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1 | AN ACT concerning public aid.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Illinois Public Aid Code is amended by | ||||||||||||||||||||||||||
5 | changing Sections 5-5 and by adding Section 5-5.28 as follows:
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6 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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7 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||||||||||||||||||||||
8 | rule, shall
determine the quantity and quality of and the rate | ||||||||||||||||||||||||||
9 | of reimbursement for the
medical assistance for which
payment | ||||||||||||||||||||||||||
10 | will be authorized, and the medical services to be provided,
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11 | which may include all or part of the following: (1) inpatient | ||||||||||||||||||||||||||
12 | hospital
services; (2) outpatient hospital services; (3) other | ||||||||||||||||||||||||||
13 | laboratory and
X-ray services; (4) skilled nursing home | ||||||||||||||||||||||||||
14 | services; (5) physicians'
services whether furnished in the | ||||||||||||||||||||||||||
15 | office, the patient's home, a
hospital, a skilled nursing | ||||||||||||||||||||||||||
16 | home, or elsewhere; (6) medical care, or any
other type of | ||||||||||||||||||||||||||
17 | remedial care furnished by licensed practitioners; (7)
home | ||||||||||||||||||||||||||
18 | health care services; (8) private duty nursing service; (9) | ||||||||||||||||||||||||||
19 | clinic
services; (10) dental services, including prevention | ||||||||||||||||||||||||||
20 | and treatment of periodontal disease and dental caries disease | ||||||||||||||||||||||||||
21 | for pregnant women, provided by an individual licensed to | ||||||||||||||||||||||||||
22 | practice dentistry or dental surgery; for purposes of this | ||||||||||||||||||||||||||
23 | item (10), "dental services" means diagnostic, preventive, or |
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1 | corrective procedures provided by or under the supervision of | ||||||
2 | a dentist in the practice of his or her profession; (11) | ||||||
3 | physical therapy and related
services; (12) prescribed drugs, | ||||||
4 | dentures, and prosthetic devices; and
eyeglasses prescribed by | ||||||
5 | a physician skilled in the diseases of the eye,
or by an | ||||||
6 | optometrist, whichever the person may select; (13) other
| ||||||
7 | diagnostic, screening, preventive, and rehabilitative | ||||||
8 | services, including to ensure that the individual's need for | ||||||
9 | intervention or treatment of mental disorders or substance use | ||||||
10 | disorders or co-occurring mental health and substance use | ||||||
11 | disorders is determined using a uniform screening, assessment, | ||||||
12 | and evaluation process inclusive of criteria, for children and | ||||||
13 | adults; for purposes of this item (13), a uniform screening, | ||||||
14 | assessment, and evaluation process refers to a process that | ||||||
15 | includes an appropriate evaluation and, as warranted, a | ||||||
16 | referral; "uniform" does not mean the use of a singular | ||||||
17 | instrument, tool, or process that all must utilize; (14)
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18 | transportation and such other expenses as may be necessary; | ||||||
19 | (15) medical
treatment of sexual assault survivors, as defined | ||||||
20 | in
Section 1a of the Sexual Assault Survivors Emergency | ||||||
21 | Treatment Act, for
injuries sustained as a result of the | ||||||
22 | sexual assault, including
examinations and laboratory tests to | ||||||
23 | discover evidence which may be used in
criminal proceedings | ||||||
24 | arising from the sexual assault; (16) the
diagnosis and | ||||||
25 | treatment of sickle cell anemia; and (17)
any other medical | ||||||
26 | care, and any other type of remedial care recognized
under the |
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1 | laws of this State. The term "any other type of remedial care" | ||||||
2 | shall
include nursing care and nursing home service for | ||||||
3 | persons who rely on
treatment by spiritual means alone through | ||||||
4 | prayer for healing.
| ||||||
5 | Notwithstanding any other provision of this Section, a | ||||||
6 | comprehensive
tobacco use cessation program that includes | ||||||
7 | purchasing prescription drugs or
prescription medical devices | ||||||
8 | approved by the Food and Drug Administration shall
be covered | ||||||
9 | under the medical assistance
program under this Article for | ||||||
10 | persons who are otherwise eligible for
assistance under this | ||||||
11 | Article.
| ||||||
12 | Notwithstanding any other provision of this Code, | ||||||
13 | reproductive health care that is otherwise legal in Illinois | ||||||
14 | shall be covered under the medical assistance program for | ||||||
15 | persons who are otherwise eligible for medical assistance | ||||||
16 | under this Article. | ||||||
17 | Notwithstanding any other provision of this Code, the | ||||||
18 | Illinois
Department may not require, as a condition of payment | ||||||
19 | for any laboratory
test authorized under this Article, that a | ||||||
20 | physician's handwritten signature
appear on the laboratory | ||||||
21 | test order form. The Illinois Department may,
however, impose | ||||||
22 | other appropriate requirements regarding laboratory test
order | ||||||
23 | documentation.
| ||||||
24 | Upon receipt of federal approval of an amendment to the | ||||||
25 | Illinois Title XIX State Plan for this purpose, the Department | ||||||
26 | shall authorize the Chicago Public Schools (CPS) to procure a |
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1 | vendor or vendors to manufacture eyeglasses for individuals | ||||||
2 | enrolled in a school within the CPS system. CPS shall ensure | ||||||
3 | that its vendor or vendors are enrolled as providers in the | ||||||
4 | medical assistance program and in any capitated Medicaid | ||||||
5 | managed care entity (MCE) serving individuals enrolled in a | ||||||
6 | school within the CPS system. Under any contract procured | ||||||
7 | under this provision, the vendor or vendors must serve only | ||||||
8 | individuals enrolled in a school within the CPS system. Claims | ||||||
9 | for services provided by CPS's vendor or vendors to recipients | ||||||
10 | of benefits in the medical assistance program under this Code, | ||||||
11 | the Children's Health Insurance Program, or the Covering ALL | ||||||
12 | KIDS Health Insurance Program shall be submitted to the | ||||||
13 | Department or the MCE in which the individual is enrolled for | ||||||
14 | payment and shall be reimbursed at the Department's or the | ||||||
15 | MCE's established rates or rate methodologies for eyeglasses. | ||||||
16 | On and after July 1, 2012, the Department of Healthcare | ||||||
17 | and Family Services may provide the following services to
| ||||||
18 | persons
eligible for assistance under this Article who are | ||||||
19 | participating in
education, training or employment programs | ||||||
20 | operated by the Department of Human
Services as successor to | ||||||
21 | the 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 | ||||||
25 | the diseases of the
eye, or by an optometrist, whichever | ||||||
26 | the person may select.
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1 | On and after July 1, 2018, the Department of Healthcare | ||||||
2 | and Family Services shall provide dental services to any adult | ||||||
3 | who is otherwise eligible for assistance under the medical | ||||||
4 | assistance program. As used in this paragraph, "dental | ||||||
5 | services" means diagnostic, preventative, restorative, or | ||||||
6 | corrective procedures, including procedures and services for | ||||||
7 | the prevention and treatment of periodontal disease and dental | ||||||
8 | caries disease, provided by an individual who is licensed to | ||||||
9 | practice dentistry or dental surgery or who is under the | ||||||
10 | supervision of a dentist in the practice of his or her | ||||||
11 | profession. | ||||||
12 | On and after July 1, 2018, targeted dental services, as | ||||||
13 | set forth in Exhibit D of the Consent Decree entered by the | ||||||
14 | United States District Court for the Northern District of | ||||||
15 | Illinois, Eastern Division, in the matter of Memisovski v. | ||||||
16 | Maram, Case No. 92 C 1982, that are provided to adults under | ||||||
17 | the medical assistance program shall be established at no less | ||||||
18 | than the rates set forth in the "New Rate" column in Exhibit D | ||||||
19 | of the Consent Decree for targeted dental services that are | ||||||
20 | provided to persons under the age of 18 under the medical | ||||||
21 | assistance program. | ||||||
22 | On and after January 1, 2022, targeted dental services | ||||||
23 | that are provided to adults and children under the Medical | ||||||
24 | Assistance Program shall be established and paid at no less | ||||||
25 | than the rates established under the State of Illinois Dental | ||||||
26 | Benefit Schedule and shall include the following dental |
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1 | procedures: D0120, D0150, D0220, D0230, D0272, D1110, D1120, | ||||||
2 | D1206, D1351, D2140, D2150, D2160, D2161, D2330, D2331, D2332, | ||||||
3 | D2335, D2391, D2392, D2393, D2394, D2751, D2930, D2931, D2950, | ||||||
4 | D5110, D5120, D5211, D5212, D5213, D5214, D7140, D7210, D7220. | ||||||
5 | The following anesthesia related codes shall be reimbursed as | ||||||
6 | follows: | ||||||
7 | (i) D9230 Inhalation of nitrous, $70.00. | ||||||
8 | (ii)
D9248 Non-intravenous conscious sedation, | ||||||
9 | $150.00. | ||||||
10 | (iii)
D9239 Intravenous moderate sedation, first 15 | ||||||
11 | minutes, $181.00. | ||||||
12 | (iv)
D9243 Intravenous moderate sedation, each | ||||||
13 | additional 15 minutes, $181.00. | ||||||
14 | (v)
D9222 Deep sedation, first 15 minutes, $214.00. | ||||||
15 | (vi)
D9223 Deep sedation, each additional 15 minutes, | ||||||
16 | $214.00. | ||||||
17 | Notwithstanding any other provision of this Code and | ||||||
18 | subject to federal approval, the Department may adopt rules to | ||||||
19 | allow a dentist who is volunteering his or her service at no | ||||||
20 | cost to render dental services through an enrolled | ||||||
21 | not-for-profit health clinic without the dentist personally | ||||||
22 | enrolling as a participating provider in the medical | ||||||
23 | assistance program. A not-for-profit health clinic shall | ||||||
24 | include a public health clinic or Federally Qualified Health | ||||||
25 | Center or other enrolled provider, as determined by the | ||||||
26 | Department, through which dental services covered under this |
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1 | Section are performed. The Department shall establish a | ||||||
2 | process for payment of claims for reimbursement for covered | ||||||
3 | dental services rendered under this provision. | ||||||
4 | On and after January 1, 2022, the Department of Healthcare | ||||||
5 | and Family Services shall administer and regulate a | ||||||
6 | school-based dental program that allows for the out-of-office | ||||||
7 | delivery of preventative dental services in a school setting | ||||||
8 | to children under 19 years of age. The Department shall | ||||||
9 | establish, by rule, guidelines for participation by providers | ||||||
10 | and set requirements for follow-up referral care based on the | ||||||
11 | requirements established in the Dental Office Reference Manual | ||||||
12 | published by the Department that establishes the requirements | ||||||
13 | for dentists participating in the All Kids Dental School | ||||||
14 | Program. Every effort shall be made by the Department when | ||||||
15 | developing the program requirements to consider the different | ||||||
16 | geographic differences of both urban and rural areas of the | ||||||
17 | State for initial treatment and necessary follow-up care. No | ||||||
18 | provider shall be charged a fee by any unit of local government | ||||||
19 | to participate in the school-based dental program administered | ||||||
20 | by the Department. | ||||||
21 | The Illinois Department, by rule, may distinguish and | ||||||
22 | classify the
medical services to be provided only in | ||||||
23 | accordance with the classes of
persons designated in Section | ||||||
24 | 5-2.
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25 | The Department of Healthcare and Family Services must | ||||||
26 | provide coverage and reimbursement for amino acid-based |
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1 | elemental formulas, regardless of delivery method, for the | ||||||
2 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
3 | short bowel syndrome when the prescribing physician has issued | ||||||
4 | a written order stating that the amino acid-based elemental | ||||||
5 | formula is medically necessary.
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6 | The Illinois Department shall authorize the provision of, | ||||||
7 | and shall
authorize payment for, screening by low-dose | ||||||
8 | mammography for the presence of
occult breast cancer for women | ||||||
9 | 35 years of age or older who are eligible
for medical | ||||||
10 | assistance under this Article, as follows: | ||||||
11 | (A) A baseline
mammogram for women 35 to 39 years of | ||||||
12 | age.
| ||||||
13 | (B) An annual mammogram for women 40 years of age or | ||||||
14 | older. | ||||||
15 | (C) A mammogram at the age and intervals considered | ||||||
16 | medically necessary by the woman's health care provider | ||||||
17 | for women under 40 years of age and having a family history | ||||||
18 | of breast cancer, prior personal history of breast cancer, | ||||||
19 | positive genetic testing, or other risk factors. | ||||||
20 | (D) A comprehensive ultrasound screening and MRI of an | ||||||
21 | entire breast or breasts if a mammogram demonstrates | ||||||
22 | heterogeneous or dense breast tissue or when medically | ||||||
23 | necessary as determined by a physician licensed to | ||||||
24 | practice medicine in all of its branches. | ||||||
25 | (E) A screening MRI when medically necessary, as | ||||||
26 | determined by a physician licensed to practice medicine in |
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1 | all of its branches. | ||||||
2 | (F) A diagnostic mammogram when medically necessary, | ||||||
3 | as determined by a physician licensed to practice medicine | ||||||
4 | in all its branches, advanced practice registered nurse, | ||||||
5 | or physician assistant. | ||||||
6 | The Department shall not impose a deductible, coinsurance, | ||||||
7 | copayment, or any other cost-sharing requirement on the | ||||||
8 | coverage provided under this paragraph; except that this | ||||||
9 | sentence does not apply to coverage of diagnostic mammograms | ||||||
10 | to the extent such coverage would disqualify a high-deductible | ||||||
11 | health plan from eligibility for a health savings account | ||||||
12 | pursuant to Section 223 of the Internal Revenue Code (26 | ||||||
13 | U.S.C. 223). | ||||||
14 | All screenings
shall
include a physical breast exam, | ||||||
15 | instruction on self-examination and
information regarding the | ||||||
16 | frequency of self-examination and its value as a
preventative | ||||||
17 | tool. | ||||||
18 | For purposes of this Section: | ||||||
19 | "Diagnostic
mammogram" means a mammogram obtained using | ||||||
20 | diagnostic mammography. | ||||||
21 | "Diagnostic
mammography" means a method of screening that | ||||||
22 | is designed to
evaluate an abnormality in a breast, including | ||||||
23 | an abnormality seen
or suspected on a screening mammogram or a | ||||||
24 | subjective or objective
abnormality otherwise detected in the | ||||||
25 | breast. | ||||||
26 | "Low-dose mammography" means
the x-ray examination of the |
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1 | breast using equipment dedicated specifically
for mammography, | ||||||
2 | including the x-ray tube, filter, compression device,
and | ||||||
3 | image receptor, with an average radiation exposure delivery
of | ||||||
4 | less than one rad per breast for 2 views of an average size | ||||||
5 | breast.
The term also includes digital mammography and | ||||||
6 | includes breast tomosynthesis. | ||||||
7 | "Breast tomosynthesis" means a radiologic procedure that | ||||||
8 | involves the acquisition of projection images over the | ||||||
9 | stationary breast to produce cross-sectional digital | ||||||
10 | three-dimensional images of the breast. | ||||||
11 | If, at any time, the Secretary of the United States | ||||||
12 | Department of Health and Human Services, or its successor | ||||||
13 | agency, promulgates rules or regulations to be published in | ||||||
14 | the Federal Register or publishes a comment in the Federal | ||||||
15 | Register or issues an opinion, guidance, or other action that | ||||||
16 | would require the State, pursuant to any provision of the | ||||||
17 | Patient Protection and Affordable Care Act (Public Law | ||||||
18 | 111-148), including, but not limited to, 42 U.S.C. | ||||||
19 | 18031(d)(3)(B) or any successor provision, to defray the cost | ||||||
20 | of any coverage for breast tomosynthesis outlined in this | ||||||
21 | paragraph, then the requirement that an insurer cover breast | ||||||
22 | tomosynthesis is inoperative other than any such coverage | ||||||
23 | authorized under Section 1902 of the Social Security Act, 42 | ||||||
24 | U.S.C. 1396a, and the State shall not assume any obligation | ||||||
25 | for the cost of coverage for breast tomosynthesis set forth in | ||||||
26 | this paragraph.
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1 | On and after January 1, 2016, the Department shall ensure | ||||||
2 | that all networks of care for adult clients of the Department | ||||||
3 | include access to at least one breast imaging Center of | ||||||
4 | Imaging Excellence as certified by the American College of | ||||||
5 | Radiology. | ||||||
6 | On and after January 1, 2012, providers participating in a | ||||||
7 | quality improvement program approved by the Department shall | ||||||
8 | be reimbursed for screening and diagnostic mammography at the | ||||||
9 | same rate as the Medicare program's rates, including the | ||||||
10 | increased reimbursement for digital mammography. | ||||||
11 | The Department shall convene an expert panel including | ||||||
12 | representatives of hospitals, free-standing mammography | ||||||
13 | facilities, and doctors, including radiologists, to establish | ||||||
14 | quality standards for mammography. | ||||||
15 | On and after January 1, 2017, providers participating in a | ||||||
16 | breast cancer treatment quality improvement program approved | ||||||
17 | by the Department shall be reimbursed for breast cancer | ||||||
18 | treatment at a rate that is no lower than 95% of the Medicare | ||||||
19 | program's rates for the data elements included in the breast | ||||||
20 | cancer treatment quality program. | ||||||
21 | The Department shall convene an expert panel, including | ||||||
22 | representatives of hospitals, free-standing breast cancer | ||||||
23 | treatment centers, breast cancer quality organizations, and | ||||||
24 | doctors, including breast surgeons, reconstructive breast | ||||||
25 | surgeons, oncologists, and primary care providers to establish | ||||||
26 | quality standards for breast cancer treatment. |
| |||||||
| |||||||
1 | Subject to federal approval, the Department shall | ||||||
2 | establish a rate methodology for mammography at federally | ||||||
3 | qualified health centers and other encounter-rate clinics. | ||||||
4 | These clinics or centers may also collaborate with other | ||||||
5 | hospital-based mammography facilities. By January 1, 2016, the | ||||||
6 | Department shall report to the General Assembly on the status | ||||||
7 | of the provision set forth in this paragraph. | ||||||
8 | The Department shall establish a methodology to remind | ||||||
9 | women who are age-appropriate for screening mammography, but | ||||||
10 | who have not received a mammogram within the previous 18 | ||||||
11 | months, of the importance and benefit of screening | ||||||
12 | mammography. The Department shall work with experts in breast | ||||||
13 | cancer outreach and patient navigation to optimize these | ||||||
14 | reminders and shall establish a methodology for evaluating | ||||||
15 | their effectiveness and modifying the methodology based on the | ||||||
16 | evaluation. | ||||||
17 | The Department shall establish a performance goal for | ||||||
18 | primary care providers with respect to their female patients | ||||||
19 | over age 40 receiving an annual mammogram. This performance | ||||||
20 | goal shall be used to provide additional reimbursement in the | ||||||
21 | form of a quality performance bonus to primary care providers | ||||||
22 | who meet that goal. | ||||||
23 | The Department shall devise a means of case-managing or | ||||||
24 | patient navigation for beneficiaries diagnosed with breast | ||||||
25 | cancer. This program shall initially operate as a pilot | ||||||
26 | program in areas of the State with the highest incidence of |
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| |||||||
1 | mortality related to breast cancer. At least one pilot program | ||||||
2 | site shall be in the metropolitan Chicago area and at least one | ||||||
3 | site shall be outside the metropolitan Chicago area. On or | ||||||
4 | after July 1, 2016, the pilot program shall be expanded to | ||||||
5 | include one site in western Illinois, one site in southern | ||||||
6 | Illinois, one site in central Illinois, and 4 sites within | ||||||
7 | metropolitan Chicago. An evaluation of the pilot program shall | ||||||
8 | be carried out measuring health outcomes and cost of care for | ||||||
9 | those served by the pilot program compared to similarly | ||||||
10 | situated patients who are not served by the pilot program. | ||||||
11 | The Department shall require all networks of care to | ||||||
12 | develop a means either internally or by contract with experts | ||||||
13 | in navigation and community outreach to navigate cancer | ||||||
14 | patients to comprehensive care in a timely fashion. The | ||||||
15 | Department shall require all networks of care to include | ||||||
16 | access for patients diagnosed with cancer to at least one | ||||||
17 | academic commission on cancer-accredited cancer program as an | ||||||
18 | in-network covered benefit. | ||||||
19 | Any medical or health care provider shall immediately | ||||||
20 | recommend, to
any pregnant woman who is being provided | ||||||
21 | prenatal services and is suspected
of having a substance use | ||||||
22 | disorder as defined in the Substance Use Disorder Act, | ||||||
23 | referral to a local substance use disorder treatment program | ||||||
24 | licensed by the Department of Human Services or to a licensed
| ||||||
25 | hospital which provides substance abuse treatment services. | ||||||
26 | The Department of Healthcare and Family Services
shall assure |
| |||||||
| |||||||
1 | coverage for the cost of treatment of the drug abuse or
| ||||||
2 | addiction for pregnant recipients in accordance with the | ||||||
3 | Illinois Medicaid
Program in conjunction with the Department | ||||||
4 | of Human Services.
| ||||||
5 | All medical providers providing medical assistance to | ||||||
6 | pregnant women
under this Code shall receive information from | ||||||
7 | the Department on the
availability of services under any
| ||||||
8 | program providing case management services for addicted women,
| ||||||
9 | including information on appropriate referrals for other | ||||||
10 | social services
that may be needed by addicted women in | ||||||
11 | addition to treatment for addiction.
| ||||||
12 | The Illinois Department, in cooperation with the | ||||||
13 | Departments of Human
Services (as successor to the Department | ||||||
14 | of Alcoholism and Substance
Abuse) and Public Health, through | ||||||
15 | a public awareness campaign, may
provide information | ||||||
16 | concerning treatment for alcoholism and drug abuse and
| ||||||
17 | addiction, prenatal health care, and other pertinent programs | ||||||
18 | directed at
reducing the number of drug-affected infants born | ||||||
19 | to recipients of medical
assistance.
| ||||||
20 | Neither the Department of Healthcare and Family Services | ||||||
21 | nor the Department of Human
Services shall sanction the | ||||||
22 | recipient solely on the basis of
her substance abuse.
| ||||||
23 | The Illinois Department shall establish such regulations | ||||||
24 | governing
the dispensing of health services under this Article | ||||||
25 | as it shall deem
appropriate. The Department
should
seek the | ||||||
26 | advice of formal professional advisory committees appointed by
|
| |||||||
| |||||||
1 | the Director of the Illinois Department for the purpose of | ||||||
2 | providing regular
advice on policy and administrative matters, | ||||||
3 | information dissemination and
educational activities for | ||||||
4 | medical and health care providers, and
consistency in | ||||||
5 | procedures to the Illinois Department.
| ||||||
6 | The Illinois Department may develop and contract with | ||||||
7 | Partnerships of
medical providers to arrange medical services | ||||||
8 | for persons eligible under
Section 5-2 of this Code. | ||||||
9 | Implementation of this Section may be by
demonstration | ||||||
10 | projects in certain geographic areas. The Partnership shall
be | ||||||
11 | represented by a sponsor organization. The Department, by | ||||||
12 | rule, shall
develop qualifications for sponsors of | ||||||
13 | Partnerships. Nothing in this
Section shall be construed to | ||||||
14 | require that the sponsor organization be a
medical | ||||||
15 | organization.
| ||||||
16 | The sponsor must negotiate formal written contracts with | ||||||
17 | medical
providers for physician services, inpatient and | ||||||
18 | outpatient hospital care,
home health services, treatment for | ||||||
19 | alcoholism and substance abuse, and
other services determined | ||||||
20 | necessary by the Illinois Department by rule for
delivery by | ||||||
21 | Partnerships. Physician services must include prenatal and
| ||||||
22 | obstetrical care. The Illinois Department shall reimburse | ||||||
23 | medical services
delivered by Partnership providers to clients | ||||||
24 | in target areas according to
provisions of this Article and | ||||||
25 | the Illinois Health Finance Reform Act,
except that:
| ||||||
26 | (1) Physicians participating in a Partnership and |
| |||||||
| |||||||
1 | providing certain
services, which shall be determined by | ||||||
2 | the Illinois Department, to persons
in areas covered by | ||||||
3 | the Partnership may receive an additional surcharge
for | ||||||
4 | such services.
| ||||||
5 | (2) The Department may elect to consider and negotiate | ||||||
6 | financial
incentives to encourage the development of | ||||||
7 | Partnerships and the efficient
delivery of medical care.
| ||||||
8 | (3) Persons receiving medical services through | ||||||
9 | Partnerships may receive
medical and case management | ||||||
10 | services above the level usually offered
through the | ||||||
11 | medical assistance program.
| ||||||
12 | Medical providers shall be required to meet certain | ||||||
13 | qualifications to
participate in Partnerships to ensure the | ||||||
14 | delivery of high quality medical
services. These | ||||||
15 | qualifications shall be determined by rule of the Illinois
| ||||||
16 | Department and may be higher than qualifications for | ||||||
17 | participation in the
medical assistance program. Partnership | ||||||
18 | sponsors may prescribe reasonable
additional qualifications | ||||||
19 | for participation by medical providers, only with
the prior | ||||||
20 | written approval of the Illinois Department.
| ||||||
21 | Nothing in this Section shall limit the free choice of | ||||||
22 | practitioners,
hospitals, and other providers of medical | ||||||
23 | services by clients.
In order to ensure patient freedom of | ||||||
24 | choice, the Illinois Department shall
immediately promulgate | ||||||
25 | all rules and take all other necessary actions so that
| ||||||
26 | provided services may be accessed from therapeutically |
| |||||||
| |||||||
1 | certified optometrists
to the full extent of the Illinois | ||||||
2 | Optometric Practice Act of 1987 without
discriminating between | ||||||
3 | service providers.
| ||||||
4 | The Department shall apply for a waiver from the United | ||||||
5 | States Health
Care Financing Administration to allow for the | ||||||
6 | implementation of
Partnerships under this Section.
| ||||||
7 | The Illinois Department shall require health care | ||||||
8 | providers to maintain
records that document the medical care | ||||||
9 | and services provided to recipients
of Medical Assistance | ||||||
10 | under this Article. Such records must be retained for a period | ||||||
11 | of not less than 6 years from the date of service or as | ||||||
12 | provided by applicable State law, whichever period is longer, | ||||||
13 | except that if an audit is initiated within the required | ||||||
14 | retention period then the records must be retained until the | ||||||
15 | audit is completed and every exception is resolved. The | ||||||
16 | Illinois Department shall
require health care providers to | ||||||
17 | make available, when authorized by the
patient, in writing, | ||||||
18 | the medical records in a timely fashion to other
health care | ||||||
19 | providers who are treating or serving persons eligible for
| ||||||
20 | Medical Assistance under this Article. All dispensers of | ||||||
21 | medical services
shall be required to maintain and retain | ||||||
22 | business and professional records
sufficient to fully and | ||||||
23 | accurately document the nature, scope, details and
receipt of | ||||||
24 | the health care provided to persons eligible for medical
| ||||||
25 | assistance under this Code, in accordance with regulations | ||||||
26 | promulgated by
the Illinois Department. The rules and |
| |||||||
| |||||||
1 | regulations shall require that proof
of the receipt of | ||||||
2 | prescription drugs, dentures, prosthetic devices and
| ||||||
3 | eyeglasses by eligible persons under this Section accompany | ||||||
4 | each claim
for reimbursement submitted by the dispenser of | ||||||
5 | such medical services.
No such claims for reimbursement shall | ||||||
6 | be approved for payment by the Illinois
Department without | ||||||
7 | such proof of receipt, unless the Illinois Department
shall | ||||||
8 | have put into effect and shall be operating a system of | ||||||
9 | post-payment
audit and review which shall, on a sampling | ||||||
10 | basis, be deemed adequate by
the Illinois Department to assure | ||||||
11 | that such drugs, dentures, prosthetic
devices and eyeglasses | ||||||
12 | for which payment is being made are actually being
received by | ||||||
13 | eligible recipients. Within 90 days after September 16, 1984 | ||||||
14 | (the effective date of Public Act 83-1439), the Illinois | ||||||
15 | Department shall establish a
current list of acquisition costs | ||||||
16 | for all prosthetic devices and any
other items recognized as | ||||||
17 | medical equipment and supplies reimbursable under
this Article | ||||||
18 | and shall update such list on a quarterly basis, except that
| ||||||
19 | the acquisition costs of all prescription drugs shall be | ||||||
20 | updated no
less frequently than every 30 days as required by | ||||||
21 | Section 5-5.12.
| ||||||
22 | Notwithstanding any other law to the contrary, the | ||||||
23 | Illinois Department shall, within 365 days after July 22, 2013 | ||||||
24 | (the effective date of Public Act 98-104), establish | ||||||
25 | procedures to permit skilled care facilities licensed under | ||||||
26 | the Nursing Home Care Act to submit monthly billing claims for |
| |||||||
| |||||||
1 | reimbursement purposes. Following development of these | ||||||
2 | procedures, the Department shall, by July 1, 2016, test the | ||||||
3 | viability of the new system and implement any necessary | ||||||
4 | operational or structural changes to its information | ||||||
5 | technology platforms in order to allow for the direct | ||||||
6 | acceptance and payment of nursing home claims. | ||||||
7 | Notwithstanding any other law to the contrary, the | ||||||
8 | Illinois Department shall, within 365 days after August 15, | ||||||
9 | 2014 (the effective date of Public Act 98-963), establish | ||||||
10 | procedures to permit ID/DD facilities licensed under the ID/DD | ||||||
11 | Community Care Act and MC/DD facilities licensed under the | ||||||
12 | MC/DD Act to submit monthly billing claims for reimbursement | ||||||
13 | purposes. Following development of these procedures, the | ||||||
14 | Department shall have an additional 365 days to test the | ||||||
15 | viability of the new system and to ensure that any necessary | ||||||
16 | operational or structural changes to its information | ||||||
17 | technology platforms are implemented. | ||||||
18 | The Illinois Department shall require all dispensers of | ||||||
19 | medical
services, other than an individual practitioner or | ||||||
20 | group of practitioners,
desiring to participate in the Medical | ||||||
21 | Assistance program
established under this Article to disclose | ||||||
22 | all financial, beneficial,
ownership, equity, surety or other | ||||||
23 | interests in any and all firms,
corporations, partnerships, | ||||||
24 | associations, business enterprises, joint
ventures, agencies, | ||||||
25 | institutions or other legal entities providing any
form of | ||||||
26 | health care services in this State under this Article.
|
| |||||||
| |||||||
1 | The Illinois Department may require that all dispensers of | ||||||
2 | medical
services desiring to participate in the medical | ||||||
3 | assistance program
established under this Article disclose, | ||||||
4 | under such terms and conditions as
the Illinois Department may | ||||||
5 | by rule establish, all inquiries from clients
and attorneys | ||||||
6 | regarding medical bills paid by the Illinois Department, which
| ||||||
7 | inquiries could indicate potential existence of claims or | ||||||
8 | liens for the
Illinois Department.
| ||||||
9 | Enrollment of a vendor
shall be
subject to a provisional | ||||||
10 | period and shall be conditional for one year. During the | ||||||
11 | period of conditional enrollment, the Department may
terminate | ||||||
12 | the vendor's eligibility to participate in, or may disenroll | ||||||
13 | the vendor from, the medical assistance
program without cause. | ||||||
14 | Unless otherwise specified, such termination of eligibility or | ||||||
15 | disenrollment is not subject to the
Department's hearing | ||||||
16 | process.
However, a disenrolled vendor may reapply without | ||||||
17 | penalty.
| ||||||
18 | The Department has the discretion to limit the conditional | ||||||
19 | enrollment period for vendors based upon category of risk of | ||||||
20 | the vendor. | ||||||
21 | Prior to enrollment and during the conditional enrollment | ||||||
22 | period in the medical assistance program, all vendors shall be | ||||||
23 | subject to enhanced oversight, screening, and review based on | ||||||
24 | the risk of fraud, waste, and abuse that is posed by the | ||||||
25 | category of risk of the vendor. The Illinois Department shall | ||||||
26 | establish the procedures for oversight, screening, and review, |
| |||||||
| |||||||
1 | which may include, but need not be limited to: criminal and | ||||||
2 | financial background checks; fingerprinting; license, | ||||||
3 | certification, and authorization verifications; unscheduled or | ||||||
4 | unannounced site visits; database checks; prepayment audit | ||||||
5 | reviews; audits; payment caps; payment suspensions; and other | ||||||
6 | screening as required by federal or State law. | ||||||
7 | The Department shall define or specify the following: (i) | ||||||
8 | by provider notice, the "category of risk of the vendor" for | ||||||
9 | each type of vendor, which shall take into account the level of | ||||||
10 | screening applicable to a particular category of vendor under | ||||||
11 | federal law and regulations; (ii) by rule or provider notice, | ||||||
12 | the maximum length of the conditional enrollment period for | ||||||
13 | each category of risk of the vendor; and (iii) by rule, the | ||||||
14 | hearing rights, if any, afforded to a vendor in each category | ||||||
15 | of risk of the vendor that is terminated or disenrolled during | ||||||
16 | the conditional enrollment period. | ||||||
17 | To be eligible for payment consideration, a vendor's | ||||||
18 | payment claim or bill, either as an initial claim or as a | ||||||
19 | resubmitted claim following prior rejection, must be received | ||||||
20 | by the Illinois Department, or its fiscal intermediary, no | ||||||
21 | later than 180 days after the latest date on the claim on which | ||||||
22 | medical goods or services were provided, with the following | ||||||
23 | exceptions: | ||||||
24 | (1) In the case of a provider whose enrollment is in | ||||||
25 | process by the Illinois Department, the 180-day period | ||||||
26 | shall not begin until the date on the written notice from |
| |||||||
| |||||||
1 | the Illinois Department that the provider enrollment is | ||||||
2 | complete. | ||||||
3 | (2) In the case of errors attributable to the Illinois | ||||||
4 | Department or any of its claims processing intermediaries | ||||||
5 | which result in an inability to receive, process, or | ||||||
6 | adjudicate a claim, the 180-day period shall not begin | ||||||
7 | until the provider has been notified of the error. | ||||||
8 | (3) In the case of a provider for whom the Illinois | ||||||
9 | Department initiates the monthly billing process. | ||||||
10 | (4) In the case of a provider operated by a unit of | ||||||
11 | local government with a population exceeding 3,000,000 | ||||||
12 | when local government funds finance federal participation | ||||||
13 | for claims payments. | ||||||
14 | For claims for services rendered during a period for which | ||||||
15 | a recipient received retroactive eligibility, claims must be | ||||||
16 | filed within 180 days after the Department determines the | ||||||
17 | applicant is eligible. For claims for which the Illinois | ||||||
18 | Department is not the primary payer, claims must be submitted | ||||||
19 | to the Illinois Department within 180 days after the final | ||||||
20 | adjudication by the primary payer. | ||||||
21 | In the case of long term care facilities, within 45 | ||||||
22 | calendar days of receipt by the facility of required | ||||||
23 | prescreening information, new admissions with associated | ||||||
24 | admission documents shall be submitted through the Medical | ||||||
25 | Electronic Data Interchange (MEDI) or the Recipient | ||||||
26 | Eligibility Verification (REV) System or shall be submitted |
| |||||||
| |||||||
1 | directly to the Department of Human Services using required | ||||||
2 | admission forms. Effective September
1, 2014, admission | ||||||
3 | documents, including all prescreening
information, must be | ||||||
4 | submitted through MEDI or REV. Confirmation numbers assigned | ||||||
5 | to an accepted transaction shall be retained by a facility to | ||||||
6 | verify timely submittal. Once an admission transaction has | ||||||
7 | been completed, all resubmitted claims following prior | ||||||
8 | rejection are subject to receipt no later than 180 days after | ||||||
9 | the admission transaction has been completed. | ||||||
10 | Claims that are not submitted and received in compliance | ||||||
11 | with the foregoing requirements shall not be eligible for | ||||||
12 | payment under the medical assistance program, and the State | ||||||
13 | shall have no liability for payment of those claims. | ||||||
14 | To the extent consistent with applicable information and | ||||||
15 | privacy, security, and disclosure laws, State and federal | ||||||
16 | agencies and departments shall provide the Illinois Department | ||||||
17 | access to confidential and other information and data | ||||||
18 | necessary to perform eligibility and payment verifications and | ||||||
19 | other Illinois Department functions. This includes, but is not | ||||||
20 | limited to: information pertaining to licensure; | ||||||
21 | certification; earnings; immigration status; citizenship; wage | ||||||
22 | reporting; unearned and earned income; pension income; | ||||||
23 | employment; supplemental security income; social security | ||||||
24 | numbers; National Provider Identifier (NPI) numbers; the | ||||||
25 | National Practitioner Data Bank (NPDB); program and agency | ||||||
26 | exclusions; taxpayer identification numbers; tax delinquency; |
| |||||||
| |||||||
1 | corporate information; and death records. | ||||||
2 | The Illinois Department shall enter into agreements with | ||||||
3 | State agencies and departments, and is authorized to enter | ||||||
4 | into agreements with federal agencies and departments, under | ||||||
5 | which such agencies and departments shall share data necessary | ||||||
6 | for medical assistance program integrity functions and | ||||||
7 | oversight. The Illinois Department shall develop, in | ||||||
8 | cooperation with other State departments and agencies, and in | ||||||
9 | compliance with applicable federal laws and regulations, | ||||||
10 | appropriate and effective methods to share such data. At a | ||||||
11 | minimum, and to the extent necessary to provide data sharing, | ||||||
12 | the Illinois Department shall enter into agreements with State | ||||||
13 | agencies and departments, and is authorized to enter into | ||||||
14 | agreements with federal agencies and departments, including , | ||||||
15 | but not limited to: the Secretary of State; the Department of | ||||||
16 | Revenue; the Department of Public Health; the Department of | ||||||
17 | Human Services; and the Department of Financial and | ||||||
18 | Professional Regulation. | ||||||
19 | Beginning in fiscal year 2013, the Illinois Department | ||||||
20 | shall set forth a request for information to identify the | ||||||
21 | benefits of a pre-payment, post-adjudication, and post-edit | ||||||
22 | claims system with the goals of streamlining claims processing | ||||||
23 | and provider reimbursement, reducing the number of pending or | ||||||
24 | rejected claims, and helping to ensure a more transparent | ||||||
25 | adjudication process through the utilization of: (i) provider | ||||||
26 | data verification and provider screening technology; and (ii) |
| |||||||
| |||||||
1 | clinical code editing; and (iii) pre-pay, pre- or | ||||||
2 | post-adjudicated predictive modeling with an integrated case | ||||||
3 | management system with link analysis. Such a request for | ||||||
4 | information shall not be considered as a request for proposal | ||||||
5 | or as an obligation on the part of the Illinois Department to | ||||||
6 | take any action or acquire any products or services. | ||||||
7 | The Illinois Department shall establish policies, | ||||||
8 | procedures,
standards and criteria by rule for the | ||||||
9 | acquisition, repair and replacement
of orthotic and prosthetic | ||||||
10 | devices and durable medical equipment. Such
rules shall | ||||||
11 | provide, but not be limited to, the following services: (1)
| ||||||
12 | immediate repair or replacement of such devices by recipients; | ||||||
13 | and (2) rental, lease, purchase or lease-purchase of
durable | ||||||
14 | medical equipment in a cost-effective manner, taking into
| ||||||
15 | consideration the recipient's medical prognosis, the extent of | ||||||
16 | the
recipient's needs, and the requirements and costs for | ||||||
17 | maintaining such
equipment. Subject to prior approval, such | ||||||
18 | rules shall enable a recipient to temporarily acquire and
use | ||||||
19 | alternative or substitute devices or equipment pending repairs | ||||||
20 | or
replacements of any device or equipment previously | ||||||
21 | authorized for such
recipient by the Department. | ||||||
22 | Notwithstanding any provision of Section 5-5f to the contrary, | ||||||
23 | the Department may, by rule, exempt certain replacement | ||||||
24 | wheelchair parts from prior approval and, for wheelchairs, | ||||||
25 | wheelchair parts, wheelchair accessories, and related seating | ||||||
26 | and positioning items, determine the wholesale price by |
| |||||||
| |||||||
1 | methods other than actual acquisition costs. | ||||||
2 | The Department shall require, by rule, all providers of | ||||||
3 | durable medical equipment to be accredited by an accreditation | ||||||
4 | organization approved by the federal Centers for Medicare and | ||||||
5 | Medicaid Services and recognized by the Department in order to | ||||||
6 | bill the Department for providing durable medical equipment to | ||||||
7 | recipients. No later than 15 months after the effective date | ||||||
8 | of the rule adopted pursuant to this paragraph, all providers | ||||||
9 | must meet the accreditation requirement.
| ||||||
10 | In order to promote environmental responsibility, meet the | ||||||
11 | needs of recipients and enrollees, and achieve significant | ||||||
12 | cost savings, the Department, or a managed care organization | ||||||
13 | under contract with the Department, may provide recipients or | ||||||
14 | managed care enrollees who have a prescription or Certificate | ||||||
15 | of Medical Necessity access to refurbished durable medical | ||||||
16 | equipment under this Section (excluding prosthetic and | ||||||
17 | orthotic devices as defined in the Orthotics, Prosthetics, and | ||||||
18 | Pedorthics Practice Act and complex rehabilitation technology | ||||||
19 | products and associated services) through the State's | ||||||
20 | assistive technology program's reutilization program, using | ||||||
21 | staff with the Assistive Technology Professional (ATP) | ||||||
22 | Certification if the refurbished durable medical equipment: | ||||||
23 | (i) is available; (ii) is less expensive, including shipping | ||||||
24 | costs, than new durable medical equipment of the same type; | ||||||
25 | (iii) is able to withstand at least 3 years of use; (iv) is | ||||||
26 | cleaned, disinfected, sterilized, and safe in accordance with |
| |||||||
| |||||||
1 | federal Food and Drug Administration regulations and guidance | ||||||
2 | governing the reprocessing of medical devices in health care | ||||||
3 | settings; and (v) equally meets the needs of the recipient or | ||||||
4 | enrollee. The reutilization program shall confirm that the | ||||||
5 | recipient or enrollee is not already in receipt of same or | ||||||
6 | similar equipment from another service provider, and that the | ||||||
7 | refurbished durable medical equipment equally meets the needs | ||||||
8 | of the recipient or enrollee. Nothing in this paragraph shall | ||||||
9 | be construed to limit recipient or enrollee choice to obtain | ||||||
10 | new durable medical equipment or place any additional prior | ||||||
11 | authorization conditions on enrollees of managed care | ||||||
12 | organizations. | ||||||
13 | The Department shall execute, relative to the nursing home | ||||||
14 | prescreening
project, written inter-agency agreements with the | ||||||
15 | Department of Human
Services and the Department on Aging, to | ||||||
16 | effect the following: (i) intake
procedures and common | ||||||
17 | eligibility criteria for those persons who are receiving
| ||||||
18 | non-institutional services; and (ii) the establishment and | ||||||
19 | development of
non-institutional services in areas of the | ||||||
20 | State where they are not currently
available or are | ||||||
21 | undeveloped; and (iii) notwithstanding any other provision of | ||||||
22 | law, subject to federal approval, on and after July 1, 2012, an | ||||||
23 | increase in the determination of need (DON) scores from 29 to | ||||||
24 | 37 for applicants for institutional and home and | ||||||
25 | community-based long term care; if and only if federal | ||||||
26 | approval is not granted, the Department may, in conjunction |
| |||||||
| |||||||
1 | with other affected agencies, implement utilization controls | ||||||
2 | or changes in benefit packages to effectuate a similar savings | ||||||
3 | amount for this population; and (iv) no later than July 1, | ||||||
4 | 2013, minimum level of care eligibility criteria for | ||||||
5 | institutional and home and community-based long term care; and | ||||||
6 | (v) no later than October 1, 2013, establish procedures to | ||||||
7 | permit long term care providers access to eligibility scores | ||||||
8 | for individuals with an admission date who are seeking or | ||||||
9 | receiving services from the long term care provider. In order | ||||||
10 | to select the minimum level of care eligibility criteria, the | ||||||
11 | Governor shall establish a workgroup that includes affected | ||||||
12 | agency representatives and stakeholders representing the | ||||||
13 | institutional and home and community-based long term care | ||||||
14 | interests. This Section shall not restrict the Department from | ||||||
15 | implementing lower level of care eligibility criteria for | ||||||
16 | community-based services in circumstances where federal | ||||||
17 | approval has been granted.
| ||||||
18 | The Illinois Department shall develop and operate, in | ||||||
19 | cooperation
with other State Departments and agencies and in | ||||||
20 | compliance with
applicable federal laws and regulations, | ||||||
21 | appropriate and effective
systems of health care evaluation | ||||||
22 | and programs for monitoring of
utilization of health care | ||||||
23 | services and facilities, as it affects
persons eligible for | ||||||
24 | medical assistance under this Code.
| ||||||
25 | The Illinois Department shall report annually to the | ||||||
26 | General Assembly,
no later than the second Friday in April of |
| |||||||
| |||||||
1 | 1979 and each year
thereafter, in regard to:
| ||||||
2 | (a) actual statistics and trends in utilization of | ||||||
3 | medical services by
public aid recipients;
| ||||||
4 | (b) actual statistics and trends in the provision of | ||||||
5 | the various medical
services by medical vendors;
| ||||||
6 | (c) current rate structures and proposed changes in | ||||||
7 | those rate structures
for the various medical vendors; and
| ||||||
8 | (d) efforts at utilization review and control by the | ||||||
9 | Illinois Department.
| ||||||
10 | The period covered by each report shall be the 3 years | ||||||
11 | ending on the June
30 prior to the report. The report shall | ||||||
12 | include suggested legislation
for consideration by the General | ||||||
13 | Assembly. The requirement for reporting to the General | ||||||
14 | Assembly shall be satisfied
by filing copies of the report as | ||||||
15 | required by Section 3.1 of the General Assembly Organization | ||||||
16 | Act, and filing such additional
copies
with the State | ||||||
17 | Government Report Distribution Center for the General
Assembly | ||||||
18 | as is required under paragraph (t) of Section 7 of the State
| ||||||
19 | Library Act.
| ||||||
20 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
21 | any, is conditioned on the rules being adopted in accordance | ||||||
22 | with all provisions of the Illinois Administrative Procedure | ||||||
23 | Act and all rules and procedures of the Joint Committee on | ||||||
24 | Administrative Rules; any purported rule not so adopted, for | ||||||
25 | whatever reason, is unauthorized. | ||||||
26 | On and after July 1, 2012, the Department shall reduce any |
| |||||||
| |||||||
1 | rate of reimbursement for services or other payments or alter | ||||||
2 | any methodologies authorized by this Code to reduce any rate | ||||||
3 | of reimbursement for services or other payments in accordance | ||||||
4 | with Section 5-5e. | ||||||
5 | Because kidney transplantation can be an appropriate, | ||||||
6 | cost-effective
alternative to renal dialysis when medically | ||||||
7 | necessary and notwithstanding the provisions of Section 1-11 | ||||||
8 | of this Code, beginning October 1, 2014, the Department shall | ||||||
9 | cover kidney transplantation for noncitizens with end-stage | ||||||
10 | renal disease who are not eligible for comprehensive medical | ||||||
11 | benefits, who meet the residency requirements of Section 5-3 | ||||||
12 | of this Code, and who would otherwise meet the financial | ||||||
13 | requirements of the appropriate class of eligible persons | ||||||
14 | under Section 5-2 of this Code. To qualify for coverage of | ||||||
15 | kidney transplantation, such person must be receiving | ||||||
16 | emergency renal dialysis services covered by the Department. | ||||||
17 | Providers under this Section shall be prior approved and | ||||||
18 | certified by the Department to perform kidney transplantation | ||||||
19 | and the services under this Section shall be limited to | ||||||
20 | services associated with kidney transplantation. | ||||||
21 | Notwithstanding any other provision of this Code to the | ||||||
22 | contrary, on or after July 1, 2015, all FDA approved forms of | ||||||
23 | medication assisted treatment prescribed for the treatment of | ||||||
24 | alcohol dependence or treatment of opioid dependence shall be | ||||||
25 | covered under both fee for service and managed care medical | ||||||
26 | assistance programs for persons who are otherwise eligible for |
| |||||||
| |||||||
1 | medical assistance under this Article and shall not be subject | ||||||
2 | to any (1) utilization control, other than those established | ||||||
3 | under the American Society of Addiction Medicine patient | ||||||
4 | placement criteria,
(2) prior authorization mandate, or (3) | ||||||
5 | lifetime restriction limit
mandate. | ||||||
6 | On or after July 1, 2015, opioid antagonists prescribed | ||||||
7 | for the treatment of an opioid overdose, including the | ||||||
8 | medication product, administration devices, and any pharmacy | ||||||
9 | fees related to the dispensing and administration of the | ||||||
10 | opioid antagonist, shall be covered under the medical | ||||||
11 | assistance program for persons who are otherwise eligible for | ||||||
12 | medical assistance under this Article. As used in this | ||||||
13 | Section, "opioid antagonist" means a drug that binds to opioid | ||||||
14 | receptors and blocks or inhibits the effect of opioids acting | ||||||
15 | on those receptors, including, but not limited to, naloxone | ||||||
16 | hydrochloride or any other similarly acting drug approved by | ||||||
17 | the U.S. Food and Drug Administration. | ||||||
18 | Upon federal approval, the Department shall provide | ||||||
19 | coverage and reimbursement for all drugs that are approved for | ||||||
20 | marketing by the federal Food and Drug Administration and that | ||||||
21 | are recommended by the federal Public Health Service or the | ||||||
22 | United States Centers for Disease Control and Prevention for | ||||||
23 | pre-exposure prophylaxis and related pre-exposure prophylaxis | ||||||
24 | services, including, but not limited to, HIV and sexually | ||||||
25 | transmitted infection screening, treatment for sexually | ||||||
26 | transmitted infections, medical monitoring, assorted labs, and |
| |||||||
| |||||||
1 | counseling to reduce the likelihood of HIV infection among | ||||||
2 | individuals who are not infected with HIV but who are at high | ||||||
3 | risk of HIV infection. | ||||||
4 | A federally qualified health center, as defined in Section | ||||||
5 | 1905(l)(2)(B) of the federal
Social Security Act, shall be | ||||||
6 | reimbursed by the Department in accordance with the federally | ||||||
7 | qualified health center's encounter rate for services provided | ||||||
8 | to medical assistance recipients that are performed by a | ||||||
9 | dental hygienist, as defined under the Illinois Dental | ||||||
10 | Practice Act, working under the general supervision of a | ||||||
11 | dentist and employed by a federally qualified health center. | ||||||
12 | (Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18; | ||||||
13 | 100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff. | ||||||
14 | 6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974, | ||||||
15 | eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; | ||||||
16 | 100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff. | ||||||
17 | 1-1-20; revised 9-18-19.) | ||||||
18 | (305 ILCS 5/5-5.28 new) | ||||||
19 | Sec. 5-5.28. Coverage for adjunctive services in dental | ||||||
20 | care. | ||||||
21 | (a) As used in this Section: | ||||||
22 | "Ambulatory surgical treatment center" has the meaning | ||||||
23 | given to that term in Section 3 of the Ambulatory Surgical | ||||||
24 | Treatment Center Act. | ||||||
25 | "Person with a disability" means a person, regardless of |
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1 | age, with a chronic disability if the chronic disability meets | ||||||
2 | all of the following conditions: | ||||||
3 | (1) It is attributable to a mental or physical
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4 | impairment or combination of mental and physical | ||||||
5 | impairments. | ||||||
6 | (2) It is likely to continue. | ||||||
7 | (3) It results in substantial functional limitations
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8 | in one or more of the following areas of major life | ||||||
9 | activity: | ||||||
10 | (A) self-care; | ||||||
11 | (B) receptive and expressive language; | ||||||
12 | (C) learning; | ||||||
13 | (D) mobility; | ||||||
14 | (E) capacity for independent living; or | ||||||
15 | (F) economic self-sufficiency. | ||||||
16 | (b) The medical assistance program shall cover charges | ||||||
17 | incurred, and anesthetics provided, in conjunction with dental | ||||||
18 | care that is provided to an individual in a hospital or an | ||||||
19 | ambulatory surgical treatment center if the individual is | ||||||
20 | otherwise eligible for medical assistance and any of the | ||||||
21 | following applies: | ||||||
22 | (1) the individual has a medical condition that
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23 | requires hospitalization or general anesthesia for dental | ||||||
24 | care; or | ||||||
25 | (2) the individual is a person with a disability. | ||||||
26 | (c) The medical assistance program shall cover charges |
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1 | incurred, and anesthetics provided by a dentist with a permit | ||||||
2 | provided under Section 8.1 of the Illinois Dental Practice | ||||||
3 | Act, in conjunction with dental care that is provided to an | ||||||
4 | individual in a dental office, oral surgeon's office, | ||||||
5 | hospital, or ambulatory surgical treatment center if the | ||||||
6 | individual, regardless of age, is otherwise eligible for | ||||||
7 | medical assistance and has been diagnosed with an autism | ||||||
8 | spectrum disorder as defined in Section 10 of the Autism | ||||||
9 | Spectrum Disorders Reporting Act or a developmental | ||||||
10 | disability. | ||||||
11 | As used in this subsection, "developmental disability" | ||||||
12 | means a disability that is attributable to an intellectual | ||||||
13 | disability or a related condition, if the related condition | ||||||
14 | meets all of the following conditions: | ||||||
15 | (1) it is attributable to cerebral palsy, epilepsy,
or | ||||||
16 | any other condition, other than mental illness, found to | ||||||
17 | be closely related to an intellectual disability because | ||||||
18 | that condition results in impairment of general | ||||||
19 | intellectual functioning or adaptive behavior similar to | ||||||
20 | that of individuals with an intellectual disability and | ||||||
21 | requires treatment or services similar to those required | ||||||
22 | for those individuals; for purposes of this definition, | ||||||
23 | autism is considered a related condition; | ||||||
24 | (2) it is manifested before the individual reaches
age | ||||||
25 | 22; | ||||||
26 | (3) it is likely to continue indefinitely; and |
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1 | (4) it results in substantial functional limitations
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2 | in 3 or more of the following areas of major life activity: | ||||||
3 | self-care, language, learning, mobility, self-direction, | ||||||
4 | and capacity for independent living. | ||||||
5 | (d) The Department shall reimburse providers of services | ||||||
6 | covered under this Section at no less than the rates | ||||||
7 | established under the State of Illinois Dental Benefit | ||||||
8 | Schedule used for State employees. | ||||||
9 | Section 99. Effective date. This Act takes effect January | ||||||
10 | 1, 2022.
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