Full Text of SB0162 101st General Assembly
SB0162enr 101ST GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Counties Code is amended by changing Section | 5 | | 5-1069 as follows:
| 6 | | (55 ILCS 5/5-1069) (from Ch. 34, par. 5-1069)
| 7 | | Sec. 5-1069. Group life, health, accident, hospital, and | 8 | | medical
insurance. | 9 | | (a) The county board of any county may arrange to provide, | 10 | | for
the benefit of employees of the county, group life, health, | 11 | | accident, hospital,
and medical insurance, or any one or any | 12 | | combination of those types of
insurance, or the county board | 13 | | may self-insure, for the benefit of its
employees, all or a | 14 | | portion of the employees' group life, health, accident,
| 15 | | hospital, and medical insurance, or any one or any combination | 16 | | of those
types of insurance, including a combination of | 17 | | self-insurance and other
types of insurance authorized by this | 18 | | Section, provided that the county
board complies with all other | 19 | | requirements of this Section. The insurance
may include | 20 | | provision for employees who rely on treatment by prayer or
| 21 | | spiritual means alone for healing in accordance with the tenets | 22 | | and
practice of a well recognized religious denomination. The | 23 | | county board may
provide for payment by the county of a portion |
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| 1 | | or all of the premium or
charge for the insurance with the | 2 | | employee paying the balance of the
premium or charge, if any. | 3 | | If the county board undertakes a plan under
which the county | 4 | | pays only a portion of the premium or charge, the county
board | 5 | | shall provide for withholding and deducting from the | 6 | | compensation of
those employees who consent to join the plan | 7 | | the balance of the premium or
charge for the insurance.
| 8 | | (b) If the county board does not provide for self-insurance | 9 | | or for a plan
under which the county pays a portion or all of | 10 | | the premium or charge for a
group insurance plan, the county | 11 | | board may provide for withholding and
deducting from the | 12 | | compensation of those employees who consent thereto the
total | 13 | | premium or charge for any group life, health, accident, | 14 | | hospital, and
medical insurance.
| 15 | | (c) The county board may exercise the powers granted in | 16 | | this Section only if
it provides for self-insurance or, where | 17 | | it makes arrangements to provide
group insurance through an | 18 | | insurance carrier, if the kinds of group
insurance are obtained | 19 | | from an insurance company authorized to do business
in the | 20 | | State of Illinois. The county board may enact an ordinance
| 21 | | prescribing the method of operation of the insurance program.
| 22 | | (d) If a county, including a home rule county, is a | 23 | | self-insurer for
purposes of providing health insurance | 24 | | coverage for its employees, the
insurance coverage shall | 25 | | include screening by low-dose mammography for all
women 35 | 26 | | years of age or older for the presence of occult breast cancer
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| 1 | | unless the county elects to provide mammograms itself under | 2 | | Section
5-1069.1. The coverage shall be as follows:
| 3 | | (1) A baseline mammogram for women 35 to 39 years of | 4 | | age.
| 5 | | (2) An annual mammogram for women 40 years of age or | 6 | | older.
| 7 | | (3) A mammogram at the age and intervals considered | 8 | | medically necessary by the woman's health care provider for | 9 | | women under 40 years of age and having a family history of | 10 | | breast cancer, prior personal history of breast cancer, | 11 | | positive genetic testing, or other risk factors. | 12 | | (4) For a group policy of accident and health insurance | 13 | | that is amended, delivered, issued, or renewed on or after | 14 | | the effective date of this amendatory Act of the 101st | 15 | | General Assembly, a A comprehensive ultrasound screening | 16 | | of an entire breast or breasts if a mammogram demonstrates | 17 | | heterogeneous or dense breast tissue or , when medically | 18 | | necessary as determined by a physician licensed to practice | 19 | | medicine in all of its branches, advanced practice | 20 | | registered nurse, or physician assistant. | 21 | | (5) For a group policy of accident and health insurance | 22 | | that is amended, delivered, issued, or renewed on or after | 23 | | the effective date of this amendatory Act of the 101st | 24 | | General Assembly, a diagnostic mammogram when medically | 25 | | necessary, as determined by a physician licensed to | 26 | | practice medicine in all its branches, advanced practice |
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| 1 | | registered nurse, or physician assistant. | 2 | | A policy subject to this subsection shall not impose a | 3 | | deductible, coinsurance, copayment, or any other cost-sharing | 4 | | requirement on the coverage provided; except that this sentence | 5 | | does not apply to coverage of diagnostic mammograms to the | 6 | | extent such coverage would disqualify a high-deductible health | 7 | | plan from eligibility for a health savings account pursuant to | 8 | | Section 223 of the Internal Revenue Code (26 U.S.C. 223). | 9 | | For purposes of this subsection : , | 10 | | "Diagnostic
mammogram" means a mammogram obtained using | 11 | | diagnostic mammography. | 12 | | "Diagnostic
mammography" means a method of screening that | 13 | | is designed to
evaluate an abnormality in a breast, including | 14 | | an abnormality seen
or suspected on a screening mammogram or a | 15 | | subjective or objective
abnormality otherwise detected in the | 16 | | breast. | 17 | | " Low-dose low-dose mammography"
means the x-ray | 18 | | examination of the breast using equipment dedicated
| 19 | | specifically for mammography, including the x-ray tube, | 20 | | filter, compression
device, and image receptor, with an average | 21 | | radiation exposure
delivery of less than one rad per breast for | 22 | | 2 views of an average size breast. The term also includes | 23 | | digital mammography. | 24 | | (d-5) Coverage as described by subsection (d) shall be | 25 | | provided at no cost to the insured and shall not be applied to | 26 | | an annual or lifetime maximum benefit. |
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| 1 | | (d-10) When health care services are available through | 2 | | contracted providers and a person does not comply with plan | 3 | | provisions specific to the use of contracted providers, the | 4 | | requirements of subsection (d-5) are not applicable. When a | 5 | | person does not comply with plan provisions specific to the use | 6 | | of contracted providers, plan provisions specific to the use of | 7 | | non-contracted providers must be applied without distinction | 8 | | for coverage required by this Section and shall be at least as | 9 | | favorable as for other radiological examinations covered by the | 10 | | policy or contract. | 11 | | (d-15) If a county, including a home rule county, is a | 12 | | self-insurer for purposes of providing health insurance | 13 | | coverage for its employees, the insurance coverage shall | 14 | | include mastectomy coverage, which includes coverage for | 15 | | prosthetic devices or reconstructive surgery incident to the | 16 | | mastectomy. Coverage for breast reconstruction in connection | 17 | | with a mastectomy shall include: | 18 | | (1) reconstruction of the breast upon which the | 19 | | mastectomy has been performed; | 20 | | (2) surgery and reconstruction of the other breast to | 21 | | produce a symmetrical appearance; and | 22 | | (3) prostheses and treatment for physical | 23 | | complications at all stages of mastectomy, including | 24 | | lymphedemas. | 25 | | Care shall be determined in consultation with the attending | 26 | | physician and the patient. The offered coverage for prosthetic |
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| 1 | | devices and reconstructive surgery shall be subject to the | 2 | | deductible and coinsurance conditions applied to the | 3 | | mastectomy, and all other terms and conditions applicable to | 4 | | other benefits. When a mastectomy is performed and there is no | 5 | | evidence of malignancy then the offered coverage may be limited | 6 | | to the provision of prosthetic devices and reconstructive | 7 | | surgery to within 2 years after the date of the mastectomy. As | 8 | | used in this Section, "mastectomy" means the removal of all or | 9 | | part of the breast for medically necessary reasons, as | 10 | | determined by a licensed physician. | 11 | | A county, including a home rule county, that is a | 12 | | self-insurer for purposes of providing health insurance | 13 | | coverage for its employees, may not penalize or reduce or limit | 14 | | the reimbursement of an attending provider or provide | 15 | | incentives (monetary or otherwise) to an attending provider to | 16 | | induce the provider to provide care to an insured in a manner | 17 | | inconsistent with this Section. | 18 | | (d-20) The
requirement that mammograms be included in | 19 | | health insurance coverage as
provided in subsections (d) | 20 | | through (d-15) is an exclusive power and function of the
State | 21 | | and is a denial and limitation under Article VII, Section 6,
| 22 | | subsection (h) of the Illinois Constitution of home rule county | 23 | | powers. A
home rule county to which subsections (d) through | 24 | | (d-15) apply must comply with every
provision of those | 25 | | subsections.
| 26 | | (e) The term "employees" as used in this Section includes |
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| 1 | | elected or
appointed officials but does not include temporary | 2 | | employees.
| 3 | | (f) The county board may, by ordinance, arrange to provide | 4 | | group life,
health, accident, hospital, and medical insurance, | 5 | | or any one or a combination
of those types of insurance, under | 6 | | this Section to retired former employees and
retired former | 7 | | elected or appointed officials of the county.
| 8 | | (g) Rulemaking authority to implement this amendatory Act | 9 | | of the 95th General Assembly, if any, is conditioned on the | 10 | | rules being adopted in accordance with all provisions of the | 11 | | Illinois Administrative Procedure Act and all rules and | 12 | | procedures of the Joint Committee on Administrative Rules; any | 13 | | purported rule not so adopted, for whatever reason, is | 14 | | unauthorized. | 15 | | (Source: P.A. 99-581, eff. 1-1-17; 100-513, eff. 1-1-18 .)
| 16 | | Section 10. The Illinois Municipal Code is amended by | 17 | | changing Section 10-4-2 as follows:
| 18 | | (65 ILCS 5/10-4-2) (from Ch. 24, par. 10-4-2)
| 19 | | Sec. 10-4-2. Group insurance.
| 20 | | (a) The corporate authorities of any municipality may | 21 | | arrange
to provide, for the benefit of employees of the | 22 | | municipality, group life,
health, accident, hospital, and | 23 | | medical insurance, or any one or any
combination of those types | 24 | | of insurance, and may arrange to provide that
insurance for the |
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| 1 | | benefit of the spouses or dependents of those employees.
The | 2 | | insurance may include provision for employees or other insured | 3 | | persons
who rely on treatment by prayer or spiritual means | 4 | | alone for healing in
accordance with the tenets and practice of | 5 | | a well recognized religious
denomination. The corporate | 6 | | authorities may provide for payment by the
municipality of a | 7 | | portion of the premium or charge for the insurance with
the | 8 | | employee paying the balance of the premium or charge. If the | 9 | | corporate
authorities undertake a plan under which the | 10 | | municipality pays a portion of
the premium or charge, the | 11 | | corporate authorities shall provide for
withholding and | 12 | | deducting from the compensation of those municipal
employees | 13 | | who consent to join the plan the balance of the premium or | 14 | | charge
for the insurance.
| 15 | | (b) If the corporate authorities do not provide for a plan | 16 | | under which
the municipality pays a portion of the premium or | 17 | | charge for a group
insurance plan, the corporate authorities | 18 | | may provide for withholding
and deducting from the compensation | 19 | | of those employees who consent thereto
the premium or charge | 20 | | for any group life, health, accident, hospital, and
medical | 21 | | insurance.
| 22 | | (c) The corporate authorities may exercise the powers | 23 | | granted in this
Section only if the kinds of group insurance | 24 | | are obtained from an
insurance company authorized to do | 25 | | business
in the State of Illinois,
or are obtained through an
| 26 | | intergovernmental joint self-insurance pool as authorized |
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| 1 | | under the
Intergovernmental Cooperation Act.
The
corporate | 2 | | authorities may enact an ordinance prescribing the method of
| 3 | | operation of the insurance program.
| 4 | | (d) If a municipality, including a home rule municipality, | 5 | | is a
self-insurer for purposes of providing health insurance | 6 | | coverage for its
employees, the insurance coverage shall | 7 | | include screening by low-dose
mammography for all women 35 | 8 | | years of age or older for the presence of
occult breast cancer | 9 | | unless the municipality elects to provide mammograms
itself | 10 | | under Section 10-4-2.1. The coverage shall be as follows:
| 11 | | (1) A baseline mammogram for women 35 to 39 years of | 12 | | age.
| 13 | | (2) An annual mammogram for women 40 years of age or | 14 | | older.
| 15 | | (3) A mammogram at the age and intervals considered | 16 | | medically necessary by the woman's health care provider for | 17 | | women under 40 years of age and having a family history of | 18 | | breast cancer, prior personal history of breast cancer, | 19 | | positive genetic testing, or other risk factors. | 20 | | (4) For a group policy of accident and health insurance | 21 | | that is amended, delivered, issued, or renewed on or after | 22 | | the effective date of this amendatory Act of the 101st | 23 | | General Assembly, a A comprehensive ultrasound screening | 24 | | of an entire breast or breasts if a mammogram demonstrates | 25 | | heterogeneous or dense breast tissue or , when medically | 26 | | necessary as determined by a physician licensed to practice |
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| 1 | | medicine in all of its branches. | 2 | | (5) For a group policy of accident and health insurance | 3 | | that is amended, delivered, issued, or renewed on or after | 4 | | the effective date of this amendatory Act of the 101st | 5 | | General Assembly, a diagnostic mammogram when medically | 6 | | necessary, as determined by a physician licensed to | 7 | | practice medicine in all its branches, advanced practice | 8 | | registered nurse, or physician assistant. | 9 | | A policy subject to this subsection shall not impose a | 10 | | deductible, coinsurance, copayment, or any other cost-sharing | 11 | | requirement on the coverage provided; except that this sentence | 12 | | does not apply to coverage of diagnostic mammograms to the | 13 | | extent such coverage would disqualify a high-deductible health | 14 | | plan from eligibility for a health savings account pursuant to | 15 | | Section 223 of the Internal Revenue Code (26 U.S.C. 223). | 16 | | For purposes of this subsection : , | 17 | | "Diagnostic
mammogram" means a mammogram obtained using | 18 | | diagnostic mammography. | 19 | | "Diagnostic
mammography" means a method of screening that | 20 | | is designed to
evaluate an abnormality in a breast, including | 21 | | an abnormality seen
or suspected on a screening mammogram or a | 22 | | subjective or objective
abnormality otherwise detected in the | 23 | | breast. | 24 | | " Low-dose low-dose mammography"
means the x-ray | 25 | | examination of the breast using equipment dedicated
| 26 | | specifically for mammography, including the x-ray tube, |
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| 1 | | filter, compression
device, and image receptor, with an average | 2 | | radiation exposure
delivery of less than one rad per breast for | 3 | | 2 views of an average size breast. The term also includes | 4 | | digital mammography. | 5 | | (d-5) Coverage as described by subsection (d) shall be | 6 | | provided at no cost to the insured and shall not be applied to | 7 | | an annual or lifetime maximum benefit. | 8 | | (d-10) When health care services are available through | 9 | | contracted providers and a person does not comply with plan | 10 | | provisions specific to the use of contracted providers, the | 11 | | requirements of subsection (d-5) are not applicable. When a | 12 | | person does not comply with plan provisions specific to the use | 13 | | of contracted providers, plan provisions specific to the use of | 14 | | non-contracted providers must be applied without distinction | 15 | | for coverage required by this Section and shall be at least as | 16 | | favorable as for other radiological examinations covered by the | 17 | | policy or contract. | 18 | | (d-15) If a municipality, including a home rule | 19 | | municipality, is a self-insurer for purposes of providing | 20 | | health insurance coverage for its employees, the insurance | 21 | | coverage shall include mastectomy coverage, which includes | 22 | | coverage for prosthetic devices or reconstructive surgery | 23 | | incident to the mastectomy. Coverage for breast reconstruction | 24 | | in connection with a mastectomy shall include: | 25 | | (1) reconstruction of the breast upon which the | 26 | | mastectomy has been performed; |
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| 1 | | (2) surgery and reconstruction of the other breast to | 2 | | produce a symmetrical appearance; and | 3 | | (3) prostheses and treatment for physical | 4 | | complications at all stages of mastectomy, including | 5 | | lymphedemas. | 6 | | Care shall be determined in consultation with the attending | 7 | | physician and the patient. The offered coverage for prosthetic | 8 | | devices and reconstructive surgery shall be subject to the | 9 | | deductible and coinsurance conditions applied to the | 10 | | mastectomy, and all other terms and conditions applicable to | 11 | | other benefits. When a mastectomy is performed and there is no | 12 | | evidence of malignancy then the offered coverage may be limited | 13 | | to the provision of prosthetic devices and reconstructive | 14 | | surgery to within 2 years after the date of the mastectomy. As | 15 | | used in this Section, "mastectomy" means the removal of all or | 16 | | part of the breast for medically necessary reasons, as | 17 | | determined by a licensed physician. | 18 | | A municipality, including a home rule municipality, that is | 19 | | a self-insurer for purposes of providing health insurance | 20 | | coverage for its employees, may not penalize or reduce or limit | 21 | | the reimbursement of an attending provider or provide | 22 | | incentives (monetary or otherwise) to an attending provider to | 23 | | induce the provider to provide care to an insured in a manner | 24 | | inconsistent with this Section. | 25 | | (d-20) The
requirement that mammograms be included in | 26 | | health insurance coverage as
provided in subsections (d) |
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| 1 | | through (d-15) is an exclusive power and function of the
State | 2 | | and is a denial and limitation under Article VII, Section 6,
| 3 | | subsection (h) of the Illinois Constitution of home rule | 4 | | municipality
powers. A home rule municipality to which | 5 | | subsections (d) through (d-15) apply must
comply with every | 6 | | provision of those subsections.
| 7 | | (e) Rulemaking authority to implement Public Act 95-1045, | 8 | | if any, is conditioned on the rules being adopted in accordance | 9 | | with all provisions of the Illinois Administrative Procedure | 10 | | Act and all rules and procedures of the Joint Committee on | 11 | | Administrative Rules; any purported rule not so adopted, for | 12 | | whatever reason, is unauthorized. | 13 | | (Source: P.A. 100-863, eff. 8-14-18.)
| 14 | | Section 15. The Illinois Insurance Code is amended by | 15 | | changing Section 356g as follows:
| 16 | | (215 ILCS 5/356g) (from Ch. 73, par. 968g)
| 17 | | Sec. 356g. Mammograms; mastectomies.
| 18 | | (a) Every insurer shall provide in each group or individual
| 19 | | policy, contract, or certificate of insurance issued or renewed | 20 | | for persons
who are residents of this State, coverage for | 21 | | screening by low-dose
mammography for all women 35 years of age | 22 | | or older for the presence of
occult breast cancer within the | 23 | | provisions of the policy, contract, or
certificate. The | 24 | | coverage shall be as follows:
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| 1 | |
(1) A baseline mammogram for women 35 to 39 years of | 2 | | age.
| 3 | |
(2) An annual mammogram for women 40 years of age or | 4 | | older.
| 5 | | (3) A mammogram at the age and intervals considered | 6 | | medically necessary by the woman's health care provider for | 7 | | women under 40 years of age and having a family history of | 8 | | breast cancer, prior personal history of breast cancer, | 9 | | positive genetic testing, or other risk factors. | 10 | | (4) For an individual or group policy of accident and | 11 | | health insurance or a managed care plan that is amended, | 12 | | delivered, issued, or renewed on or after the effective | 13 | | date of this amendatory Act of the 101st General Assembly, | 14 | | a A comprehensive ultrasound screening and MRI of an entire | 15 | | breast or breasts if a mammogram demonstrates | 16 | | heterogeneous or dense breast tissue or , when medically | 17 | | necessary as determined by a physician licensed to practice | 18 | | medicine in all of its branches. | 19 | | (5) A screening MRI when medically necessary, as | 20 | | determined by a physician licensed to practice medicine in | 21 | | all of its branches. | 22 | | (6) For an individual or group policy of accident and | 23 | | health insurance or a managed care plan that is amended, | 24 | | delivered, issued, or renewed on or after the effective | 25 | | date of this amendatory Act of the 101st General Assembly, | 26 | | a diagnostic mammogram when medically necessary, as |
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| 1 | | determined by a physician licensed to practice medicine in | 2 | | all its branches, advanced practice registered nurse, or | 3 | | physician assistant. | 4 | | A policy subject to this subsection shall not impose a | 5 | | deductible, coinsurance, copayment, or any other cost-sharing | 6 | | requirement on the coverage provided; except that this sentence | 7 | | does not apply to coverage of diagnostic mammograms to the | 8 | | extent such coverage would disqualify a high-deductible health | 9 | | plan from eligibility for a health savings account pursuant to | 10 | | Section 223 of the Internal Revenue Code (26 U.S.C. 223). | 11 | | For purposes of this Section : , | 12 | | "Diagnostic
mammogram" means a mammogram obtained using | 13 | | diagnostic mammography. | 14 | | "Diagnostic
mammography" means a method of screening that | 15 | | is designed to
evaluate an abnormality in a breast, including | 16 | | an abnormality seen
or suspected on a screening mammogram or a | 17 | | subjective or objective
abnormality otherwise detected in the | 18 | | breast. | 19 | | " Low-dose low-dose mammography"
means the x-ray | 20 | | examination of the breast using equipment dedicated
| 21 | | specifically for mammography, including the x-ray tube, | 22 | | filter, compression
device, and image receptor, with radiation | 23 | | exposure delivery of less than
1 rad per breast for 2 views of | 24 | | an average size breast. The term also includes digital | 25 | | mammography and includes breast tomosynthesis. As used in this | 26 | | Section, the term "breast tomosynthesis" means a radiologic |
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| 1 | | procedure that involves the acquisition of projection images | 2 | | over the stationary breast to produce cross-sectional digital | 3 | | three-dimensional images of the breast.
| 4 | | If, at any time, the Secretary of the United States | 5 | | Department of Health and Human Services, or its successor | 6 | | agency, promulgates rules or regulations to be published in the | 7 | | Federal Register or publishes a comment in the Federal Register | 8 | | or issues an opinion, guidance, or other action that would | 9 | | require the State, pursuant to any provision of the Patient | 10 | | Protection and Affordable Care Act (Public Law 111-148), | 11 | | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any | 12 | | successor provision, to defray the cost of any coverage for | 13 | | breast tomosynthesis outlined in this subsection, then the | 14 | | requirement that an insurer cover breast tomosynthesis is | 15 | | inoperative other than any such coverage authorized under | 16 | | Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and | 17 | | the State shall not assume any obligation for the cost of | 18 | | coverage for breast tomosynthesis set forth in this subsection. | 19 | | (a-5) Coverage as described by subsection (a) shall be | 20 | | provided at no cost to the insured and shall not be applied to | 21 | | an annual or lifetime maximum benefit. | 22 | | (a-10) When health care services are available through | 23 | | contracted providers and a person does not comply with plan | 24 | | provisions specific to the use of contracted providers, the | 25 | | requirements of subsection (a-5) are not applicable. When a | 26 | | person does not comply with plan provisions specific to the use |
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| 1 | | of contracted providers, plan provisions specific to the use of | 2 | | non-contracted providers must be applied without distinction | 3 | | for coverage required by this Section and shall be at least as | 4 | | favorable as for other radiological examinations covered by the | 5 | | policy or contract. | 6 | | (b) No policy of accident or health insurance that provides | 7 | | for
the surgical procedure known as a mastectomy shall be | 8 | | issued, amended,
delivered, or renewed in this State unless
| 9 | | that coverage also provides for prosthetic devices
or | 10 | | reconstructive surgery
incident to the mastectomy.
Coverage | 11 | | for breast reconstruction in connection with a mastectomy shall
| 12 | | include:
| 13 | | (1) reconstruction of the breast upon which the | 14 | | mastectomy has been
performed;
| 15 | | (2) surgery and reconstruction of the other breast to | 16 | | produce a
symmetrical appearance; and
| 17 | | (3) prostheses and treatment for physical | 18 | | complications at all stages of
mastectomy, including | 19 | | lymphedemas.
| 20 | | Care shall be determined in consultation with the attending | 21 | | physician and the
patient.
The offered coverage for prosthetic | 22 | | devices and
reconstructive surgery shall be subject to the | 23 | | deductible and coinsurance
conditions applied to the | 24 | | mastectomy, and all other terms and conditions
applicable to | 25 | | other benefits. When a mastectomy is performed and there is
no | 26 | | evidence of malignancy then the offered coverage may be limited |
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| 1 | | to the
provision of prosthetic devices and reconstructive | 2 | | surgery to within 2
years after the date of the mastectomy. As | 3 | | used in this Section,
"mastectomy" means the removal of all or | 4 | | part of the breast for medically
necessary reasons, as | 5 | | determined by a licensed physician.
| 6 | | Written notice of the availability of coverage under this | 7 | | Section shall be
delivered to the insured upon enrollment and | 8 | | annually thereafter. An insurer
may not deny to an insured | 9 | | eligibility, or continued eligibility, to enroll or
to renew | 10 | | coverage under the terms of the plan solely for the purpose of
| 11 | | avoiding the requirements of this Section. An insurer may not | 12 | | penalize or
reduce or
limit the reimbursement of an attending | 13 | | provider or provide incentives
(monetary or otherwise) to an | 14 | | attending provider to induce the provider to
provide care to an | 15 | | insured in a manner inconsistent with this Section.
| 16 | | (c) Rulemaking authority to implement Public Act 95-1045, | 17 | | if any, is conditioned on the rules being adopted in accordance | 18 | | with all provisions of the Illinois Administrative Procedure | 19 | | Act and all rules and procedures of the Joint Committee on | 20 | | Administrative Rules; any purported rule not so adopted, for | 21 | | whatever reason, is unauthorized. | 22 | | (Source: P.A. 99-407 (see Section 20 of P.A. 99-588 for the | 23 | | effective date of P.A. 99-407); 99-433, eff. 8-21-15; 99-588, | 24 | | eff. 7-20-16; 99-642, eff. 7-28-16; 100-395, eff. 1-1-18 .) | 25 | | Section 20. The Health Maintenance Organization Act is |
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| 1 | | amended by changing Section 4-6.1 as follows:
| 2 | | (215 ILCS 125/4-6.1) (from Ch. 111 1/2, par. 1408.7)
| 3 | | Sec. 4-6.1. Mammograms; mastectomies.
| 4 | | (a) Every contract or evidence of coverage
issued by a | 5 | | Health Maintenance Organization for persons who are residents | 6 | | of
this State shall contain coverage for screening by low-dose | 7 | | mammography
for all women 35 years of age or older for the | 8 | | presence of occult breast
cancer. The coverage shall be as | 9 | | follows:
| 10 | | (1) A baseline mammogram for women 35 to 39 years of | 11 | | age.
| 12 | | (2) An annual mammogram for women 40 years of age or | 13 | | older.
| 14 | | (3) A mammogram at the age and intervals considered | 15 | | medically necessary by the woman's health care provider for | 16 | | women under 40 years of age and having a family history of | 17 | | breast cancer, prior personal history of breast cancer, | 18 | | positive genetic testing, or other risk factors. | 19 | | (4) For an individual or group policy of accident and | 20 | | health insurance or a managed care plan that is amended, | 21 | | delivered, issued, or renewed on or after the effective | 22 | | date of this amendatory Act of the 101st General Assembly, | 23 | | a A comprehensive ultrasound screening and MRI of an entire | 24 | | breast or breasts if a mammogram demonstrates | 25 | | heterogeneous or dense breast tissue or , when medically |
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| 1 | | necessary as determined by a physician licensed to practice | 2 | | medicine in all of its branches. | 3 | | (5) For an individual or group policy of accident and | 4 | | health insurance or a managed care plan that is amended, | 5 | | delivered, issued, or renewed on or after the effective | 6 | | date of this amendatory Act of the 101st General Assembly, | 7 | | a diagnostic mammogram when medically necessary, as | 8 | | determined by a physician licensed to practice medicine in | 9 | | all its branches, advanced practice registered nurse, or | 10 | | physician assistant. | 11 | | A policy subject to this subsection shall not impose a | 12 | | deductible, coinsurance, copayment, or any other cost-sharing | 13 | | requirement on the coverage provided; except that this sentence | 14 | | does not apply to coverage of diagnostic mammograms to the | 15 | | extent such coverage would disqualify a high-deductible health | 16 | | plan from eligibility for a health savings account pursuant to | 17 | | Section 223 of the Internal Revenue Code (26 U.S.C. 223). | 18 | | For purposes of this Section : , | 19 | | "Diagnostic
mammogram" means a mammogram obtained using | 20 | | diagnostic mammography. | 21 | | "Diagnostic
mammography" means a method of screening that | 22 | | is designed to
evaluate an abnormality in a breast, including | 23 | | an abnormality seen
or suspected on a screening mammogram or a | 24 | | subjective or objective
abnormality otherwise detected in the | 25 | | breast. | 26 | | " Low-dose low-dose mammography"
means the x-ray |
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| 1 | | examination of the breast using equipment dedicated
| 2 | | specifically for mammography, including the x-ray tube, | 3 | | filter, compression
device, and image receptor, with radiation | 4 | | exposure delivery of less than 1
rad per breast for 2 views of | 5 | | an average size breast. The term also includes digital | 6 | | mammography and includes breast tomosynthesis. | 7 | | "Breast As used in this Section, the term "breast | 8 | | tomosynthesis" means a radiologic procedure that involves the | 9 | | acquisition of projection images over the stationary breast to | 10 | | produce cross-sectional digital three-dimensional images of | 11 | | the breast.
| 12 | | If, at any time, the Secretary of the United States | 13 | | Department of Health and Human Services, or its successor | 14 | | agency, promulgates rules or regulations to be published in the | 15 | | Federal Register or publishes a comment in the Federal Register | 16 | | or issues an opinion, guidance, or other action that would | 17 | | require the State, pursuant to any provision of the Patient | 18 | | Protection and Affordable Care Act (Public Law 111-148), | 19 | | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any | 20 | | successor provision, to defray the cost of any coverage for | 21 | | breast tomosynthesis outlined in this subsection, then the | 22 | | requirement that an insurer cover breast tomosynthesis is | 23 | | inoperative other than any such coverage authorized under | 24 | | Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and | 25 | | the State shall not assume any obligation for the cost of | 26 | | coverage for breast tomosynthesis set forth in this subsection. |
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| 1 | | (a-5) Coverage as described in subsection (a) shall be | 2 | | provided at no cost to the enrollee and shall not be applied to | 3 | | an annual or lifetime maximum benefit. | 4 | | (b) No contract or evidence of coverage issued by a health | 5 | | maintenance
organization that provides for the
surgical | 6 | | procedure known as a mastectomy shall be issued, amended, | 7 | | delivered,
or renewed in this State on or after the effective | 8 | | date of this amendatory Act
of the 92nd General Assembly unless | 9 | | that coverage also provides for prosthetic
devices or | 10 | | reconstructive surgery incident to the mastectomy, providing | 11 | | that
the mastectomy is performed after the effective date of | 12 | | this amendatory Act.
Coverage for breast reconstruction in | 13 | | connection
with a mastectomy shall
include:
| 14 | | (1) reconstruction of the breast upon which the | 15 | | mastectomy has been
performed;
| 16 | | (2) surgery and reconstruction of the other breast to | 17 | | produce a
symmetrical appearance; and
| 18 | | (3) prostheses and treatment for physical | 19 | | complications at all stages of
mastectomy, including | 20 | | lymphedemas.
| 21 | | Care shall be determined in consultation with the attending | 22 | | physician and the
patient.
The offered coverage for prosthetic | 23 | | devices and
reconstructive surgery shall be subject to the | 24 | | deductible and coinsurance
conditions applied to the | 25 | | mastectomy and all other terms and conditions
applicable to | 26 | | other benefits. When a mastectomy is performed and there is
no |
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| 1 | | evidence of malignancy, then the offered coverage may be | 2 | | limited to the
provision of prosthetic devices and | 3 | | reconstructive surgery to within 2
years after the date of the | 4 | | mastectomy. As used in this Section,
"mastectomy" means the | 5 | | removal of all or part of the breast for medically
necessary | 6 | | reasons, as determined by a licensed physician.
| 7 | | Written notice of the availability of coverage under this | 8 | | Section shall be
delivered to the enrollee upon enrollment and | 9 | | annually thereafter. A
health maintenance organization may not | 10 | | deny to an enrollee eligibility, or
continued eligibility, to | 11 | | enroll or
to renew coverage under the terms of the plan solely | 12 | | for the purpose of
avoiding the requirements of this Section. A | 13 | | health maintenance organization
may not penalize or
reduce or
| 14 | | limit the reimbursement of an attending provider or provide | 15 | | incentives
(monetary or otherwise) to an attending provider to | 16 | | induce the provider to
provide care to an insured in a manner | 17 | | inconsistent with this Section.
| 18 | | (c) Rulemaking authority to implement this amendatory Act | 19 | | of the 95th General Assembly, if any, is conditioned on the | 20 | | rules being adopted in accordance with all provisions of the | 21 | | Illinois Administrative Procedure Act and all rules and | 22 | | procedures of the Joint Committee on Administrative Rules; any | 23 | | purported rule not so adopted, for whatever reason, is | 24 | | unauthorized. | 25 | | (Source: P.A. 99-407 (see Section 20 of P.A. 99-588 for the | 26 | | effective date of P.A. 99-407); 99-588, eff. 7-20-16; 100-395, |
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| 1 | | eff. 1-1-18 .)
| 2 | | Section 25. The Illinois Public Aid Code is amended by | 3 | | changing Section 5-5 as follows:
| 4 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| 5 | | Sec. 5-5. Medical services. The Illinois Department, by | 6 | | rule, shall
determine the quantity and quality of and the rate | 7 | | of reimbursement for the
medical assistance for which
payment | 8 | | will be authorized, and the medical services to be provided,
| 9 | | which may include all or part of the following: (1) inpatient | 10 | | hospital
services; (2) outpatient hospital services; (3) other | 11 | | laboratory and
X-ray services; (4) skilled nursing home | 12 | | services; (5) physicians'
services whether furnished in the | 13 | | office, the patient's home, a
hospital, a skilled nursing home, | 14 | | or elsewhere; (6) medical care, or any
other type of remedial | 15 | | care furnished by licensed practitioners; (7)
home health care | 16 | | services; (8) private duty nursing service; (9) clinic
| 17 | | services; (10) dental services, including prevention and | 18 | | treatment of periodontal disease and dental caries disease for | 19 | | pregnant women, provided by an individual licensed to practice | 20 | | dentistry or dental surgery; for purposes of this item (10), | 21 | | "dental services" means diagnostic, preventive, or corrective | 22 | | procedures provided by or under the supervision of a dentist in | 23 | | the practice of his or her profession; (11) physical therapy | 24 | | and related
services; (12) prescribed drugs, dentures, and |
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| 1 | | prosthetic devices; and
eyeglasses prescribed by a physician | 2 | | skilled in the diseases of the eye,
or by an optometrist, | 3 | | whichever the person may select; (13) other
diagnostic, | 4 | | screening, preventive, and rehabilitative services, including | 5 | | to ensure that the individual's need for intervention or | 6 | | treatment of mental disorders or substance use disorders or | 7 | | co-occurring mental health and substance use disorders is | 8 | | determined using a uniform screening, assessment, and | 9 | | evaluation process inclusive of criteria, for children and | 10 | | adults; for purposes of this item (13), a uniform screening, | 11 | | assessment, and evaluation process refers to a process that | 12 | | includes an appropriate evaluation and, as warranted, a | 13 | | referral; "uniform" does not mean the use of a singular | 14 | | instrument, tool, or process that all must utilize; (14)
| 15 | | transportation and such other expenses as may be necessary; | 16 | | (15) medical
treatment of sexual assault survivors, as defined | 17 | | in
Section 1a of the Sexual Assault Survivors Emergency | 18 | | Treatment Act, for
injuries sustained as a result of the sexual | 19 | | assault, including
examinations and laboratory tests to | 20 | | discover evidence which may be used in
criminal proceedings | 21 | | arising from the sexual assault; (16) the
diagnosis and | 22 | | treatment of sickle cell anemia; and (17)
any other medical | 23 | | care, and any other type of remedial care recognized
under the | 24 | | laws of this State. The term "any other type of remedial care" | 25 | | shall
include nursing care and nursing home service for persons | 26 | | who rely on
treatment by spiritual means alone through prayer |
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| 1 | | for healing.
| 2 | | Notwithstanding any other provision of this Section, a | 3 | | comprehensive
tobacco use cessation program that includes | 4 | | purchasing prescription drugs or
prescription medical devices | 5 | | approved by the Food and Drug Administration shall
be covered | 6 | | under the medical assistance
program under this Article for | 7 | | persons who are otherwise eligible for
assistance under this | 8 | | Article.
| 9 | | Notwithstanding any other provision of this Code, | 10 | | reproductive health care that is otherwise legal in Illinois | 11 | | shall be covered under the medical assistance program for | 12 | | persons who are otherwise eligible for medical assistance under | 13 | | this Article. | 14 | | Notwithstanding any other provision of this Code, the | 15 | | Illinois
Department may not require, as a condition of payment | 16 | | for any laboratory
test authorized under this Article, that a | 17 | | physician's handwritten signature
appear on the laboratory | 18 | | test order form. The Illinois Department may,
however, impose | 19 | | other appropriate requirements regarding laboratory test
order | 20 | | documentation.
| 21 | | Upon receipt of federal approval of an amendment to the | 22 | | Illinois Title XIX State Plan for this purpose, the Department | 23 | | shall authorize the Chicago Public Schools (CPS) to procure a | 24 | | vendor or vendors to manufacture eyeglasses for individuals | 25 | | enrolled in a school within the CPS system. CPS shall ensure | 26 | | that its vendor or vendors are enrolled as providers in the |
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| 1 | | medical assistance program and in any capitated Medicaid | 2 | | managed care entity (MCE) serving individuals enrolled in a | 3 | | school within the CPS system. Under any contract procured under | 4 | | this provision, the vendor or vendors must serve only | 5 | | individuals enrolled in a school within the CPS system. Claims | 6 | | for services provided by CPS's vendor or vendors to recipients | 7 | | of benefits in the medical assistance program under this Code, | 8 | | the Children's Health Insurance Program, or the Covering ALL | 9 | | KIDS Health Insurance Program shall be submitted to the | 10 | | Department or the MCE in which the individual is enrolled for | 11 | | payment and shall be reimbursed at the Department's or the | 12 | | MCE's established rates or rate methodologies for eyeglasses. | 13 | | On and after July 1, 2012, the Department of Healthcare and | 14 | | Family Services may provide the following services to
persons
| 15 | | eligible for assistance under this Article who are | 16 | | participating in
education, training or employment programs | 17 | | operated by the Department of Human
Services as successor to | 18 | | the Department of Public Aid:
| 19 | | (1) dental services provided by or under the | 20 | | supervision of a dentist; and
| 21 | | (2) eyeglasses prescribed by a physician skilled in the | 22 | | diseases of the
eye, or by an optometrist, whichever the | 23 | | person may select.
| 24 | | On and after July 1, 2018, the Department of Healthcare and | 25 | | Family Services shall provide dental services to any adult who | 26 | | is otherwise eligible for assistance under the medical |
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| 1 | | assistance program. As used in this paragraph, "dental | 2 | | services" means diagnostic, preventative, restorative, or | 3 | | corrective procedures, including procedures and services for | 4 | | the prevention and treatment of periodontal disease and dental | 5 | | caries disease, provided by an individual who is licensed to | 6 | | practice dentistry or dental surgery or who is under the | 7 | | supervision of a dentist in the practice of his or her | 8 | | profession. | 9 | | On and after July 1, 2018, targeted dental services, as set | 10 | | forth in Exhibit D of the Consent Decree entered by the United | 11 | | States District Court for the Northern District of Illinois, | 12 | | Eastern Division, in the matter of Memisovski v. Maram, Case | 13 | | No. 92 C 1982, that are provided to adults under the medical | 14 | | assistance program shall be established at no less than the | 15 | | rates set forth in the "New Rate" column in Exhibit D of the | 16 | | Consent Decree for targeted dental services that are provided | 17 | | to persons under the age of 18 under the medical assistance | 18 | | program. | 19 | | Notwithstanding any other provision of this Code and | 20 | | subject to federal approval, the Department may adopt rules to | 21 | | allow a dentist who is volunteering his or her service at no | 22 | | cost to render dental services through an enrolled | 23 | | not-for-profit health clinic without the dentist personally | 24 | | enrolling as a participating provider in the medical assistance | 25 | | program. A not-for-profit health clinic shall include a public | 26 | | health clinic or Federally Qualified Health Center or other |
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| 1 | | enrolled provider, as determined by the Department, through | 2 | | which dental services covered under this Section are performed. | 3 | | The Department shall establish a process for payment of claims | 4 | | for reimbursement for covered dental services rendered under | 5 | | this provision. | 6 | | The Illinois Department, by rule, may distinguish and | 7 | | classify the
medical services to be provided only in accordance | 8 | | with the classes of
persons designated in Section 5-2.
| 9 | | The Department of Healthcare and Family Services must | 10 | | provide coverage and reimbursement for amino acid-based | 11 | | elemental formulas, regardless of delivery method, for the | 12 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 13 | | short bowel syndrome when the prescribing physician has issued | 14 | | a written order stating that the amino acid-based elemental | 15 | | formula is medically necessary.
| 16 | | The Illinois Department shall authorize the provision of, | 17 | | and shall
authorize payment for, screening by low-dose | 18 | | mammography for the presence of
occult breast cancer for women | 19 | | 35 years of age or older who are eligible
for medical | 20 | | assistance under this Article, as follows: | 21 | | (A) A baseline
mammogram for women 35 to 39 years of | 22 | | age.
| 23 | | (B) An annual mammogram for women 40 years of age or | 24 | | older. | 25 | | (C) A mammogram at the age and intervals considered | 26 | | medically necessary by the woman's health care provider for |
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| 1 | | women under 40 years of age and having a family history of | 2 | | breast cancer, prior personal history of breast cancer, | 3 | | positive genetic testing, or other risk factors. | 4 | | (D) A comprehensive ultrasound screening and MRI of an | 5 | | entire breast or breasts if a mammogram demonstrates | 6 | | heterogeneous or dense breast tissue or , when medically | 7 | | necessary as determined by a physician licensed to practice | 8 | | medicine in all of its branches. | 9 | | (E) A screening MRI when medically necessary, as | 10 | | determined by a physician licensed to practice medicine in | 11 | | all of its branches. | 12 | | (F) A diagnostic mammogram when medically necessary, | 13 | | as determined by a physician licensed to practice medicine | 14 | | in all its branches, advanced practice registered nurse, or | 15 | | physician assistant. | 16 | | The Department shall not impose a deductible, coinsurance, | 17 | | copayment, or any other cost-sharing requirement on the | 18 | | coverage provided under this paragraph; except that this | 19 | | sentence does not apply to coverage of diagnostic mammograms to | 20 | | the extent such coverage would disqualify a high-deductible | 21 | | health plan from eligibility for a health savings account | 22 | | pursuant to Section 223 of the Internal Revenue Code (26 U.S.C. | 23 | | 223). | 24 | | All screenings
shall
include a physical breast exam, | 25 | | instruction on self-examination and
information regarding the | 26 | | frequency of self-examination and its value as a
preventative |
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| 1 | | tool. | 2 | | For purposes of this Section : , | 3 | | "Diagnostic
mammogram" means a mammogram obtained using | 4 | | diagnostic mammography. | 5 | | "Diagnostic
mammography" means a method of screening that | 6 | | is designed to
evaluate an abnormality in a breast, including | 7 | | an abnormality seen
or suspected on a screening mammogram or a | 8 | | subjective or objective
abnormality otherwise detected in the | 9 | | breast. | 10 | | " Low-dose low-dose mammography" means
the x-ray | 11 | | examination of the breast using equipment dedicated | 12 | | specifically
for mammography, including the x-ray tube, | 13 | | filter, compression device,
and image receptor, with an average | 14 | | radiation exposure delivery
of less than one rad per breast for | 15 | | 2 views of an average size breast.
The term also includes | 16 | | digital mammography and includes breast tomosynthesis. | 17 | | "Breast As used in this Section, the term "breast | 18 | | tomosynthesis" means a radiologic procedure that involves the | 19 | | acquisition of projection images over the stationary breast to | 20 | | produce cross-sectional digital three-dimensional images of | 21 | | the breast. | 22 | | If, at any time, the Secretary of the United States | 23 | | Department of Health and Human Services, or its successor | 24 | | agency, promulgates rules or regulations to be published in the | 25 | | Federal Register or publishes a comment in the Federal Register | 26 | | or issues an opinion, guidance, or other action that would |
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| 1 | | require the State, pursuant to any provision of the Patient | 2 | | Protection and Affordable Care Act (Public Law 111-148), | 3 | | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any | 4 | | successor provision, to defray the cost of any coverage for | 5 | | breast tomosynthesis outlined in this paragraph, then the | 6 | | requirement that an insurer cover breast tomosynthesis is | 7 | | inoperative other than any such coverage authorized under | 8 | | Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and | 9 | | the State shall not assume any obligation for the cost of | 10 | | coverage for breast tomosynthesis set forth in this paragraph.
| 11 | | On and after January 1, 2016, the Department shall ensure | 12 | | that all networks of care for adult clients of the Department | 13 | | include access to at least one breast imaging Center of Imaging | 14 | | Excellence as certified by the American College of Radiology. | 15 | | On and after January 1, 2012, providers participating in a | 16 | | quality improvement program approved by the Department shall be | 17 | | reimbursed for screening and diagnostic mammography at the same | 18 | | rate as the Medicare program's rates, including the increased | 19 | | reimbursement for digital mammography. | 20 | | The Department shall convene an expert panel including | 21 | | representatives of hospitals, free-standing mammography | 22 | | facilities, and doctors, including radiologists, to establish | 23 | | quality standards for mammography. | 24 | | On and after January 1, 2017, providers participating in a | 25 | | breast cancer treatment quality improvement program approved | 26 | | by the Department shall be reimbursed for breast cancer |
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| 1 | | treatment at a rate that is no lower than 95% of the Medicare | 2 | | program's rates for the data elements included in the breast | 3 | | cancer treatment quality program. | 4 | | The Department shall convene an expert panel, including | 5 | | representatives of hospitals, free-standing breast cancer | 6 | | treatment centers, breast cancer quality organizations, and | 7 | | doctors, including breast surgeons, reconstructive breast | 8 | | surgeons, oncologists, and primary care providers to establish | 9 | | quality standards for breast cancer treatment. | 10 | | Subject to federal approval, the Department shall | 11 | | establish a rate methodology for mammography at federally | 12 | | qualified health centers and other encounter-rate clinics. | 13 | | These clinics or centers may also collaborate with other | 14 | | hospital-based mammography facilities. By January 1, 2016, the | 15 | | Department shall report to the General Assembly on the status | 16 | | of the provision set forth in this paragraph. | 17 | | The Department shall establish a methodology to remind | 18 | | women who are age-appropriate for screening mammography, but | 19 | | who have not received a mammogram within the previous 18 | 20 | | months, of the importance and benefit of screening mammography. | 21 | | The Department shall work with experts in breast cancer | 22 | | outreach and patient navigation to optimize these reminders and | 23 | | shall establish a methodology for evaluating their | 24 | | effectiveness and modifying the methodology based on the | 25 | | evaluation. | 26 | | The Department shall establish a performance goal for |
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| 1 | | primary care providers with respect to their female patients | 2 | | over age 40 receiving an annual mammogram. This performance | 3 | | goal shall be used to provide additional reimbursement in the | 4 | | form of a quality performance bonus to primary care providers | 5 | | who meet that goal. | 6 | | The Department shall devise a means of case-managing or | 7 | | patient navigation for beneficiaries diagnosed with breast | 8 | | cancer. This program shall initially operate as a pilot program | 9 | | in areas of the State with the highest incidence of mortality | 10 | | related to breast cancer. At least one pilot program site shall | 11 | | be in the metropolitan Chicago area and at least one site shall | 12 | | be outside the metropolitan Chicago area. On or after July 1, | 13 | | 2016, the pilot program shall be expanded to include one site | 14 | | in western Illinois, one site in southern Illinois, one site in | 15 | | central Illinois, and 4 sites within metropolitan Chicago. An | 16 | | evaluation of the pilot program shall be carried out measuring | 17 | | health outcomes and cost of care for those served by the pilot | 18 | | program compared to similarly situated patients who are not | 19 | | served by the pilot program. | 20 | | The Department shall require all networks of care to | 21 | | develop a means either internally or by contract with experts | 22 | | in navigation and community outreach to navigate cancer | 23 | | patients to comprehensive care in a timely fashion. The | 24 | | Department shall require all networks of care to include access | 25 | | for patients diagnosed with cancer to at least one academic | 26 | | commission on cancer-accredited cancer program as an |
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| 1 | | in-network covered benefit. | 2 | | Any medical or health care provider shall immediately | 3 | | recommend, to
any pregnant woman who is being provided prenatal | 4 | | services and is suspected
of having a substance use disorder as | 5 | | defined in the Substance Use Disorder Act, referral to a local | 6 | | substance use disorder treatment program licensed by the | 7 | | Department of Human Services or to a licensed
hospital which | 8 | | provides substance abuse treatment services. The Department of | 9 | | Healthcare and Family Services
shall assure coverage for the | 10 | | cost of treatment of the drug abuse or
addiction for pregnant | 11 | | recipients in accordance with the Illinois Medicaid
Program in | 12 | | conjunction with the Department of Human Services.
| 13 | | All medical providers providing medical assistance to | 14 | | pregnant women
under this Code shall receive information from | 15 | | the Department on the
availability of services under any
| 16 | | program providing case management services for addicted women,
| 17 | | including information on appropriate referrals for other | 18 | | social services
that may be needed by addicted women in | 19 | | addition to treatment for addiction.
| 20 | | The Illinois Department, in cooperation with the | 21 | | Departments of Human
Services (as successor to the Department | 22 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 23 | | public awareness campaign, may
provide information concerning | 24 | | treatment for alcoholism and drug abuse and
addiction, prenatal | 25 | | health care, and other pertinent programs directed at
reducing | 26 | | the number of drug-affected infants born to recipients of |
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| 1 | | medical
assistance.
| 2 | | Neither the Department of Healthcare and Family Services | 3 | | nor the Department of Human
Services shall sanction the | 4 | | recipient solely on the basis of
her substance abuse.
| 5 | | The Illinois Department shall establish such regulations | 6 | | governing
the dispensing of health services under this Article | 7 | | as it shall deem
appropriate. The Department
should
seek the | 8 | | advice of formal professional advisory committees appointed by
| 9 | | the Director of the Illinois Department for the purpose of | 10 | | providing regular
advice on policy and administrative matters, | 11 | | information dissemination and
educational activities for | 12 | | medical and health care providers, and
consistency in | 13 | | procedures to the Illinois Department.
| 14 | | The Illinois Department may develop and contract with | 15 | | Partnerships of
medical providers to arrange medical services | 16 | | for persons eligible under
Section 5-2 of this Code. | 17 | | Implementation of this Section may be by
demonstration projects | 18 | | in certain geographic areas. The Partnership shall
be | 19 | | represented by a sponsor organization. The Department, by rule, | 20 | | shall
develop qualifications for sponsors of Partnerships. | 21 | | Nothing in this
Section shall be construed to require that the | 22 | | sponsor organization be a
medical organization.
| 23 | | The sponsor must negotiate formal written contracts with | 24 | | medical
providers for physician services, inpatient and | 25 | | outpatient hospital care,
home health services, treatment for | 26 | | alcoholism and substance abuse, and
other services determined |
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| 1 | | necessary by the Illinois Department by rule for
delivery by | 2 | | Partnerships. Physician services must include prenatal and
| 3 | | obstetrical care. The Illinois Department shall reimburse | 4 | | medical services
delivered by Partnership providers to clients | 5 | | in target areas according to
provisions of this Article and the | 6 | | Illinois Health Finance Reform Act,
except that:
| 7 | | (1) Physicians participating in a Partnership and | 8 | | providing certain
services, which shall be determined by | 9 | | the Illinois Department, to persons
in areas covered by the | 10 | | Partnership may receive an additional surcharge
for such | 11 | | services.
| 12 | | (2) The Department may elect to consider and negotiate | 13 | | financial
incentives to encourage the development of | 14 | | Partnerships and the efficient
delivery of medical care.
| 15 | | (3) Persons receiving medical services through | 16 | | Partnerships may receive
medical and case management | 17 | | services above the level usually offered
through the | 18 | | medical assistance program.
| 19 | | Medical providers shall be required to meet certain | 20 | | qualifications to
participate in Partnerships to ensure the | 21 | | delivery of high quality medical
services. These | 22 | | qualifications shall be determined by rule of the Illinois
| 23 | | Department and may be higher than qualifications for | 24 | | participation in the
medical assistance program. Partnership | 25 | | sponsors may prescribe reasonable
additional qualifications | 26 | | for participation by medical providers, only with
the prior |
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| 1 | | written approval of the Illinois Department.
| 2 | | Nothing in this Section shall limit the free choice of | 3 | | practitioners,
hospitals, and other providers of medical | 4 | | services by clients.
In order to ensure patient freedom of | 5 | | choice, the Illinois Department shall
immediately promulgate | 6 | | all rules and take all other necessary actions so that
provided | 7 | | services may be accessed from therapeutically certified | 8 | | optometrists
to the full extent of the Illinois Optometric | 9 | | Practice Act of 1987 without
discriminating between service | 10 | | providers.
| 11 | | The Department shall apply for a waiver from the United | 12 | | States Health
Care Financing Administration to allow for the | 13 | | implementation of
Partnerships under this Section.
| 14 | | The Illinois Department shall require health care | 15 | | providers to maintain
records that document the medical care | 16 | | and services provided to recipients
of Medical Assistance under | 17 | | this Article. Such records must be retained for a period of not | 18 | | less than 6 years from the date of service or as provided by | 19 | | applicable State law, whichever period is longer, except that | 20 | | if an audit is initiated within the required retention period | 21 | | then the records must be retained until the audit is completed | 22 | | and every exception is resolved. The Illinois Department shall
| 23 | | require health care providers to make available, when | 24 | | authorized by the
patient, in writing, the medical records in a | 25 | | timely fashion to other
health care providers who are treating | 26 | | or serving persons eligible for
Medical Assistance under this |
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| 1 | | Article. All dispensers of medical services
shall be required | 2 | | to maintain and retain business and professional records
| 3 | | sufficient to fully and accurately document the nature, scope, | 4 | | details and
receipt of the health care provided to persons | 5 | | eligible for medical
assistance under this Code, in accordance | 6 | | with regulations promulgated by
the Illinois Department. The | 7 | | rules and regulations shall require that proof
of the receipt | 8 | | of prescription drugs, dentures, prosthetic devices and
| 9 | | eyeglasses by eligible persons under this Section accompany | 10 | | each claim
for reimbursement submitted by the dispenser of such | 11 | | medical services.
No such claims for reimbursement shall be | 12 | | approved for payment by the Illinois
Department without such | 13 | | proof of receipt, unless the Illinois Department
shall have put | 14 | | into effect and shall be operating a system of post-payment
| 15 | | audit and review which shall, on a sampling basis, be deemed | 16 | | adequate by
the Illinois Department to assure that such drugs, | 17 | | dentures, prosthetic
devices and eyeglasses for which payment | 18 | | is being made are actually being
received by eligible | 19 | | recipients. Within 90 days after September 16, 1984 (the | 20 | | effective date of Public Act 83-1439), the Illinois Department | 21 | | shall establish a
current list of acquisition costs for all | 22 | | prosthetic devices and any
other items recognized as medical | 23 | | equipment and supplies reimbursable under
this Article and | 24 | | shall update such list on a quarterly basis, except that
the | 25 | | acquisition costs of all prescription drugs shall be updated no
| 26 | | less frequently than every 30 days as required by Section |
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| 1 | | 5-5.12.
| 2 | | Notwithstanding any other law to the contrary, the Illinois | 3 | | Department shall, within 365 days after July 22, 2013 (the | 4 | | effective date of Public Act 98-104), establish procedures to | 5 | | permit skilled care facilities licensed under the Nursing Home | 6 | | Care Act to submit monthly billing claims for reimbursement | 7 | | purposes. Following development of these procedures, the | 8 | | Department shall, by July 1, 2016, test the viability of the | 9 | | new system and implement any necessary operational or | 10 | | structural changes to its information technology platforms in | 11 | | order to allow for the direct acceptance and payment of nursing | 12 | | home claims. | 13 | | Notwithstanding any other law to the contrary, the Illinois | 14 | | Department shall, within 365 days after August 15, 2014 (the | 15 | | effective date of Public Act 98-963), establish procedures to | 16 | | permit ID/DD facilities licensed under the ID/DD Community Care | 17 | | Act and MC/DD facilities licensed under the MC/DD Act to submit | 18 | | monthly billing claims for reimbursement purposes. Following | 19 | | development of these procedures, the Department shall have an | 20 | | additional 365 days to test the viability of the new system and | 21 | | to ensure that any necessary operational or structural changes | 22 | | to its information technology platforms are implemented. | 23 | | The Illinois Department shall require all dispensers of | 24 | | medical
services, other than an individual practitioner or | 25 | | group of practitioners,
desiring to participate in the Medical | 26 | | Assistance program
established under this Article to disclose |
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| 1 | | all financial, beneficial,
ownership, equity, surety or other | 2 | | interests in any and all firms,
corporations, partnerships, | 3 | | associations, business enterprises, joint
ventures, agencies, | 4 | | institutions or other legal entities providing any
form of | 5 | | health care services in this State under this Article.
| 6 | | The Illinois Department may require that all dispensers of | 7 | | medical
services desiring to participate in the medical | 8 | | assistance program
established under this Article disclose, | 9 | | under such terms and conditions as
the Illinois Department may | 10 | | by rule establish, all inquiries from clients
and attorneys | 11 | | regarding medical bills paid by the Illinois Department, which
| 12 | | inquiries could indicate potential existence of claims or liens | 13 | | for the
Illinois Department.
| 14 | | Enrollment of a vendor
shall be
subject to a provisional | 15 | | period and shall be conditional for one year. During the period | 16 | | of conditional enrollment, the Department may
terminate the | 17 | | vendor's eligibility to participate in, or may disenroll the | 18 | | vendor from, the medical assistance
program without cause. | 19 | | Unless otherwise specified, such termination of eligibility or | 20 | | disenrollment is not subject to the
Department's hearing | 21 | | process.
However, a disenrolled vendor may reapply without | 22 | | penalty.
| 23 | | The Department has the discretion to limit the conditional | 24 | | enrollment period for vendors based upon category of risk of | 25 | | the vendor. | 26 | | Prior to enrollment and during the conditional enrollment |
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| 1 | | period in the medical assistance program, all vendors shall be | 2 | | subject to enhanced oversight, screening, and review based on | 3 | | the risk of fraud, waste, and abuse that is posed by the | 4 | | category of risk of the vendor. The Illinois Department shall | 5 | | establish the procedures for oversight, screening, and review, | 6 | | which may include, but need not be limited to: criminal and | 7 | | financial background checks; fingerprinting; license, | 8 | | certification, and authorization verifications; unscheduled or | 9 | | unannounced site visits; database checks; prepayment audit | 10 | | reviews; audits; payment caps; payment suspensions; and other | 11 | | screening as required by federal or State law. | 12 | | The Department shall define or specify the following: (i) | 13 | | by provider notice, the "category of risk of the vendor" for | 14 | | each type of vendor, which shall take into account the level of | 15 | | screening applicable to a particular category of vendor under | 16 | | federal law and regulations; (ii) by rule or provider notice, | 17 | | the maximum length of the conditional enrollment period for | 18 | | each category of risk of the vendor; and (iii) by rule, the | 19 | | hearing rights, if any, afforded to a vendor in each category | 20 | | of risk of the vendor that is terminated or disenrolled during | 21 | | the conditional enrollment period. | 22 | | To be eligible for payment consideration, a vendor's | 23 | | payment claim or bill, either as an initial claim or as a | 24 | | resubmitted claim following prior rejection, must be received | 25 | | by the Illinois Department, or its fiscal intermediary, no | 26 | | later than 180 days after the latest date on the claim on which |
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| 1 | | medical goods or services were provided, with the following | 2 | | exceptions: | 3 | | (1) In the case of a provider whose enrollment is in | 4 | | process by the Illinois Department, the 180-day period | 5 | | shall not begin until the date on the written notice from | 6 | | the Illinois Department that the provider enrollment is | 7 | | complete. | 8 | | (2) In the case of errors attributable to the Illinois | 9 | | Department or any of its claims processing intermediaries | 10 | | which result in an inability to receive, process, or | 11 | | adjudicate a claim, the 180-day period shall not begin | 12 | | until the provider has been notified of the error. | 13 | | (3) In the case of a provider for whom the Illinois | 14 | | Department initiates the monthly billing process. | 15 | | (4) In the case of a provider operated by a unit of | 16 | | local government with a population exceeding 3,000,000 | 17 | | when local government funds finance federal participation | 18 | | for claims payments. | 19 | | For claims for services rendered during a period for which | 20 | | a recipient received retroactive eligibility, claims must be | 21 | | filed within 180 days after the Department determines the | 22 | | applicant is eligible. For claims for which the Illinois | 23 | | Department is not the primary payer, claims must be submitted | 24 | | to the Illinois Department within 180 days after the final | 25 | | adjudication by the primary payer. | 26 | | In the case of long term care facilities, within 45 |
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| 1 | | calendar days of receipt by the facility of required | 2 | | prescreening information, new admissions with associated | 3 | | admission documents shall be submitted through the Medical | 4 | | Electronic Data Interchange (MEDI) or the Recipient | 5 | | Eligibility Verification (REV) System or shall be submitted | 6 | | directly to the Department of Human Services using required | 7 | | admission forms. Effective September
1, 2014, admission | 8 | | documents, including all prescreening
information, must be | 9 | | submitted through MEDI or REV. Confirmation numbers assigned to | 10 | | an accepted transaction shall be retained by a facility to | 11 | | verify timely submittal. Once an admission transaction has been | 12 | | completed, all resubmitted claims following prior rejection | 13 | | are subject to receipt no later than 180 days after the | 14 | | admission transaction has been completed. | 15 | | Claims that are not submitted and received in compliance | 16 | | with the foregoing requirements shall not be eligible for | 17 | | payment under the medical assistance program, and the State | 18 | | shall have no liability for payment of those claims. | 19 | | To the extent consistent with applicable information and | 20 | | privacy, security, and disclosure laws, State and federal | 21 | | agencies and departments shall provide the Illinois Department | 22 | | access to confidential and other information and data necessary | 23 | | to perform eligibility and payment verifications and other | 24 | | Illinois Department functions. This includes, but is not | 25 | | limited to: information pertaining to licensure; | 26 | | certification; earnings; immigration status; citizenship; wage |
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| 1 | | reporting; unearned and earned income; pension income; | 2 | | employment; supplemental security income; social security | 3 | | numbers; National Provider Identifier (NPI) numbers; the | 4 | | National Practitioner Data Bank (NPDB); program and agency | 5 | | exclusions; taxpayer identification numbers; tax delinquency; | 6 | | corporate information; and death records. | 7 | | The Illinois Department shall enter into agreements with | 8 | | State agencies and departments, and is authorized to enter into | 9 | | agreements with federal agencies and departments, under which | 10 | | such agencies and departments shall share data necessary for | 11 | | medical assistance program integrity functions and oversight. | 12 | | The Illinois Department shall develop, in cooperation with | 13 | | other State departments and agencies, and in compliance with | 14 | | applicable federal laws and regulations, appropriate and | 15 | | effective methods to share such data. At a minimum, and to the | 16 | | extent necessary to provide data sharing, the Illinois | 17 | | Department shall enter into agreements with State agencies and | 18 | | departments, and is authorized to enter into agreements with | 19 | | federal agencies and departments, including but not limited to: | 20 | | the Secretary of State; the Department of Revenue; the | 21 | | Department of Public Health; the Department of Human Services; | 22 | | and the Department of Financial and Professional Regulation. | 23 | | Beginning in fiscal year 2013, the Illinois Department | 24 | | shall set forth a request for information to identify the | 25 | | benefits of a pre-payment, post-adjudication, and post-edit | 26 | | claims system with the goals of streamlining claims processing |
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| 1 | | and provider reimbursement, reducing the number of pending or | 2 | | rejected claims, and helping to ensure a more transparent | 3 | | adjudication process through the utilization of: (i) provider | 4 | | data verification and provider screening technology; and (ii) | 5 | | clinical code editing; and (iii) pre-pay, pre- or | 6 | | post-adjudicated predictive modeling with an integrated case | 7 | | management system with link analysis. Such a request for | 8 | | information shall not be considered as a request for proposal | 9 | | or as an obligation on the part of the Illinois Department to | 10 | | take any action or acquire any products or services. | 11 | | The Illinois Department shall establish policies, | 12 | | procedures,
standards and criteria by rule for the acquisition, | 13 | | repair and replacement
of orthotic and prosthetic devices and | 14 | | durable medical equipment. Such
rules shall provide, but not be | 15 | | limited to, the following services: (1)
immediate repair or | 16 | | replacement of such devices by recipients; and (2) rental, | 17 | | lease, purchase or lease-purchase of
durable medical equipment | 18 | | in a cost-effective manner, taking into
consideration the | 19 | | recipient's medical prognosis, the extent of the
recipient's | 20 | | needs, and the requirements and costs for maintaining such
| 21 | | equipment. Subject to prior approval, such rules shall enable a | 22 | | recipient to temporarily acquire and
use alternative or | 23 | | substitute devices or equipment pending repairs or
| 24 | | replacements of any device or equipment previously authorized | 25 | | for such
recipient by the Department. Notwithstanding any | 26 | | provision of Section 5-5f to the contrary, the Department may, |
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| 1 | | by rule, exempt certain replacement wheelchair parts from prior | 2 | | approval and, for wheelchairs, wheelchair parts, wheelchair | 3 | | accessories, and related seating and positioning items, | 4 | | determine the wholesale price by methods other than actual | 5 | | acquisition costs. | 6 | | The Department shall require, by rule, all providers of | 7 | | durable medical equipment to be accredited by an accreditation | 8 | | organization approved by the federal Centers for Medicare and | 9 | | Medicaid Services and recognized by the Department in order to | 10 | | bill the Department for providing durable medical equipment to | 11 | | recipients. No later than 15 months after the effective date of | 12 | | the rule adopted pursuant to this paragraph, all providers must | 13 | | meet the accreditation requirement.
| 14 | | In order to promote environmental responsibility, meet the | 15 | | needs of recipients and enrollees, and achieve significant cost | 16 | | savings, the Department, or a managed care organization under | 17 | | contract with the Department, may provide recipients or managed | 18 | | care enrollees who have a prescription or Certificate of | 19 | | Medical Necessity access to refurbished durable medical | 20 | | equipment under this Section (excluding prosthetic and | 21 | | orthotic devices as defined in the Orthotics, Prosthetics, and | 22 | | Pedorthics Practice Act and complex rehabilitation technology | 23 | | products and associated services) through the State's | 24 | | assistive technology program's reutilization program, using | 25 | | staff with the Assistive Technology Professional (ATP) | 26 | | Certification if the refurbished durable medical equipment: |
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| 1 | | (i) is available; (ii) is less expensive, including shipping | 2 | | costs, than new durable medical equipment of the same type; | 3 | | (iii) is able to withstand at least 3 years of use; (iv) is | 4 | | cleaned, disinfected, sterilized, and safe in accordance with | 5 | | federal Food and Drug Administration regulations and guidance | 6 | | governing the reprocessing of medical devices in health care | 7 | | settings; and (v) equally meets the needs of the recipient or | 8 | | enrollee. The reutilization program shall confirm that the | 9 | | recipient or enrollee is not already in receipt of same or | 10 | | similar equipment from another service provider, and that the | 11 | | refurbished durable medical equipment equally meets the needs | 12 | | of the recipient or enrollee. Nothing in this paragraph shall | 13 | | be construed to limit recipient or enrollee choice to obtain | 14 | | new durable medical equipment or place any additional prior | 15 | | authorization conditions on enrollees of managed care | 16 | | organizations. | 17 | | The Department shall execute, relative to the nursing home | 18 | | prescreening
project, written inter-agency agreements with the | 19 | | Department of Human
Services and the Department on Aging, to | 20 | | effect the following: (i) intake
procedures and common | 21 | | eligibility criteria for those persons who are receiving
| 22 | | non-institutional services; and (ii) the establishment and | 23 | | development of
non-institutional services in areas of the State | 24 | | where they are not currently
available or are undeveloped; and | 25 | | (iii) notwithstanding any other provision of law, subject to | 26 | | federal approval, on and after July 1, 2012, an increase in the |
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| 1 | | determination of need (DON) scores from 29 to 37 for applicants | 2 | | for institutional and home and community-based long term care; | 3 | | if and only if federal approval is not granted, the Department | 4 | | may, in conjunction with other affected agencies, implement | 5 | | utilization controls or changes in benefit packages to | 6 | | effectuate a similar savings amount for this population; and | 7 | | (iv) no later than July 1, 2013, minimum level of care | 8 | | eligibility criteria for institutional and home and | 9 | | community-based long term care; and (v) no later than October | 10 | | 1, 2013, establish procedures to permit long term care | 11 | | providers access to eligibility scores for individuals with an | 12 | | admission date who are seeking or receiving services from the | 13 | | long term care provider. In order to select the minimum level | 14 | | of care eligibility criteria, the Governor shall establish a | 15 | | workgroup that includes affected agency representatives and | 16 | | stakeholders representing the institutional and home and | 17 | | community-based long term care interests. This Section shall | 18 | | not restrict the Department from implementing lower level of | 19 | | care eligibility criteria for community-based services in | 20 | | circumstances where federal approval has been granted.
| 21 | | The Illinois Department shall develop and operate, in | 22 | | cooperation
with other State Departments and agencies and in | 23 | | compliance with
applicable federal laws and regulations, | 24 | | appropriate and effective
systems of health care evaluation and | 25 | | programs for monitoring of
utilization of health care services | 26 | | and facilities, as it affects
persons eligible for medical |
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| 1 | | assistance under this Code.
| 2 | | The Illinois Department shall report annually to the | 3 | | General Assembly,
no later than the second Friday in April of | 4 | | 1979 and each year
thereafter, in regard to:
| 5 | | (a) actual statistics and trends in utilization of | 6 | | medical services by
public aid recipients;
| 7 | | (b) actual statistics and trends in the provision of | 8 | | the various medical
services by medical vendors;
| 9 | | (c) current rate structures and proposed changes in | 10 | | those rate structures
for the various medical vendors; and
| 11 | | (d) efforts at utilization review and control by the | 12 | | Illinois Department.
| 13 | | The period covered by each report shall be the 3 years | 14 | | ending on the June
30 prior to the report. The report shall | 15 | | include suggested legislation
for consideration by the General | 16 | | Assembly. The requirement for reporting to the General Assembly | 17 | | shall be satisfied
by filing copies of the report as required | 18 | | by Section 3.1 of the General Assembly Organization Act, and | 19 | | filing such additional
copies
with the State Government Report | 20 | | Distribution Center for the General
Assembly as is required | 21 | | under paragraph (t) of Section 7 of the State
Library Act.
| 22 | | Rulemaking authority to implement Public Act 95-1045, if | 23 | | any, is conditioned on the rules being adopted in accordance | 24 | | with all provisions of the Illinois Administrative Procedure | 25 | | Act and all rules and procedures of the Joint Committee on | 26 | | Administrative Rules; any purported rule not so adopted, for |
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| 1 | | whatever reason, is unauthorized. | 2 | | On and after July 1, 2012, the Department shall reduce any | 3 | | rate of reimbursement for services or other payments or alter | 4 | | any methodologies authorized by this Code to reduce any rate of | 5 | | reimbursement for services or other payments in accordance with | 6 | | Section 5-5e. | 7 | | Because kidney transplantation can be an appropriate, | 8 | | cost-effective
alternative to renal dialysis when medically | 9 | | necessary and notwithstanding the provisions of Section 1-11 of | 10 | | this Code, beginning October 1, 2014, the Department shall | 11 | | cover kidney transplantation for noncitizens with end-stage | 12 | | renal disease who are not eligible for comprehensive medical | 13 | | benefits, who meet the residency requirements of Section 5-3 of | 14 | | this Code, and who would otherwise meet the financial | 15 | | requirements of the appropriate class of eligible persons under | 16 | | Section 5-2 of this Code. To qualify for coverage of kidney | 17 | | transplantation, such person must be receiving emergency renal | 18 | | dialysis services covered by the Department. Providers under | 19 | | this Section shall be prior approved and certified by the | 20 | | Department to perform kidney transplantation and the services | 21 | | under this Section shall be limited to services associated with | 22 | | kidney transplantation. | 23 | | Notwithstanding any other provision of this Code to the | 24 | | contrary, on or after July 1, 2015, all FDA approved forms of | 25 | | medication assisted treatment prescribed for the treatment of | 26 | | alcohol dependence or treatment of opioid dependence shall be |
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| 1 | | covered under both fee for service and managed care medical | 2 | | assistance programs for persons who are otherwise eligible for | 3 | | medical assistance under this Article and shall not be subject | 4 | | to any (1) utilization control, other than those established | 5 | | under the American Society of Addiction Medicine patient | 6 | | placement criteria,
(2) prior authorization mandate, or (3) | 7 | | lifetime restriction limit
mandate. | 8 | | On or after July 1, 2015, opioid antagonists prescribed for | 9 | | the treatment of an opioid overdose, including the medication | 10 | | product, administration devices, and any pharmacy fees related | 11 | | to the dispensing and administration of the opioid antagonist, | 12 | | shall be covered under the medical assistance program for | 13 | | persons who are otherwise eligible for medical assistance under | 14 | | this Article. As used in this Section, "opioid antagonist" | 15 | | means a drug that binds to opioid receptors and blocks or | 16 | | inhibits the effect of opioids acting on those receptors, | 17 | | including, but not limited to, naloxone hydrochloride or any | 18 | | other similarly acting drug approved by the U.S. Food and Drug | 19 | | Administration. | 20 | | Upon federal approval, the Department shall provide | 21 | | coverage and reimbursement for all drugs that are approved for | 22 | | marketing by the federal Food and Drug Administration and that | 23 | | are recommended by the federal Public Health Service or the | 24 | | United States Centers for Disease Control and Prevention for | 25 | | pre-exposure prophylaxis and related pre-exposure prophylaxis | 26 | | services, including, but not limited to, HIV and sexually |
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| 1 | | transmitted infection screening, treatment for sexually | 2 | | transmitted infections, medical monitoring, assorted labs, and | 3 | | counseling to reduce the likelihood of HIV infection among | 4 | | individuals who are not infected with HIV but who are at high | 5 | | risk of HIV infection. | 6 | | A federally qualified health center, as defined in Section | 7 | | 1905(l)(2)(B) of the federal
Social Security Act, shall be | 8 | | reimbursed by the Department in accordance with the federally | 9 | | qualified health center's encounter rate for services provided | 10 | | to medical assistance recipients that are performed by a dental | 11 | | hygienist, as defined under the Illinois Dental Practice Act, | 12 | | working under the general supervision of a dentist and employed | 13 | | by a federally qualified health center. | 14 | | Notwithstanding any other provision of this Code, the | 15 | | Illinois Department shall authorize licensed dietitian | 16 | | nutritionists and certified diabetes educators to counsel | 17 | | senior diabetes patients in the senior diabetes patients' homes | 18 | | to remove the hurdle of transportation for senior diabetes | 19 | | patients to receive treatment. | 20 | | (Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15; | 21 | | 99-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for | 22 | | the effective date of P.A. 99-407); 99-433, eff. 8-21-15; | 23 | | 99-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff. | 24 | | 7-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201, | 25 | | eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18; | 26 | | 100-538, eff. 1-1-18; 100-587, eff. 6-4-18; 100-759, eff. |
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| 1 | | 1-1-19; 100-863, eff. 8-14-18; 100-974, eff. 8-19-18; | 2 | | 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; 100-1148, eff. | 3 | | 12-10-18.)
| 4 | | Section 99. Effective date. This Act takes effect January | 5 | | 1, 2020.
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