99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
SB1254

 

Introduced 2/17/2015, by Sen. Antonio Muņoz

 

SYNOPSIS AS INTRODUCED:
 
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, 2016, 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, 2016, 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, 2015.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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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
2Services.
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, 2016, 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, 2016, 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, 2016, 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, 2016 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
3member.
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
17purposes.
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
21route.
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) Beginning 90 days after July 20, 2012 (the effective
15date of Public Act 97-842), (i) no denial of a request for
16approval for payment of non-emergency transportation by means
17of ground ambulance service, and (ii) no approval of
18non-emergency transportation by means of ground ambulance
19service at a level of service that entitles the ground
20ambulance service provider to a lower level of compensation
21from the Department than would have been received at the level
22of service submitted by the ground ambulance service provider,
23may be issued by the Department or its agent unless the
24Department has submitted the criteria for determining the
25appropriateness of the transport for first notice publication
26in the Illinois Register pursuant to Section 5-40 of the

 

 

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1Illinois 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; 98-463, eff. 8-16-13.)
 
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
22Article.
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
3documentation.
4    Upon receipt of federal approval of an amendment to the
5Illinois Title XIX State Plan for this purpose, the Department
6shall authorize the Chicago Public Schools (CPS) to procure a
7vendor or vendors to manufacture eyeglasses for individuals
8enrolled in a school within the CPS system. CPS shall ensure
9that its vendor or vendors are enrolled as providers in the
10medical assistance program and in any capitated Medicaid
11managed care entity (MCE) serving individuals enrolled in a
12school within the CPS system. Under any contract procured under
13this provision, the vendor or vendors must serve only
14individuals enrolled in a school within the CPS system. Claims
15for services provided by CPS's vendor or vendors to recipients
16of benefits in the medical assistance program under this Code,
17the Children's Health Insurance Program, or the Covering ALL
18KIDS Health Insurance Program shall be submitted to the
19Department or the MCE in which the individual is enrolled for
20payment and shall be reimbursed at the Department's or the
21MCE's established rates or rate methodologies for eyeglasses.
22    On and after July 1, 2012, the Department of Healthcare and
23Family Services may provide the following services to persons
24eligible for assistance under this Article who are
25participating in education, training or employment programs
26operated by the Department of Human Services as successor to

 

 

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1the Department of Public Aid:
2        (1) dental services provided by or under the
3    supervision of a dentist; and
4        (2) eyeglasses prescribed by a physician skilled in the
5    diseases of the eye, or by an optometrist, whichever the
6    person may select.
7    Notwithstanding any other provision of this Code and
8subject to federal approval, the Department may adopt rules to
9allow a dentist who is volunteering his or her service at no
10cost to render dental services through an enrolled
11not-for-profit health clinic without the dentist personally
12enrolling as a participating provider in the medical assistance
13program. A not-for-profit health clinic shall include a public
14health clinic or Federally Qualified Health Center or other
15enrolled provider, as determined by the Department, through
16which dental services covered under this Section are performed.
17The Department shall establish a process for payment of claims
18for reimbursement for covered dental services rendered under
19this provision.
20    The Illinois Department, by rule, may distinguish and
21classify the medical services to be provided only in accordance
22with the classes of persons designated in Section 5-2.
23    The Department of Healthcare and Family Services must
24provide coverage and reimbursement for amino acid-based
25elemental formulas, regardless of delivery method, for the
26diagnosis and treatment of (i) eosinophilic disorders and (ii)

 

 

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1short bowel syndrome when the prescribing physician has issued
2a written order stating that the amino acid-based elemental
3formula is medically necessary.
4    The Illinois Department shall authorize the provision of,
5and shall authorize payment for, screening by low-dose
6mammography for the presence of occult breast cancer for women
735 years of age or older who are eligible for medical
8assistance under this Article, as follows:
9        (A) A baseline mammogram for women 35 to 39 years of
10    age.
11        (B) An annual mammogram for women 40 years of age or
12    older.
13        (C) A mammogram at the age and intervals considered
14    medically necessary by the woman's health care provider for
15    women under 40 years of age and having a family history of
16    breast cancer, prior personal history of breast cancer,
17    positive genetic testing, or other risk factors.
18        (D) A comprehensive ultrasound screening of an entire
19    breast or breasts if a mammogram demonstrates
20    heterogeneous or dense breast tissue, when medically
21    necessary as determined by a physician licensed to practice
22    medicine in all of its branches.
23    All screenings shall include a physical breast exam,
24instruction on self-examination and information regarding the
25frequency of self-examination and its value as a preventative
26tool. For purposes of this Section, "low-dose mammography"

 

 

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1means the x-ray examination of the breast using equipment
2dedicated specifically for mammography, including the x-ray
3tube, filter, compression device, and image receptor, with an
4average radiation exposure delivery of less than one rad per
5breast for 2 views of an average size breast. The term also
6includes digital mammography.
7    On and after January 1, 2012, providers participating in a
8quality improvement program approved by the Department shall be
9reimbursed for screening and diagnostic mammography at the same
10rate as the Medicare program's rates, including the increased
11reimbursement for digital mammography.
12    The Department shall convene an expert panel including
13representatives of hospitals, free-standing mammography
14facilities, and doctors, including radiologists, to establish
15quality standards.
16    Subject to federal approval, the Department shall
17establish a rate methodology for mammography at federally
18qualified health centers and other encounter-rate clinics.
19These clinics or centers may also collaborate with other
20hospital-based mammography facilities.
21    The Department shall establish a methodology to remind
22women who are age-appropriate for screening mammography, but
23who have not received a mammogram within the previous 18
24months, of the importance and benefit of screening mammography.
25    The Department shall establish a performance goal for
26primary care providers with respect to their female patients

 

 

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1over age 40 receiving an annual mammogram. This performance
2goal shall be used to provide additional reimbursement in the
3form of a quality performance bonus to primary care providers
4who meet that goal.
5    The Department shall devise a means of case-managing or
6patient navigation for beneficiaries diagnosed with breast
7cancer. This program shall initially operate as a pilot program
8in areas of the State with the highest incidence of mortality
9related to breast cancer. At least one pilot program site shall
10be in the metropolitan Chicago area and at least one site shall
11be outside the metropolitan Chicago area. An evaluation of the
12pilot program shall be carried out measuring health outcomes
13and cost of care for those served by the pilot program compared
14to similarly situated patients who are not served by the pilot
15program.
16    Any medical or health care provider shall immediately
17recommend, to any pregnant woman who is being provided prenatal
18services and is suspected of drug abuse or is addicted as
19defined in the Alcoholism and Other Drug Abuse and Dependency
20Act, referral to a local substance abuse treatment provider
21licensed by the Department of Human Services or to a licensed
22hospital which provides substance abuse treatment services.
23The Department of Healthcare and Family Services shall assure
24coverage for the cost of treatment of the drug abuse or
25addiction for pregnant recipients in accordance with the
26Illinois Medicaid Program in conjunction with the Department of

 

 

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1Human Services.
2    All medical providers providing medical assistance to
3pregnant women under this Code shall receive information from
4the Department on the availability of services under the Drug
5Free Families with a Future or any comparable program providing
6case management services for addicted women, including
7information on appropriate referrals for other social services
8that may be needed by addicted women in addition to treatment
9for addiction.
10    The Illinois Department, in cooperation with the
11Departments of Human Services (as successor to the Department
12of Alcoholism and Substance Abuse) and Public Health, through a
13public awareness campaign, may provide information concerning
14treatment for alcoholism and drug abuse and addiction, prenatal
15health care, and other pertinent programs directed at reducing
16the number of drug-affected infants born to recipients of
17medical assistance.
18    Neither the Department of Healthcare and Family Services
19nor the Department of Human Services shall sanction the
20recipient solely on the basis of her substance abuse.
21    The Illinois Department shall establish such regulations
22governing the dispensing of health services under this Article
23as it shall deem appropriate. The Department should seek the
24advice of formal professional advisory committees appointed by
25the Director of the Illinois Department for the purpose of
26providing regular advice on policy and administrative matters,

 

 

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1information dissemination and educational activities for
2medical and health care providers, and consistency in
3procedures to the Illinois Department.
4    The Illinois Department may develop and contract with
5Partnerships of medical providers to arrange medical services
6for persons eligible under Section 5-2 of this Code.
7Implementation of this Section may be by demonstration projects
8in certain geographic areas. The Partnership shall be
9represented by a sponsor organization. The Department, by rule,
10shall develop qualifications for sponsors of Partnerships.
11Nothing in this Section shall be construed to require that the
12sponsor organization be a medical organization.
13    The sponsor must negotiate formal written contracts with
14medical providers for physician services, inpatient and
15outpatient hospital care, home health services, treatment for
16alcoholism and substance abuse, and other services determined
17necessary by the Illinois Department by rule for delivery by
18Partnerships. Physician services must include prenatal and
19obstetrical care. The Illinois Department shall reimburse
20medical services delivered by Partnership providers to clients
21in target areas according to provisions of this Article and the
22Illinois Health Finance Reform Act, except that:
23        (1) Physicians participating in a Partnership and
24    providing certain services, which shall be determined by
25    the Illinois Department, to persons in areas covered by the
26    Partnership may receive an additional surcharge for such

 

 

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1    services.
2        (2) The Department may elect to consider and negotiate
3    financial incentives to encourage the development of
4    Partnerships and the efficient delivery of medical care.
5        (3) Persons receiving medical services through
6    Partnerships may receive medical and case management
7    services above the level usually offered through the
8    medical assistance program.
9    Medical providers shall be required to meet certain
10qualifications to participate in Partnerships to ensure the
11delivery of high quality medical services. These
12qualifications shall be determined by rule of the Illinois
13Department and may be higher than qualifications for
14participation in the medical assistance program. Partnership
15sponsors may prescribe reasonable additional qualifications
16for participation by medical providers, only with the prior
17written approval of the Illinois Department.
18    Nothing in this Section shall limit the free choice of
19practitioners, hospitals, and other providers of medical
20services by clients. In order to ensure patient freedom of
21choice, the Illinois Department shall immediately promulgate
22all rules and take all other necessary actions so that provided
23services may be accessed from therapeutically certified
24optometrists to the full extent of the Illinois Optometric
25Practice Act of 1987 without discriminating between service
26providers.

 

 

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1    The Department shall apply for a waiver from the United
2States Health Care Financing Administration to allow for the
3implementation of Partnerships under this Section.
4    The Illinois Department shall require health care
5providers to maintain records that document the medical care
6and services provided to recipients of Medical Assistance under
7this Article. Such records must be retained for a period of not
8less than 6 years from the date of service or as provided by
9applicable State law, whichever period is longer, except that
10if an audit is initiated within the required retention period
11then the records must be retained until the audit is completed
12and every exception is resolved. The Illinois Department shall
13require health care providers to make available, when
14authorized by the patient, in writing, the medical records in a
15timely fashion to other health care providers who are treating
16or serving persons eligible for Medical Assistance under this
17Article. All dispensers of medical services shall be required
18to maintain and retain business and professional records
19sufficient to fully and accurately document the nature, scope,
20details and receipt of the health care provided to persons
21eligible for medical assistance under this Code, in accordance
22with regulations promulgated by the Illinois Department. The
23rules and regulations shall require that proof of the receipt
24of prescription drugs, dentures, prosthetic devices and
25eyeglasses by eligible persons under this Section accompany
26each claim for reimbursement submitted by the dispenser of such

 

 

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1medical services. No such claims for reimbursement shall be
2approved for payment by the Illinois Department without such
3proof of receipt, unless the Illinois Department shall have put
4into effect and shall be operating a system of post-payment
5audit and review which shall, on a sampling basis, be deemed
6adequate by the Illinois Department to assure that such drugs,
7dentures, prosthetic devices and eyeglasses for which payment
8is being made are actually being received by eligible
9recipients. Within 90 days after the effective date of this
10amendatory Act of 1984, the Illinois Department shall establish
11a current list of acquisition costs for all prosthetic devices
12and any other items recognized as medical equipment and
13supplies reimbursable under this Article and shall update such
14list on a quarterly basis, except that the acquisition costs of
15all prescription drugs shall be updated no less frequently than
16every 30 days as required by Section 5-5.12.
17    The rules and regulations of the Illinois Department shall
18require that a written statement including the required opinion
19of a physician shall accompany any claim for reimbursement for
20abortions, or induced miscarriages or premature births. This
21statement shall indicate what procedures were used in providing
22such medical services.
23    Notwithstanding any other law to the contrary, the Illinois
24Department shall, within 365 days after July 22, 2013, (the
25effective date of Public Act 98-104), establish procedures to
26permit skilled care facilities licensed under the Nursing Home

 

 

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1Care Act to submit monthly billing claims for reimbursement
2purposes. Following development of these procedures, the
3Department shall have an additional 365 days to test the
4viability of the new system and to ensure that any necessary
5operational or structural changes to its information
6technology platforms are implemented.
7    Notwithstanding any other law to the contrary, the Illinois
8Department shall, within 365 days after August 15, 2014 (the
9effective date of Public Act 98-963) this amendatory Act of the
1098th General Assembly, establish procedures to permit ID/DD
11facilities licensed under the ID/DD Community Care Act to
12submit monthly billing claims for reimbursement purposes.
13Following development of these procedures, the Department
14shall have an additional 365 days to test the viability of the
15new system and to ensure that any necessary operational or
16structural changes to its information technology platforms are
17implemented.
18    The Illinois Department shall require all dispensers of
19medical services, other than an individual practitioner or
20group of practitioners, desiring to participate in the Medical
21Assistance program established under this Article to disclose
22all financial, beneficial, ownership, equity, surety or other
23interests in any and all firms, corporations, partnerships,
24associations, business enterprises, joint ventures, agencies,
25institutions or other legal entities providing any form of
26health care services in this State under this Article.

 

 

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1    The Illinois Department may require that all dispensers of
2medical services desiring to participate in the medical
3assistance program established under this Article disclose,
4under such terms and conditions as the Illinois Department may
5by rule establish, all inquiries from clients and attorneys
6regarding medical bills paid by the Illinois Department, which
7inquiries could indicate potential existence of claims or liens
8for the Illinois Department.
9    Enrollment of a vendor shall be subject to a provisional
10period and shall be conditional for one year. During the period
11of conditional enrollment, the Department may terminate the
12vendor's eligibility to participate in, or may disenroll the
13vendor from, the medical assistance program without cause.
14Unless otherwise specified, such termination of eligibility or
15disenrollment is not subject to the Department's hearing
16process. However, a disenrolled vendor may reapply without
17penalty.
18    The Department has the discretion to limit the conditional
19enrollment period for vendors based upon category of risk of
20the vendor.
21    Prior to enrollment and during the conditional enrollment
22period in the medical assistance program, all vendors shall be
23subject to enhanced oversight, screening, and review based on
24the risk of fraud, waste, and abuse that is posed by the
25category of risk of the vendor. The Illinois Department shall
26establish the procedures for oversight, screening, and review,

 

 

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1which may include, but need not be limited to: criminal and
2financial background checks; fingerprinting; license,
3certification, and authorization verifications; unscheduled or
4unannounced site visits; database checks; prepayment audit
5reviews; audits; payment caps; payment suspensions; and other
6screening as required by federal or State law.
7    The Department shall define or specify the following: (i)
8by provider notice, the "category of risk of the vendor" for
9each type of vendor, which shall take into account the level of
10screening applicable to a particular category of vendor under
11federal law and regulations; (ii) by rule or provider notice,
12the maximum length of the conditional enrollment period for
13each category of risk of the vendor; and (iii) by rule, the
14hearing rights, if any, afforded to a vendor in each category
15of risk of the vendor that is terminated or disenrolled during
16the conditional enrollment period.
17    To be eligible for payment consideration, a vendor's
18payment claim or bill, either as an initial claim or as a
19resubmitted claim following prior rejection, must be received
20by the Illinois Department, or its fiscal intermediary, no
21later than 180 days after the latest date on the claim on which
22medical goods or services were provided, with the following
23exceptions:
24        (1) In the case of a provider whose enrollment is in
25    process by the Illinois Department, the 180-day period
26    shall not begin until the date on the written notice from

 

 

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1    the Illinois Department that the provider enrollment is
2    complete.
3        (2) In the case of errors attributable to the Illinois
4    Department or any of its claims processing intermediaries
5    which result in an inability to receive, process, or
6    adjudicate a claim, the 180-day period shall not begin
7    until the provider has been notified of the error.
8        (3) In the case of a provider for whom the Illinois
9    Department initiates the monthly billing process.
10        (4) In the case of a provider operated by a unit of
11    local government with a population exceeding 3,000,000
12    when local government funds finance federal participation
13    for claims payments.
14    For claims for services rendered during a period for which
15a recipient received retroactive eligibility, claims must be
16filed within 180 days after the Department determines the
17applicant is eligible. For claims for which the Illinois
18Department is not the primary payer, claims must be submitted
19to the Illinois Department within 180 days after the final
20adjudication by the primary payer.
21    In the case of long term care facilities, within 5 days of
22receipt by the facility of required prescreening information,
23data for new admissions shall be entered into the Medical
24Electronic Data Interchange (MEDI) or the Recipient
25Eligibility Verification (REV) System or successor system, and
26within 15 days of receipt by the facility of required

 

 

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1prescreening information, admission documents shall be
2submitted through MEDI or REV or shall be submitted directly to
3the Department of Human Services using required admission
4forms. Effective September 1, 2014, admission documents,
5including all prescreening information, must be submitted
6through MEDI or REV. Confirmation numbers assigned to an
7accepted transaction shall be retained by a facility to verify
8timely submittal. Once an admission transaction has been
9completed, all resubmitted claims following prior rejection
10are subject to receipt no later than 180 days after the
11admission transaction has been completed.
12    Claims that are not submitted and received in compliance
13with the foregoing requirements shall not be eligible for
14payment under the medical assistance program, and the State
15shall have no liability for payment of those claims.
16    To the extent consistent with applicable information and
17privacy, security, and disclosure laws, State and federal
18agencies and departments shall provide the Illinois Department
19access to confidential and other information and data necessary
20to perform eligibility and payment verifications and other
21Illinois Department functions. This includes, but is not
22limited to: information pertaining to licensure;
23certification; earnings; immigration status; citizenship; wage
24reporting; unearned and earned income; pension income;
25employment; supplemental security income; social security
26numbers; National Provider Identifier (NPI) numbers; the

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1transplantation, such person must be receiving emergency renal
2dialysis services covered by the Department. Providers under
3this Section shall be prior approved and certified by the
4Department to perform kidney transplantation and the services
5under this Section shall be limited to services associated with
6kidney transplantation.
7(Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689,
8eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section
99-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff.
107-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; 98-651,
11eff. 6-16-14; 98-756, eff. 7-16-14; 98-963, eff. 8-15-14;
12revised 10-2-14.)
 
13    Section 99. Effective date. This Act takes effect July 1,
142015.