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Sen. John G. Mulroe
Filed: 3/4/2015
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1 | | AMENDMENT TO SENATE BILL 54
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2 | | AMENDMENT NO. ______. Amend Senate Bill 54 on page 8, below |
3 | | line 7, by inserting the following:
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4 | | "(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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5 | | Sec. 5-5. Medical services. The Illinois Department, by |
6 | | rule, shall
determine the quantity and quality of and the rate |
7 | | of reimbursement for the
medical assistance for which
payment |
8 | | will be authorized, and the medical services to be provided,
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9 | | which may include all or part of the following: (1) inpatient |
10 | | hospital
services; (2) outpatient hospital services; (3) other |
11 | | laboratory and
X-ray services; (4) skilled nursing home |
12 | | services; (5) physicians'
services whether furnished in the |
13 | | office, the patient's home, a
hospital, a skilled nursing home, |
14 | | or elsewhere; (6) medical care, or any
other type of remedial |
15 | | care furnished by licensed practitioners; (7)
home health care |
16 | | services; (8) private duty nursing service; (9) clinic
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17 | | services; (10) dental services, including prevention and |
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1 | | treatment of periodontal disease and dental caries disease for |
2 | | pregnant women, provided by an individual licensed to practice |
3 | | dentistry or dental surgery; for purposes of this item (10), |
4 | | "dental services" means diagnostic, preventive, or corrective |
5 | | procedures provided by or under the supervision of a dentist in |
6 | | the practice of his or her profession; (11) physical therapy |
7 | | and related
services; (12) prescribed drugs, dentures, and |
8 | | prosthetic devices; and
eyeglasses prescribed by a physician |
9 | | skilled in the diseases of the eye,
or by an optometrist, |
10 | | whichever the person may select; (13) other
diagnostic, |
11 | | screening, preventive, and rehabilitative services, including |
12 | | to ensure that the individual's need for intervention or |
13 | | treatment of mental disorders or substance use disorders or |
14 | | co-occurring mental health and substance use disorders is |
15 | | determined using a uniform screening, assessment, and |
16 | | evaluation process inclusive of criteria, for children and |
17 | | adults; for purposes of this item (13), a uniform screening, |
18 | | assessment, and evaluation process refers to a process that |
19 | | includes an appropriate evaluation and, as warranted, a |
20 | | referral; "uniform" does not mean the use of a singular |
21 | | instrument, tool, or process that all must utilize; (14)
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22 | | transportation and such other expenses as may be necessary; |
23 | | (15) medical
treatment of sexual assault survivors, as defined |
24 | | in
Section 1a of the Sexual Assault Survivors Emergency |
25 | | Treatment Act, for
injuries sustained as a result of the sexual |
26 | | assault, including
examinations and laboratory tests to |
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1 | | discover evidence which may be used in
criminal proceedings |
2 | | arising from the sexual assault; (16) the
diagnosis and |
3 | | treatment of sickle cell anemia; and (17)
any other medical |
4 | | care, and any other type of remedial care recognized
under the |
5 | | laws of this State, but not including abortions, or induced
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6 | | miscarriages or premature births, unless, in the opinion of a |
7 | | physician,
such procedures are necessary for the preservation |
8 | | of the life of the
woman seeking such treatment, or except an |
9 | | induced premature birth
intended to produce a live viable child |
10 | | and such procedure is necessary
for the health of the mother or |
11 | | her unborn child. The Illinois Department,
by rule, shall |
12 | | prohibit any physician from providing medical assistance
to |
13 | | anyone eligible therefor under this Code where such physician |
14 | | has been
found guilty of performing an abortion procedure in a |
15 | | wilful and wanton
manner upon a woman who was not pregnant at |
16 | | the time such abortion
procedure was performed. The term "any |
17 | | other type of remedial care" shall
include nursing care and |
18 | | nursing home service for persons who rely on
treatment by |
19 | | spiritual means alone through prayer for healing.
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20 | | Notwithstanding any other provision of this Section, a |
21 | | comprehensive
tobacco use cessation program that includes |
22 | | purchasing prescription drugs or
prescription medical devices |
23 | | approved by the Food and Drug Administration shall
be covered |
24 | | under the medical assistance
program under this Article for |
25 | | persons who are otherwise eligible for
assistance under this |
26 | | Article.
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1 | | Notwithstanding any other provision of this Code, the |
2 | | Illinois
Department may not require, as a condition of payment |
3 | | for any laboratory
test authorized under this Article, that a |
4 | | physician's handwritten signature
appear on the laboratory |
5 | | test order form. The Illinois Department may,
however, impose |
6 | | other appropriate requirements regarding laboratory test
order |
7 | | documentation.
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8 | | Upon receipt of federal approval of an amendment to the |
9 | | Illinois Title XIX State Plan for this purpose, the Department |
10 | | shall authorize the Chicago Public Schools (CPS) to procure a |
11 | | vendor or vendors to manufacture eyeglasses for individuals |
12 | | enrolled in a school within the CPS system. CPS shall ensure |
13 | | that its vendor or vendors are enrolled as providers in the |
14 | | medical assistance program and in any capitated Medicaid |
15 | | managed care entity (MCE) serving individuals enrolled in a |
16 | | school within the CPS system. Under any contract procured under |
17 | | this provision, the vendor or vendors must serve only |
18 | | individuals enrolled in a school within the CPS system. Claims |
19 | | for services provided by CPS's vendor or vendors to recipients |
20 | | of benefits in the medical assistance program under this Code, |
21 | | the Children's Health Insurance Program, or the Covering ALL |
22 | | KIDS Health Insurance Program shall be submitted to the |
23 | | Department or the MCE in which the individual is enrolled for |
24 | | payment and shall be reimbursed at the Department's or the |
25 | | MCE's established rates or rate methodologies for eyeglasses. |
26 | | On and after July 1, 2012, the Department of Healthcare and |
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1 | | Family Services may provide the following services to
persons
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2 | | eligible for assistance under this Article who are |
3 | | participating in
education, training or employment programs |
4 | | operated by the Department of Human
Services as successor to |
5 | | the Department of Public Aid:
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6 | | (1) dental services provided by or under the |
7 | | supervision of a dentist; and
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8 | | (2) eyeglasses prescribed by a physician skilled in the |
9 | | diseases of the
eye, or by an optometrist, whichever the |
10 | | person may select.
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11 | | Notwithstanding any other provision of this Code and |
12 | | subject to federal approval, the Department may adopt rules to |
13 | | allow a dentist who is volunteering his or her service at no |
14 | | cost to render dental services through an enrolled |
15 | | not-for-profit health clinic without the dentist personally |
16 | | enrolling as a participating provider in the medical assistance |
17 | | program. A not-for-profit health clinic shall include a public |
18 | | health clinic or Federally Qualified Health Center or other |
19 | | enrolled provider, as determined by the Department, through |
20 | | which dental services covered under this Section are performed. |
21 | | The Department shall establish a process for payment of claims |
22 | | for reimbursement for covered dental services rendered under |
23 | | this provision. |
24 | | The Illinois Department, by rule, may distinguish and |
25 | | classify the
medical services to be provided only in accordance |
26 | | with the classes of
persons designated in Section 5-2.
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1 | | The Department of Healthcare and Family Services must |
2 | | provide coverage and reimbursement for amino acid-based |
3 | | elemental formulas, regardless of delivery method, for the |
4 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) |
5 | | short bowel syndrome when the prescribing physician has issued |
6 | | a written order stating that the amino acid-based elemental |
7 | | formula is medically necessary.
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8 | | The Illinois Department shall authorize the provision of, |
9 | | and shall
authorize payment for, screening by low-dose |
10 | | mammography for the presence of
occult breast cancer for women |
11 | | 35 years of age or older who are eligible
for medical |
12 | | assistance under this Article, as follows: |
13 | | (A) A baseline
mammogram for women 35 to 39 years of |
14 | | age.
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15 | | (B) An annual mammogram for women 40 years of age or |
16 | | older. |
17 | | (C) A mammogram at the age and intervals considered |
18 | | medically necessary by the woman's health care provider for |
19 | | women under 40 years of age and having a family history of |
20 | | breast cancer, prior personal history of breast cancer, |
21 | | positive genetic testing, or other risk factors. |
22 | | (D) A comprehensive ultrasound screening of an entire |
23 | | breast or breasts if a mammogram demonstrates |
24 | | heterogeneous or dense breast tissue, when medically |
25 | | necessary as determined by a physician licensed to practice |
26 | | medicine in all of its branches. |
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1 | | All screenings
shall
include a physical breast exam, |
2 | | instruction on self-examination and
information regarding the |
3 | | frequency of self-examination and its value as a
preventative |
4 | | tool. For purposes of this Section, "low-dose mammography" |
5 | | means
the x-ray examination of the breast using equipment |
6 | | dedicated specifically
for mammography, including the x-ray |
7 | | tube, filter, compression device,
and image receptor, with an |
8 | | average radiation exposure delivery
of less than one rad per |
9 | | breast for 2 views of an average size breast.
The term also |
10 | | includes digital mammography and breast tomosynthesis. As used |
11 | | in this Section, the term "breast tomosynthesis" means a |
12 | | radiologic procedure that involves the acquisition of |
13 | | projection images over the stationary breast to produce |
14 | | cross-sectional digital three-dimensional images of the |
15 | | breast .
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16 | | On and after January 1, 2012, providers participating in a |
17 | | quality improvement program approved by the Department shall be |
18 | | reimbursed for screening and diagnostic mammography at the same |
19 | | rate as the Medicare program's rates, including the increased |
20 | | reimbursement for digital mammography. |
21 | | The Department shall convene an expert panel including |
22 | | representatives of hospitals, free-standing mammography |
23 | | facilities, and doctors, including radiologists, to establish |
24 | | quality standards. |
25 | | Subject to federal approval, the Department shall |
26 | | establish a rate methodology for mammography at federally |
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1 | | qualified health centers and other encounter-rate clinics. |
2 | | These clinics or centers may also collaborate with other |
3 | | hospital-based mammography facilities. |
4 | | The Department shall establish a methodology to remind |
5 | | women who are age-appropriate for screening mammography, but |
6 | | who have not received a mammogram within the previous 18 |
7 | | months, of the importance and benefit of screening mammography. |
8 | | The Department shall establish a performance goal for |
9 | | primary care providers with respect to their female patients |
10 | | over age 40 receiving an annual mammogram. This performance |
11 | | goal shall be used to provide additional reimbursement in the |
12 | | form of a quality performance bonus to primary care providers |
13 | | who meet that goal. |
14 | | The Department shall devise a means of case-managing or |
15 | | patient navigation for beneficiaries diagnosed with breast |
16 | | cancer. This program shall initially operate as a pilot program |
17 | | in areas of the State with the highest incidence of mortality |
18 | | related to breast cancer. At least one pilot program site shall |
19 | | be in the metropolitan Chicago area and at least one site shall |
20 | | be outside the metropolitan Chicago area. An evaluation of the |
21 | | pilot program shall be carried out measuring health outcomes |
22 | | and cost of care for those served by the pilot program compared |
23 | | to similarly situated patients who are not served by the pilot |
24 | | program. |
25 | | Any medical or health care provider shall immediately |
26 | | recommend, to
any pregnant woman who is being provided prenatal |
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1 | | services and is suspected
of drug abuse or is addicted as |
2 | | defined in the Alcoholism and Other Drug Abuse
and Dependency |
3 | | Act, referral to a local substance abuse treatment provider
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4 | | licensed by the Department of Human Services or to a licensed
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5 | | hospital which provides substance abuse treatment services. |
6 | | The Department of Healthcare and Family Services
shall assure |
7 | | coverage for the cost of treatment of the drug abuse or
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8 | | addiction for pregnant recipients in accordance with the |
9 | | Illinois Medicaid
Program in conjunction with the Department of |
10 | | Human Services.
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11 | | All medical providers providing medical assistance to |
12 | | pregnant women
under this Code shall receive information from |
13 | | the Department on the
availability of services under the Drug |
14 | | Free Families with a Future or any
comparable program providing |
15 | | case management services for addicted women,
including |
16 | | information on appropriate referrals for other social services
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17 | | that may be needed by addicted women in addition to treatment |
18 | | for addiction.
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19 | | The Illinois Department, in cooperation with the |
20 | | Departments of Human
Services (as successor to the Department |
21 | | of Alcoholism and Substance
Abuse) and Public Health, through a |
22 | | public awareness campaign, may
provide information concerning |
23 | | treatment for alcoholism and drug abuse and
addiction, prenatal |
24 | | health care, and other pertinent programs directed at
reducing |
25 | | the number of drug-affected infants born to recipients of |
26 | | medical
assistance.
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1 | | Neither the Department of Healthcare and Family Services |
2 | | nor the Department of Human
Services shall sanction the |
3 | | recipient solely on the basis of
her substance abuse.
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4 | | The Illinois Department shall establish such regulations |
5 | | governing
the dispensing of health services under this Article |
6 | | as it shall deem
appropriate. The Department
should
seek the |
7 | | advice of formal professional advisory committees appointed by
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8 | | the Director of the Illinois Department for the purpose of |
9 | | providing regular
advice on policy and administrative matters, |
10 | | information dissemination and
educational activities for |
11 | | medical and health care providers, and
consistency in |
12 | | procedures to the Illinois Department.
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13 | | The Illinois Department may develop and contract with |
14 | | Partnerships of
medical providers to arrange medical services |
15 | | for persons eligible under
Section 5-2 of this Code. |
16 | | Implementation of this Section may be by
demonstration projects |
17 | | in certain geographic areas. The Partnership shall
be |
18 | | represented by a sponsor organization. The Department, by rule, |
19 | | shall
develop qualifications for sponsors of Partnerships. |
20 | | Nothing in this
Section shall be construed to require that the |
21 | | sponsor organization be a
medical organization.
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22 | | The sponsor must negotiate formal written contracts with |
23 | | medical
providers for physician services, inpatient and |
24 | | outpatient hospital care,
home health services, treatment for |
25 | | alcoholism and substance abuse, and
other services determined |
26 | | necessary by the Illinois Department by rule for
delivery by |
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1 | | Partnerships. Physician services must include prenatal and
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2 | | obstetrical care. The Illinois Department shall reimburse |
3 | | medical services
delivered by Partnership providers to clients |
4 | | in target areas according to
provisions of this Article and the |
5 | | Illinois Health Finance Reform Act,
except that:
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6 | | (1) Physicians participating in a Partnership and |
7 | | providing certain
services, which shall be determined by |
8 | | the Illinois Department, to persons
in areas covered by the |
9 | | Partnership may receive an additional surcharge
for such |
10 | | services.
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11 | | (2) The Department may elect to consider and negotiate |
12 | | financial
incentives to encourage the development of |
13 | | Partnerships and the efficient
delivery of medical care.
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14 | | (3) Persons receiving medical services through |
15 | | Partnerships may receive
medical and case management |
16 | | services above the level usually offered
through the |
17 | | medical assistance program.
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18 | | Medical providers shall be required to meet certain |
19 | | qualifications to
participate in Partnerships to ensure the |
20 | | delivery of high quality medical
services. These |
21 | | qualifications shall be determined by rule of the Illinois
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22 | | Department and may be higher than qualifications for |
23 | | participation in the
medical assistance program. Partnership |
24 | | sponsors may prescribe reasonable
additional qualifications |
25 | | for participation by medical providers, only with
the prior |
26 | | written approval of the Illinois Department.
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1 | | Nothing in this Section shall limit the free choice of |
2 | | practitioners,
hospitals, and other providers of medical |
3 | | services by clients.
In order to ensure patient freedom of |
4 | | choice, the Illinois Department shall
immediately promulgate |
5 | | all rules and take all other necessary actions so that
provided |
6 | | services may be accessed from therapeutically certified |
7 | | optometrists
to the full extent of the Illinois Optometric |
8 | | Practice Act of 1987 without
discriminating between service |
9 | | providers.
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10 | | The Department shall apply for a waiver from the United |
11 | | States Health
Care Financing Administration to allow for the |
12 | | implementation of
Partnerships under this Section.
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13 | | The Illinois Department shall require health care |
14 | | providers to maintain
records that document the medical care |
15 | | and services provided to recipients
of Medical Assistance under |
16 | | this Article. Such records must be retained for a period of not |
17 | | less than 6 years from the date of service or as provided by |
18 | | applicable State law, whichever period is longer, except that |
19 | | if an audit is initiated within the required retention period |
20 | | then the records must be retained until the audit is completed |
21 | | and every exception is resolved. The Illinois Department shall
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22 | | require health care providers to make available, when |
23 | | authorized by the
patient, in writing, the medical records in a |
24 | | timely fashion to other
health care providers who are treating |
25 | | or serving persons eligible for
Medical Assistance under this |
26 | | Article. All dispensers of medical services
shall be required |
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1 | | to maintain and retain business and professional records
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2 | | sufficient to fully and accurately document the nature, scope, |
3 | | details and
receipt of the health care provided to persons |
4 | | eligible for medical
assistance under this Code, in accordance |
5 | | with regulations promulgated by
the Illinois Department. The |
6 | | rules and regulations shall require that proof
of the receipt |
7 | | of prescription drugs, dentures, prosthetic devices and
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8 | | eyeglasses by eligible persons under this Section accompany |
9 | | each claim
for reimbursement submitted by the dispenser of such |
10 | | medical services.
No such claims for reimbursement shall be |
11 | | approved for payment by the Illinois
Department without such |
12 | | proof of receipt, unless the Illinois Department
shall have put |
13 | | into effect and shall be operating a system of post-payment
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14 | | audit and review which shall, on a sampling basis, be deemed |
15 | | adequate by
the Illinois Department to assure that such drugs, |
16 | | dentures, prosthetic
devices and eyeglasses for which payment |
17 | | is being made are actually being
received by eligible |
18 | | recipients. Within 90 days after the effective date of
this |
19 | | amendatory Act of 1984, the Illinois Department shall establish |
20 | | a
current list of acquisition costs for all prosthetic devices |
21 | | and any
other items recognized as medical equipment and |
22 | | supplies reimbursable under
this Article and shall update such |
23 | | list on a quarterly basis, except that
the acquisition costs of |
24 | | all prescription drugs shall be updated no
less frequently than |
25 | | every 30 days as required by Section 5-5.12.
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26 | | The rules and regulations of the Illinois Department shall |
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1 | | require
that a written statement including the required opinion |
2 | | of a physician
shall accompany any claim for reimbursement for |
3 | | abortions, or induced
miscarriages or premature births. This |
4 | | statement shall indicate what
procedures were used in providing |
5 | | such medical services.
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6 | | Notwithstanding any other law to the contrary, the Illinois |
7 | | Department shall, within 365 days after July 22, 2013 , (the |
8 | | effective date of Public Act 98-104), establish procedures to |
9 | | permit skilled care facilities licensed under the Nursing Home |
10 | | Care Act to submit monthly billing claims for reimbursement |
11 | | purposes. Following development of these procedures, the |
12 | | Department shall have an additional 365 days to test the |
13 | | viability of the new system and to ensure that any necessary |
14 | | operational or structural changes to its information |
15 | | technology platforms are implemented. |
16 | | Notwithstanding any other law to the contrary, the Illinois |
17 | | Department shall, within 365 days after August 15, 2014 ( the |
18 | | effective date of Public Act 98-963) this amendatory Act of the |
19 | | 98th General Assembly , establish procedures to permit ID/DD |
20 | | facilities licensed under the ID/DD Community Care Act to |
21 | | submit monthly billing claims for reimbursement purposes. |
22 | | Following development of these procedures, the Department |
23 | | shall have an additional 365 days to test the viability of the |
24 | | new system and to ensure that any necessary operational or |
25 | | structural changes to its information technology platforms are |
26 | | implemented. |
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1 | | The Illinois Department shall require all dispensers of |
2 | | medical
services, other than an individual practitioner or |
3 | | group of practitioners,
desiring to participate in the Medical |
4 | | Assistance program
established under this Article to disclose |
5 | | all financial, beneficial,
ownership, equity, surety or other |
6 | | interests in any and all firms,
corporations, partnerships, |
7 | | associations, business enterprises, joint
ventures, agencies, |
8 | | institutions or other legal entities providing any
form of |
9 | | health care services in this State under this Article.
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10 | | The Illinois Department may require that all dispensers of |
11 | | medical
services desiring to participate in the medical |
12 | | assistance program
established under this Article disclose, |
13 | | under such terms and conditions as
the Illinois Department may |
14 | | by rule establish, all inquiries from clients
and attorneys |
15 | | regarding medical bills paid by the Illinois Department, which
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16 | | inquiries could indicate potential existence of claims or liens |
17 | | for the
Illinois Department.
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18 | | Enrollment of a vendor
shall be
subject to a provisional |
19 | | period and shall be conditional for one year. During the period |
20 | | of conditional enrollment, the Department may
terminate the |
21 | | vendor's eligibility to participate in, or may disenroll the |
22 | | vendor from, the medical assistance
program without cause. |
23 | | Unless otherwise specified, such termination of eligibility or |
24 | | disenrollment is not subject to the
Department's hearing |
25 | | process.
However, a disenrolled vendor may reapply without |
26 | | penalty.
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1 | | The Department has the discretion to limit the conditional |
2 | | enrollment period for vendors based upon category of risk of |
3 | | the vendor. |
4 | | Prior to enrollment and during the conditional enrollment |
5 | | period in the medical assistance program, all vendors shall be |
6 | | subject to enhanced oversight, screening, and review based on |
7 | | the risk of fraud, waste, and abuse that is posed by the |
8 | | category of risk of the vendor. The Illinois Department shall |
9 | | establish the procedures for oversight, screening, and review, |
10 | | which may include, but need not be limited to: criminal and |
11 | | financial background checks; fingerprinting; license, |
12 | | certification, and authorization verifications; unscheduled or |
13 | | unannounced site visits; database checks; prepayment audit |
14 | | reviews; audits; payment caps; payment suspensions; and other |
15 | | screening as required by federal or State law. |
16 | | The Department shall define or specify the following: (i) |
17 | | by provider notice, the "category of risk of the vendor" for |
18 | | each type of vendor, which shall take into account the level of |
19 | | screening applicable to a particular category of vendor under |
20 | | federal law and regulations; (ii) by rule or provider notice, |
21 | | the maximum length of the conditional enrollment period for |
22 | | each category of risk of the vendor; and (iii) by rule, the |
23 | | hearing rights, if any, afforded to a vendor in each category |
24 | | of risk of the vendor that is terminated or disenrolled during |
25 | | the conditional enrollment period. |
26 | | To be eligible for payment consideration, a vendor's |
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1 | | payment claim or bill, either as an initial claim or as a |
2 | | resubmitted claim following prior rejection, must be received |
3 | | by the Illinois Department, or its fiscal intermediary, no |
4 | | later than 180 days after the latest date on the claim on which |
5 | | medical goods or services were provided, with the following |
6 | | exceptions: |
7 | | (1) In the case of a provider whose enrollment is in |
8 | | process by the Illinois Department, the 180-day period |
9 | | shall not begin until the date on the written notice from |
10 | | the Illinois Department that the provider enrollment is |
11 | | complete. |
12 | | (2) In the case of errors attributable to the Illinois |
13 | | Department or any of its claims processing intermediaries |
14 | | which result in an inability to receive, process, or |
15 | | adjudicate a claim, the 180-day period shall not begin |
16 | | until the provider has been notified of the error. |
17 | | (3) In the case of a provider for whom the Illinois |
18 | | Department initiates the monthly billing process. |
19 | | (4) In the case of a provider operated by a unit of |
20 | | local government with a population exceeding 3,000,000 |
21 | | when local government funds finance federal participation |
22 | | for claims payments. |
23 | | For claims for services rendered during a period for which |
24 | | a recipient received retroactive eligibility, claims must be |
25 | | filed within 180 days after the Department determines the |
26 | | applicant is eligible. For claims for which the Illinois |
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1 | | Department is not the primary payer, claims must be submitted |
2 | | to the Illinois Department within 180 days after the final |
3 | | adjudication by the primary payer. |
4 | | In the case of long term care facilities, within 5 days of |
5 | | receipt by the facility of required prescreening information, |
6 | | data for new admissions shall be entered into the Medical |
7 | | Electronic Data Interchange (MEDI) or the Recipient |
8 | | Eligibility Verification (REV) System or successor system, and |
9 | | within 15 days of receipt by the facility of required |
10 | | prescreening information, admission documents shall be |
11 | | submitted through MEDI or REV or shall be submitted directly to |
12 | | the Department of Human Services using required admission |
13 | | forms. Effective September
1, 2014, admission documents, |
14 | | including all prescreening
information, must be submitted |
15 | | through MEDI or REV. Confirmation numbers assigned to an |
16 | | accepted transaction shall be retained by a facility to verify |
17 | | timely submittal. Once an admission transaction has been |
18 | | completed, all resubmitted claims following prior rejection |
19 | | are subject to receipt no later than 180 days after the |
20 | | admission transaction has been completed. |
21 | | Claims that are not submitted and received in compliance |
22 | | with the foregoing requirements shall not be eligible for |
23 | | payment under the medical assistance program, and the State |
24 | | shall have no liability for payment of those claims. |
25 | | To the extent consistent with applicable information and |
26 | | privacy, security, and disclosure laws, State and federal |
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1 | | agencies and departments shall provide the Illinois Department |
2 | | access to confidential and other information and data necessary |
3 | | to perform eligibility and payment verifications and other |
4 | | Illinois Department functions. This includes, but is not |
5 | | limited to: information pertaining to licensure; |
6 | | certification; earnings; immigration status; citizenship; wage |
7 | | reporting; unearned and earned income; pension income; |
8 | | employment; supplemental security income; social security |
9 | | numbers; National Provider Identifier (NPI) numbers; the |
10 | | National Practitioner Data Bank (NPDB); program and agency |
11 | | exclusions; taxpayer identification numbers; tax delinquency; |
12 | | corporate information; and death records. |
13 | | The Illinois Department shall enter into agreements with |
14 | | State agencies and departments, and is authorized to enter into |
15 | | agreements with federal agencies and departments, under which |
16 | | such agencies and departments shall share data necessary for |
17 | | medical assistance program integrity functions and oversight. |
18 | | The Illinois Department shall develop, in cooperation with |
19 | | other State departments and agencies, and in compliance with |
20 | | applicable federal laws and regulations, appropriate and |
21 | | effective methods to share such data. At a minimum, and to the |
22 | | extent necessary to provide data sharing, the Illinois |
23 | | Department shall enter into agreements with State agencies and |
24 | | departments, and is authorized to enter into agreements with |
25 | | federal agencies and departments, including but not limited to: |
26 | | the Secretary of State; the Department of Revenue; the |
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1 | | Department of Public Health; the Department of Human Services; |
2 | | and the Department of Financial and Professional Regulation. |
3 | | Beginning in fiscal year 2013, the Illinois Department |
4 | | shall set forth a request for information to identify the |
5 | | benefits of a pre-payment, post-adjudication, and post-edit |
6 | | claims system with the goals of streamlining claims processing |
7 | | and provider reimbursement, reducing the number of pending or |
8 | | rejected claims, and helping to ensure a more transparent |
9 | | adjudication process through the utilization of: (i) provider |
10 | | data verification and provider screening technology; and (ii) |
11 | | clinical code editing; and (iii) pre-pay, pre- or |
12 | | post-adjudicated predictive modeling with an integrated case |
13 | | management system with link analysis. Such a request for |
14 | | information shall not be considered as a request for proposal |
15 | | or as an obligation on the part of the Illinois Department to |
16 | | take any action or acquire any products or services. |
17 | | The Illinois Department shall establish policies, |
18 | | procedures,
standards and criteria by rule for the acquisition, |
19 | | repair and replacement
of orthotic and prosthetic devices and |
20 | | durable medical equipment. Such
rules shall provide, but not be |
21 | | limited to, the following services: (1)
immediate repair or |
22 | | replacement of such devices by recipients; and (2) rental, |
23 | | lease, purchase or lease-purchase of
durable medical equipment |
24 | | in a cost-effective manner, taking into
consideration the |
25 | | recipient's medical prognosis, the extent of the
recipient's |
26 | | needs, and the requirements and costs for maintaining such
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1 | | equipment. Subject to prior approval, such rules shall enable a |
2 | | recipient to temporarily acquire and
use alternative or |
3 | | substitute devices or equipment pending repairs or
|
4 | | replacements of any device or equipment previously authorized |
5 | | for such
recipient by the Department.
|
6 | | The Department shall execute, relative to the nursing home |
7 | | prescreening
project, written inter-agency agreements with the |
8 | | Department of Human
Services and the Department on Aging, to |
9 | | effect the following: (i) intake
procedures and common |
10 | | eligibility criteria for those persons who are receiving
|
11 | | non-institutional services; and (ii) the establishment and |
12 | | development of
non-institutional services in areas of the State |
13 | | where they are not currently
available or are undeveloped; and |
14 | | (iii) notwithstanding any other provision of law, subject to |
15 | | federal approval, on and after July 1, 2012, an increase in the |
16 | | determination of need (DON) scores from 29 to 37 for applicants |
17 | | for institutional and home and community-based long term care; |
18 | | if and only if federal approval is not granted, the Department |
19 | | may, in conjunction with other affected agencies, implement |
20 | | utilization controls or changes in benefit packages to |
21 | | effectuate a similar savings amount for this population; and |
22 | | (iv) no later than July 1, 2013, minimum level of care |
23 | | eligibility criteria for institutional and home and |
24 | | community-based long term care; and (v) no later than October |
25 | | 1, 2013, establish procedures to permit long term care |
26 | | providers access to eligibility scores for individuals with an |
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1 | | admission date who are seeking or receiving services from the |
2 | | long term care provider. In order to select the minimum level |
3 | | of care eligibility criteria, the Governor shall establish a |
4 | | workgroup that includes affected agency representatives and |
5 | | stakeholders representing the institutional and home and |
6 | | community-based long term care interests. This Section shall |
7 | | not restrict the Department from implementing lower level of |
8 | | care eligibility criteria for community-based services in |
9 | | circumstances where federal approval has been granted.
|
10 | | The Illinois Department shall develop and operate, in |
11 | | cooperation
with other State Departments and agencies and in |
12 | | compliance with
applicable federal laws and regulations, |
13 | | appropriate and effective
systems of health care evaluation and |
14 | | programs for monitoring of
utilization of health care services |
15 | | and facilities, as it affects
persons eligible for medical |
16 | | assistance under this Code.
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17 | | The Illinois Department shall report annually to the |
18 | | General Assembly,
no later than the second Friday in April of |
19 | | 1979 and each year
thereafter, in regard to:
|
20 | | (a) actual statistics and trends in utilization of |
21 | | medical services by
public aid recipients;
|
22 | | (b) actual statistics and trends in the provision of |
23 | | the various medical
services by medical vendors;
|
24 | | (c) current rate structures and proposed changes in |
25 | | those rate structures
for the various medical vendors; and
|
26 | | (d) efforts at utilization review and control by the |
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1 | | Illinois Department.
|
2 | | The period covered by each report shall be the 3 years |
3 | | ending on the June
30 prior to the report. The report shall |
4 | | include suggested legislation
for consideration by the General |
5 | | Assembly. The filing of one copy of the
report with the |
6 | | Speaker, one copy with the Minority Leader and one copy
with |
7 | | the Clerk of the House of Representatives, one copy with the |
8 | | President,
one copy with the Minority Leader and one copy with |
9 | | the Secretary of the
Senate, one copy with the Legislative |
10 | | Research Unit, and such additional
copies
with the State |
11 | | Government Report Distribution Center for the General
Assembly |
12 | | as is required under paragraph (t) of Section 7 of the State
|
13 | | Library Act shall be deemed sufficient to comply with this |
14 | | Section.
|
15 | | Rulemaking authority to implement Public Act 95-1045, if |
16 | | any, is conditioned on the rules being adopted in accordance |
17 | | with all provisions of the Illinois Administrative Procedure |
18 | | Act and all rules and procedures of the Joint Committee on |
19 | | Administrative Rules; any purported rule not so adopted, for |
20 | | whatever reason, is unauthorized. |
21 | | On and after July 1, 2012, the Department shall reduce any |
22 | | rate of reimbursement for services or other payments or alter |
23 | | any methodologies authorized by this Code to reduce any rate of |
24 | | reimbursement for services or other payments in accordance with |
25 | | Section 5-5e. |
26 | | Because kidney transplantation can be an appropriate, cost |
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1 | | effective
alternative to renal dialysis when medically |
2 | | necessary and notwithstanding the provisions of Section 1-11 of |
3 | | this Code, beginning October 1, 2014, the Department shall |
4 | | cover kidney transplantation for noncitizens with end-stage |
5 | | renal disease who are not eligible for comprehensive medical |
6 | | benefits, who meet the residency requirements of Section 5-3 of |
7 | | this Code, and who would otherwise meet the financial |
8 | | requirements of the appropriate class of eligible persons under |
9 | | Section 5-2 of this Code. To qualify for coverage of kidney |
10 | | transplantation, such person must be receiving emergency renal |
11 | | dialysis services covered by the Department. Providers under |
12 | | this Section shall be prior approved and certified by the |
13 | | Department to perform kidney transplantation and the services |
14 | | under this Section shall be limited to services associated with |
15 | | kidney transplantation. |
16 | | (Source: P.A. 97-48, eff. 6-28-11; 97-638, eff. 1-1-12; 97-689, |
17 | | eff. 6-14-12; 97-1061, eff. 8-24-12; 98-104, Article 9, Section |
18 | | 9-5, eff. 7-22-13; 98-104, Article 12, Section 12-20, eff. |
19 | | 7-22-13; 98-303, eff. 8-9-13; 98-463, eff. 8-16-13; 98-651, |
20 | | eff. 6-16-14; 98-756, eff. 7-16-14; 98-963, eff. 8-15-14; |
21 | | revised 10-2-14.)".
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