Full Text of SB1909 101st General Assembly
SB1909sam004 101ST GENERAL ASSEMBLY | Sen. Cristina Castro Filed: 4/5/2019
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| 1 | | AMENDMENT TO SENATE BILL 1909
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 1909, AS AMENDED, | 3 | | by replacing everything after the enacting clause with the | 4 | | following:
| 5 | | "Section 1. This Act may be referred to as the Improving | 6 | | Health Care for Pregnant and Postpartum Individuals Act. | 7 | | Section 5. The State Employees Group Insurance Act of 1971 | 8 | | is amended by changing Section 6.11 as follows:
| 9 | | (5 ILCS 375/6.11)
| 10 | | (Text of Section before amendment by P.A. 100-1170 ) | 11 | | Sec. 6.11. Required health benefits; Illinois Insurance | 12 | | Code
requirements. The program of health
benefits shall provide | 13 | | the post-mastectomy care benefits required to be covered
by a | 14 | | policy of accident and health insurance under Section 356t of | 15 | | the Illinois
Insurance Code. The program of health benefits |
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| 1 | | shall provide the coverage
required under Sections 356g, | 2 | | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, | 3 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 4 | | 356z.14, 356z.15, 356z.17, 356z.22, 356z.25, and 356z.26, and | 5 | | 356z.29 , 356z.32, and 356z.33 of the
Illinois Insurance Code.
| 6 | | The program of health benefits must comply with Sections | 7 | | 155.22a, 155.37, 355b, 356z.19, 370c, and 370c.1 of the
| 8 | | Illinois Insurance Code. The Department of Insurance shall | 9 | | enforce the requirements of this Section.
| 10 | | Rulemaking authority to implement Public Act 95-1045, if | 11 | | any, is conditioned on the rules being adopted in accordance | 12 | | with all provisions of the Illinois Administrative Procedure | 13 | | Act and all rules and procedures of the Joint Committee on | 14 | | Administrative Rules; any purported rule not so adopted, for | 15 | | whatever reason, is unauthorized. | 16 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 17 | | 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff. | 18 | | 1-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised | 19 | | 1-8-19.) | 20 | | (Text of Section after amendment by P.A. 100-1170 ) | 21 | | Sec. 6.11. Required health benefits; Illinois Insurance | 22 | | Code
requirements. The program of health
benefits shall provide | 23 | | the post-mastectomy care benefits required to be covered
by a | 24 | | policy of accident and health insurance under Section 356t of | 25 | | the Illinois
Insurance Code. The program of health benefits |
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| 1 | | shall provide the coverage
required under Sections 356g, | 2 | | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, | 3 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 4 | | 356z.14, 356z.15, 356z.17, 356z.22, 356z.25, 356z.26, 356z.29, | 5 | | and 356z.32 , and 356z.33 of the
Illinois Insurance Code.
The | 6 | | program of health benefits must comply with Sections 155.22a, | 7 | | 155.37, 355b, 356z.19, 370c, and 370c.1 of the
Illinois | 8 | | Insurance Code. The Department of Insurance shall enforce the | 9 | | requirements of this Section with respect to Sections 370c and | 10 | | 370c.1 of the Illinois Insurance Code; all other requirements | 11 | | of this Section shall be enforced by the Department of Central | 12 | | Management Services.
| 13 | | Rulemaking authority to implement Public Act 95-1045, if | 14 | | any, is conditioned on the rules being adopted in accordance | 15 | | with all provisions of the Illinois Administrative Procedure | 16 | | Act and all rules and procedures of the Joint Committee on | 17 | | Administrative Rules; any purported rule not so adopted, for | 18 | | whatever reason, is unauthorized. | 19 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 20 | | 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff. | 21 | | 1-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; | 22 | | 100-1170, eff. 6-1-19.) | 23 | | Section 10. The Department of Human Services Act is amended | 24 | | by adding Sections 10-23 and 10-24 as follows: |
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| 1 | | (20 ILCS 1305/10-23 new) | 2 | | Sec. 10-23. High-risk pregnant or postpartum women. The | 3 | | Department shall expand and update its maternal child health | 4 | | programs to serve any pregnant or postpartum woman identified | 5 | | as high-risk by her primary care provider or hospital according | 6 | | to standards developed by the Department of Public Health under | 7 | | Section 3 of the Developmental Disability Prevention Act. The | 8 | | services shall be provided by registered nurses, licensed | 9 | | social workers, or other staff with behavioral health or | 10 | | medical training, as approved by the Department. The persons | 11 | | providing the services may collaborate with other providers, | 12 | | including, but not limited to, obstetricians, gynecologists, | 13 | | or pediatricians, when providing services to a patient. | 14 | | (20 ILCS 1305/10-24 new) | 15 | | Sec. 10-24. Nurse-Family Partnership Pilot Program. | 16 | | Subject to the availability of funds provided for this
purpose | 17 | | by public or private sources, the Department may, in its | 18 | | discretion, establish an evidence-based, voluntary, nurse home | 19 | | visitation program that improves the health and well-being of | 20 | | low-income, first-time pregnant women and their children. The | 21 | | program shall be known as the Nurse-Family Partnership Pilot | 22 | | Program and shall include, but not be limited to, the following | 23 | | components: | 24 | | (1) Eligibility criteria. Program participants must be | 25 | | first-time pregnant women who have yet to reach the 28th |
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| 1 | | week of pregnancy and who are eligible for medical | 2 | | assistance under Article V of the Illinois Public Aid Code. | 3 | | (2) Maternal health education. Registered nurses shall | 4 | | make home visits to program participants and shall provide | 5 | | education, support, and guidance regarding pregnancy and | 6 | | maternal health, child health and development, parenting, | 7 | | the mother's life course development, and instruction on | 8 | | how to identify and use family and community supports. | 9 | | (3) Pre-natal and post-natal care. Home visits to | 10 | | program participants shall begin before their 28th week of | 11 | | pregnancy and shall continue on a weekly or biweekly basis | 12 | | until their children reach the age of 2. | 13 | | Section 15. The Department of Public Health Powers and | 14 | | Duties Law of the
Civil Administrative Code of Illinois is | 15 | | amended by adding Section 2310-455 as follows: | 16 | | (20 ILCS 2310/2310-455 new) | 17 | | Sec. 2310-455. High Risk Infant Follow-up. The Department, | 18 | | in collaboration with the Department of Human Services, the | 19 | | Department of Healthcare and Family Services, and other key | 20 | | providers of maternal child health services, shall revise or | 21 | | add to the rules of the Maternal and Child Health Services Code | 22 | | (77 Ill. Adm. Code 630) that govern the High Risk Infant | 23 | | Follow-up, using current scientific and national and State | 24 | | outcomes data, to expand existing services to improve both |
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| 1 | | maternal and infant outcomes overall and to reduce racial | 2 | | disparities in outcomes and services provided. The rules shall | 3 | | be revised or adopted on or before June 1, 2021.
| 4 | | Section 20. The Counties Code is amended by changing | 5 | | Section 5-1069.3 as follows: | 6 | | (55 ILCS 5/5-1069.3)
| 7 | | Sec. 5-1069.3. Required health benefits. If a county, | 8 | | including a home
rule
county, is a self-insurer for purposes of | 9 | | providing health insurance coverage
for its employees, the | 10 | | coverage shall include coverage for the post-mastectomy
care | 11 | | benefits required to be covered by a policy of accident and | 12 | | health
insurance under Section 356t and the coverage required | 13 | | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, | 14 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | 15 | | 356z.14, 356z.15, 356z.22, 356z.25, and 356z.26, and 356z.29 , | 16 | | 356z.32, and 356z.33 of
the Illinois Insurance Code. The | 17 | | coverage shall comply with Sections 155.22a, 355b, 356z.19, and | 18 | | 370c of
the Illinois Insurance Code. The Department of | 19 | | Insurance shall enforce the requirements of this Section. The | 20 | | requirement that health benefits be covered
as provided in this | 21 | | Section is an
exclusive power and function of the State and is | 22 | | a denial and limitation under
Article VII, Section 6, | 23 | | subsection (h) of the Illinois Constitution. A home
rule county | 24 | | to which this Section applies must comply with every provision |
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| 1 | | of
this Section.
| 2 | | Rulemaking authority to implement Public Act 95-1045, if | 3 | | any, is conditioned on the rules being adopted in accordance | 4 | | with all provisions of the Illinois Administrative Procedure | 5 | | Act and all rules and procedures of the Joint Committee on | 6 | | Administrative Rules; any purported rule not so adopted, for | 7 | | whatever reason, is unauthorized. | 8 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 9 | | 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff. | 10 | | 1-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised | 11 | | 10-3-18.) | 12 | | Section 25. The Illinois Municipal Code is amended by | 13 | | changing Section 10-4-2.3 as follows: | 14 | | (65 ILCS 5/10-4-2.3)
| 15 | | Sec. 10-4-2.3. Required health benefits. If a | 16 | | municipality, including a
home rule municipality, is a | 17 | | self-insurer for purposes of providing health
insurance | 18 | | coverage for its employees, the coverage shall include coverage | 19 | | for
the post-mastectomy care benefits required to be covered by | 20 | | a policy of
accident and health insurance under Section 356t | 21 | | and the coverage required
under Sections 356g, 356g.5, | 22 | | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, | 23 | | 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, | 24 | | and 356z.26, and 356z.29 , 356z.32, and 356z.33 of the Illinois
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| 1 | | Insurance
Code. The coverage shall comply with Sections | 2 | | 155.22a, 355b, 356z.19, and 370c of
the Illinois Insurance | 3 | | Code. The Department of Insurance shall enforce the | 4 | | requirements of this Section. The requirement that health
| 5 | | benefits be covered as provided in this is an exclusive power | 6 | | and function of
the State and is a denial and limitation under | 7 | | Article VII, Section 6,
subsection (h) of the Illinois | 8 | | Constitution. A home rule municipality to which
this Section | 9 | | applies must comply with every provision of this Section.
| 10 | | Rulemaking authority to implement Public Act 95-1045, if | 11 | | any, is conditioned on the rules being adopted in accordance | 12 | | with all provisions of the Illinois Administrative Procedure | 13 | | Act and all rules and procedures of the Joint Committee on | 14 | | Administrative Rules; any purported rule not so adopted, for | 15 | | whatever reason, is unauthorized. | 16 | | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | 17 | | 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff. | 18 | | 1-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised | 19 | | 10-4-18.) | 20 | | Section 30. The School Code is amended by changing Section | 21 | | 10-22.3f as follows: | 22 | | (105 ILCS 5/10-22.3f)
| 23 | | Sec. 10-22.3f. Required health benefits. Insurance | 24 | | protection and
benefits
for employees shall provide the |
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| 1 | | post-mastectomy care benefits required to be
covered by a | 2 | | policy of accident and health insurance under Section 356t and | 3 | | the
coverage required under Sections 356g, 356g.5, 356g.5-1, | 4 | | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, | 5 | | 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, and 356z.26, and | 6 | | 356z.29 , 356z.32, and 356z.33 of
the
Illinois Insurance Code.
| 7 | | Insurance policies shall comply with Section 356z.19 of the | 8 | | Illinois Insurance Code. The coverage shall comply with | 9 | | Sections 155.22a, 355b, and 370c of
the Illinois Insurance | 10 | | Code. The Department of Insurance shall enforce the | 11 | | requirements of this Section.
| 12 | | Rulemaking authority to implement Public Act 95-1045, if | 13 | | any, is conditioned on the rules being adopted in accordance | 14 | | with all provisions of the Illinois Administrative Procedure | 15 | | Act and all rules and procedures of the Joint Committee on | 16 | | Administrative Rules; any purported rule not so adopted, for | 17 | | whatever reason, is unauthorized. | 18 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 19 | | 100-863, eff. 8-14-18; 100-1024, eff. 1-1-19; 100-1057, eff. | 20 | | 1-1-19; 100-1102, eff. 1-1-19; revised 10-4-18.) | 21 | | Section 35. The Illinois Insurance Code is amended by | 22 | | adding Sections 356z.4a and 356z.33 as follows: | 23 | | (215 ILCS 5/356z.4a new) | 24 | | Sec. 356z.4a. Billing for long-acting reversible |
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| 1 | | contraceptives. | 2 | | (a) "Long-acting reversible contraceptive device" means | 3 | | any intrauterine device or contraceptive implant. | 4 | | (b) Any group health insurance policy, individual health | 5 | | policy, group policy of accident and health insurance, group | 6 | | health benefit plan, or qualified health plan that is offered | 7 | | through the health insurance marketplace, a small employer | 8 | | group health plan, or a large employer group health plan that | 9 | | is amended, delivered, issued, or renewed on or after the | 10 | | effective date of this amendatory Act of the 101st General | 11 | | Assembly shall allow hospitals separate reimbursement for a | 12 | | long-acting reversible contraceptive device provided | 13 | | immediately postpartum in the inpatient hospital setting | 14 | | before hospital discharge. The payment shall be made in | 15 | | addition to a bundled or Diagnostic Related Group reimbursement | 16 | | for labor and delivery. | 17 | | (215 ILCS 5/356z.33 new) | 18 | | Sec. 356z.33. Pregnancy and postpartum coverage. | 19 | | (a) A group health insurance policy, individual health | 20 | | policy, group policy of accident and health insurance, group | 21 | | health benefit plan, qualified health plan that is offered | 22 | | through the health insurance marketplace, small employer group | 23 | | health plan, or large employer group health plan that is | 24 | | amended, delivered, issued, or renewed on or after the | 25 | | effective date of this amendatory Act of the 101st General |
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| 1 | | Assembly shall provide coverage for medically necessary | 2 | | treatment for postpartum complications, including, but not | 3 | | limited to, infection, depression, and hemorrhaging, up to one | 4 | | year after the woman has given birth to a child as set forth in | 5 | | this Section and consistent with other Sections of this Code, | 6 | | including, but not limited to, Sections 370c and 370c.1. The | 7 | | coverage under this Section shall be subject to other general | 8 | | exclusions, limitations, and financial requirements of the | 9 | | policy, including coordination of benefits, participating | 10 | | provider requirements, and utilization review of health care | 11 | | services, including review of medical necessity, case | 12 | | management, experimental and investigational treatments, | 13 | | managed care provisions, and other terms and conditions. | 14 | | (b) A group health insurance policy, individual health | 15 | | policy, group policy of accident and health insurance, group | 16 | | health benefit plan, qualified health plan that is offered | 17 | | through the health insurance marketplace, small employer group | 18 | | health plan, or large employer group health plan that is | 19 | | amended, delivered, issued, or renewed on or after the | 20 | | effective date of this amendatory Act of the 101st General | 21 | | Assembly shall provide coverage for medically necessary | 22 | | treatment of mental, emotional, nervous, or substance use | 23 | | disorder or conditions at in-network facilities for a pregnant | 24 | | or postpartum woman up to one year after giving birth to a | 25 | | child consistent with the requirements set forth in this | 26 | | Section and in Sections 370c and 370c.1 of this Code. The |
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| 1 | | services for the treatment of mental, emotional, nervous, or | 2 | | substance use disorder or condition shall be prescribed or | 3 | | ordered by a licensed physician, licensed psychologist, | 4 | | licensed psychiatrist, or licensed advanced practice | 5 | | registered nurse and provided by licensed health care | 6 | | professionals or licensed or certified mental, emotional, | 7 | | nervous, or substance use disorder or conditions providers in | 8 | | licensed, certified, or otherwise State-approved facilities. | 9 | | As used in this subsection (b), "provider" includes | 10 | | licensed physicians, licensed psychologists, licensed | 11 | | psychiatrists, licensed advanced practice registered nurses, | 12 | | and licensed and certified mental, emotional, nervous, and | 13 | | substance use disorder and conditions providers. | 14 | | Benefits under this subsection (b) shall be as follows: | 15 | | (1) The benefits provided for inpatient and outpatient | 16 | | services for the treatment of mental, emotional, nervous, | 17 | | or substance use disorder or conditions related to | 18 | | pregnancy or postpartum complications shall be provided | 19 | | when determined to be medically necessary consistent with | 20 | | the requirements of Sections 370c and 370c.1 of this Code. | 21 | | The facility or provider shall notify the insurer of both | 22 | | the admission and the initial treatment plan within 48 | 23 | | hours after admission or initiation of treatment. Nothing | 24 | | shall prevent an insurer from applying concurrent and | 25 | | post-service utilization review of health care services, | 26 | | including review of medical necessity, case management, |
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| 1 | | experimental and investigational treatments, managed care | 2 | | provisions, and other terms and conditions of the insurance | 3 | | policy. | 4 | | (2) The benefits for the first 48 hours of initiation | 5 | | of services for an inpatient admission, | 6 | | detoxification/withdrawal management program, or a partial | 7 | | hospitalization admission for the treatment of mental, | 8 | | emotional, nervous, or substance use disorder or | 9 | | conditions related to pregnancy or postpartum | 10 | | complications shall be provided without post-service or | 11 | | concurrent review of medical necessity, as the medical | 12 | | necessity for the first 48 hours of such services shall be | 13 | | determined solely by the covered pregnant or postpartum | 14 | | woman's provider. Nothing shall prevent an insurer from | 15 | | applying concurrent and post-service utilization review, | 16 | | including the review of medical necessity, case | 17 | | management, experimental and investigational treatments, | 18 | | managed care provisions, and other terms and conditions of | 19 | | the insurance policy of any inpatient admission, | 20 | | detoxification/withdrawal management program admission, or | 21 | | a partial hospitalization admission services for the | 22 | | treatment of mental emotional, nervous, or substance use | 23 | | disorder or conditions related to pregnancy or postpartum | 24 | | complications received 48 hours after the initiation of | 25 | | such services. If an insurer determines that the services | 26 | | are no longer medically necessary, then the covered person |
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| 1 | | shall have the right to external review pursuant to the | 2 | | requirements of the Health Carrier External Review Act. | 3 | | (3) If an insurer determines that continued inpatient | 4 | | care, detoxification/withdrawal management, partial | 5 | | hospitalization, intensive outpatient treatment, or | 6 | | outpatient treatment in a facility is no longer medically | 7 | | necessary, the insurer shall, within 24 hours, provide | 8 | | written notice to the covered pregnant or postpartum woman | 9 | | and the covered pregnant or postpartum woman's provider of | 10 | | its decision and the right to file an expedited internal | 11 | | appeal of the determination. The insurer shall review and | 12 | | make a determination with respect to the internal appeal | 13 | | within 24 hours and communicate such determination to the | 14 | | covered pregnant or postpartum woman and the covered | 15 | | pregnant or postpartum woman's provider. If the | 16 | | determination is to uphold the denial, the covered pregnant | 17 | | or postpartum woman and the covered pregnant or postpartum | 18 | | woman's provider have the right to file an expedited | 19 | | external appeal. An independent utilization review | 20 | | organization shall make a determination within 72 hours. If | 21 | | the insurer's determination is upheld and it is determined | 22 | | continued inpatient care, detoxification/withdrawal | 23 | | management, partial hospitalization, intensive outpatient | 24 | | treatment, or outpatient treatment is not medically | 25 | | necessary, the insurer shall remain responsible to provide | 26 | | benefits for the inpatient care, detoxification/withdrawal |
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| 1 | | management, partial hospitalization, intensive outpatient | 2 | | treatment, or outpatient treatment through the day | 3 | | following the date the determination is made and the | 4 | | covered pregnant or postpartum woman shall only be | 5 | | responsible for any applicable copayment, deductible, and | 6 | | coinsurance for the stay through that date as applicable | 7 | | under the policy. The covered pregnant or postpartum woman | 8 | | shall not be discharged or released from the inpatient | 9 | | facility, detoxification/withdrawal management, partial | 10 | | hospitalization, intensive outpatient treatment, or | 11 | | outpatient treatment until all internal appeals and | 12 | | independent utilization review organization appeals are | 13 | | exhausted. A decision to reverse an adverse determination | 14 | | shall comply with the Health Carrier External Review Act. | 15 | | (4) Except as otherwise stated in this subsection (b), | 16 | | the benefits and cost-sharing shall be provided to the same | 17 | | extent as for any other medical condition covered under the | 18 | | policy. | 19 | | (5) The benefits required by this subsection (b) are to | 20 | | be provided to all covered pregnant or postpartum woman | 21 | | with a diagnosis of mental, emotional, nervous, or | 22 | | substance use disorder or conditions. The presence of | 23 | | additional related or unrelated diagnoses shall not be a | 24 | | basis to reduce or deny the benefits required by this | 25 | | subsection (b). | 26 | | (c) A group health insurance policy, individual health |
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| 1 | | policy, group policy of accident and health insurance, group | 2 | | health benefit plan, qualified health plan that is offered | 3 | | through the health insurance marketplace, small employer group | 4 | | health plan, or large employer group health plan that is | 5 | | amended, delivered, issued, executed, or renewed in this State | 6 | | or approved for issuance or renewal in this State on or after | 7 | | the effective date of this amendatory Act of the 101st General | 8 | | Assembly shall provide coverage for case management and | 9 | | outreach for a postpartum woman that had a high-risk pregnancy. | 10 | | The coverage under this subsection (c) shall take into | 11 | | consideration the cultural differences of the covered | 12 | | postpartum woman in case coordination. As used in this | 13 | | subsection (c), "high-risk pregnancy" means a pregnancy in | 14 | | which the mother or baby is at increased risk for poor health | 15 | | or complications during pregnancy or childbirth. | 16 | | Section 40. The Health Maintenance Organization Act is | 17 | | amended by changing Section 5-3 as follows:
| 18 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| 19 | | Sec. 5-3. Insurance Code provisions.
| 20 | | (a) Health Maintenance Organizations
shall be subject to | 21 | | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
| 22 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, | 23 | | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | 24 | | 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, |
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| 1 | | 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | 2 | | 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, | 3 | | 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, | 4 | | 364, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, | 5 | | 368e, 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, | 6 | | 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of | 7 | | Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, | 8 | | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
| 9 | | (b) For purposes of the Illinois Insurance Code, except for | 10 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | 11 | | Maintenance Organizations in
the following categories are | 12 | | deemed to be "domestic companies":
| 13 | | (1) a corporation authorized under the
Dental Service | 14 | | Plan Act or the Voluntary Health Services Plans Act;
| 15 | | (2) a corporation organized under the laws of this | 16 | | State; or
| 17 | | (3) a corporation organized under the laws of another | 18 | | state, 30% or more
of the enrollees of which are residents | 19 | | of this State, except a
corporation subject to | 20 | | substantially the same requirements in its state of
| 21 | | organization as is a "domestic company" under Article VIII | 22 | | 1/2 of the
Illinois Insurance Code.
| 23 | | (c) In considering the merger, consolidation, or other | 24 | | acquisition of
control of a Health Maintenance Organization | 25 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| 26 | | (1) the Director shall give primary consideration to |
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| 1 | | the continuation of
benefits to enrollees and the financial | 2 | | conditions of the acquired Health
Maintenance Organization | 3 | | after the merger, consolidation, or other
acquisition of | 4 | | control takes effect;
| 5 | | (2)(i) the criteria specified in subsection (1)(b) of | 6 | | Section 131.8 of
the Illinois Insurance Code shall not | 7 | | apply and (ii) the Director, in making
his determination | 8 | | with respect to the merger, consolidation, or other
| 9 | | acquisition of control, need not take into account the | 10 | | effect on
competition of the merger, consolidation, or | 11 | | other acquisition of control;
| 12 | | (3) the Director shall have the power to require the | 13 | | following
information:
| 14 | | (A) certification by an independent actuary of the | 15 | | adequacy
of the reserves of the Health Maintenance | 16 | | Organization sought to be acquired;
| 17 | | (B) pro forma financial statements reflecting the | 18 | | combined balance
sheets of the acquiring company and | 19 | | the Health Maintenance Organization sought
to be | 20 | | acquired as of the end of the preceding year and as of | 21 | | a date 90 days
prior to the acquisition, as well as pro | 22 | | forma financial statements
reflecting projected | 23 | | combined operation for a period of 2 years;
| 24 | | (C) a pro forma business plan detailing an | 25 | | acquiring party's plans with
respect to the operation | 26 | | of the Health Maintenance Organization sought to
be |
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| 1 | | acquired for a period of not less than 3 years; and
| 2 | | (D) such other information as the Director shall | 3 | | require.
| 4 | | (d) The provisions of Article VIII 1/2 of the Illinois | 5 | | Insurance Code
and this Section 5-3 shall apply to the sale by | 6 | | any health maintenance
organization of greater than 10% of its
| 7 | | enrollee population (including without limitation the health | 8 | | maintenance
organization's right, title, and interest in and to | 9 | | its health care
certificates).
| 10 | | (e) In considering any management contract or service | 11 | | agreement subject
to Section 141.1 of the Illinois Insurance | 12 | | Code, the Director (i) shall, in
addition to the criteria | 13 | | specified in Section 141.2 of the Illinois
Insurance Code, take | 14 | | into account the effect of the management contract or
service | 15 | | agreement on the continuation of benefits to enrollees and the
| 16 | | financial condition of the health maintenance organization to | 17 | | be managed or
serviced, and (ii) need not take into account the | 18 | | effect of the management
contract or service agreement on | 19 | | competition.
| 20 | | (f) Except for small employer groups as defined in the | 21 | | Small Employer
Rating, Renewability and Portability Health | 22 | | Insurance Act and except for
medicare supplement policies as | 23 | | defined in Section 363 of the Illinois
Insurance Code, a Health | 24 | | Maintenance Organization may by contract agree with a
group or | 25 | | other enrollment unit to effect refunds or charge additional | 26 | | premiums
under the following terms and conditions:
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| 1 | | (i) the amount of, and other terms and conditions with | 2 | | respect to, the
refund or additional premium are set forth | 3 | | in the group or enrollment unit
contract agreed in advance | 4 | | of the period for which a refund is to be paid or
| 5 | | additional premium is to be charged (which period shall not | 6 | | be less than one
year); and
| 7 | | (ii) the amount of the refund or additional premium | 8 | | shall not exceed 20%
of the Health Maintenance | 9 | | Organization's profitable or unprofitable experience
with | 10 | | respect to the group or other enrollment unit for the | 11 | | period (and, for
purposes of a refund or additional | 12 | | premium, the profitable or unprofitable
experience shall | 13 | | be calculated taking into account a pro rata share of the
| 14 | | Health Maintenance Organization's administrative and | 15 | | marketing expenses, but
shall not include any refund to be | 16 | | made or additional premium to be paid
pursuant to this | 17 | | subsection (f)). The Health Maintenance Organization and | 18 | | the
group or enrollment unit may agree that the profitable | 19 | | or unprofitable
experience may be calculated taking into | 20 | | account the refund period and the
immediately preceding 2 | 21 | | plan years.
| 22 | | The Health Maintenance Organization shall include a | 23 | | statement in the
evidence of coverage issued to each enrollee | 24 | | describing the possibility of a
refund or additional premium, | 25 | | and upon request of any group or enrollment unit,
provide to | 26 | | the group or enrollment unit a description of the method used |
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| 1 | | to
calculate (1) the Health Maintenance Organization's | 2 | | profitable experience with
respect to the group or enrollment | 3 | | unit and the resulting refund to the group
or enrollment unit | 4 | | or (2) the Health Maintenance Organization's unprofitable
| 5 | | experience with respect to the group or enrollment unit and the | 6 | | resulting
additional premium to be paid by the group or | 7 | | enrollment unit.
| 8 | | In no event shall the Illinois Health Maintenance | 9 | | Organization
Guaranty Association be liable to pay any | 10 | | contractual obligation of an
insolvent organization to pay any | 11 | | refund authorized under this Section.
| 12 | | (g) Rulemaking authority to implement Public Act 95-1045, | 13 | | if any, is conditioned on the rules being adopted in accordance | 14 | | with all provisions of the Illinois Administrative Procedure | 15 | | Act and all rules and procedures of the Joint Committee on | 16 | | Administrative Rules; any purported rule not so adopted, for | 17 | | whatever reason, is unauthorized. | 18 | | (Source: P.A. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17; | 19 | | 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1026, eff. | 20 | | 8-22-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised | 21 | | 10-4-18.) | 22 | | Section 45. The Voluntary Health Services Plans Act is | 23 | | amended by changing Section 10 as follows:
| 24 | | (215 ILCS 165/10) (from Ch. 32, par. 604)
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| 1 | | Sec. 10. Application of Insurance Code provisions. Health | 2 | | services
plan corporations and all persons interested therein | 3 | | or dealing therewith
shall be subject to the provisions of | 4 | | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, | 5 | | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g, | 6 | | 356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, 356x, 356y, | 7 | | 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
| 8 | | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18, | 9 | | 356z.19, 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, | 10 | | 356z.32, 356z.33, 364.01, 367.2, 368a, 401, 401.1,
402,
403, | 11 | | 403A, 408,
408.2, and 412, and paragraphs (7) and (15) of | 12 | | Section 367 of the Illinois
Insurance Code.
| 13 | | Rulemaking authority to implement Public Act 95-1045, if | 14 | | any, is conditioned on the rules being adopted in accordance | 15 | | with all provisions of the Illinois Administrative Procedure | 16 | | Act and all rules and procedures of the Joint Committee on | 17 | | Administrative Rules; any purported rule not so adopted, for | 18 | | whatever reason, is unauthorized. | 19 | | (Source: P.A. 100-24, eff. 7-18-17; 100-138, eff. 8-18-17; | 20 | | 100-863, eff. 8-14-18; 100-1026, eff. 8-22-18; 100-1057, eff. | 21 | | 1-1-19; 100-1102, eff. 1-1-19; revised 10-4-18.) | 22 | | Section 50. The Illinois Public Aid Code is amended by | 23 | | changing Sections 5-2, 5-5, and 5-5.24 and by adding Section | 24 | | 5-5.27 as follows:
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| 1 | | (305 ILCS 5/5-2) (from Ch. 23, par. 5-2)
| 2 | | Sec. 5-2. Classes of Persons Eligible. | 3 | | Medical assistance under this
Article shall be available to | 4 | | any of the following classes of persons in
respect to whom a | 5 | | plan for coverage has been submitted to the Governor
by the | 6 | | Illinois Department and approved by him. If changes made in | 7 | | this Section 5-2 require federal approval, they shall not take | 8 | | effect until such approval has been received:
| 9 | | 1. Recipients of basic maintenance grants under | 10 | | Articles III and IV.
| 11 | | 2. Beginning January 1, 2014, persons otherwise | 12 | | eligible for basic maintenance under Article
III, | 13 | | excluding any eligibility requirements that are | 14 | | inconsistent with any federal law or federal regulation, as | 15 | | interpreted by the U.S. Department of Health and Human | 16 | | Services, but who fail to qualify thereunder on the basis | 17 | | of need, and
who have insufficient income and resources to | 18 | | meet the costs of
necessary medical care, including but not | 19 | | limited to the following:
| 20 | | (a) All persons otherwise eligible for basic | 21 | | maintenance under Article
III but who fail to qualify | 22 | | under that Article on the basis of need and who
meet | 23 | | either of the following requirements:
| 24 | | (i) their income, as determined by the | 25 | | Illinois Department in
accordance with any federal | 26 | | requirements, is equal to or less than 100% of the |
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| 1 | | federal poverty level; or
| 2 | | (ii) their income, after the deduction of | 3 | | costs incurred for medical
care and for other types | 4 | | of remedial care, is equal to or less than 100% of | 5 | | the federal poverty level.
| 6 | | (b) (Blank).
| 7 | | 3. (Blank).
| 8 | | 4. Persons not eligible under any of the preceding | 9 | | paragraphs who fall
sick, are injured, or die, not having | 10 | | sufficient money, property or other
resources to meet the | 11 | | costs of necessary medical care or funeral and burial
| 12 | | expenses.
| 13 | | 5.(a) Women during pregnancy and during the
12-month | 14 | | 60-day period beginning on the last day of the pregnancy, | 15 | | together with
their infants,
whose income is at or below | 16 | | 200% of the federal poverty level. Until September 30, | 17 | | 2019, or sooner if the maintenance of effort requirements | 18 | | under the Patient Protection and Affordable Care Act are | 19 | | eliminated or may be waived before then, women during | 20 | | pregnancy and during the 12-month 60-day period beginning | 21 | | on the last day of the pregnancy, whose countable monthly | 22 | | income, after the deduction of costs incurred for medical | 23 | | care and for other types of remedial care as specified in | 24 | | administrative rule, is equal to or less than the Medical | 25 | | Assistance-No Grant(C) (MANG(C)) Income Standard in effect | 26 | | on April 1, 2013 as set forth in administrative rule.
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| 1 | | (b) The plan for coverage shall provide ambulatory | 2 | | prenatal care to pregnant women during a
presumptive | 3 | | eligibility period and establish an income eligibility | 4 | | standard
that is equal to 200% of the federal poverty | 5 | | level, provided that costs incurred
for medical care are | 6 | | not taken into account in determining such income
| 7 | | eligibility.
| 8 | | (c) The Illinois Department may conduct a | 9 | | demonstration in at least one
county that will provide | 10 | | medical assistance to pregnant women, together
with their | 11 | | infants and children up to one year of age,
where the | 12 | | income
eligibility standard is set up to 185% of the | 13 | | nonfarm income official
poverty line, as defined by the | 14 | | federal Office of Management and Budget.
The Illinois | 15 | | Department shall seek and obtain necessary authorization
| 16 | | provided under federal law to implement such a | 17 | | demonstration. Such
demonstration may establish resource | 18 | | standards that are not more
restrictive than those | 19 | | established under Article IV of this Code.
| 20 | | 6. (a) Children younger than age 19 when countable | 21 | | income is at or below 133% of the federal poverty level. | 22 | | Until September 30, 2019, or sooner if the maintenance of | 23 | | effort requirements under the Patient Protection and | 24 | | Affordable Care Act are eliminated or may be waived before | 25 | | then, children younger than age 19 whose countable monthly | 26 | | income, after the deduction of costs incurred for medical |
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| 1 | | care and for other types of remedial care as specified in | 2 | | administrative rule, is equal to or less than the Medical | 3 | | Assistance-No Grant(C) (MANG(C)) Income Standard in effect | 4 | | on April 1, 2013 as set forth in administrative rule. | 5 | | (b) Children and youth who are under temporary custody | 6 | | or guardianship of the Department of Children and Family | 7 | | Services or who receive financial assistance in support of | 8 | | an adoption or guardianship placement from the Department | 9 | | of Children and Family Services.
| 10 | | 7. (Blank).
| 11 | | 8. As required under federal law, persons who are | 12 | | eligible for Transitional Medical Assistance as a result of | 13 | | an increase in earnings or child or spousal support | 14 | | received. The plan for coverage for this class of persons | 15 | | shall:
| 16 | | (a) extend the medical assistance coverage to the | 17 | | extent required by federal law; and
| 18 | | (b) offer persons who have initially received 6 | 19 | | months of the
coverage provided in paragraph (a) above, | 20 | | the option of receiving an
additional 6 months of | 21 | | coverage, subject to the following:
| 22 | | (i) such coverage shall be pursuant to | 23 | | provisions of the federal
Social Security Act;
| 24 | | (ii) such coverage shall include all services | 25 | | covered under Illinois' State Medicaid Plan;
| 26 | | (iii) no premium shall be charged for such |
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| 1 | | coverage; and
| 2 | | (iv) such coverage shall be suspended in the | 3 | | event of a person's
failure without good cause to | 4 | | file in a timely fashion reports required for
this | 5 | | coverage under the Social Security Act and | 6 | | coverage shall be reinstated
upon the filing of | 7 | | such reports if the person remains otherwise | 8 | | eligible.
| 9 | | 9. Persons with acquired immunodeficiency syndrome | 10 | | (AIDS) or with
AIDS-related conditions with respect to whom | 11 | | there has been a determination
that but for home or | 12 | | community-based services such individuals would
require | 13 | | the level of care provided in an inpatient hospital, | 14 | | skilled
nursing facility or intermediate care facility the | 15 | | cost of which is
reimbursed under this Article. Assistance | 16 | | shall be provided to such
persons to the maximum extent | 17 | | permitted under Title
XIX of the Federal Social Security | 18 | | Act.
| 19 | | 10. Participants in the long-term care insurance | 20 | | partnership program
established under the Illinois | 21 | | Long-Term Care Partnership Program Act who meet the
| 22 | | qualifications for protection of resources described in | 23 | | Section 15 of that
Act.
| 24 | | 11. Persons with disabilities who are employed and | 25 | | eligible for Medicaid,
pursuant to Section | 26 | | 1902(a)(10)(A)(ii)(xv) of the Social Security Act, and, |
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| 1 | | subject to federal approval, persons with a medically | 2 | | improved disability who are employed and eligible for | 3 | | Medicaid pursuant to Section 1902(a)(10)(A)(ii)(xvi) of | 4 | | the Social Security Act, as
provided by the Illinois | 5 | | Department by rule. In establishing eligibility standards | 6 | | under this paragraph 11, the Department shall, subject to | 7 | | federal approval: | 8 | | (a) set the income eligibility standard at not | 9 | | lower than 350% of the federal poverty level; | 10 | | (b) exempt retirement accounts that the person | 11 | | cannot access without penalty before the age
of 59 1/2, | 12 | | and medical savings accounts established pursuant to | 13 | | 26 U.S.C. 220; | 14 | | (c) allow non-exempt assets up to $25,000 as to | 15 | | those assets accumulated during periods of eligibility | 16 | | under this paragraph 11; and
| 17 | | (d) continue to apply subparagraphs (b) and (c) in | 18 | | determining the eligibility of the person under this | 19 | | Article even if the person loses eligibility under this | 20 | | paragraph 11.
| 21 | | 12. Subject to federal approval, persons who are | 22 | | eligible for medical
assistance coverage under applicable | 23 | | provisions of the federal Social Security
Act and the | 24 | | federal Breast and Cervical Cancer Prevention and | 25 | | Treatment Act of
2000. Those eligible persons are defined | 26 | | to include, but not be limited to,
the following persons:
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| 1 | | (1) persons who have been screened for breast or | 2 | | cervical cancer under
the U.S. Centers for Disease | 3 | | Control and Prevention Breast and Cervical Cancer
| 4 | | Program established under Title XV of the federal | 5 | | Public Health Services Act in
accordance with the | 6 | | requirements of Section 1504 of that Act as | 7 | | administered by
the Illinois Department of Public | 8 | | Health; and
| 9 | | (2) persons whose screenings under the above | 10 | | program were funded in whole
or in part by funds | 11 | | appropriated to the Illinois Department of Public | 12 | | Health
for breast or cervical cancer screening.
| 13 | | "Medical assistance" under this paragraph 12 shall be | 14 | | identical to the benefits
provided under the State's | 15 | | approved plan under Title XIX of the Social Security
Act. | 16 | | The Department must request federal approval of the | 17 | | coverage under this
paragraph 12 within 30 days after the | 18 | | effective date of this amendatory Act of
the 92nd General | 19 | | Assembly.
| 20 | | In addition to the persons who are eligible for medical | 21 | | assistance pursuant to subparagraphs (1) and (2) of this | 22 | | paragraph 12, and to be paid from funds appropriated to the | 23 | | Department for its medical programs, any uninsured person | 24 | | as defined by the Department in rules residing in Illinois | 25 | | who is younger than 65 years of age, who has been screened | 26 | | for breast and cervical cancer in accordance with standards |
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| 1 | | and procedures adopted by the Department of Public Health | 2 | | for screening, and who is referred to the Department by the | 3 | | Department of Public Health as being in need of treatment | 4 | | for breast or cervical cancer is eligible for medical | 5 | | assistance benefits that are consistent with the benefits | 6 | | provided to those persons described in subparagraphs (1) | 7 | | and (2). Medical assistance coverage for the persons who | 8 | | are eligible under the preceding sentence is not dependent | 9 | | on federal approval, but federal moneys may be used to pay | 10 | | for services provided under that coverage upon federal | 11 | | approval. | 12 | | 13. Subject to appropriation and to federal approval, | 13 | | persons living with HIV/AIDS who are not otherwise eligible | 14 | | under this Article and who qualify for services covered | 15 | | under Section 5-5.04 as provided by the Illinois Department | 16 | | by rule.
| 17 | | 14. Subject to the availability of funds for this | 18 | | purpose, the Department may provide coverage under this | 19 | | Article to persons who reside in Illinois who are not | 20 | | eligible under any of the preceding paragraphs and who meet | 21 | | the income guidelines of paragraph 2(a) of this Section and | 22 | | (i) have an application for asylum pending before the | 23 | | federal Department of Homeland Security or on appeal before | 24 | | a court of competent jurisdiction and are represented | 25 | | either by counsel or by an advocate accredited by the | 26 | | federal Department of Homeland Security and employed by a |
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| 1 | | not-for-profit organization in regard to that application | 2 | | or appeal, or (ii) are receiving services through a | 3 | | federally funded torture treatment center. Medical | 4 | | coverage under this paragraph 14 may be provided for up to | 5 | | 24 continuous months from the initial eligibility date so | 6 | | long as an individual continues to satisfy the criteria of | 7 | | this paragraph 14. If an individual has an appeal pending | 8 | | regarding an application for asylum before the Department | 9 | | of Homeland Security, eligibility under this paragraph 14 | 10 | | may be extended until a final decision is rendered on the | 11 | | appeal. The Department may adopt rules governing the | 12 | | implementation of this paragraph 14.
| 13 | | 15. Family Care Eligibility. | 14 | | (a) On and after July 1, 2012, a parent or other | 15 | | caretaker relative who is 19 years of age or older when | 16 | | countable income is at or below 133% of the federal | 17 | | poverty level. A person may not spend down to become | 18 | | eligible under this paragraph 15. | 19 | | (b) Eligibility shall be reviewed annually. | 20 | | (c) (Blank). | 21 | | (d) (Blank). | 22 | | (e) (Blank). | 23 | | (f) (Blank). | 24 | | (g) (Blank). | 25 | | (h) (Blank). | 26 | | (i) Following termination of an individual's |
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| 1 | | coverage under this paragraph 15, the individual must | 2 | | be determined eligible before the person can be | 3 | | re-enrolled. | 4 | | 16. Subject to appropriation, uninsured persons who | 5 | | are not otherwise eligible under this Section who have been | 6 | | certified and referred by the Department of Public Health | 7 | | as having been screened and found to need diagnostic | 8 | | evaluation or treatment, or both diagnostic evaluation and | 9 | | treatment, for prostate or testicular cancer. For the | 10 | | purposes of this paragraph 16, uninsured persons are those | 11 | | who do not have creditable coverage, as defined under the | 12 | | Health Insurance Portability and Accountability Act, or | 13 | | have otherwise exhausted any insurance benefits they may | 14 | | have had, for prostate or testicular cancer diagnostic | 15 | | evaluation or treatment, or both diagnostic evaluation and | 16 | | treatment.
To be eligible, a person must furnish a Social | 17 | | Security number.
A person's assets are exempt from | 18 | | consideration in determining eligibility under this | 19 | | paragraph 16.
Such persons shall be eligible for medical | 20 | | assistance under this paragraph 16 for so long as they need | 21 | | treatment for the cancer. A person shall be considered to | 22 | | need treatment if, in the opinion of the person's treating | 23 | | physician, the person requires therapy directed toward | 24 | | cure or palliation of prostate or testicular cancer, | 25 | | including recurrent metastatic cancer that is a known or | 26 | | presumed complication of prostate or testicular cancer and |
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| 1 | | complications resulting from the treatment modalities | 2 | | themselves. Persons who require only routine monitoring | 3 | | services are not considered to need treatment.
"Medical | 4 | | assistance" under this paragraph 16 shall be identical to | 5 | | the benefits provided under the State's approved plan under | 6 | | Title XIX of the Social Security Act.
Notwithstanding any | 7 | | other provision of law, the Department (i) does not have a | 8 | | claim against the estate of a deceased recipient of | 9 | | services under this paragraph 16 and (ii) does not have a | 10 | | lien against any homestead property or other legal or | 11 | | equitable real property interest owned by a recipient of | 12 | | services under this paragraph 16. | 13 | | 17. Persons who, pursuant to a waiver approved by the | 14 | | Secretary of the U.S. Department of Health and Human | 15 | | Services, are eligible for medical assistance under Title | 16 | | XIX or XXI of the federal Social Security Act. | 17 | | Notwithstanding any other provision of this Code and | 18 | | consistent with the terms of the approved waiver, the | 19 | | Illinois Department, may by rule: | 20 | | (a) Limit the geographic areas in which the waiver | 21 | | program operates. | 22 | | (b) Determine the scope, quantity, duration, and | 23 | | quality, and the rate and method of reimbursement, of | 24 | | the medical services to be provided, which may differ | 25 | | from those for other classes of persons eligible for | 26 | | assistance under this Article. |
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| 1 | | (c) Restrict the persons' freedom in choice of | 2 | | providers. | 3 | | 18. Beginning January 1, 2014, persons aged 19 or | 4 | | older, but younger than 65, who are not otherwise eligible | 5 | | for medical assistance under this Section 5-2, who qualify | 6 | | for medical assistance pursuant to 42 U.S.C. | 7 | | 1396a(a)(10)(A)(i)(VIII) and applicable federal | 8 | | regulations, and who have income at or below 133% of the | 9 | | federal poverty level plus 5% for the applicable family | 10 | | size as determined pursuant to 42 U.S.C. 1396a(e)(14) and | 11 | | applicable federal regulations. Persons eligible for | 12 | | medical assistance under this paragraph 18 shall receive | 13 | | coverage for the Health Benefits Service Package as that | 14 | | term is defined in subsection (m) of Section 5-1.1 of this | 15 | | Code. If Illinois' federal medical assistance percentage | 16 | | (FMAP) is reduced below 90% for persons eligible for | 17 | | medical
assistance under this paragraph 18, eligibility | 18 | | under this paragraph 18 shall cease no later than the end | 19 | | of the third month following the month in which the | 20 | | reduction in FMAP takes effect. | 21 | | 19. Beginning January 1, 2014, as required under 42 | 22 | | U.S.C. 1396a(a)(10)(A)(i)(IX), persons older than age 18 | 23 | | and younger than age 26 who are not otherwise eligible for | 24 | | medical assistance under paragraphs (1) through (17) of | 25 | | this Section who (i) were in foster care under the | 26 | | responsibility of the State on the date of attaining age 18 |
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| 1 | | or on the date of attaining age 21 when a court has | 2 | | continued wardship for good cause as provided in Section | 3 | | 2-31 of the Juvenile Court Act of 1987 and (ii) received | 4 | | medical assistance under the Illinois Title XIX State Plan | 5 | | or waiver of such plan while in foster care. | 6 | | 20. Beginning January 1, 2018, persons who are | 7 | | foreign-born victims of human trafficking, torture, or | 8 | | other serious crimes as defined in Section 2-19 of this | 9 | | Code and their derivative family members if such persons: | 10 | | (i) reside in Illinois; (ii) are not eligible under any of | 11 | | the preceding paragraphs; (iii) meet the income guidelines | 12 | | of subparagraph (a) of paragraph 2; and (iv) meet the | 13 | | nonfinancial eligibility requirements of Sections 16-2, | 14 | | 16-3, and 16-5 of this Code. The Department may extend | 15 | | medical assistance for persons who are foreign-born | 16 | | victims of human trafficking, torture, or other serious | 17 | | crimes whose medical assistance would be terminated | 18 | | pursuant to subsection (b) of Section 16-5 if the | 19 | | Department determines that the person, during the year of | 20 | | initial eligibility (1) experienced a health crisis, (2) | 21 | | has been unable, after reasonable attempts, to obtain | 22 | | necessary information from a third party, or (3) has other | 23 | | extenuating circumstances that prevented the person from | 24 | | completing his or her application for status. The | 25 | | Department may adopt any rules necessary to implement the | 26 | | provisions of this paragraph. |
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| 1 | | In implementing the provisions of Public Act 96-20, the | 2 | | Department is authorized to adopt only those rules necessary, | 3 | | including emergency rules. Nothing in Public Act 96-20 permits | 4 | | the Department to adopt rules or issue a decision that expands | 5 | | eligibility for the FamilyCare Program to a person whose income | 6 | | exceeds 185% of the Federal Poverty Level as determined from | 7 | | time to time by the U.S. Department of Health and Human | 8 | | Services, unless the Department is provided with express | 9 | | statutory authority.
| 10 | | The eligibility of any such person for medical assistance | 11 | | under this
Article is not affected by the payment of any grant | 12 | | under the Senior
Citizens and Persons with Disabilities | 13 | | Property Tax Relief Act or any distributions or items of income | 14 | | described under
subparagraph (X) of
paragraph (2) of subsection | 15 | | (a) of Section 203 of the Illinois Income Tax
Act. | 16 | | The Department shall by rule establish the amounts of
| 17 | | assets to be disregarded in determining eligibility for medical | 18 | | assistance,
which shall at a minimum equal the amounts to be | 19 | | disregarded under the
Federal Supplemental Security Income | 20 | | Program. The amount of assets of a
single person to be | 21 | | disregarded
shall not be less than $2,000, and the amount of | 22 | | assets of a married couple
to be disregarded shall not be less | 23 | | than $3,000.
| 24 | | To the extent permitted under federal law, any person found | 25 | | guilty of a
second violation of Article VIIIA
shall be | 26 | | ineligible for medical assistance under this Article, as |
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| 1 | | provided
in Section 8A-8.
| 2 | | The eligibility of any person for medical assistance under | 3 | | this Article
shall not be affected by the receipt by the person | 4 | | of donations or benefits
from fundraisers held for the person | 5 | | in cases of serious illness,
as long as neither the person nor | 6 | | members of the person's family
have actual control over the | 7 | | donations or benefits or the disbursement
of the donations or | 8 | | benefits.
| 9 | | Notwithstanding any other provision of this Code, if the | 10 | | United States Supreme Court holds Title II, Subtitle A, Section | 11 | | 2001(a) of Public Law 111-148 to be unconstitutional, or if a | 12 | | holding of Public Law 111-148 makes Medicaid eligibility | 13 | | allowed under Section 2001(a) inoperable, the State or a unit | 14 | | of local government shall be prohibited from enrolling | 15 | | individuals in the Medical Assistance Program as the result of | 16 | | federal approval of a State Medicaid waiver on or after the | 17 | | effective date of this amendatory Act of the 97th General | 18 | | Assembly, and any individuals enrolled in the Medical | 19 | | Assistance Program pursuant to eligibility permitted as a | 20 | | result of such a State Medicaid waiver shall become immediately | 21 | | ineligible. | 22 | | Notwithstanding any other provision of this Code, if an Act | 23 | | of Congress that becomes a Public Law eliminates Section | 24 | | 2001(a) of Public Law 111-148, the State or a unit of local | 25 | | government shall be prohibited from enrolling individuals in | 26 | | the Medical Assistance Program as the result of federal |
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| 1 | | approval of a State Medicaid waiver on or after the effective | 2 | | date of this amendatory Act of the 97th General Assembly, and | 3 | | any individuals enrolled in the Medical Assistance Program | 4 | | pursuant to eligibility permitted as a result of such a State | 5 | | Medicaid waiver shall become immediately ineligible. | 6 | | Effective October 1, 2013, the determination of | 7 | | eligibility of persons who qualify under paragraphs 5, 6, 8, | 8 | | 15, 17, and 18 of this Section shall comply with the | 9 | | requirements of 42 U.S.C. 1396a(e)(14) and applicable federal | 10 | | regulations. | 11 | | The Department of Healthcare and Family Services, the | 12 | | Department of Human Services, and the Illinois health insurance | 13 | | marketplace shall work cooperatively to assist persons who | 14 | | would otherwise lose health benefits as a result of changes | 15 | | made under this amendatory Act of the 98th General Assembly to | 16 | | transition to other health insurance coverage. | 17 | | (Source: P.A. 98-104, eff. 7-22-13; 98-463, eff. 8-16-13; | 18 | | 99-143, eff. 7-27-15; 99-870, eff. 8-22-16.)
| 19 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| 20 | | Sec. 5-5. Medical services. The Illinois Department, by | 21 | | rule, shall
determine the quantity and quality of and the rate | 22 | | of reimbursement for the
medical assistance for which
payment | 23 | | will be authorized, and the medical services to be provided,
| 24 | | which may include all or part of the following: (1) inpatient | 25 | | hospital
services; (2) outpatient hospital services; (3) other |
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| 1 | | laboratory and
X-ray services; (4) skilled nursing home | 2 | | services; (5) physicians'
services whether furnished in the | 3 | | office, the patient's home, a
hospital, a skilled nursing home, | 4 | | or elsewhere; (6) medical care, or any
other type of remedial | 5 | | care furnished by licensed practitioners; (7)
home health care | 6 | | services; (8) private duty nursing service; (9) clinic
| 7 | | services; (10) dental services, including prevention and | 8 | | treatment of periodontal disease and dental caries disease for | 9 | | pregnant women, provided by an individual licensed to practice | 10 | | dentistry or dental surgery; for purposes of this item (10), | 11 | | "dental services" means diagnostic, preventive, or corrective | 12 | | procedures provided by or under the supervision of a dentist in | 13 | | the practice of his or her profession; (11) physical therapy | 14 | | and related
services; (12) prescribed drugs, dentures, and | 15 | | prosthetic devices; and
eyeglasses prescribed by a physician | 16 | | skilled in the diseases of the eye,
or by an optometrist, | 17 | | whichever the person may select; (13) other
diagnostic, | 18 | | screening, preventive, and rehabilitative services, including | 19 | | to ensure that the individual's need for intervention or | 20 | | treatment of mental disorders or substance use disorders or | 21 | | co-occurring mental health and substance use disorders is | 22 | | determined using a uniform screening, assessment, and | 23 | | evaluation process inclusive of criteria, for children and | 24 | | adults; for purposes of this item (13), a uniform screening, | 25 | | assessment, and evaluation process refers to a process that | 26 | | includes an appropriate evaluation and, as warranted, a |
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| 1 | | referral; "uniform" does not mean the use of a singular | 2 | | instrument, tool, or process that all must utilize; (14)
| 3 | | transportation and such other expenses as may be necessary; | 4 | | (15) medical
treatment of sexual assault survivors, as defined | 5 | | in
Section 1a of the Sexual Assault Survivors Emergency | 6 | | Treatment Act, for
injuries sustained as a result of the sexual | 7 | | assault, including
examinations and laboratory tests to | 8 | | discover evidence which may be used in
criminal proceedings | 9 | | arising from the sexual assault; (16) the
diagnosis and | 10 | | treatment of sickle cell anemia; and (17)
any other medical | 11 | | care, and any other type of remedial care recognized
under the | 12 | | laws of this State. The term "any other type of remedial care" | 13 | | shall
include nursing care and nursing home service for persons | 14 | | who rely on
treatment by spiritual means alone through prayer | 15 | | for healing.
| 16 | | Notwithstanding any other provision of this Section, a | 17 | | comprehensive
tobacco use cessation program that includes | 18 | | purchasing prescription drugs or
prescription medical devices | 19 | | approved by the Food and Drug Administration shall
be covered | 20 | | under the medical assistance
program under this Article for | 21 | | persons who are otherwise eligible for
assistance under this | 22 | | Article.
| 23 | | Notwithstanding any other provision of this Code, | 24 | | reproductive health care that is otherwise legal in Illinois | 25 | | shall be covered under the medical assistance program for | 26 | | persons who are otherwise eligible for medical assistance under |
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| 1 | | this Article. | 2 | | Notwithstanding any other provision of this Code, the | 3 | | Illinois
Department may not require, as a condition of payment | 4 | | for any laboratory
test authorized under this Article, that a | 5 | | physician's handwritten signature
appear on the laboratory | 6 | | test order form. The Illinois Department may,
however, impose | 7 | | other appropriate requirements regarding laboratory test
order | 8 | | documentation.
| 9 | | Upon receipt of federal approval of an amendment to the | 10 | | Illinois Title XIX State Plan for this purpose, the Department | 11 | | shall authorize the Chicago Public Schools (CPS) to procure a | 12 | | vendor or vendors to manufacture eyeglasses for individuals | 13 | | enrolled in a school within the CPS system. CPS shall ensure | 14 | | that its vendor or vendors are enrolled as providers in the | 15 | | medical assistance program and in any capitated Medicaid | 16 | | managed care entity (MCE) serving individuals enrolled in a | 17 | | school within the CPS system. Under any contract procured under | 18 | | this provision, the vendor or vendors must serve only | 19 | | individuals enrolled in a school within the CPS system. Claims | 20 | | for services provided by CPS's vendor or vendors to recipients | 21 | | of benefits in the medical assistance program under this Code, | 22 | | the Children's Health Insurance Program, or the Covering ALL | 23 | | KIDS Health Insurance Program shall be submitted to the | 24 | | Department or the MCE in which the individual is enrolled for | 25 | | payment and shall be reimbursed at the Department's or the | 26 | | MCE's established rates or rate methodologies for eyeglasses. |
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| 1 | | On and after July 1, 2012, the Department of Healthcare and | 2 | | Family Services may provide the following services to
persons
| 3 | | eligible for assistance under this Article who are | 4 | | participating in
education, training or employment programs | 5 | | operated by the Department of Human
Services as successor to | 6 | | the Department of Public Aid:
| 7 | | (1) dental services provided by or under the | 8 | | supervision of a dentist; and
| 9 | | (2) eyeglasses prescribed by a physician skilled in the | 10 | | diseases of the
eye, or by an optometrist, whichever the | 11 | | person may select.
| 12 | | On and after July 1, 2018, the Department of Healthcare and | 13 | | Family Services shall provide dental services to any adult who | 14 | | is otherwise eligible for assistance under the medical | 15 | | assistance program. As used in this paragraph, "dental | 16 | | services" means diagnostic, preventative, restorative, or | 17 | | corrective procedures, including procedures and services for | 18 | | the prevention and treatment of periodontal disease and dental | 19 | | caries disease, provided by an individual who is licensed to | 20 | | practice dentistry or dental surgery or who is under the | 21 | | supervision of a dentist in the practice of his or her | 22 | | profession. | 23 | | On and after July 1, 2018, targeted dental services, as set | 24 | | forth in Exhibit D of the Consent Decree entered by the United | 25 | | States District Court for the Northern District of Illinois, | 26 | | Eastern Division, in the matter of Memisovski v. Maram, Case |
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| 1 | | No. 92 C 1982, that are provided to adults under the medical | 2 | | assistance program shall be established at no less than the | 3 | | rates set forth in the "New Rate" column in Exhibit D of the | 4 | | Consent Decree for targeted dental services that are provided | 5 | | to persons under the age of 18 under the medical assistance | 6 | | program. | 7 | | Notwithstanding any other provision of this Code and | 8 | | subject to federal approval, the Department may adopt rules to | 9 | | allow a dentist who is volunteering his or her service at no | 10 | | cost to render dental services through an enrolled | 11 | | not-for-profit health clinic without the dentist personally | 12 | | enrolling as a participating provider in the medical assistance | 13 | | program. A not-for-profit health clinic shall include a public | 14 | | health clinic or Federally Qualified Health Center or other | 15 | | enrolled provider, as determined by the Department, through | 16 | | which dental services covered under this Section are performed. | 17 | | The Department shall establish a process for payment of claims | 18 | | for reimbursement for covered dental services rendered under | 19 | | this provision. | 20 | | The Illinois Department, by rule, may distinguish and | 21 | | classify the
medical services to be provided only in accordance | 22 | | with the classes of
persons designated in Section 5-2.
| 23 | | The Department of Healthcare and Family Services must | 24 | | provide coverage and reimbursement for amino acid-based | 25 | | elemental formulas, regardless of delivery method, for the | 26 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) |
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| 1 | | short bowel syndrome when the prescribing physician has issued | 2 | | a written order stating that the amino acid-based elemental | 3 | | formula is medically necessary.
| 4 | | The Illinois Department shall authorize the provision of, | 5 | | and shall
authorize payment for, screening by low-dose | 6 | | mammography for the presence of
occult breast cancer for women | 7 | | 35 years of age or older who are eligible
for medical | 8 | | assistance under this Article, as follows: | 9 | | (A) A baseline
mammogram for women 35 to 39 years of | 10 | | age.
| 11 | | (B) An annual mammogram for women 40 years of age or | 12 | | older. | 13 | | (C) A mammogram at the age and intervals considered | 14 | | medically necessary by the woman's health care provider for | 15 | | women under 40 years of age and having a family history of | 16 | | breast cancer, prior personal history of breast cancer, | 17 | | positive genetic testing, or other risk factors. | 18 | | (D) A comprehensive ultrasound screening and MRI of an | 19 | | entire breast or breasts if a mammogram demonstrates | 20 | | heterogeneous or dense breast tissue, when medically | 21 | | necessary as determined by a physician licensed to practice | 22 | | medicine in all of its branches. | 23 | | (E) A screening MRI when medically necessary, as | 24 | | determined by a physician licensed to practice medicine in | 25 | | all of its branches. | 26 | | All screenings
shall
include a physical breast exam, |
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| 1 | | instruction on self-examination and
information regarding the | 2 | | frequency of self-examination and its value as a
preventative | 3 | | tool. For purposes of this Section, "low-dose mammography" | 4 | | means
the x-ray examination of the breast using equipment | 5 | | dedicated specifically
for mammography, including the x-ray | 6 | | tube, filter, compression device,
and image receptor, with an | 7 | | average radiation exposure delivery
of less than one rad per | 8 | | breast for 2 views of an average size breast.
The term also | 9 | | includes digital mammography and includes breast | 10 | | tomosynthesis. As used in this Section, the term "breast | 11 | | tomosynthesis" means a radiologic procedure that involves the | 12 | | acquisition of projection images over the stationary breast to | 13 | | produce cross-sectional digital three-dimensional images of | 14 | | the breast. If, at any time, the Secretary of the United States | 15 | | Department of Health and Human Services, or its successor | 16 | | agency, promulgates rules or regulations to be published in the | 17 | | Federal Register or publishes a comment in the Federal Register | 18 | | or issues an opinion, guidance, or other action that would | 19 | | require the State, pursuant to any provision of the Patient | 20 | | Protection and Affordable Care Act (Public Law 111-148), | 21 | | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any | 22 | | successor provision, to defray the cost of any coverage for | 23 | | breast tomosynthesis outlined in this paragraph, then the | 24 | | requirement that an insurer cover breast tomosynthesis is | 25 | | inoperative other than any such coverage authorized under | 26 | | Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and |
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| 1 | | the State shall not assume any obligation for the cost of | 2 | | coverage for breast tomosynthesis set forth in this paragraph.
| 3 | | On and after January 1, 2016, the Department shall ensure | 4 | | that all networks of care for adult clients of the Department | 5 | | include access to at least one breast imaging Center of Imaging | 6 | | Excellence as certified by the American College of Radiology. | 7 | | On and after January 1, 2012, providers participating in a | 8 | | quality improvement program approved by the Department shall be | 9 | | reimbursed for screening and diagnostic mammography at the same | 10 | | rate as the Medicare program's rates, including the increased | 11 | | reimbursement for digital mammography. | 12 | | The Department shall convene an expert panel including | 13 | | representatives of hospitals, free-standing mammography | 14 | | facilities, and doctors, including radiologists, to establish | 15 | | quality standards for mammography. | 16 | | On and after January 1, 2017, providers participating in a | 17 | | breast cancer treatment quality improvement program approved | 18 | | by the Department shall be reimbursed for breast cancer | 19 | | treatment at a rate that is no lower than 95% of the Medicare | 20 | | program's rates for the data elements included in the breast | 21 | | cancer treatment quality program. | 22 | | The Department shall convene an expert panel, including | 23 | | representatives of hospitals, free-standing breast cancer | 24 | | treatment centers, breast cancer quality organizations, and | 25 | | doctors, including breast surgeons, reconstructive breast | 26 | | surgeons, oncologists, and primary care providers to establish |
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| 1 | | quality standards for breast cancer treatment. | 2 | | Subject to federal approval, the Department shall | 3 | | establish a rate methodology for mammography at federally | 4 | | qualified health centers and other encounter-rate clinics. | 5 | | These clinics or centers may also collaborate with other | 6 | | hospital-based mammography facilities. By January 1, 2016, the | 7 | | Department shall report to the General Assembly on the status | 8 | | of the provision set forth in this paragraph. | 9 | | The Department shall establish a methodology to remind | 10 | | women who are age-appropriate for screening mammography, but | 11 | | who have not received a mammogram within the previous 18 | 12 | | months, of the importance and benefit of screening mammography. | 13 | | The Department shall work with experts in breast cancer | 14 | | outreach and patient navigation to optimize these reminders and | 15 | | shall establish a methodology for evaluating their | 16 | | effectiveness and modifying the methodology based on the | 17 | | evaluation. | 18 | | The Department shall establish a performance goal for | 19 | | primary care providers with respect to their female patients | 20 | | over age 40 receiving an annual mammogram. This performance | 21 | | goal shall be used to provide additional reimbursement in the | 22 | | form of a quality performance bonus to primary care providers | 23 | | who meet that goal. | 24 | | The Department shall devise a means of case-managing or | 25 | | patient navigation for beneficiaries diagnosed with breast | 26 | | cancer. This program shall initially operate as a pilot program |
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| 1 | | in areas of the State with the highest incidence of mortality | 2 | | related to breast cancer. At least one pilot program site shall | 3 | | be in the metropolitan Chicago area and at least one site shall | 4 | | be outside the metropolitan Chicago area. On or after July 1, | 5 | | 2016, the pilot program shall be expanded to include one site | 6 | | in western Illinois, one site in southern Illinois, one site in | 7 | | central Illinois, and 4 sites within metropolitan Chicago. An | 8 | | evaluation of the pilot program shall be carried out measuring | 9 | | health outcomes and cost of care for those served by the pilot | 10 | | program compared to similarly situated patients who are not | 11 | | served by the pilot program. | 12 | | The Department shall require all networks of care to | 13 | | develop a means either internally or by contract with experts | 14 | | in navigation and community outreach to navigate cancer | 15 | | patients to comprehensive care in a timely fashion. The | 16 | | Department shall require all networks of care to include access | 17 | | for patients diagnosed with cancer to at least one academic | 18 | | commission on cancer-accredited cancer program as an | 19 | | in-network covered benefit. | 20 | | On or after July 1, 2019, women who are otherwise eligible | 21 | | for medical assistance under this Article shall receive | 22 | | coverage for doula services by a certified doula during their | 23 | | pregnancy and during the 12-month period beginning on the last | 24 | | day of their pregnancy. As used in this paragraph, "certified | 25 | | doula" means an individual who has received a certification to | 26 | | perform doula services from the International Childbirth |
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| 1 | | Education Association, the Doulas of North America, the | 2 | | Association of Labor Assistants and Childbirth Educators, | 3 | | BirthWorks, the Childbirth and Postpartum Professional | 4 | | Association, Childbirth International, the International | 5 | | Center for Traditional Childbearing, or Commonsense Childbirth | 6 | | Inc. As used in this paragraph, "doula services" means | 7 | | continuous personal, non-medical emotional and physical | 8 | | support throughout labor and birth, and intermittently during | 9 | | the prenatal and postpartum periods. | 10 | | On or after July 1, 2019, women who are otherwise eligible | 11 | | for medical assistance under this Article shall receive | 12 | | coverage for perinatal depression screenings for the 12-month | 13 | | period beginning on the last day of their pregnancy. Medical | 14 | | assistance coverage under this paragraph shall be conditioned | 15 | | on the use of a screening instrument approved by the | 16 | | Department. | 17 | | Any medical or health care provider shall immediately | 18 | | recommend, to
any pregnant woman who is being provided prenatal | 19 | | services and is suspected
of having a substance use disorder as | 20 | | defined in the Substance Use Disorder Act, referral to a local | 21 | | substance use disorder treatment program licensed by the | 22 | | Department of Human Services or to a licensed
hospital which | 23 | | provides substance abuse treatment services. The Department of | 24 | | Healthcare and Family Services
shall assure coverage for the | 25 | | cost of treatment of the drug abuse or
addiction for pregnant | 26 | | recipients in accordance with the Illinois Medicaid
Program in |
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| 1 | | conjunction with the Department of Human Services.
| 2 | | All medical providers providing medical assistance to | 3 | | pregnant women
under this Code shall receive information from | 4 | | the Department on the
availability of services under any
| 5 | | program providing case management services for addicted women,
| 6 | | including information on appropriate referrals for other | 7 | | social services
that may be needed by addicted women in | 8 | | addition to treatment for addiction.
| 9 | | The Illinois Department, in cooperation with the | 10 | | Departments of Human
Services (as successor to the Department | 11 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 12 | | public awareness campaign, may
provide information concerning | 13 | | treatment for alcoholism and drug abuse and
addiction, prenatal | 14 | | health care, and other pertinent programs directed at
reducing | 15 | | the number of drug-affected infants born to recipients of | 16 | | medical
assistance.
| 17 | | Neither the Department of Healthcare and Family Services | 18 | | nor the Department of Human
Services shall sanction the | 19 | | recipient solely on the basis of
her substance abuse.
| 20 | | The Illinois Department shall establish such regulations | 21 | | governing
the dispensing of health services under this Article | 22 | | as it shall deem
appropriate. The Department
should
seek the | 23 | | advice of formal professional advisory committees appointed by
| 24 | | the Director of the Illinois Department for the purpose of | 25 | | providing regular
advice on policy and administrative matters, | 26 | | information dissemination and
educational activities for |
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| 1 | | medical and health care providers, and
consistency in | 2 | | procedures to the Illinois Department.
| 3 | | The Illinois Department may develop and contract with | 4 | | Partnerships of
medical providers to arrange medical services | 5 | | for persons eligible under
Section 5-2 of this Code. | 6 | | Implementation of this Section may be by
demonstration projects | 7 | | in certain geographic areas. The Partnership shall
be | 8 | | represented by a sponsor organization. The Department, by rule, | 9 | | shall
develop qualifications for sponsors of Partnerships. | 10 | | Nothing in this
Section shall be construed to require that the | 11 | | sponsor organization be a
medical organization.
| 12 | | The sponsor must negotiate formal written contracts with | 13 | | medical
providers for physician services, inpatient and | 14 | | outpatient hospital care,
home health services, treatment for | 15 | | alcoholism and substance abuse, and
other services determined | 16 | | necessary by the Illinois Department by rule for
delivery by | 17 | | Partnerships. Physician services must include prenatal and
| 18 | | obstetrical care. The Illinois Department shall reimburse | 19 | | medical services
delivered by Partnership providers to clients | 20 | | in target areas according to
provisions of this Article and the | 21 | | Illinois Health Finance Reform Act,
except that:
| 22 | | (1) Physicians participating in a Partnership and | 23 | | providing certain
services, which shall be determined by | 24 | | the Illinois Department, to persons
in areas covered by the | 25 | | Partnership may receive an additional surcharge
for such | 26 | | services.
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| 1 | | (2) The Department may elect to consider and negotiate | 2 | | financial
incentives to encourage the development of | 3 | | Partnerships and the efficient
delivery of medical care.
| 4 | | (3) Persons receiving medical services through | 5 | | Partnerships may receive
medical and case management | 6 | | services above the level usually offered
through the | 7 | | medical assistance program.
| 8 | | Medical providers shall be required to meet certain | 9 | | qualifications to
participate in Partnerships to ensure the | 10 | | delivery of high quality medical
services. These | 11 | | qualifications shall be determined by rule of the Illinois
| 12 | | Department and may be higher than qualifications for | 13 | | participation in the
medical assistance program. Partnership | 14 | | sponsors may prescribe reasonable
additional qualifications | 15 | | for participation by medical providers, only with
the prior | 16 | | written approval of the Illinois Department.
| 17 | | Nothing in this Section shall limit the free choice of | 18 | | practitioners,
hospitals, and other providers of medical | 19 | | services by clients.
In order to ensure patient freedom of | 20 | | choice, the Illinois Department shall
immediately promulgate | 21 | | all rules and take all other necessary actions so that
provided | 22 | | services may be accessed from therapeutically certified | 23 | | optometrists
to the full extent of the Illinois Optometric | 24 | | Practice Act of 1987 without
discriminating between service | 25 | | providers.
| 26 | | The Department shall apply for a waiver from the United |
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| 1 | | States Health
Care Financing Administration to allow for the | 2 | | implementation of
Partnerships under this Section.
| 3 | | The Illinois Department shall require health care | 4 | | providers to maintain
records that document the medical care | 5 | | and services provided to recipients
of Medical Assistance under | 6 | | this Article. Such records must be retained for a period of not | 7 | | less than 6 years from the date of service or as provided by | 8 | | applicable State law, whichever period is longer, except that | 9 | | if an audit is initiated within the required retention period | 10 | | then the records must be retained until the audit is completed | 11 | | and every exception is resolved. The Illinois Department shall
| 12 | | require health care providers to make available, when | 13 | | authorized by the
patient, in writing, the medical records in a | 14 | | timely fashion to other
health care providers who are treating | 15 | | or serving persons eligible for
Medical Assistance under this | 16 | | Article. All dispensers of medical services
shall be required | 17 | | to maintain and retain business and professional records
| 18 | | sufficient to fully and accurately document the nature, scope, | 19 | | details and
receipt of the health care provided to persons | 20 | | eligible for medical
assistance under this Code, in accordance | 21 | | with regulations promulgated by
the Illinois Department. The | 22 | | rules and regulations shall require that proof
of the receipt | 23 | | of prescription drugs, dentures, prosthetic devices and
| 24 | | eyeglasses by eligible persons under this Section accompany | 25 | | each claim
for reimbursement submitted by the dispenser of such | 26 | | medical services.
No such claims for reimbursement shall be |
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| 1 | | approved for payment by the Illinois
Department without such | 2 | | proof of receipt, unless the Illinois Department
shall have put | 3 | | into effect and shall be operating a system of post-payment
| 4 | | audit and review which shall, on a sampling basis, be deemed | 5 | | adequate by
the Illinois Department to assure that such drugs, | 6 | | dentures, prosthetic
devices and eyeglasses for which payment | 7 | | is being made are actually being
received by eligible | 8 | | recipients. Within 90 days after September 16, 1984 (the | 9 | | effective date of Public Act 83-1439), the Illinois Department | 10 | | shall establish a
current list of acquisition costs for all | 11 | | prosthetic devices and any
other items recognized as medical | 12 | | equipment and supplies reimbursable under
this Article and | 13 | | shall update such list on a quarterly basis, except that
the | 14 | | acquisition costs of all prescription drugs shall be updated no
| 15 | | less frequently than every 30 days as required by Section | 16 | | 5-5.12.
| 17 | | Notwithstanding any other law to the contrary, the Illinois | 18 | | Department shall, within 365 days after July 22, 2013 (the | 19 | | effective date of Public Act 98-104), establish procedures to | 20 | | permit skilled care facilities licensed under the Nursing Home | 21 | | Care Act to submit monthly billing claims for reimbursement | 22 | | purposes. Following development of these procedures, the | 23 | | Department shall, by July 1, 2016, test the viability of the | 24 | | new system and implement any necessary operational or | 25 | | structural changes to its information technology platforms in | 26 | | order to allow for the direct acceptance and payment of nursing |
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| 1 | | home claims. | 2 | | Notwithstanding any other law to the contrary, the Illinois | 3 | | Department shall, within 365 days after August 15, 2014 (the | 4 | | effective date of Public Act 98-963), establish procedures to | 5 | | permit ID/DD facilities licensed under the ID/DD Community Care | 6 | | Act and MC/DD facilities licensed under the MC/DD Act to submit | 7 | | monthly billing claims for reimbursement purposes. Following | 8 | | development of these procedures, the Department shall have an | 9 | | additional 365 days to test the viability of the new system and | 10 | | to ensure that any necessary operational or structural changes | 11 | | to its information technology platforms are implemented. | 12 | | The Illinois Department shall require all dispensers of | 13 | | medical
services, other than an individual practitioner or | 14 | | group of practitioners,
desiring to participate in the Medical | 15 | | Assistance program
established under this Article to disclose | 16 | | all financial, beneficial,
ownership, equity, surety or other | 17 | | interests in any and all firms,
corporations, partnerships, | 18 | | associations, business enterprises, joint
ventures, agencies, | 19 | | institutions or other legal entities providing any
form of | 20 | | health care services in this State under this Article.
| 21 | | The Illinois Department may require that all dispensers of | 22 | | medical
services desiring to participate in the medical | 23 | | assistance program
established under this Article disclose, | 24 | | under such terms and conditions as
the Illinois Department may | 25 | | by rule establish, all inquiries from clients
and attorneys | 26 | | regarding medical bills paid by the Illinois Department, which
|
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| 1 | | inquiries could indicate potential existence of claims or liens | 2 | | for the
Illinois Department.
| 3 | | Enrollment of a vendor
shall be
subject to a provisional | 4 | | period and shall be conditional for one year. During the period | 5 | | of conditional enrollment, the Department may
terminate the | 6 | | vendor's eligibility to participate in, or may disenroll the | 7 | | vendor from, the medical assistance
program without cause. | 8 | | Unless otherwise specified, such termination of eligibility or | 9 | | disenrollment is not subject to the
Department's hearing | 10 | | process.
However, a disenrolled vendor may reapply without | 11 | | penalty.
| 12 | | The Department has the discretion to limit the conditional | 13 | | enrollment period for vendors based upon category of risk of | 14 | | the vendor. | 15 | | Prior to enrollment and during the conditional enrollment | 16 | | period in the medical assistance program, all vendors shall be | 17 | | subject to enhanced oversight, screening, and review based on | 18 | | the risk of fraud, waste, and abuse that is posed by the | 19 | | category of risk of the vendor. The Illinois Department shall | 20 | | establish the procedures for oversight, screening, and review, | 21 | | which may include, but need not be limited to: criminal and | 22 | | financial background checks; fingerprinting; license, | 23 | | certification, and authorization verifications; unscheduled or | 24 | | unannounced site visits; database checks; prepayment audit | 25 | | reviews; audits; payment caps; payment suspensions; and other | 26 | | screening as required by federal or State law. |
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| 1 | | The Department shall define or specify the following: (i) | 2 | | by provider notice, the "category of risk of the vendor" for | 3 | | each type of vendor, which shall take into account the level of | 4 | | screening applicable to a particular category of vendor under | 5 | | federal law and regulations; (ii) by rule or provider notice, | 6 | | the maximum length of the conditional enrollment period for | 7 | | each category of risk of the vendor; and (iii) by rule, the | 8 | | hearing rights, if any, afforded to a vendor in each category | 9 | | of risk of the vendor that is terminated or disenrolled during | 10 | | the conditional enrollment period. | 11 | | To be eligible for payment consideration, a vendor's | 12 | | payment claim or bill, either as an initial claim or as a | 13 | | resubmitted claim following prior rejection, must be received | 14 | | by the Illinois Department, or its fiscal intermediary, no | 15 | | later than 180 days after the latest date on the claim on which | 16 | | medical goods or services were provided, with the following | 17 | | exceptions: | 18 | | (1) In the case of a provider whose enrollment is in | 19 | | process by the Illinois Department, the 180-day period | 20 | | shall not begin until the date on the written notice from | 21 | | the Illinois Department that the provider enrollment is | 22 | | complete. | 23 | | (2) In the case of errors attributable to the Illinois | 24 | | Department or any of its claims processing intermediaries | 25 | | which result in an inability to receive, process, or | 26 | | adjudicate a claim, the 180-day period shall not begin |
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| 1 | | until the provider has been notified of the error. | 2 | | (3) In the case of a provider for whom the Illinois | 3 | | Department initiates the monthly billing process. | 4 | | (4) In the case of a provider operated by a unit of | 5 | | local government with a population exceeding 3,000,000 | 6 | | when local government funds finance federal participation | 7 | | for claims payments. | 8 | | For claims for services rendered during a period for which | 9 | | a recipient received retroactive eligibility, claims must be | 10 | | filed within 180 days after the Department determines the | 11 | | applicant is eligible. For claims for which the Illinois | 12 | | Department is not the primary payer, claims must be submitted | 13 | | to the Illinois Department within 180 days after the final | 14 | | adjudication by the primary payer. | 15 | | In the case of long term care facilities, within 45 | 16 | | calendar days of receipt by the facility of required | 17 | | prescreening information, new admissions with associated | 18 | | admission documents shall be submitted through the Medical | 19 | | Electronic Data Interchange (MEDI) or the Recipient | 20 | | Eligibility Verification (REV) System or shall be submitted | 21 | | directly to the Department of Human Services using required | 22 | | admission forms. Effective September
1, 2014, admission | 23 | | documents, including all prescreening
information, must be | 24 | | submitted through MEDI or REV. Confirmation numbers assigned to | 25 | | an accepted transaction shall be retained by a facility to | 26 | | verify timely submittal. Once an admission transaction has been |
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| 1 | | completed, all resubmitted claims following prior rejection | 2 | | are subject to receipt no later than 180 days after the | 3 | | admission transaction has been completed. | 4 | | Claims that are not submitted and received in compliance | 5 | | with the foregoing requirements shall not be eligible for | 6 | | payment under the medical assistance program, and the State | 7 | | shall have no liability for payment of those claims. | 8 | | To the extent consistent with applicable information and | 9 | | privacy, security, and disclosure laws, State and federal | 10 | | agencies and departments shall provide the Illinois Department | 11 | | access to confidential and other information and data necessary | 12 | | to perform eligibility and payment verifications and other | 13 | | Illinois Department functions. This includes, but is not | 14 | | limited to: information pertaining to licensure; | 15 | | certification; earnings; immigration status; citizenship; wage | 16 | | reporting; unearned and earned income; pension income; | 17 | | employment; supplemental security income; social security | 18 | | numbers; National Provider Identifier (NPI) numbers; the | 19 | | National Practitioner Data Bank (NPDB); program and agency | 20 | | exclusions; taxpayer identification numbers; tax delinquency; | 21 | | corporate information; and death records. | 22 | | The Illinois Department shall enter into agreements with | 23 | | State agencies and departments, and is authorized to enter into | 24 | | agreements with federal agencies and departments, under which | 25 | | such agencies and departments shall share data necessary for | 26 | | medical assistance program integrity functions and oversight. |
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| 1 | | The Illinois Department shall develop, in cooperation with | 2 | | other State departments and agencies, and in compliance with | 3 | | applicable federal laws and regulations, appropriate and | 4 | | effective methods to share such data. At a minimum, and to the | 5 | | extent necessary to provide data sharing, the Illinois | 6 | | Department shall enter into agreements with State agencies and | 7 | | departments, and is authorized to enter into agreements with | 8 | | federal agencies and departments, including but not limited to: | 9 | | the Secretary of State; the Department of Revenue; the | 10 | | Department of Public Health; the Department of Human Services; | 11 | | and the Department of Financial and Professional Regulation. | 12 | | Beginning in fiscal year 2013, the Illinois Department | 13 | | shall set forth a request for information to identify the | 14 | | benefits of a pre-payment, post-adjudication, and post-edit | 15 | | claims system with the goals of streamlining claims processing | 16 | | and provider reimbursement, reducing the number of pending or | 17 | | rejected claims, and helping to ensure a more transparent | 18 | | adjudication process through the utilization of: (i) provider | 19 | | data verification and provider screening technology; and (ii) | 20 | | clinical code editing; and (iii) pre-pay, pre- or | 21 | | post-adjudicated predictive modeling with an integrated case | 22 | | management system with link analysis. Such a request for | 23 | | information shall not be considered as a request for proposal | 24 | | or as an obligation on the part of the Illinois Department to | 25 | | take any action or acquire any products or services. | 26 | | The Illinois Department shall establish policies, |
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| 1 | | procedures,
standards and criteria by rule for the acquisition, | 2 | | repair and replacement
of orthotic and prosthetic devices and | 3 | | durable medical equipment. Such
rules shall provide, but not be | 4 | | limited to, the following services: (1)
immediate repair or | 5 | | replacement of such devices by recipients; and (2) rental, | 6 | | lease, purchase or lease-purchase of
durable medical equipment | 7 | | in a cost-effective manner, taking into
consideration the | 8 | | recipient's medical prognosis, the extent of the
recipient's | 9 | | needs, and the requirements and costs for maintaining such
| 10 | | equipment. Subject to prior approval, such rules shall enable a | 11 | | recipient to temporarily acquire and
use alternative or | 12 | | substitute devices or equipment pending repairs or
| 13 | | replacements of any device or equipment previously authorized | 14 | | for such
recipient by the Department. Notwithstanding any | 15 | | provision of Section 5-5f to the contrary, the Department may, | 16 | | by rule, exempt certain replacement wheelchair parts from prior | 17 | | approval and, for wheelchairs, wheelchair parts, wheelchair | 18 | | accessories, and related seating and positioning items, | 19 | | determine the wholesale price by methods other than actual | 20 | | acquisition costs. | 21 | | The Department shall require, by rule, all providers of | 22 | | durable medical equipment to be accredited by an accreditation | 23 | | organization approved by the federal Centers for Medicare and | 24 | | Medicaid Services and recognized by the Department in order to | 25 | | bill the Department for providing durable medical equipment to | 26 | | recipients. No later than 15 months after the effective date of |
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| 1 | | the rule adopted pursuant to this paragraph, all providers must | 2 | | meet the accreditation requirement.
| 3 | | In order to promote environmental responsibility, meet the | 4 | | needs of recipients and enrollees, and achieve significant cost | 5 | | savings, the Department, or a managed care organization under | 6 | | contract with the Department, may provide recipients or managed | 7 | | care enrollees who have a prescription or Certificate of | 8 | | Medical Necessity access to refurbished durable medical | 9 | | equipment under this Section (excluding prosthetic and | 10 | | orthotic devices as defined in the Orthotics, Prosthetics, and | 11 | | Pedorthics Practice Act and complex rehabilitation technology | 12 | | products and associated services) through the State's | 13 | | assistive technology program's reutilization program, using | 14 | | staff with the Assistive Technology Professional (ATP) | 15 | | Certification if the refurbished durable medical equipment: | 16 | | (i) is available; (ii) is less expensive, including shipping | 17 | | costs, than new durable medical equipment of the same type; | 18 | | (iii) is able to withstand at least 3 years of use; (iv) is | 19 | | cleaned, disinfected, sterilized, and safe in accordance with | 20 | | federal Food and Drug Administration regulations and guidance | 21 | | governing the reprocessing of medical devices in health care | 22 | | settings; and (v) equally meets the needs of the recipient or | 23 | | enrollee. The reutilization program shall confirm that the | 24 | | recipient or enrollee is not already in receipt of same or | 25 | | similar equipment from another service provider, and that the | 26 | | refurbished durable medical equipment equally meets the needs |
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| 1 | | of the recipient or enrollee. Nothing in this paragraph shall | 2 | | be construed to limit recipient or enrollee choice to obtain | 3 | | new durable medical equipment or place any additional prior | 4 | | authorization conditions on enrollees of managed care | 5 | | organizations. | 6 | | The Department shall execute, relative to the nursing home | 7 | | prescreening
project, written inter-agency agreements with the | 8 | | Department of Human
Services and the Department on Aging, to | 9 | | effect the following: (i) intake
procedures and common | 10 | | eligibility criteria for those persons who are receiving
| 11 | | non-institutional services; and (ii) the establishment and | 12 | | development of
non-institutional services in areas of the State | 13 | | where they are not currently
available or are undeveloped; and | 14 | | (iii) notwithstanding any other provision of law, subject to | 15 | | federal approval, on and after July 1, 2012, an increase in the | 16 | | determination of need (DON) scores from 29 to 37 for applicants | 17 | | for institutional and home and community-based long term care; | 18 | | if and only if federal approval is not granted, the Department | 19 | | may, in conjunction with other affected agencies, implement | 20 | | utilization controls or changes in benefit packages to | 21 | | effectuate a similar savings amount for this population; and | 22 | | (iv) no later than July 1, 2013, minimum level of care | 23 | | eligibility criteria for institutional and home and | 24 | | community-based long term care; and (v) no later than October | 25 | | 1, 2013, establish procedures to permit long term care | 26 | | providers access to eligibility scores for individuals with an |
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| 1 | | admission date who are seeking or receiving services from the | 2 | | long term care provider. In order to select the minimum level | 3 | | of care eligibility criteria, the Governor shall establish a | 4 | | workgroup that includes affected agency representatives and | 5 | | stakeholders representing the institutional and home and | 6 | | community-based long term care interests. This Section shall | 7 | | not restrict the Department from implementing lower level of | 8 | | care eligibility criteria for community-based services in | 9 | | circumstances where federal approval has been granted.
| 10 | | The Illinois Department shall develop and operate, in | 11 | | cooperation
with other State Departments and agencies and in | 12 | | compliance with
applicable federal laws and regulations, | 13 | | appropriate and effective
systems of health care evaluation and | 14 | | programs for monitoring of
utilization of health care services | 15 | | and facilities, as it affects
persons eligible for medical | 16 | | assistance under this Code.
| 17 | | The Illinois Department shall report annually to the | 18 | | General Assembly,
no later than the second Friday in April of | 19 | | 1979 and each year
thereafter, in regard to:
| 20 | | (a) actual statistics and trends in utilization of | 21 | | medical services by
public aid recipients;
| 22 | | (b) actual statistics and trends in the provision of | 23 | | the various medical
services by medical vendors;
| 24 | | (c) current rate structures and proposed changes in | 25 | | those rate structures
for the various medical vendors; and
| 26 | | (d) efforts at utilization review and control by the |
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| 1 | | Illinois Department.
| 2 | | The period covered by each report shall be the 3 years | 3 | | ending on the June
30 prior to the report. The report shall | 4 | | include suggested legislation
for consideration by the General | 5 | | Assembly. The requirement for reporting to the General Assembly | 6 | | shall be satisfied
by filing copies of the report as required | 7 | | by Section 3.1 of the General Assembly Organization Act, and | 8 | | filing such additional
copies
with the State Government Report | 9 | | Distribution Center for the General
Assembly as is required | 10 | | under paragraph (t) of Section 7 of the State
Library Act.
| 11 | | Rulemaking authority to implement Public Act 95-1045, if | 12 | | any, is conditioned on the rules being adopted in accordance | 13 | | with all provisions of the Illinois Administrative Procedure | 14 | | Act and all rules and procedures of the Joint Committee on | 15 | | Administrative Rules; any purported rule not so adopted, for | 16 | | whatever reason, is unauthorized. | 17 | | On and after July 1, 2012, the Department shall reduce any | 18 | | rate of reimbursement for services or other payments or alter | 19 | | any methodologies authorized by this Code to reduce any rate of | 20 | | reimbursement for services or other payments in accordance with | 21 | | Section 5-5e. | 22 | | Because kidney transplantation can be an appropriate, | 23 | | cost-effective
alternative to renal dialysis when medically | 24 | | necessary and notwithstanding the provisions of Section 1-11 of | 25 | | this Code, beginning October 1, 2014, the Department shall | 26 | | cover kidney transplantation for noncitizens with end-stage |
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| 1 | | renal disease who are not eligible for comprehensive medical | 2 | | benefits, who meet the residency requirements of Section 5-3 of | 3 | | this Code, and who would otherwise meet the financial | 4 | | requirements of the appropriate class of eligible persons under | 5 | | Section 5-2 of this Code. To qualify for coverage of kidney | 6 | | transplantation, such person must be receiving emergency renal | 7 | | dialysis services covered by the Department. Providers under | 8 | | this Section shall be prior approved and certified by the | 9 | | Department to perform kidney transplantation and the services | 10 | | under this Section shall be limited to services associated with | 11 | | kidney transplantation. | 12 | | Notwithstanding any other provision of this Code to the | 13 | | contrary, on or after July 1, 2015, all FDA approved forms of | 14 | | medication assisted treatment prescribed for the treatment of | 15 | | alcohol dependence or treatment of opioid dependence shall be | 16 | | covered under both fee for service and managed care medical | 17 | | assistance programs for persons who are otherwise eligible for | 18 | | medical assistance under this Article and shall not be subject | 19 | | to any (1) utilization control, other than those established | 20 | | under the American Society of Addiction Medicine patient | 21 | | placement criteria,
(2) prior authorization mandate, or (3) | 22 | | lifetime restriction limit
mandate. | 23 | | On or after July 1, 2015, opioid antagonists prescribed for | 24 | | the treatment of an opioid overdose, including the medication | 25 | | product, administration devices, and any pharmacy fees related | 26 | | to the dispensing and administration of the opioid antagonist, |
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| 1 | | shall be covered under the medical assistance program for | 2 | | persons who are otherwise eligible for medical assistance under | 3 | | this Article. As used in this Section, "opioid antagonist" | 4 | | means a drug that binds to opioid receptors and blocks or | 5 | | inhibits the effect of opioids acting on those receptors, | 6 | | including, but not limited to, naloxone hydrochloride or any | 7 | | other similarly acting drug approved by the U.S. Food and Drug | 8 | | Administration. | 9 | | Upon federal approval, the Department shall provide | 10 | | coverage and reimbursement for all drugs that are approved for | 11 | | marketing by the federal Food and Drug Administration and that | 12 | | are recommended by the federal Public Health Service or the | 13 | | United States Centers for Disease Control and Prevention for | 14 | | pre-exposure prophylaxis and related pre-exposure prophylaxis | 15 | | services, including, but not limited to, HIV and sexually | 16 | | transmitted infection screening, treatment for sexually | 17 | | transmitted infections, medical monitoring, assorted labs, and | 18 | | counseling to reduce the likelihood of HIV infection among | 19 | | individuals who are not infected with HIV but who are at high | 20 | | risk of HIV infection. | 21 | | A federally qualified health center, as defined in Section | 22 | | 1905(l)(2)(B) of the federal
Social Security Act, shall be | 23 | | reimbursed by the Department in accordance with the federally | 24 | | qualified health center's encounter rate for services provided | 25 | | to medical assistance recipients that are performed by a dental | 26 | | hygienist, as defined under the Illinois Dental Practice Act, |
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| 1 | | working under the general supervision of a dentist and employed | 2 | | by a federally qualified health center. | 3 | | Notwithstanding any other provision of this Code, the | 4 | | Illinois Department shall authorize licensed dietitian | 5 | | nutritionists and certified diabetes educators to counsel | 6 | | senior diabetes patients in the senior diabetes patients' homes | 7 | | to remove the hurdle of transportation for senior diabetes | 8 | | patients to receive treatment. | 9 | | The Department shall seek approval of a State Plan | 10 | | amendment to expand coverage for family planning services to | 11 | | women whose income is at or below 200% of the federal poverty | 12 | | level. | 13 | | (Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15; | 14 | | 99-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for | 15 | | the effective date of P.A. 99-407); 99-433, eff. 8-21-15; | 16 | | 99-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff. | 17 | | 7-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201, | 18 | | eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18; | 19 | | 100-538, eff. 1-1-18; 100-587, eff. 6-4-18; 100-759, eff. | 20 | | 1-1-19; 100-863, eff. 8-14-18; 100-974, eff. 8-19-18; | 21 | | 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; 100-1148, eff. | 22 | | 12-10-18.)
| 23 | | (305 ILCS 5/5-5.24)
| 24 | | Sec. 5-5.24. Prenatal and perinatal care. The Department of
| 25 | | Healthcare and Family Services may provide reimbursement under |
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| 1 | | this Article for all prenatal and
perinatal health care | 2 | | services that are provided for the purpose of preventing
| 3 | | low-birthweight infants, reducing the need for neonatal | 4 | | intensive care hospital
services, and promoting perinatal and | 5 | | maternal health. These services may include
comprehensive risk | 6 | | assessments for pregnant women, women with infants, and
| 7 | | infants, lactation counseling, nutrition counseling, | 8 | | childbirth support,
psychosocial counseling, treatment and | 9 | | prevention of periodontal disease, language translation, nurse | 10 | | home visitation, and
other support
services
that have been | 11 | | proven to improve birth and maternal health outcomes.
The | 12 | | Department
shall
maximize the use of preventive prenatal and | 13 | | perinatal health care services
consistent with
federal | 14 | | statutes, rules, and regulations.
The Department of Public Aid | 15 | | (now Department of Healthcare and Family Services)
shall | 16 | | develop a plan for prenatal and perinatal preventive
health | 17 | | care and
shall present the plan to the General Assembly by | 18 | | January 1, 2004.
On or before January 1, 2006 and
every 2 years
| 19 | | thereafter, the Department shall report to the General Assembly | 20 | | concerning the
effectiveness of prenatal and perinatal health | 21 | | care services reimbursed under
this Section
in preventing | 22 | | low-birthweight infants and reducing the need for neonatal
| 23 | | intensive care
hospital services. Each such report shall | 24 | | include an evaluation of how the
ratio of
expenditures for | 25 | | treating
low-birthweight infants compared with the investment | 26 | | in promoting healthy
births and
infants in local community |
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| 1 | | areas throughout Illinois relates to healthy infant
| 2 | | development
in those areas.
| 3 | | On and after July 1, 2012, the Department shall reduce any | 4 | | rate of reimbursement for services or other payments or alter | 5 | | any methodologies authorized by this Code to reduce any rate of | 6 | | reimbursement for services or other payments in accordance with | 7 | | Section 5-5e. | 8 | | (Source: P.A. 97-689, eff. 6-14-12.)
| 9 | | Section 55. The Developmental Disability Prevention Act is | 10 | | amended by adding Section 11.2 as follows: | 11 | | (410 ILCS 250/11.2 new) | 12 | | Sec. 11.2. Birthing facilities; maternal care | 13 | | designations. | 14 | | (a) In this Section, "birthing facility" means: (1) a | 15 | | hospital, as defined in the Hospital Licensing Act, with more | 16 | | than one licensed obstetric bed or a neonatal intensive care | 17 | | unit; (2) a hospital operated by a State university; or (3) a | 18 | | birth center, as defined in the Alternative Health Care | 19 | | Delivery Act. | 20 | | (b) Every birthing facility shall, at a minimum, have an | 21 | | obstetric hemorrhage protocol and conduct a drill or simulation | 22 | | of the protocol. Every contracted provider who may encounter a | 23 | | pregnant woman shall participate in the drill or simulation on | 24 | | a regular basis. The Department shall adopt rules to implement |
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| 1 | | this subsection. | 2 | | (c) After holding multiple public hearings with | 3 | | representatives from diverse geographical regions and | 4 | | professional backgrounds and seeking broad public and | 5 | | stakeholder input, the Department shall establish criteria for | 6 | | levels of maternal care designations for birthing facilities. | 7 | | All hearings shall be open to the public and held at specific | 8 | | times and places that are convenient and available to the | 9 | | public. No hearing shall be held on a legal holiday. Public | 10 | | notice of hearings shall state the dates, times, and places of | 11 | | the hearings. Notice of hearings shall be posted on the | 12 | | Department's website and in the Department's main office, and | 13 | | minutes from the hearings shall be recorded. The levels of | 14 | | maternal care designations developed under this Section shall | 15 | | be based upon: | 16 | | (1) the most current published version of the "Levels | 17 | | of Maternal Care" developed by the American Congress of | 18 | | Obstetricians and Gynecologists and the Society for | 19 | | Maternal-Fetal Medicine; and | 20 | | (2) necessary variance when considering the geographic | 21 | | and varied needs of citizens of this State. | 22 | | (d) Nothing in this Section shall be construed in any way | 23 | | to modify or expand the licensure of any health care | 24 | | professional. | 25 | | (e) Nothing in this Section shall be construed in any way | 26 | | to require a patient to be transferred to a different facility. |
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| 1 | | (f) The Department shall adopt rules to implement the | 2 | | provisions of this Section no later than June 1, 2021. These | 3 | | rules shall be limited to those necessary for the establishment | 4 | | of levels of maternal care designations for birthing facilities | 5 | | under subsection (c) of this Section. | 6 | | Section 95. No acceleration or delay. Where this Act makes | 7 | | changes in a statute that is represented in this Act by text | 8 | | that is not yet or no longer in effect (for example, a Section | 9 | | represented by multiple versions), the use of that text does | 10 | | not accelerate or delay the taking effect of (i) the changes | 11 | | made by this Act or (ii) provisions derived from any other | 12 | | Public Act. | 13 | | Section 99. Effective date. This Act takes effect upon | 14 | | becoming law.".
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