102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
SB2899

 

Introduced 5/11/2021, by Sen. Julie A. Morrison

 

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

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that, on and after January 1, 2022, targeted dental services that are provided to adults and children under the medical assistance program shall be established and paid at no less than the rates published by the Department of Healthcare and Family Services and effective January 1, 2020 for all local health departments as the fee schedule for children and adult recipients. Sets forth the reimbursement rates for certain anesthesia services.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

SB2899LRB102 18405 KTG 26332 b

1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5changing 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
17remedial care furnished by licensed practitioners; (7) home
18health care services; (8) private duty nursing service; (9)
19clinic services; (10) dental services, including prevention
20and treatment of periodontal disease and dental caries disease
21for pregnant women, provided by an individual licensed to
22practice dentistry or dental surgery; for purposes of this
23item (10), "dental services" means diagnostic, preventive, or

 

 

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

 

 

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

 

 

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1vendor or vendors to manufacture eyeglasses for individuals
2enrolled in a school within the CPS system. CPS shall ensure
3that its vendor or vendors are enrolled as providers in the
4medical assistance program and in any capitated Medicaid
5managed care entity (MCE) serving individuals enrolled in a
6school within the CPS system. Under any contract procured
7under this provision, the vendor or vendors must serve only
8individuals enrolled in a school within the CPS system. Claims
9for services provided by CPS's vendor or vendors to recipients
10of benefits in the medical assistance program under this Code,
11the Children's Health Insurance Program, or the Covering ALL
12KIDS Health Insurance Program shall be submitted to the
13Department or the MCE in which the individual is enrolled for
14payment and shall be reimbursed at the Department's or the
15MCE's established rates or rate methodologies for eyeglasses.
16    On and after July 1, 2012, the Department of Healthcare
17and Family Services may provide the following services to
18persons eligible for assistance under this Article who are
19participating in education, training or employment programs
20operated by the Department of Human Services as successor to
21the Department of Public Aid:
22        (1) dental services provided by or under the
23    supervision of a dentist; and
24        (2) eyeglasses prescribed by a physician skilled in
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
2and Family Services shall provide dental services to any adult
3who is otherwise eligible for assistance under the medical
4assistance program. As used in this paragraph, "dental
5services" means diagnostic, preventative, restorative, or
6corrective procedures, including procedures and services for
7the prevention and treatment of periodontal disease and dental
8caries disease, provided by an individual who is licensed to
9practice dentistry or dental surgery or who is under the
10supervision of a dentist in the practice of his or her
11profession.
12    On and after July 1, 2018, targeted dental services, as
13set forth in Exhibit D of the Consent Decree entered by the
14United States District Court for the Northern District of
15Illinois, Eastern Division, in the matter of Memisovski v.
16Maram, Case No. 92 C 1982, that are provided to adults under
17the medical assistance program shall be established at no less
18than the rates set forth in the "New Rate" column in Exhibit D
19of the Consent Decree for targeted dental services that are
20provided to persons under the age of 18 under the medical
21assistance program.
22    On and after January 1, 2022, targeted dental services
23that are provided to adults and children under the medical
24assistance program shall be established and paid at no less
25than the rates published by the Department and effective
26January 1, 2020 for all local health departments as the fee

 

 

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1schedule for children and adult recipients. In addition, in
2order to address the growing crisis in the need for anesthesia
3related services for children and adults with disabilities,
4the following anesthesia related codes shall be reimbursed as
5follows:
6        (i) D9230 Inhalation of nitrous oxide, $70.
7        (ii) D9248 Non-intravenous conscious sedation, $150.
8        (iii) D9239 Intravenous moderate sedation, first 15
9    minutes, $181.
10        (iv) D9243 Intravenous moderate sedation, each
11    additional 15 minutes, $181.
12        (v) D9222 Deep sedation, first 15 minutes, $214.
13        (vi) D9223 Deep sedation, each additional 15 minutes,
14    $214.
15    Notwithstanding any other provision of this Code and
16subject to federal approval, the Department may adopt rules to
17allow a dentist who is volunteering his or her service at no
18cost to render dental services through an enrolled
19not-for-profit health clinic without the dentist personally
20enrolling as a participating provider in the medical
21assistance program. A not-for-profit health clinic shall
22include a public health clinic or Federally Qualified Health
23Center or other enrolled provider, as determined by the
24Department, through which dental services covered under this
25Section are performed. The Department shall establish a
26process for payment of claims for reimbursement for covered

 

 

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1dental services rendered under this provision.
2    The Illinois Department, by rule, may distinguish and
3classify the medical services to be provided only in
4accordance with the classes of persons designated in Section
55-2.
6    The Department of Healthcare and Family Services must
7provide coverage and reimbursement for amino acid-based
8elemental formulas, regardless of delivery method, for the
9diagnosis and treatment of (i) eosinophilic disorders and (ii)
10short bowel syndrome when the prescribing physician has issued
11a written order stating that the amino acid-based elemental
12formula is medically necessary.
13    The Illinois Department shall authorize the provision of,
14and shall authorize payment for, screening by low-dose
15mammography for the presence of occult breast cancer for women
1635 years of age or older who are eligible for medical
17assistance under this Article, as follows:
18        (A) A baseline mammogram for women 35 to 39 years of
19    age.
20        (B) An annual mammogram for women 40 years of age or
21    older.
22        (C) A mammogram at the age and intervals considered
23    medically necessary by the woman's health care provider
24    for women under 40 years of age and having a family history
25    of breast cancer, prior personal history of breast cancer,
26    positive genetic testing, or other risk factors.

 

 

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1        (D) A comprehensive ultrasound screening and MRI of an
2    entire breast or breasts if a mammogram demonstrates
3    heterogeneous or dense breast tissue or when medically
4    necessary as determined by a physician licensed to
5    practice medicine in all of its branches.
6        (E) A screening MRI when medically necessary, as
7    determined by a physician licensed to practice medicine in
8    all of its branches.
9        (F) A diagnostic mammogram when medically necessary,
10    as determined by a physician licensed to practice medicine
11    in all its branches, advanced practice registered nurse,
12    or physician assistant.
13    The Department shall not impose a deductible, coinsurance,
14copayment, or any other cost-sharing requirement on the
15coverage provided under this paragraph; except that this
16sentence does not apply to coverage of diagnostic mammograms
17to the extent such coverage would disqualify a high-deductible
18health plan from eligibility for a health savings account
19pursuant to Section 223 of the Internal Revenue Code (26
20U.S.C. 223).
21    All screenings shall include a physical breast exam,
22instruction on self-examination and information regarding the
23frequency of self-examination and its value as a preventative
24tool.
25     For purposes of this Section:
26    "Diagnostic mammogram" means a mammogram obtained using

 

 

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1diagnostic mammography.
2    "Diagnostic mammography" means a method of screening that
3is designed to evaluate an abnormality in a breast, including
4an abnormality seen or suspected on a screening mammogram or a
5subjective or objective abnormality otherwise detected in the
6breast.
7    "Low-dose mammography" means the x-ray examination of the
8breast using equipment dedicated specifically for mammography,
9including the x-ray tube, filter, compression device, and
10image receptor, with an average radiation exposure delivery of
11less than one rad per breast for 2 views of an average size
12breast. The term also includes digital mammography and
13includes breast tomosynthesis.
14    "Breast tomosynthesis" means a radiologic procedure that
15involves the acquisition of projection images over the
16stationary breast to produce cross-sectional digital
17three-dimensional images of the breast.
18    If, at any time, the Secretary of the United States
19Department of Health and Human Services, or its successor
20agency, promulgates rules or regulations to be published in
21the Federal Register or publishes a comment in the Federal
22Register or issues an opinion, guidance, or other action that
23would require the State, pursuant to any provision of the
24Patient Protection and Affordable Care Act (Public Law
25111-148), including, but not limited to, 42 U.S.C.
2618031(d)(3)(B) or any successor provision, to defray the cost

 

 

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

 

 

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1cancer treatment quality program.
2    The Department shall convene an expert panel, including
3representatives of hospitals, free-standing breast cancer
4treatment centers, breast cancer quality organizations, and
5doctors, including breast surgeons, reconstructive breast
6surgeons, oncologists, and primary care providers to establish
7quality standards for breast cancer treatment.
8    Subject to federal approval, the Department shall
9establish a rate methodology for mammography at federally
10qualified health centers and other encounter-rate clinics.
11These clinics or centers may also collaborate with other
12hospital-based mammography facilities. By January 1, 2016, the
13Department shall report to the General Assembly on the status
14of the provision set forth in this paragraph.
15    The Department shall establish a methodology to remind
16women who are age-appropriate for screening mammography, but
17who have not received a mammogram within the previous 18
18months, of the importance and benefit of screening
19mammography. The Department shall work with experts in breast
20cancer outreach and patient navigation to optimize these
21reminders and shall establish a methodology for evaluating
22their effectiveness and modifying the methodology based on the
23evaluation.
24    The Department shall establish a performance goal for
25primary care providers with respect to their female patients
26over age 40 receiving an annual mammogram. This performance

 

 

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1goal shall be used to provide additional reimbursement in the
2form of a quality performance bonus to primary care providers
3who meet that goal.
4    The Department shall devise a means of case-managing or
5patient navigation for beneficiaries diagnosed with breast
6cancer. This program shall initially operate as a pilot
7program in areas of the State with the highest incidence of
8mortality related to breast cancer. At least one pilot program
9site shall be in the metropolitan Chicago area and at least one
10site shall be outside the metropolitan Chicago area. On or
11after July 1, 2016, the pilot program shall be expanded to
12include one site in western Illinois, one site in southern
13Illinois, one site in central Illinois, and 4 sites within
14metropolitan Chicago. An evaluation of the pilot program shall
15be carried out measuring health outcomes and cost of care for
16those served by the pilot program compared to similarly
17situated patients who are not served by the pilot program.
18    The Department shall require all networks of care to
19develop a means either internally or by contract with experts
20in navigation and community outreach to navigate cancer
21patients to comprehensive care in a timely fashion. The
22Department shall require all networks of care to include
23access for patients diagnosed with cancer to at least one
24academic commission on cancer-accredited cancer program as an
25in-network covered benefit.
26    Any medical or health care provider shall immediately

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1Medical Assistance under this Article. All dispensers of
2medical services shall be required to maintain and retain
3business and professional records sufficient to fully and
4accurately document the nature, scope, details and receipt of
5the health care provided to persons eligible for medical
6assistance under this Code, in accordance with regulations
7promulgated by the Illinois Department. The rules and
8regulations shall require that proof of the receipt of
9prescription drugs, dentures, prosthetic devices and
10eyeglasses by eligible persons under this Section accompany
11each claim for reimbursement submitted by the dispenser of
12such medical services. No such claims for reimbursement shall
13be approved for payment by the Illinois Department without
14such proof of receipt, unless the Illinois Department shall
15have put into effect and shall be operating a system of
16post-payment audit and review which shall, on a sampling
17basis, be deemed adequate by the Illinois Department to assure
18that such drugs, dentures, prosthetic devices and eyeglasses
19for which payment is being made are actually being received by
20eligible recipients. Within 90 days after September 16, 1984
21(the effective date of Public Act 83-1439), the Illinois
22Department shall establish a current list of acquisition costs
23for all prosthetic devices and any other items recognized as
24medical equipment and supplies reimbursable under this Article
25and shall update such list on a quarterly basis, except that
26the acquisition costs of all prescription drugs shall be

 

 

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1updated no less frequently than every 30 days as required by
2Section 5-5.12.
3    Notwithstanding any other law to the contrary, the
4Illinois Department shall, within 365 days after July 22, 2013
5(the effective date of Public Act 98-104), establish
6procedures to permit skilled care facilities licensed under
7the Nursing Home Care Act to submit monthly billing claims for
8reimbursement purposes. Following development of these
9procedures, the Department shall, by July 1, 2016, test the
10viability of the new system and implement any necessary
11operational or structural changes to its information
12technology platforms in order to allow for the direct
13acceptance and payment of nursing home claims.
14    Notwithstanding any other law to the contrary, the
15Illinois Department shall, within 365 days after August 15,
162014 (the effective date of Public Act 98-963), establish
17procedures to permit ID/DD facilities licensed under the ID/DD
18Community Care Act and MC/DD facilities licensed under the
19MC/DD Act to submit monthly billing claims for reimbursement
20purposes. Following development of these procedures, the
21Department shall have an additional 365 days to test the
22viability of the new system and to ensure that any necessary
23operational or structural changes to its information
24technology platforms are implemented.
25    The Illinois Department shall require all dispensers of
26medical services, other than an individual practitioner or

 

 

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

 

 

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1the vendor.
2    Prior to enrollment and during the conditional enrollment
3period in the medical assistance program, all vendors shall be
4subject to enhanced oversight, screening, and review based on
5the risk of fraud, waste, and abuse that is posed by the
6category of risk of the vendor. The Illinois Department shall
7establish the procedures for oversight, screening, and review,
8which may include, but need not be limited to: criminal and
9financial background checks; fingerprinting; license,
10certification, and authorization verifications; unscheduled or
11unannounced site visits; database checks; prepayment audit
12reviews; audits; payment caps; payment suspensions; and other
13screening as required by federal or State law.
14    The Department shall define or specify the following: (i)
15by provider notice, the "category of risk of the vendor" for
16each type of vendor, which shall take into account the level of
17screening applicable to a particular category of vendor under
18federal law and regulations; (ii) by rule or provider notice,
19the maximum length of the conditional enrollment period for
20each category of risk of the vendor; and (iii) by rule, the
21hearing rights, if any, afforded to a vendor in each category
22of risk of the vendor that is terminated or disenrolled during
23the conditional enrollment period.
24    To be eligible for payment consideration, a vendor's
25payment claim or bill, either as an initial claim or as a
26resubmitted claim following prior rejection, must be received

 

 

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

 

 

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

 

 

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1limited to: information pertaining to licensure;
2certification; earnings; immigration status; citizenship; wage
3reporting; unearned and earned income; pension income;
4employment; supplemental security income; social security
5numbers; National Provider Identifier (NPI) numbers; the
6National Practitioner Data Bank (NPDB); program and agency
7exclusions; taxpayer identification numbers; tax delinquency;
8corporate information; and death records.
9    The Illinois Department shall enter into agreements with
10State agencies and departments, and is authorized to enter
11into agreements with federal agencies and departments, under
12which such agencies and departments shall share data necessary
13for medical assistance program integrity functions and
14oversight. The Illinois Department shall develop, in
15cooperation with other State departments and agencies, and in
16compliance with applicable federal laws and regulations,
17appropriate and effective methods to share such data. At a
18minimum, and to the extent necessary to provide data sharing,
19the Illinois Department shall enter into agreements with State
20agencies and departments, and is authorized to enter into
21agreements with federal agencies and departments, including,
22but not limited to: the Secretary of State; the Department of
23Revenue; the Department of Public Health; the Department of
24Human Services; and the Department of Financial and
25Professional Regulation.
26    Beginning in fiscal year 2013, the Illinois Department

 

 

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

 

 

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

 

 

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

 

 

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1State where they are not currently available or are
2undeveloped; and (iii) notwithstanding any other provision of
3law, subject to federal approval, on and after July 1, 2012, an
4increase in the determination of need (DON) scores from 29 to
537 for applicants for institutional and home and
6community-based long term care; if and only if federal
7approval is not granted, the Department may, in conjunction
8with other affected agencies, implement utilization controls
9or changes in benefit packages to effectuate a similar savings
10amount for this population; and (iv) no later than July 1,
112013, minimum level of care eligibility criteria for
12institutional and home and community-based long term care; and
13(v) no later than October 1, 2013, establish procedures to
14permit long term care providers access to eligibility scores
15for individuals with an admission date who are seeking or
16receiving services from the long term care provider. In order
17to select the minimum level of care eligibility criteria, the
18Governor shall establish a workgroup that includes affected
19agency representatives and stakeholders representing the
20institutional and home and community-based long term care
21interests. This Section shall not restrict the Department from
22implementing lower level of care eligibility criteria for
23community-based services in circumstances where federal
24approval has been granted.
25    The Illinois Department shall develop and operate, in
26cooperation with other State Departments and agencies and in

 

 

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1compliance with applicable federal laws and regulations,
2appropriate and effective systems of health care evaluation
3and programs for monitoring of utilization of health care
4services and facilities, as it affects persons eligible for
5medical assistance under this Code.
6    The Illinois Department shall report annually to the
7General Assembly, no later than the second Friday in April of
81979 and each year thereafter, in regard to:
9        (a) actual statistics and trends in utilization of
10    medical services by public aid recipients;
11        (b) actual statistics and trends in the provision of
12    the various medical services by medical vendors;
13        (c) current rate structures and proposed changes in
14    those rate structures for the various medical vendors; and
15        (d) efforts at utilization review and control by the
16    Illinois Department.
17    The period covered by each report shall be the 3 years
18ending on the June 30 prior to the report. The report shall
19include suggested legislation for consideration by the General
20Assembly. The requirement for reporting to the General
21Assembly shall be satisfied by filing copies of the report as
22required by Section 3.1 of the General Assembly Organization
23Act, and filing such additional copies with the State
24Government Report Distribution Center for the General Assembly
25as is required under paragraph (t) of Section 7 of the State
26Library Act.

 

 

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

 

 

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

 

 

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1marketing by the federal Food and Drug Administration and that
2are recommended by the federal Public Health Service or the
3United States Centers for Disease Control and Prevention for
4pre-exposure prophylaxis and related pre-exposure prophylaxis
5services, including, but not limited to, HIV and sexually
6transmitted infection screening, treatment for sexually
7transmitted infections, medical monitoring, assorted labs, and
8counseling to reduce the likelihood of HIV infection among
9individuals who are not infected with HIV but who are at high
10risk of HIV infection.
11    A federally qualified health center, as defined in Section
121905(l)(2)(B) of the federal Social Security Act, shall be
13reimbursed by the Department in accordance with the federally
14qualified health center's encounter rate for services provided
15to medical assistance recipients that are performed by a
16dental hygienist, as defined under the Illinois Dental
17Practice Act, working under the general supervision of a
18dentist and employed by a federally qualified health center.
19(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
20100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
216-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
22eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
23100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
241-1-20; revised 9-18-19.)