State of Illinois
2013 and 2014


Introduced 2/15/2013, by Sen. Donne E. Trotter


305 ILCS 5/5-5f

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that the Department of Healthcare and Family Services shall require prior approval of wheelchair repairs when the cost of any one part is greater than or equal to $500 per line item, when the sum of the parts is greater than or equal to a total of $1,500, or when 8 or more units of labor are to be billed (rather than shall require prior approval of wheelchair repairs regardless of the cost of repairs). Provides that the payment rate for custom manual wheelchairs, power wheelchairs, seating and positioning items, and related options and accessories shall be set at the current Medicare fee schedule minus 6%; and that for those items that do not have an established rate on the Medicare fee schedule, the payment rate shall be the manufacturer's suggested retail price minus 10%. Effective immediately.

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SB1734LRB098 05559 KTG 36761 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 5-5f as follows:
6    (305 ILCS 5/5-5f)
7    Sec. 5-5f. Elimination and limitations of medical
8assistance services. Notwithstanding any other provision of
9this Code to the contrary, on and after July 1, 2012:
10    (a) The following services shall no longer be a covered
11service available under this Code: group psychotherapy for
12residents of any facility licensed under the Nursing Home Care
13Act or the Specialized Mental Health Rehabilitation Act; and
14adult chiropractic services.
15    (b) The Department shall place the following limitations on
16services: (i) the Department shall limit adult eyeglasses to
17one pair every 2 years; (ii) the Department shall set an annual
18limit of a maximum of 20 visits for each of the following
19services: adult speech, hearing, and language therapy
20services, adult occupational therapy services, and physical
21therapy services; (iii) the Department shall limit podiatry
22services to individuals with diabetes; (iv) the Department
23shall pay for caesarean sections at the normal vaginal delivery



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1rate unless a caesarean section was medically necessary; (v)
2the Department shall limit adult dental services to
3emergencies; and (vi) effective July 1, 2012, the Department
4shall place limitations and require concurrent review on every
5inpatient detoxification stay to prevent repeat admissions to
6any hospital for detoxification within 60 days of a previous
7inpatient detoxification stay. The Department shall convene a
8workgroup of hospitals, substance abuse providers, care
9coordination entities, managed care plans, and other
10stakeholders to develop recommendations for quality standards,
11diversion to other settings, and admission criteria for
12patients who need inpatient detoxification.
13    (c) The Department shall require prior approval of the
14following services: wheelchair repairs when the cost of any one
15part is greater than or equal to $500 per line item, when the
16sum of the parts is greater than or equal to a total of $1,500,
17or when 8 or more units of labor are to be billed; , regardless
18of the cost of the repairs, coronary artery bypass graft; , and
19bariatric surgery consistent with Medicare standards
20concerning patient responsibility. The payment rate for custom
21manual wheelchairs, power wheelchairs, seating and positioning
22items, and related options and accessories shall be set at the
23current Medicare fee schedule minus 6%. For those items that do
24not have an established rate on the Medicare fee schedule, the
25payment rate shall be the manufacturer's suggested retail price
26minus 10%. The wholesale cost of power wheelchairs shall be



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1actual acquisition cost including all discounts.
2    (d) The Department shall establish benchmarks for
3hospitals to measure and align payments to reduce potentially
4preventable hospital readmissions, inpatient complications,
5and unnecessary emergency room visits. In doing so, the
6Department shall consider items, including, but not limited to,
7historic and current acuity of care and historic and current
8trends in readmission. The Department shall publish
9provider-specific historical readmission data and anticipated
10potentially preventable targets 60 days prior to the start of
11the program. In the instance of readmissions, the Department
12shall adopt policies and rates of reimbursement for services
13and other payments provided under this Code to ensure that, by
14June 30, 2013, expenditures to hospitals are reduced by, at a
15minimum, $40,000,000.
16    (e) The Department shall establish utilization controls
17for the hospice program such that it shall not pay for other
18care services when an individual is in hospice.
19    (f) For home health services, the Department shall require
20Medicare certification of providers participating in the
21program, implement the Medicare face-to-face encounter rule,
22and limit services to post-hospitalization. The Department
23shall require providers to implement auditable electronic
24service verification based on global positioning systems or
25other cost-effective technology.
26    (g) For the Home Services Program operated by the



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1Department of Human Services and the Community Care Program
2operated by the Department on Aging, the Department of Human
3Services, in cooperation with the Department on Aging, shall
4implement an electronic service verification based on global
5positioning systems or other cost-effective technology.
6    (h) The Department shall not pay for hospital admissions
7when the claim indicates a hospital acquired condition that
8would cause Medicare to reduce its payment on the claim had the
9claim been submitted to Medicare, nor shall the Department pay
10for hospital admissions where a Medicare identified "never
11event" occurred.
12    (i) The Department shall implement cost savings
13initiatives for advanced imaging services, cardiac imaging
14services, pain management services, and back surgery. Such
15initiatives shall be designed to achieve annual costs savings.
16(Source: P.A. 97-689, eff. 6-14-12.)
17    Section 99. Effective date. This Act takes effect upon
18becoming law.