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1 | AN ACT concerning public aid.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Illinois Public Aid Code is amended by | ||||||||||||||||||||||||
5 | changing Section 5-5 as follows:
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6 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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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,
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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
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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, including | ||||||
8 | to ensure that the individual's need for intervention or | ||||||
9 | treatment of mental disorders or substance use disorders or | ||||||
10 | co-occurring mental health and substance use disorders is | ||||||
11 | determined using a uniform screening, assessment, and | ||||||
12 | evaluation process inclusive of criteria, for children and | ||||||
13 | adults; for purposes of this item (13), a uniform screening, | ||||||
14 | assessment, and evaluation process refers to a process that | ||||||
15 | includes an appropriate evaluation and, as warranted, a | ||||||
16 | referral; "uniform" does not mean the use of a singular | ||||||
17 | instrument, tool, or process that all must utilize; (14)
| ||||||
18 | transportation and such other expenses as may be necessary; | ||||||
19 | (15) medical
treatment of sexual assault survivors, as defined | ||||||
20 | in
Section 1a of the Sexual Assault Survivors Emergency | ||||||
21 | Treatment Act, for
injuries sustained as a result of the sexual | ||||||
22 | assault, including
examinations and laboratory tests to | ||||||
23 | discover evidence which may be used in
criminal proceedings | ||||||
24 | arising from the sexual assault; (16) the
diagnosis and | ||||||
25 | treatment of sickle cell anemia; and (17)
any other medical | ||||||
26 | care, and any other type of remedial care recognized
under the |
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| |||||||
1 | laws of this State. The term "any other type of remedial care" | ||||||
2 | shall
include nursing care and nursing home service for persons | ||||||
3 | who rely on
treatment by spiritual means alone through prayer | ||||||
4 | for healing.
| ||||||
5 | Notwithstanding any other provision of this Section, a | ||||||
6 | comprehensive
tobacco use cessation program that includes | ||||||
7 | purchasing prescription drugs or
prescription medical devices | ||||||
8 | approved by the Food and Drug Administration shall
be covered | ||||||
9 | under the medical assistance
program under this Article for | ||||||
10 | persons who are otherwise eligible for
assistance under this | ||||||
11 | Article.
| ||||||
12 | Notwithstanding any other provision of this Code, | ||||||
13 | reproductive health care that is otherwise legal in Illinois | ||||||
14 | shall be covered under the medical assistance program for | ||||||
15 | persons who are otherwise eligible for medical assistance under | ||||||
16 | this Article. | ||||||
17 | Notwithstanding any other provision of this Code, the | ||||||
18 | Illinois
Department may not require, as a condition of payment | ||||||
19 | for any laboratory
test authorized under this Article, that a | ||||||
20 | physician's handwritten signature
appear on the laboratory | ||||||
21 | test order form. The Illinois Department may,
however, impose | ||||||
22 | other appropriate requirements regarding laboratory test
order | ||||||
23 | documentation.
| ||||||
24 | Upon receipt of federal approval of an amendment to the | ||||||
25 | Illinois Title XIX State Plan for this purpose, the Department | ||||||
26 | shall authorize the Chicago Public Schools (CPS) to procure a |
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| |||||||
1 | vendor or vendors to manufacture eyeglasses for individuals | ||||||
2 | enrolled in a school within the CPS system. CPS shall ensure | ||||||
3 | that its vendor or vendors are enrolled as providers in the | ||||||
4 | medical assistance program and in any capitated Medicaid | ||||||
5 | managed care entity (MCE) serving individuals enrolled in a | ||||||
6 | school within the CPS system. Under any contract procured under | ||||||
7 | this provision, the vendor or vendors must serve only | ||||||
8 | individuals enrolled in a school within the CPS system. Claims | ||||||
9 | for services provided by CPS's vendor or vendors to recipients | ||||||
10 | of benefits in the medical assistance program under this Code, | ||||||
11 | the Children's Health Insurance Program, or the Covering ALL | ||||||
12 | KIDS Health Insurance Program shall be submitted to the | ||||||
13 | Department or the MCE in which the individual is enrolled for | ||||||
14 | payment and shall be reimbursed at the Department's or the | ||||||
15 | MCE's established rates or rate methodologies for eyeglasses. | ||||||
16 | On and after July 1, 2012, the Department of Healthcare and | ||||||
17 | Family Services may provide the following services to
persons
| ||||||
18 | eligible for assistance under this Article who are | ||||||
19 | participating in
education, training or employment programs | ||||||
20 | operated by the Department of Human
Services as successor to | ||||||
21 | the 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 | Notwithstanding any other provision of this Code and | ||||||
2 | subject to federal approval, the Department may adopt rules to | ||||||
3 | allow a dentist who is volunteering his or her service at no | ||||||
4 | cost to render dental services through an enrolled | ||||||
5 | not-for-profit health clinic without the dentist personally | ||||||
6 | enrolling as a participating provider in the medical assistance | ||||||
7 | program. A not-for-profit health clinic shall include a public | ||||||
8 | health clinic or Federally Qualified Health Center or other | ||||||
9 | enrolled provider, as determined by the Department, through | ||||||
10 | which dental services covered under this Section are performed. | ||||||
11 | The Department shall establish a process for payment of claims | ||||||
12 | for reimbursement for covered dental services rendered under | ||||||
13 | this provision. | ||||||
14 | The Illinois Department, by rule, may distinguish and | ||||||
15 | classify the
medical services to be provided only in accordance | ||||||
16 | with the classes of
persons designated in Section 5-2.
| ||||||
17 | The Department of Healthcare and Family Services must | ||||||
18 | provide coverage and reimbursement for amino acid-based | ||||||
19 | elemental formulas, regardless of delivery method, for the | ||||||
20 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
21 | short bowel syndrome when the prescribing physician has issued | ||||||
22 | a written order stating that the amino acid-based elemental | ||||||
23 | formula is medically necessary.
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24 | The Illinois Department shall authorize the provision of, | ||||||
25 | and shall
authorize payment for, screening by low-dose | ||||||
26 | mammography for the presence of
occult breast cancer for women |
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1 | 35 years of age or older who are eligible
for medical | ||||||
2 | assistance under this Article, as follows: | ||||||
3 | (A) A baseline
mammogram for women 35 to 39 years of | ||||||
4 | age.
| ||||||
5 | (B) An annual mammogram for women 40 years of age or | ||||||
6 | older. | ||||||
7 | (C) A mammogram at the age and intervals considered | ||||||
8 | medically necessary by the woman's health care provider for | ||||||
9 | women under 40 years of age and having a family history of | ||||||
10 | breast cancer, prior personal history of breast cancer, | ||||||
11 | positive genetic testing, or other risk factors. | ||||||
12 | (D) A comprehensive ultrasound screening and MRI of an | ||||||
13 | entire breast or breasts if a mammogram demonstrates | ||||||
14 | heterogeneous or dense breast tissue, when medically | ||||||
15 | necessary as determined by a physician licensed to practice | ||||||
16 | medicine in all of its branches. | ||||||
17 | (E) A screening MRI when medically necessary, as | ||||||
18 | determined by a physician licensed to practice medicine in | ||||||
19 | all of its branches. | ||||||
20 | All screenings
shall
include a physical breast exam, | ||||||
21 | instruction on self-examination and
information regarding the | ||||||
22 | frequency of self-examination and its value as a
preventative | ||||||
23 | tool. For purposes of this Section, "low-dose mammography" | ||||||
24 | means
the x-ray examination of the breast using equipment | ||||||
25 | dedicated specifically
for mammography, including the x-ray | ||||||
26 | tube, filter, compression device,
and image receptor, with an |
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| |||||||
1 | average radiation exposure delivery
of less than one rad per | ||||||
2 | breast for 2 views of an average size breast.
The term also | ||||||
3 | includes digital mammography and includes breast | ||||||
4 | tomosynthesis. As used in this Section, the term "breast | ||||||
5 | tomosynthesis" means a radiologic procedure that involves the | ||||||
6 | acquisition of projection images over the stationary breast to | ||||||
7 | produce cross-sectional digital three-dimensional images of | ||||||
8 | the breast. If, at any time, the Secretary of the United States | ||||||
9 | Department of Health and Human Services, or its successor | ||||||
10 | agency, promulgates rules or regulations to be published in the | ||||||
11 | Federal Register or publishes a comment in the Federal Register | ||||||
12 | or issues an opinion, guidance, or other action that would | ||||||
13 | require the State, pursuant to any provision of the Patient | ||||||
14 | Protection and Affordable Care Act (Public Law 111-148), | ||||||
15 | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any | ||||||
16 | successor provision, to defray the cost of any coverage for | ||||||
17 | breast tomosynthesis outlined in this paragraph, then the | ||||||
18 | requirement that an insurer cover breast tomosynthesis is | ||||||
19 | inoperative other than any such coverage authorized under | ||||||
20 | Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and | ||||||
21 | the State shall not assume any obligation for the cost of | ||||||
22 | coverage for breast tomosynthesis set forth in this paragraph.
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23 | On and after January 1, 2016, the Department shall ensure | ||||||
24 | that all networks of care for adult clients of the Department | ||||||
25 | include access to at least one breast imaging Center of Imaging | ||||||
26 | Excellence as certified by the American College of Radiology. |
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1 | On and after January 1, 2012, providers participating in a | ||||||
2 | quality improvement program approved by the Department shall be | ||||||
3 | reimbursed for screening and diagnostic mammography at the same | ||||||
4 | rate as the Medicare program's rates, including the increased | ||||||
5 | reimbursement for digital mammography. | ||||||
6 | The Department shall convene an expert panel including | ||||||
7 | representatives of hospitals, free-standing mammography | ||||||
8 | facilities, and doctors, including radiologists, to establish | ||||||
9 | quality standards for mammography. | ||||||
10 | On and after January 1, 2017, providers participating in a | ||||||
11 | breast cancer treatment quality improvement program approved | ||||||
12 | by the Department shall be reimbursed for breast cancer | ||||||
13 | treatment at a rate that is no lower than 95% of the Medicare | ||||||
14 | program's rates for the data elements included in the breast | ||||||
15 | cancer treatment quality program. | ||||||
16 | The Department shall convene an expert panel, including | ||||||
17 | representatives of hospitals, free standing breast cancer | ||||||
18 | treatment centers, breast cancer quality organizations, and | ||||||
19 | doctors, including breast surgeons, reconstructive breast | ||||||
20 | surgeons, oncologists, and primary care providers to establish | ||||||
21 | quality standards for breast cancer treatment. | ||||||
22 | Subject to federal approval, the Department shall | ||||||
23 | establish a rate methodology for mammography at federally | ||||||
24 | qualified health centers and other encounter-rate clinics. | ||||||
25 | These clinics or centers may also collaborate with other | ||||||
26 | hospital-based mammography facilities. By January 1, 2016, the |
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| |||||||
1 | Department shall report to the General Assembly on the status | ||||||
2 | of the provision set forth in this paragraph. | ||||||
3 | The Department shall establish a methodology to remind | ||||||
4 | women who are age-appropriate for screening mammography, but | ||||||
5 | who have not received a mammogram within the previous 18 | ||||||
6 | months, of the importance and benefit of screening mammography. | ||||||
7 | The Department shall work with experts in breast cancer | ||||||
8 | outreach and patient navigation to optimize these reminders and | ||||||
9 | shall establish a methodology for evaluating their | ||||||
10 | effectiveness and modifying the methodology based on the | ||||||
11 | evaluation. | ||||||
12 | The Department shall establish a performance goal for | ||||||
13 | primary care providers with respect to their female patients | ||||||
14 | over age 40 receiving an annual mammogram. This performance | ||||||
15 | goal shall be used to provide additional reimbursement in the | ||||||
16 | form of a quality performance bonus to primary care providers | ||||||
17 | who meet that goal. | ||||||
18 | The Department shall devise a means of case-managing or | ||||||
19 | patient navigation for beneficiaries diagnosed with breast | ||||||
20 | cancer. This program shall initially operate as a pilot program | ||||||
21 | in areas of the State with the highest incidence of mortality | ||||||
22 | related to breast cancer. At least one pilot program site shall | ||||||
23 | be in the metropolitan Chicago area and at least one site shall | ||||||
24 | be outside the metropolitan Chicago area. On or after July 1, | ||||||
25 | 2016, the pilot program shall be expanded to include one site | ||||||
26 | in western Illinois, one site in southern Illinois, one site in |
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| |||||||
1 | central Illinois, and 4 sites within metropolitan Chicago. An | ||||||
2 | evaluation of the pilot program shall be carried out measuring | ||||||
3 | health outcomes and cost of care for those served by the pilot | ||||||
4 | program compared to similarly situated patients who are not | ||||||
5 | served by the pilot program. | ||||||
6 | The Department shall require all networks of care to | ||||||
7 | develop a means either internally or by contract with experts | ||||||
8 | in navigation and community outreach to navigate cancer | ||||||
9 | patients to comprehensive care in a timely fashion. The | ||||||
10 | Department shall require all networks of care to include access | ||||||
11 | for patients diagnosed with cancer to at least one academic | ||||||
12 | commission on cancer-accredited cancer program as an | ||||||
13 | in-network covered benefit. | ||||||
14 | Any medical or health care provider shall immediately | ||||||
15 | recommend, to
any pregnant woman who is being provided prenatal | ||||||
16 | services and is suspected
of drug abuse or is addicted as | ||||||
17 | defined in the Alcoholism and Other Drug Abuse
and Dependency | ||||||
18 | Act, referral to a local substance abuse treatment provider
| ||||||
19 | licensed by the Department of Human Services or to a licensed
| ||||||
20 | hospital which provides substance abuse treatment services. | ||||||
21 | The Department of Healthcare and Family Services
shall assure | ||||||
22 | coverage for the cost of treatment of the drug abuse or
| ||||||
23 | addiction for pregnant recipients in accordance with the | ||||||
24 | Illinois Medicaid
Program in conjunction with the Department of | ||||||
25 | Human Services.
| ||||||
26 | All medical providers providing medical assistance to |
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| |||||||
1 | pregnant women
under this Code shall receive information from | ||||||
2 | the Department on the
availability of services under the Drug | ||||||
3 | Free Families with a Future or any
comparable program providing | ||||||
4 | case management services for addicted women,
including | ||||||
5 | information on appropriate referrals for other social services
| ||||||
6 | that may be needed by addicted women in addition to treatment | ||||||
7 | for addiction.
| ||||||
8 | The Illinois Department, in cooperation with the | ||||||
9 | Departments of Human
Services (as successor to the Department | ||||||
10 | of Alcoholism and Substance
Abuse) and Public Health, through a | ||||||
11 | public awareness campaign, may
provide information concerning | ||||||
12 | treatment for alcoholism and drug abuse and
addiction, prenatal | ||||||
13 | health care, and other pertinent programs directed at
reducing | ||||||
14 | the number of drug-affected infants born to recipients of | ||||||
15 | medical
assistance.
| ||||||
16 | Neither the Department of Healthcare and Family Services | ||||||
17 | nor the Department of Human
Services shall sanction the | ||||||
18 | recipient solely on the basis of
her substance abuse.
| ||||||
19 | The Illinois Department shall establish such regulations | ||||||
20 | governing
the dispensing of health services under this Article | ||||||
21 | as it shall deem
appropriate. The Department
should
seek the | ||||||
22 | advice of formal professional advisory committees appointed by
| ||||||
23 | the Director of the Illinois Department for the purpose of | ||||||
24 | providing regular
advice on policy and administrative matters, | ||||||
25 | information dissemination and
educational activities for | ||||||
26 | medical and health care providers, and
consistency in |
| |||||||
| |||||||
1 | procedures to the Illinois Department.
| ||||||
2 | The Illinois Department may develop and contract with | ||||||
3 | Partnerships of
medical providers to arrange medical services | ||||||
4 | for persons eligible under
Section 5-2 of this Code. | ||||||
5 | Implementation of this Section may be by
demonstration projects | ||||||
6 | in certain geographic areas. The Partnership shall
be | ||||||
7 | represented by a sponsor organization. The Department, by rule, | ||||||
8 | shall
develop qualifications for sponsors of Partnerships. | ||||||
9 | Nothing in this
Section shall be construed to require that the | ||||||
10 | sponsor organization be a
medical organization.
| ||||||
11 | The sponsor must negotiate formal written contracts with | ||||||
12 | medical
providers for physician services, inpatient and | ||||||
13 | outpatient hospital care,
home health services, treatment for | ||||||
14 | alcoholism and substance abuse, and
other services determined | ||||||
15 | necessary by the Illinois Department by rule for
delivery by | ||||||
16 | Partnerships. Physician services must include prenatal and
| ||||||
17 | obstetrical care. The Illinois Department shall reimburse | ||||||
18 | medical services
delivered by Partnership providers to clients | ||||||
19 | in target areas according to
provisions of this Article and the | ||||||
20 | Illinois Health Finance Reform Act,
except that:
| ||||||
21 | (1) Physicians participating in a Partnership and | ||||||
22 | providing certain
services, which shall be determined by | ||||||
23 | the Illinois Department, to persons
in areas covered by the | ||||||
24 | Partnership may receive an additional surcharge
for such | ||||||
25 | services.
| ||||||
26 | (2) The Department may elect to consider and negotiate |
| |||||||
| |||||||
1 | financial
incentives to encourage the development of | ||||||
2 | Partnerships and the efficient
delivery of medical care.
| ||||||
3 | (3) Persons receiving medical services through | ||||||
4 | Partnerships may receive
medical and case management | ||||||
5 | services above the level usually offered
through the | ||||||
6 | medical assistance program.
| ||||||
7 | Medical providers shall be required to meet certain | ||||||
8 | qualifications to
participate in Partnerships to ensure the | ||||||
9 | delivery of high quality medical
services. These | ||||||
10 | qualifications shall be determined by rule of the Illinois
| ||||||
11 | Department and may be higher than qualifications for | ||||||
12 | participation in the
medical assistance program. Partnership | ||||||
13 | sponsors may prescribe reasonable
additional qualifications | ||||||
14 | for participation by medical providers, only with
the prior | ||||||
15 | written approval of the Illinois Department.
| ||||||
16 | Nothing in this Section shall limit the free choice of | ||||||
17 | practitioners,
hospitals, and other providers of medical | ||||||
18 | services by clients.
In order to ensure patient freedom of | ||||||
19 | choice, the Illinois Department shall
immediately promulgate | ||||||
20 | all rules and take all other necessary actions so that
provided | ||||||
21 | services may be accessed from therapeutically certified | ||||||
22 | optometrists
to the full extent of the Illinois Optometric | ||||||
23 | Practice Act of 1987 without
discriminating between service | ||||||
24 | providers.
| ||||||
25 | The Department shall apply for a waiver from the United | ||||||
26 | States Health
Care Financing Administration to allow for the |
| |||||||
| |||||||
1 | implementation of
Partnerships under this Section.
| ||||||
2 | The Illinois Department shall require health care | ||||||
3 | providers to maintain
records that document the medical care | ||||||
4 | and services provided to recipients
of Medical Assistance under | ||||||
5 | this Article. Such records must be retained for a period of not | ||||||
6 | less than 6 years from the date of service or as provided by | ||||||
7 | applicable State law, whichever period is longer, except that | ||||||
8 | if an audit is initiated within the required retention period | ||||||
9 | then the records must be retained until the audit is completed | ||||||
10 | and every exception is resolved. The Illinois Department shall
| ||||||
11 | require health care providers to make available, when | ||||||
12 | authorized by the
patient, in writing, the medical records in a | ||||||
13 | timely fashion to other
health care providers who are treating | ||||||
14 | or serving persons eligible for
Medical Assistance under this | ||||||
15 | Article. All dispensers of medical services
shall be required | ||||||
16 | to maintain and retain business and professional records
| ||||||
17 | sufficient to fully and accurately document the nature, scope, | ||||||
18 | details and
receipt of the health care provided to persons | ||||||
19 | eligible for medical
assistance under this Code, in accordance | ||||||
20 | with regulations promulgated by
the Illinois Department. The | ||||||
21 | rules and regulations shall require that proof
of the receipt | ||||||
22 | of prescription drugs, dentures, prosthetic devices and
| ||||||
23 | eyeglasses by eligible persons under this Section accompany | ||||||
24 | each claim
for reimbursement submitted by the dispenser of such | ||||||
25 | medical services.
No such claims for reimbursement shall be | ||||||
26 | approved for payment by the Illinois
Department without such |
| |||||||
| |||||||
1 | proof of receipt, unless the Illinois Department
shall have put | ||||||
2 | into effect and shall be operating a system of post-payment
| ||||||
3 | audit and review which shall, on a sampling basis, be deemed | ||||||
4 | adequate by
the Illinois Department to assure that such drugs, | ||||||
5 | dentures, prosthetic
devices and eyeglasses for which payment | ||||||
6 | is being made are actually being
received by eligible | ||||||
7 | recipients. Within 90 days after September 16, 1984 (the | ||||||
8 | effective date of Public Act 83-1439), the Illinois Department | ||||||
9 | shall establish a
current list of acquisition costs for all | ||||||
10 | prosthetic devices and any
other items recognized as medical | ||||||
11 | equipment and supplies reimbursable under
this Article and | ||||||
12 | shall update such list on a quarterly basis, except that
the | ||||||
13 | acquisition costs of all prescription drugs shall be updated no
| ||||||
14 | less frequently than every 30 days as required by Section | ||||||
15 | 5-5.12.
| ||||||
16 | Notwithstanding any other law to the contrary, the Illinois | ||||||
17 | Department shall, within 365 days after July 22, 2013 (the | ||||||
18 | effective date of Public Act 98-104), establish procedures to | ||||||
19 | permit skilled care facilities licensed under the Nursing Home | ||||||
20 | Care Act to submit monthly billing claims for reimbursement | ||||||
21 | purposes. Following development of these procedures, the | ||||||
22 | Department shall, by July 1, 2016, test the viability of the | ||||||
23 | new system and implement any necessary operational or | ||||||
24 | structural changes to its information technology platforms in | ||||||
25 | order to allow for the direct acceptance and payment of nursing | ||||||
26 | home claims. |
| |||||||
| |||||||
1 | Notwithstanding any other law to the contrary, the Illinois | ||||||
2 | Department shall, within 365 days after August 15, 2014 (the | ||||||
3 | effective date of Public Act 98-963), establish procedures to | ||||||
4 | permit ID/DD facilities licensed under the ID/DD Community Care | ||||||
5 | Act and MC/DD facilities licensed under the MC/DD Act to submit | ||||||
6 | monthly billing claims for reimbursement purposes. Following | ||||||
7 | development of these procedures, the Department shall have an | ||||||
8 | additional 365 days to test the viability of the new system and | ||||||
9 | to ensure that any necessary operational or structural changes | ||||||
10 | to its information technology platforms are implemented. | ||||||
11 | The Illinois Department shall require all dispensers of | ||||||
12 | medical
services, other than an individual practitioner or | ||||||
13 | group of practitioners,
desiring to participate in the Medical | ||||||
14 | Assistance program
established under this Article to disclose | ||||||
15 | all financial, beneficial,
ownership, equity, surety or other | ||||||
16 | interests in any and all firms,
corporations, partnerships, | ||||||
17 | associations, business enterprises, joint
ventures, agencies, | ||||||
18 | institutions or other legal entities providing any
form of | ||||||
19 | health care services in this State under this Article.
| ||||||
20 | The Illinois Department may require that all dispensers of | ||||||
21 | medical
services desiring to participate in the medical | ||||||
22 | assistance program
established under this Article disclose, | ||||||
23 | under such terms and conditions as
the Illinois Department may | ||||||
24 | by rule establish, all inquiries from clients
and attorneys | ||||||
25 | regarding medical bills paid by the Illinois Department, which
| ||||||
26 | inquiries could indicate potential existence of claims or liens |
| |||||||
| |||||||
1 | for the
Illinois Department.
| ||||||
2 | Enrollment of a vendor
shall be
subject to a provisional | ||||||
3 | period and shall be conditional for one year. During the period | ||||||
4 | of conditional enrollment, the Department may
terminate the | ||||||
5 | vendor's eligibility to participate in, or may disenroll the | ||||||
6 | vendor from, the medical assistance
program without cause. | ||||||
7 | Unless otherwise specified, such termination of eligibility or | ||||||
8 | disenrollment is not subject to the
Department's hearing | ||||||
9 | process.
However, a disenrolled vendor may reapply without | ||||||
10 | penalty.
| ||||||
11 | The Department has the discretion to limit the conditional | ||||||
12 | enrollment period for vendors based upon category of risk of | ||||||
13 | the vendor. | ||||||
14 | Prior to enrollment and during the conditional enrollment | ||||||
15 | period in the medical assistance program, all vendors shall be | ||||||
16 | subject to enhanced oversight, screening, and review based on | ||||||
17 | the risk of fraud, waste, and abuse that is posed by the | ||||||
18 | category of risk of the vendor. The Illinois Department shall | ||||||
19 | establish the procedures for oversight, screening, and review, | ||||||
20 | which may include, but need not be limited to: criminal and | ||||||
21 | financial background checks; fingerprinting; license, | ||||||
22 | certification, and authorization verifications; unscheduled or | ||||||
23 | unannounced site visits; database checks; prepayment audit | ||||||
24 | reviews; audits; payment caps; payment suspensions; and other | ||||||
25 | screening as required by federal or State law. | ||||||
26 | The Department shall define or specify the following: (i) |
| |||||||
| |||||||
1 | by provider notice, the "category of risk of the vendor" for | ||||||
2 | each type of vendor, which shall take into account the level of | ||||||
3 | screening applicable to a particular category of vendor under | ||||||
4 | federal law and regulations; (ii) by rule or provider notice, | ||||||
5 | the maximum length of the conditional enrollment period for | ||||||
6 | each category of risk of the vendor; and (iii) by rule, the | ||||||
7 | hearing rights, if any, afforded to a vendor in each category | ||||||
8 | of risk of the vendor that is terminated or disenrolled during | ||||||
9 | the conditional enrollment period. | ||||||
10 | To be eligible for payment consideration, a vendor's | ||||||
11 | payment claim or bill, either as an initial claim or as a | ||||||
12 | resubmitted claim following prior rejection, must be received | ||||||
13 | by the Illinois Department, or its fiscal intermediary, no | ||||||
14 | later than 180 days after the latest date on the claim on which | ||||||
15 | medical goods or services were provided, with the following | ||||||
16 | exceptions: | ||||||
17 | (1) In the case of a provider whose enrollment is in | ||||||
18 | process by the Illinois Department, the 180-day period | ||||||
19 | shall not begin until the date on the written notice from | ||||||
20 | the Illinois Department that the provider enrollment is | ||||||
21 | complete. | ||||||
22 | (2) In the case of errors attributable to the Illinois | ||||||
23 | Department or any of its claims processing intermediaries | ||||||
24 | which result in an inability to receive, process, or | ||||||
25 | adjudicate a claim, the 180-day period shall not begin | ||||||
26 | until the provider has been notified of the error. |
| |||||||
| |||||||
1 | (3) In the case of a provider for whom the Illinois | ||||||
2 | Department initiates the monthly billing process. | ||||||
3 | (4) In the case of a provider operated by a unit of | ||||||
4 | local government with a population exceeding 3,000,000 | ||||||
5 | when local government funds finance federal participation | ||||||
6 | for claims payments. | ||||||
7 | For claims for services rendered during a period for which | ||||||
8 | a recipient received retroactive eligibility, claims must be | ||||||
9 | filed within 180 days after the Department determines the | ||||||
10 | applicant is eligible. For claims for which the Illinois | ||||||
11 | Department is not the primary payer, claims must be submitted | ||||||
12 | to the Illinois Department within 180 days after the final | ||||||
13 | adjudication by the primary payer. | ||||||
14 | In the case of long term care facilities, within 45 | ||||||
15 | calendar days of receipt by the facility of required | ||||||
16 | prescreening information, new admissions with associated | ||||||
17 | admission documents shall be submitted through the Medical | ||||||
18 | Electronic Data Interchange (MEDI) or the Recipient | ||||||
19 | Eligibility Verification (REV) System or shall be submitted | ||||||
20 | directly to the Department of Human Services using required | ||||||
21 | admission forms. Effective September
1, 2014, admission | ||||||
22 | documents, including all prescreening
information, must be | ||||||
23 | submitted through MEDI or REV. Confirmation numbers assigned to | ||||||
24 | an accepted transaction shall be retained by a facility to | ||||||
25 | verify timely submittal. Once an admission transaction has been | ||||||
26 | completed, all resubmitted claims following prior rejection |
| |||||||
| |||||||
1 | are subject to receipt no later than 180 days after the | ||||||
2 | admission transaction has been completed. | ||||||
3 | Claims that are not submitted and received in compliance | ||||||
4 | with the foregoing requirements shall not be eligible for | ||||||
5 | payment under the medical assistance program, and the State | ||||||
6 | shall have no liability for payment of those claims. | ||||||
7 | To the extent consistent with applicable information and | ||||||
8 | privacy, security, and disclosure laws, State and federal | ||||||
9 | agencies and departments shall provide the Illinois Department | ||||||
10 | access to confidential and other information and data necessary | ||||||
11 | to perform eligibility and payment verifications and other | ||||||
12 | Illinois Department functions. This includes, but is not | ||||||
13 | limited to: information pertaining to licensure; | ||||||
14 | certification; earnings; immigration status; citizenship; wage | ||||||
15 | reporting; unearned and earned income; pension income; | ||||||
16 | employment; supplemental security income; social security | ||||||
17 | numbers; National Provider Identifier (NPI) numbers; the | ||||||
18 | National Practitioner Data Bank (NPDB); program and agency | ||||||
19 | exclusions; taxpayer identification numbers; tax delinquency; | ||||||
20 | corporate information; and death records. | ||||||
21 | The Illinois Department shall enter into agreements with | ||||||
22 | State agencies and departments, and is authorized to enter into | ||||||
23 | agreements with federal agencies and departments, under which | ||||||
24 | such agencies and departments shall share data necessary for | ||||||
25 | medical assistance program integrity functions and oversight. | ||||||
26 | The Illinois Department shall develop, in cooperation with |
| |||||||
| |||||||
1 | other State departments and agencies, and in compliance with | ||||||
2 | applicable federal laws and regulations, appropriate and | ||||||
3 | effective methods to share such data. At a minimum, and to the | ||||||
4 | extent necessary to provide data sharing, the Illinois | ||||||
5 | Department shall enter into agreements with State agencies and | ||||||
6 | departments, and is authorized to enter into agreements with | ||||||
7 | federal agencies and departments, including but not limited to: | ||||||
8 | the Secretary of State; the Department of Revenue; the | ||||||
9 | Department of Public Health; the Department of Human Services; | ||||||
10 | and the Department of Financial and Professional Regulation. | ||||||
11 | Beginning in fiscal year 2013, the Illinois Department | ||||||
12 | shall set forth a request for information to identify the | ||||||
13 | benefits of a pre-payment, post-adjudication, and post-edit | ||||||
14 | claims system with the goals of streamlining claims processing | ||||||
15 | and provider reimbursement, reducing the number of pending or | ||||||
16 | rejected claims, and helping to ensure a more transparent | ||||||
17 | adjudication process through the utilization of: (i) provider | ||||||
18 | data verification and provider screening technology; and (ii) | ||||||
19 | clinical code editing; and (iii) pre-pay, pre- or | ||||||
20 | post-adjudicated predictive modeling with an integrated case | ||||||
21 | management system with link analysis. Such a request for | ||||||
22 | information shall not be considered as a request for proposal | ||||||
23 | or as an obligation on the part of the Illinois Department to | ||||||
24 | take any action or acquire any products or services. | ||||||
25 | The Illinois Department shall establish policies, | ||||||
26 | procedures,
standards and criteria by rule for the acquisition, |
| |||||||
| |||||||
1 | repair and replacement
of orthotic and prosthetic devices and | ||||||
2 | durable medical equipment. Such
rules shall provide, but not be | ||||||
3 | limited to, the following services: (1)
immediate repair or | ||||||
4 | replacement of such devices by recipients; and (2) rental, | ||||||
5 | lease, purchase or lease-purchase of
durable medical equipment | ||||||
6 | in a cost-effective manner, taking into
consideration the | ||||||
7 | recipient's medical prognosis, the extent of the
recipient's | ||||||
8 | needs, and the requirements and costs for maintaining such
| ||||||
9 | equipment. Subject to prior approval, such rules shall enable a | ||||||
10 | recipient to temporarily acquire and
use alternative or | ||||||
11 | substitute devices or equipment pending repairs or
| ||||||
12 | replacements of any device or equipment previously authorized | ||||||
13 | for such
recipient by the Department. Notwithstanding any | ||||||
14 | provision of Section 5-5f to the contrary, the Department may, | ||||||
15 | by rule, exempt certain replacement wheelchair parts from prior | ||||||
16 | approval and, for wheelchairs, wheelchair parts, wheelchair | ||||||
17 | accessories, and related seating and positioning items, | ||||||
18 | determine the wholesale price by methods other than actual | ||||||
19 | acquisition costs. | ||||||
20 | The Department shall require, by rule, all providers of | ||||||
21 | durable medical equipment to be accredited by an accreditation | ||||||
22 | organization approved by the federal Centers for Medicare and | ||||||
23 | Medicaid Services and recognized by the Department in order to | ||||||
24 | bill the Department for providing durable medical equipment to | ||||||
25 | recipients. No later than 15 months after the effective date of | ||||||
26 | the rule adopted pursuant to this paragraph, all providers must |
| |||||||
| |||||||
1 | meet the accreditation requirement.
| ||||||
2 | Whenever the Department or a managed care organization | ||||||
3 | under contract with the Department authorizes the purchase of | ||||||
4 | durable medical equipment under this Section, the Department or | ||||||
5 | managed care organization may require a recipient to purchase | ||||||
6 | used or refurbished durable medical equipment, if used or | ||||||
7 | refurbished medical equipment: (i) is available; (ii) is less | ||||||
8 | expensive, including shipping costs, than new durable medical | ||||||
9 | equipment of the same type; (iii) is able to withstand at least | ||||||
10 | 3 years of use; and (iv) equally meets the needs of the | ||||||
11 | recipient. | ||||||
12 | The Department shall execute, relative to the nursing home | ||||||
13 | prescreening
project, written inter-agency agreements with the | ||||||
14 | Department of Human
Services and the Department on Aging, to | ||||||
15 | effect the following: (i) intake
procedures and common | ||||||
16 | eligibility criteria for those persons who are receiving
| ||||||
17 | non-institutional services; and (ii) the establishment and | ||||||
18 | development of
non-institutional services in areas of the State | ||||||
19 | where they are not currently
available or are undeveloped; and | ||||||
20 | (iii) notwithstanding any other provision of law, subject to | ||||||
21 | federal approval, on and after July 1, 2012, an increase in the | ||||||
22 | determination of need (DON) scores from 29 to 37 for applicants | ||||||
23 | for institutional and home and community-based long term care; | ||||||
24 | if and only if federal approval is not granted, the Department | ||||||
25 | may, in conjunction with other affected agencies, implement | ||||||
26 | utilization controls or changes in benefit packages to |
| |||||||
| |||||||
1 | effectuate a similar savings amount for this population; and | ||||||
2 | (iv) no later than July 1, 2013, minimum level of care | ||||||
3 | eligibility criteria for institutional and home and | ||||||
4 | community-based long term care; and (v) no later than October | ||||||
5 | 1, 2013, establish procedures to permit long term care | ||||||
6 | providers access to eligibility scores for individuals with an | ||||||
7 | admission date who are seeking or receiving services from the | ||||||
8 | long term care provider. In order to select the minimum level | ||||||
9 | of care eligibility criteria, the Governor shall establish a | ||||||
10 | workgroup that includes affected agency representatives and | ||||||
11 | stakeholders representing the institutional and home and | ||||||
12 | community-based long term care interests. This Section shall | ||||||
13 | not restrict the Department from implementing lower level of | ||||||
14 | care eligibility criteria for community-based services in | ||||||
15 | circumstances where federal approval has been granted.
| ||||||
16 | The Illinois Department shall develop and operate, in | ||||||
17 | cooperation
with other State Departments and agencies and in | ||||||
18 | compliance with
applicable federal laws and regulations, | ||||||
19 | appropriate and effective
systems of health care evaluation and | ||||||
20 | programs for monitoring of
utilization of health care services | ||||||
21 | and facilities, as it affects
persons eligible for medical | ||||||
22 | assistance under this Code.
| ||||||
23 | The Illinois Department shall report annually to the | ||||||
24 | General Assembly,
no later than the second Friday in April of | ||||||
25 | 1979 and each year
thereafter, in regard to:
| ||||||
26 | (a) actual statistics and trends in utilization of |
| |||||||
| |||||||
1 | medical services by
public aid recipients;
| ||||||
2 | (b) actual statistics and trends in the provision of | ||||||
3 | the various medical
services by medical vendors;
| ||||||
4 | (c) current rate structures and proposed changes in | ||||||
5 | those rate structures
for the various medical vendors; and
| ||||||
6 | (d) efforts at utilization review and control by the | ||||||
7 | Illinois Department.
| ||||||
8 | The period covered by each report shall be the 3 years | ||||||
9 | ending on the June
30 prior to the report. The report shall | ||||||
10 | include suggested legislation
for consideration by the General | ||||||
11 | Assembly. The filing of one copy of the
report with the | ||||||
12 | Speaker, one copy with the Minority Leader and one copy
with | ||||||
13 | the Clerk of the House of Representatives, one copy with the | ||||||
14 | President,
one copy with the Minority Leader and one copy with | ||||||
15 | the Secretary of the
Senate, one copy with the Legislative | ||||||
16 | Research Unit, and such additional
copies
with the State | ||||||
17 | Government Report Distribution Center for the General
Assembly | ||||||
18 | as is required under paragraph (t) of Section 7 of the State
| ||||||
19 | Library Act shall be deemed sufficient to comply with this | ||||||
20 | Section.
| ||||||
21 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
22 | any, is conditioned on the rules being adopted in accordance | ||||||
23 | with all provisions of the Illinois Administrative Procedure | ||||||
24 | Act and all rules and procedures of the Joint Committee on | ||||||
25 | Administrative Rules; any purported rule not so adopted, for | ||||||
26 | whatever reason, is unauthorized. |
| |||||||
| |||||||
1 | On and after July 1, 2012, the Department shall reduce any | ||||||
2 | rate of reimbursement for services or other payments or alter | ||||||
3 | any methodologies authorized by this Code to reduce any rate of | ||||||
4 | reimbursement for services or other payments in accordance with | ||||||
5 | Section 5-5e. | ||||||
6 | Because kidney transplantation can be an appropriate, cost | ||||||
7 | effective
alternative to renal dialysis when medically | ||||||
8 | necessary and notwithstanding the provisions of Section 1-11 of | ||||||
9 | this Code, beginning October 1, 2014, the Department shall | ||||||
10 | cover kidney transplantation for noncitizens with end-stage | ||||||
11 | renal disease who are not eligible for comprehensive medical | ||||||
12 | benefits, who meet the residency requirements of Section 5-3 of | ||||||
13 | this Code, and who would otherwise meet the financial | ||||||
14 | requirements of the appropriate class of eligible persons under | ||||||
15 | Section 5-2 of this Code. To qualify for coverage of kidney | ||||||
16 | transplantation, such person must be receiving emergency renal | ||||||
17 | dialysis services covered by the Department. Providers under | ||||||
18 | this Section shall be prior approved and certified by the | ||||||
19 | Department to perform kidney transplantation and the services | ||||||
20 | under this Section shall be limited to services associated with | ||||||
21 | kidney transplantation. | ||||||
22 | Notwithstanding any other provision of this Code to the | ||||||
23 | contrary, on or after July 1, 2015, all FDA approved forms of | ||||||
24 | medication assisted treatment prescribed for the treatment of | ||||||
25 | alcohol dependence or treatment of opioid dependence shall be | ||||||
26 | covered under both fee for service and managed care medical |
| |||||||
| |||||||
1 | assistance programs for persons who are otherwise eligible for | ||||||
2 | medical assistance under this Article and shall not be subject | ||||||
3 | to any (1) utilization control, other than those established | ||||||
4 | under the American Society of Addiction Medicine patient | ||||||
5 | placement criteria,
(2) prior authorization mandate, or (3) | ||||||
6 | lifetime restriction limit
mandate. | ||||||
7 | On or after July 1, 2015, opioid antagonists prescribed for | ||||||
8 | the treatment of an opioid overdose, including the medication | ||||||
9 | product, administration devices, and any pharmacy fees related | ||||||
10 | to the dispensing and administration of the opioid antagonist, | ||||||
11 | shall be covered under the medical assistance program for | ||||||
12 | persons who are otherwise eligible for medical assistance under | ||||||
13 | this Article. As used in this Section, "opioid antagonist" | ||||||
14 | means a drug that binds to opioid receptors and blocks or | ||||||
15 | inhibits the effect of opioids acting on those receptors, | ||||||
16 | including, but not limited to, naloxone hydrochloride or any | ||||||
17 | other similarly acting drug approved by the U.S. Food and Drug | ||||||
18 | Administration. | ||||||
19 | Upon federal approval, the Department shall provide | ||||||
20 | coverage and reimbursement for all drugs that are approved for | ||||||
21 | marketing by the federal Food and Drug Administration and that | ||||||
22 | are recommended by the federal Public Health Service or the | ||||||
23 | United States Centers for Disease Control and Prevention for | ||||||
24 | pre-exposure prophylaxis and related pre-exposure prophylaxis | ||||||
25 | services, including, but not limited to, HIV and sexually | ||||||
26 | transmitted infection screening, treatment for sexually |
| |||||||
| |||||||
1 | transmitted infections, medical monitoring, assorted labs, and | ||||||
2 | counseling to reduce the likelihood of HIV infection among | ||||||
3 | individuals who are not infected with HIV but who are at high | ||||||
4 | risk of HIV infection. | ||||||
5 | (Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15; | ||||||
6 | 99-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for | ||||||
7 | the effective date of P.A. 99-407); 99-433, eff. 8-21-15; | ||||||
8 | 99-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff. | ||||||
9 | 7-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201, | ||||||
10 | eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18; | ||||||
11 | 100-538, eff. 1-1-18; revised 10-26-17.)
| ||||||
12 | Section 99. Effective date. This Act takes effect upon | ||||||
13 | becoming law.
|