101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
SB0162

 

Introduced 1/30/2019, by Sen. Linda Holmes

 

SYNOPSIS AS INTRODUCED:
 
55 ILCS 5/5-1069  from Ch. 34, par. 5-1069
65 ILCS 5/10-4-2  from Ch. 24, par. 10-4-2
215 ILCS 5/356g  from Ch. 73, par. 968g
215 ILCS 125/4-6.1  from Ch. 111 1/2, par. 1408.7
305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the Counties Code, the Illinois Municipal Code, Illinois Insurance Code, the Health Maintenance Organization Act, and the Illinois Public Aid Code. In provisions concerning coverage for mammograms, provides that coverage shall also include a diagnostic mammogram when medically necessary, as determined by a physician licensed to practice medicine in all its branches, advanced practice registered nurse, or physician assistant. Makes changes to coverage for a comprehensive ultrasound screening and MRI. Effective immediately.


LRB101 07839 SMS 52893 b

FISCAL NOTE ACT MAY APPLY
STATE MANDATES ACT MAY REQUIRE REIMBURSEMENT

 

 

A BILL FOR

 

SB0162LRB101 07839 SMS 52893 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Counties Code is amended by changing Section
55-1069 as follows:
 
6    (55 ILCS 5/5-1069)  (from Ch. 34, par. 5-1069)
7    Sec. 5-1069. Group life, health, accident, hospital, and
8medical insurance.
9    (a) The county board of any county may arrange to provide,
10for the benefit of employees of the county, group life, health,
11accident, hospital, and medical insurance, or any one or any
12combination of those types of insurance, or the county board
13may self-insure, for the benefit of its employees, all or a
14portion of the employees' group life, health, accident,
15hospital, and medical insurance, or any one or any combination
16of those types of insurance, including a combination of
17self-insurance and other types of insurance authorized by this
18Section, provided that the county board complies with all other
19requirements of this Section. The insurance may include
20provision for employees who rely on treatment by prayer or
21spiritual means alone for healing in accordance with the tenets
22and practice of a well recognized religious denomination. The
23county board may provide for payment by the county of a portion

 

 

SB0162- 2 -LRB101 07839 SMS 52893 b

1or all of the premium or charge for the insurance with the
2employee paying the balance of the premium or charge, if any.
3If the county board undertakes a plan under which the county
4pays only a portion of the premium or charge, the county board
5shall provide for withholding and deducting from the
6compensation of those employees who consent to join the plan
7the balance of the premium or charge for the insurance.
8    (b) If the county board does not provide for self-insurance
9or for a plan under which the county pays a portion or all of
10the premium or charge for a group insurance plan, the county
11board may provide for withholding and deducting from the
12compensation of those employees who consent thereto the total
13premium or charge for any group life, health, accident,
14hospital, and medical insurance.
15    (c) The county board may exercise the powers granted in
16this Section only if it provides for self-insurance or, where
17it makes arrangements to provide group insurance through an
18insurance carrier, if the kinds of group insurance are obtained
19from an insurance company authorized to do business in the
20State of Illinois. The county board may enact an ordinance
21prescribing the method of operation of the insurance program.
22    (d) If a county, including a home rule county, is a
23self-insurer for purposes of providing health insurance
24coverage for its employees, the insurance coverage shall
25include screening by low-dose mammography for all women 35
26years of age or older for the presence of occult breast cancer

 

 

SB0162- 3 -LRB101 07839 SMS 52893 b

1unless the county elects to provide mammograms itself under
2Section 5-1069.1. The coverage shall be as follows:
3        (1) A baseline mammogram for women 35 to 39 years of
4    age.
5        (2) An annual mammogram for women 40 years of age or
6    older.
7        (3) A mammogram at the age and intervals considered
8    medically necessary by the woman's health care provider for
9    women under 40 years of age and having a family history of
10    breast cancer, prior personal history of breast cancer,
11    positive genetic testing, or other risk factors.
12        (4) For a group policy of accident and health insurance
13    that is amended, delivered, issued, or renewed on or after
14    the effective date of this amendatory Act of the 101st
15    General Assembly, a A comprehensive ultrasound screening
16    of an entire breast or breasts if a mammogram demonstrates
17    heterogeneous or dense breast tissue or , when medically
18    necessary as determined by a physician licensed to practice
19    medicine in all of its branches, advanced practice
20    registered nurse, or physician assistant.
21        (5) For a group policy of accident and health insurance
22    that is amended, delivered, issued, or renewed on or after
23    the effective date of this amendatory Act of the 101st
24    General Assembly, a diagnostic mammogram when medically
25    necessary, as determined by a physician licensed to
26    practice medicine in all its branches, advanced practice

 

 

SB0162- 4 -LRB101 07839 SMS 52893 b

1    registered nurse, or physician assistant.
2    For purposes of this subsection, "low-dose mammography"
3means the x-ray examination of the breast using equipment
4dedicated specifically for mammography, including the x-ray
5tube, filter, compression device, and image receptor, with an
6average radiation exposure delivery of less than one rad per
7breast for 2 views of an average size breast. The term also
8includes digital mammography.
9    (d-5) Coverage as described by subsection (d) shall be
10provided at no cost to the insured and shall not be applied to
11an annual or lifetime maximum benefit.
12    (d-10) When health care services are available through
13contracted providers and a person does not comply with plan
14provisions specific to the use of contracted providers, the
15requirements of subsection (d-5) are not applicable. When a
16person does not comply with plan provisions specific to the use
17of contracted providers, plan provisions specific to the use of
18non-contracted providers must be applied without distinction
19for coverage required by this Section and shall be at least as
20favorable as for other radiological examinations covered by the
21policy or contract.
22    (d-15) If a county, including a home rule county, is a
23self-insurer for purposes of providing health insurance
24coverage for its employees, the insurance coverage shall
25include mastectomy coverage, which includes coverage for
26prosthetic devices or reconstructive surgery incident to the

 

 

SB0162- 5 -LRB101 07839 SMS 52893 b

1mastectomy. Coverage for breast reconstruction in connection
2with a mastectomy shall include:
3        (1) reconstruction of the breast upon which the
4    mastectomy has been performed;
5        (2) surgery and reconstruction of the other breast to
6    produce a symmetrical appearance; and
7        (3) prostheses and treatment for physical
8    complications at all stages of mastectomy, including
9    lymphedemas.
10Care shall be determined in consultation with the attending
11physician and the patient. The offered coverage for prosthetic
12devices and reconstructive surgery shall be subject to the
13deductible and coinsurance conditions applied to the
14mastectomy, and all other terms and conditions applicable to
15other benefits. When a mastectomy is performed and there is no
16evidence of malignancy then the offered coverage may be limited
17to the provision of prosthetic devices and reconstructive
18surgery to within 2 years after the date of the mastectomy. As
19used in this Section, "mastectomy" means the removal of all or
20part of the breast for medically necessary reasons, as
21determined by a licensed physician.
22    A county, including a home rule county, that is a
23self-insurer for purposes of providing health insurance
24coverage for its employees, may not penalize or reduce or limit
25the reimbursement of an attending provider or provide
26incentives (monetary or otherwise) to an attending provider to

 

 

SB0162- 6 -LRB101 07839 SMS 52893 b

1induce the provider to provide care to an insured in a manner
2inconsistent with this Section.
3    (d-20) The requirement that mammograms be included in
4health insurance coverage as provided in subsections (d)
5through (d-15) is an exclusive power and function of the State
6and is a denial and limitation under Article VII, Section 6,
7subsection (h) of the Illinois Constitution of home rule county
8powers. A home rule county to which subsections (d) through
9(d-15) apply must comply with every provision of those
10subsections.
11    (e) The term "employees" as used in this Section includes
12elected or appointed officials but does not include temporary
13employees.
14    (f) The county board may, by ordinance, arrange to provide
15group life, health, accident, hospital, and medical insurance,
16or any one or a combination of those types of insurance, under
17this Section to retired former employees and retired former
18elected or appointed officials of the county.
19    (g) Rulemaking authority to implement this amendatory Act
20of the 95th General Assembly, if any, is conditioned on the
21rules being adopted in accordance with all provisions of the
22Illinois Administrative Procedure Act and all rules and
23procedures of the Joint Committee on Administrative Rules; any
24purported rule not so adopted, for whatever reason, is
25unauthorized.
26(Source: P.A. 99-581, eff. 1-1-17; 100-513, eff. 1-1-18.)
 

 

 

SB0162- 7 -LRB101 07839 SMS 52893 b

1    Section 10. The Illinois Municipal Code is amended by
2changing Section 10-4-2 as follows:
 
3    (65 ILCS 5/10-4-2)  (from Ch. 24, par. 10-4-2)
4    Sec. 10-4-2. Group insurance.
5    (a) The corporate authorities of any municipality may
6arrange to provide, for the benefit of employees of the
7municipality, group life, health, accident, hospital, and
8medical insurance, or any one or any combination of those types
9of insurance, and may arrange to provide that insurance for the
10benefit of the spouses or dependents of those employees. The
11insurance may include provision for employees or other insured
12persons who rely on treatment by prayer or spiritual means
13alone for healing in accordance with the tenets and practice of
14a well recognized religious denomination. The corporate
15authorities may provide for payment by the municipality of a
16portion of the premium or charge for the insurance with the
17employee paying the balance of the premium or charge. If the
18corporate authorities undertake a plan under which the
19municipality pays a portion of the premium or charge, the
20corporate authorities shall provide for withholding and
21deducting from the compensation of those municipal employees
22who consent to join the plan the balance of the premium or
23charge for the insurance.
24    (b) If the corporate authorities do not provide for a plan

 

 

SB0162- 8 -LRB101 07839 SMS 52893 b

1under which the municipality pays a portion of the premium or
2charge for a group insurance plan, the corporate authorities
3may provide for withholding and deducting from the compensation
4of those employees who consent thereto the premium or charge
5for any group life, health, accident, hospital, and medical
6insurance.
7    (c) The corporate authorities may exercise the powers
8granted in this Section only if the kinds of group insurance
9are obtained from an insurance company authorized to do
10business in the State of Illinois, or are obtained through an
11intergovernmental joint self-insurance pool as authorized
12under the Intergovernmental Cooperation Act. The corporate
13authorities may enact an ordinance prescribing the method of
14operation of the insurance program.
15    (d) If a municipality, including a home rule municipality,
16is a self-insurer for purposes of providing health insurance
17coverage for its employees, the insurance coverage shall
18include screening by low-dose mammography for all women 35
19years of age or older for the presence of occult breast cancer
20unless the municipality elects to provide mammograms itself
21under Section 10-4-2.1. The coverage shall be as follows:
22        (1) A baseline mammogram for women 35 to 39 years of
23    age.
24        (2) An annual mammogram for women 40 years of age or
25    older.
26        (3) A mammogram at the age and intervals considered

 

 

SB0162- 9 -LRB101 07839 SMS 52893 b

1    medically necessary by the woman's health care provider for
2    women under 40 years of age and having a family history of
3    breast cancer, prior personal history of breast cancer,
4    positive genetic testing, or other risk factors.
5        (4) For a group policy of accident and health insurance
6    that is amended, delivered, issued, or renewed on or after
7    the effective date of this amendatory Act of the 101st
8    General Assembly, a A comprehensive ultrasound screening
9    of an entire breast or breasts if a mammogram demonstrates
10    heterogeneous or dense breast tissue or , when medically
11    necessary as determined by a physician licensed to practice
12    medicine in all of its branches.
13        (5) For a group policy of accident and health insurance
14    that is amended, delivered, issued, or renewed on or after
15    the effective date of this amendatory Act of the 101st
16    General Assembly, a diagnostic mammogram when medically
17    necessary, as determined by a physician licensed to
18    practice medicine in all its branches, advanced practice
19    registered nurse, or physician assistant.
20    For purposes of this subsection, "low-dose mammography"
21means the x-ray examination of the breast using equipment
22dedicated specifically for mammography, including the x-ray
23tube, filter, compression device, and image receptor, with an
24average radiation exposure delivery of less than one rad per
25breast for 2 views of an average size breast. The term also
26includes digital mammography.

 

 

SB0162- 10 -LRB101 07839 SMS 52893 b

1    (d-5) Coverage as described by subsection (d) shall be
2provided at no cost to the insured and shall not be applied to
3an annual or lifetime maximum benefit.
4    (d-10) When health care services are available through
5contracted providers and a person does not comply with plan
6provisions specific to the use of contracted providers, the
7requirements of subsection (d-5) are not applicable. When a
8person does not comply with plan provisions specific to the use
9of contracted providers, plan provisions specific to the use of
10non-contracted providers must be applied without distinction
11for coverage required by this Section and shall be at least as
12favorable as for other radiological examinations covered by the
13policy or contract.
14    (d-15) If a municipality, including a home rule
15municipality, is a self-insurer for purposes of providing
16health insurance coverage for its employees, the insurance
17coverage shall include mastectomy coverage, which includes
18coverage for prosthetic devices or reconstructive surgery
19incident to the mastectomy. Coverage for breast reconstruction
20in connection with a mastectomy shall include:
21        (1) reconstruction of the breast upon which the
22    mastectomy has been performed;
23        (2) surgery and reconstruction of the other breast to
24    produce a symmetrical appearance; and
25        (3) prostheses and treatment for physical
26    complications at all stages of mastectomy, including

 

 

SB0162- 11 -LRB101 07839 SMS 52893 b

1    lymphedemas.
2Care shall be determined in consultation with the attending
3physician and the patient. The offered coverage for prosthetic
4devices and reconstructive surgery shall be subject to the
5deductible and coinsurance conditions applied to the
6mastectomy, and all other terms and conditions applicable to
7other benefits. When a mastectomy is performed and there is no
8evidence of malignancy then the offered coverage may be limited
9to the provision of prosthetic devices and reconstructive
10surgery to within 2 years after the date of the mastectomy. As
11used in this Section, "mastectomy" means the removal of all or
12part of the breast for medically necessary reasons, as
13determined by a licensed physician.
14    A municipality, including a home rule municipality, that is
15a self-insurer for purposes of providing health insurance
16coverage for its employees, may not penalize or reduce or limit
17the reimbursement of an attending provider or provide
18incentives (monetary or otherwise) to an attending provider to
19induce the provider to provide care to an insured in a manner
20inconsistent with this Section.
21    (d-20) The requirement that mammograms be included in
22health insurance coverage as provided in subsections (d)
23through (d-15) is an exclusive power and function of the State
24and is a denial and limitation under Article VII, Section 6,
25subsection (h) of the Illinois Constitution of home rule
26municipality powers. A home rule municipality to which

 

 

SB0162- 12 -LRB101 07839 SMS 52893 b

1subsections (d) through (d-15) apply must comply with every
2provision of those subsections.
3    (e) Rulemaking authority to implement Public Act 95-1045,
4if any, is conditioned on the rules being adopted in accordance
5with all provisions of the Illinois Administrative Procedure
6Act and all rules and procedures of the Joint Committee on
7Administrative Rules; any purported rule not so adopted, for
8whatever reason, is unauthorized.
9(Source: P.A. 100-863, eff. 8-14-18.)
 
10    Section 15. The Illinois Insurance Code is amended by
11changing Section 356g as follows:
 
12    (215 ILCS 5/356g)  (from Ch. 73, par. 968g)
13    Sec. 356g. Mammograms; mastectomies.
14    (a) Every insurer shall provide in each group or individual
15policy, contract, or certificate of insurance issued or renewed
16for persons who are residents of this State, coverage for
17screening by low-dose mammography for all women 35 years of age
18or older for the presence of occult breast cancer within the
19provisions of the policy, contract, or certificate. The
20coverage shall be as follows:
21         (1) A baseline mammogram for women 35 to 39 years of
22    age.
23         (2) An annual mammogram for women 40 years of age or
24    older.

 

 

SB0162- 13 -LRB101 07839 SMS 52893 b

1         (3) A mammogram at the age and intervals considered
2    medically necessary by the woman's health care provider for
3    women under 40 years of age and having a family history of
4    breast cancer, prior personal history of breast cancer,
5    positive genetic testing, or other risk factors.
6        (4) For an individual or group policy of accident and
7    health insurance or a managed care plan that is amended,
8    delivered, issued, or renewed on or after the effective
9    date of this amendatory Act of the 101st General Assembly,
10    a A comprehensive ultrasound screening and MRI of an entire
11    breast or breasts if a mammogram demonstrates
12    heterogeneous or dense breast tissue or , when medically
13    necessary as determined by a physician licensed to practice
14    medicine in all of its branches.
15        (5) A screening MRI when medically necessary, as
16    determined by a physician licensed to practice medicine in
17    all of its branches.
18        (6) For an individual or group policy of accident and
19    health insurance or a managed care plan that is amended,
20    delivered, issued, or renewed on or after the effective
21    date of this amendatory Act of the 101st General Assembly,
22    a diagnostic mammogram when medically necessary, as
23    determined by a physician licensed to practice medicine in
24    all its branches, advanced practice registered nurse, or
25    physician assistant.
26    For purposes of this Section, "low-dose mammography" means

 

 

SB0162- 14 -LRB101 07839 SMS 52893 b

1the x-ray examination of the breast using equipment dedicated
2specifically for mammography, including the x-ray tube,
3filter, compression device, and image receptor, with radiation
4exposure delivery of less than 1 rad per breast for 2 views of
5an average size breast. The term also includes digital
6mammography and includes breast tomosynthesis. As used in this
7Section, the term "breast tomosynthesis" means a radiologic
8procedure that involves the acquisition of projection images
9over the stationary breast to produce cross-sectional digital
10three-dimensional images of the breast.
11    If, at any time, the Secretary of the United States
12Department of Health and Human Services, or its successor
13agency, promulgates rules or regulations to be published in the
14Federal Register or publishes a comment in the Federal Register
15or issues an opinion, guidance, or other action that would
16require the State, pursuant to any provision of the Patient
17Protection and Affordable Care Act (Public Law 111-148),
18including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
19successor provision, to defray the cost of any coverage for
20breast tomosynthesis outlined in this subsection, then the
21requirement that an insurer cover breast tomosynthesis is
22inoperative other than any such coverage authorized under
23Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
24the State shall not assume any obligation for the cost of
25coverage for breast tomosynthesis set forth in this subsection.
26    (a-5) Coverage as described by subsection (a) shall be

 

 

SB0162- 15 -LRB101 07839 SMS 52893 b

1provided at no cost to the insured and shall not be applied to
2an annual or lifetime maximum benefit.
3    (a-10) When health care services are available through
4contracted providers and a person does not comply with plan
5provisions specific to the use of contracted providers, the
6requirements of subsection (a-5) are not applicable. When a
7person does not comply with plan provisions specific to the use
8of contracted providers, plan provisions specific to the use of
9non-contracted providers must be applied without distinction
10for coverage required by this Section and shall be at least as
11favorable as for other radiological examinations covered by the
12policy or contract.
13    (b) No policy of accident or health insurance that provides
14for the surgical procedure known as a mastectomy shall be
15issued, amended, delivered, or renewed in this State unless
16that coverage also provides for prosthetic devices or
17reconstructive surgery incident to the mastectomy. Coverage
18for breast reconstruction in connection with a mastectomy shall
19include:
20        (1) reconstruction of the breast upon which the
21    mastectomy has been performed;
22        (2) surgery and reconstruction of the other breast to
23    produce a symmetrical appearance; and
24        (3) prostheses and treatment for physical
25    complications at all stages of mastectomy, including
26    lymphedemas.

 

 

SB0162- 16 -LRB101 07839 SMS 52893 b

1Care shall be determined in consultation with the attending
2physician and the patient. The offered coverage for prosthetic
3devices and reconstructive surgery shall be subject to the
4deductible and coinsurance conditions applied to the
5mastectomy, and all other terms and conditions applicable to
6other benefits. When a mastectomy is performed and there is no
7evidence of malignancy then the offered coverage may be limited
8to the provision of prosthetic devices and reconstructive
9surgery to within 2 years after the date of the mastectomy. As
10used in this Section, "mastectomy" means the removal of all or
11part of the breast for medically necessary reasons, as
12determined by a licensed physician.
13    Written notice of the availability of coverage under this
14Section shall be delivered to the insured upon enrollment and
15annually thereafter. An insurer may not deny to an insured
16eligibility, or continued eligibility, to enroll or to renew
17coverage under the terms of the plan solely for the purpose of
18avoiding the requirements of this Section. An insurer may not
19penalize or reduce or limit the reimbursement of an attending
20provider or provide incentives (monetary or otherwise) to an
21attending provider to induce the provider to provide care to an
22insured in a manner inconsistent with this Section.
23    (c) Rulemaking authority to implement Public Act 95-1045,
24if any, is conditioned on the rules being adopted in accordance
25with all provisions of the Illinois Administrative Procedure
26Act and all rules and procedures of the Joint Committee on

 

 

SB0162- 17 -LRB101 07839 SMS 52893 b

1Administrative Rules; any purported rule not so adopted, for
2whatever reason, is unauthorized.
3(Source: P.A. 99-407 (see Section 20 of P.A. 99-588 for the
4effective date of P.A. 99-407); 99-433, eff. 8-21-15; 99-588,
5eff. 7-20-16; 99-642, eff. 7-28-16; 100-395, eff. 1-1-18.)
 
6    Section 20. The Health Maintenance Organization Act is
7amended by changing Section 4-6.1 as follows:
 
8    (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)
9    Sec. 4-6.1. Mammograms; mastectomies.
10    (a) Every contract or evidence of coverage issued by a
11Health Maintenance Organization for persons who are residents
12of this State shall contain coverage for screening by low-dose
13mammography for all women 35 years of age or older for the
14presence of occult breast cancer. The coverage shall be as
15follows:
16        (1) A baseline mammogram for women 35 to 39 years of
17    age.
18        (2) An annual mammogram for women 40 years of age or
19    older.
20        (3) A mammogram at the age and intervals considered
21    medically necessary by the woman's health care provider for
22    women under 40 years of age and having a family history of
23    breast cancer, prior personal history of breast cancer,
24    positive genetic testing, or other risk factors.

 

 

SB0162- 18 -LRB101 07839 SMS 52893 b

1        (4) For an individual or group policy of accident and
2    health insurance or a managed care plan that is amended,
3    delivered, issued, or renewed on or after the effective
4    date of this amendatory Act of the 101st General Assembly,
5    a A comprehensive ultrasound screening and MRI of an entire
6    breast or breasts if a mammogram demonstrates
7    heterogeneous or dense breast tissue or , when medically
8    necessary as determined by a physician licensed to practice
9    medicine in all of its branches.
10        (5) For an individual or group policy of accident and
11    health insurance or a managed care plan that is amended,
12    delivered, issued, or renewed on or after the effective
13    date of this amendatory Act of the 101st General Assembly,
14    a diagnostic mammogram when medically necessary, as
15    determined by a physician licensed to practice medicine in
16    all its branches, advanced practice registered nurse, or
17    physician assistant.
18    For purposes of this Section, "low-dose mammography" means
19the x-ray examination of the breast using equipment dedicated
20specifically for mammography, including the x-ray tube,
21filter, compression device, and image receptor, with radiation
22exposure delivery of less than 1 rad per breast for 2 views of
23an average size breast. The term also includes digital
24mammography and includes breast tomosynthesis. As used in this
25Section, the term "breast tomosynthesis" means a radiologic
26procedure that involves the acquisition of projection images

 

 

SB0162- 19 -LRB101 07839 SMS 52893 b

1over the stationary breast to produce cross-sectional digital
2three-dimensional images of the breast.
3    If, at any time, the Secretary of the United States
4Department of Health and Human Services, or its successor
5agency, promulgates rules or regulations to be published in the
6Federal Register or publishes a comment in the Federal Register
7or issues an opinion, guidance, or other action that would
8require the State, pursuant to any provision of the Patient
9Protection and Affordable Care Act (Public Law 111-148),
10including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
11successor provision, to defray the cost of any coverage for
12breast tomosynthesis outlined in this subsection, then the
13requirement that an insurer cover breast tomosynthesis is
14inoperative other than any such coverage authorized under
15Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
16the State shall not assume any obligation for the cost of
17coverage for breast tomosynthesis set forth in this subsection.
18    (a-5) Coverage as described in subsection (a) shall be
19provided at no cost to the enrollee and shall not be applied to
20an annual or lifetime maximum benefit.
21    (b) No contract or evidence of coverage issued by a health
22maintenance organization that provides for the surgical
23procedure known as a mastectomy shall be issued, amended,
24delivered, or renewed in this State on or after the effective
25date of this amendatory Act of the 92nd General Assembly unless
26that coverage also provides for prosthetic devices or

 

 

SB0162- 20 -LRB101 07839 SMS 52893 b

1reconstructive surgery incident to the mastectomy, providing
2that the mastectomy is performed after the effective date of
3this amendatory Act. Coverage for breast reconstruction in
4connection with a mastectomy shall include:
5        (1) reconstruction of the breast upon which the
6    mastectomy has been performed;
7        (2) surgery and reconstruction of the other breast to
8    produce a symmetrical appearance; and
9        (3) prostheses and treatment for physical
10    complications at all stages of mastectomy, including
11    lymphedemas.
12Care shall be determined in consultation with the attending
13physician and the patient. The offered coverage for prosthetic
14devices and reconstructive surgery shall be subject to the
15deductible and coinsurance conditions applied to the
16mastectomy and all other terms and conditions applicable to
17other benefits. When a mastectomy is performed and there is no
18evidence of malignancy, then the offered coverage may be
19limited to the provision of prosthetic devices and
20reconstructive surgery to within 2 years after the date of the
21mastectomy. As used in this Section, "mastectomy" means the
22removal of all or part of the breast for medically necessary
23reasons, as determined by a licensed physician.
24    Written notice of the availability of coverage under this
25Section shall be delivered to the enrollee upon enrollment and
26annually thereafter. A health maintenance organization may not

 

 

SB0162- 21 -LRB101 07839 SMS 52893 b

1deny to an enrollee eligibility, or continued eligibility, to
2enroll or to renew coverage under the terms of the plan solely
3for the purpose of avoiding the requirements of this Section. A
4health maintenance organization may not penalize or reduce or
5limit the reimbursement of an attending provider or provide
6incentives (monetary or otherwise) to an attending provider to
7induce the provider to provide care to an insured in a manner
8inconsistent with this Section.
9    (c) Rulemaking authority to implement this amendatory Act
10of the 95th General Assembly, if any, is conditioned on the
11rules being adopted in accordance with all provisions of the
12Illinois Administrative Procedure Act and all rules and
13procedures of the Joint Committee on Administrative Rules; any
14purported rule not so adopted, for whatever reason, is
15unauthorized.
16(Source: P.A. 99-407 (see Section 20 of P.A. 99-588 for the
17effective date of P.A. 99-407); 99-588, eff. 7-20-16; 100-395,
18eff. 1-1-18.)
 
19    Section 25. The Illinois Public Aid Code is amended by
20changing Section 5-5 and by adding Section 95 as follows:
 
21    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
22    Sec. 5-5. Medical services. The Illinois Department, by
23rule, shall determine the quantity and quality of and the rate
24of reimbursement for the medical assistance for which payment

 

 

SB0162- 22 -LRB101 07839 SMS 52893 b

1will be authorized, and the medical services to be provided,
2which may include all or part of the following: (1) inpatient
3hospital services; (2) outpatient hospital services; (3) other
4laboratory and X-ray services; (4) skilled nursing home
5services; (5) physicians' services whether furnished in the
6office, the patient's home, a hospital, a skilled nursing home,
7or elsewhere; (6) medical care, or any other type of remedial
8care furnished by licensed practitioners; (7) home health care
9services; (8) private duty nursing service; (9) clinic
10services; (10) dental services, including prevention and
11treatment of periodontal disease and dental caries disease for
12pregnant women, provided by an individual licensed to practice
13dentistry or dental surgery; for purposes of this item (10),
14"dental services" means diagnostic, preventive, or corrective
15procedures provided by or under the supervision of a dentist in
16the practice of his or her profession; (11) physical therapy
17and related services; (12) prescribed drugs, dentures, and
18prosthetic devices; and eyeglasses prescribed by a physician
19skilled in the diseases of the eye, or by an optometrist,
20whichever the person may select; (13) other diagnostic,
21screening, preventive, and rehabilitative services, including
22to ensure that the individual's need for intervention or
23treatment of mental disorders or substance use disorders or
24co-occurring mental health and substance use disorders is
25determined using a uniform screening, assessment, and
26evaluation process inclusive of criteria, for children and

 

 

SB0162- 23 -LRB101 07839 SMS 52893 b

1adults; for purposes of this item (13), a uniform screening,
2assessment, and evaluation process refers to a process that
3includes an appropriate evaluation and, as warranted, a
4referral; "uniform" does not mean the use of a singular
5instrument, tool, or process that all must utilize; (14)
6transportation and such other expenses as may be necessary;
7(15) medical treatment of sexual assault survivors, as defined
8in Section 1a of the Sexual Assault Survivors Emergency
9Treatment Act, for injuries sustained as a result of the sexual
10assault, including examinations and laboratory tests to
11discover evidence which may be used in criminal proceedings
12arising from the sexual assault; (16) the diagnosis and
13treatment of sickle cell anemia; and (17) any other medical
14care, and any other type of remedial care recognized under the
15laws of this State. The term "any other type of remedial care"
16shall include nursing care and nursing home service for persons
17who rely on treatment by spiritual means alone through prayer
18for healing.
19    Notwithstanding any other provision of this Section, a
20comprehensive tobacco use cessation program that includes
21purchasing prescription drugs or prescription medical devices
22approved by the Food and Drug Administration shall be covered
23under the medical assistance program under this Article for
24persons who are otherwise eligible for assistance under this
25Article.
26    Notwithstanding any other provision of this Code,

 

 

SB0162- 24 -LRB101 07839 SMS 52893 b

1reproductive health care that is otherwise legal in Illinois
2shall be covered under the medical assistance program for
3persons who are otherwise eligible for medical assistance under
4this Article.
5    Notwithstanding any other provision of this Code, the
6Illinois Department may not require, as a condition of payment
7for any laboratory test authorized under this Article, that a
8physician's handwritten signature appear on the laboratory
9test order form. The Illinois Department may, however, impose
10other appropriate requirements regarding laboratory test order
11documentation.
12    Upon receipt of federal approval of an amendment to the
13Illinois Title XIX State Plan for this purpose, the Department
14shall authorize the Chicago Public Schools (CPS) to procure a
15vendor or vendors to manufacture eyeglasses for individuals
16enrolled in a school within the CPS system. CPS shall ensure
17that its vendor or vendors are enrolled as providers in the
18medical assistance program and in any capitated Medicaid
19managed care entity (MCE) serving individuals enrolled in a
20school within the CPS system. Under any contract procured under
21this provision, the vendor or vendors must serve only
22individuals enrolled in a school within the CPS system. Claims
23for services provided by CPS's vendor or vendors to recipients
24of benefits in the medical assistance program under this Code,
25the Children's Health Insurance Program, or the Covering ALL
26KIDS Health Insurance Program shall be submitted to the

 

 

SB0162- 25 -LRB101 07839 SMS 52893 b

1Department or the MCE in which the individual is enrolled for
2payment and shall be reimbursed at the Department's or the
3MCE's established rates or rate methodologies for eyeglasses.
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    On and after July 1, 2018, the Department of Healthcare and
16Family Services shall provide dental services to any adult who
17is otherwise eligible for assistance under the medical
18assistance program. As used in this paragraph, "dental
19services" means diagnostic, preventative, restorative, or
20corrective procedures, including procedures and services for
21the prevention and treatment of periodontal disease and dental
22caries disease, provided by an individual who is licensed to
23practice dentistry or dental surgery or who is under the
24supervision of a dentist in the practice of his or her
25profession.
26    On and after July 1, 2018, targeted dental services, as set

 

 

SB0162- 26 -LRB101 07839 SMS 52893 b

1forth in Exhibit D of the Consent Decree entered by the United
2States District Court for the Northern District of Illinois,
3Eastern Division, in the matter of Memisovski v. Maram, Case
4No. 92 C 1982, that are provided to adults under the medical
5assistance program shall be established at no less than the
6rates set forth in the "New Rate" column in Exhibit D of the
7Consent Decree for targeted dental services that are provided
8to persons under the age of 18 under the medical assistance
9program.
10    Notwithstanding any other provision of this Code and
11subject to federal approval, the Department may adopt rules to
12allow a dentist who is volunteering his or her service at no
13cost to render dental services through an enrolled
14not-for-profit health clinic without the dentist personally
15enrolling as a participating provider in the medical assistance
16program. A not-for-profit health clinic shall include a public
17health clinic or Federally Qualified Health Center or other
18enrolled provider, as determined by the Department, through
19which dental services covered under this Section are performed.
20The Department shall establish a process for payment of claims
21for reimbursement for covered dental services rendered under
22this provision.
23    The Illinois Department, by rule, may distinguish and
24classify the medical services to be provided only in accordance
25with the classes of persons designated in Section 5-2.
26    The Department of Healthcare and Family Services must

 

 

SB0162- 27 -LRB101 07839 SMS 52893 b

1provide coverage and reimbursement for amino acid-based
2elemental formulas, regardless of delivery method, for the
3diagnosis and treatment of (i) eosinophilic disorders and (ii)
4short bowel syndrome when the prescribing physician has issued
5a written order stating that the amino acid-based elemental
6formula is medically necessary.
7    The Illinois Department shall authorize the provision of,
8and shall authorize payment for, screening by low-dose
9mammography for the presence of occult breast cancer for women
1035 years of age or older who are eligible for medical
11assistance under this Article, as follows:
12        (A) A baseline mammogram for women 35 to 39 years of
13    age.
14        (B) An annual mammogram for women 40 years of age or
15    older.
16        (C) A mammogram at the age and intervals considered
17    medically necessary by the woman's health care provider for
18    women under 40 years of age and having a family history of
19    breast cancer, prior personal history of breast cancer,
20    positive genetic testing, or other risk factors.
21        (D) A comprehensive ultrasound screening and MRI of an
22    entire breast or breasts if a mammogram demonstrates
23    heterogeneous or dense breast tissue or , when medically
24    necessary as determined by a physician licensed to practice
25    medicine in all of its branches.
26        (E) A screening MRI when medically necessary, as

 

 

SB0162- 28 -LRB101 07839 SMS 52893 b

1    determined by a physician licensed to practice medicine in
2    all of its branches.
3        (F) A diagnostic mammogram when medically necessary,
4    as determined by a physician licensed to practice medicine
5    in all its branches, advanced practice registered nurse, or
6    physician assistant.
7    All screenings shall include a physical breast exam,
8instruction on self-examination and information regarding the
9frequency of self-examination and its value as a preventative
10tool. For purposes of this Section, "low-dose mammography"
11means the x-ray examination of the breast using equipment
12dedicated specifically for mammography, including the x-ray
13tube, filter, compression device, and image receptor, with an
14average radiation exposure delivery of less than one rad per
15breast for 2 views of an average size breast. The term also
16includes digital mammography and includes breast
17tomosynthesis. As used in this Section, the term "breast
18tomosynthesis" means a radiologic procedure that involves the
19acquisition of projection images over the stationary breast to
20produce cross-sectional digital three-dimensional images of
21the breast. If, at any time, the Secretary of the United States
22Department of Health and Human Services, or its successor
23agency, promulgates rules or regulations to be published in the
24Federal Register or publishes a comment in the Federal Register
25or issues an opinion, guidance, or other action that would
26require the State, pursuant to any provision of the Patient

 

 

SB0162- 29 -LRB101 07839 SMS 52893 b

1Protection and Affordable Care Act (Public Law 111-148),
2including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
3successor provision, to defray the cost of any coverage for
4breast tomosynthesis outlined in this paragraph, then the
5requirement that an insurer cover breast tomosynthesis is
6inoperative other than any such coverage authorized under
7Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
8the State shall not assume any obligation for the cost of
9coverage for breast tomosynthesis set forth in this paragraph.
10    On and after January 1, 2016, the Department shall ensure
11that all networks of care for adult clients of the Department
12include access to at least one breast imaging Center of Imaging
13Excellence as certified by the American College of Radiology.
14    On and after January 1, 2012, providers participating in a
15quality improvement program approved by the Department shall be
16reimbursed for screening and diagnostic mammography at the same
17rate as the Medicare program's rates, including the increased
18reimbursement for digital mammography.
19    The Department shall convene an expert panel including
20representatives of hospitals, free-standing mammography
21facilities, and doctors, including radiologists, to establish
22quality standards for mammography.
23    On and after January 1, 2017, providers participating in a
24breast cancer treatment quality improvement program approved
25by the Department shall be reimbursed for breast cancer
26treatment at a rate that is no lower than 95% of the Medicare

 

 

SB0162- 30 -LRB101 07839 SMS 52893 b

1program's rates for the data elements included in the breast
2cancer treatment quality program.
3    The Department shall convene an expert panel, including
4representatives of hospitals, free-standing breast cancer
5treatment centers, breast cancer quality organizations, and
6doctors, including breast surgeons, reconstructive breast
7surgeons, oncologists, and primary care providers to establish
8quality standards for breast cancer treatment.
9    Subject to federal approval, the Department shall
10establish a rate methodology for mammography at federally
11qualified health centers and other encounter-rate clinics.
12These clinics or centers may also collaborate with other
13hospital-based mammography facilities. By January 1, 2016, the
14Department shall report to the General Assembly on the status
15of the provision set forth in this paragraph.
16    The Department shall establish a methodology to remind
17women who are age-appropriate for screening mammography, but
18who have not received a mammogram within the previous 18
19months, of the importance and benefit of screening mammography.
20The Department shall work with experts in breast cancer
21outreach and patient navigation to optimize these reminders and
22shall establish a methodology for evaluating their
23effectiveness and modifying the methodology based on the
24evaluation.
25    The Department shall establish a performance goal for
26primary care providers with respect to their female patients

 

 

SB0162- 31 -LRB101 07839 SMS 52893 b

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. On or after July 1,
122016, the pilot program shall be expanded to include one site
13in western Illinois, one site in southern Illinois, one site in
14central Illinois, and 4 sites within metropolitan Chicago. An
15evaluation of the pilot program shall be carried out measuring
16health outcomes and cost of care for those served by the pilot
17program compared to similarly situated patients who are not
18served by the pilot program.
19    The Department shall require all networks of care to
20develop a means either internally or by contract with experts
21in navigation and community outreach to navigate cancer
22patients to comprehensive care in a timely fashion. The
23Department shall require all networks of care to include access
24for patients diagnosed with cancer to at least one academic
25commission on cancer-accredited cancer program as an
26in-network covered benefit.

 

 

SB0162- 32 -LRB101 07839 SMS 52893 b

1    Any medical or health care provider shall immediately
2recommend, to any pregnant woman who is being provided prenatal
3services and is suspected of having a substance use disorder as
4defined in the Substance Use Disorder Act, referral to a local
5substance use disorder treatment program licensed by the
6Department of Human Services or to a licensed hospital which
7provides substance abuse treatment services. The Department of
8Healthcare and Family Services shall assure coverage for the
9cost of treatment of the drug abuse or addiction for pregnant
10recipients in accordance with the Illinois Medicaid Program in
11conjunction with the Department of Human Services.
12    All medical providers providing medical assistance to
13pregnant women under this Code shall receive information from
14the Department on the availability of services under any
15program providing case management services for addicted women,
16including information on appropriate referrals for other
17social services that may be needed by addicted women in
18addition to treatment for addiction.
19    The Illinois Department, in cooperation with the
20Departments of Human Services (as successor to the Department
21of Alcoholism and Substance Abuse) and Public Health, through a
22public awareness campaign, may provide information concerning
23treatment for alcoholism and drug abuse and addiction, prenatal
24health care, and other pertinent programs directed at reducing
25the number of drug-affected infants born to recipients of
26medical assistance.

 

 

SB0162- 33 -LRB101 07839 SMS 52893 b

1    Neither the Department of Healthcare and Family Services
2nor the Department of Human Services shall sanction the
3recipient solely on the basis of her substance abuse.
4    The Illinois Department shall establish such regulations
5governing the dispensing of health services under this Article
6as it shall deem appropriate. The Department should seek the
7advice of formal professional advisory committees appointed by
8the Director of the Illinois Department for the purpose of
9providing regular advice on policy and administrative matters,
10information dissemination and educational activities for
11medical and health care providers, and consistency in
12procedures to the Illinois Department.
13    The Illinois Department may develop and contract with
14Partnerships of medical providers to arrange medical services
15for persons eligible under Section 5-2 of this Code.
16Implementation of this Section may be by demonstration projects
17in certain geographic areas. The Partnership shall be
18represented by a sponsor organization. The Department, by rule,
19shall develop qualifications for sponsors of Partnerships.
20Nothing in this Section shall be construed to require that the
21sponsor organization be a medical organization.
22    The sponsor must negotiate formal written contracts with
23medical providers for physician services, inpatient and
24outpatient hospital care, home health services, treatment for
25alcoholism and substance abuse, and other services determined
26necessary by the Illinois Department by rule for delivery by

 

 

SB0162- 34 -LRB101 07839 SMS 52893 b

1Partnerships. Physician services must include prenatal and
2obstetrical care. The Illinois Department shall reimburse
3medical services delivered by Partnership providers to clients
4in target areas according to provisions of this Article and the
5Illinois Health Finance Reform Act, except that:
6        (1) Physicians participating in a Partnership and
7    providing certain services, which shall be determined by
8    the Illinois Department, to persons in areas covered by the
9    Partnership may receive an additional surcharge for such
10    services.
11        (2) The Department may elect to consider and negotiate
12    financial incentives to encourage the development of
13    Partnerships and the efficient delivery of medical care.
14        (3) Persons receiving medical services through
15    Partnerships may receive medical and case management
16    services above the level usually offered through the
17    medical assistance program.
18    Medical providers shall be required to meet certain
19qualifications to participate in Partnerships to ensure the
20delivery of high quality medical services. These
21qualifications shall be determined by rule of the Illinois
22Department and may be higher than qualifications for
23participation in the medical assistance program. Partnership
24sponsors may prescribe reasonable additional qualifications
25for participation by medical providers, only with the prior
26written approval of the Illinois Department.

 

 

SB0162- 35 -LRB101 07839 SMS 52893 b

1    Nothing in this Section shall limit the free choice of
2practitioners, hospitals, and other providers of medical
3services by clients. In order to ensure patient freedom of
4choice, the Illinois Department shall immediately promulgate
5all rules and take all other necessary actions so that provided
6services may be accessed from therapeutically certified
7optometrists to the full extent of the Illinois Optometric
8Practice Act of 1987 without discriminating between service
9providers.
10    The Department shall apply for a waiver from the United
11States Health Care Financing Administration to allow for the
12implementation of Partnerships under this Section.
13    The Illinois Department shall require health care
14providers to maintain records that document the medical care
15and services provided to recipients of Medical Assistance under
16this Article. Such records must be retained for a period of not
17less than 6 years from the date of service or as provided by
18applicable State law, whichever period is longer, except that
19if an audit is initiated within the required retention period
20then the records must be retained until the audit is completed
21and every exception is resolved. The Illinois Department shall
22require health care providers to make available, when
23authorized by the patient, in writing, the medical records in a
24timely fashion to other health care providers who are treating
25or serving persons eligible for Medical Assistance under this
26Article. All dispensers of medical services shall be required

 

 

SB0162- 36 -LRB101 07839 SMS 52893 b

1to maintain and retain business and professional records
2sufficient to fully and accurately document the nature, scope,
3details and receipt of the health care provided to persons
4eligible for medical assistance under this Code, in accordance
5with regulations promulgated by the Illinois Department. The
6rules and regulations shall require that proof of the receipt
7of prescription drugs, dentures, prosthetic devices and
8eyeglasses by eligible persons under this Section accompany
9each claim for reimbursement submitted by the dispenser of such
10medical services. No such claims for reimbursement shall be
11approved for payment by the Illinois Department without such
12proof of receipt, unless the Illinois Department shall have put
13into effect and shall be operating a system of post-payment
14audit and review which shall, on a sampling basis, be deemed
15adequate by the Illinois Department to assure that such drugs,
16dentures, prosthetic devices and eyeglasses for which payment
17is being made are actually being received by eligible
18recipients. Within 90 days after September 16, 1984 (the
19effective date of Public Act 83-1439), the Illinois Department
20shall establish a current list of acquisition costs for all
21prosthetic devices and any other items recognized as medical
22equipment and supplies reimbursable under this Article and
23shall update such list on a quarterly basis, except that the
24acquisition costs of all prescription drugs shall be updated no
25less frequently than every 30 days as required by Section
265-5.12.

 

 

SB0162- 37 -LRB101 07839 SMS 52893 b

1    Notwithstanding any other law to the contrary, the Illinois
2Department shall, within 365 days after July 22, 2013 (the
3effective date of Public Act 98-104), establish procedures to
4permit skilled care facilities licensed under the Nursing Home
5Care Act to submit monthly billing claims for reimbursement
6purposes. Following development of these procedures, the
7Department shall, by July 1, 2016, test the viability of the
8new system and implement any necessary operational or
9structural changes to its information technology platforms in
10order to allow for the direct acceptance and payment of nursing
11home claims.
12    Notwithstanding any other law to the contrary, the Illinois
13Department shall, within 365 days after August 15, 2014 (the
14effective date of Public Act 98-963), establish procedures to
15permit ID/DD facilities licensed under the ID/DD Community Care
16Act and MC/DD facilities licensed under the MC/DD Act to submit
17monthly billing claims for reimbursement purposes. Following
18development of these procedures, the Department shall have an
19additional 365 days to test the viability of the new system and
20to ensure that any necessary operational or structural changes
21to its information technology platforms are implemented.
22    The Illinois Department shall require all dispensers of
23medical services, other than an individual practitioner or
24group of practitioners, desiring to participate in the Medical
25Assistance program established under this Article to disclose
26all financial, beneficial, ownership, equity, surety or other

 

 

SB0162- 38 -LRB101 07839 SMS 52893 b

1interests in any and all firms, corporations, partnerships,
2associations, business enterprises, joint ventures, agencies,
3institutions or other legal entities providing any form of
4health care services in this State under this Article.
5    The Illinois Department may require that all dispensers of
6medical services desiring to participate in the medical
7assistance program established under this Article disclose,
8under such terms and conditions as the Illinois Department may
9by rule establish, all inquiries from clients and attorneys
10regarding medical bills paid by the Illinois Department, which
11inquiries could indicate potential existence of claims or liens
12for the Illinois Department.
13    Enrollment of a vendor shall be subject to a provisional
14period and shall be conditional for one year. During the period
15of conditional enrollment, the Department may terminate the
16vendor's eligibility to participate in, or may disenroll the
17vendor from, the medical assistance program without cause.
18Unless otherwise specified, such termination of eligibility or
19disenrollment is not subject to the Department's hearing
20process. However, a disenrolled vendor may reapply without
21penalty.
22    The Department has the discretion to limit the conditional
23enrollment period for vendors based upon category of risk of
24the vendor.
25    Prior to enrollment and during the conditional enrollment
26period in the medical assistance program, all vendors shall be

 

 

SB0162- 39 -LRB101 07839 SMS 52893 b

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

 

 

SB0162- 40 -LRB101 07839 SMS 52893 b

1exceptions:
2        (1) In the case of a provider whose enrollment is in
3    process by the Illinois Department, the 180-day period
4    shall not begin until the date on the written notice from
5    the Illinois Department that the provider enrollment is
6    complete.
7        (2) In the case of errors attributable to the Illinois
8    Department or any of its claims processing intermediaries
9    which result in an inability to receive, process, or
10    adjudicate a claim, the 180-day period shall not begin
11    until the provider has been notified of the error.
12        (3) In the case of a provider for whom the Illinois
13    Department initiates the monthly billing process.
14        (4) In the case of a provider operated by a unit of
15    local government with a population exceeding 3,000,000
16    when local government funds finance federal participation
17    for claims payments.
18    For claims for services rendered during a period for which
19a recipient received retroactive eligibility, claims must be
20filed within 180 days after the Department determines the
21applicant is eligible. For claims for which the Illinois
22Department is not the primary payer, claims must be submitted
23to the Illinois Department within 180 days after the final
24adjudication by the primary payer.
25    In the case of long term care facilities, within 45
26calendar days of receipt by the facility of required

 

 

SB0162- 41 -LRB101 07839 SMS 52893 b

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

 

 

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

 

 

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

 

 

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1approval and, for wheelchairs, wheelchair parts, wheelchair
2accessories, and related seating and positioning items,
3determine the wholesale price by methods other than actual
4acquisition costs.
5    The Department shall require, by rule, all providers of
6durable medical equipment to be accredited by an accreditation
7organization approved by the federal Centers for Medicare and
8Medicaid Services and recognized by the Department in order to
9bill the Department for providing durable medical equipment to
10recipients. No later than 15 months after the effective date of
11the rule adopted pursuant to this paragraph, all providers must
12meet the accreditation requirement.
13    In order to promote environmental responsibility, meet the
14needs of recipients and enrollees, and achieve significant cost
15savings, the Department, or a managed care organization under
16contract with the Department, may provide recipients or managed
17care enrollees who have a prescription or Certificate of
18Medical Necessity access to refurbished durable medical
19equipment under this Section (excluding prosthetic and
20orthotic devices as defined in the Orthotics, Prosthetics, and
21Pedorthics Practice Act and complex rehabilitation technology
22products and associated services) through the State's
23assistive technology program's reutilization program, using
24staff with the Assistive Technology Professional (ATP)
25Certification if the refurbished durable medical equipment:
26(i) is available; (ii) is less expensive, including shipping

 

 

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1costs, than new durable medical equipment of the same type;
2(iii) is able to withstand at least 3 years of use; (iv) is
3cleaned, disinfected, sterilized, and safe in accordance with
4federal Food and Drug Administration regulations and guidance
5governing the reprocessing of medical devices in health care
6settings; and (v) equally meets the needs of the recipient or
7enrollee. The reutilization program shall confirm that the
8recipient or enrollee is not already in receipt of same or
9similar equipment from another service provider, and that the
10refurbished durable medical equipment equally meets the needs
11of the recipient or enrollee. Nothing in this paragraph shall
12be construed to limit recipient or enrollee choice to obtain
13new durable medical equipment or place any additional prior
14authorization conditions on enrollees of managed care
15organizations.
16    The Department shall execute, relative to the nursing home
17prescreening project, written inter-agency agreements with the
18Department of Human Services and the Department on Aging, to
19effect the following: (i) intake procedures and common
20eligibility criteria for those persons who are receiving
21non-institutional services; and (ii) the establishment and
22development of non-institutional services in areas of the State
23where they are not currently available or are undeveloped; and
24(iii) notwithstanding any other provision of law, subject to
25federal approval, on and after July 1, 2012, an increase in the
26determination of need (DON) scores from 29 to 37 for applicants

 

 

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1for institutional and home and community-based long term care;
2if and only if federal approval is not granted, the Department
3may, in conjunction with other affected agencies, implement
4utilization controls or changes in benefit packages to
5effectuate a similar savings amount for this population; and
6(iv) no later than July 1, 2013, minimum level of care
7eligibility criteria for institutional and home and
8community-based long term care; and (v) no later than October
91, 2013, establish procedures to permit long term care
10providers access to eligibility scores for individuals with an
11admission date who are seeking or receiving services from the
12long term care provider. In order to select the minimum level
13of care eligibility criteria, the Governor shall establish a
14workgroup that includes affected agency representatives and
15stakeholders representing the institutional and home and
16community-based long term care interests. This Section shall
17not restrict the Department from implementing lower level of
18care eligibility criteria for community-based services in
19circumstances where federal approval has been granted.
20    The Illinois Department shall develop and operate, in
21cooperation with other State Departments and agencies and in
22compliance with applicable federal laws and regulations,
23appropriate and effective systems of health care evaluation and
24programs for monitoring of utilization of health care services
25and facilities, as it affects persons eligible for medical
26assistance under this Code.

 

 

SB0162- 47 -LRB101 07839 SMS 52893 b

1    The Illinois Department shall report annually to the
2General Assembly, no later than the second Friday in April of
31979 and each year thereafter, in regard to:
4        (a) actual statistics and trends in utilization of
5    medical services by public aid recipients;
6        (b) actual statistics and trends in the provision of
7    the various medical services by medical vendors;
8        (c) current rate structures and proposed changes in
9    those rate structures for the various medical vendors; and
10        (d) efforts at utilization review and control by the
11    Illinois Department.
12    The period covered by each report shall be the 3 years
13ending on the June 30 prior to the report. The report shall
14include suggested legislation for consideration by the General
15Assembly. The requirement for reporting to the General Assembly
16shall be satisfied by filing copies of the report as required
17by Section 3.1 of the General Assembly Organization Act, and
18filing such additional copies with the State Government Report
19Distribution Center for the General Assembly as is required
20under paragraph (t) of Section 7 of the State Library Act.
21    Rulemaking authority to implement Public Act 95-1045, if
22any, is conditioned on the rules being adopted in accordance
23with all provisions of the Illinois Administrative Procedure
24Act and all rules and procedures of the Joint Committee on
25Administrative Rules; any purported rule not so adopted, for
26whatever reason, is unauthorized.

 

 

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1    On and after July 1, 2012, the Department shall reduce any
2rate of reimbursement for services or other payments or alter
3any methodologies authorized by this Code to reduce any rate of
4reimbursement for services or other payments in accordance with
5Section 5-5e.
6    Because kidney transplantation can be an appropriate,
7cost-effective alternative to renal dialysis when medically
8necessary and notwithstanding the provisions of Section 1-11 of
9this Code, beginning October 1, 2014, the Department shall
10cover kidney transplantation for noncitizens with end-stage
11renal disease who are not eligible for comprehensive medical
12benefits, who meet the residency requirements of Section 5-3 of
13this Code, and who would otherwise meet the financial
14requirements of the appropriate class of eligible persons under
15Section 5-2 of this Code. To qualify for coverage of kidney
16transplantation, such person must be receiving emergency renal
17dialysis services covered by the Department. Providers under
18this Section shall be prior approved and certified by the
19Department to perform kidney transplantation and the services
20under this Section shall be limited to services associated with
21kidney transplantation.
22    Notwithstanding any other provision of this Code to the
23contrary, on or after July 1, 2015, all FDA approved forms of
24medication assisted treatment prescribed for the treatment of
25alcohol dependence or treatment of opioid dependence shall be
26covered under both fee for service and managed care medical

 

 

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1assistance programs for persons who are otherwise eligible for
2medical assistance under this Article and shall not be subject
3to any (1) utilization control, other than those established
4under the American Society of Addiction Medicine patient
5placement criteria, (2) prior authorization mandate, or (3)
6lifetime restriction limit mandate.
7    On or after July 1, 2015, opioid antagonists prescribed for
8the treatment of an opioid overdose, including the medication
9product, administration devices, and any pharmacy fees related
10to the dispensing and administration of the opioid antagonist,
11shall be covered under the medical assistance program for
12persons who are otherwise eligible for medical assistance under
13this Article. As used in this Section, "opioid antagonist"
14means a drug that binds to opioid receptors and blocks or
15inhibits the effect of opioids acting on those receptors,
16including, but not limited to, naloxone hydrochloride or any
17other similarly acting drug approved by the U.S. Food and Drug
18Administration.
19    Upon federal approval, the Department shall provide
20coverage and reimbursement for all drugs that are approved for
21marketing by the federal Food and Drug Administration and that
22are recommended by the federal Public Health Service or the
23United States Centers for Disease Control and Prevention for
24pre-exposure prophylaxis and related pre-exposure prophylaxis
25services, including, but not limited to, HIV and sexually
26transmitted infection screening, treatment for sexually

 

 

SB0162- 50 -LRB101 07839 SMS 52893 b

1transmitted infections, medical monitoring, assorted labs, and
2counseling to reduce the likelihood of HIV infection among
3individuals who are not infected with HIV but who are at high
4risk of HIV infection.
5    A federally qualified health center, as defined in Section
61905(l)(2)(B) of the federal Social Security Act, shall be
7reimbursed by the Department in accordance with the federally
8qualified health center's encounter rate for services provided
9to medical assistance recipients that are performed by a dental
10hygienist, as defined under the Illinois Dental Practice Act,
11working under the general supervision of a dentist and employed
12by a federally qualified health center.
13    Notwithstanding any other provision of this Code, the
14Illinois Department shall authorize licensed dietitian
15nutritionists and certified diabetes educators to counsel
16senior diabetes patients in the senior diabetes patients' homes
17to remove the hurdle of transportation for senior diabetes
18patients to receive treatment.
19(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
2099-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
21the effective date of P.A. 99-407); 99-433, eff. 8-21-15;
2299-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
237-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
24eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
25100-538, eff. 1-1-18; 100-587, eff. 6-4-18; 100-759, eff.
261-1-19; 100-863, eff. 8-14-18; 100-974, eff. 8-19-18;

 

 

SB0162- 51 -LRB101 07839 SMS 52893 b

1100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; 100-1148, eff.
212-10-18.)
 
3    Section 99. Effective date. This Act takes effect upon
4becoming law.