Illinois General Assembly - Full Text of SB1722
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Full Text of SB1722  98th General Assembly




State of Illinois
2013 and 2014


Introduced 2/15/2013, by Sen. John M. Sullivan


305 ILCS 5/5-4.2  from Ch. 23, par. 5-4.2
305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides for payment for ground ambulance services under the medical assistance program. Provides that for ground ambulance services provided to a medical assistance recipient on or after January 1, 2014, the Department of Healthcare and Family Services shall provide payment to ground ambulance services providers for base charges and mileage charges based upon the lesser of the provider's charge, as reflected on the provider's claim form, or the Illinois Medicaid Ambulance Fee Schedule payment rates. Provides that effective January 1, 2014, the Illinois Medicaid Ambulance Fee Schedule shall be established and shall include only the ground ambulance services payment rates outlined in the Medicare Ambulance Fee Schedule as promulgated by the Centers for Medicare and Medicaid Services in effect as of July 1, 2013 and adjusted for the 4 Medicare Localities in Illinois, with an adjustment of 80% of the Medicare Ambulance Fee Schedule payment rates, by Medicare Locality, for both base rates and mileage for all counties. Provides that for ground ambulance services provided where the point of pickup is in a rural county, the Department shall pay an amount equal to one and one-half times the ground mileage rate for the first 17 miles of such a transport and the ground mileage rate for the remaining miles of the transport. Makes other changes in connection with medical assistance payments for ground ambulance services. Effective July 1, 2013.

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1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Sections 5-4.2 and 5-5 as follows:
6    (305 ILCS 5/5-4.2)  (from Ch. 23, par. 5-4.2)
7    Sec. 5-4.2. Ground ambulance Ambulance services payments.
8    (a) For purposes of this Section, the following terms have
9the following meanings:
10    "Department" means the Illinois Department of Healthcare
11and Family Services.
12    "Ground ambulance services" means medical transportation
13services that are described as ground ambulance services by the
14Centers for Medicare and Medicaid Services and provided in a
15vehicle that is licensed as an ambulance by the Illinois
16Department of Public Health pursuant to the Emergency Medical
17Services (EMS) Systems Act.
18    "Ground ambulance services provider" means a vehicle
19service provider as described in the Emergency Medical Services
20(EMS) Systems Act that operates licensed ambulances for the
21purpose of providing emergency ambulance services, or
22non-emergency ambulance services, or both. For purposes of this
23Section, this includes both ambulance providers and ambulance



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1suppliers as described by the Centers for Medicare and Medicaid
3    "Payment principles of Medicare" means: the accepted
4method propounded by the Centers for Medicare and Medicaid
5Services and used to determine the payment system for ground
6ambulance services providers and suppliers under Title XVIII of
7the Social Security Act. These principles are outlined in the
8United States Code, the Code of Federal Regulations, and the
9CMS Online Manual System, including, but not limited to, the
10Medicare Benefit Policy Manual and the Medicare Claims
11Processing Manual, and include the statutes, regulations,
12policies, procedures, definitions, guidelines, and coding
13systems, including the Health Care Common Procedure Coding
14System (HCPCS) and ambulance condition coding system, as well
15as other resources which have been or will be developed and
16recognized by the Centers for Medicare and Medicaid Services.
17    "Rural county" means: any county not located in a U.S.
18Bureau of the Census Metropolitan Statistical Area (MSA); or
19any county located within a U.S. Bureau of the Census
20Metropolitan Statistical Area but having a population of 60,000
21or less.
22    (b) It is the intent of the General Assembly to provide for
23the payment for ground ambulance services as part of the State
24Medicaid plan and to provide adequate payment for ground
25ambulance services under the State Medicaid plan so as to
26ensure adequate access to ground ambulance services for both



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1recipients of aid under this Article and for the general
2population of Illinois. Unless otherwise indicated in this
3Section, the practices of the Department concerning payments
4for ground ambulance services provided to recipients of aid
5under this Article shall be consistent with the payment
6principles of Medicare.
7    (c) For ground ambulance services provided to a recipient
8of aid under this Article on or after January 1, 2014, the
9Department shall provide payment to ground ambulance services
10providers for base charges and mileage charges based upon the
11lesser of the provider's charge, as reflected on the provider's
12claim form, or the Illinois Medicaid Ambulance Fee Schedule
13payment rates calculated in accordance with this Section.
14    Effective January 1, 2014, the Illinois Medicaid Ambulance
15Fee Schedule shall be established and shall include only the
16ground ambulance services payment rates outlined in the
17Medicare Ambulance Fee Schedule as promulgated by the Centers
18for Medicare and Medicaid Services in effect as of July 1, 2013
19and adjusted for the 4 Medicare Localities in Illinois, with an
20adjustment of 80% of the Medicare Ambulance Fee Schedule
21payment rates, by Medicare Locality, for both base rates and
22mileage for all counties. The transition from the current
23payment system to the Illinois Medicaid Ambulance Fee Schedule
24shall be as follows: Effective for dates of service on or after
25January 1, 2014, for each individual base rate and mileage
26rate, the payment rate for ground ambulance services shall be



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1based on the Illinois Medicaid Ambulance Fee Schedule amount in
2effect on January 1, 2014 for the designated Medicare Locality,
3except that any payment rate that was previously approved by
4the Department that exceeds this amount shall remain in force.
5    Notwithstanding the payment principles in subsection (b)
6of this Section, the Department shall develop the Illinois
7Medicaid Ambulance Fee Schedule using the ground mileage
8payment rate, as defined by the Centers for Medicare and
9Medicaid Services. For ground ambulance services provided
10where the point of pickup is in a rural county, the Department
11shall pay an amount equal to one and one-half times the ground
12mileage rate for the first 17 miles of such a transport and the
13ground mileage rate for the remaining miles of the transport.
14    (d) Payment for mileage shall be per loaded mile with no
15loaded mileage included in the base rate. If a natural
16disaster, weather, road repairs, traffic congestion, or other
17conditions necessitate a route other than the most direct
18route, payment shall be based upon the actual distance
19traveled. When a ground ambulance services provider provides
20transport pursuant to an emergency call as defined by the
21Centers for Medicare and Medicaid Services, no reduction in the
22mileage payment shall be made based upon the fact that a closer
23facility may have been available, so long as the ground
24ambulance services provider provided transport to the
25recipient's facility of choice or other appropriate facility
26described within the scope of the Illinois Emergency Medical



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1Services (EMS) Systems Act and associated rules or the policies
2and procedures of the EMS System of which the provider is a
4    (d-5) The Department shall provide payment for emergency
5ground ambulance services provided to a recipient of aid under
6this Article according to the requirements provided in
7subsection (b) of this Section when those services are provided
8pursuant to a request made through a 9-1-1 or equivalent
9emergency telephone number for evaluation, treatment, and
10transport from or on behalf of an individual with a condition
11of such a nature that a prudent layperson would have reasonably
12expected that a delay in seeking immediate medical attention
13would have been hazardous to life or health. This standard is
14deemed to be met if there is an emergency medical condition
15manifesting itself by acute symptoms of sufficient severity,
16including but not limited to severe pain, such that a prudent
17layperson who possesses an average knowledge of medicine and
18health can reasonably expect that the absence of immediate
19medical attention could result in placing the health of the
20individual or, with respect to a pregnant woman, the health of
21the woman or her unborn child, in serious jeopardy, cause
22serious impairment to bodily functions, or cause serious
23dysfunction of any bodily organ or part.
24    (e) For ground ambulance services provided to a recipient
25enrolled in a Medicaid managed care plan by a ground ambulance
26services provider that is not a contracted provider to the



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1Medicaid managed care plan in question, the amount of the
2payment for ground ambulance services by the Medicaid managed
3care plan shall be the lesser of the provider's charge, as
4reflected on the provider's claim form, or the Illinois
5Medicaid Ambulance Fee Schedule payment rates calculated in
6accordance with this Section.
7    (f) Nothing in this Section prohibits the Department from
8setting payment rates for out-of-State ground ambulance
9services providers by administrative rule.
10    (f-1) Nothing in this Section prohibits the Department from
11setting payment rates for ground ambulance services providers
12by administrative rule pending the availability of
13appropriations dedicated to rate increases provided under
14subsection (c).
15    (f-2) All payments under subsection (c) of this Section are
16subject to the availability of appropriations for those
18    (a) For ambulance services provided to a recipient of aid
19under this Article on or after January 1, 1993, the Illinois
20Department shall reimburse ambulance service providers at
21rates calculated in accordance with this Section. It is the
22intent of the General Assembly to provide adequate
23reimbursement for ambulance services so as to ensure adequate
24access to services for recipients of aid under this Article and
25to provide appropriate incentives to ambulance service
26providers to provide services in an efficient and



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1cost-effective manner. Thus, it is the intent of the General
2Assembly that the Illinois Department implement a
3reimbursement system for ambulance services that, to the extent
4practicable and subject to the availability of funds
5appropriated by the General Assembly for this purpose, is
6consistent with the payment principles of Medicare. To ensure
7uniformity between the payment principles of Medicare and
8Medicaid, the Illinois Department shall follow, to the extent
9necessary and practicable and subject to the availability of
10funds appropriated by the General Assembly for this purpose,
11the statutes, laws, regulations, policies, procedures,
12principles, definitions, guidelines, and manuals used to
13determine the amounts paid to ambulance service providers under
14Title XVIII of the Social Security Act (Medicare).
15    (b) For ambulance services provided to a recipient of aid
16under this Article on or after January 1, 1996, the Illinois
17Department shall reimburse ambulance service providers based
18upon the actual distance traveled if a natural disaster,
19weather conditions, road repairs, or traffic congestion
20necessitates the use of a route other than the most direct
22    (c) For purposes of this Section, "ambulance services"
23includes medical transportation services provided by means of
24an ambulance, medi-car, service car, or taxi.
25    (c-1) For purposes of this Section, "ground ambulance
26service" means medical transportation services that are



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1described as ground ambulance services by the Centers for
2Medicare and Medicaid Services and provided in a vehicle that
3is licensed as an ambulance by the Illinois Department of
4Public Health pursuant to the Emergency Medical Services (EMS)
5Systems Act.
6    (c-2) For purposes of this Section, "ground ambulance
7service provider" means a vehicle service provider as described
8in the Emergency Medical Services (EMS) Systems Act that
9operates licensed ambulances for the purpose of providing
10emergency ambulance services, or non-emergency ambulance
11services, or both. For purposes of this Section, this includes
12both ambulance providers and ambulance suppliers as described
13by the Centers for Medicare and Medicaid Services.
14    (d) This Section does not prohibit separate billing by
15ambulance service providers for oxygen furnished while
16providing advanced life support services.
17    (f-3) (e) Beginning with services rendered on or after July
181, 2008, all providers of non-emergency medi-car and service
19car transportation must certify that the driver and employee
20attendant, as applicable, have completed a safety program
21approved by the Department to protect both the patient and the
22driver, prior to transporting a patient. The provider must
23maintain this certification in its records. The provider shall
24produce such documentation upon demand by the Department or its
25representative. Failure to produce documentation of such
26training shall result in recovery of any payments made by the



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1Department for services rendered by a non-certified driver or
2employee attendant. Medi-car and service car providers must
3maintain legible documentation in their records of the driver
4and, as applicable, employee attendant that actually
5transported the patient. Providers must recertify all drivers
6and employee attendants every 3 years.
7    Notwithstanding the requirements above, any public
8transportation provider of medi-car and service car
9transportation that receives federal funding under 49 U.S.C.
105307 and 5311 need not certify its drivers and employee
11attendants under this Section, since safety training is already
12federally mandated.
13    (f-4) (f) With respect to any policy or program
14administered by the Department or its agent regarding approval
15of non-emergency medical transportation by ground ambulance
16service providers, including, but not limited to, the
17Non-Emergency Transportation Services Prior Approval Program
18(NETSPAP), the Department shall establish by rule a process by
19which ground ambulance service providers of non-emergency
20medical transportation may appeal any decision by the
21Department or its agent for which no denial was received prior
22to the time of transport that either (i) denies a request for
23approval for payment of non-emergency transportation by means
24of ground ambulance service or (ii) grants a request for
25approval of non-emergency transportation by means of ground
26ambulance service at a level of service that entitles the



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1ground ambulance service provider to a lower level of
2compensation from the Department than the ground ambulance
3service provider would have received as compensation for the
4level of service requested. The rule shall be filed by December
515, 2012 and shall provide that, for any decision rendered by
6the Department or its agent on or after the date the rule takes
7effect, the ground ambulance service provider shall have 60
8days from the date the decision is received to file an appeal.
9The rule established by the Department shall be, insofar as is
10practical, consistent with the Illinois Administrative
11Procedure Act. The Director's decision on an appeal under this
12Section shall be a final administrative decision subject to
13review under the Administrative Review Law.
14    (f-5) (g) Beginning 90 days after July 20, 2012 (the
15effective date of Public Act 97-842) this amendatory Act of the
1697th General Assembly, (i) no denial of a request for approval
17for payment of non-emergency transportation by means of ground
18ambulance service, and (ii) no approval of non-emergency
19transportation by means of ground ambulance service at a level
20of service that entitles the ground ambulance service provider
21to a lower level of compensation from the Department than would
22have been received at the level of service submitted by the
23ground ambulance service provider, may be issued by the
24Department or its agent unless the Department has submitted the
25criteria for determining the appropriateness of the transport
26for first notice publication in the Illinois Register pursuant



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1to Section 5-40 of the Illinois Administrative Procedure Act.
2    (g) Whenever a patient covered by a medical assistance
3program under this Code or by another medical program
4administered by the Department is being discharged from a
5facility, a physician discharge order as described in this
6Section shall be required for each patient whose discharge
7requires medically supervised ground ambulance services.
8Facilities shall develop procedures for a physician with
9medical staff privileges to provide a written and signed
10physician discharge order. The physician discharge order shall
11specify the level of ground ambulance services needed and
12complete a medical certification establishing the criteria for
13approval of non-emergency ambulance transportation, as
14published by the Department of Healthcare and Family Services,
15that is met by the patient. This order and the medical
16certification shall be completed prior to ordering an ambulance
17service and prior to patient discharge.
18    Pursuant to subsection (E) of Section 12-4.25 of this Code,
19the Department is entitled to recover overpayments paid to a
20provider or vendor, including, but not limited to, from the
21discharging physician, the discharging facility, and the
22ground ambulance service provider, in instances where a
23non-emergency ground ambulance service is rendered as the
24result of improper or false certification.
25    (h) On and after July 1, 2012, the Department shall reduce
26any rate of reimbursement for services or other payments or



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1alter any methodologies authorized by this Code to reduce any
2rate of reimbursement for services or other payments in
3accordance with Section 5-5e.
4(Source: P.A. 97-584, eff. 8-26-11; 97-689, eff. 6-14-12;
597-842, eff. 7-20-12; revised 8-3-12.)
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    Sec. 5-5. Medical services. The Illinois Department, by
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing home,
16or elsewhere; (6) medical care, or any other type of remedial
17care furnished by licensed practitioners; (7) home health care
18services; (8) private duty nursing service; (9) clinic
19services; (10) dental services, including prevention and
20treatment of periodontal disease and dental caries disease for
21pregnant women, provided by an individual licensed to practice
22dentistry or dental surgery; for purposes of this item (10),
23"dental services" means diagnostic, preventive, or corrective
24procedures provided by or under the supervision of a dentist in
25the practice of his or her profession; (11) physical therapy



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1and related services; (12) prescribed drugs, dentures, and
2prosthetic devices; and eyeglasses prescribed by a physician
3skilled in the diseases of the eye, or by an optometrist,
4whichever the person may select; (13) other diagnostic,
5screening, preventive, and rehabilitative services, including
6to ensure that the individual's need for intervention or
7treatment of mental disorders or substance use disorders or
8co-occurring mental health and substance use disorders is
9determined using a uniform screening, assessment, and
10evaluation process inclusive of criteria, for children and
11adults; for purposes of this item (13), a uniform screening,
12assessment, and evaluation process refers to a process that
13includes an appropriate evaluation and, as warranted, a
14referral; "uniform" does not mean the use of a singular
15instrument, tool, or process that all must utilize; (14)
16transportation and such other expenses as may be necessary,
17provided that payment for ground ambulance services shall be as
18provided in Section 5-4.2; (15) medical treatment of sexual
19assault survivors, as defined in Section 1a of the Sexual
20Assault Survivors Emergency Treatment Act, for injuries
21sustained as a result of the sexual assault, including
22examinations and laboratory tests to discover evidence which
23may be used in criminal proceedings arising from the sexual
24assault; (16) the diagnosis and treatment of sickle cell
25anemia; and (17) any other medical care, and any other type of
26remedial care recognized under the laws of this State, but not



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1including abortions, or induced miscarriages or premature
2births, unless, in the opinion of a physician, such procedures
3are necessary for the preservation of the life of the woman
4seeking such treatment, or except an induced premature birth
5intended to produce a live viable child and such procedure is
6necessary for the health of the mother or her unborn child. The
7Illinois Department, by rule, shall prohibit any physician from
8providing medical assistance to anyone eligible therefor under
9this Code where such physician has been found guilty of
10performing an abortion procedure in a wilful and wanton manner
11upon a woman who was not pregnant at the time such abortion
12procedure was performed. The term "any other type of remedial
13care" shall include nursing care and nursing home service for
14persons who rely on treatment by spiritual means alone through
15prayer for healing.
16    Notwithstanding any other provision of this Section, a
17comprehensive tobacco use cessation program that includes
18purchasing prescription drugs or prescription medical devices
19approved by the Food and Drug Administration shall be covered
20under the medical assistance program under this Article for
21persons who are otherwise eligible for assistance under this
23    Notwithstanding any other provision of this Code, the
24Illinois Department may not require, as a condition of payment
25for any laboratory test authorized under this Article, that a
26physician's handwritten signature appear on the laboratory



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1test order form. The Illinois Department may, however, impose
2other appropriate requirements regarding laboratory test order
4    On and after July 1, 2012, the Department of Healthcare and
5Family Services may provide the following services to persons
6eligible for assistance under this Article who are
7participating in education, training or employment programs
8operated by the Department of Human Services as successor to
9the Department of Public Aid:
10        (1) dental services provided by or under the
11    supervision of a dentist; and
12        (2) eyeglasses prescribed by a physician skilled in the
13    diseases of the eye, or by an optometrist, whichever the
14    person may select.
15    Notwithstanding any other provision of this Code and
16subject to federal approval, the Department may adopt rules to
17allow a dentist who is volunteering his or her service at no
18cost to render dental services through an enrolled
19not-for-profit health clinic without the dentist personally
20enrolling as a participating provider in the medical assistance
21program. A not-for-profit health clinic shall include a public
22health clinic or Federally Qualified Health Center or other
23enrolled provider, as determined by the Department, through
24which dental services covered under this Section are performed.
25The Department shall establish a process for payment of claims
26for reimbursement for covered dental services rendered under



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1this provision.
2    The Illinois Department, by rule, may distinguish and
3classify the medical services to be provided only in accordance
4with the classes of persons designated in Section 5-2.
5    The Department of Healthcare and Family Services must
6provide coverage and reimbursement for amino acid-based
7elemental formulas, regardless of delivery method, for the
8diagnosis and treatment of (i) eosinophilic disorders and (ii)
9short bowel syndrome when the prescribing physician has issued
10a written order stating that the amino acid-based elemental
11formula is medically necessary.
12    The Illinois Department shall authorize the provision of,
13and shall authorize payment for, screening by low-dose
14mammography for the presence of occult breast cancer for women
1535 years of age or older who are eligible for medical
16assistance under this Article, as follows:
17        (A) A baseline mammogram for women 35 to 39 years of
18    age.
19        (B) An annual mammogram for women 40 years of age or
20    older.
21        (C) A mammogram at the age and intervals considered
22    medically necessary by the woman's health care provider for
23    women under 40 years of age and having a family history of
24    breast cancer, prior personal history of breast cancer,
25    positive genetic testing, or other risk factors.
26        (D) A comprehensive ultrasound screening of an entire



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1    breast or breasts if a mammogram demonstrates
2    heterogeneous or dense breast tissue, when medically
3    necessary as determined by a physician licensed to practice
4    medicine in all of its branches.
5    All screenings shall include a physical breast exam,
6instruction on self-examination and information regarding the
7frequency of self-examination and its value as a preventative
8tool. For purposes of this Section, "low-dose mammography"
9means the x-ray examination of the breast using equipment
10dedicated specifically for mammography, including the x-ray
11tube, filter, compression device, and image receptor, with an
12average radiation exposure delivery of less than one rad per
13breast for 2 views of an average size breast. The term also
14includes digital mammography.
15    On and after January 1, 2012, providers participating in a
16quality improvement program approved by the Department shall be
17reimbursed for screening and diagnostic mammography at the same
18rate as the Medicare program's rates, including the increased
19reimbursement for digital mammography.
20    The Department shall convene an expert panel including
21representatives of hospitals, free-standing mammography
22facilities, and doctors, including radiologists, to establish
23quality standards.
24    Subject to federal approval, the Department shall
25establish a rate methodology for mammography at federally
26qualified health centers and other encounter-rate clinics.



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1These clinics or centers may also collaborate with other
2hospital-based mammography facilities.
3    The Department shall establish a methodology to remind
4women who are age-appropriate for screening mammography, but
5who have not received a mammogram within the previous 18
6months, of the importance and benefit of screening mammography.
7    The Department shall establish a performance goal for
8primary care providers with respect to their female patients
9over age 40 receiving an annual mammogram. This performance
10goal shall be used to provide additional reimbursement in the
11form of a quality performance bonus to primary care providers
12who meet that goal.
13    The Department shall devise a means of case-managing or
14patient navigation for beneficiaries diagnosed with breast
15cancer. This program shall initially operate as a pilot program
16in areas of the State with the highest incidence of mortality
17related to breast cancer. At least one pilot program site shall
18be in the metropolitan Chicago area and at least one site shall
19be outside the metropolitan Chicago area. An evaluation of the
20pilot program shall be carried out measuring health outcomes
21and cost of care for those served by the pilot program compared
22to similarly situated patients who are not served by the pilot
24    Any medical or health care provider shall immediately
25recommend, to any pregnant woman who is being provided prenatal
26services and is suspected of drug abuse or is addicted as



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1defined in the Alcoholism and Other Drug Abuse and Dependency
2Act, referral to a local substance abuse treatment provider
3licensed by the Department of Human Services or to a licensed
4hospital which provides substance abuse treatment services.
5The Department of Healthcare and Family Services shall assure
6coverage for the cost of treatment of the drug abuse or
7addiction for pregnant recipients in accordance with the
8Illinois Medicaid Program in conjunction with the Department of
9Human Services.
10    All medical providers providing medical assistance to
11pregnant women under this Code shall receive information from
12the Department on the availability of services under the Drug
13Free Families with a Future or any comparable program providing
14case management services for addicted women, including
15information on appropriate referrals for other social services
16that may be needed by addicted women in addition to treatment
17for addiction.
18    The Illinois Department, in cooperation with the
19Departments of Human Services (as successor to the Department
20of Alcoholism and Substance Abuse) and Public Health, through a
21public awareness campaign, may provide information concerning
22treatment for alcoholism and drug abuse and addiction, prenatal
23health care, and other pertinent programs directed at reducing
24the number of drug-affected infants born to recipients of
25medical assistance.
26    Neither the Department of Healthcare and Family Services



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1nor the Department of Human Services shall sanction the
2recipient solely on the basis of her substance abuse.
3    The Illinois Department shall establish such regulations
4governing the dispensing of health services under this Article
5as it shall deem appropriate. The Department should seek the
6advice of formal professional advisory committees appointed by
7the Director of the Illinois Department for the purpose of
8providing regular advice on policy and administrative matters,
9information dissemination and educational activities for
10medical and health care providers, and consistency in
11procedures to the Illinois Department.
12    The Illinois Department may develop and contract with
13Partnerships of medical providers to arrange medical services
14for persons eligible under Section 5-2 of this Code.
15Implementation of this Section may be by demonstration projects
16in certain geographic areas. The Partnership shall be
17represented by a sponsor organization. The Department, by rule,
18shall develop qualifications for sponsors of Partnerships.
19Nothing in this Section shall be construed to require that the
20sponsor organization be a medical organization.
21    The sponsor must negotiate formal written contracts with
22medical providers for physician services, inpatient and
23outpatient hospital care, home health services, treatment for
24alcoholism and substance abuse, and other services determined
25necessary by the Illinois Department by rule for delivery by
26Partnerships. Physician services must include prenatal and



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1obstetrical care. The Illinois Department shall reimburse
2medical services delivered by Partnership providers to clients
3in target areas according to provisions of this Article and the
4Illinois Health Finance Reform Act, except that:
5        (1) Physicians participating in a Partnership and
6    providing certain services, which shall be determined by
7    the Illinois Department, to persons in areas covered by the
8    Partnership may receive an additional surcharge for such
9    services.
10        (2) The Department may elect to consider and negotiate
11    financial incentives to encourage the development of
12    Partnerships and the efficient delivery of medical care.
13        (3) Persons receiving medical services through
14    Partnerships may receive medical and case management
15    services above the level usually offered through the
16    medical assistance program.
17    Medical providers shall be required to meet certain
18qualifications to participate in Partnerships to ensure the
19delivery of high quality medical services. These
20qualifications shall be determined by rule of the Illinois
21Department and may be higher than qualifications for
22participation in the medical assistance program. Partnership
23sponsors may prescribe reasonable additional qualifications
24for participation by medical providers, only with the prior
25written approval of the Illinois Department.
26    Nothing in this Section shall limit the free choice of



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1practitioners, hospitals, and other providers of medical
2services by clients. In order to ensure patient freedom of
3choice, the Illinois Department shall immediately promulgate
4all rules and take all other necessary actions so that provided
5services may be accessed from therapeutically certified
6optometrists to the full extent of the Illinois Optometric
7Practice Act of 1987 without discriminating between service
9    The Department shall apply for a waiver from the United
10States Health Care Financing Administration to allow for the
11implementation of Partnerships under this Section.
12    The Illinois Department shall require health care
13providers to maintain records that document the medical care
14and services provided to recipients of Medical Assistance under
15this Article. Such records must be retained for a period of not
16less than 6 years from the date of service or as provided by
17applicable State law, whichever period is longer, except that
18if an audit is initiated within the required retention period
19then the records must be retained until the audit is completed
20and every exception is resolved. The Illinois Department shall
21require health care providers to make available, when
22authorized by the patient, in writing, the medical records in a
23timely fashion to other health care providers who are treating
24or serving persons eligible for Medical Assistance under this
25Article. All dispensers of medical services shall be required
26to maintain and retain business and professional records



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1sufficient to fully and accurately document the nature, scope,
2details and receipt of the health care provided to persons
3eligible for medical assistance under this Code, in accordance
4with regulations promulgated by the Illinois Department. The
5rules and regulations shall require that proof of the receipt
6of prescription drugs, dentures, prosthetic devices and
7eyeglasses by eligible persons under this Section accompany
8each claim for reimbursement submitted by the dispenser of such
9medical services. No such claims for reimbursement shall be
10approved for payment by the Illinois Department without such
11proof of receipt, unless the Illinois Department shall have put
12into effect and shall be operating a system of post-payment
13audit and review which shall, on a sampling basis, be deemed
14adequate by the Illinois Department to assure that such drugs,
15dentures, prosthetic devices and eyeglasses for which payment
16is being made are actually being received by eligible
17recipients. Within 90 days after the effective date of this
18amendatory Act of 1984, the Illinois Department shall establish
19a current list of acquisition costs for all prosthetic devices
20and any other items recognized as medical equipment and
21supplies reimbursable under this Article and shall update such
22list on a quarterly basis, except that the acquisition costs of
23all prescription drugs shall be updated no less frequently than
24every 30 days as required by Section 5-5.12.
25    The rules and regulations of the Illinois Department shall
26require that a written statement including the required opinion



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1of a physician shall accompany any claim for reimbursement for
2abortions, or induced miscarriages or premature births. This
3statement shall indicate what procedures were used in providing
4such medical services.
5    The Illinois Department shall require all dispensers of
6medical services, other than an individual practitioner or
7group of practitioners, desiring to participate in the Medical
8Assistance program established under this Article to disclose
9all financial, beneficial, ownership, equity, surety or other
10interests in any and all firms, corporations, partnerships,
11associations, business enterprises, joint ventures, agencies,
12institutions or other legal entities providing any form of
13health care services in this State under this Article.
14    The Illinois Department may require that all dispensers of
15medical services desiring to participate in the medical
16assistance program established under this Article disclose,
17under such terms and conditions as the Illinois Department may
18by rule establish, all inquiries from clients and attorneys
19regarding medical bills paid by the Illinois Department, which
20inquiries could indicate potential existence of claims or liens
21for the Illinois Department.
22    Enrollment of a vendor shall be subject to a provisional
23period and shall be conditional for one year. During the period
24of conditional enrollment, the Department may terminate the
25vendor's eligibility to participate in, or may disenroll the
26vendor from, the medical assistance program without cause.



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



SB1722- 26 -LRB098 07791 KTG 37871 b

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



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1Department is not the primary payer, claims must be submitted
2to the Illinois Department within 180 days after the final
3adjudication by the primary payer.
4    In the case of long term care facilities, admission
5documents shall be submitted within 30 days of an admission to
6the facility through the Medical Electronic Data Interchange
7(MEDI) or the Recipient Eligibility Verification (REV) System,
8or shall be submitted directly to the Department of Human
9Services using required admission forms. Confirmation numbers
10assigned to an accepted transaction shall be retained by a
11facility to verify timely submittal. Once an admission
12transaction has been completed, all resubmitted claims
13following prior rejection are subject to receipt no later than
14180 days after the admission transaction has been completed.
15    Claims that are not submitted and received in compliance
16with the foregoing requirements shall not be eligible for
17payment under the medical assistance program, and the State
18shall have no liability for payment of those claims.
19    To the extent consistent with applicable information and
20privacy, security, and disclosure laws, State and federal
21agencies and departments shall provide the Illinois Department
22access to confidential and other information and data necessary
23to perform eligibility and payment verifications and other
24Illinois Department functions. This includes, but is not
25limited to: information pertaining to licensure;
26certification; earnings; immigration status; citizenship; wage



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1reporting; unearned and earned income; pension income;
2employment; supplemental security income; social security
3numbers; National Provider Identifier (NPI) numbers; the
4National Practitioner Data Bank (NPDB); program and agency
5exclusions; taxpayer identification numbers; tax delinquency;
6corporate information; and death records.
7    The Illinois Department shall enter into agreements with
8State agencies and departments, and is authorized to enter into
9agreements with federal agencies and departments, under which
10such agencies and departments shall share data necessary for
11medical assistance program integrity functions and oversight.
12The Illinois Department shall develop, in cooperation with
13other State departments and agencies, and in compliance with
14applicable federal laws and regulations, appropriate and
15effective methods to share such data. At a minimum, and to the
16extent necessary to provide data sharing, the Illinois
17Department shall enter into agreements with State agencies and
18departments, and is authorized to enter into agreements with
19federal agencies and departments, including but not limited to:
20the Secretary of State; the Department of Revenue; the
21Department of Public Health; the Department of Human Services;
22and the Department of Financial and Professional Regulation.
23    Beginning in fiscal year 2013, the Illinois Department
24shall set forth a request for information to identify the
25benefits of a pre-payment, post-adjudication, and post-edit
26claims system with the goals of streamlining claims processing



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1and provider reimbursement, reducing the number of pending or
2rejected claims, and helping to ensure a more transparent
3adjudication process through the utilization of: (i) provider
4data verification and provider screening technology; and (ii)
5clinical code editing; and (iii) pre-pay, pre- or
6post-adjudicated predictive modeling with an integrated case
7management system with link analysis. Such a request for
8information shall not be considered as a request for proposal
9or as an obligation on the part of the Illinois Department to
10take any action or acquire any products or services.
11    The Illinois Department shall establish policies,
12procedures, standards and criteria by rule for the acquisition,
13repair and replacement of orthotic and prosthetic devices and
14durable medical equipment. Such rules shall provide, but not be
15limited to, the following services: (1) immediate repair or
16replacement of such devices by recipients; and (2) rental,
17lease, purchase or lease-purchase of durable medical equipment
18in a cost-effective manner, taking into consideration the
19recipient's medical prognosis, the extent of the recipient's
20needs, and the requirements and costs for maintaining such
21equipment. Subject to prior approval, such rules shall enable a
22recipient to temporarily acquire and use alternative or
23substitute devices or equipment pending repairs or
24replacements of any device or equipment previously authorized
25for such recipient by the Department.
26    The Department shall execute, relative to the nursing home



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



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



SB1722- 32 -LRB098 07791 KTG 37871 b

1Research Unit, and such additional copies with the State
2Government Report Distribution Center for the General Assembly
3as is required under paragraph (t) of Section 7 of the State
4Library Act shall be deemed sufficient to comply with this
6    Rulemaking authority to implement Public Act 95-1045, if
7any, is conditioned on the rules being adopted in accordance
8with all provisions of the Illinois Administrative Procedure
9Act and all rules and procedures of the Joint Committee on
10Administrative Rules; any purported rule not so adopted, for
11whatever reason, is unauthorized.
12    On and after July 1, 2012, the Department shall reduce any
13rate of reimbursement for services or other payments or alter
14any methodologies authorized by this Code to reduce any rate of
15reimbursement for services or other payments in accordance with
16Section 5-5e.
17(Source: P.A. 96-156, eff. 1-1-10; 96-806, eff. 7-1-10; 96-926,
18eff. 1-1-11; 96-1000, eff. 7-2-10; 97-48, eff. 6-28-11; 97-638,
19eff. 1-1-12; 97-689, eff. 6-14-12; 97-1061, eff. 8-24-12;
20revised 9-20-12.)
21    Section 99. Effective date. This Act takes effect July 1,