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1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Sections 5-5, 5-30, and 5-30.1 as follows:
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    Sec. 5-5. Medical services. The Illinois Department, by
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing home,
16or elsewhere; (6) medical care, or any other type of remedial
17care furnished by licensed practitioners; (7) home health care
18services; (8) private duty nursing service; (9) clinic
19services; (10) dental services, including prevention and
20treatment of periodontal disease and dental caries disease for
21pregnant women, provided by an individual licensed to practice
22dentistry or dental surgery; for purposes of this item (10),
23"dental services" means diagnostic, preventive, or corrective



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



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



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



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



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1enrolling as a participating provider in the medical assistance
2program. A not-for-profit health clinic shall include a public
3health clinic or Federally Qualified Health Center or other
4enrolled provider, as determined by the Department, through
5which dental services covered under this Section are performed.
6The Department shall establish a process for payment of claims
7for reimbursement for covered dental services rendered under
8this provision.
9    The Illinois Department, by rule, may distinguish and
10classify the medical services to be provided only in accordance
11with the classes of persons designated in Section 5-2.
12    The Department of Healthcare and Family Services must
13provide coverage and reimbursement for amino acid-based
14elemental formulas, regardless of delivery method, for the
15diagnosis and treatment of (i) eosinophilic disorders and (ii)
16short bowel syndrome when the prescribing physician has issued
17a written order stating that the amino acid-based elemental
18formula is medically necessary.
19    The Illinois Department shall authorize the provision of,
20and shall authorize payment for, screening by low-dose
21mammography for the presence of occult breast cancer for women
2235 years of age or older who are eligible for medical
23assistance under this Article, as follows:
24        (A) A baseline mammogram for women 35 to 39 years of
25    age.
26        (B) An annual mammogram for women 40 years of age or



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1    older.
2        (C) A mammogram at the age and intervals considered
3    medically necessary by the woman's health care provider for
4    women under 40 years of age and having a family history of
5    breast cancer, prior personal history of breast cancer,
6    positive genetic testing, or other risk factors.
7        (D) A comprehensive ultrasound screening and MRI of an
8    entire breast or breasts if a mammogram demonstrates
9    heterogeneous or dense breast tissue, when medically
10    necessary as determined by a physician licensed to practice
11    medicine in all of its branches.
12        (E) A screening MRI when medically necessary, as
13    determined by a physician licensed to practice medicine in
14    all of its branches.
15    All screenings shall include a physical breast exam,
16instruction on self-examination and information regarding the
17frequency of self-examination and its value as a preventative
18tool. For purposes of this Section, "low-dose mammography"
19means the x-ray examination of the breast using equipment
20dedicated specifically for mammography, including the x-ray
21tube, filter, compression device, and image receptor, with an
22average radiation exposure delivery of less than one rad per
23breast for 2 views of an average size breast. The term also
24includes digital mammography and includes breast
25tomosynthesis. As used in this Section, the term "breast
26tomosynthesis" means a radiologic procedure that involves the



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



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



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1months, of the importance and benefit of screening mammography.
2The Department shall work with experts in breast cancer
3outreach and patient navigation to optimize these reminders and
4shall establish a methodology for evaluating their
5effectiveness and modifying the methodology based on the
7    The Department shall establish a performance goal for
8primary care providers with respect to their female patients
9over age 40 receiving an annual mammogram. This performance
10goal shall be used to provide additional reimbursement in the
11form of a quality performance bonus to primary care providers
12who meet that goal.
13    The Department shall devise a means of case-managing or
14patient navigation for beneficiaries diagnosed with breast
15cancer. This program shall initially operate as a pilot program
16in areas of the State with the highest incidence of mortality
17related to breast cancer. At least one pilot program site shall
18be in the metropolitan Chicago area and at least one site shall
19be outside the metropolitan Chicago area. On or after July 1,
202016, the pilot program shall be expanded to include one site
21in western Illinois, one site in southern Illinois, one site in
22central Illinois, and 4 sites within metropolitan Chicago. An
23evaluation of the pilot program shall be carried out measuring
24health outcomes and cost of care for those served by the pilot
25program compared to similarly situated patients who are not
26served by the pilot program.



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



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



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



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



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



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1is being made are actually being received by eligible
2recipients. Within 90 days after September 16, 1984 (the
3effective date of Public Act 83-1439), the Illinois Department
4shall establish a current list of acquisition costs for all
5prosthetic devices and any other items recognized as medical
6equipment and supplies reimbursable under this Article and
7shall update such list on a quarterly basis, except that the
8acquisition costs of all prescription drugs shall be updated no
9less frequently than every 30 days as required by Section
11    Notwithstanding any other law to the contrary, the Illinois
12Department shall, within 365 days after July 22, 2013 (the
13effective date of Public Act 98-104), establish procedures to
14permit skilled care facilities licensed under the Nursing Home
15Care Act to submit monthly billing claims for reimbursement
16purposes. Following development of these procedures, the
17Department shall, by July 1, 2016, test the viability of the
18new system and implement any necessary operational or
19structural changes to its information technology platforms in
20order to allow for the direct acceptance and payment of nursing
21home claims.
22    Notwithstanding any other law to the contrary, the Illinois
23Department shall, within 365 days after August 15, 2014 (the
24effective date of Public Act 98-963), establish procedures to
25permit ID/DD facilities licensed under the ID/DD Community Care
26Act and MC/DD facilities licensed under the MC/DD Act to submit



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1monthly billing claims for reimbursement purposes. Following
2development of these procedures, the Department shall have an
3additional 365 days to test the viability of the new system and
4to ensure that any necessary operational or structural changes
5to its information technology platforms are implemented.
6    The Illinois Department shall require all dispensers of
7medical services, other than an individual practitioner or
8group of practitioners, desiring to participate in the Medical
9Assistance program established under this Article to disclose
10all financial, beneficial, ownership, equity, surety or other
11interests in any and all firms, corporations, partnerships,
12associations, business enterprises, joint ventures, agencies,
13institutions or other legal entities providing any form of
14health care services in this State under this Article.
15    The Illinois Department may require that all dispensers of
16medical services desiring to participate in the medical
17assistance program established under this Article disclose,
18under such terms and conditions as the Illinois Department may
19by rule establish, all inquiries from clients and attorneys
20regarding medical bills paid by the Illinois Department, which
21inquiries could indicate potential existence of claims or liens
22for the Illinois Department.
23    Enrollment of a vendor shall be subject to a provisional
24period and shall be conditional for one year. During the period
25of conditional enrollment, the Department may terminate the
26vendor's eligibility to participate in, or may disenroll the



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



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1each category of risk of the vendor; and (iii) by rule, the
2hearing rights, if any, afforded to a vendor in each category
3of risk of the vendor that is terminated or disenrolled during
4the conditional enrollment period.
5    To be eligible for payment consideration, a vendor's
6payment claim or bill, either as an initial claim or as a
7resubmitted claim following prior rejection, must be received
8by the Illinois Department, or its fiscal intermediary, no
9later than 180 days after the latest date on the claim on which
10medical goods or services were provided, with the following
12        (1) In the case of a provider whose enrollment is in
13    process by the Illinois Department, the 180-day period
14    shall not begin until the date on the written notice from
15    the Illinois Department that the provider enrollment is
16    complete.
17        (2) In the case of errors attributable to the Illinois
18    Department or any of its claims processing intermediaries
19    which result in an inability to receive, process, or
20    adjudicate a claim, the 180-day period shall not begin
21    until the provider has been notified of the error.
22        (3) In the case of a provider for whom the Illinois
23    Department initiates the monthly billing process.
24        (4) In the case of a provider operated by a unit of
25    local government with a population exceeding 3,000,000
26    when local government funds finance federal participation



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



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



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



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1in a cost-effective manner, taking into consideration the
2recipient's medical prognosis, the extent of the recipient's
3needs, and the requirements and costs for maintaining such
4equipment. Subject to prior approval, such rules shall enable a
5recipient to temporarily acquire and use alternative or
6substitute devices or equipment pending repairs or
7replacements of any device or equipment previously authorized
8for such recipient by the Department. Notwithstanding any
9provision of Section 5-5f to the contrary, the Department may,
10by rule, exempt certain replacement wheelchair parts from prior
11approval and, for wheelchairs, wheelchair parts, wheelchair
12accessories, and related seating and positioning items,
13determine the wholesale price by methods other than actual
14acquisition costs.
15    The Department shall require, by rule, all providers of
16durable medical equipment to be accredited by an accreditation
17organization approved by the federal Centers for Medicare and
18Medicaid Services and recognized by the Department in order to
19bill the Department for providing durable medical equipment to
20recipients. No later than 15 months after the effective date of
21the rule adopted pursuant to this paragraph, all providers must
22meet the accreditation requirement.
23    The Department shall execute, relative to the nursing home
24prescreening project, written inter-agency agreements with the
25Department of Human Services and the Department on Aging, to
26effect the following: (i) intake procedures and common



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1eligibility criteria for those persons who are receiving
2non-institutional services; and (ii) the establishment and
3development of non-institutional services in areas of the State
4where they are not currently available or are undeveloped; and
5(iii) notwithstanding any other provision of law, subject to
6federal approval, on and after July 1, 2012, an increase in the
7determination of need (DON) scores from 29 to 37 for applicants
8for institutional and home and community-based long term care;
9if and only if federal approval is not granted, the Department
10may, in conjunction with other affected agencies, implement
11utilization controls or changes in benefit packages to
12effectuate a similar savings amount for this population; and
13(iv) no later than July 1, 2013, minimum level of care
14eligibility criteria for institutional and home and
15community-based long term care; and (v) no later than October
161, 2013, establish procedures to permit long term care
17providers access to eligibility scores for individuals with an
18admission date who are seeking or receiving services from the
19long term care provider. In order to select the minimum level
20of care eligibility criteria, the Governor shall establish a
21workgroup that includes affected agency representatives and
22stakeholders representing the institutional and home and
23community-based long term care interests. This Section shall
24not restrict the Department from implementing lower level of
25care eligibility criteria for community-based services in
26circumstances where federal approval has been granted.



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1    The Illinois Department shall develop and operate, in
2cooperation with other State Departments and agencies and in
3compliance with applicable federal laws and regulations,
4appropriate and effective systems of health care evaluation and
5programs for monitoring of utilization of health care services
6and facilities, as it affects persons eligible for medical
7assistance under this Code.
8    The Illinois Department shall report annually to the
9General Assembly, no later than the second Friday in April of
101979 and each year thereafter, in regard to:
11        (a) actual statistics and trends in utilization of
12    medical services by public aid recipients;
13        (b) actual statistics and trends in the provision of
14    the various medical services by medical vendors;
15        (c) current rate structures and proposed changes in
16    those rate structures for the various medical vendors; and
17        (d) efforts at utilization review and control by the
18    Illinois Department.
19    The period covered by each report shall be the 3 years
20ending on the June 30 prior to the report. The report shall
21include suggested legislation for consideration by the General
22Assembly. The filing of one copy of the report with the
23Speaker, one copy with the Minority Leader and one copy with
24the Clerk of the House of Representatives, one copy with the
25President, one copy with the Minority Leader and one copy with
26the Secretary of the Senate, one copy with the Legislative



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



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1transplantation, such person must be receiving emergency renal
2dialysis services covered by the Department. Providers under
3this Section shall be prior approved and certified by the
4Department to perform kidney transplantation and the services
5under this Section shall be limited to services associated with
6kidney transplantation.
7    Notwithstanding any other provision of this Code to the
8contrary, on or after July 1, 2015, all FDA approved forms of
9medication assisted treatment prescribed for the treatment of
10alcohol dependence or treatment of opioid dependence shall be
11covered under both fee for service and managed care medical
12assistance programs for persons who are otherwise eligible for
13medical assistance under this Article and shall not be subject
14to any (1) utilization control, other than those established
15under the American Society of Addiction Medicine patient
16placement criteria, (2) prior authorization mandate, or (3)
17lifetime restriction limit mandate.
18    On or after July 1, 2015, opioid antagonists prescribed for
19the treatment of an opioid overdose, including the medication
20product, administration devices, and any pharmacy fees related
21to the dispensing and administration of the opioid antagonist,
22shall be covered under the medical assistance program for
23persons who are otherwise eligible for medical assistance under
24this Article. As used in this Section, "opioid antagonist"
25means a drug that binds to opioid receptors and blocks or
26inhibits the effect of opioids acting on those receptors,



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1including, but not limited to, naloxone hydrochloride or any
2other similarly acting drug approved by the U.S. Food and Drug
4    Upon federal approval, the Department shall provide
5coverage and reimbursement for all drugs that are approved for
6marketing by the federal Food and Drug Administration and that
7are recommended by the federal Public Health Service or the
8United States Centers for Disease Control and Prevention for
9pre-exposure prophylaxis and related pre-exposure prophylaxis
10services, including, but not limited to, HIV and sexually
11transmitted infection screening, treatment for sexually
12transmitted infections, medical monitoring, assorted labs, and
13counseling to reduce the likelihood of HIV infection among
14individuals who are not infected with HIV but who are at high
15risk of HIV infection.
16(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
1799-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
18the effective date of P.A. 99-407); 99-433, eff. 8-21-15;
1999-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
207-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
21eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
22100-538, eff. 1-1-18; revised 10-26-17.)
23    (305 ILCS 5/5-30)
24    Sec. 5-30. Care coordination.
25    (a) At least 50% of recipients eligible for comprehensive



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1medical benefits in all medical assistance programs or other
2health benefit programs administered by the Department,
3including the Children's Health Insurance Program Act and the
4Covering ALL KIDS Health Insurance Act, shall be enrolled in a
5care coordination program by no later than January 1, 2015. For
6purposes of this Section, "coordinated care" or "care
7coordination" means delivery systems where recipients will
8receive their care from providers who participate under
9contract in integrated delivery systems that are responsible
10for providing or arranging the majority of care, including
11primary care physician services, referrals from primary care
12physicians, diagnostic and treatment services, behavioral
13health services, in-patient and outpatient hospital services,
14dental services, and rehabilitation and long-term care
15services. The Department shall designate or contract for such
16integrated delivery systems (i) to ensure enrollees have a
17choice of systems and of primary care providers within such
18systems; (ii) to ensure that enrollees receive quality care in
19a culturally and linguistically appropriate manner; and (iii)
20to ensure that coordinated care programs meet the diverse needs
21of enrollees with developmental, mental health, physical, and
22age-related disabilities.
23    (b) Payment for such coordinated care shall be based on
24arrangements where the State pays for performance related to
25health care outcomes, the use of evidence-based practices, the
26use of primary care delivered through comprehensive medical



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1homes, the use of electronic medical records, and the
2appropriate exchange of health information electronically made
3either on a capitated basis in which a fixed monthly premium
4per recipient is paid and full financial risk is assumed for
5the delivery of services, or through other risk-based payment
7    (c) To qualify for compliance with this Section, the 50%
8goal shall be achieved by enrolling medical assistance
9enrollees from each medical assistance enrollment category,
10including parents, children, seniors, and people with
11disabilities to the extent that current State Medicaid payment
12laws would not limit federal matching funds for recipients in
13care coordination programs. In addition, services must be more
14comprehensively defined and more risk shall be assumed than in
15the Department's primary care case management program as of
16January 25, 2011 (the effective date of Public Act 96-1501).
17    (d) The Department shall report to the General Assembly in
18a separate part of its annual medical assistance program
19report, beginning April, 2012 until April, 2016, on the
20progress and implementation of the care coordination program
21initiatives established by the provisions of Public Act
2296-1501. The Department shall include in its April 2011 report
23a full analysis of federal laws or regulations regarding upper
24payment limitations to providers and the necessary revisions or
25adjustments in rate methodologies and payments to providers
26under this Code that would be necessary to implement



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1coordinated care with full financial risk by a party other than
2the Department.
3    (e) Integrated Care Program for individuals with chronic
4mental health conditions.
5        (1) The Integrated Care Program shall encompass
6    services administered to recipients of medical assistance
7    under this Article to prevent exacerbations and
8    complications using cost-effective, evidence-based
9    practice guidelines and mental health management
10    strategies.
11        (2) The Department may utilize and expand upon existing
12    contractual arrangements with integrated care plans under
13    the Integrated Care Program for providing the coordinated
14    care provisions of this Section.
15        (3) Payment for such coordinated care shall be based on
16    arrangements where the State pays for performance related
17    to mental health outcomes on a capitated basis in which a
18    fixed monthly premium per recipient is paid and full
19    financial risk is assumed for the delivery of services, or
20    through other risk-based payment arrangements such as
21    provider-based care coordination.
22        (4) The Department shall examine whether chronic
23    mental health management programs and services for
24    recipients with specific chronic mental health conditions
25    do any or all of the following:
26            (A) Improve the patient's overall mental health in



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1        a more expeditious and cost-effective manner.
2            (B) Lower costs in other aspects of the medical
3        assistance program, such as hospital admissions,
4        emergency room visits, or more frequent and
5        inappropriate psychotropic drug use.
6        (5) The Department shall work with the facilities and
7    any integrated care plan participating in the program to
8    identify and correct barriers to the successful
9    implementation of this subsection (e) prior to and during
10    the implementation to best facilitate the goals and
11    objectives of this subsection (e).
12    (f) A hospital that is located in a county of the State in
13which the Department mandates some or all of the beneficiaries
14of the Medical Assistance Program residing in the county to
15enroll in a Care Coordination Program, as set forth in Section
165-30 of this Code, shall not be eligible for any non-claims
17based payments not mandated by Article V-A of this Code for
18which it would otherwise be qualified to receive, unless the
19hospital is a Coordinated Care Participating Hospital no later
20than 60 days after June 14, 2012 (the effective date of Public
21Act 97-689) or 60 days after the first mandatory enrollment of
22a beneficiary in a Coordinated Care program. For purposes of
23this subsection, "Coordinated Care Participating Hospital"
24means a hospital that meets one of the following criteria:
25        (1) The hospital has entered into a contract to provide
26    hospital services with one or more MCOs to enrollees of the



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1    care coordination program.
2        (2) The hospital has not been offered a contract by a
3    care coordination plan that the Department has determined
4    to be a good faith offer and that pays at least as much as
5    the Department would pay, on a fee-for-service basis, not
6    including disproportionate share hospital adjustment
7    payments or any other supplemental adjustment or add-on
8    payment to the base fee-for-service rate, except to the
9    extent such adjustments or add-on payments are
10    incorporated into the development of the applicable MCO
11    capitated rates.
12    As used in this subsection (f), "MCO" means any entity
13which contracts with the Department to provide services where
14payment for medical services is made on a capitated basis.
15    (g) No later than August 1, 2013, the Department shall
16issue a purchase of care solicitation for Accountable Care
17Entities (ACE) to serve any children and parents or caretaker
18relatives of children eligible for medical assistance under
19this Article. An ACE may be a single corporate structure or a
20network of providers organized through contractual
21relationships with a single corporate entity. The solicitation
22shall require that:
23        (1) An ACE operating in Cook County be capable of
24    serving at least 40,000 eligible individuals in that
25    county; an ACE operating in Lake, Kane, DuPage, or Will
26    Counties be capable of serving at least 20,000 eligible



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1    individuals in those counties and an ACE operating in other
2    regions of the State be capable of serving at least 10,000
3    eligible individuals in the region in which it operates.
4    During initial periods of mandatory enrollment, the
5    Department shall require its enrollment services
6    contractor to use a default assignment algorithm that
7    ensures if possible an ACE reaches the minimum enrollment
8    levels set forth in this paragraph.
9        (2) An ACE must include at a minimum the following
10    types of providers: primary care, specialty care,
11    hospitals, and behavioral healthcare.
12        (3) An ACE shall have a governance structure that
13    includes the major components of the health care delivery
14    system, including one representative from each of the
15    groups listed in paragraph (2).
16        (4) An ACE must be an integrated delivery system,
17    including a network able to provide the full range of
18    services needed by Medicaid beneficiaries and system
19    capacity to securely pass clinical information across
20    participating entities and to aggregate and analyze that
21    data in order to coordinate care.
22        (5) An ACE must be capable of providing both care
23    coordination and complex case management, as necessary, to
24    beneficiaries. To be responsive to the solicitation, a
25    potential ACE must outline its care coordination and
26    complex case management model and plan to reduce the cost



SB2429 Engrossed- 35 -LRB100 16511 KTG 31643 b

1    of care.
2        (6) In the first 18 months of operation, unless the ACE
3    selects a shorter period, an ACE shall be paid care
4    coordination fees on a per member per month basis that are
5    projected to be cost neutral to the State during the term
6    of their payment and, subject to federal approval, be
7    eligible to share in additional savings generated by their
8    care coordination.
9        (7) In months 19 through 36 of operation, unless the
10    ACE selects a shorter period, an ACE shall be paid on a
11    pre-paid capitation basis for all medical assistance
12    covered services, under contract terms similar to Managed
13    Care Organizations (MCO), with the Department sharing the
14    risk through either stop-loss insurance for extremely high
15    cost individuals or corridors of shared risk based on the
16    overall cost of the total enrollment in the ACE. The ACE
17    shall be responsible for claims processing, encounter data
18    submission, utilization control, and quality assurance.
19        (8) In the fourth and subsequent years of operation, an
20    ACE shall convert to a Managed Care Community Network
21    (MCCN), as defined in this Article, or Health Maintenance
22    Organization pursuant to the Illinois Insurance Code,
23    accepting full-risk capitation payments.
24    The Department shall allow potential ACE entities 5 months
25from the date of the posting of the solicitation to submit
26proposals. After the solicitation is released, in addition to



SB2429 Engrossed- 36 -LRB100 16511 KTG 31643 b

1the MCO rate development data available on the Department's
2website, subject to federal and State confidentiality and
3privacy laws and regulations, the Department shall provide 2
4years of de-identified summary service data on the targeted
5population, split between children and adults, showing the
6historical type and volume of services received and the cost of
7those services to those potential bidders that sign a data use
8agreement. The Department may add up to 2 non-state government
9employees with expertise in creating integrated delivery
10systems to its review team for the purchase of care
11solicitation described in this subsection. Any such
12individuals must sign a no-conflict disclosure and
13confidentiality agreement and agree to act in accordance with
14all applicable State laws.
15    During the first 2 years of an ACE's operation, the
16Department shall provide claims data to the ACE on its
17enrollees on a periodic basis no less frequently than monthly.
18    Nothing in this subsection shall be construed to limit the
19Department's mandate to enroll 50% of its beneficiaries into
20care coordination systems by January 1, 2015, using all
21available care coordination delivery systems, including Care
22Coordination Entities (CCE), MCCNs, or MCOs, nor be construed
23to affect the current CCEs, MCCNs, and MCOs selected to serve
24seniors and persons with disabilities prior to that date.
25    Nothing in this subsection precludes the Department from
26considering future proposals for new ACEs or expansion of



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1existing ACEs at the discretion of the Department.
2    (h) Department contracts with MCOs and other entities
3reimbursed by risk based capitation shall have a minimum
4medical loss ratio of 85%, shall require the entity to
5establish an appeals and grievances process for consumers and
6providers, and shall require the entity to provide a quality
7assurance and utilization review program. Entities contracted
8with the Department to coordinate healthcare regardless of risk
9shall be measured utilizing the same quality metrics. The
10quality metrics may be population specific. Any contracted
11entity serving at least 5,000 seniors or people with
12disabilities or 15,000 individuals in other populations
13covered by the Medical Assistance Program that has been
14receiving full-risk capitation for a year shall be accredited
15by a national accreditation organization authorized by the
16Department within 2 years after the date it is eligible to
17become accredited. The requirements of this subsection shall
18apply to contracts with MCOs entered into or renewed or
19extended after June 1, 2013.
20    (h-5) The Department shall monitor and enforce compliance
21by MCOs with agreements they have entered into with providers
22on issues that include, but are not limited to, timeliness of
23payment, payment rates, and processes for obtaining prior
24approval. The Department may impose sanctions on MCOs for
25violating provisions of those agreements that include, but are
26not limited to, financial penalties, suspension of enrollment



SB2429 Engrossed- 38 -LRB100 16511 KTG 31643 b

1of new enrollees, and termination of the MCO's contract with
2the Department. As used in this subsection (h-5), "MCO" has the
3meaning ascribed to that term in Section 5-30.1 of this Code.
4    (i) Unless otherwise required by federal law, Medicaid
5Managed Care Entities and their respective business associates
6shall not disclose, directly or indirectly, including by
7sending a bill or explanation of benefits, information
8concerning the sensitive health services received by enrollees
9of the Medicaid Managed Care Entity to any person other than
10covered entities and business associates, which may receive,
11use, and further disclose such information solely for the
12purposes permitted under applicable federal and State laws and
13regulations if such use and further disclosure satisfies all
14applicable requirements of such laws and regulations. The
15Medicaid Managed Care Entity or its respective business
16associates may disclose information concerning the sensitive
17health services if the enrollee who received the sensitive
18health services requests the information from the Medicaid
19Managed Care Entity or its respective business associates and
20authorized the sending of a bill or explanation of benefits.
21Communications including, but not limited to, statements of
22care received or appointment reminders either directly or
23indirectly to the enrollee from the health care provider,
24health care professional, and care coordinators, remain
25permissible. Medicaid Managed Care Entities or their
26respective business associates may communicate directly with



SB2429 Engrossed- 39 -LRB100 16511 KTG 31643 b

1their enrollees regarding care coordination activities for
2those enrollees.
3    For the purposes of this subsection, the term "Medicaid
4Managed Care Entity" includes Care Coordination Entities,
5Accountable Care Entities, Managed Care Organizations, and
6Managed Care Community Networks.
7    For purposes of this subsection, the term "sensitive health
8services" means mental health services, substance abuse
9treatment services, reproductive health services, family
10planning services, services for sexually transmitted
11infections and sexually transmitted diseases, and services for
12sexual assault or domestic abuse. Services include prevention,
13screening, consultation, examination, treatment, or follow-up.
14    For purposes of this subsection, "business associate",
15"covered entity", "disclosure", and "use" have the meanings
16ascribed to those terms in 45 CFR 160.103.
17    Nothing in this subsection shall be construed to relieve a
18Medicaid Managed Care Entity or the Department of any duty to
19report incidents of sexually transmitted infections to the
20Department of Public Health or to the local board of health in
21accordance with regulations adopted under a statute or
22ordinance or to report incidents of sexually transmitted
23infections as necessary to comply with the requirements under
24Section 5 of the Abused and Neglected Child Reporting Act or as
25otherwise required by State or federal law.
26    The Department shall create policy in order to implement



SB2429 Engrossed- 40 -LRB100 16511 KTG 31643 b

1the requirements in this subsection.
2    (j) Managed Care Entities (MCEs), including MCOs and all
3other care coordination organizations, shall develop and
4maintain a written language access policy that sets forth the
5standards, guidelines, and operational plan to ensure language
6appropriate services and that is consistent with the standard
7of meaningful access for populations with limited English
8proficiency. The language access policy shall describe how the
9MCEs will provide all of the following required services:
10        (1) Translation (the written replacement of text from
11    one language into another) of all vital documents and forms
12    as identified by the Department.
13        (2) Qualified interpreter services (the oral
14    communication of a message from one language into another
15    by a qualified interpreter).
16        (3) Staff training on the language access policy,
17    including how to identify language needs, access and
18    provide language assistance services, work with
19    interpreters, request translations, and track the use of
20    language assistance services.
21        (4) Data tracking that identifies the language need.
22        (5) Notification to participants on the availability
23    of language access services and on how to access such
24    services.
25    (k) The Department shall actively monitor the contractual
26relationship between Managed Care Organizations (MCOs) and any



SB2429 Engrossed- 41 -LRB100 16511 KTG 31643 b

1dental administrator contracted by an MCO to provide dental
2services. The Department shall adopt appropriate dental
3Healthcare Effectiveness Data and Information Set (HEDIS)
4measures and shall include the Annual Dental Visit (ADV) HEDIS
5measure in its Health Plan Comparison Tool and Illinois
6Medicaid Plan Report Card that is available on the Department's
7website for enrolled individuals.
8    The Department shall collect from each MCO specific
9information about the types of contracted, broad-based care
10coordination occurring between the MCO and any dental
11administrator, including, but not limited to, pregnant women
12and diabetic patients in need of oral care.
13(Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14;
1499-106, eff. 1-1-16; 99-181, eff. 7-29-15; 99-566, eff. 1-1-17;
1599-642, eff. 7-28-16.)
16    (305 ILCS 5/5-30.1)
17    Sec. 5-30.1. Managed care protections.
18    (a) As used in this Section:
19    "Managed care organization" or "MCO" means any entity which
20contracts with the Department to provide services where payment
21for medical services is made on a capitated basis.
22    "Emergency services" include:
23        (1) emergency services, as defined by Section 10 of the
24    Managed Care Reform and Patient Rights Act;
25        (2) emergency medical screening examinations, as



SB2429 Engrossed- 42 -LRB100 16511 KTG 31643 b

1    defined by Section 10 of the Managed Care Reform and
2    Patient Rights Act;
3        (3) post-stabilization medical services, as defined by
4    Section 10 of the Managed Care Reform and Patient Rights
5    Act; and
6        (4) emergency medical conditions, as defined by
7    Section 10 of the Managed Care Reform and Patient Rights
8    Act.
9    (b) As provided by Section 5-16.12, managed care
10organizations are subject to the provisions of the Managed Care
11Reform and Patient Rights Act.
12    (c) An MCO shall pay any provider of emergency services
13that does not have in effect a contract with the contracted
14Medicaid MCO. The default rate of reimbursement shall be the
15rate paid under Illinois Medicaid fee-for-service program
16methodology, including all policy adjusters, including but not
17limited to Medicaid High Volume Adjustments, Medicaid
18Percentage Adjustments, Outpatient High Volume Adjustments,
19and all outlier add-on adjustments to the extent such
20adjustments are incorporated in the development of the
21applicable MCO capitated rates.
22    (d) An MCO shall pay for all post-stabilization services as
23a covered service in any of the following situations:
24        (1) the MCO authorized such services;
25        (2) such services were administered to maintain the
26    enrollee's stabilized condition within one hour after a



SB2429 Engrossed- 43 -LRB100 16511 KTG 31643 b

1    request to the MCO for authorization of further
2    post-stabilization services;
3        (3) the MCO did not respond to a request to authorize
4    such services within one hour;
5        (4) the MCO could not be contacted; or
6        (5) the MCO and the treating provider, if the treating
7    provider is a non-affiliated provider, could not reach an
8    agreement concerning the enrollee's care and an affiliated
9    provider was unavailable for a consultation, in which case
10    the MCO must pay for such services rendered by the treating
11    non-affiliated provider until an affiliated provider was
12    reached and either concurred with the treating
13    non-affiliated provider's plan of care or assumed
14    responsibility for the enrollee's care. Such payment shall
15    be made at the default rate of reimbursement paid under
16    Illinois Medicaid fee-for-service program methodology,
17    including all policy adjusters, including but not limited
18    to Medicaid High Volume Adjustments, Medicaid Percentage
19    Adjustments, Outpatient High Volume Adjustments and all
20    outlier add-on adjustments to the extent that such
21    adjustments are incorporated in the development of the
22    applicable MCO capitated rates.
23    (e) The following requirements apply to MCOs in determining
24payment for all emergency services:
25        (1) MCOs shall not impose any requirements for prior
26    approval of emergency services.



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1        (2) The MCO shall cover emergency services provided to
2    enrollees who are temporarily away from their residence and
3    outside the contracting area to the extent that the
4    enrollees would be entitled to the emergency services if
5    they still were within the contracting area.
6        (3) The MCO shall have no obligation to cover medical
7    services provided on an emergency basis that are not
8    covered services under the contract.
9        (4) The MCO shall not condition coverage for emergency
10    services on the treating provider notifying the MCO of the
11    enrollee's screening and treatment within 10 days after
12    presentation for emergency services.
13        (5) The determination of the attending emergency
14    physician, or the provider actually treating the enrollee,
15    of whether an enrollee is sufficiently stabilized for
16    discharge or transfer to another facility, shall be binding
17    on the MCO. The MCO shall cover emergency services for all
18    enrollees whether the emergency services are provided by an
19    affiliated or non-affiliated provider.
20        (6) The MCO's financial responsibility for
21    post-stabilization care services it has not pre-approved
22    ends when:
23            (A) a plan physician with privileges at the
24        treating hospital assumes responsibility for the
25        enrollee's care;
26            (B) a plan physician assumes responsibility for



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1        the enrollee's care through transfer;
2            (C) a contracting entity representative and the
3        treating physician reach an agreement concerning the
4        enrollee's care; or
5            (D) the enrollee is discharged.
6    (f) Network adequacy and transparency.
7        (1) The Department shall:
8            (A) ensure that an adequate provider network is in
9        place, taking into consideration health professional
10        shortage areas and medically underserved areas;
11            (B) publicly release an explanation of its process
12        for analyzing network adequacy;
13            (C) periodically ensure that an MCO continues to
14        have an adequate network in place; and
15            (D) require MCOs, including Medicaid Managed Care
16        Entities as defined in Section 5-30.2, to meet provider
17        directory requirements under Section 5-30.3.
18        (2) Each MCO shall confirm its receipt of information
19    submitted specific to physician or dentist additions or
20    physician or dentist deletions from the MCO's provider
21    network within 3 days after receiving all required
22    information from contracted physicians or dentists, and
23    electronic physician and dental directories must be
24    updated consistent with current rules as published by the
25    Centers for Medicare and Medicaid Services or its successor
26    agency.



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1    (g) Timely payment of claims.
2        (1) The MCO shall pay a claim within 30 days of
3    receiving a claim that contains all the essential
4    information needed to adjudicate the claim.
5        (2) The MCO shall notify the billing party of its
6    inability to adjudicate a claim within 30 days of receiving
7    that claim.
8        (3) The MCO shall pay a penalty that is at least equal
9    to the penalty imposed under the Illinois Insurance Code
10    for any claims not timely paid.
11        (4) The Department may establish a process for MCOs to
12    expedite payments to providers based on criteria
13    established by the Department.
14    (g-5) Recognizing that the rapid transformation of the
15Illinois Medicaid program may have unintended operational
16challenges for both payers and providers:
17        (1) in no instance shall a medically necessary covered
18    service rendered in good faith, based upon eligibility
19    information documented by the provider, be denied coverage
20    or diminished in payment amount if the eligibility or
21    coverage information available at the time the service was
22    rendered is later found to be inaccurate; and
23        (2) the Department shall, by December 31, 2016, adopt
24    rules establishing policies that shall be included in the
25    Medicaid managed care policy and procedures manual
26    addressing payment resolutions in situations in which a



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1    provider renders services based upon information obtained
2    after verifying a patient's eligibility and coverage plan
3    through either the Department's current enrollment system
4    or a system operated by the coverage plan identified by the
5    patient presenting for services:
6            (A) such medically necessary covered services
7        shall be considered rendered in good faith;
8            (B) such policies and procedures shall be
9        developed in consultation with industry
10        representatives of the Medicaid managed care health
11        plans and representatives of provider associations
12        representing the majority of providers within the
13        identified provider industry; and
14            (C) such rules shall be published for a review and
15        comment period of no less than 30 days on the
16        Department's website with final rules remaining
17        available on the Department's website.
18        (3) The rules on payment resolutions shall include, but
19    not be limited to:
20            (A) the extension of the timely filing period;
21            (B) retroactive prior authorizations; and
22            (C) guaranteed minimum payment rate of no less than
23        the current, as of the date of service, fee-for-service
24        rate, plus all applicable add-ons, when the resulting
25        service relationship is out of network.
26        (4) The rules shall be applicable for both MCO coverage



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1    and fee-for-service coverage.
2    (g-6) MCO Performance Metrics Report.
3        (1) The Department shall publish, on at least a
4    quarterly basis, each MCO's operational performance,
5    including, but not limited to, the following categories of
6    metrics:
7            (A) claims payment, including timeliness and
8        accuracy;
9            (B) prior authorizations;
10            (C) grievance and appeals;
11            (D) utilization statistics;
12            (E) provider disputes;
13            (F) provider credentialing; and
14            (G) member and provider customer service.
15        (2) The Department shall ensure that the metrics report
16    is accessible to providers online by January 1, 2017.
17        (3) The metrics shall be developed in consultation with
18    industry representatives of the Medicaid managed care
19    health plans and representatives of associations
20    representing the majority of providers within the
21    identified industry.
22        (4) Metrics shall be defined and incorporated into the
23    applicable Managed Care Policy Manual issued by the
24    Department.
25    (g-7) MCO claims processing and performance analysis. In
26order to monitor MCO payments to hospital providers, pursuant



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1to this amendatory Act of the 100th General Assembly, the
2Department shall post an analysis of MCO claims processing and
3payment performance on its website every 6 months. Such
4analysis shall include a review and evaluation of a
5representative sample of hospital claims that are rejected and
6denied for clean and unclean claims and the top 5 reasons for
7such actions and timeliness of claims adjudication, which
8identifies the percentage of claims adjudicated within 30, 60,
990, and over 90 days, and the dollar amounts associated with
10those claims. The Department shall post the contracted claims
11report required by HealthChoice Illinois on its website every 3
13    (h) The Department shall not expand mandatory MCO
14enrollment into new counties beyond those counties already
15designated by the Department as of June 1, 2014 for the
16individuals whose eligibility for medical assistance is not the
17seniors or people with disabilities population until the
18Department provides an opportunity for accountable care
19entities and MCOs to participate in such newly designated
21    (i) The requirements of this Section apply to contracts
22with accountable care entities and MCOs entered into, amended,
23or renewed after June 16, 2014 (the effective date of Public
24Act 98-651).
25(Source: P.A. 99-725, eff. 8-5-16; 99-751, eff. 8-5-16;
26100-201, eff. 8-18-17; 100-580, eff. 3-12-18.)



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1    Section 99. Effective date. This Act takes effect upon
2becoming law.