the federally
14qualified health center's encounter rate for services provided
15to medical assistance recipients that are performed by a dental
16hygienist, as defined under the Illinois Dental Practice Act,
17working under the general supervision of a dentist and employed
18by a federally qualified health center.
19(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
20100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
216-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
22eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
23100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
241-1-20; revised 9-18-19.)