Full Text of SB2840 97th General Assembly
SB2840eng 97TH GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning public aid.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Public Aid Code is amended by | 5 | | changing Sections 5-5, 11-13, 11-26, and 12-13.1 as follows: | 6 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| 7 | | Sec. 5-5. Medical services. The Illinois Department, by | 8 | | rule, shall
determine the quantity and quality of and the rate | 9 | | of reimbursement for the
medical assistance for which
payment | 10 | | will be authorized, and the medical services to be provided,
| 11 | | which may include all or part of the following: (1) inpatient | 12 | | hospital
services; (2) outpatient hospital services; (3) other | 13 | | laboratory and
X-ray services; (4) skilled nursing home | 14 | | services; (5) physicians'
services whether furnished in the | 15 | | office, the patient's home, a
hospital, a skilled nursing home, | 16 | | or elsewhere; (6) medical care, or any
other type of remedial | 17 | | care furnished by licensed practitioners; (7)
home health care | 18 | | services; (8) private duty nursing service; (9) clinic
| 19 | | services; (10) dental services, including prevention and | 20 | | treatment of periodontal disease and dental caries disease for | 21 | | pregnant women, provided by an individual licensed to practice | 22 | | dentistry or dental surgery; for purposes of this item (10), | 23 | | "dental services" means diagnostic, preventive, or corrective |
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| 1 | | procedures provided by or under the supervision of a dentist in | 2 | | the practice of his or her profession; (11) physical therapy | 3 | | and related
services; (12) prescribed drugs, dentures, and | 4 | | prosthetic devices; and
eyeglasses prescribed by a physician | 5 | | skilled in the diseases of the eye,
or by an optometrist, | 6 | | whichever the person may select; (13) other
diagnostic, | 7 | | screening, preventive, and rehabilitative services, for | 8 | | children and adults; (14)
transportation and such other | 9 | | expenses as may be necessary; (15) medical
treatment of sexual | 10 | | assault survivors, as defined in
Section 1a of the Sexual | 11 | | Assault Survivors Emergency Treatment Act, for
injuries | 12 | | sustained as a result of the sexual assault, including
| 13 | | examinations and laboratory tests to discover evidence which | 14 | | may be used in
criminal proceedings arising from the sexual | 15 | | assault; (16) the
diagnosis and treatment of sickle cell | 16 | | anemia; and (17)
any other medical care, and any other type of | 17 | | remedial care recognized
under the laws of this State, but not | 18 | | including abortions, or induced
miscarriages or premature | 19 | | births, unless, in the opinion of a physician,
such procedures | 20 | | are necessary for the preservation of the life of the
woman | 21 | | seeking such treatment, or except an induced premature birth
| 22 | | intended to produce a live viable child and such procedure is | 23 | | necessary
for the health of the mother or her unborn child. The | 24 | | Illinois Department,
by rule, shall prohibit any physician from | 25 | | providing medical assistance
to anyone eligible therefor under | 26 | | this Code where such physician has been
found guilty of |
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| 1 | | performing an abortion procedure in a wilful and wanton
manner | 2 | | upon a woman who was not pregnant at the time such abortion
| 3 | | procedure was performed. The term "any other type of remedial | 4 | | care" shall
include nursing care and nursing home service for | 5 | | persons who rely on
treatment by spiritual means alone through | 6 | | prayer for healing.
| 7 | | Notwithstanding any other provision of this Section, a | 8 | | comprehensive
tobacco use cessation program that includes | 9 | | purchasing prescription drugs or
prescription medical devices | 10 | | approved by the Food and Drug Administration shall
be covered | 11 | | under the medical assistance
program under this Article for | 12 | | persons who are otherwise eligible for
assistance under this | 13 | | Article.
| 14 | | Notwithstanding any other provision of this Code, the | 15 | | Illinois
Department may not require, as a condition of payment | 16 | | for any laboratory
test authorized under this Article, that a | 17 | | physician's handwritten signature
appear on the laboratory | 18 | | test order form. The Illinois Department may,
however, impose | 19 | | other appropriate requirements regarding laboratory test
order | 20 | | documentation.
| 21 | | The Department of Healthcare and Family Services shall | 22 | | provide the following services to
persons
eligible for | 23 | | assistance under this Article who are participating in
| 24 | | education, training or employment programs operated by the | 25 | | Department of Human
Services as successor to the Department of | 26 | | Public Aid:
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| 1 | | (1) dental services provided by or under the | 2 | | supervision of a dentist; and
| 3 | | (2) eyeglasses prescribed by a physician skilled in the | 4 | | diseases of the
eye, or by an optometrist, whichever the | 5 | | person may select.
| 6 | | Notwithstanding any other provision of this Code and | 7 | | subject to federal approval, the Department may adopt rules to | 8 | | allow a dentist who is volunteering his or her service at no | 9 | | cost to render dental services through an enrolled | 10 | | not-for-profit health clinic without the dentist personally | 11 | | enrolling as a participating provider in the medical assistance | 12 | | program. A not-for-profit health clinic shall include a public | 13 | | health clinic or Federally Qualified Health Center or other | 14 | | enrolled provider, as determined by the Department, through | 15 | | which dental services covered under this Section are performed. | 16 | | The Department shall establish a process for payment of claims | 17 | | for reimbursement for covered dental services rendered under | 18 | | this provision. | 19 | | The Illinois Department, by rule, may distinguish and | 20 | | classify the
medical services to be provided only in accordance | 21 | | with the classes of
persons designated in Section 5-2.
| 22 | | The Department of Healthcare and Family Services must | 23 | | provide coverage and reimbursement for amino acid-based | 24 | | elemental formulas, regardless of delivery method, for the | 25 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 26 | | short bowel syndrome when the prescribing physician has issued |
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| 1 | | a written order stating that the amino acid-based elemental | 2 | | formula is medically necessary.
| 3 | | The Illinois Department shall authorize the provision of, | 4 | | and shall
authorize payment for, screening by low-dose | 5 | | mammography for the presence of
occult breast cancer for women | 6 | | 35 years of age or older who are eligible
for medical | 7 | | assistance under this Article, as follows: | 8 | | (A) A baseline
mammogram for women 35 to 39 years of | 9 | | age.
| 10 | | (B) An annual mammogram for women 40 years of age or | 11 | | older. | 12 | | (C) A mammogram at the age and intervals considered | 13 | | medically necessary by the woman's health care provider for | 14 | | women under 40 years of age and having a family history of | 15 | | breast cancer, prior personal history of breast cancer, | 16 | | positive genetic testing, or other risk factors. | 17 | | (D) A comprehensive ultrasound screening of an entire | 18 | | breast or breasts if a mammogram demonstrates | 19 | | heterogeneous or dense breast tissue, when medically | 20 | | necessary as determined by a physician licensed to practice | 21 | | medicine in all of its branches. | 22 | | All screenings
shall
include a physical breast exam, | 23 | | instruction on self-examination and
information regarding the | 24 | | frequency of self-examination and its value as a
preventative | 25 | | tool. For purposes of this Section, "low-dose mammography" | 26 | | means
the x-ray examination of the breast using equipment |
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| 1 | | dedicated specifically
for mammography, including the x-ray | 2 | | tube, filter, compression device,
and image receptor, with an | 3 | | average radiation exposure delivery
of less than one rad per | 4 | | breast for 2 views of an average size breast.
The term also | 5 | | includes digital mammography.
| 6 | | On and after January 1, 2012, providers participating in a | 7 | | quality improvement program approved by the Department shall be | 8 | | reimbursed for screening and diagnostic mammography at the same | 9 | | rate as the Medicare program's rates, including the increased | 10 | | reimbursement for digital mammography. | 11 | | The Department shall convene an expert panel including | 12 | | representatives of hospitals, free-standing mammography | 13 | | facilities, and doctors, including radiologists, to establish | 14 | | quality standards. | 15 | | Subject to federal approval, the Department shall | 16 | | establish a rate methodology for mammography at federally | 17 | | qualified health centers and other encounter-rate clinics. | 18 | | These clinics or centers may also collaborate with other | 19 | | hospital-based mammography facilities. | 20 | | The Department shall establish a methodology to remind | 21 | | women who are age-appropriate for screening mammography, but | 22 | | who have not received a mammogram within the previous 18 | 23 | | months, of the importance and benefit of screening mammography. | 24 | | The Department shall establish a performance goal for | 25 | | primary care providers with respect to their female patients | 26 | | over age 40 receiving an annual mammogram. This performance |
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| 1 | | goal shall be used to provide additional reimbursement in the | 2 | | form of a quality performance bonus to primary care providers | 3 | | who meet that goal. | 4 | | The Department shall devise a means of case-managing or | 5 | | patient navigation for beneficiaries diagnosed with breast | 6 | | cancer. This program shall initially operate as a pilot program | 7 | | in areas of the State with the highest incidence of mortality | 8 | | related to breast cancer. At least one pilot program site shall | 9 | | be in the metropolitan Chicago area and at least one site shall | 10 | | be outside the metropolitan Chicago area. An evaluation of the | 11 | | pilot program shall be carried out measuring health outcomes | 12 | | and cost of care for those served by the pilot program compared | 13 | | to similarly situated patients who are not served by the pilot | 14 | | program. | 15 | | Any medical or health care provider shall immediately | 16 | | recommend, to
any pregnant woman who is being provided prenatal | 17 | | services and is suspected
of drug abuse or is addicted as | 18 | | defined in the Alcoholism and Other Drug Abuse
and Dependency | 19 | | Act, referral to a local substance abuse treatment provider
| 20 | | licensed by the Department of Human Services or to a licensed
| 21 | | hospital which provides substance abuse treatment services. | 22 | | The Department of Healthcare and Family Services
shall assure | 23 | | coverage for the cost of treatment of the drug abuse or
| 24 | | addiction for pregnant recipients in accordance with the | 25 | | Illinois Medicaid
Program in conjunction with the Department of | 26 | | Human Services.
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| 1 | | All medical providers providing medical assistance to | 2 | | pregnant women
under this Code shall receive information from | 3 | | the Department on the
availability of services under the Drug | 4 | | Free Families with a Future or any
comparable program providing | 5 | | case management services for addicted women,
including | 6 | | information on appropriate referrals for other social services
| 7 | | that may be needed by addicted women in addition to treatment | 8 | | for addiction.
| 9 | | The Illinois Department, in cooperation with the | 10 | | Departments of Human
Services (as successor to the Department | 11 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 12 | | public awareness campaign, may
provide information concerning | 13 | | treatment for alcoholism and drug abuse and
addiction, prenatal | 14 | | health care, and other pertinent programs directed at
reducing | 15 | | the number of drug-affected infants born to recipients of | 16 | | medical
assistance.
| 17 | | Neither the Department of Healthcare and Family Services | 18 | | nor the Department of Human
Services shall sanction the | 19 | | recipient solely on the basis of
her substance abuse.
| 20 | | The Illinois Department shall establish such regulations | 21 | | governing
the dispensing of health services under this Article | 22 | | as it shall deem
appropriate. The Department
should
seek the | 23 | | advice of formal professional advisory committees appointed by
| 24 | | the Director of the Illinois Department for the purpose of | 25 | | providing regular
advice on policy and administrative matters, | 26 | | information dissemination and
educational activities for |
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| 1 | | medical and health care providers, and
consistency in | 2 | | procedures to the Illinois Department.
| 3 | | Notwithstanding any other provision of law, a health care | 4 | | provider under the medical assistance program may elect, in | 5 | | lieu of receiving direct payment for services provided under | 6 | | that program, to participate in the State Employees Deferred | 7 | | Compensation Plan adopted under Article 24 of the Illinois | 8 | | Pension Code. A health care provider who elects to participate | 9 | | in the plan does not have a cause of action against the State | 10 | | for any damages allegedly suffered by the provider as a result | 11 | | of any delay by the State in crediting the amount of any | 12 | | contribution to the provider's plan account. | 13 | | The Illinois Department may develop and contract with | 14 | | Partnerships of
medical providers to arrange medical services | 15 | | for persons eligible under
Section 5-2 of this Code. | 16 | | Implementation of this Section may be by
demonstration projects | 17 | | in certain geographic areas. The Partnership shall
be | 18 | | represented by a sponsor organization. The Department, by rule, | 19 | | shall
develop qualifications for sponsors of Partnerships. | 20 | | Nothing in this
Section shall be construed to require that the | 21 | | sponsor organization be a
medical organization.
| 22 | | The sponsor must negotiate formal written contracts with | 23 | | medical
providers for physician services, inpatient and | 24 | | outpatient hospital care,
home health services, treatment for | 25 | | alcoholism and substance abuse, and
other services determined | 26 | | necessary by the Illinois Department by rule for
delivery by |
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| 1 | | Partnerships. Physician services must include prenatal and
| 2 | | obstetrical care. The Illinois Department shall reimburse | 3 | | medical services
delivered by Partnership providers to clients | 4 | | in target areas according to
provisions of this Article and the | 5 | | Illinois Health Finance Reform Act,
except that:
| 6 | | (1) Physicians participating in a Partnership and | 7 | | providing certain
services, which shall be determined by | 8 | | the Illinois Department, to persons
in areas covered by the | 9 | | Partnership may receive an additional surcharge
for such | 10 | | services.
| 11 | | (2) The Department may elect to consider and negotiate | 12 | | financial
incentives to encourage the development of | 13 | | Partnerships and the efficient
delivery of medical care.
| 14 | | (3) Persons receiving medical services through | 15 | | Partnerships may receive
medical and case management | 16 | | services above the level usually offered
through the | 17 | | medical assistance program.
| 18 | | Medical providers shall be required to meet certain | 19 | | qualifications to
participate in Partnerships to ensure the | 20 | | delivery of high quality medical
services. These | 21 | | qualifications shall be determined by rule of the Illinois
| 22 | | Department and may be higher than qualifications for | 23 | | participation in the
medical assistance program. Partnership | 24 | | sponsors may prescribe reasonable
additional qualifications | 25 | | for participation by medical providers, only with
the prior | 26 | | written approval of the Illinois Department.
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| 1 | | Nothing in this Section shall limit the free choice of | 2 | | practitioners,
hospitals, and other providers of medical | 3 | | services by clients.
In order to ensure patient freedom of | 4 | | choice, the Illinois Department shall
immediately promulgate | 5 | | all rules and take all other necessary actions so that
provided | 6 | | services may be accessed from therapeutically certified | 7 | | optometrists
to the full extent of the Illinois Optometric | 8 | | Practice Act of 1987 without
discriminating between service | 9 | | providers.
| 10 | | The Department shall apply for a waiver from the United | 11 | | States Health
Care Financing Administration to allow for the | 12 | | implementation of
Partnerships under this Section.
| 13 | | The Illinois Department shall require health care | 14 | | providers to maintain
records that document the medical care | 15 | | and services provided to recipients
of Medical Assistance under | 16 | | this Article. Such records must be retained for a period of not | 17 | | less than 6 years from the date of service or as provided by | 18 | | applicable State law, whichever period is longer, except that | 19 | | if an audit is initiated within the required retention period | 20 | | then the records must be retained until the audit is completed | 21 | | and every exception is resolved. The Illinois Department shall
| 22 | | require health care providers to make available, when | 23 | | authorized by the
patient, in writing, the medical records in a | 24 | | timely fashion to other
health care providers who are treating | 25 | | or serving persons eligible for
Medical Assistance under this | 26 | | Article. All dispensers of medical services
shall be required |
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| 1 | | to maintain and retain business and professional records
| 2 | | sufficient to fully and accurately document the nature, scope, | 3 | | details and
receipt of the health care provided to persons | 4 | | eligible for medical
assistance under this Code, in accordance | 5 | | with regulations promulgated by
the Illinois Department. The | 6 | | rules and regulations shall require that proof
of the receipt | 7 | | of prescription drugs, dentures, prosthetic devices and
| 8 | | eyeglasses by eligible persons under this Section accompany | 9 | | each claim
for reimbursement submitted by the dispenser of such | 10 | | medical services.
No such claims for reimbursement shall be | 11 | | approved for payment by the Illinois
Department without such | 12 | | proof of receipt, unless the Illinois Department
shall have put | 13 | | into effect and shall be operating a system of post-payment
| 14 | | audit and review which shall, on a sampling basis, be deemed | 15 | | adequate by
the Illinois Department to assure that such drugs, | 16 | | dentures, prosthetic
devices and eyeglasses for which payment | 17 | | is being made are actually being
received by eligible | 18 | | recipients. Within 90 days after the effective date of
this | 19 | | amendatory Act of 1984, the Illinois Department shall establish | 20 | | a
current list of acquisition costs for all prosthetic devices | 21 | | and any
other items recognized as medical equipment and | 22 | | supplies reimbursable under
this Article and shall update such | 23 | | list on a quarterly basis, except that
the acquisition costs of | 24 | | all prescription drugs shall be updated no
less frequently than | 25 | | every 30 days as required by Section 5-5.12.
| 26 | | The rules and regulations of the Illinois Department shall |
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| 1 | | require
that a written statement including the required opinion | 2 | | of a physician
shall accompany any claim for reimbursement for | 3 | | abortions, or induced
miscarriages or premature births. This | 4 | | statement shall indicate what
procedures were used in providing | 5 | | such medical services.
| 6 | | The Illinois Department shall require all dispensers of | 7 | | medical
services, other than an individual practitioner or | 8 | | group of practitioners,
desiring to participate in the Medical | 9 | | Assistance program
established under this Article to disclose | 10 | | all financial, beneficial,
ownership, equity, surety or other | 11 | | interests in any and all firms,
corporations, partnerships, | 12 | | associations, business enterprises, joint
ventures, agencies, | 13 | | institutions or other legal entities providing any
form of | 14 | | health care services in this State under this Article.
| 15 | | The Illinois Department may require that all dispensers of | 16 | | medical
services desiring to participate in the medical | 17 | | assistance program
established under this Article disclose, | 18 | | under such terms and conditions as
the Illinois Department may | 19 | | by rule establish, all inquiries from clients
and attorneys | 20 | | regarding medical bills paid by the Illinois Department, which
| 21 | | inquiries could indicate potential existence of claims or liens | 22 | | for the
Illinois Department.
| 23 | | The Illinois Department shall have the authority to | 24 | | establish by rule the necessary procedures and policies to | 25 | | comply with the federal Patient Protection and Affordable Care | 26 | | Act as amended by the Health Care and Education Reconciliation |
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| 1 | | Act of 2010, and with subsequent federal statutes, rules, and | 2 | | regulations pertaining to Department functions. | 3 | | Prior to enrollment in the medical assistance program, all | 4 | | vendors shall be subject to enhanced oversight, screening, and | 5 | | review based on categories of risk of fraud, waste, and abuse. | 6 | | The Illinois Department shall establish by rule the procedures | 7 | | for such screening and review. | 8 | | Enrollment of a vendor that provides non-emergency medical | 9 | | transportation,
defined by the Department by rule,
shall be
| 10 | | subject to a provisional period and shall be conditional for | 11 | | one year 180 days . During the period of conditional enrollment | 12 | | that time , the Department of Healthcare and Family Services may
| 13 | | terminate the vendor's eligibility to participate in , or may | 14 | | disenroll the vendor from, the medical assistance
program | 15 | | without cause. Such That termination of eligibility or | 16 | | disenrollment is not subject to the
Department's hearing | 17 | | process.
| 18 | | Prior to enrollment and during the conditional enrollment | 19 | | period, a vendor shall be subject to enhanced oversight based | 20 | | on risk categories that may include, but are not limited to, | 21 | | criminal and financial background checks; fingerprinting; | 22 | | license, certification, and authorization verifications; | 23 | | unscheduled or unannounced site visits; database checks; | 24 | | pre-payment audit reviews; audits; payment caps; payment | 25 | | suspensions; and other screening as required by federal or | 26 | | State law. |
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| 1 | | To be eligible for payment consideration, a provider's | 2 | | vendor-payment claim or bill, either as an initial or | 3 | | resubmitted claim following prior rejection, must be received | 4 | | by the Illinois Department, or its fiscal intermediary, no | 5 | | later than 90 days after the date on which medical goods or | 6 | | services were provided, with the following exception: the | 7 | | Illinois Department must receive a claim after disposition by | 8 | | Medicare or its fiscal intermediary no later than 24 months | 9 | | after the date on which medical goods or services were | 10 | | provided. | 11 | | For claims for services rendered during a period for which | 12 | | a recipient received retroactive eligibility, claims must be | 13 | | filed within 90 days after the recipient was made eligible. For | 14 | | claims for which the Illinois Department is not the
primary | 15 | | payer, claims must be submitted to the Illinois Department | 16 | | within 90 days after the final adjudication by the primary | 17 | | payer, but in no event more than 1 year after the date of | 18 | | service. | 19 | | Claims that are not submitted and received in compliance | 20 | | with the foregoing requirement shall not be eligible for | 21 | | payment under the medical assistance program, and the State | 22 | | shall have no liability for payment of those claims. | 23 | | To the extent consistent with applicable information, | 24 | | privacy, security, and disclosure laws, State and federal | 25 | | agencies shall provide the Illinois Department access to | 26 | | confidential and other information and data necessary to |
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| 1 | | perform eligibility and payment verifications and other | 2 | | Illinois Department functions. This includes, but is not | 3 | | limited to, information pertaining to licensure; | 4 | | certification; earnings; immigration status; citizenship; wage | 5 | | reporting; unearned and earned income; pension income; | 6 | | employment; supplemental security income; social security | 7 | | numbers; National Provider Identifier (NPI) numbers; the | 8 | | National Practitioner Data Bank (NPDB); program and agency | 9 | | exclusions; taxpayer identification numbers; tax delinquency; | 10 | | corporate information; and death records. | 11 | | The Illinois Department shall enter into agreements with | 12 | | State and federal agencies and Departments under which such | 13 | | agencies shall share data necessary for program integrity | 14 | | functions and oversight. The Illinois Department shall | 15 | | develop, in cooperation with other State departments and | 16 | | agencies, and in compliance with applicable federal laws and | 17 | | regulations, appropriate and effective methods to share such | 18 | | data. At a minimum, and to the extent necessary to provide data | 19 | | sharing, the Illinois Department shall enter into agreements | 20 | | with State and federal agencies, including but not limited to, | 21 | | the Secretary of State; the Department of Revenue; the | 22 | | Department of Public Health; the Department of Human Services; | 23 | | and the Department of Financial and Professional Regulation. | 24 | | Beginning in fiscal year 2013, the Illinois Department | 25 | | shall set forth a request for information to identify the | 26 | | benefits of a pre-payment, post-adjudication, and post-edit |
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| 1 | | claims system with the goals of streamlining claims processing | 2 | | and provider reimbursement, reducing the number of pending or | 3 | | rejected claims, and helping to ensure a more transparent | 4 | | adjudication process through the utilization of: (i) provider | 5 | | data verification and provider screening technology; and (ii) | 6 | | clinical code editing. Such request for information shall not | 7 | | be considered as a request for proposal, or as an obligation on | 8 | | the part of the Illinois Department to take any action or | 9 | | acquire any products or services. | 10 | | The Illinois Department shall establish policies, | 11 | | procedures,
standards and criteria by rule for the acquisition, | 12 | | repair and replacement
of orthotic and prosthetic devices and | 13 | | durable medical equipment. Such
rules shall provide, but not be | 14 | | limited to, the following services: (1)
immediate repair or | 15 | | replacement of such devices by recipients without
medical | 16 | | authorization; and (2) rental, lease, purchase or | 17 | | lease-purchase of
durable medical equipment in a | 18 | | cost-effective manner, taking into
consideration the | 19 | | recipient's medical prognosis, the extent of the
recipient's | 20 | | needs, and the requirements and costs for maintaining such
| 21 | | equipment. Such rules shall enable a recipient to temporarily | 22 | | acquire and
use alternative or substitute devices or equipment | 23 | | pending repairs or
replacements of any device or equipment | 24 | | previously authorized for such
recipient by the Department.
| 25 | | The Department shall execute, relative to the nursing home | 26 | | prescreening
project, written inter-agency agreements with the |
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| 1 | | Department of Human
Services and the Department on Aging, to | 2 | | effect the following: (i) intake
procedures and common | 3 | | eligibility criteria for those persons who are receiving
| 4 | | non-institutional services; and (ii) the establishment and | 5 | | development of
non-institutional services in areas of the State | 6 | | where they are not currently
available or are undeveloped.
| 7 | | The Illinois Department shall develop and operate, in | 8 | | cooperation
with other State Departments and agencies and in | 9 | | compliance with
applicable federal laws and regulations, | 10 | | appropriate and effective
systems of health care evaluation and | 11 | | programs for monitoring of
utilization of health care services | 12 | | and facilities, as it affects
persons eligible for medical | 13 | | assistance under this Code.
| 14 | | The Illinois Department shall report annually to the | 15 | | General Assembly,
no later than the second Friday in April of | 16 | | 1979 and each year
thereafter, in regard to:
| 17 | | (a) actual statistics and trends in utilization of | 18 | | medical services by
public aid recipients;
| 19 | | (b) actual statistics and trends in the provision of | 20 | | the various medical
services by medical vendors;
| 21 | | (c) current rate structures and proposed changes in | 22 | | those rate structures
for the various medical vendors; and
| 23 | | (d) efforts at utilization review and control by the | 24 | | Illinois Department.
| 25 | | The period covered by each report shall be the 3 years | 26 | | ending on the June
30 prior to the report. The report shall |
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| 1 | | include suggested legislation
for consideration by the General | 2 | | Assembly. The filing of one copy of the
report with the | 3 | | Speaker, one copy with the Minority Leader and one copy
with | 4 | | the Clerk of the House of Representatives, one copy with the | 5 | | President,
one copy with the Minority Leader and one copy with | 6 | | the Secretary of the
Senate, one copy with the Legislative | 7 | | Research Unit, and such additional
copies
with the State | 8 | | Government Report Distribution Center for the General
Assembly | 9 | | as is required under paragraph (t) of Section 7 of the State
| 10 | | Library Act shall be deemed sufficient to comply with this | 11 | | Section.
| 12 | | Rulemaking authority to implement Public Act 95-1045, if | 13 | | any, is conditioned on the rules being adopted in accordance | 14 | | with all provisions of the Illinois Administrative Procedure | 15 | | Act and all rules and procedures of the Joint Committee on | 16 | | Administrative Rules; any purported rule not so adopted, for | 17 | | whatever reason, is unauthorized. | 18 | | (Source: P.A. 96-156, eff. 1-1-10; 96-806, eff. 7-1-10; 96-926, | 19 | | eff. 1-1-11; 96-1000, eff. 7-2-10; 97-48, eff. 6-28-11; 97-638, | 20 | | eff. 1-1-12.)
| 21 | | (305 ILCS 5/11-13) (from Ch. 23, par. 11-13)
| 22 | | Sec. 11-13.
Conditions For Receipt of Vendor Payments - | 23 | | Limitation Period
For Vendor Action - Penalty For Violation. A | 24 | | vendor payment, as defined in
Section 2-5 of Article II, shall | 25 | | constitute payment in full for the goods
or services covered |
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| 1 | | thereby. Acceptance of the payment by or in behalf of
the | 2 | | vendor shall bar him from obtaining, or attempting to obtain,
| 3 | | additional payment therefor from the recipient or any other | 4 | | person. A
vendor payment shall not, however, bar recovery of | 5 | | the value of goods and
services the obligation for which, under | 6 | | the rules and regulations of the
Illinois Department, is to be | 7 | | met from the income and resources available
to the recipient, | 8 | | and in respect to which the vendor payment of the
Illinois | 9 | | Department or the local governmental unit represents
| 10 | | supplementation of such available income and resources.
| 11 | | Vendors seeking to enforce obligations of a governmental | 12 | | unit or the
Illinois Department for goods or services (1) | 13 | | furnished to or in behalf of
recipients and (2) subject to a | 14 | | vendor payment as defined in Section 2-5,
shall commence their | 15 | | actions in the appropriate Circuit Court or the Court
of | 16 | | Claims, as the case may require, within one year next after the | 17 | | cause of
action accrued.
| 18 | | A cause of action accrues within the meaning of this | 19 | | Section upon the following date:
| 20 | | (1) If the vendor can prove that he submitted a bill for | 21 | | the service
rendered to the Illinois Department or a | 22 | | governmental unit within 90 days after 12 months
of the date | 23 | | the service was rendered, then (a) upon the date the Illinois
| 24 | | Department or a governmental unit mails to the vendor | 25 | | information that it
is paying a bill in part or is refusing to | 26 | | pay a bill in whole or in part,
or (b) upon the date one year |
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| 1 | | following the date the vendor submitted such
bill if the | 2 | | Illinois Department or a governmental unit fails to mail to
the | 3 | | vendor such payment information within one year following the | 4 | | date the
vendor submitted the bill; or
| 5 | | (2) If the vendor cannot prove that he submitted a bill for | 6 | | the service
rendered within 90 days after 12 months of the date | 7 | | the service was rendered, then upon
the date 12 months | 8 | | following the date the vendor rendered the
service to the | 9 | | recipient.
| 10 | | This paragraph governs only vendor payments as
defined in | 11 | | this Code and as limited by regulations of the Illinois
| 12 | | Department; it does not apply to goods or services purchased or | 13 | | contracted
for by a recipient under circumstances in which the | 14 | | payment is to be made
directly by the recipient.
| 15 | | Any vendor who accepts a vendor payment and who knowingly | 16 | | obtains or
attempts to obtain additional payment for the goods | 17 | | or services covered by
the vendor payment from the recipient or | 18 | | any other person shall be guilty
of a Class B misdemeanor.
| 19 | | (Source: P.A. 86-430.)
| 20 | | (305 ILCS 5/11-26) (from Ch. 23, par. 11-26)
| 21 | | Sec. 11-26. Recipient's abuse of medical care; | 22 | | restrictions on access to
medical care. | 23 | | (a) When the Department determines, on the basis of | 24 | | statistical norms and
medical judgment, that a medical care | 25 | | recipient has received medical services
in excess of need and |
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| 1 | | with such frequency or in such a manner as to constitute
an | 2 | | abuse of the recipient's medical care privileges, the | 3 | | recipient's access to
medical care may be restricted.
| 4 | | (b) When the Department has determined that a recipient is | 5 | | abusing his or
her medical care privileges as described in this | 6 | | Section, it may require that
the recipient designate a primary | 7 | | provider type of the recipient's own choosing to assume
| 8 | | responsibility for the recipient's care. For the purposes of | 9 | | this subsection, "primary provider type" means a provider type | 10 | | as determined by the Department primary care provider, primary | 11 | | care pharmacy, primary dentist, primary podiatrist, or primary | 12 | | durable medical equipment provider . Instead of requiring a | 13 | | recipient to
make a designation as provided in this subsection, | 14 | | the Department, pursuant to
rules adopted by the Department and | 15 | | without regard to any choice of an entity
that the recipient | 16 | | might otherwise make, may initially designate a primary | 17 | | provider type provided that the primary provider type is | 18 | | willing to provide that care.
| 19 | | (c) When the Department has requested that a recipient | 20 | | designate a
primary provider type and the recipient fails or | 21 | | refuses to do so, the Department
may, after a reasonable period | 22 | | of time, assign the recipient to a primary provider type of its | 23 | | own choice and determination, provided such primary provider | 24 | | type is willing to provide such care.
| 25 | | (d) When a recipient has been restricted to a designated | 26 | | primary provider type, the
recipient may change the primary |
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| 1 | | provider type:
| 2 | | (1) when the designated source becomes unavailable, as | 3 | | the Department
shall determine by rule; or
| 4 | | (2) when the designated primary provider type notifies | 5 | | the Department that it wishes to
withdraw from any | 6 | | obligation as primary provider type; or
| 7 | | (3) in other situations, as the Department shall | 8 | | provide by rule.
| 9 | | The Department shall, by rule, establish procedures for | 10 | | providing medical or
pharmaceutical services when the | 11 | | designated source becomes unavailable or
wishes to withdraw | 12 | | from any obligation as primary provider type, shall, by rule, | 13 | | take into
consideration the need for emergency or temporary | 14 | | medical assistance and shall
ensure that the recipient has | 15 | | continuous and unrestricted access to medical
care from the | 16 | | date on which such unavailability or withdrawal becomes | 17 | | effective
until such time as the recipient designates a primary | 18 | | provider type or a primary provider type willing to provide | 19 | | such care is designated by the Department
consistent with | 20 | | subsections (b) and (c) and such restriction becomes effective.
| 21 | | (e) Prior to initiating any action to restrict a | 22 | | recipient's access to
medical or pharmaceutical care, the | 23 | | Department shall notify the recipient
of its intended action. | 24 | | Such notification shall be in writing and shall set
forth the | 25 | | reasons for and nature of the proposed action. In addition, the
| 26 | | notification shall:
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| 1 | | (1) inform the recipient that (i) the recipient has a | 2 | | right to
designate a primary provider type of the | 3 | | recipient's own choosing willing to accept such | 4 | | designation
and that the recipient's failure to do so | 5 | | within a reasonable time may result
in such designation | 6 | | being made by the Department or (ii) the Department has
| 7 | | designated a primary provider type to assume | 8 | | responsibility for the recipient's care; and
| 9 | | (2) inform the recipient that the recipient has a right | 10 | | to appeal the
Department's determination to restrict the | 11 | | recipient's access to medical care
and provide the | 12 | | recipient with an explanation of how such appeal is to be
| 13 | | made. The notification shall also inform the recipient of | 14 | | the circumstances
under which unrestricted medical | 15 | | eligibility shall continue until a decision is
made on | 16 | | appeal and that if the recipient chooses to appeal, the | 17 | | recipient will
be able to review the medical payment data | 18 | | that was utilized by the Department
to decide that the | 19 | | recipient's access to medical care should be restricted.
| 20 | | (f) The Department shall, by rule or regulation, establish | 21 | | procedures for
appealing a determination to restrict a | 22 | | recipient's access to medical care,
which procedures shall, at | 23 | | a minimum, provide for a reasonable opportunity
to be heard | 24 | | and, where the appeal is denied, for a written statement
of the | 25 | | reason or reasons for such denial.
| 26 | | (g) Except as otherwise provided in this subsection, when a |
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| 1 | | recipient
has had his or her medical card restricted for 4 full | 2 | | quarters (without regard
to any period of ineligibility for | 3 | | medical assistance under this Code, or any
period for which the | 4 | | recipient voluntarily terminates his or her receipt of
medical | 5 | | assistance, that may occur before the expiration of those 4 | 6 | | full
quarters), the Department shall reevaluate the | 7 | | recipient's medical usage to
determine whether it is still in | 8 | | excess of need and with such frequency or in
such a manner as | 9 | | to constitute an abuse of the receipt of medical assistance.
If | 10 | | it is still in excess of need, the restriction shall be | 11 | | continued for
another 4 full quarters. If it is no longer in | 12 | | excess of need, the restriction
shall be discontinued. If a | 13 | | recipient's access to medical care has been
restricted under | 14 | | this Section and the Department then determines, either at
| 15 | | reevaluation or after the restriction has been discontinued, to | 16 | | restrict the
recipient's access to medical care a second or | 17 | | subsequent time, the second or
subsequent restriction may be | 18 | | imposed for a period of more than 4 full
quarters. If the | 19 | | Department restricts a recipient's access to medical care for
a | 20 | | period of more than 4 full quarters, as determined by rule, the | 21 | | Department
shall reevaluate the recipient's medical usage | 22 | | after the end of the restriction
period rather than after the | 23 | | end of 4 full quarters. The Department shall
notify the | 24 | | recipient, in writing, of any decision to continue the | 25 | | restriction
and the reason or reasons therefor. A "quarter", | 26 | | for purposes of this Section,
shall be defined as one of the |
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| 1 | | following 3-month periods of time:
January-March, April-June, | 2 | | July-September or October-December.
| 3 | | (h) In addition to any other recipient whose acquisition of | 4 | | medical care
is determined to be in excess of need, the | 5 | | Department may restrict the medical
care privileges of the | 6 | | following persons:
| 7 | | (1) recipients found to have loaned or altered their | 8 | | cards or misused or
falsely represented medical coverage;
| 9 | | (2) recipients found in possession of blank or forged | 10 | | prescription pads;
| 11 | | (3) recipients who knowingly assist providers in | 12 | | rendering excessive
services or defrauding the medical | 13 | | assistance program.
| 14 | | The procedural safeguards in this Section shall apply to | 15 | | the above
individuals.
| 16 | | (i) Restrictions under this Section shall be in addition to | 17 | | and shall
not in any way be limited by or limit any actions | 18 | | taken under Article
VIII-A of this Code.
| 19 | | (Source: P.A. 96-1501, eff. 1-25-11.)
| 20 | | (305 ILCS 5/12-13.1)
| 21 | | Sec. 12-13.1. Inspector General.
| 22 | | (a) The Governor shall appoint, and the Senate shall | 23 | | confirm, an Inspector
General who shall function within the | 24 | | Illinois Department of Public Aid (now Healthcare and Family | 25 | | Services) and
report to the Governor. The term of the Inspector |
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| 1 | | General shall expire on the
third Monday of January, 1997 and | 2 | | every 4 years thereafter.
| 3 | | (b) In order to prevent, detect, and eliminate fraud, | 4 | | waste, abuse,
mismanagement, and misconduct, the Inspector | 5 | | General shall oversee the
Department of Healthcare and Family | 6 | | Services' integrity
functions, which include, but are not | 7 | | limited to, the following:
| 8 | | (1) Investigation of misconduct by employees, vendors, | 9 | | contractors and
medical providers, except for allegations | 10 | | of violations of the State Officials and Employees Ethics | 11 | | Act which shall be referred to the Office of the Governor's | 12 | | Executive Inspector General for investigation.
| 13 | | (2) Pre-payment and post-payment audits Audits of | 14 | | medical providers related to ensuring that appropriate
| 15 | | payments are made for services rendered and to the | 16 | | prevention and recovery of overpayments.
| 17 | | (3) Monitoring of quality assurance programs | 18 | | administered by the Department of Healthcare and Family | 19 | | Services generally related to the
medical assistance | 20 | | program and specifically related to any managed care
| 21 | | program .
| 22 | | (4) Quality control measurements of the programs | 23 | | administered by the
Department of Healthcare and Family | 24 | | Services.
| 25 | | (5) Investigations of fraud or intentional program | 26 | | violations committed by
clients of the Department of |
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| 1 | | Healthcare and Family Services.
| 2 | | (6) Actions initiated against contractors , vendors, or | 3 | | medical providers for any of
the following reasons:
| 4 | | (A) Violations of the medical assistance program.
| 5 | | (B) Sanctions against providers brought in | 6 | | conjunction with the
Department of Public Health or the | 7 | | Department of Human Services (as successor
to the | 8 | | Department of Mental Health and Developmental | 9 | | Disabilities).
| 10 | | (C) Recoveries of assessments against hospitals | 11 | | and long-term care
facilities.
| 12 | | (D) Sanctions mandated by the United States | 13 | | Department of Health and
Human Services against | 14 | | medical providers.
| 15 | | (E) Violations of contracts related to any | 16 | | programs administered by the Department of Healthcare | 17 | | and Family Services managed care programs .
| 18 | | (7) Representation of the Department of Healthcare and | 19 | | Family Services at
hearings with the Illinois Department of | 20 | | Financial and Professional Regulation in actions
taken | 21 | | against professional licenses held by persons who are in | 22 | | violation of
orders for child support payments.
| 23 | | (b-5) At the request of the Secretary of Human Services, | 24 | | the Inspector
General shall, in relation to any function | 25 | | performed by the Department of Human
Services as successor to | 26 | | the Department of Public Aid, exercise one or more
of the |
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| 1 | | powers provided under this Section as if those powers related | 2 | | to the
Department of Human Services; in such matters, the | 3 | | Inspector General shall
report his or her findings to the | 4 | | Secretary of Human Services.
| 5 | | (c) Notwithstanding, and in addition to, any other | 6 | | provision of law, the The Inspector General shall have access | 7 | | to all information, personnel
and facilities of the
Department | 8 | | of Healthcare and Family Services and the Department of
Human | 9 | | Services (as successor to the Department of Public Aid), their | 10 | | employees, vendors, contractors and medical providers and any | 11 | | federal,
State or local governmental agency that are necessary | 12 | | to perform the duties of
the Office as directly related to | 13 | | public assistance programs administered by
those departments. | 14 | | No medical provider shall
be compelled, however, to provide | 15 | | individual medical records of patients who
are not clients of | 16 | | the programs administered by the Department of Healthcare and | 17 | | Family Services Medical Assistance Program . State and local
| 18 | | governmental agencies are authorized and directed to provide | 19 | | the requested
information, assistance or cooperation.
| 20 | | For purposes of enhanced program integrity functions and | 21 | | oversight, and to the extent consistent with applicable | 22 | | information, privacy, security, and disclosure laws, State and | 23 | | federal agencies shall provide the Inspector General access to | 24 | | confidential and other information and data. This includes, but | 25 | | is not limited to, information pertaining to licensure; | 26 | | certification; earnings; immigration status; citizenship; wage |
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| 1 | | reporting; unearned and earned income; pension income; | 2 | | employment; supplemental security income; social security | 3 | | numbers; National Provider Identifier (NPI) numbers; the | 4 | | National Practitioner Data Bank (NPDB); program and agency | 5 | | exclusions; taxpayer identification numbers; tax delinquency; | 6 | | corporate information; and death records. | 7 | | The Department of Healthcare and Family Services shall | 8 | | enter into agreements with State and federal agencies under | 9 | | which such agencies share data necessary for vendor screening, | 10 | | vendor review, and payment verification. The Department shall | 11 | | develop, in cooperation with other State and federal | 12 | | departments and agencies, and in compliance with applicable | 13 | | federal laws and regulations, appropriate and effective | 14 | | methods to share such data necessary for vendor screening, | 15 | | vendor review, and payment verification. The Department shall | 16 | | enter into agreements with State and federal agencies, | 17 | | including but not limited to, the Secretary of State; the | 18 | | Department of Revenue; the Department of Public Health; the | 19 | | Department of Human Services; and the Department of Financial | 20 | | and Professional Regulation. | 21 | | The Inspector General shall have the authority to deny | 22 | | payment, prevent overpayments, and recover overpayments. | 23 | | The Inspector General shall have the authority to deny or | 24 | | suspend payment to, and deny, terminate, or suspend the | 25 | | eligibility of, any vendor who fails to grant the Inspector | 26 | | General timely access to full and complete records in |
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| 1 | | accordance with Section 140.28 of Title 89 of the Illinois | 2 | | Administrative Code, and other information for the purpose of | 3 | | audits, investigations, or other program integrity functions, | 4 | | after reasonable written request by the Inspector General. | 5 | | The Inspector General shall have the authority to establish | 6 | | by rule the necessary procedures and policies to comply with | 7 | | the federal Patient Protection and Affordable Care Act as | 8 | | amended by the Health Care and Education Reconciliation Act of | 9 | | 2010, and with subsequent federal statutes and rules pertaining | 10 | | to state program integrity requirements. | 11 | | (d) The Inspector General shall serve as the
Department of | 12 | | Healthcare and Family Services'
primary liaison with law | 13 | | enforcement,
investigatory and prosecutorial agencies, | 14 | | including but not limited to the
following:
| 15 | | (1) The Department of State Police.
| 16 | | (2) The Federal Bureau of Investigation and other | 17 | | federal law enforcement
agencies.
| 18 | | (3) The various Inspectors General of federal agencies | 19 | | overseeing the
programs administered by the
Department of | 20 | | Healthcare and Family Services.
| 21 | | (4) The various Inspectors General of any other State | 22 | | agencies with
responsibilities for portions of programs | 23 | | primarily administered by the
Department of Healthcare and | 24 | | Family Services.
| 25 | | (5) The Offices of the several United States Attorneys | 26 | | in Illinois.
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| 1 | | (6) The several State's Attorneys.
| 2 | | (7) The offices of the Centers for Medicare and | 3 | | Medicaid Services that administer the Medicare and | 4 | | Medicaid integrity programs. | 5 | | The Inspector General shall meet on a regular basis with | 6 | | these entities to
share information regarding possible | 7 | | misconduct by any persons or entities
involved with the public | 8 | | aid programs administered by the Department
of Healthcare and | 9 | | Family Services.
| 10 | | (e) All investigations conducted by the Inspector General | 11 | | shall be conducted
in a manner that ensures the preservation of | 12 | | evidence for use in criminal
prosecutions. If the Inspector | 13 | | General determines that a possible criminal act
relating to | 14 | | fraud in the provision or administration of the medical | 15 | | assistance
program has been committed, the Inspector General | 16 | | shall immediately notify the
Medicaid Fraud Control Unit. If | 17 | | the Inspector General determines that a
possible criminal act | 18 | | has been committed within the jurisdiction of the Office,
the | 19 | | Inspector General may request the special expertise of the | 20 | | Department of
State Police. The Inspector General may present | 21 | | for prosecution the findings
of any criminal investigation to | 22 | | the Office of the Attorney General, the
Offices of the several | 23 | | United States Attorneys in Illinois or the several
State's | 24 | | Attorneys.
| 25 | | (f) To carry out his or her duties as described in this | 26 | | Section, the
Inspector General and his or her designees shall |
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| 1 | | have the power to compel
by subpoena the attendance and | 2 | | testimony of witnesses and the production
of books, electronic | 3 | | records and papers as directly related to public
assistance | 4 | | programs administered by the Department of Healthcare and | 5 | | Family Services or
the Department of Human Services (as | 6 | | successor to the Department of Public
Aid). No medical provider | 7 | | shall be compelled, however, to provide individual
medical | 8 | | records of patients who are not clients of the Medical | 9 | | Assistance
Program.
| 10 | | (g) The Inspector General shall report all convictions, | 11 | | terminations, and
suspensions taken against vendors, | 12 | | contractors and medical providers to the
Department of | 13 | | Healthcare and Family Services and to any agency responsible | 14 | | for
licensing or regulating those persons or entities.
| 15 | | (h) The Inspector General shall make annual
reports, | 16 | | findings, and recommendations regarding the Office's | 17 | | investigations
into reports of fraud, waste, abuse, | 18 | | mismanagement, or misconduct relating to
any public aid | 19 | | programs administered by the Department
of Healthcare and | 20 | | Family Services or the Department of Human Services (as | 21 | | successor to the
Department of Public Aid) to the General | 22 | | Assembly and the Governor. These
reports shall include, but not | 23 | | be limited to, the following information:
| 24 | | (1) Aggregate provider billing and payment | 25 | | information, including the
number of providers at various | 26 | | Medicaid earning levels.
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| 1 | | (2) The number of audits of the medical assistance
| 2 | | program and the dollar savings resulting from those audits.
| 3 | | (3) The number of prescriptions rejected annually | 4 | | under the
Department of Healthcare and Family Services' | 5 | | Refill Too Soon program and the
dollar savings resulting | 6 | | from that program.
| 7 | | (4) Provider sanctions, in the aggregate, including | 8 | | terminations and
suspensions.
| 9 | | (5) A detailed summary of the investigations | 10 | | undertaken in the previous
fiscal year. These summaries | 11 | | shall comply with all laws and rules regarding
maintaining | 12 | | confidentiality in the public aid programs.
| 13 | | (i) Nothing in this Section shall limit investigations by | 14 | | the
Department of Healthcare and Family Services or the | 15 | | Department of Human Services that may
otherwise be required by | 16 | | law or that may be necessary in their capacity as the
central | 17 | | administrative authorities responsible for administration of | 18 | | their agency's public aid
programs in this
State.
| 19 | | (j) The Inspector General may issue shields or other | 20 | | distinctive identification to his or her employees not | 21 | | exercising the powers of a peace officer if the Inspector | 22 | | General determines that a shield or distinctive identification | 23 | | is needed by an employee to carry out his or her | 24 | | responsibilities. | 25 | | (Source: P.A. 95-331, eff. 8-21-07; 96-555, eff. 8-18-09; | 26 | | 96-1316, eff. 1-1-11.)
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| 1 | | Section 99. Effective date. This Act takes effect upon | 2 | | becoming law.
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