101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
SB1716

 

Introduced 2/15/2019, by Sen. Michael E. Hastings

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that on or after July 1, 2019, all FDA approved prescription medications that are recognized by a generally accepted standard medical reference as effective in the treatment of conditions specified in the most recent Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association must be covered under both fee-for-service and managed care medical assistance programs for persons who are otherwise eligible for medical assistance and shall not be subject to any (i) utilization control, (ii) prior authorization mandate, or (iii) lifetime restriction limit mandate.


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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 1. The Illinois Public Aid Code is amended by
5changing Section 5-5 as follows:
 
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

 

 

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

 

 

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1laws of this State. The term "any other type of remedial care"
2shall include nursing care and nursing home service for persons
3who rely on treatment by spiritual means alone through prayer
4for healing.
5    Notwithstanding any other provision of this Section, a
6comprehensive tobacco use cessation program that includes
7purchasing prescription drugs or prescription medical devices
8approved by the Food and Drug Administration shall be covered
9under the medical assistance program under this Article for
10persons who are otherwise eligible for assistance under this
11Article.
12    Notwithstanding any other provision of this Code,
13reproductive health care that is otherwise legal in Illinois
14shall be covered under the medical assistance program for
15persons who are otherwise eligible for medical assistance under
16this Article.
17    Notwithstanding any other provision of this Code, the
18Illinois Department may not require, as a condition of payment
19for any laboratory test authorized under this Article, that a
20physician's handwritten signature appear on the laboratory
21test order form. The Illinois Department may, however, impose
22other appropriate requirements regarding laboratory test order
23documentation.
24    Upon receipt of federal approval of an amendment to the
25Illinois Title XIX State Plan for this purpose, the Department
26shall authorize the Chicago Public Schools (CPS) to procure a

 

 

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1vendor or vendors to manufacture eyeglasses for individuals
2enrolled in a school within the CPS system. CPS shall ensure
3that its vendor or vendors are enrolled as providers in the
4medical assistance program and in any capitated Medicaid
5managed care entity (MCE) serving individuals enrolled in a
6school within the CPS system. Under any contract procured under
7this provision, the vendor or vendors must serve only
8individuals enrolled in a school within the CPS system. Claims
9for services provided by CPS's vendor or vendors to recipients
10of benefits in the medical assistance program under this Code,
11the Children's Health Insurance Program, or the Covering ALL
12KIDS Health Insurance Program shall be submitted to the
13Department or the MCE in which the individual is enrolled for
14payment and shall be reimbursed at the Department's or the
15MCE's established rates or rate methodologies for eyeglasses.
16    On and after July 1, 2012, the Department of Healthcare and
17Family Services may provide the following services to persons
18eligible for assistance under this Article who are
19participating in education, training or employment programs
20operated by the Department of Human Services as successor to
21the Department of Public Aid:
22        (1) dental services provided by or under the
23    supervision of a dentist; and
24        (2) eyeglasses prescribed by a physician skilled in the
25    diseases of the eye, or by an optometrist, whichever the
26    person may select.

 

 

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1    On and after July 1, 2018, the Department of Healthcare and
2Family Services shall provide dental services to any adult who
3is otherwise eligible for assistance under the medical
4assistance program. As used in this paragraph, "dental
5services" means diagnostic, preventative, restorative, or
6corrective procedures, including procedures and services for
7the prevention and treatment of periodontal disease and dental
8caries disease, provided by an individual who is licensed to
9practice dentistry or dental surgery or who is under the
10supervision of a dentist in the practice of his or her
11profession.
12    On and after July 1, 2018, targeted dental services, as set
13forth in Exhibit D of the Consent Decree entered by the United
14States District Court for the Northern District of Illinois,
15Eastern Division, in the matter of Memisovski v. Maram, Case
16No. 92 C 1982, that are provided to adults under the medical
17assistance program shall be established at no less than the
18rates set forth in the "New Rate" column in Exhibit D of the
19Consent Decree for targeted dental services that are provided
20to persons under the age of 18 under the medical assistance
21program.
22    Notwithstanding any other provision of this Code and
23subject to federal approval, the Department may adopt rules to
24allow a dentist who is volunteering his or her service at no
25cost to render dental services through an enrolled
26not-for-profit health clinic without the dentist personally

 

 

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1enrolling as a participating provider in the medical assistance
2program. A not-for-profit health clinic shall include a public
3health clinic or Federally Qualified Health Center or other
4enrolled provider, as determined by the Department, through
5which dental services covered under this Section are performed.
6The Department shall establish a process for payment of claims
7for reimbursement for covered dental services rendered under
8this provision.
9    The Illinois Department, by rule, may distinguish and
10classify the medical services to be provided only in accordance
11with the classes of persons designated in Section 5-2.
12    The Department of Healthcare and Family Services must
13provide coverage and reimbursement for amino acid-based
14elemental formulas, regardless of delivery method, for the
15diagnosis and treatment of (i) eosinophilic disorders and (ii)
16short bowel syndrome when the prescribing physician has issued
17a written order stating that the amino acid-based elemental
18formula is medically necessary.
19    The Illinois Department shall authorize the provision of,
20and shall authorize payment for, screening by low-dose
21mammography for the presence of occult breast cancer for women
2235 years of age or older who are eligible for medical
23assistance under this Article, as follows:
24        (A) A baseline mammogram for women 35 to 39 years of
25    age.
26        (B) An annual mammogram for women 40 years of age or

 

 

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1    older.
2        (C) A mammogram at the age and intervals considered
3    medically necessary by the woman's health care provider for
4    women under 40 years of age and having a family history of
5    breast cancer, prior personal history of breast cancer,
6    positive genetic testing, or other risk factors.
7        (D) A comprehensive ultrasound screening and MRI of an
8    entire breast or breasts if a mammogram demonstrates
9    heterogeneous or dense breast tissue, when medically
10    necessary as determined by a physician licensed to practice
11    medicine in all of its branches.
12        (E) A screening MRI when medically necessary, as
13    determined by a physician licensed to practice medicine in
14    all of its branches.
15    All screenings shall include a physical breast exam,
16instruction on self-examination and information regarding the
17frequency of self-examination and its value as a preventative
18tool. For purposes of this Section, "low-dose mammography"
19means the x-ray examination of the breast using equipment
20dedicated specifically for mammography, including the x-ray
21tube, filter, compression device, and image receptor, with an
22average radiation exposure delivery of less than one rad per
23breast for 2 views of an average size breast. The term also
24includes digital mammography and includes breast
25tomosynthesis. As used in this Section, the term "breast
26tomosynthesis" means a radiologic procedure that involves the

 

 

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1acquisition of projection images over the stationary breast to
2produce cross-sectional digital three-dimensional images of
3the breast. 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 paragraph, 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 paragraph.
18    On and after January 1, 2016, the Department shall ensure
19that all networks of care for adult clients of the Department
20include access to at least one breast imaging Center of Imaging
21Excellence as certified by the American College of Radiology.
22    On and after January 1, 2012, providers participating in a
23quality improvement program approved by the Department shall be
24reimbursed for screening and diagnostic mammography at the same
25rate as the Medicare program's rates, including the increased
26reimbursement for digital mammography.

 

 

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1    The Department shall convene an expert panel including
2representatives of hospitals, free-standing mammography
3facilities, and doctors, including radiologists, to establish
4quality standards for mammography.
5    On and after January 1, 2017, providers participating in a
6breast cancer treatment quality improvement program approved
7by the Department shall be reimbursed for breast cancer
8treatment at a rate that is no lower than 95% of the Medicare
9program's rates for the data elements included in the breast
10cancer treatment quality program.
11    The Department shall convene an expert panel, including
12representatives of hospitals, free-standing breast cancer
13treatment centers, breast cancer quality organizations, and
14doctors, including breast surgeons, reconstructive breast
15surgeons, oncologists, and primary care providers to establish
16quality standards for breast cancer treatment.
17    Subject to federal approval, the Department shall
18establish a rate methodology for mammography at federally
19qualified health centers and other encounter-rate clinics.
20These clinics or centers may also collaborate with other
21hospital-based mammography facilities. By January 1, 2016, the
22Department shall report to the General Assembly on the status
23of the provision set forth in this paragraph.
24    The Department shall establish a methodology to remind
25women who are age-appropriate for screening mammography, but
26who have not received a mammogram within the previous 18

 

 

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1months, of the importance and benefit of screening mammography.
2The Department shall work with experts in breast cancer
3outreach and patient navigation to optimize these reminders and
4shall establish a methodology for evaluating their
5effectiveness and modifying the methodology based on the
6evaluation.
7    The Department shall establish a performance goal for
8primary care providers with respect to their female patients
9over age 40 receiving an annual mammogram. This performance
10goal shall be used to provide additional reimbursement in the
11form of a quality performance bonus to primary care providers
12who meet that goal.
13    The Department shall devise a means of case-managing or
14patient navigation for beneficiaries diagnosed with breast
15cancer. This program shall initially operate as a pilot program
16in areas of the State with the highest incidence of mortality
17related to breast cancer. At least one pilot program site shall
18be in the metropolitan Chicago area and at least one site shall
19be outside the metropolitan Chicago area. On or after July 1,
202016, the pilot program shall be expanded to include one site
21in western Illinois, one site in southern Illinois, one site in
22central Illinois, and 4 sites within metropolitan Chicago. An
23evaluation of the pilot program shall be carried out measuring
24health outcomes and cost of care for those served by the pilot
25program compared to similarly situated patients who are not
26served by the pilot program.

 

 

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1    The Department shall require all networks of care to
2develop a means either internally or by contract with experts
3in navigation and community outreach to navigate cancer
4patients to comprehensive care in a timely fashion. The
5Department shall require all networks of care to include access
6for patients diagnosed with cancer to at least one academic
7commission on cancer-accredited cancer program as an
8in-network covered benefit.
9    Any medical or health care provider shall immediately
10recommend, to any pregnant woman who is being provided prenatal
11services and is suspected of having a substance use disorder as
12defined in the Substance Use Disorder Act, referral to a local
13substance use disorder treatment program licensed by the
14Department of Human Services or to a licensed hospital which
15provides substance abuse treatment services. The Department of
16Healthcare and Family Services shall assure coverage for the
17cost of treatment of the drug abuse or addiction for pregnant
18recipients in accordance with the Illinois Medicaid Program in
19conjunction with the Department of Human Services.
20    All medical providers providing medical assistance to
21pregnant women under this Code shall receive information from
22the Department on the availability of services under any
23program providing case management services for addicted women,
24including information on appropriate referrals for other
25social services that may be needed by addicted women in
26addition to treatment for addiction.

 

 

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1    The Illinois Department, in cooperation with the
2Departments of Human Services (as successor to the Department
3of Alcoholism and Substance Abuse) and Public Health, through a
4public awareness campaign, may provide information concerning
5treatment for alcoholism and drug abuse and addiction, prenatal
6health care, and other pertinent programs directed at reducing
7the number of drug-affected infants born to recipients of
8medical assistance.
9    Neither the Department of Healthcare and Family Services
10nor the Department of Human Services shall sanction the
11recipient solely on the basis of her substance abuse.
12    The Illinois Department shall establish such regulations
13governing the dispensing of health services under this Article
14as it shall deem appropriate. The Department should seek the
15advice of formal professional advisory committees appointed by
16the Director of the Illinois Department for the purpose of
17providing regular advice on policy and administrative matters,
18information dissemination and educational activities for
19medical and health care providers, and consistency in
20procedures to the Illinois Department.
21    The Illinois Department may develop and contract with
22Partnerships of medical providers to arrange medical services
23for persons eligible under Section 5-2 of this Code.
24Implementation of this Section may be by demonstration projects
25in certain geographic areas. The Partnership shall be
26represented by a sponsor organization. The Department, by rule,

 

 

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1shall develop qualifications for sponsors of Partnerships.
2Nothing in this Section shall be construed to require that the
3sponsor organization be a medical organization.
4    The sponsor must negotiate formal written contracts with
5medical providers for physician services, inpatient and
6outpatient hospital care, home health services, treatment for
7alcoholism and substance abuse, and other services determined
8necessary by the Illinois Department by rule for delivery by
9Partnerships. Physician services must include prenatal and
10obstetrical care. The Illinois Department shall reimburse
11medical services delivered by Partnership providers to clients
12in target areas according to provisions of this Article and the
13Illinois Health Finance Reform Act, except that:
14        (1) Physicians participating in a Partnership and
15    providing certain services, which shall be determined by
16    the Illinois Department, to persons in areas covered by the
17    Partnership may receive an additional surcharge for such
18    services.
19        (2) The Department may elect to consider and negotiate
20    financial incentives to encourage the development of
21    Partnerships and the efficient delivery of medical care.
22        (3) Persons receiving medical services through
23    Partnerships may receive medical and case management
24    services above the level usually offered through the
25    medical assistance program.
26    Medical providers shall be required to meet certain

 

 

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1qualifications to participate in Partnerships to ensure the
2delivery of high quality medical services. These
3qualifications shall be determined by rule of the Illinois
4Department and may be higher than qualifications for
5participation in the medical assistance program. Partnership
6sponsors may prescribe reasonable additional qualifications
7for participation by medical providers, only with the prior
8written approval of the Illinois Department.
9    Nothing in this Section shall limit the free choice of
10practitioners, hospitals, and other providers of medical
11services by clients. In order to ensure patient freedom of
12choice, the Illinois Department shall immediately promulgate
13all rules and take all other necessary actions so that provided
14services may be accessed from therapeutically certified
15optometrists to the full extent of the Illinois Optometric
16Practice Act of 1987 without discriminating between service
17providers.
18    The Department shall apply for a waiver from the United
19States Health Care Financing Administration to allow for the
20implementation of Partnerships under this Section.
21    The Illinois Department shall require health care
22providers to maintain records that document the medical care
23and services provided to recipients of Medical Assistance under
24this Article. Such records must be retained for a period of not
25less than 6 years from the date of service or as provided by
26applicable State law, whichever period is longer, except that

 

 

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1if an audit is initiated within the required retention period
2then the records must be retained until the audit is completed
3and every exception is resolved. The Illinois Department shall
4require health care providers to make available, when
5authorized by the patient, in writing, the medical records in a
6timely fashion to other health care providers who are treating
7or serving persons eligible for Medical Assistance under this
8Article. All dispensers of medical services shall be required
9to maintain and retain business and professional records
10sufficient to fully and accurately document the nature, scope,
11details and receipt of the health care provided to persons
12eligible for medical assistance under this Code, in accordance
13with regulations promulgated by the Illinois Department. The
14rules and regulations shall require that proof of the receipt
15of prescription drugs, dentures, prosthetic devices and
16eyeglasses by eligible persons under this Section accompany
17each claim for reimbursement submitted by the dispenser of such
18medical services. No such claims for reimbursement shall be
19approved for payment by the Illinois Department without such
20proof of receipt, unless the Illinois Department shall have put
21into effect and shall be operating a system of post-payment
22audit and review which shall, on a sampling basis, be deemed
23adequate by the Illinois Department to assure that such drugs,
24dentures, prosthetic devices and eyeglasses for which payment
25is being made are actually being received by eligible
26recipients. Within 90 days after September 16, 1984 (the

 

 

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1effective date of Public Act 83-1439), the Illinois Department
2shall establish a current list of acquisition costs for all
3prosthetic devices and any other items recognized as medical
4equipment and supplies reimbursable under this Article and
5shall update such list on a quarterly basis, except that the
6acquisition costs of all prescription drugs shall be updated no
7less frequently than every 30 days as required by Section
85-5.12.
9    Notwithstanding any other law to the contrary, the Illinois
10Department shall, within 365 days after July 22, 2013 (the
11effective date of Public Act 98-104), establish procedures to
12permit skilled care facilities licensed under the Nursing Home
13Care Act to submit monthly billing claims for reimbursement
14purposes. Following development of these procedures, the
15Department shall, by July 1, 2016, test the viability of the
16new system and implement any necessary operational or
17structural changes to its information technology platforms in
18order to allow for the direct acceptance and payment of nursing
19home claims.
20    Notwithstanding any other law to the contrary, the Illinois
21Department shall, within 365 days after August 15, 2014 (the
22effective date of Public Act 98-963), establish procedures to
23permit ID/DD facilities licensed under the ID/DD Community Care
24Act and MC/DD facilities licensed under the MC/DD Act to submit
25monthly billing claims for reimbursement purposes. Following
26development of these procedures, the Department shall have an

 

 

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1additional 365 days to test the viability of the new system and
2to ensure that any necessary operational or structural changes
3to its information technology platforms are implemented.
4    The Illinois Department shall require all dispensers of
5medical services, other than an individual practitioner or
6group of practitioners, desiring to participate in the Medical
7Assistance program established under this Article to disclose
8all financial, beneficial, ownership, equity, surety or other
9interests in any and all firms, corporations, partnerships,
10associations, business enterprises, joint ventures, agencies,
11institutions or other legal entities providing any form of
12health care services in this State under this Article.
13    The Illinois Department may require that all dispensers of
14medical services desiring to participate in the medical
15assistance program established under this Article disclose,
16under such terms and conditions as the Illinois Department may
17by rule establish, all inquiries from clients and attorneys
18regarding medical bills paid by the Illinois Department, which
19inquiries could indicate potential existence of claims or liens
20for the Illinois Department.
21    Enrollment of a vendor shall be subject to a provisional
22period and shall be conditional for one year. During the period
23of conditional enrollment, the Department may terminate the
24vendor's eligibility to participate in, or may disenroll the
25vendor from, the medical assistance program without cause.
26Unless otherwise specified, such termination of eligibility or

 

 

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

 

 

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1of risk of the vendor that is terminated or disenrolled during
2the conditional enrollment period.
3    To be eligible for payment consideration, a vendor's
4payment claim or bill, either as an initial claim or as a
5resubmitted claim following prior rejection, must be received
6by the Illinois Department, or its fiscal intermediary, no
7later than 180 days after the latest date on the claim on which
8medical goods or services were provided, with the following
9exceptions:
10        (1) In the case of a provider whose enrollment is in
11    process by the Illinois Department, the 180-day period
12    shall not begin until the date on the written notice from
13    the Illinois Department that the provider enrollment is
14    complete.
15        (2) In the case of errors attributable to the Illinois
16    Department or any of its claims processing intermediaries
17    which result in an inability to receive, process, or
18    adjudicate a claim, the 180-day period shall not begin
19    until the provider has been notified of the error.
20        (3) In the case of a provider for whom the Illinois
21    Department initiates the monthly billing process.
22        (4) In the case of a provider operated by a unit of
23    local government with a population exceeding 3,000,000
24    when local government funds finance federal participation
25    for claims payments.
26    For claims for services rendered during a period for which

 

 

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1a recipient received retroactive eligibility, claims must be
2filed within 180 days after the Department determines the
3applicant is eligible. For claims for which the Illinois
4Department is not the primary payer, claims must be submitted
5to the Illinois Department within 180 days after the final
6adjudication by the primary payer.
7    In the case of long term care facilities, within 45
8calendar days of receipt by the facility of required
9prescreening information, new admissions with associated
10admission documents shall be submitted through the Medical
11Electronic Data Interchange (MEDI) or the Recipient
12Eligibility Verification (REV) System or shall be submitted
13directly to the Department of Human Services using required
14admission forms. Effective September 1, 2014, admission
15documents, including all prescreening information, must be
16submitted through MEDI or REV. Confirmation numbers assigned to
17an accepted transaction shall be retained by a facility to
18verify timely submittal. Once an admission transaction has been
19completed, all resubmitted claims following prior rejection
20are subject to receipt no later than 180 days after the
21admission transaction has been completed.
22    Claims that are not submitted and received in compliance
23with the foregoing requirements shall not be eligible for
24payment under the medical assistance program, and the State
25shall have no liability for payment of those claims.
26    To the extent consistent with applicable information and

 

 

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1privacy, security, and disclosure laws, State and federal
2agencies and departments shall provide the Illinois Department
3access to confidential and other information and data necessary
4to perform eligibility and payment verifications and other
5Illinois Department functions. This includes, but is not
6limited to: information pertaining to licensure;
7certification; earnings; immigration status; citizenship; wage
8reporting; unearned and earned income; pension income;
9employment; supplemental security income; social security
10numbers; National Provider Identifier (NPI) numbers; the
11National Practitioner Data Bank (NPDB); program and agency
12exclusions; taxpayer identification numbers; tax delinquency;
13corporate information; and death records.
14    The Illinois Department shall enter into agreements with
15State agencies and departments, and is authorized to enter into
16agreements with federal agencies and departments, under which
17such agencies and departments shall share data necessary for
18medical assistance program integrity functions and oversight.
19The Illinois Department shall develop, in cooperation with
20other State departments and agencies, and in compliance with
21applicable federal laws and regulations, appropriate and
22effective methods to share such data. At a minimum, and to the
23extent necessary to provide data sharing, the Illinois
24Department shall enter into agreements with State agencies and
25departments, and is authorized to enter into agreements with
26federal agencies and departments, including but not limited to:

 

 

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1the Secretary of State; the Department of Revenue; the
2Department of Public Health; the Department of Human Services;
3and the Department of Financial and Professional Regulation.
4    Beginning in fiscal year 2013, the Illinois Department
5shall set forth a request for information to identify the
6benefits of a pre-payment, post-adjudication, and post-edit
7claims system with the goals of streamlining claims processing
8and provider reimbursement, reducing the number of pending or
9rejected claims, and helping to ensure a more transparent
10adjudication process through the utilization of: (i) provider
11data verification and provider screening technology; and (ii)
12clinical code editing; and (iii) pre-pay, pre- or
13post-adjudicated predictive modeling with an integrated case
14management system with link analysis. Such a request for
15information shall not be considered as a request for proposal
16or as an obligation on the part of the Illinois Department to
17take any action or acquire any products or services.
18    The Illinois Department shall establish policies,
19procedures, standards and criteria by rule for the acquisition,
20repair and replacement of orthotic and prosthetic devices and
21durable medical equipment. Such rules shall provide, but not be
22limited to, the following services: (1) immediate repair or
23replacement of such devices by recipients; and (2) rental,
24lease, purchase or lease-purchase of durable medical equipment
25in a cost-effective manner, taking into consideration the
26recipient's medical prognosis, the extent of the recipient's

 

 

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1needs, and the requirements and costs for maintaining such
2equipment. Subject to prior approval, such rules shall enable a
3recipient to temporarily acquire and use alternative or
4substitute devices or equipment pending repairs or
5replacements of any device or equipment previously authorized
6for such recipient by the Department. Notwithstanding any
7provision of Section 5-5f to the contrary, the Department may,
8by rule, exempt certain replacement wheelchair parts from prior
9approval and, for wheelchairs, wheelchair parts, wheelchair
10accessories, and related seating and positioning items,
11determine the wholesale price by methods other than actual
12acquisition costs.
13    The Department shall require, by rule, all providers of
14durable medical equipment to be accredited by an accreditation
15organization approved by the federal Centers for Medicare and
16Medicaid Services and recognized by the Department in order to
17bill the Department for providing durable medical equipment to
18recipients. No later than 15 months after the effective date of
19the rule adopted pursuant to this paragraph, all providers must
20meet the accreditation requirement.
21    In order to promote environmental responsibility, meet the
22needs of recipients and enrollees, and achieve significant cost
23savings, the Department, or a managed care organization under
24contract with the Department, may provide recipients or managed
25care enrollees who have a prescription or Certificate of
26Medical Necessity access to refurbished durable medical

 

 

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1equipment under this Section (excluding prosthetic and
2orthotic devices as defined in the Orthotics, Prosthetics, and
3Pedorthics Practice Act and complex rehabilitation technology
4products and associated services) through the State's
5assistive technology program's reutilization program, using
6staff with the Assistive Technology Professional (ATP)
7Certification if the refurbished durable medical equipment:
8(i) is available; (ii) is less expensive, including shipping
9costs, than new durable medical equipment of the same type;
10(iii) is able to withstand at least 3 years of use; (iv) is
11cleaned, disinfected, sterilized, and safe in accordance with
12federal Food and Drug Administration regulations and guidance
13governing the reprocessing of medical devices in health care
14settings; and (v) equally meets the needs of the recipient or
15enrollee. The reutilization program shall confirm that the
16recipient or enrollee is not already in receipt of same or
17similar equipment from another service provider, and that the
18refurbished durable medical equipment equally meets the needs
19of the recipient or enrollee. Nothing in this paragraph shall
20be construed to limit recipient or enrollee choice to obtain
21new durable medical equipment or place any additional prior
22authorization conditions on enrollees of managed care
23organizations.
24    The Department shall execute, relative to the nursing home
25prescreening project, written inter-agency agreements with the
26Department of Human Services and the Department on Aging, to

 

 

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1effect the following: (i) intake procedures and common
2eligibility criteria for those persons who are receiving
3non-institutional services; and (ii) the establishment and
4development of non-institutional services in areas of the State
5where they are not currently available or are undeveloped; and
6(iii) notwithstanding any other provision of law, subject to
7federal approval, on and after July 1, 2012, an increase in the
8determination of need (DON) scores from 29 to 37 for applicants
9for institutional and home and community-based long term care;
10if and only if federal approval is not granted, the Department
11may, in conjunction with other affected agencies, implement
12utilization controls or changes in benefit packages to
13effectuate a similar savings amount for this population; and
14(iv) no later than July 1, 2013, minimum level of care
15eligibility criteria for institutional and home and
16community-based long term care; and (v) no later than October
171, 2013, establish procedures to permit long term care
18providers access to eligibility scores for individuals with an
19admission date who are seeking or receiving services from the
20long term care provider. In order to select the minimum level
21of care eligibility criteria, the Governor shall establish a
22workgroup that includes affected agency representatives and
23stakeholders representing the institutional and home and
24community-based long term care interests. This Section shall
25not restrict the Department from implementing lower level of
26care eligibility criteria for community-based services in

 

 

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1circumstances where federal approval has been granted.
2    The Illinois Department shall develop and operate, in
3cooperation with other State Departments and agencies and in
4compliance with applicable federal laws and regulations,
5appropriate and effective systems of health care evaluation and
6programs for monitoring of utilization of health care services
7and facilities, as it affects persons eligible for medical
8assistance under this Code.
9    The Illinois Department shall report annually to the
10General Assembly, no later than the second Friday in April of
111979 and each year thereafter, in regard to:
12        (a) actual statistics and trends in utilization of
13    medical services by public aid recipients;
14        (b) actual statistics and trends in the provision of
15    the various medical services by medical vendors;
16        (c) current rate structures and proposed changes in
17    those rate structures for the various medical vendors; and
18        (d) efforts at utilization review and control by the
19    Illinois Department.
20    The period covered by each report shall be the 3 years
21ending on the June 30 prior to the report. The report shall
22include suggested legislation for consideration by the General
23Assembly. The requirement for reporting to the General Assembly
24shall be satisfied by filing copies of the report as required
25by Section 3.1 of the General Assembly Organization Act, and
26filing such additional copies with the State Government Report

 

 

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1Distribution Center for the General Assembly as is required
2under paragraph (t) of Section 7 of the State Library Act.
3    Rulemaking authority to implement Public Act 95-1045, if
4any, 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    On and after July 1, 2012, the Department shall reduce any
10rate of reimbursement for services or other payments or alter
11any methodologies authorized by this Code to reduce any rate of
12reimbursement for services or other payments in accordance with
13Section 5-5e.
14    Because kidney transplantation can be an appropriate,
15cost-effective alternative to renal dialysis when medically
16necessary and notwithstanding the provisions of Section 1-11 of
17this Code, beginning October 1, 2014, the Department shall
18cover kidney transplantation for noncitizens with end-stage
19renal disease who are not eligible for comprehensive medical
20benefits, who meet the residency requirements of Section 5-3 of
21this Code, and who would otherwise meet the financial
22requirements of the appropriate class of eligible persons under
23Section 5-2 of this Code. To qualify for coverage of kidney
24transplantation, such person must be receiving emergency renal
25dialysis services covered by the Department. Providers under
26this Section shall be prior approved and certified by the

 

 

SB1716- 28 -LRB101 08631 KTG 53715 b

1Department to perform kidney transplantation and the services
2under this Section shall be limited to services associated with
3kidney transplantation.
4    Notwithstanding any other provision of this Code to the
5contrary, on or after July 1, 2015, all FDA approved forms of
6medication assisted treatment prescribed for the treatment of
7alcohol dependence or treatment of opioid dependence shall be
8covered under both fee for service and managed care medical
9assistance programs for persons who are otherwise eligible for
10medical assistance under this Article and shall not be subject
11to any (1) utilization control, other than those established
12under the American Society of Addiction Medicine patient
13placement criteria, (2) prior authorization mandate, or (3)
14lifetime restriction limit mandate.
15    On or after July 1, 2015, opioid antagonists prescribed for
16the treatment of an opioid overdose, including the medication
17product, administration devices, and any pharmacy fees related
18to the dispensing and administration of the opioid antagonist,
19shall be covered under the medical assistance program for
20persons who are otherwise eligible for medical assistance under
21this Article. As used in this Section, "opioid antagonist"
22means a drug that binds to opioid receptors and blocks or
23inhibits the effect of opioids acting on those receptors,
24including, but not limited to, naloxone hydrochloride or any
25other similarly acting drug approved by the U.S. Food and Drug
26Administration.

 

 

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1    Upon federal approval, the Department shall provide
2coverage and reimbursement for all drugs that are approved for
3marketing by the federal Food and Drug Administration and that
4are recommended by the federal Public Health Service or the
5United States Centers for Disease Control and Prevention for
6pre-exposure prophylaxis and related pre-exposure prophylaxis
7services, including, but not limited to, HIV and sexually
8transmitted infection screening, treatment for sexually
9transmitted infections, medical monitoring, assorted labs, and
10counseling to reduce the likelihood of HIV infection among
11individuals who are not infected with HIV but who are at high
12risk of HIV infection.
13    A federally qualified health center, as defined in Section
141905(l)(2)(B) of the federal Social Security Act, shall be
15reimbursed by the Department in accordance with the federally
16qualified health center's encounter rate for services provided
17to medical assistance recipients that are performed by a dental
18hygienist, as defined under the Illinois Dental Practice Act,
19working under the general supervision of a dentist and employed
20by a federally qualified health center.
21    Notwithstanding any other provision of this Code, the
22Illinois Department shall authorize licensed dietitian
23nutritionists and certified diabetes educators to counsel
24senior diabetes patients in the senior diabetes patients' homes
25to remove the hurdle of transportation for senior diabetes
26patients to receive treatment.

 

 

SB1716- 30 -LRB101 08631 KTG 53715 b

1    Notwithstanding any other provision of this Code to the
2contrary, on or after July 1, 2019, all FDA approved
3prescription medications that are recognized by a generally
4accepted standard medical reference as effective in the
5treatment of conditions specified in the most recent Diagnostic
6and Statistical Manual of Mental Disorders published by the
7American Psychiatric Association must be covered under both
8fee-for-service and managed care medical assistance programs
9for persons who are otherwise eligible for medical assistance
10under this Article and shall not be subject to any (i)
11utilization control, (ii) prior authorization mandate, or
12(iii) lifetime restriction limit mandate.
13(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
1499-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
15the effective date of P.A. 99-407); 99-433, eff. 8-21-15;
1699-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
177-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
18eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
19100-538, eff. 1-1-18; 100-587, eff. 6-4-18; 100-759, eff.
201-1-19; 100-863, eff. 8-14-18; 100-974, eff. 8-19-18;
21100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; 100-1148, eff.
2212-10-18.)