Full Text of SB0054 99th General Assembly
SB0054enr 99TH GENERAL ASSEMBLY |
| | SB0054 Enrolled | | LRB099 03946 MLM 23963 b |
|
| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Insurance Code is amended by | 5 | | changing Section 356g as follows:
| 6 | | (215 ILCS 5/356g) (from Ch. 73, par. 968g)
| 7 | | Sec. 356g. Mammograms; mastectomies.
| 8 | | (a) Every insurer shall provide in each group or individual
| 9 | | policy, contract, or certificate of insurance issued or renewed | 10 | | for persons
who are residents of this State, coverage for | 11 | | screening by low-dose
mammography for all women 35 years of age | 12 | | or older for the presence of
occult breast cancer within the | 13 | | provisions of the policy, contract, or
certificate. The | 14 | | coverage shall be as follows:
| 15 | |
(1) A baseline mammogram for women 35 to 39 years of | 16 | | age.
| 17 | |
(2) An annual mammogram for women 40 years of age or | 18 | | older.
| 19 | | (3) A mammogram at the age and intervals considered | 20 | | medically necessary by the woman's health care provider for | 21 | | women under 40 years of age and having a family history of | 22 | | breast cancer, prior personal history of breast cancer, | 23 | | positive genetic testing, or other risk factors.
|
| | | SB0054 Enrolled | - 2 - | LRB099 03946 MLM 23963 b |
|
| 1 | | (4) A comprehensive ultrasound screening of an entire | 2 | | breast or breasts if a mammogram demonstrates | 3 | | heterogeneous or dense breast tissue, when medically | 4 | | necessary as determined by a physician licensed to practice | 5 | | medicine in all of its branches.
| 6 | | For purposes of this Section, "low-dose mammography"
means | 7 | | the x-ray examination of the breast using equipment dedicated
| 8 | | specifically for mammography, including the x-ray tube, | 9 | | filter, compression
device, and image receptor, with radiation | 10 | | exposure delivery of less than
1 rad per breast for 2 views of | 11 | | an average size breast. The term also includes digital | 12 | | mammography and includes breast tomosynthesis. As used in this | 13 | | Section, the term "breast tomosynthesis" means a radiologic | 14 | | procedure that involves the acquisition of projection images | 15 | | over the stationary breast to produce cross-sectional digital | 16 | | three-dimensional images of the breast .
| 17 | | (a-5) Coverage as described by subsection (a) shall be | 18 | | provided at no cost to the insured and shall not be applied to | 19 | | an annual or lifetime maximum benefit. | 20 | | (a-10) When health care services are available through | 21 | | contracted providers and a person does not comply with plan | 22 | | provisions specific to the use of contracted providers, the | 23 | | requirements of subsection (a-5) are not applicable. When a | 24 | | person does not comply with plan provisions specific to the use | 25 | | of contracted providers, plan provisions specific to the use of | 26 | | non-contracted providers must be applied without distinction |
| | | SB0054 Enrolled | - 3 - | LRB099 03946 MLM 23963 b |
|
| 1 | | for coverage required by this Section and shall be at least as | 2 | | favorable as for other radiological examinations covered by the | 3 | | policy or contract. | 4 | | (b) No policy of accident or health insurance that provides | 5 | | for
the surgical procedure known as a mastectomy shall be | 6 | | issued, amended,
delivered, or renewed in this State unless
| 7 | | that coverage also provides for prosthetic devices
or | 8 | | reconstructive surgery
incident to the mastectomy.
Coverage | 9 | | for breast reconstruction in connection with a mastectomy shall
| 10 | | include:
| 11 | | (1) reconstruction of the breast upon which the | 12 | | mastectomy has been
performed;
| 13 | | (2) surgery and reconstruction of the other breast to | 14 | | produce a
symmetrical appearance; and
| 15 | | (3) prostheses and treatment for physical | 16 | | complications at all stages of
mastectomy, including | 17 | | lymphedemas.
| 18 | | Care shall be determined in consultation with the attending | 19 | | physician and the
patient.
The offered coverage for prosthetic | 20 | | devices and
reconstructive surgery shall be subject to the | 21 | | deductible and coinsurance
conditions applied to the | 22 | | mastectomy, and all other terms and conditions
applicable to | 23 | | other benefits. When a mastectomy is performed and there is
no | 24 | | evidence of malignancy then the offered coverage may be limited | 25 | | to the
provision of prosthetic devices and reconstructive | 26 | | surgery to within 2
years after the date of the mastectomy. As |
| | | SB0054 Enrolled | - 4 - | LRB099 03946 MLM 23963 b |
|
| 1 | | used in this Section,
"mastectomy" means the removal of all or | 2 | | part of the breast for medically
necessary reasons, as | 3 | | determined by a licensed physician.
| 4 | | Written notice of the availability of coverage under this | 5 | | Section shall be
delivered to the insured upon enrollment and | 6 | | annually thereafter. An insurer
may not deny to an insured | 7 | | eligibility, or continued eligibility, to enroll or
to renew | 8 | | coverage under the terms of the plan solely for the purpose of
| 9 | | avoiding the requirements of this Section. An insurer may not | 10 | | penalize or
reduce or
limit the reimbursement of an attending | 11 | | provider or provide incentives
(monetary or otherwise) to an | 12 | | attending provider to induce the provider to
provide care to an | 13 | | insured in a manner inconsistent with this Section.
| 14 | | (c) Rulemaking authority to implement this amendatory Act | 15 | | of the 95th General Assembly, if any, is conditioned on the | 16 | | rules being adopted in accordance with all provisions of the | 17 | | Illinois Administrative Procedure Act and all rules and | 18 | | procedures of the Joint Committee on Administrative Rules; any | 19 | | purported rule not so adopted, for whatever reason, is | 20 | | unauthorized. | 21 | | (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07; | 22 | | 95-1045, eff. 3-27-09.)
| 23 | | Section 10. The Health Maintenance Organization Act is | 24 | | amended by changing Section 4-6.1 as follows:
|
| | | SB0054 Enrolled | - 5 - | LRB099 03946 MLM 23963 b |
|
| 1 | | (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
| 2 | | Sec. 4-6.1. Mammograms; mastectomies.
| 3 | | (a) Every contract or evidence of coverage
issued by a | 4 | | Health Maintenance Organization for persons who are residents | 5 | | of
this State shall contain coverage for screening by low-dose | 6 | | mammography
for all women 35 years of age or older for the | 7 | | presence of occult breast
cancer. The coverage shall be as | 8 | | follows:
| 9 | | (1) A baseline mammogram for women 35 to 39 years of | 10 | | age.
| 11 | | (2) An annual mammogram for women 40 years of age or | 12 | | older.
| 13 | | (3) A mammogram at the age and intervals considered | 14 | | medically necessary by the woman's health care provider for | 15 | | women under 40 years of age and having a family history of | 16 | | breast cancer, prior personal history of breast cancer, | 17 | | positive genetic testing, or other risk factors. | 18 | | (4) A comprehensive ultrasound screening of an entire | 19 | | breast or breasts if a mammogram demonstrates | 20 | | heterogeneous or dense breast tissue, when medically | 21 | | necessary as determined by a physician licensed to practice | 22 | | medicine in all of its branches.
| 23 | | For purposes of this Section, "low-dose mammography"
means | 24 | | the x-ray examination of the breast using equipment dedicated
| 25 | | specifically for mammography, including the x-ray tube, | 26 | | filter, compression
device, and image receptor, with radiation |
| | | SB0054 Enrolled | - 6 - | LRB099 03946 MLM 23963 b |
|
| 1 | | exposure delivery of less than 1
rad per breast for 2 views of | 2 | | an average size breast. The term also includes digital | 3 | | mammography and includes breast tomosynthesis. As used in this | 4 | | Section, the term "breast tomosynthesis" means a radiologic | 5 | | procedure that involves the acquisition of projection images | 6 | | over the stationary breast to produce cross-sectional digital | 7 | | three-dimensional images of the breast .
| 8 | | (a-5) Coverage as described in subsection (a) shall be | 9 | | provided at no cost to the enrollee and shall not be applied to | 10 | | an annual or lifetime maximum benefit. | 11 | | (b) No contract or evidence of coverage issued by a health | 12 | | maintenance
organization that provides for the
surgical | 13 | | procedure known as a mastectomy shall be issued, amended, | 14 | | delivered,
or renewed in this State on or after the effective | 15 | | date of this amendatory Act
of the 92nd General Assembly unless | 16 | | that coverage also provides for prosthetic
devices or | 17 | | reconstructive surgery incident to the mastectomy, providing | 18 | | that
the mastectomy is performed after the effective date of | 19 | | this amendatory Act.
Coverage for breast reconstruction in | 20 | | connection
with a mastectomy shall
include:
| 21 | | (1) reconstruction of the breast upon which the | 22 | | mastectomy has been
performed;
| 23 | | (2) surgery and reconstruction of the other breast to | 24 | | produce a
symmetrical appearance; and
| 25 | | (3) prostheses and treatment for physical | 26 | | complications at all stages of
mastectomy, including |
| | | SB0054 Enrolled | - 7 - | LRB099 03946 MLM 23963 b |
|
| 1 | | lymphedemas.
| 2 | | Care shall be determined in consultation with the attending | 3 | | physician and the
patient.
The offered coverage for prosthetic | 4 | | devices and
reconstructive surgery shall be subject to the | 5 | | deductible and coinsurance
conditions applied to the | 6 | | mastectomy and all other terms and conditions
applicable to | 7 | | other benefits. When a mastectomy is performed and there is
no | 8 | | evidence of malignancy, then the offered coverage may be | 9 | | limited to the
provision of prosthetic devices and | 10 | | reconstructive surgery to within 2
years after the date of the | 11 | | mastectomy. As used in this Section,
"mastectomy" means the | 12 | | removal of all or part of the breast for medically
necessary | 13 | | reasons, as determined by a licensed physician.
| 14 | | Written notice of the availability of coverage under this | 15 | | Section shall be
delivered to the enrollee upon enrollment and | 16 | | annually thereafter. A
health maintenance organization may not | 17 | | deny to an enrollee eligibility, or
continued eligibility, to | 18 | | enroll or
to renew coverage under the terms of the plan solely | 19 | | for the purpose of
avoiding the requirements of this Section. A | 20 | | health maintenance organization
may not penalize or
reduce or
| 21 | | limit the reimbursement of an attending provider or provide | 22 | | incentives
(monetary or otherwise) to an attending provider to | 23 | | induce the provider to
provide care to an insured in a manner | 24 | | inconsistent with this Section.
| 25 | | (c) Rulemaking authority to implement this amendatory Act | 26 | | of the 95th General Assembly, if any, is conditioned on the |
| | | SB0054 Enrolled | - 8 - | LRB099 03946 MLM 23963 b |
|
| 1 | | rules being adopted in accordance with all provisions of the | 2 | | Illinois Administrative Procedure Act and all rules and | 3 | | procedures of the Joint Committee on Administrative Rules; any | 4 | | purported rule not so adopted, for whatever reason, is | 5 | | unauthorized. | 6 | | (Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07; | 7 | | 95-1045, eff. 3-27-09.)
| 8 | | Section 15. The Illinois Public Aid Code is amended by | 9 | | changing Section 5-5 as follows:
| 10 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| 11 | | Sec. 5-5. Medical services. The Illinois Department, by | 12 | | rule, shall
determine the quantity and quality of and the rate | 13 | | of reimbursement for the
medical assistance for which
payment | 14 | | will be authorized, and the medical services to be provided,
| 15 | | which may include all or part of the following: (1) inpatient | 16 | | hospital
services; (2) outpatient hospital services; (3) other | 17 | | laboratory and
X-ray services; (4) skilled nursing home | 18 | | services; (5) physicians'
services whether furnished in the | 19 | | office, the patient's home, a
hospital, a skilled nursing home, | 20 | | or elsewhere; (6) medical care, or any
other type of remedial | 21 | | care furnished by licensed practitioners; (7)
home health care | 22 | | services; (8) private duty nursing service; (9) clinic
| 23 | | services; (10) dental services, including prevention and | 24 | | treatment of periodontal disease and dental caries disease for |
| | | SB0054 Enrolled | - 9 - | LRB099 03946 MLM 23963 b |
|
| 1 | | pregnant women, provided by an individual licensed to practice | 2 | | dentistry or dental surgery; for purposes of this item (10), | 3 | | "dental services" means diagnostic, preventive, or corrective | 4 | | procedures provided by or under the supervision of a dentist in | 5 | | the practice of his or her profession; (11) physical therapy | 6 | | and related
services; (12) prescribed drugs, dentures, and | 7 | | prosthetic devices; and
eyeglasses prescribed by a physician | 8 | | skilled in the diseases of the eye,
or by an optometrist, | 9 | | whichever the person may select; (13) other
diagnostic, | 10 | | screening, preventive, and rehabilitative services, including | 11 | | to ensure that the individual's need for intervention or | 12 | | treatment of mental disorders or substance use disorders or | 13 | | co-occurring mental health and substance use disorders is | 14 | | determined using a uniform screening, assessment, and | 15 | | evaluation process inclusive of criteria, for children and | 16 | | adults; for purposes of this item (13), a uniform screening, | 17 | | assessment, and evaluation process refers to a process that | 18 | | includes an appropriate evaluation and, as warranted, a | 19 | | referral; "uniform" does not mean the use of a singular | 20 | | instrument, tool, or process that all must utilize; (14)
| 21 | | transportation and such other expenses as may be necessary; | 22 | | (15) medical
treatment of sexual assault survivors, as defined | 23 | | in
Section 1a of the Sexual Assault Survivors Emergency | 24 | | Treatment Act, for
injuries sustained as a result of the sexual | 25 | | assault, including
examinations and laboratory tests to | 26 | | discover evidence which may be used in
criminal proceedings |
| | | SB0054 Enrolled | - 10 - | LRB099 03946 MLM 23963 b |
|
| 1 | | arising from the sexual assault; (16) the
diagnosis and | 2 | | treatment of sickle cell anemia; and (17)
any other medical | 3 | | care, and any other type of remedial care recognized
under the | 4 | | laws of this State, but not including abortions, or induced
| 5 | | miscarriages or premature births, unless, in the opinion of a | 6 | | physician,
such procedures are necessary for the preservation | 7 | | of the life of the
woman seeking such treatment, or except an | 8 | | induced premature birth
intended to produce a live viable child | 9 | | and such procedure is necessary
for the health of the mother or | 10 | | her unborn child. The Illinois Department,
by rule, shall | 11 | | prohibit any physician from providing medical assistance
to | 12 | | anyone eligible therefor under this Code where such physician | 13 | | has been
found guilty of performing an abortion procedure in a | 14 | | wilful and wanton
manner upon a woman who was not pregnant at | 15 | | the time such abortion
procedure was performed. The term "any | 16 | | other type of remedial care" shall
include nursing care and | 17 | | nursing home service for persons who rely on
treatment by | 18 | | spiritual means alone through prayer for healing.
| 19 | | Notwithstanding any other provision of this Section, a | 20 | | comprehensive
tobacco use cessation program that includes | 21 | | purchasing prescription drugs or
prescription medical devices | 22 | | approved by the Food and Drug Administration shall
be covered | 23 | | under the medical assistance
program under this Article for | 24 | | persons who are otherwise eligible for
assistance under this | 25 | | Article.
| 26 | | Notwithstanding any other provision of this Code, the |
| | | SB0054 Enrolled | - 11 - | LRB099 03946 MLM 23963 b |
|
| 1 | | Illinois
Department may not require, as a condition of payment | 2 | | for any laboratory
test authorized under this Article, that a | 3 | | physician's handwritten signature
appear on the laboratory | 4 | | test order form. The Illinois Department may,
however, impose | 5 | | other appropriate requirements regarding laboratory test
order | 6 | | documentation.
| 7 | | Upon receipt of federal approval of an amendment to the | 8 | | Illinois Title XIX State Plan for this purpose, the Department | 9 | | shall authorize the Chicago Public Schools (CPS) to procure a | 10 | | vendor or vendors to manufacture eyeglasses for individuals | 11 | | enrolled in a school within the CPS system. CPS shall ensure | 12 | | that its vendor or vendors are enrolled as providers in the | 13 | | medical assistance program and in any capitated Medicaid | 14 | | managed care entity (MCE) serving individuals enrolled in a | 15 | | school within the CPS system. Under any contract procured under | 16 | | this provision, the vendor or vendors must serve only | 17 | | individuals enrolled in a school within the CPS system. Claims | 18 | | for services provided by CPS's vendor or vendors to recipients | 19 | | of benefits in the medical assistance program under this Code, | 20 | | the Children's Health Insurance Program, or the Covering ALL | 21 | | KIDS Health Insurance Program shall be submitted to the | 22 | | Department or the MCE in which the individual is enrolled for | 23 | | payment and shall be reimbursed at the Department's or the | 24 | | MCE's established rates or rate methodologies for eyeglasses. | 25 | | On and after July 1, 2012, the Department of Healthcare and | 26 | | Family Services may provide the following services to
persons
|
| | | SB0054 Enrolled | - 12 - | LRB099 03946 MLM 23963 b |
|
| 1 | | eligible for assistance under this Article who are | 2 | | participating in
education, training or employment programs | 3 | | operated by the Department of Human
Services as successor to | 4 | | the Department of Public Aid:
| 5 | | (1) dental services provided by or under the | 6 | | supervision of a dentist; and
| 7 | | (2) eyeglasses prescribed by a physician skilled in the | 8 | | diseases of the
eye, or by an optometrist, whichever the | 9 | | person may select.
| 10 | | Notwithstanding any other provision of this Code and | 11 | | subject to federal approval, the Department may adopt rules to | 12 | | allow a dentist who is volunteering his or her service at no | 13 | | cost to render dental services through an enrolled | 14 | | not-for-profit health clinic without the dentist personally | 15 | | enrolling as a participating provider in the medical assistance | 16 | | program. A not-for-profit health clinic shall include a public | 17 | | health clinic or Federally Qualified Health Center or other | 18 | | enrolled provider, as determined by the Department, through | 19 | | which dental services covered under this Section are performed. | 20 | | The Department shall establish a process for payment of claims | 21 | | for reimbursement for covered dental services rendered under | 22 | | this provision. | 23 | | The Illinois Department, by rule, may distinguish and | 24 | | classify the
medical services to be provided only in accordance | 25 | | with the classes of
persons designated in Section 5-2.
| 26 | | The Department of Healthcare and Family Services must |
| | | SB0054 Enrolled | - 13 - | LRB099 03946 MLM 23963 b |
|
| 1 | | provide coverage and reimbursement for amino acid-based | 2 | | elemental formulas, regardless of delivery method, for the | 3 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 4 | | short bowel syndrome when the prescribing physician has issued | 5 | | a written order stating that the amino acid-based elemental | 6 | | formula is medically necessary.
| 7 | | The Illinois Department shall authorize the provision of, | 8 | | and shall
authorize payment for, screening by low-dose | 9 | | mammography for the presence of
occult breast cancer for women | 10 | | 35 years of age or older who are eligible
for medical | 11 | | assistance under this Article, as follows: | 12 | | (A) A baseline
mammogram for women 35 to 39 years of | 13 | | age.
| 14 | | (B) An annual mammogram for women 40 years of age or | 15 | | older. | 16 | | (C) A mammogram at the age and intervals considered | 17 | | medically necessary by the woman's health care provider for | 18 | | women under 40 years of age and having a family history of | 19 | | breast cancer, prior personal history of breast cancer, | 20 | | positive genetic testing, or other risk factors. | 21 | | (D) A comprehensive ultrasound screening of an entire | 22 | | breast or breasts if a mammogram demonstrates | 23 | | heterogeneous or dense breast tissue, when medically | 24 | | necessary as determined by a physician licensed to practice | 25 | | medicine in all of its branches. | 26 | | All screenings
shall
include a physical breast exam, |
| | | SB0054 Enrolled | - 14 - | LRB099 03946 MLM 23963 b |
|
| 1 | | instruction on self-examination and
information regarding the | 2 | | frequency of self-examination and its value as a
preventative | 3 | | tool. For purposes of this Section, "low-dose mammography" | 4 | | means
the x-ray examination of the breast using equipment | 5 | | dedicated specifically
for mammography, including the x-ray | 6 | | tube, filter, compression device,
and image receptor, with an | 7 | | average radiation exposure delivery
of less than one rad per | 8 | | breast for 2 views of an average size breast.
The term also | 9 | | includes digital mammography and includes breast | 10 | | tomosynthesis. As used in this Section, the term "breast | 11 | | tomosynthesis" means a radiologic procedure that involves the | 12 | | acquisition of projection images over the stationary breast to | 13 | | produce cross-sectional digital three-dimensional images of | 14 | | the breast .
| 15 | | On and after January 1, 2012, providers participating in a | 16 | | quality improvement program approved by the Department shall be | 17 | | reimbursed for screening and diagnostic mammography at the same | 18 | | rate as the Medicare program's rates, including the increased | 19 | | reimbursement for digital mammography. | 20 | | The Department shall convene an expert panel including | 21 | | representatives of hospitals, free-standing mammography | 22 | | facilities, and doctors, including radiologists, to establish | 23 | | quality standards. | 24 | | Subject to federal approval, the Department shall | 25 | | establish a rate methodology for mammography at federally | 26 | | qualified health centers and other encounter-rate clinics. |
| | | SB0054 Enrolled | - 15 - | LRB099 03946 MLM 23963 b |
|
| 1 | | These clinics or centers may also collaborate with other | 2 | | hospital-based mammography facilities. | 3 | | The Department shall establish a methodology to remind | 4 | | women who are age-appropriate for screening mammography, but | 5 | | who have not received a mammogram within the previous 18 | 6 | | months, of the importance and benefit of screening mammography. | 7 | | The Department shall establish a performance goal for | 8 | | primary care providers with respect to their female patients | 9 | | over age 40 receiving an annual mammogram. This performance | 10 | | goal shall be used to provide additional reimbursement in the | 11 | | form of a quality performance bonus to primary care providers | 12 | | who meet that goal. | 13 | | The Department shall devise a means of case-managing or | 14 | | patient navigation for beneficiaries diagnosed with breast | 15 | | cancer. This program shall initially operate as a pilot program | 16 | | in areas of the State with the highest incidence of mortality | 17 | | related to breast cancer. At least one pilot program site shall | 18 | | be in the metropolitan Chicago area and at least one site shall | 19 | | be outside the metropolitan Chicago area. An evaluation of the | 20 | | pilot program shall be carried out measuring health outcomes | 21 | | and cost of care for those served by the pilot program compared | 22 | | to similarly situated patients who are not served by the pilot | 23 | | program. | 24 | | Any medical or health care provider shall immediately | 25 | | recommend, to
any pregnant woman who is being provided prenatal | 26 | | services and is suspected
of drug abuse or is addicted as |
| | | SB0054 Enrolled | - 16 - | LRB099 03946 MLM 23963 b |
|
| 1 | | defined in the Alcoholism and Other Drug Abuse
and Dependency | 2 | | Act, referral to a local substance abuse treatment provider
| 3 | | licensed by the Department of Human Services or to a licensed
| 4 | | hospital which provides substance abuse treatment services. | 5 | | The Department of Healthcare and Family Services
shall assure | 6 | | coverage for the cost of treatment of the drug abuse or
| 7 | | addiction for pregnant recipients in accordance with the | 8 | | Illinois Medicaid
Program in conjunction with the Department of | 9 | | Human Services.
| 10 | | All medical providers providing medical assistance to | 11 | | pregnant women
under this Code shall receive information from | 12 | | the Department on the
availability of services under the Drug | 13 | | Free Families with a Future or any
comparable program providing | 14 | | case management services for addicted women,
including | 15 | | information on appropriate referrals for other social services
| 16 | | that may be needed by addicted women in addition to treatment | 17 | | for addiction.
| 18 | | The Illinois Department, in cooperation with the | 19 | | Departments of Human
Services (as successor to the Department | 20 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 21 | | public awareness campaign, may
provide information concerning | 22 | | treatment for alcoholism and drug abuse and
addiction, prenatal | 23 | | health care, and other pertinent programs directed at
reducing | 24 | | the number of drug-affected infants born to recipients of | 25 | | medical
assistance.
| 26 | | Neither the Department of Healthcare and Family Services |
| | | SB0054 Enrolled | - 17 - | LRB099 03946 MLM 23963 b |
|
| 1 | | nor the Department of Human
Services shall sanction the | 2 | | recipient solely on the basis of
her substance abuse.
| 3 | | The Illinois Department shall establish such regulations | 4 | | governing
the dispensing of health services under this Article | 5 | | as it shall deem
appropriate. The Department
should
seek the | 6 | | advice of formal professional advisory committees appointed by
| 7 | | the Director of the Illinois Department for the purpose of | 8 | | providing regular
advice on policy and administrative matters, | 9 | | information dissemination and
educational activities for | 10 | | medical and health care providers, and
consistency in | 11 | | procedures to the Illinois Department.
| 12 | | The Illinois Department may develop and contract with | 13 | | Partnerships of
medical providers to arrange medical services | 14 | | for persons eligible under
Section 5-2 of this Code. | 15 | | Implementation of this Section may be by
demonstration projects | 16 | | in certain geographic areas. The Partnership shall
be | 17 | | represented by a sponsor organization. The Department, by rule, | 18 | | shall
develop qualifications for sponsors of Partnerships. | 19 | | Nothing in this
Section shall be construed to require that the | 20 | | sponsor organization be a
medical organization.
| 21 | | The sponsor must negotiate formal written contracts with | 22 | | medical
providers for physician services, inpatient and | 23 | | outpatient hospital care,
home health services, treatment for | 24 | | alcoholism and substance abuse, and
other services determined | 25 | | necessary by the Illinois Department by rule for
delivery by | 26 | | Partnerships. Physician services must include prenatal and
|
| | | SB0054 Enrolled | - 18 - | LRB099 03946 MLM 23963 b |
|
| 1 | | obstetrical care. The Illinois Department shall reimburse | 2 | | medical services
delivered by Partnership providers to clients | 3 | | in target areas according to
provisions of this Article and the | 4 | | Illinois Health Finance Reform Act,
except that:
| 5 | | (1) Physicians participating in a Partnership and | 6 | | providing certain
services, which shall be determined by | 7 | | the Illinois Department, to persons
in areas covered by the | 8 | | Partnership may receive an additional surcharge
for such | 9 | | services.
| 10 | | (2) The Department may elect to consider and negotiate | 11 | | financial
incentives to encourage the development of | 12 | | Partnerships and the efficient
delivery of medical care.
| 13 | | (3) Persons receiving medical services through | 14 | | Partnerships may receive
medical and case management | 15 | | services above the level usually offered
through the | 16 | | medical assistance program.
| 17 | | Medical providers shall be required to meet certain | 18 | | qualifications to
participate in Partnerships to ensure the | 19 | | delivery of high quality medical
services. These | 20 | | qualifications shall be determined by rule of the Illinois
| 21 | | Department and may be higher than qualifications for | 22 | | participation in the
medical assistance program. Partnership | 23 | | sponsors may prescribe reasonable
additional qualifications | 24 | | for participation by medical providers, only with
the prior | 25 | | written approval of the Illinois Department.
| 26 | | Nothing in this Section shall limit the free choice of |
| | | SB0054 Enrolled | - 19 - | LRB099 03946 MLM 23963 b |
|
| 1 | | practitioners,
hospitals, and other providers of medical | 2 | | services by clients.
In order to ensure patient freedom of | 3 | | choice, the Illinois Department shall
immediately promulgate | 4 | | all rules and take all other necessary actions so that
provided | 5 | | services may be accessed from therapeutically certified | 6 | | optometrists
to the full extent of the Illinois Optometric | 7 | | Practice Act of 1987 without
discriminating between service | 8 | | providers.
| 9 | | The Department shall apply for a waiver from the United | 10 | | States Health
Care Financing Administration to allow for the | 11 | | implementation of
Partnerships under this Section.
| 12 | | The Illinois Department shall require health care | 13 | | providers to maintain
records that document the medical care | 14 | | and services provided to recipients
of Medical Assistance under | 15 | | this Article. Such records must be retained for a period of not | 16 | | less than 6 years from the date of service or as provided by | 17 | | applicable State law, whichever period is longer, except that | 18 | | if an audit is initiated within the required retention period | 19 | | then the records must be retained until the audit is completed | 20 | | and every exception is resolved. The Illinois Department shall
| 21 | | require health care providers to make available, when | 22 | | authorized by the
patient, in writing, the medical records in a | 23 | | timely fashion to other
health care providers who are treating | 24 | | or serving persons eligible for
Medical Assistance under this | 25 | | Article. All dispensers of medical services
shall be required | 26 | | to maintain and retain business and professional records
|
| | | SB0054 Enrolled | - 20 - | LRB099 03946 MLM 23963 b |
|
| 1 | | sufficient to fully and accurately document the nature, scope, | 2 | | details and
receipt of the health care provided to persons | 3 | | eligible for medical
assistance under this Code, in accordance | 4 | | with regulations promulgated by
the Illinois Department. The | 5 | | rules and regulations shall require that proof
of the receipt | 6 | | of prescription drugs, dentures, prosthetic devices and
| 7 | | eyeglasses by eligible persons under this Section accompany | 8 | | each claim
for reimbursement submitted by the dispenser of such | 9 | | medical services.
No such claims for reimbursement shall be | 10 | | approved for payment by the Illinois
Department without such | 11 | | proof of receipt, unless the Illinois Department
shall have put | 12 | | into effect and shall be operating a system of post-payment
| 13 | | audit and review which shall, on a sampling basis, be deemed | 14 | | adequate by
the Illinois Department to assure that such drugs, | 15 | | dentures, prosthetic
devices and eyeglasses for which payment | 16 | | is being made are actually being
received by eligible | 17 | | recipients. Within 90 days after the effective date of
this | 18 | | amendatory Act of 1984, the Illinois Department shall establish | 19 | | a
current list of acquisition costs for all prosthetic devices | 20 | | and any
other items recognized as medical equipment and | 21 | | supplies reimbursable under
this Article and shall update such | 22 | | list on a quarterly basis, except that
the acquisition costs of | 23 | | all prescription drugs shall be updated no
less frequently than | 24 | | every 30 days as required by Section 5-5.12.
| 25 | | The rules and regulations of the Illinois Department shall | 26 | | require
that a written statement including the required opinion |
| | | SB0054 Enrolled | - 21 - | LRB099 03946 MLM 23963 b |
|
| 1 | | of a physician
shall accompany any claim for reimbursement for | 2 | | abortions, or induced
miscarriages or premature births. This | 3 | | statement shall indicate what
procedures were used in providing | 4 | | such medical services.
| 5 | | Notwithstanding any other law to the contrary, the Illinois | 6 | | Department shall, within 365 days after July 22, 2013 , (the | 7 | | effective date of Public Act 98-104), establish procedures to | 8 | | permit skilled care facilities licensed under the Nursing Home | 9 | | Care Act to submit monthly billing claims for reimbursement | 10 | | purposes. Following development of these procedures, the | 11 | | Department shall have an additional 365 days to test the | 12 | | viability of the new system and to ensure that any necessary | 13 | | operational or structural changes to its information | 14 | | technology platforms are implemented. | 15 | | Notwithstanding any other law to the contrary, the Illinois | 16 | | Department shall, within 365 days after August 15, 2014 ( the | 17 | | effective date of Public Act 98-963) this amendatory Act of the | 18 | | 98th General Assembly , establish procedures to permit ID/DD | 19 | | facilities licensed under the ID/DD Community Care Act to | 20 | | submit monthly billing claims for reimbursement purposes. | 21 | | Following development of these procedures, the Department | 22 | | shall have an additional 365 days to test the viability of the | 23 | | new system and to ensure that any necessary operational or | 24 | | structural changes to its information technology platforms are | 25 | | implemented. | 26 | | The Illinois Department shall require all dispensers of |
| | | SB0054 Enrolled | - 22 - | LRB099 03946 MLM 23963 b |
|
| 1 | | medical
services, other than an individual practitioner or | 2 | | group of practitioners,
desiring to participate in the Medical | 3 | | Assistance program
established under this Article to disclose | 4 | | all financial, beneficial,
ownership, equity, surety or other | 5 | | interests in any and all firms,
corporations, partnerships, | 6 | | associations, business enterprises, joint
ventures, agencies, | 7 | | institutions or other legal entities providing any
form of | 8 | | health care services in this State under this Article.
| 9 | | The Illinois Department may require that all dispensers of | 10 | | medical
services desiring to participate in the medical | 11 | | assistance program
established under this Article disclose, | 12 | | under such terms and conditions as
the Illinois Department may | 13 | | by rule establish, all inquiries from clients
and attorneys | 14 | | regarding medical bills paid by the Illinois Department, which
| 15 | | inquiries could indicate potential existence of claims or liens | 16 | | for the
Illinois Department.
| 17 | | Enrollment of a vendor
shall be
subject to a provisional | 18 | | period and shall be conditional for one year. During the period | 19 | | of conditional enrollment, the Department may
terminate the | 20 | | vendor's eligibility to participate in, or may disenroll the | 21 | | vendor from, the medical assistance
program without cause. | 22 | | Unless otherwise specified, such termination of eligibility or | 23 | | disenrollment is not subject to the
Department's hearing | 24 | | process.
However, a disenrolled vendor may reapply without | 25 | | penalty.
| 26 | | The Department has the discretion to limit the conditional |
| | | SB0054 Enrolled | - 23 - | LRB099 03946 MLM 23963 b |
|
| 1 | | enrollment period for vendors based upon category of risk of | 2 | | the vendor. | 3 | | Prior to enrollment and during the conditional enrollment | 4 | | period in the medical assistance program, all vendors shall be | 5 | | subject to enhanced oversight, screening, and review based on | 6 | | the risk of fraud, waste, and abuse that is posed by the | 7 | | category of risk of the vendor. The Illinois Department shall | 8 | | establish the procedures for oversight, screening, and review, | 9 | | which may include, but need not be limited to: criminal and | 10 | | financial background checks; fingerprinting; license, | 11 | | certification, and authorization verifications; unscheduled or | 12 | | unannounced site visits; database checks; prepayment audit | 13 | | reviews; audits; payment caps; payment suspensions; and other | 14 | | screening as required by federal or State law. | 15 | | The Department shall define or specify the following: (i) | 16 | | by provider notice, the "category of risk of the vendor" for | 17 | | each type of vendor, which shall take into account the level of | 18 | | screening applicable to a particular category of vendor under | 19 | | federal law and regulations; (ii) by rule or provider notice, | 20 | | the maximum length of the conditional enrollment period for | 21 | | each category of risk of the vendor; and (iii) by rule, the | 22 | | hearing rights, if any, afforded to a vendor in each category | 23 | | of risk of the vendor that is terminated or disenrolled during | 24 | | the conditional enrollment period. | 25 | | To be eligible for payment consideration, a vendor's | 26 | | payment claim or bill, either as an initial claim or as a |
| | | SB0054 Enrolled | - 24 - | LRB099 03946 MLM 23963 b |
|
| 1 | | resubmitted claim following prior rejection, must be received | 2 | | by the Illinois Department, or its fiscal intermediary, no | 3 | | later than 180 days after the latest date on the claim on which | 4 | | medical goods or services were provided, with the following | 5 | | exceptions: | 6 | | (1) In the case of a provider whose enrollment is in | 7 | | process by the Illinois Department, the 180-day period | 8 | | shall not begin until the date on the written notice from | 9 | | the Illinois Department that the provider enrollment is | 10 | | complete. | 11 | | (2) In the case of errors attributable to the Illinois | 12 | | Department or any of its claims processing intermediaries | 13 | | which result in an inability to receive, process, or | 14 | | adjudicate a claim, the 180-day period shall not begin | 15 | | until the provider has been notified of the error. | 16 | | (3) In the case of a provider for whom the Illinois | 17 | | Department initiates the monthly billing process. | 18 | | (4) In the case of a provider operated by a unit of | 19 | | local government with a population exceeding 3,000,000 | 20 | | when local government funds finance federal participation | 21 | | for claims payments. | 22 | | For claims for services rendered during a period for which | 23 | | a recipient received retroactive eligibility, claims must be | 24 | | filed within 180 days after the Department determines the | 25 | | applicant is eligible. For claims for which the Illinois | 26 | | Department is not the primary payer, claims must be submitted |
| | | SB0054 Enrolled | - 25 - | LRB099 03946 MLM 23963 b |
|
| 1 | | to the Illinois Department within 180 days after the final | 2 | | adjudication by the primary payer. | 3 | | In the case of long term care facilities, within 5 days of | 4 | | receipt by the facility of required prescreening information, | 5 | | data for new admissions shall be entered into the Medical | 6 | | Electronic Data Interchange (MEDI) or the Recipient | 7 | | Eligibility Verification (REV) System or successor system, and | 8 | | within 15 days of receipt by the facility of required | 9 | | prescreening information, admission documents shall be | 10 | | submitted through MEDI or REV or shall be submitted directly to | 11 | | the Department of Human Services using required admission | 12 | | forms. Effective September
1, 2014, admission documents, | 13 | | including all prescreening
information, must be submitted | 14 | | through MEDI or REV. Confirmation numbers assigned to an | 15 | | accepted transaction shall be retained by a facility to verify | 16 | | timely submittal. Once an admission transaction has been | 17 | | completed, all resubmitted claims following prior rejection | 18 | | are subject to receipt no later than 180 days after the | 19 | | admission transaction has been completed. | 20 | | Claims that are not submitted and received in compliance | 21 | | with the foregoing requirements shall not be eligible for | 22 | | payment under the medical assistance program, and the State | 23 | | shall have no liability for payment of those claims. | 24 | | To the extent consistent with applicable information and | 25 | | privacy, security, and disclosure laws, State and federal | 26 | | agencies and departments shall provide the Illinois Department |
| | | SB0054 Enrolled | - 26 - | LRB099 03946 MLM 23963 b |
|
| 1 | | access to confidential and other information and data necessary | 2 | | to perform eligibility and payment verifications and other | 3 | | Illinois Department functions. This includes, but is not | 4 | | limited to: information pertaining to licensure; | 5 | | certification; earnings; immigration status; citizenship; wage | 6 | | reporting; unearned and earned income; pension income; | 7 | | employment; supplemental security income; social security | 8 | | numbers; National Provider Identifier (NPI) numbers; the | 9 | | National Practitioner Data Bank (NPDB); program and agency | 10 | | exclusions; taxpayer identification numbers; tax delinquency; | 11 | | corporate information; and death records. | 12 | | The Illinois Department shall enter into agreements with | 13 | | State agencies and departments, and is authorized to enter into | 14 | | agreements with federal agencies and departments, under which | 15 | | such agencies and departments shall share data necessary for | 16 | | medical assistance program integrity functions and oversight. | 17 | | The Illinois Department shall develop, in cooperation with | 18 | | other State departments and agencies, and in compliance with | 19 | | applicable federal laws and regulations, appropriate and | 20 | | effective methods to share such data. At a minimum, and to the | 21 | | extent necessary to provide data sharing, the Illinois | 22 | | Department shall enter into agreements with State agencies and | 23 | | departments, and is authorized to enter into agreements with | 24 | | federal agencies and departments, including but not limited to: | 25 | | the Secretary of State; the Department of Revenue; the | 26 | | Department of Public Health; the Department of Human Services; |
| | | SB0054 Enrolled | - 27 - | LRB099 03946 MLM 23963 b |
|
| 1 | | and the Department of Financial and Professional Regulation. | 2 | | Beginning in fiscal year 2013, the Illinois Department | 3 | | shall set forth a request for information to identify the | 4 | | benefits of a pre-payment, post-adjudication, and post-edit | 5 | | claims system with the goals of streamlining claims processing | 6 | | and provider reimbursement, reducing the number of pending or | 7 | | rejected claims, and helping to ensure a more transparent | 8 | | adjudication process through the utilization of: (i) provider | 9 | | data verification and provider screening technology; and (ii) | 10 | | clinical code editing; and (iii) pre-pay, pre- or | 11 | | post-adjudicated predictive modeling with an integrated case | 12 | | management system with link analysis. Such a request for | 13 | | information shall not be considered as a request for proposal | 14 | | or as an obligation on the part of the Illinois Department to | 15 | | take any action or acquire any products or services. | 16 | | The Illinois Department shall establish policies, | 17 | | procedures,
standards and criteria by rule for the acquisition, | 18 | | repair and replacement
of orthotic and prosthetic devices and | 19 | | durable medical equipment. Such
rules shall provide, but not be | 20 | | limited to, the following services: (1)
immediate repair or | 21 | | replacement of such devices by recipients; and (2) rental, | 22 | | lease, purchase or lease-purchase of
durable medical equipment | 23 | | in a cost-effective manner, taking into
consideration the | 24 | | recipient's medical prognosis, the extent of the
recipient's | 25 | | needs, and the requirements and costs for maintaining such
| 26 | | equipment. Subject to prior approval, such rules shall enable a |
| | | SB0054 Enrolled | - 28 - | LRB099 03946 MLM 23963 b |
|
| 1 | | recipient to temporarily acquire and
use alternative or | 2 | | substitute devices or equipment pending repairs or
| 3 | | replacements of any device or equipment previously authorized | 4 | | for such
recipient by the Department.
| 5 | | The Department shall execute, relative to the nursing home | 6 | | prescreening
project, written inter-agency agreements with the | 7 | | Department of Human
Services and the Department on Aging, to | 8 | | effect the following: (i) intake
procedures and common | 9 | | eligibility criteria for those persons who are receiving
| 10 | | non-institutional services; and (ii) the establishment and | 11 | | development of
non-institutional services in areas of the State | 12 | | where they are not currently
available or are undeveloped; and | 13 | | (iii) notwithstanding any other provision of law, subject to | 14 | | federal approval, on and after July 1, 2012, an increase in the | 15 | | determination of need (DON) scores from 29 to 37 for applicants | 16 | | for institutional and home and community-based long term care; | 17 | | if and only if federal approval is not granted, the Department | 18 | | may, in conjunction with other affected agencies, implement | 19 | | utilization controls or changes in benefit packages to | 20 | | effectuate a similar savings amount for this population; and | 21 | | (iv) no later than July 1, 2013, minimum level of care | 22 | | eligibility criteria for institutional and home and | 23 | | community-based long term care; and (v) no later than October | 24 | | 1, 2013, establish procedures to permit long term care | 25 | | providers access to eligibility scores for individuals with an | 26 | | admission date who are seeking or receiving services from the |
| | | SB0054 Enrolled | - 29 - | LRB099 03946 MLM 23963 b |
|
| 1 | | long term care provider. In order to select the minimum level | 2 | | of care eligibility criteria, the Governor shall establish a | 3 | | workgroup that includes affected agency representatives and | 4 | | stakeholders representing the institutional and home and | 5 | | community-based long term care interests. This Section shall | 6 | | not restrict the Department from implementing lower level of | 7 | | care eligibility criteria for community-based services in | 8 | | circumstances where federal approval has been granted.
| 9 | | The Illinois Department shall develop and operate, in | 10 | | cooperation
with other State Departments and agencies and in | 11 | | compliance with
applicable federal laws and regulations, | 12 | | appropriate and effective
systems of health care evaluation and | 13 | | programs for monitoring of
utilization of health care services | 14 | | and facilities, as it affects
persons eligible for medical | 15 | | assistance under this Code.
| 16 | | The Illinois Department shall report annually to the | 17 | | General Assembly,
no later than the second Friday in April of | 18 | | 1979 and each year
thereafter, in regard to:
| 19 | | (a) actual statistics and trends in utilization of | 20 | | medical services by
public aid recipients;
| 21 | | (b) actual statistics and trends in the provision of | 22 | | the various medical
services by medical vendors;
| 23 | | (c) current rate structures and proposed changes in | 24 | | those rate structures
for the various medical vendors; and
| 25 | | (d) efforts at utilization review and control by the | 26 | | Illinois Department.
|
| | | SB0054 Enrolled | - 30 - | LRB099 03946 MLM 23963 b |
|
| 1 | | The period covered by each report shall be the 3 years | 2 | | ending on the June
30 prior to the report. The report shall | 3 | | include suggested legislation
for consideration by the General | 4 | | Assembly. The filing of one copy of the
report with the | 5 | | Speaker, one copy with the Minority Leader and one copy
with | 6 | | the Clerk of the House of Representatives, one copy with the | 7 | | President,
one copy with the Minority Leader and one copy with | 8 | | the Secretary of the
Senate, one copy with the Legislative | 9 | | Research Unit, and such additional
copies
with the State | 10 | | Government Report Distribution Center for the General
Assembly | 11 | | as is required under paragraph (t) of Section 7 of the State
| 12 | | Library Act shall be deemed sufficient to comply with this | 13 | | Section.
| 14 | | Rulemaking authority to implement Public Act 95-1045, if | 15 | | any, is conditioned on the rules being adopted in accordance | 16 | | with all provisions of the Illinois Administrative Procedure | 17 | | Act and all rules and procedures of the Joint Committee on | 18 | | Administrative Rules; any purported rule not so adopted, for | 19 | | whatever reason, is unauthorized. | 20 | | On and after July 1, 2012, the Department shall reduce any | 21 | | rate of reimbursement for services or other payments or alter | 22 | | any methodologies authorized by this Code to reduce any rate of | 23 | | reimbursement for services or other payments in accordance with | 24 | | Section 5-5e. | 25 | | Because kidney transplantation can be an appropriate, cost | 26 | | effective
alternative to renal dialysis when medically |
| | | SB0054 Enrolled | - 31 - | LRB099 03946 MLM 23963 b |
|
| 1 | | necessary and notwithstanding the provisions of Section 1-11 of | 2 | | this Code, beginning October 1, 2014, the Department shall | 3 | | cover kidney transplantation for noncitizens with end-stage | 4 | | renal disease who are not eligible for comprehensive medical | 5 | | benefits, who meet the residency requirements of Section 5-3 of | 6 | | this Code, and who would otherwise meet the financial | 7 | | requirements of the appropriate class of eligible persons under | 8 | | Section 5-2 of this Code. To qualify for coverage of kidney | 9 | | transplantation, such person must be receiving emergency renal | 10 | | dialysis services covered by the Department. Providers under | 11 | | this Section shall be prior approved and certified by the | 12 | | Department to perform kidney transplantation and the services | 13 | | under this Section shall be limited to services associated with | 14 | | kidney transplantation. | 15 | | (Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689, | 16 | | eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section | 17 | | 9-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff. | 18 | | 7-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; 98-651, | 19 | | eff. 6-16-14; 98-756, eff. 7-16-14; 98-963, eff. 8-15-14; | 20 | | revised 10-2-14.)
| 21 | | Section 99. Effective date. This Act takes effect on July | 22 | | 1, 2016, if and only if on or before July 1, 2016: | 23 | | (1) the Secretary of the United States Department of | 24 | | Health and Human Services, or its successor agency, promulgates | 25 | | rules or regulations published in the Federal Register or | 26 | | publishes a comment in the Federal Register: |
| | | SB0054 Enrolled | - 32 - | LRB099 03946 MLM 23963 b |
|
| 1 | | (A) repealing, amending, or reinterpreting 45 CFR | 2 | | 155.170 to eliminate the State's responsibility to defray | 3 | | the cost of a state-mandated benefit enacted on or after | 4 | | January 1, 2012; | 5 | | (B) requiring qualified health plans, as defined in the | 6 | | federal Patient Protection and Affordable Care Act, as | 7 | | amended by the Health Care and Education Reconciliation Act | 8 | | of 2010 and any subsequent amendatory Acts, rules, or | 9 | | regulations issued pursuant thereto, to cover breast | 10 | | tomosynthesis as an essential health benefit; or | 11 | | (C) including breast tomosynthesis as a standard as | 12 | | part of the essential health benefits required of benchmark | 13 | | plans under 45 CFR 156.110; or | 14 | | (2) the federal Patient Protection and Affordable Care Act | 15 | | is repealed by an Act of Congress or is invalidated by a | 16 | | decision of the U.S. Supreme Court. |
|