Sen. Ann Gillespie

Filed: 4/21/2021





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2    AMENDMENT NO. ______. Amend Senate Bill 1040 by replacing
3everything after the enacting clause with the following:
4    "Section 5. 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
16home, or elsewhere; (6) medical care, or any other type of



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1remedial care furnished by licensed practitioners; (7) home
2health care services; (8) private duty nursing service; (9)
3clinic services; (10) dental services, including prevention
4and treatment of periodontal disease and dental caries disease
5for pregnant women, provided by an individual licensed to
6practice dentistry or dental surgery; for purposes of this
7item (10), "dental services" means diagnostic, preventive, or
8corrective procedures provided by or under the supervision of
9a dentist in the practice of his or her profession; (11)
10physical therapy and related services; (12) prescribed drugs,
11dentures, and prosthetic devices; and eyeglasses prescribed by
12a physician skilled in the diseases of the eye, or by an
13optometrist, whichever the person may select; (13) other
14diagnostic, screening, preventive, and rehabilitative
15services, including to ensure that the individual's need for
16intervention or treatment of mental disorders or substance use
17disorders or co-occurring mental health and substance use
18disorders is determined using a uniform screening, assessment,
19and evaluation process inclusive of criteria, for children and
20adults; for purposes of this item (13), a uniform screening,
21assessment, and evaluation process refers to a process that
22includes an appropriate evaluation and, as warranted, a
23referral; "uniform" does not mean the use of a singular
24instrument, tool, or process that all must utilize; (14)
25transportation and such other expenses as may be necessary;
26(15) medical treatment of sexual assault survivors, as defined



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1in Section 1a of the Sexual Assault Survivors Emergency
2Treatment Act, for injuries sustained as a result of the
3sexual assault, including examinations and laboratory tests to
4discover evidence which may be used in criminal proceedings
5arising from the sexual assault; (16) the diagnosis and
6treatment of sickle cell anemia; and (17) any other medical
7care, and any other type of remedial care recognized under the
8laws of this State. The term "any other type of remedial care"
9shall include nursing care and nursing home service for
10persons who rely on treatment by spiritual means alone through
11prayer for healing.
12    Notwithstanding any other provision of this Section, a
13comprehensive tobacco use cessation program that includes
14purchasing prescription drugs or prescription medical devices
15approved by the Food and Drug Administration shall be covered
16under the medical assistance program under this Article for
17persons who are otherwise eligible for assistance under this
19    Notwithstanding any other provision of this Code,
20reproductive health care that is otherwise legal in Illinois
21shall be covered under the medical assistance program for
22persons who are otherwise eligible for medical assistance
23under this Article.
24    Notwithstanding any other provision of this Code, the
25Illinois Department may not require, as a condition of payment
26for any laboratory test authorized under this Article, that a



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1physician's handwritten signature appear on the laboratory
2test order form. The Illinois Department may, however, impose
3other appropriate requirements regarding laboratory test order
5    Upon receipt of federal approval of an amendment to the
6Illinois Title XIX State Plan for this purpose, the Department
7shall authorize the Chicago Public Schools (CPS) to procure a
8vendor or vendors to manufacture eyeglasses for individuals
9enrolled in a school within the CPS system. CPS shall ensure
10that its vendor or vendors are enrolled as providers in the
11medical assistance program and in any capitated Medicaid
12managed care entity (MCE) serving individuals enrolled in a
13school within the CPS system. Under any contract procured
14under this provision, the vendor or vendors must serve only
15individuals enrolled in a school within the CPS system. Claims
16for services provided by CPS's vendor or vendors to recipients
17of benefits in the medical assistance program under this Code,
18the Children's Health Insurance Program, or the Covering ALL
19KIDS Health Insurance Program shall be submitted to the
20Department or the MCE in which the individual is enrolled for
21payment and shall be reimbursed at the Department's or the
22MCE's established rates or rate methodologies for eyeglasses.
23    On and after July 1, 2012, the Department of Healthcare
24and Family Services may provide the following services to
25persons eligible for assistance under this Article who are
26participating in education, training or employment programs



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1operated by the Department of Human Services as successor to
2the Department of Public Aid:
3        (1) dental services provided by or under the
4    supervision of a dentist; and
5        (2) eyeglasses prescribed by a physician skilled in
6    the diseases of the eye, or by an optometrist, whichever
7    the person may select.
8    On and after July 1, 2018, the Department of Healthcare
9and Family Services shall provide dental services to any adult
10who is otherwise eligible for assistance under the medical
11assistance program. As used in this paragraph, "dental
12services" means diagnostic, preventative, restorative, or
13corrective procedures, including procedures and services for
14the prevention and treatment of periodontal disease and dental
15caries disease, provided by an individual who is licensed to
16practice dentistry or dental surgery or who is under the
17supervision of a dentist in the practice of his or her
19    On and after July 1, 2018, targeted dental services, as
20set forth in Exhibit D of the Consent Decree entered by the
21United States District Court for the Northern District of
22Illinois, Eastern Division, in the matter of Memisovski v.
23Maram, Case No. 92 C 1982, that are provided to adults under
24the medical assistance program shall be established at no less
25than the rates set forth in the "New Rate" column in Exhibit D
26of the Consent Decree for targeted dental services that are



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



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1    The Illinois Department shall authorize the provision of,
2and shall authorize payment for, screening by low-dose
3mammography for the presence of occult breast cancer for women
435 years of age or older who are eligible for medical
5assistance under this Article, as follows:
6        (A) A baseline mammogram for women 35 to 39 years of
7    age.
8        (B) An annual mammogram for women 40 years of age or
9    older.
10        (C) A mammogram at the age and intervals considered
11    medically necessary by the woman's health care provider
12    for women under 40 years of age and having a family history
13    of breast cancer, prior personal history of breast cancer,
14    positive genetic testing, or other risk factors.
15        (D) A comprehensive ultrasound screening and MRI of an
16    entire breast or breasts if a mammogram demonstrates
17    heterogeneous or dense breast tissue or when medically
18    necessary as determined by a physician licensed to
19    practice medicine in all of its branches.
20        (E) A screening MRI when medically necessary, as
21    determined by a physician licensed to practice medicine in
22    all of its branches.
23        (F) A diagnostic mammogram when medically necessary,
24    as determined by a physician licensed to practice medicine
25    in all its branches, advanced practice registered nurse,
26    or physician assistant.



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1    The Department shall not impose a deductible, coinsurance,
2copayment, or any other cost-sharing requirement on the
3coverage provided under this paragraph; except that this
4sentence does not apply to coverage of diagnostic mammograms
5to the extent such coverage would disqualify a high-deductible
6health plan from eligibility for a health savings account
7pursuant to Section 223 of the Internal Revenue Code (26
8U.S.C. 223).
9    All screenings shall include a physical breast exam,
10instruction on self-examination and information regarding the
11frequency of self-examination and its value as a preventative
13     For purposes of this Section:
14    "Diagnostic mammogram" means a mammogram obtained using
15diagnostic mammography.
16    "Diagnostic mammography" means a method of screening that
17is designed to evaluate an abnormality in a breast, including
18an abnormality seen or suspected on a screening mammogram or a
19subjective or objective abnormality otherwise detected in the
21    "Low-dose mammography" means the x-ray examination of the
22breast using equipment dedicated specifically for mammography,
23including the x-ray tube, filter, compression device, and
24image receptor, with an average radiation exposure delivery of
25less than one rad per breast for 2 views of an average size
26breast. The term also includes digital mammography and



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1includes breast tomosynthesis.
2    "Breast tomosynthesis" means a radiologic procedure that
3involves the acquisition of projection images over the
4stationary breast to produce cross-sectional digital
5three-dimensional images of the breast.
6    If, at any time, the Secretary of the United States
7Department of Health and Human Services, or its successor
8agency, promulgates rules or regulations to be published in
9the Federal Register or publishes a comment in the Federal
10Register or issues an opinion, guidance, or other action that
11would require the State, pursuant to any provision of the
12Patient Protection and Affordable Care Act (Public Law
13111-148), including, but not limited to, 42 U.S.C.
1418031(d)(3)(B) or any successor provision, to defray the cost
15of any coverage for breast tomosynthesis outlined in this
16paragraph, then the requirement that an insurer cover breast
17tomosynthesis is inoperative other than any such coverage
18authorized under Section 1902 of the Social Security Act, 42
19U.S.C. 1396a, and the State shall not assume any obligation
20for the cost of coverage for breast tomosynthesis set forth in
21this paragraph.
22    On and after January 1, 2016, the Department shall ensure
23that all networks of care for adult clients of the Department
24include access to at least one breast imaging Center of
25Imaging Excellence as certified by the American College of



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1    On and after January 1, 2012, providers participating in a
2quality improvement program approved by the Department shall
3be reimbursed for screening and diagnostic mammography at the
4same rate as the Medicare program's rates, including the
5increased reimbursement for digital mammography.
6    The Department shall convene an expert panel including
7representatives of hospitals, free-standing mammography
8facilities, and doctors, including radiologists, to establish
9quality standards for mammography.
10    On and after January 1, 2017, providers participating in a
11breast cancer treatment quality improvement program approved
12by the Department shall be reimbursed for breast cancer
13treatment at a rate that is no lower than 95% of the Medicare
14program's rates for the data elements included in the breast
15cancer treatment quality program.
16    The Department shall convene an expert panel, including
17representatives of hospitals, free-standing breast cancer
18treatment centers, breast cancer quality organizations, and
19doctors, including breast surgeons, reconstructive breast
20surgeons, oncologists, and primary care providers to establish
21quality standards for breast cancer treatment.
22    Subject to federal approval, the Department shall
23establish a rate methodology for mammography at federally
24qualified health centers and other encounter-rate clinics.
25These clinics or centers may also collaborate with other
26hospital-based mammography facilities. By January 1, 2016, the



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1Department shall report to the General Assembly on the status
2of the provision set forth in this paragraph.
3    The Department shall establish a methodology to remind
4women who are age-appropriate for screening mammography, but
5who have not received a mammogram within the previous 18
6months, of the importance and benefit of screening
7mammography. The Department shall work with experts in breast
8cancer outreach and patient navigation to optimize these
9reminders and shall establish a methodology for evaluating
10their effectiveness and modifying the methodology based on the
12    The Department shall establish a performance goal for
13primary care providers with respect to their female patients
14over age 40 receiving an annual mammogram. This performance
15goal shall be used to provide additional reimbursement in the
16form of a quality performance bonus to primary care providers
17who meet that goal.
18    The Department shall devise a means of case-managing or
19patient navigation for beneficiaries diagnosed with breast
20cancer. This program shall initially operate as a pilot
21program in areas of the State with the highest incidence of
22mortality related to breast cancer. At least one pilot program
23site shall be in the metropolitan Chicago area and at least one
24site shall be outside the metropolitan Chicago area. On or
25after July 1, 2016, the pilot program shall be expanded to
26include one site in western Illinois, one site in southern



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1Illinois, one site in central Illinois, and 4 sites within
2metropolitan Chicago. An evaluation of the pilot program shall
3be carried out measuring health outcomes and cost of care for
4those served by the pilot program compared to similarly
5situated patients who are not served by the pilot program.
6    The Department shall require all networks of care to
7develop a means either internally or by contract with experts
8in navigation and community outreach to navigate cancer
9patients to comprehensive care in a timely fashion. The
10Department shall require all networks of care to include
11access for patients diagnosed with cancer to at least one
12academic commission on cancer-accredited cancer program as an
13in-network covered benefit.
14    Any medical or health care provider shall immediately
15recommend, to any pregnant woman who is being provided
16prenatal services and is suspected of having a substance use
17disorder as defined in the Substance Use Disorder Act,
18referral to a local substance use disorder treatment program
19licensed by the Department of Human Services or to a licensed
20hospital which provides substance abuse treatment services.
21The Department of Healthcare and Family Services shall assure
22coverage for the cost of treatment of the drug abuse or
23addiction for pregnant recipients in accordance with the
24Illinois Medicaid Program in conjunction with the Department
25of Human Services.
26    All medical providers providing medical assistance to



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



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



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



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1implementation of Partnerships under this Section.
2    The Illinois Department shall require health care
3providers to maintain records that document the medical care
4and services provided to recipients of Medical Assistance
5under this Article. Such records must be retained for a period
6of not less than 6 years from the date of service or as
7provided by applicable State law, whichever period is longer,
8except that if an audit is initiated within the required
9retention period then the records must be retained until the
10audit is completed and every exception is resolved. The
11Illinois Department shall require health care providers to
12make available, when authorized by the patient, in writing,
13the medical records in a timely fashion to other health care
14providers who are treating or serving persons eligible for
15Medical Assistance under this Article. All dispensers of
16medical services shall be required to maintain and retain
17business and professional records sufficient to fully and
18accurately document the nature, scope, details and receipt of
19the health care provided to persons eligible for medical
20assistance under this Code, in accordance with regulations
21promulgated by the Illinois Department. The rules and
22regulations shall require that proof of the receipt of
23prescription drugs, dentures, prosthetic devices and
24eyeglasses by eligible persons under this Section accompany
25each claim for reimbursement submitted by the dispenser of
26such medical services. No such claims for reimbursement shall



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1be approved for payment by the Illinois Department without
2such proof of receipt, unless the Illinois Department shall
3have put into effect and shall be operating a system of
4post-payment audit and review which shall, on a sampling
5basis, be deemed adequate by the Illinois Department to assure
6that such drugs, dentures, prosthetic devices and eyeglasses
7for which payment is being made are actually being received by
8eligible recipients. Within 90 days after September 16, 1984
9(the effective date of Public Act 83-1439), the Illinois
10Department shall establish a current list of acquisition costs
11for all prosthetic devices and any other items recognized as
12medical equipment and supplies reimbursable under this Article
13and shall update such list on a quarterly basis, except that
14the acquisition costs of all prescription drugs shall be
15updated no less frequently than every 30 days as required by
16Section 5-5.12.
17    Notwithstanding any other law to the contrary, the
18Illinois Department shall, within 365 days after July 22, 2013
19(the effective date of Public Act 98-104), establish
20procedures to permit skilled care facilities licensed under
21the Nursing Home Care Act to submit monthly billing claims for
22reimbursement purposes. Following development of these
23procedures, the Department shall, by July 1, 2016, test the
24viability of the new system and implement any necessary
25operational or structural changes to its information
26technology platforms in order to allow for the direct



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1acceptance and payment of nursing home claims.
2    Notwithstanding any other law to the contrary, the
3Illinois Department shall, within 365 days after August 15,
42014 (the effective date of Public Act 98-963), establish
5procedures to permit ID/DD facilities licensed under the ID/DD
6Community Care Act and MC/DD facilities licensed under the
7MC/DD Act to submit monthly billing claims for reimbursement
8purposes. Following development of these procedures, the
9Department shall have an additional 365 days to test the
10viability of the new system and to ensure that any necessary
11operational or structural changes to its information
12technology platforms are implemented.
13    The Illinois Department shall require all dispensers of
14medical services, other than an individual practitioner or
15group of practitioners, desiring to participate in the Medical
16Assistance program established under this Article to disclose
17all financial, beneficial, ownership, equity, surety or other
18interests in any and all firms, corporations, partnerships,
19associations, business enterprises, joint ventures, agencies,
20institutions or other legal entities providing any form of
21health care services in this State under this Article.
22    The Illinois Department may require that all dispensers of
23medical services desiring to participate in the medical
24assistance program established under this Article disclose,
25under such terms and conditions as the Illinois Department may
26by rule establish, all inquiries from clients and attorneys



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1regarding medical bills paid by the Illinois Department, which
2inquiries could indicate potential existence of claims or
3liens for the Illinois Department.
4    Enrollment of a vendor shall be subject to a provisional
5period and shall be conditional for one year. During the
6period of conditional enrollment, the Department may terminate
7the vendor's eligibility to participate in, or may disenroll
8the vendor from, the medical assistance program without cause.
9Unless otherwise specified, such termination of eligibility or
10disenrollment is not subject to the Department's hearing
11process. However, a disenrolled vendor may reapply without
13    The Department has the discretion to limit the conditional
14enrollment period for vendors based upon category of risk of
15the vendor.
16    Prior to enrollment and during the conditional enrollment
17period in the medical assistance program, all vendors shall be
18subject to enhanced oversight, screening, and review based on
19the risk of fraud, waste, and abuse that is posed by the
20category of risk of the vendor. The Illinois Department shall
21establish the procedures for oversight, screening, and review,
22which may include, but need not be limited to: criminal and
23financial background checks; fingerprinting; license,
24certification, and authorization verifications; unscheduled or
25unannounced site visits; database checks; prepayment audit
26reviews; audits; payment caps; payment suspensions; and other



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1screening as required by federal or State law.
2    The Department shall define or specify the following: (i)
3by provider notice, the "category of risk of the vendor" for
4each type of vendor, which shall take into account the level of
5screening applicable to a particular category of vendor under
6federal law and regulations; (ii) by rule or provider notice,
7the maximum length of the conditional enrollment period for
8each category of risk of the vendor; and (iii) by rule, the
9hearing rights, if any, afforded to a vendor in each category
10of risk of the vendor that is terminated or disenrolled during
11the conditional enrollment period.
12    To be eligible for payment consideration, a vendor's
13payment claim or bill, either as an initial claim or as a
14resubmitted claim following prior rejection, must be received
15by the Illinois Department, or its fiscal intermediary, no
16later than 180 days after the latest date on the claim on which
17medical goods or services were provided, with the following
19        (1) In the case of a provider whose enrollment is in
20    process by the Illinois Department, the 180-day period
21    shall not begin until the date on the written notice from
22    the Illinois Department that the provider enrollment is
23    complete.
24        (2) In the case of errors attributable to the Illinois
25    Department or any of its claims processing intermediaries
26    which result in an inability to receive, process, or



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1    adjudicate a claim, the 180-day period shall not begin
2    until the provider has been notified of the error.
3        (3) In the case of a provider for whom the Illinois
4    Department initiates the monthly billing process.
5        (4) In the case of a provider operated by a unit of
6    local government with a population exceeding 3,000,000
7    when local government funds finance federal participation
8    for claims payments.
9        (5) In cases established by Department rule.
10    For claims for services rendered during a period for which
11a recipient received retroactive eligibility, claims must be
12filed within 180 days after the Department determines the
13applicant is eligible. For claims for which the Illinois
14Department is not the primary payer, claims must be submitted
15to the Illinois Department within 180 days after the final
16adjudication by the primary payer.
17    In the case of long term care facilities, within 45
18calendar days of receipt by the facility of required
19prescreening information, new admissions with associated
20admission documents shall be submitted through the Medical
21Electronic Data Interchange (MEDI) or the Recipient
22Eligibility Verification (REV) System or shall be submitted
23directly to the Department of Human Services using required
24admission forms. Effective September 1, 2014, admission
25documents, including all prescreening information, must be
26submitted through MEDI or REV. Confirmation numbers assigned



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1to an accepted transaction shall be retained by a facility to
2verify timely submittal. Once an admission transaction has
3been completed, all resubmitted claims following prior
4rejection are subject to receipt no later than 180 days after
5the admission transaction has been completed.
6    Claims that are not submitted and received in compliance
7with the foregoing requirements shall not be eligible for
8payment under the medical assistance program, and the State
9shall have no liability for payment of those claims.
10    To the extent consistent with applicable information and
11privacy, security, and disclosure laws, State and federal
12agencies and departments shall provide the Illinois Department
13access to confidential and other information and data
14necessary to perform eligibility and payment verifications and
15other Illinois Department functions. This includes, but is not
16limited to: information pertaining to licensure;
17certification; earnings; immigration status; citizenship; wage
18reporting; unearned and earned income; pension income;
19employment; supplemental security income; social security
20numbers; National Provider Identifier (NPI) numbers; the
21National Practitioner Data Bank (NPDB); program and agency
22exclusions; taxpayer identification numbers; tax delinquency;
23corporate information; and death records.
24    The Illinois Department shall enter into agreements with
25State agencies and departments, and is authorized to enter
26into agreements with federal agencies and departments, under



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1which such agencies and departments shall share data necessary
2for medical assistance program integrity functions and
3oversight. The Illinois Department shall develop, in
4cooperation with other State departments and agencies, and in
5compliance with applicable federal laws and regulations,
6appropriate and effective methods to share such data. At a
7minimum, and to the extent necessary to provide data sharing,
8the Illinois Department shall enter into agreements with State
9agencies and departments, and is authorized to enter into
10agreements with federal agencies and departments, including,
11but not limited to: the Secretary of State; the Department of
12Revenue; the Department of Public Health; the Department of
13Human Services; and the Department of Financial and
14Professional Regulation.
15    Beginning in fiscal year 2013, the Illinois Department
16shall set forth a request for information to identify the
17benefits of a pre-payment, post-adjudication, and post-edit
18claims system with the goals of streamlining claims processing
19and provider reimbursement, reducing the number of pending or
20rejected claims, and helping to ensure a more transparent
21adjudication process through the utilization of: (i) provider
22data verification and provider screening technology; and (ii)
23clinical code editing; and (iii) pre-pay, pre- or
24post-adjudicated predictive modeling with an integrated case
25management system with link analysis. Such a request for
26information shall not be considered as a request for proposal



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1or as an obligation on the part of the Illinois Department to
2take any action or acquire any products or services.
3    The Illinois Department shall establish policies,
4procedures, standards and criteria by rule for the
5acquisition, repair and replacement of orthotic and prosthetic
6devices and durable medical equipment. Such rules shall
7provide, but not be limited to, the following services: (1)
8immediate repair or replacement of such devices by recipients;
9and (2) rental, lease, purchase or lease-purchase of durable
10medical equipment in a cost-effective manner, taking into
11consideration the recipient's medical prognosis, the extent of
12the recipient's needs, and the requirements and costs for
13maintaining such equipment. Subject to prior approval, such
14rules shall enable a recipient to temporarily acquire and use
15alternative or substitute devices or equipment pending repairs
16or replacements of any device or equipment previously
17authorized for such recipient by the Department.
18Notwithstanding any provision of Section 5-5f to the contrary,
19the Department may, by rule, exempt certain replacement
20wheelchair parts from prior approval and, for wheelchairs,
21wheelchair parts, wheelchair accessories, and related seating
22and positioning items, determine the wholesale price by
23methods other than actual acquisition costs.
24    The Department shall require, by rule, all providers of
25durable medical equipment to be accredited by an accreditation
26organization approved by the federal Centers for Medicare and



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1Medicaid Services and recognized by the Department in order to
2bill the Department for providing durable medical equipment to
3recipients. No later than 15 months after the effective date
4of the rule adopted pursuant to this paragraph, all providers
5must meet the accreditation requirement.
6    In order to promote environmental responsibility, meet the
7needs of recipients and enrollees, and achieve significant
8cost savings, the Department, or a managed care organization
9under contract with the Department, may provide recipients or
10managed care enrollees who have a prescription or Certificate
11of Medical Necessity access to refurbished durable medical
12equipment under this Section (excluding prosthetic and
13orthotic devices as defined in the Orthotics, Prosthetics, and
14Pedorthics Practice Act and complex rehabilitation technology
15products and associated services) through the State's
16assistive technology program's reutilization program, using
17staff with the Assistive Technology Professional (ATP)
18Certification if the refurbished durable medical equipment:
19(i) is available; (ii) is less expensive, including shipping
20costs, than new durable medical equipment of the same type;
21(iii) is able to withstand at least 3 years of use; (iv) is
22cleaned, disinfected, sterilized, and safe in accordance with
23federal Food and Drug Administration regulations and guidance
24governing the reprocessing of medical devices in health care
25settings; and (v) equally meets the needs of the recipient or
26enrollee. The reutilization program shall confirm that the



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1recipient or enrollee is not already in receipt of same or
2similar equipment from another service provider, and that the
3refurbished durable medical equipment equally meets the needs
4of the recipient or enrollee. Nothing in this paragraph shall
5be construed to limit recipient or enrollee choice to obtain
6new durable medical equipment or place any additional prior
7authorization conditions on enrollees of managed care
9    The Department shall execute, relative to the nursing home
10prescreening project, written inter-agency agreements with the
11Department of Human Services and the Department on Aging, to
12effect the following: (i) intake procedures and common
13eligibility criteria for those persons who are receiving
14non-institutional services; and (ii) the establishment and
15development of non-institutional services in areas of the
16State where they are not currently available or are
17undeveloped; and (iii) notwithstanding any other provision of
18law, subject to federal approval, on and after July 1, 2012, an
19increase in the determination of need (DON) scores from 29 to
2037 for applicants for institutional and home and
21community-based long term care; if and only if federal
22approval is not granted, the Department may, in conjunction
23with other affected agencies, implement utilization controls
24or changes in benefit packages to effectuate a similar savings
25amount for this population; and (iv) no later than July 1,
262013, minimum level of care eligibility criteria for



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1institutional and home and community-based long term care; and
2(v) no later than October 1, 2013, establish procedures to
3permit long term care providers access to eligibility scores
4for individuals with an admission date who are seeking or
5receiving services from the long term care provider. In order
6to select the minimum level of care eligibility criteria, the
7Governor shall establish a workgroup that includes affected
8agency representatives and stakeholders representing the
9institutional and home and community-based long term care
10interests. This Section shall not restrict the Department from
11implementing lower level of care eligibility criteria for
12community-based services in circumstances where federal
13approval has been granted.
14    The Illinois Department shall develop and operate, in
15cooperation with other State Departments and agencies and in
16compliance with applicable federal laws and regulations,
17appropriate and effective systems of health care evaluation
18and programs for monitoring of utilization of health care
19services and facilities, as it affects persons eligible for
20medical assistance under this Code.
21    The Illinois Department shall report annually to the
22General Assembly, no later than the second Friday in April of
231979 and each year thereafter, in regard to:
24        (a) actual statistics and trends in utilization of
25    medical services by public aid recipients;
26        (b) actual statistics and trends in the provision of



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1    the various medical services by medical vendors;
2        (c) current rate structures and proposed changes in
3    those rate structures for the various medical vendors; and
4        (d) efforts at utilization review and control by the
5    Illinois Department.
6    The period covered by each report shall be the 3 years
7ending on the June 30 prior to the report. The report shall
8include suggested legislation for consideration by the General
9Assembly. The requirement for reporting to the General
10Assembly shall be satisfied by filing copies of the report as
11required by Section 3.1 of the General Assembly Organization
12Act, and filing such additional copies with the State
13Government Report Distribution Center for the General Assembly
14as is required under paragraph (t) of Section 7 of the State
15Library Act.
16    Rulemaking authority to implement Public Act 95-1045, if
17any, is conditioned on the rules being adopted in accordance
18with all provisions of the Illinois Administrative Procedure
19Act and all rules and procedures of the Joint Committee on
20Administrative Rules; any purported rule not so adopted, for
21whatever reason, is unauthorized.
22    On and after July 1, 2012, the Department shall reduce any
23rate of reimbursement for services or other payments or alter
24any methodologies authorized by this Code to reduce any rate
25of reimbursement for services or other payments in accordance
26with Section 5-5e.



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1    Because kidney transplantation can be an appropriate,
2cost-effective alternative to renal dialysis when medically
3necessary and notwithstanding the provisions of Section 1-11
4of this Code, beginning October 1, 2014, the Department shall
5cover kidney transplantation for noncitizens with end-stage
6renal disease who are not eligible for comprehensive medical
7benefits, who meet the residency requirements of Section 5-3
8of this Code, and who would otherwise meet the financial
9requirements of the appropriate class of eligible persons
10under Section 5-2 of this Code. To qualify for coverage of
11kidney transplantation, such person must be receiving
12emergency renal dialysis services covered by the Department.
13Providers under this Section shall be prior approved and
14certified by the Department to perform kidney transplantation
15and the services under this Section shall be limited to
16services associated with kidney transplantation.
17    Notwithstanding any other provision of this Code to the
18contrary, on or after July 1, 2015, all FDA approved forms of
19medication assisted treatment prescribed for the treatment of
20alcohol dependence or treatment of opioid dependence shall be
21covered under both fee for service and managed care medical
22assistance programs for persons who are otherwise eligible for
23medical assistance under this Article and shall not be subject
24to any (1) utilization control, other than those established
25under the American Society of Addiction Medicine patient
26placement criteria, (2) prior authorization mandate, or (3)



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1lifetime restriction limit mandate.
2    On or after July 1, 2015, opioid antagonists prescribed
3for the treatment of an opioid overdose, including the
4medication product, administration devices, and any pharmacy
5fees related to the dispensing and administration of the
6opioid antagonist, shall be covered under the medical
7assistance program for persons who are otherwise eligible for
8medical assistance under this Article. As used in this
9Section, "opioid antagonist" means a drug that binds to opioid
10receptors and blocks or inhibits the effect of opioids acting
11on those receptors, including, but not limited to, naloxone
12hydrochloride or any other similarly acting drug approved by
13the U.S. Food and Drug Administration.
14    Upon federal approval, the Department shall provide
15coverage and reimbursement for all drugs that are approved for
16marketing by the federal Food and Drug Administration and that
17are recommended by the federal Public Health Service or the
18United States Centers for Disease Control and Prevention for
19pre-exposure prophylaxis and related pre-exposure prophylaxis
20services, including, but not limited to, HIV and sexually
21transmitted infection screening, treatment for sexually
22transmitted infections, medical monitoring, assorted labs, and
23counseling to reduce the likelihood of HIV infection among
24individuals who are not infected with HIV but who are at high
25risk of HIV infection.
26    A federally qualified health center, as defined in Section



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11905(l)(2)(B) of the federal Social Security Act, shall be
2reimbursed by the Department in accordance with the federally
3qualified health center's encounter rate for services provided
4to medical assistance recipients that are performed by a
5dental hygienist, as defined under the Illinois Dental
6Practice Act, working under the general supervision of a
7dentist and employed by a federally qualified health center.
8(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
9100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
106-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
11eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
12100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
131-1-20; revised 9-18-19.)
14    Section 99. Effective date. This Act takes effect upon
15becoming law.".