Sen. John G. Mulroe

Filed: 4/15/2016

 

 


 

 


 
09900SB0466sam001LRB099 03184 EGJ 47643 a

1
AMENDMENT TO SENATE BILL 466

2    AMENDMENT NO. ______. Amend Senate Bill 466 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Insurance Code is amended by
5changing Section 356g as follows:
 
6    (215 ILCS 5/356g)  (from Ch. 73, par. 968g)
7    (Text of Section before amendment by P.A. 99-407)
8    Sec. 356g. Mammograms; mastectomies.
9    (a) Every insurer shall provide in each group or individual
10policy, contract, or certificate of insurance issued or renewed
11for persons who are residents of this State, coverage for
12screening by low-dose mammography for all women 35 years of age
13or older for the presence of occult breast cancer within the
14provisions of the policy, contract, or certificate. The
15coverage shall be as follows:
16         (1) A baseline mammogram for women 35 to 39 years of

 

 

09900SB0466sam001- 2 -LRB099 03184 EGJ 47643 a

1    age.
2         (2) An annual mammogram for women 40 years of age or
3    older.
4         (3) A mammogram at the age and intervals considered
5    medically necessary by the woman's health care provider for
6    women under 40 years of age and having a family history of
7    breast cancer, prior personal history of breast cancer,
8    positive genetic testing, or other risk factors.
9        (4) A comprehensive ultrasound screening of an entire
10    breast or breasts if a mammogram demonstrates
11    heterogeneous or dense breast tissue, when medically
12    necessary as determined by a physician licensed to practice
13    medicine in all of its branches.
14        (5) A screening MRI when medically necessary, as
15    determined by a physician licensed to practice medicine in
16    all of its branches.
17    For purposes of this Section, "low-dose mammography" means
18the x-ray examination of the breast using equipment dedicated
19specifically for mammography, including the x-ray tube,
20filter, compression device, and image receptor, with radiation
21exposure delivery of less than 1 rad per breast for 2 views of
22an average size breast. The term also includes digital
23mammography.
24    (a-5) Coverage as described by subsection (a) shall be
25provided at no cost to the insured and shall not be applied to
26an annual or lifetime maximum benefit.

 

 

09900SB0466sam001- 3 -LRB099 03184 EGJ 47643 a

1    (a-10) When health care services are available through
2contracted providers and a person does not comply with plan
3provisions specific to the use of contracted providers, the
4requirements of subsection (a-5) are not applicable. When a
5person does not comply with plan provisions specific to the use
6of contracted providers, plan provisions specific to the use of
7non-contracted providers must be applied without distinction
8for coverage required by this Section and shall be at least as
9favorable as for other radiological examinations covered by the
10policy or contract.
11    (b) No policy of accident or health insurance that provides
12for the surgical procedure known as a mastectomy shall be
13issued, amended, delivered, or renewed in this State unless
14that coverage also provides for prosthetic devices or
15reconstructive surgery incident to the mastectomy. Coverage
16for breast reconstruction in connection with a mastectomy shall
17include:
18        (1) reconstruction of the breast upon which the
19    mastectomy has been performed;
20        (2) surgery and reconstruction of the other breast to
21    produce a symmetrical appearance; and
22        (3) prostheses and treatment for physical
23    complications at all stages of mastectomy, including
24    lymphedemas.
25Care shall be determined in consultation with the attending
26physician and the patient. The offered coverage for prosthetic

 

 

09900SB0466sam001- 4 -LRB099 03184 EGJ 47643 a

1devices and reconstructive surgery shall be subject to the
2deductible and coinsurance conditions applied to the
3mastectomy, and all other terms and conditions applicable to
4other benefits. When a mastectomy is performed and there is no
5evidence of malignancy then the offered coverage may be limited
6to the provision of prosthetic devices and reconstructive
7surgery to within 2 years after the date of the mastectomy. As
8used in this Section, "mastectomy" means the removal of all or
9part of the breast for medically necessary reasons, as
10determined by a licensed physician.
11    Written notice of the availability of coverage under this
12Section shall be delivered to the insured upon enrollment and
13annually thereafter. An insurer may not deny to an insured
14eligibility, or continued eligibility, to enroll or to renew
15coverage under the terms of the plan solely for the purpose of
16avoiding the requirements of this Section. An insurer may not
17penalize or reduce or limit the reimbursement of an attending
18provider or provide incentives (monetary or otherwise) to an
19attending provider to induce the provider to provide care to an
20insured in a manner inconsistent with this Section.
21    (c) Rulemaking authority to implement Public Act 95-1045
22this amendatory Act of the 95th General Assembly, if any, is
23conditioned on the rules being adopted in accordance with all
24provisions of the Illinois Administrative Procedure Act and all
25rules and procedures of the Joint Committee on Administrative
26Rules; any purported rule not so adopted, for whatever reason,

 

 

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1is unauthorized.
2(Source: P.A. 99-433, eff. 8-21-15; revised 10-20-15.)
 
3    (Text of Section after amendment by P.A. 99-407)
4    Sec. 356g. Mammograms; mastectomies.
5    (a) Every insurer shall provide in each group or individual
6policy, contract, or certificate of insurance issued or renewed
7for persons who are residents of this State, coverage for
8screening by low-dose mammography for all women 35 years of age
9or older for the presence of occult breast cancer within the
10provisions of the policy, contract, or certificate. The
11coverage shall be as follows:
12         (1) A baseline mammogram for women 35 to 39 years of
13    age.
14         (2) An annual mammogram for women 40 years of age or
15    older.
16         (3) A mammogram at the age and intervals considered
17    medically necessary by the woman's health care provider for
18    women under 40 years of age and having a family history of
19    breast cancer, prior personal history of breast cancer,
20    positive genetic testing, or other risk factors.
21        (4) A comprehensive ultrasound screening of an entire
22    breast or breasts if a mammogram demonstrates
23    heterogeneous or dense breast tissue, when medically
24    necessary as determined by a physician licensed to practice
25    medicine in all of its branches.

 

 

09900SB0466sam001- 6 -LRB099 03184 EGJ 47643 a

1        (5) A screening MRI when medically necessary, as
2    determined by a physician licensed to practice medicine in
3    all of its branches.
4    For purposes of this Section, "low-dose mammography" means
5the x-ray examination of the breast using equipment dedicated
6specifically for mammography, including the x-ray tube,
7filter, compression device, and image receptor, with radiation
8exposure delivery of less than 1 rad per breast for 2 views of
9an average size breast. The term also includes digital
10mammography and includes breast tomosynthesis. As used in this
11Section, the term "breast tomosynthesis" means a radiologic
12procedure that involves the acquisition of projection images
13over the stationary breast to produce cross-sectional digital
14three-dimensional images of the breast.
15    If, at any time, the Secretary of the United States
16Department of Health and Human Services, or its successor
17agency, promulgates rules or regulations to be published in the
18Federal Register or publishes a comment in the Federal Register
19or issues an opinion, guidance, or other action that would
20require the State, pursuant to any provision of the Patient
21Protection and Affordable Care Act (Public Law 111-148),
22including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
23successor provision, to defray the cost of any coverage for
24screening by breast tomosynthesis outlined in this subsection,
25then the requirement that an insurer cover screening by breast
26tomosynthesis is inoperative other than any such coverage

 

 

09900SB0466sam001- 7 -LRB099 03184 EGJ 47643 a

1authorized under Section 1902 of the Social Security Act, 42
2U.S.C. 1396a, and the State shall not assume any obligation for
3the cost of coverage for screening by breast tomosynthesis set
4forth in this subsection.
5    (a-5) Coverage as described by subsection (a) shall be
6provided at no cost to the insured and shall not be applied to
7an annual or lifetime maximum benefit.
8    (a-10) When health care services are available through
9contracted providers and a person does not comply with plan
10provisions specific to the use of contracted providers, the
11requirements of subsection (a-5) are not applicable. When a
12person does not comply with plan provisions specific to the use
13of contracted providers, plan provisions specific to the use of
14non-contracted providers must be applied without distinction
15for coverage required by this Section and shall be at least as
16favorable as for other radiological examinations covered by the
17policy or contract.
18    (b) No policy of accident or health insurance that provides
19for the surgical procedure known as a mastectomy shall be
20issued, amended, delivered, or renewed in this State unless
21that coverage also provides for prosthetic devices or
22reconstructive surgery incident to the mastectomy. Coverage
23for breast reconstruction in connection with a mastectomy shall
24include:
25        (1) reconstruction of the breast upon which the
26    mastectomy has been performed;

 

 

09900SB0466sam001- 8 -LRB099 03184 EGJ 47643 a

1        (2) surgery and reconstruction of the other breast to
2    produce a symmetrical appearance; and
3        (3) prostheses and treatment for physical
4    complications at all stages of mastectomy, including
5    lymphedemas.
6Care shall be determined in consultation with the attending
7physician and the patient. The offered coverage for prosthetic
8devices and reconstructive surgery shall be subject to the
9deductible and coinsurance conditions applied to the
10mastectomy, and all other terms and conditions applicable to
11other benefits. When a mastectomy is performed and there is no
12evidence of malignancy then the offered coverage may be limited
13to the provision of prosthetic devices and reconstructive
14surgery to within 2 years after the date of the mastectomy. As
15used in this Section, "mastectomy" means the removal of all or
16part of the breast for medically necessary reasons, as
17determined by a licensed physician.
18    Written notice of the availability of coverage under this
19Section shall be delivered to the insured upon enrollment and
20annually thereafter. An insurer may not deny to an insured
21eligibility, or continued eligibility, to enroll or to renew
22coverage under the terms of the plan solely for the purpose of
23avoiding the requirements of this Section. An insurer may not
24penalize or reduce or limit the reimbursement of an attending
25provider or provide incentives (monetary or otherwise) to an
26attending provider to induce the provider to provide care to an

 

 

09900SB0466sam001- 9 -LRB099 03184 EGJ 47643 a

1insured in a manner inconsistent with this Section.
2    (c) Rulemaking authority to implement Public Act 95-1045
3this amendatory Act of the 95th General Assembly, if any, is
4conditioned on the rules being adopted in accordance with all
5provisions of the Illinois Administrative Procedure Act and all
6rules and procedures of the Joint Committee on Administrative
7Rules; any purported rule not so adopted, for whatever reason,
8is unauthorized.
9(Source: P.A. 99-407 (see Section 99 of P.A. 99-407 for its
10effective date); 99-433, eff. 8-21-15; revised 10-20-15.)
 
11    Section 10. The Health Maintenance Organization Act is
12amended by changing Section 4-6.1 as follows:
 
13    (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)
14    (Text of Section before amendment by P.A. 99-407)
15    Sec. 4-6.1. Mammograms; mastectomies.
16    (a) Every contract or evidence of coverage issued by a
17Health Maintenance Organization for persons who are residents
18of this State shall contain coverage for screening by low-dose
19mammography for all women 35 years of age or older for the
20presence of occult breast cancer. The coverage shall be as
21follows:
22        (1) A baseline mammogram for women 35 to 39 years of
23    age.
24        (2) An annual mammogram for women 40 years of age or

 

 

09900SB0466sam001- 10 -LRB099 03184 EGJ 47643 a

1    older.
2        (3) A mammogram at the age and intervals considered
3    medically necessary by the woman's health care provider for
4    women under 40 years of age and having a family history of
5    breast cancer, prior personal history of breast cancer,
6    positive genetic testing, or other risk factors.
7        (4) A comprehensive ultrasound screening of an entire
8    breast or breasts if a mammogram demonstrates
9    heterogeneous or dense breast tissue, when medically
10    necessary as determined by a physician licensed to practice
11    medicine in all of its branches.
12    For purposes of this Section, "low-dose mammography" means
13the x-ray examination of the breast using equipment dedicated
14specifically for mammography, including the x-ray tube,
15filter, compression device, and image receptor, with radiation
16exposure delivery of less than 1 rad per breast for 2 views of
17an average size breast. The term also includes digital
18mammography.
19    (a-5) Coverage as described in subsection (a) shall be
20provided at no cost to the enrollee and shall not be applied to
21an annual or lifetime maximum benefit.
22    (b) No contract or evidence of coverage issued by a health
23maintenance organization that provides for the surgical
24procedure known as a mastectomy shall be issued, amended,
25delivered, or renewed in this State on or after the effective
26date of this amendatory Act of the 92nd General Assembly unless

 

 

09900SB0466sam001- 11 -LRB099 03184 EGJ 47643 a

1that coverage also provides for prosthetic devices or
2reconstructive surgery incident to the mastectomy, providing
3that the mastectomy is performed after the effective date of
4this amendatory Act. Coverage for breast reconstruction in
5connection with a mastectomy shall include:
6        (1) reconstruction of the breast upon which the
7    mastectomy has been performed;
8        (2) surgery and reconstruction of the other breast to
9    produce a symmetrical appearance; and
10        (3) prostheses and treatment for physical
11    complications at all stages of mastectomy, including
12    lymphedemas.
13Care shall be determined in consultation with the attending
14physician and the patient. The offered coverage for prosthetic
15devices and reconstructive surgery shall be subject to the
16deductible and coinsurance conditions applied to the
17mastectomy and all other terms and conditions applicable to
18other benefits. When a mastectomy is performed and there is no
19evidence of malignancy, then the offered coverage may be
20limited to the provision of prosthetic devices and
21reconstructive surgery to within 2 years after the date of the
22mastectomy. As used in this Section, "mastectomy" means the
23removal of all or part of the breast for medically necessary
24reasons, as determined by a licensed physician.
25    Written notice of the availability of coverage under this
26Section shall be delivered to the enrollee upon enrollment and

 

 

09900SB0466sam001- 12 -LRB099 03184 EGJ 47643 a

1annually thereafter. A health maintenance organization may not
2deny to an enrollee eligibility, or continued eligibility, to
3enroll or to renew coverage under the terms of the plan solely
4for the purpose of avoiding the requirements of this Section. A
5health maintenance organization may not penalize or reduce or
6limit the reimbursement of an attending provider or provide
7incentives (monetary or otherwise) to an attending provider to
8induce the provider to provide care to an insured in a manner
9inconsistent with this Section.
10    (c) Rulemaking authority to implement this amendatory Act
11of the 95th General Assembly, if any, is conditioned on the
12rules being adopted in accordance with all provisions of the
13Illinois Administrative Procedure Act and all rules and
14procedures of the Joint Committee on Administrative Rules; any
15purported rule not so adopted, for whatever reason, is
16unauthorized.
17(Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07;
1895-1045, eff. 3-27-09.)
 
19    (Text of Section after amendment by P.A. 99-407)
20    Sec. 4-6.1. Mammograms; mastectomies.
21    (a) Every contract or evidence of coverage issued by a
22Health Maintenance Organization for persons who are residents
23of this State shall contain coverage for screening by low-dose
24mammography for all women 35 years of age or older for the
25presence of occult breast cancer. The coverage shall be as

 

 

09900SB0466sam001- 13 -LRB099 03184 EGJ 47643 a

1follows:
2        (1) A baseline mammogram for women 35 to 39 years of
3    age.
4        (2) An annual mammogram for women 40 years of age or
5    older.
6        (3) A mammogram at the age and intervals considered
7    medically necessary by the woman's health care provider for
8    women under 40 years of age and having a family history of
9    breast cancer, prior personal history of breast cancer,
10    positive genetic testing, or other risk factors.
11        (4) A comprehensive ultrasound screening of an entire
12    breast or breasts if a mammogram demonstrates
13    heterogeneous or dense breast tissue, when medically
14    necessary as determined by a physician licensed to practice
15    medicine in all of its branches.
16    For purposes of this Section, "low-dose mammography" means
17the x-ray examination of the breast using equipment dedicated
18specifically for mammography, including the x-ray tube,
19filter, compression device, and image receptor, with radiation
20exposure delivery of less than 1 rad per breast for 2 views of
21an average size breast. The term also includes digital
22mammography and includes breast tomosynthesis. As used in this
23Section, the term "breast tomosynthesis" means a radiologic
24procedure that involves the acquisition of projection images
25over the stationary breast to produce cross-sectional digital
26three-dimensional images of the breast.

 

 

09900SB0466sam001- 14 -LRB099 03184 EGJ 47643 a

1    If, at any time, the Secretary of the United States
2Department of Health and Human Services, or its successor
3agency, promulgates rules or regulations to be published in the
4Federal Register or publishes a comment in the Federal Register
5or issues an opinion, guidance, or other action that would
6require the State, pursuant to any provision of the Patient
7Protection and Affordable Care Act (Public Law 111-148),
8including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
9successor provision, to defray the cost of any coverage for
10screening by breast tomosynthesis outlined in this subsection,
11then the requirement that an insurer cover screening by breast
12tomosynthesis is inoperative other than any such coverage
13authorized under Section 1902 of the Social Security Act, 42
14U.S.C. 1396a, and the State shall not assume any obligation for
15the cost of coverage for screening by breast tomosynthesis set
16forth in this subsection.
17    (a-5) Coverage as described in subsection (a) shall be
18provided at no cost to the enrollee and shall not be applied to
19an annual or lifetime maximum benefit.
20    (b) No contract or evidence of coverage issued by a health
21maintenance organization that provides for the surgical
22procedure known as a mastectomy shall be issued, amended,
23delivered, or renewed in this State on or after the effective
24date of this amendatory Act of the 92nd General Assembly unless
25that coverage also provides for prosthetic devices or
26reconstructive surgery incident to the mastectomy, providing

 

 

09900SB0466sam001- 15 -LRB099 03184 EGJ 47643 a

1that the mastectomy is performed after the effective date of
2this amendatory Act. Coverage for breast reconstruction in
3connection with a mastectomy shall include:
4        (1) reconstruction of the breast upon which the
5    mastectomy has been performed;
6        (2) surgery and reconstruction of the other breast to
7    produce a symmetrical appearance; and
8        (3) prostheses and treatment for physical
9    complications at all stages of mastectomy, including
10    lymphedemas.
11Care shall be determined in consultation with the attending
12physician and the patient. The offered coverage for prosthetic
13devices and reconstructive surgery shall be subject to the
14deductible and coinsurance conditions applied to the
15mastectomy and all other terms and conditions applicable to
16other benefits. When a mastectomy is performed and there is no
17evidence of malignancy, then the offered coverage may be
18limited to the provision of prosthetic devices and
19reconstructive surgery to within 2 years after the date of the
20mastectomy. As used in this Section, "mastectomy" means the
21removal of all or part of the breast for medically necessary
22reasons, as determined by a licensed physician.
23    Written notice of the availability of coverage under this
24Section shall be delivered to the enrollee upon enrollment and
25annually thereafter. A health maintenance organization may not
26deny to an enrollee eligibility, or continued eligibility, to

 

 

09900SB0466sam001- 16 -LRB099 03184 EGJ 47643 a

1enroll or to renew coverage under the terms of the plan solely
2for the purpose of avoiding the requirements of this Section. A
3health maintenance organization may not penalize or reduce or
4limit the reimbursement of an attending provider or provide
5incentives (monetary or otherwise) to an attending provider to
6induce the provider to provide care to an insured in a manner
7inconsistent with this Section.
8    (c) Rulemaking authority to implement this amendatory Act
9of the 95th General Assembly, if any, is conditioned on the
10rules being adopted in accordance with all provisions of the
11Illinois Administrative Procedure Act and all rules and
12procedures of the Joint Committee on Administrative Rules; any
13purported rule not so adopted, for whatever reason, is
14unauthorized.
15(Source: P.A. 99-407 (see Section 99 of P.A. 99-407 for its
16effective date).)
 
17    Section 15. The Illinois Public Aid Code is amended by
18changing Section 5-5 as follows:
 
19    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
20    (Text of Section before amendment by P.A. 99-407)
21    Sec. 5-5. Medical services. The Illinois Department, by
22rule, shall determine the quantity and quality of and the rate
23of reimbursement for the medical assistance for which payment
24will be authorized, and the medical services to be provided,

 

 

09900SB0466sam001- 17 -LRB099 03184 EGJ 47643 a

1which may include all or part of the following: (1) inpatient
2hospital services; (2) outpatient hospital services; (3) other
3laboratory and X-ray services; (4) skilled nursing home
4services; (5) physicians' services whether furnished in the
5office, the patient's home, a hospital, a skilled nursing home,
6or elsewhere; (6) medical care, or any other type of remedial
7care furnished by licensed practitioners; (7) home health care
8services; (8) private duty nursing service; (9) clinic
9services; (10) dental services, including prevention and
10treatment of periodontal disease and dental caries disease for
11pregnant women, provided by an individual licensed to practice
12dentistry or dental surgery; for purposes of this item (10),
13"dental services" means diagnostic, preventive, or corrective
14procedures provided by or under the supervision of a dentist in
15the practice of his or her profession; (11) physical therapy
16and related services; (12) prescribed drugs, dentures, and
17prosthetic devices; and eyeglasses prescribed by a physician
18skilled in the diseases of the eye, or by an optometrist,
19whichever the person may select; (13) other diagnostic,
20screening, preventive, and rehabilitative services, including
21to ensure that the individual's need for intervention or
22treatment of mental disorders or substance use disorders or
23co-occurring mental health and substance use disorders is
24determined using a uniform screening, assessment, and
25evaluation process inclusive of criteria, for children and
26adults; for purposes of this item (13), a uniform screening,

 

 

09900SB0466sam001- 18 -LRB099 03184 EGJ 47643 a

1assessment, and evaluation process refers to a process that
2includes an appropriate evaluation and, as warranted, a
3referral; "uniform" does not mean the use of a singular
4instrument, tool, or process that all must utilize; (14)
5transportation and such other expenses as may be necessary;
6(15) medical treatment of sexual assault survivors, as defined
7in Section 1a of the Sexual Assault Survivors Emergency
8Treatment Act, for injuries sustained as a result of the sexual
9assault, including examinations and laboratory tests to
10discover evidence which may be used in criminal proceedings
11arising from the sexual assault; (16) the diagnosis and
12treatment of sickle cell anemia; and (17) any other medical
13care, and any other type of remedial care recognized under the
14laws of this State, but not including abortions, or induced
15miscarriages or premature births, unless, in the opinion of a
16physician, such procedures are necessary for the preservation
17of the life of the woman seeking such treatment, or except an
18induced premature birth intended to produce a live viable child
19and such procedure is necessary for the health of the mother or
20her unborn child. The Illinois Department, by rule, shall
21prohibit any physician from providing medical assistance to
22anyone eligible therefor under this Code where such physician
23has been found guilty of performing an abortion procedure in a
24wilful and wanton manner upon a woman who was not pregnant at
25the time such abortion procedure was performed. The term "any
26other type of remedial care" shall include nursing care and

 

 

09900SB0466sam001- 19 -LRB099 03184 EGJ 47643 a

1nursing home service for persons who rely on treatment by
2spiritual means alone through prayer for healing.
3    Notwithstanding any other provision of this Section, a
4comprehensive tobacco use cessation program that includes
5purchasing prescription drugs or prescription medical devices
6approved by the Food and Drug Administration shall be covered
7under the medical assistance program under this Article for
8persons who are otherwise eligible for assistance under this
9Article.
10    Notwithstanding any other provision of this Code, the
11Illinois Department may not require, as a condition of payment
12for any laboratory test authorized under this Article, that a
13physician's handwritten signature appear on the laboratory
14test order form. The Illinois Department may, however, impose
15other appropriate requirements regarding laboratory test order
16documentation.
17    Upon receipt of federal approval of an amendment to the
18Illinois Title XIX State Plan for this purpose, the Department
19shall authorize the Chicago Public Schools (CPS) to procure a
20vendor or vendors to manufacture eyeglasses for individuals
21enrolled in a school within the CPS system. CPS shall ensure
22that its vendor or vendors are enrolled as providers in the
23medical assistance program and in any capitated Medicaid
24managed care entity (MCE) serving individuals enrolled in a
25school within the CPS system. Under any contract procured under
26this provision, the vendor or vendors must serve only

 

 

09900SB0466sam001- 20 -LRB099 03184 EGJ 47643 a

1individuals enrolled in a school within the CPS system. Claims
2for services provided by CPS's vendor or vendors to recipients
3of benefits in the medical assistance program under this Code,
4the Children's Health Insurance Program, or the Covering ALL
5KIDS Health Insurance Program shall be submitted to the
6Department or the MCE in which the individual is enrolled for
7payment and shall be reimbursed at the Department's or the
8MCE's established rates or rate methodologies for eyeglasses.
9    On and after July 1, 2012, the Department of Healthcare and
10Family Services may provide the following services to persons
11eligible for assistance under this Article who are
12participating in education, training or employment programs
13operated by the Department of Human Services as successor to
14the Department of Public Aid:
15        (1) dental services provided by or under the
16    supervision of a dentist; and
17        (2) eyeglasses prescribed by a physician skilled in the
18    diseases of the eye, or by an optometrist, whichever the
19    person may select.
20    Notwithstanding any other provision of this Code and
21subject to federal approval, the Department may adopt rules to
22allow a dentist who is volunteering his or her service at no
23cost to render dental services through an enrolled
24not-for-profit health clinic without the dentist personally
25enrolling as a participating provider in the medical assistance
26program. A not-for-profit health clinic shall include a public

 

 

09900SB0466sam001- 21 -LRB099 03184 EGJ 47643 a

1health clinic or Federally Qualified Health Center or other
2enrolled provider, as determined by the Department, through
3which dental services covered under this Section are performed.
4The Department shall establish a process for payment of claims
5for reimbursement for covered dental services rendered under
6this provision.
7    The Illinois Department, by rule, may distinguish and
8classify the medical services to be provided only in accordance
9with the classes of persons designated in Section 5-2.
10    The Department of Healthcare and Family Services must
11provide coverage and reimbursement for amino acid-based
12elemental formulas, regardless of delivery method, for the
13diagnosis and treatment of (i) eosinophilic disorders and (ii)
14short bowel syndrome when the prescribing physician has issued
15a written order stating that the amino acid-based elemental
16formula is medically necessary.
17    The Illinois Department shall authorize the provision of,
18and shall authorize payment for, screening by low-dose
19mammography for the presence of occult breast cancer for women
2035 years of age or older who are eligible for medical
21assistance under this Article, as follows:
22        (A) A baseline mammogram for women 35 to 39 years of
23    age.
24        (B) An annual mammogram for women 40 years of age or
25    older.
26        (C) A mammogram at the age and intervals considered

 

 

09900SB0466sam001- 22 -LRB099 03184 EGJ 47643 a

1    medically necessary by the woman's health care provider for
2    women under 40 years of age and having a family history of
3    breast cancer, prior personal history of breast cancer,
4    positive genetic testing, or other risk factors.
5        (D) A comprehensive ultrasound screening of an entire
6    breast or breasts if a mammogram demonstrates
7    heterogeneous or dense breast tissue, when medically
8    necessary as determined by a physician licensed to practice
9    medicine in all of its branches.
10        (E) A screening MRI when medically necessary, as
11    determined by a physician licensed to practice medicine in
12    all of its branches.
13    All screenings shall include a physical breast exam,
14instruction on self-examination and information regarding the
15frequency of self-examination and its value as a preventative
16tool. For purposes of this Section, "low-dose mammography"
17means the x-ray examination of the breast using equipment
18dedicated specifically for mammography, including the x-ray
19tube, filter, compression device, and image receptor, with an
20average radiation exposure delivery of less than one rad per
21breast for 2 views of an average size breast. The term also
22includes digital mammography.
23    On and after January 1, 2016, the Department shall ensure
24that all networks of care for adult clients of the Department
25include access to at least one breast imaging Center of Imaging
26Excellence as certified by the American College of Radiology.

 

 

09900SB0466sam001- 23 -LRB099 03184 EGJ 47643 a

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

 

 

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1Department shall report to the General Assembly on the status
2of the provision set forth in this paragraph.
3    The Department shall establish a methodology to remind
4women who are age-appropriate for screening mammography, but
5who have not received a mammogram within the previous 18
6months, of the importance and benefit of screening mammography.
7The Department shall work with experts in breast cancer
8outreach and patient navigation to optimize these reminders and
9shall establish a methodology for evaluating their
10effectiveness and modifying the methodology based on the
11evaluation.
12    The Department shall establish a performance goal for
13primary care providers with respect to their female patients
14over age 40 receiving an annual mammogram. This performance
15goal shall be used to provide additional reimbursement in the
16form of a quality performance bonus to primary care providers
17who meet that goal.
18    The Department shall devise a means of case-managing or
19patient navigation for beneficiaries diagnosed with breast
20cancer. This program shall initially operate as a pilot program
21in areas of the State with the highest incidence of mortality
22related to breast cancer. At least one pilot program site shall
23be in the metropolitan Chicago area and at least one site shall
24be outside the metropolitan Chicago area. On or after July 1,
252016, the pilot program shall be expanded to include one site
26in western Illinois, one site in southern Illinois, one site in

 

 

09900SB0466sam001- 25 -LRB099 03184 EGJ 47643 a

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

 

 

09900SB0466sam001- 26 -LRB099 03184 EGJ 47643 a

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

 

 

09900SB0466sam001- 27 -LRB099 03184 EGJ 47643 a

1procedures to the Illinois Department.
2    The Illinois Department may develop and contract with
3Partnerships of medical providers to arrange medical services
4for persons eligible under Section 5-2 of this Code.
5Implementation of this Section may be by demonstration projects
6in certain geographic areas. The Partnership shall be
7represented by a sponsor organization. The Department, by rule,
8shall develop qualifications for sponsors of Partnerships.
9Nothing in this Section shall be construed to require that the
10sponsor organization be a medical organization.
11    The sponsor must negotiate formal written contracts with
12medical providers for physician services, inpatient and
13outpatient hospital care, home health services, treatment for
14alcoholism and substance abuse, and other services determined
15necessary by the Illinois Department by rule for delivery by
16Partnerships. Physician services must include prenatal and
17obstetrical care. The Illinois Department shall reimburse
18medical services delivered by Partnership providers to clients
19in target areas according to provisions of this Article and the
20Illinois Health Finance Reform Act, except that:
21        (1) Physicians participating in a Partnership and
22    providing certain services, which shall be determined by
23    the Illinois Department, to persons in areas covered by the
24    Partnership may receive an additional surcharge for such
25    services.
26        (2) The Department may elect to consider and negotiate

 

 

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

 

 

09900SB0466sam001- 29 -LRB099 03184 EGJ 47643 a

1implementation of Partnerships under this Section.
2    The Illinois Department shall require health care
3providers to maintain records that document the medical care
4and services provided to recipients of Medical Assistance under
5this Article. Such records must be retained for a period of not
6less than 6 years from the date of service or as provided by
7applicable State law, whichever period is longer, except that
8if an audit is initiated within the required retention period
9then the records must be retained until the audit is completed
10and every exception is resolved. The Illinois Department shall
11require health care providers to make available, when
12authorized by the patient, in writing, the medical records in a
13timely fashion to other health care providers who are treating
14or serving persons eligible for Medical Assistance under this
15Article. All dispensers of medical services shall be required
16to maintain and retain business and professional records
17sufficient to fully and accurately document the nature, scope,
18details and receipt of the health care provided to persons
19eligible for medical assistance under this Code, in accordance
20with regulations promulgated by the Illinois Department. The
21rules and regulations shall require that proof of the receipt
22of prescription drugs, dentures, prosthetic devices and
23eyeglasses by eligible persons under this Section accompany
24each claim for reimbursement submitted by the dispenser of such
25medical services. No such claims for reimbursement shall be
26approved for payment by the Illinois Department without such

 

 

09900SB0466sam001- 30 -LRB099 03184 EGJ 47643 a

1proof of receipt, unless the Illinois Department shall have put
2into effect and shall be operating a system of post-payment
3audit and review which shall, on a sampling basis, be deemed
4adequate by the Illinois Department to assure that such drugs,
5dentures, prosthetic devices and eyeglasses for which payment
6is being made are actually being received by eligible
7recipients. Within 90 days after September 16, 1984 (the
8effective date of Public Act 83-1439) this amendatory Act of
91984, the Illinois Department shall establish a current list of
10acquisition costs for all prosthetic devices and any other
11items recognized as medical equipment and supplies
12reimbursable under this Article and shall update such list on a
13quarterly basis, except that the acquisition costs of all
14prescription drugs shall be updated no less frequently than
15every 30 days as required by Section 5-5.12.
16    The rules and regulations of the Illinois Department shall
17require that a written statement including the required opinion
18of a physician shall accompany any claim for reimbursement for
19abortions, or induced miscarriages or premature births. This
20statement shall indicate what procedures were used in providing
21such medical services.
22    Notwithstanding any other law to the contrary, the Illinois
23Department shall, within 365 days after July 22, 2013 (the
24effective date of Public Act 98-104), establish procedures to
25permit skilled care facilities licensed under the Nursing Home
26Care Act to submit monthly billing claims for reimbursement

 

 

09900SB0466sam001- 31 -LRB099 03184 EGJ 47643 a

1purposes. Following development of these procedures, the
2Department shall, by July 1, 2016, test the viability of the
3new system and implement any necessary operational or
4structural changes to its information technology platforms in
5order to allow for the direct acceptance and payment of nursing
6home claims.
7    Notwithstanding any other law to the contrary, the Illinois
8Department shall, within 365 days after August 15, 2014 (the
9effective date of Public Act 98-963), establish procedures to
10permit ID/DD facilities licensed under the ID/DD Community Care
11Act and MC/DD facilities licensed under the MC/DD Act to submit
12monthly billing claims for reimbursement purposes. Following
13development of these procedures, the Department shall have an
14additional 365 days to test the viability of the new system and
15to ensure that any necessary operational or structural changes
16to its information technology platforms are implemented.
17    The Illinois Department shall require all dispensers of
18medical services, other than an individual practitioner or
19group of practitioners, desiring to participate in the Medical
20Assistance program established under this Article to disclose
21all financial, beneficial, ownership, equity, surety or other
22interests in any and all firms, corporations, partnerships,
23associations, business enterprises, joint ventures, agencies,
24institutions or other legal entities providing any form of
25health care services in this State under this Article.
26    The Illinois Department may require that all dispensers of

 

 

09900SB0466sam001- 32 -LRB099 03184 EGJ 47643 a

1medical services desiring to participate in the medical
2assistance program established under this Article disclose,
3under such terms and conditions as the Illinois Department may
4by rule establish, all inquiries from clients and attorneys
5regarding medical bills paid by the Illinois Department, which
6inquiries could indicate potential existence of claims or liens
7for the Illinois Department.
8    Enrollment of a vendor shall be subject to a provisional
9period and shall be conditional for one year. During the period
10of conditional enrollment, the Department may terminate the
11vendor's eligibility to participate in, or may disenroll the
12vendor from, the medical assistance program without cause.
13Unless otherwise specified, such termination of eligibility or
14disenrollment is not subject to the Department's hearing
15process. However, a disenrolled vendor may reapply without
16penalty.
17    The Department has the discretion to limit the conditional
18enrollment period for vendors based upon category of risk of
19the vendor.
20    Prior to enrollment and during the conditional enrollment
21period in the medical assistance program, all vendors shall be
22subject to enhanced oversight, screening, and review based on
23the risk of fraud, waste, and abuse that is posed by the
24category of risk of the vendor. The Illinois Department shall
25establish the procedures for oversight, screening, and review,
26which may include, but need not be limited to: criminal and

 

 

09900SB0466sam001- 33 -LRB099 03184 EGJ 47643 a

1financial background checks; fingerprinting; license,
2certification, and authorization verifications; unscheduled or
3unannounced site visits; database checks; prepayment audit
4reviews; audits; payment caps; payment suspensions; and other
5screening as required by federal or State law.
6    The Department shall define or specify the following: (i)
7by provider notice, the "category of risk of the vendor" for
8each type of vendor, which shall take into account the level of
9screening applicable to a particular category of vendor under
10federal law and regulations; (ii) by rule or provider notice,
11the maximum length of the conditional enrollment period for
12each category of risk of the vendor; and (iii) by rule, the
13hearing rights, if any, afforded to a vendor in each category
14of risk of the vendor that is terminated or disenrolled during
15the conditional enrollment period.
16    To be eligible for payment consideration, a vendor's
17payment claim or bill, either as an initial claim or as a
18resubmitted claim following prior rejection, must be received
19by the Illinois Department, or its fiscal intermediary, no
20later than 180 days after the latest date on the claim on which
21medical goods or services were provided, with the following
22exceptions:
23        (1) In the case of a provider whose enrollment is in
24    process by the Illinois Department, the 180-day period
25    shall not begin until the date on the written notice from
26    the Illinois Department that the provider enrollment is

 

 

09900SB0466sam001- 34 -LRB099 03184 EGJ 47643 a

1    complete.
2        (2) In the case of errors attributable to the Illinois
3    Department or any of its claims processing intermediaries
4    which result in an inability to receive, process, or
5    adjudicate a claim, the 180-day period shall not begin
6    until the provider has been notified of the error.
7        (3) In the case of a provider for whom the Illinois
8    Department initiates the monthly billing process.
9        (4) In the case of a provider operated by a unit of
10    local government with a population exceeding 3,000,000
11    when local government funds finance federal participation
12    for claims payments.
13    For claims for services rendered during a period for which
14a recipient received retroactive eligibility, claims must be
15filed within 180 days after the Department determines the
16applicant is eligible. For claims for which the Illinois
17Department is not the primary payer, claims must be submitted
18to the Illinois Department within 180 days after the final
19adjudication by the primary payer.
20    In the case of long term care facilities, within 5 days of
21receipt by the facility of required prescreening information,
22data for new admissions shall be entered into the Medical
23Electronic Data Interchange (MEDI) or the Recipient
24Eligibility Verification (REV) System or successor system, and
25within 15 days of receipt by the facility of required
26prescreening information, admission documents shall be

 

 

09900SB0466sam001- 35 -LRB099 03184 EGJ 47643 a

1submitted through MEDI or REV or shall be submitted directly to
2the Department of Human Services using required admission
3forms. Effective September 1, 2014, admission documents,
4including all prescreening information, must be submitted
5through MEDI or REV. Confirmation numbers assigned to an
6accepted transaction shall be retained by a facility to verify
7timely submittal. Once an admission transaction has been
8completed, all resubmitted claims following prior rejection
9are subject to receipt no later than 180 days after the
10admission transaction has been completed.
11    Claims that are not submitted and received in compliance
12with the foregoing requirements shall not be eligible for
13payment under the medical assistance program, and the State
14shall have no liability for payment of those claims.
15    To the extent consistent with applicable information and
16privacy, security, and disclosure laws, State and federal
17agencies and departments shall provide the Illinois Department
18access to confidential and other information and data necessary
19to perform eligibility and payment verifications and other
20Illinois Department functions. This includes, but is not
21limited to: information pertaining to licensure;
22certification; earnings; immigration status; citizenship; wage
23reporting; unearned and earned income; pension income;
24employment; supplemental security income; social security
25numbers; National Provider Identifier (NPI) numbers; the
26National Practitioner Data Bank (NPDB); program and agency

 

 

09900SB0466sam001- 36 -LRB099 03184 EGJ 47643 a

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

 

 

09900SB0466sam001- 37 -LRB099 03184 EGJ 47643 a

1clinical code editing; and (iii) pre-pay, pre- or
2post-adjudicated predictive modeling with an integrated case
3management system with link analysis. Such a request for
4information shall not be considered as a request for proposal
5or as an obligation on the part of the Illinois Department to
6take any action or acquire any products or services.
7    The Illinois Department shall establish policies,
8procedures, standards and criteria by rule for the acquisition,
9repair and replacement of orthotic and prosthetic devices and
10durable medical equipment. Such rules shall provide, but not be
11limited to, the following services: (1) immediate repair or
12replacement of such devices by recipients; and (2) rental,
13lease, purchase or lease-purchase of durable medical equipment
14in a cost-effective manner, taking into consideration the
15recipient's medical prognosis, the extent of the recipient's
16needs, and the requirements and costs for maintaining such
17equipment. Subject to prior approval, such rules shall enable a
18recipient to temporarily acquire and use alternative or
19substitute devices or equipment pending repairs or
20replacements of any device or equipment previously authorized
21for such recipient by the Department.
22    The Department shall execute, relative to the nursing home
23prescreening project, written inter-agency agreements with the
24Department of Human Services and the Department on Aging, to
25effect the following: (i) intake procedures and common
26eligibility criteria for those persons who are receiving

 

 

09900SB0466sam001- 38 -LRB099 03184 EGJ 47643 a

1non-institutional services; and (ii) the establishment and
2development of non-institutional services in areas of the State
3where they are not currently available or are undeveloped; and
4(iii) notwithstanding any other provision of law, subject to
5federal approval, on and after July 1, 2012, an increase in the
6determination of need (DON) scores from 29 to 37 for applicants
7for institutional and home and community-based long term care;
8if and only if federal approval is not granted, the Department
9may, in conjunction with other affected agencies, implement
10utilization controls or changes in benefit packages to
11effectuate a similar savings amount for this population; and
12(iv) no later than July 1, 2013, minimum level of care
13eligibility criteria for institutional and home and
14community-based long term care; and (v) no later than October
151, 2013, establish procedures to permit long term care
16providers access to eligibility scores for individuals with an
17admission date who are seeking or receiving services from the
18long term care provider. In order to select the minimum level
19of care eligibility criteria, the Governor shall establish a
20workgroup that includes affected agency representatives and
21stakeholders representing the institutional and home and
22community-based long term care interests. This Section shall
23not restrict the Department from implementing lower level of
24care eligibility criteria for community-based services in
25circumstances where federal approval has been granted.
26    The Illinois Department shall develop and operate, in

 

 

09900SB0466sam001- 39 -LRB099 03184 EGJ 47643 a

1cooperation with other State Departments and agencies and in
2compliance with applicable federal laws and regulations,
3appropriate and effective systems of health care evaluation and
4programs for monitoring of utilization of health care services
5and facilities, as it affects persons eligible for medical
6assistance under this Code.
7    The Illinois Department shall report annually to the
8General Assembly, no later than the second Friday in April of
91979 and each year thereafter, in regard to:
10        (a) actual statistics and trends in utilization of
11    medical services by public aid recipients;
12        (b) actual statistics and trends in the provision of
13    the various medical services by medical vendors;
14        (c) current rate structures and proposed changes in
15    those rate structures for the various medical vendors; and
16        (d) efforts at utilization review and control by the
17    Illinois Department.
18    The period covered by each report shall be the 3 years
19ending on the June 30 prior to the report. The report shall
20include suggested legislation for consideration by the General
21Assembly. The filing of one copy of the report with the
22Speaker, one copy with the Minority Leader and one copy with
23the Clerk of the House of Representatives, one copy with the
24President, one copy with the Minority Leader and one copy with
25the Secretary of the Senate, one copy with the Legislative
26Research Unit, and such additional copies with the State

 

 

09900SB0466sam001- 40 -LRB099 03184 EGJ 47643 a

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

 

 

09900SB0466sam001- 41 -LRB099 03184 EGJ 47643 a

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

 

 

09900SB0466sam001- 42 -LRB099 03184 EGJ 47643 a

1other similarly acting drug approved by the U.S. Food and Drug
2Administration.
3(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
498-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
58-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
6eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
799-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-433, eff.
88-21-15; 99-480, eff. 9-9-15; revised 10-13-15.)
 
9    (Text of Section after amendment by P.A. 99-407)
10    Sec. 5-5. Medical services. The Illinois Department, by
11rule, shall determine the quantity and quality of and the rate
12of reimbursement for the medical assistance for which payment
13will be authorized, and the medical services to be provided,
14which may include all or part of the following: (1) inpatient
15hospital services; (2) outpatient hospital services; (3) other
16laboratory and X-ray services; (4) skilled nursing home
17services; (5) physicians' services whether furnished in the
18office, the patient's home, a hospital, a skilled nursing home,
19or elsewhere; (6) medical care, or any other type of remedial
20care furnished by licensed practitioners; (7) home health care
21services; (8) private duty nursing service; (9) clinic
22services; (10) dental services, including prevention and
23treatment of periodontal disease and dental caries disease for
24pregnant women, provided by an individual licensed to practice
25dentistry or dental surgery; for purposes of this item (10),

 

 

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

 

 

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1care, and any other type of remedial care recognized under the
2laws of this State, but not including abortions, or induced
3miscarriages or premature births, unless, in the opinion of a
4physician, such procedures are necessary for the preservation
5of the life of the woman seeking such treatment, or except an
6induced premature birth intended to produce a live viable child
7and such procedure is necessary for the health of the mother or
8her unborn child. The Illinois Department, by rule, shall
9prohibit any physician from providing medical assistance to
10anyone eligible therefor under this Code where such physician
11has been found guilty of performing an abortion procedure in a
12wilful and wanton manner upon a woman who was not pregnant at
13the time such abortion procedure was performed. The term "any
14other type of remedial care" shall include nursing care and
15nursing home service for persons who rely on treatment by
16spiritual means alone through prayer for healing.
17    Notwithstanding any other provision of this Section, a
18comprehensive tobacco use cessation program that includes
19purchasing prescription drugs or prescription medical devices
20approved by the Food and Drug Administration shall be covered
21under the medical assistance program under this Article for
22persons who are otherwise eligible for assistance under this
23Article.
24    Notwithstanding any other provision of this Code, the
25Illinois Department may not require, as a condition of payment
26for any laboratory test authorized under this Article, that a

 

 

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1physician's handwritten signature appear on the laboratory
2test order form. The Illinois Department may, however, impose
3other appropriate requirements regarding laboratory test order
4documentation.
5    Upon receipt of federal approval of an amendment to the
6Illinois Title XIX State Plan for this purpose, the Department
7shall authorize the Chicago Public Schools (CPS) to procure a
8vendor or vendors to manufacture eyeglasses for individuals
9enrolled in a school within the CPS system. CPS shall ensure
10that its vendor or vendors are enrolled as providers in the
11medical assistance program and in any capitated Medicaid
12managed care entity (MCE) serving individuals enrolled in a
13school within the CPS system. Under any contract procured under
14this provision, the vendor or vendors must serve only
15individuals enrolled in a school within the CPS system. Claims
16for services provided by CPS's vendor or vendors to recipients
17of benefits in the medical assistance program under this Code,
18the Children's Health Insurance Program, or the Covering ALL
19KIDS Health Insurance Program shall be submitted to the
20Department or the MCE in which the individual is enrolled for
21payment and shall be reimbursed at the Department's or the
22MCE's established rates or rate methodologies for eyeglasses.
23    On and after July 1, 2012, the Department of Healthcare and
24Family Services may provide the following services to persons
25eligible for assistance under this Article who are
26participating in education, training or employment programs

 

 

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1operated by the Department of Human Services as successor to
2the Department of Public Aid:
3        (1) dental services provided by or under the
4    supervision of a dentist; and
5        (2) eyeglasses prescribed by a physician skilled in the
6    diseases of the eye, or by an optometrist, whichever the
7    person may select.
8    Notwithstanding any other provision of this Code and
9subject to federal approval, the Department may adopt rules to
10allow a dentist who is volunteering his or her service at no
11cost to render dental services through an enrolled
12not-for-profit health clinic without the dentist personally
13enrolling as a participating provider in the medical assistance
14program. A not-for-profit health clinic shall include a public
15health clinic or Federally Qualified Health Center or other
16enrolled provider, as determined by the Department, through
17which dental services covered under this Section are performed.
18The Department shall establish a process for payment of claims
19for reimbursement for covered dental services rendered under
20this provision.
21    The Illinois Department, by rule, may distinguish and
22classify the medical services to be provided only in accordance
23with the classes of persons designated in Section 5-2.
24    The Department of Healthcare and Family Services must
25provide coverage and reimbursement for amino acid-based
26elemental formulas, regardless of delivery method, for the

 

 

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1diagnosis and treatment of (i) eosinophilic disorders and (ii)
2short bowel syndrome when the prescribing physician has issued
3a written order stating that the amino acid-based elemental
4formula is medically necessary.
5    The Illinois Department shall authorize the provision of,
6and shall authorize payment for, screening by low-dose
7mammography for the presence of occult breast cancer for women
835 years of age or older who are eligible for medical
9assistance under this Article, as follows:
10        (A) A baseline mammogram for women 35 to 39 years of
11    age.
12        (B) An annual mammogram for women 40 years of age or
13    older.
14        (C) A mammogram at the age and intervals considered
15    medically necessary by the woman's health care provider for
16    women under 40 years of age and having a family history of
17    breast cancer, prior personal history of breast cancer,
18    positive genetic testing, or other risk factors.
19        (D) A comprehensive ultrasound screening of an entire
20    breast or breasts if a mammogram demonstrates
21    heterogeneous or dense breast tissue, when medically
22    necessary as determined by a physician licensed to practice
23    medicine in all of its branches.
24        (E) A screening MRI when medically necessary, as
25    determined by a physician licensed to practice medicine in
26    all of its branches.

 

 

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1    All screenings shall include a physical breast exam,
2instruction on self-examination and information regarding the
3frequency of self-examination and its value as a preventative
4tool. For purposes of this Section, "low-dose mammography"
5means the x-ray examination of the breast using equipment
6dedicated specifically for mammography, including the x-ray
7tube, filter, compression device, and image receptor, with an
8average radiation exposure delivery of less than one rad per
9breast for 2 views of an average size breast. The term also
10includes digital mammography and includes breast
11tomosynthesis. As used in this Section, the term "breast
12tomosynthesis" means a radiologic procedure that involves the
13acquisition of projection images over the stationary breast to
14produce cross-sectional digital three-dimensional images of
15the breast. If, at any time, the Secretary of the United States
16Department of Health and Human Services, or its successor
17agency, promulgates rules or regulations to be published in the
18Federal Register or publishes a comment in the Federal Register
19or issues an opinion, guidance, or other action that would
20require the State, pursuant to any provision of the Patient
21Protection and Affordable Care Act (Public Law 111-148),
22including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
23successor provision, to defray the cost of any coverage for
24screening by breast tomosynthesis outlined in this paragraph,
25then the requirement that an insurer cover screening by breast
26tomosynthesis is inoperative other than any such coverage

 

 

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

 

 

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

 

 

09900SB0466sam001- 51 -LRB099 03184 EGJ 47643 a

1patient navigation for beneficiaries diagnosed with breast
2cancer. This program shall initially operate as a pilot program
3in areas of the State with the highest incidence of mortality
4related to breast cancer. At least one pilot program site shall
5be in the metropolitan Chicago area and at least one site shall
6be outside the metropolitan Chicago area. On or after July 1,
72016, the pilot program shall be expanded to include one site
8in western Illinois, one site in southern Illinois, one site in
9central Illinois, and 4 sites within metropolitan Chicago. An
10evaluation of the pilot program shall be carried out measuring
11health outcomes and cost of care for those served by the pilot
12program compared to similarly situated patients who are not
13served by the pilot program.
14    The Department shall require all networks of care to
15develop a means either internally or by contract with experts
16in navigation and community outreach to navigate cancer
17patients to comprehensive care in a timely fashion. The
18Department shall require all networks of care to include access
19for patients diagnosed with cancer to at least one academic
20commission on cancer-accredited cancer program as an
21in-network covered benefit.
22    Any medical or health care provider shall immediately
23recommend, to any pregnant woman who is being provided prenatal
24services and is suspected of drug abuse or is addicted as
25defined in the Alcoholism and Other Drug Abuse and Dependency
26Act, referral to a local substance abuse treatment provider

 

 

09900SB0466sam001- 52 -LRB099 03184 EGJ 47643 a

1licensed by the Department of Human Services or to a licensed
2hospital which provides substance abuse treatment services.
3The Department of Healthcare and Family Services shall assure
4coverage for the cost of treatment of the drug abuse or
5addiction for pregnant recipients in accordance with the
6Illinois Medicaid Program in conjunction with the Department of
7Human Services.
8    All medical providers providing medical assistance to
9pregnant women under this Code shall receive information from
10the Department on the availability of services under the Drug
11Free Families with a Future or any comparable program providing
12case management services for addicted women, including
13information on appropriate referrals for other social services
14that may be needed by addicted women in addition to treatment
15for addiction.
16    The Illinois Department, in cooperation with the
17Departments of Human Services (as successor to the Department
18of Alcoholism and Substance Abuse) and Public Health, through a
19public awareness campaign, may provide information concerning
20treatment for alcoholism and drug abuse and addiction, prenatal
21health care, and other pertinent programs directed at reducing
22the number of drug-affected infants born to recipients of
23medical assistance.
24    Neither the Department of Healthcare and Family Services
25nor the Department of Human Services shall sanction the
26recipient solely on the basis of her substance abuse.

 

 

09900SB0466sam001- 53 -LRB099 03184 EGJ 47643 a

1    The Illinois Department shall establish such regulations
2governing the dispensing of health services under this Article
3as it shall deem appropriate. The Department should seek the
4advice of formal professional advisory committees appointed by
5the Director of the Illinois Department for the purpose of
6providing regular advice on policy and administrative matters,
7information dissemination and educational activities for
8medical and health care providers, and consistency in
9procedures to the Illinois Department.
10    The Illinois Department may develop and contract with
11Partnerships of medical providers to arrange medical services
12for persons eligible under Section 5-2 of this Code.
13Implementation of this Section may be by demonstration projects
14in certain geographic areas. The Partnership shall be
15represented by a sponsor organization. The Department, by rule,
16shall develop qualifications for sponsors of Partnerships.
17Nothing in this Section shall be construed to require that the
18sponsor organization be a medical organization.
19    The sponsor must negotiate formal written contracts with
20medical providers for physician services, inpatient and
21outpatient hospital care, home health services, treatment for
22alcoholism and substance abuse, and other services determined
23necessary by the Illinois Department by rule for delivery by
24Partnerships. Physician services must include prenatal and
25obstetrical care. The Illinois Department shall reimburse
26medical services delivered by Partnership providers to clients

 

 

09900SB0466sam001- 54 -LRB099 03184 EGJ 47643 a

1in target areas according to provisions of this Article and the
2Illinois Health Finance Reform Act, except that:
3        (1) Physicians participating in a Partnership and
4    providing certain services, which shall be determined by
5    the Illinois Department, to persons in areas covered by the
6    Partnership may receive an additional surcharge for such
7    services.
8        (2) The Department may elect to consider and negotiate
9    financial incentives to encourage the development of
10    Partnerships and the efficient delivery of medical care.
11        (3) Persons receiving medical services through
12    Partnerships may receive medical and case management
13    services above the level usually offered through the
14    medical assistance program.
15    Medical providers shall be required to meet certain
16qualifications to participate in Partnerships to ensure the
17delivery of high quality medical services. These
18qualifications shall be determined by rule of the Illinois
19Department and may be higher than qualifications for
20participation in the medical assistance program. Partnership
21sponsors may prescribe reasonable additional qualifications
22for participation by medical providers, only with the prior
23written approval of the Illinois Department.
24    Nothing in this Section shall limit the free choice of
25practitioners, hospitals, and other providers of medical
26services by clients. In order to ensure patient freedom of

 

 

09900SB0466sam001- 55 -LRB099 03184 EGJ 47643 a

1choice, the Illinois Department shall immediately promulgate
2all rules and take all other necessary actions so that provided
3services may be accessed from therapeutically certified
4optometrists to the full extent of the Illinois Optometric
5Practice Act of 1987 without discriminating between service
6providers.
7    The Department shall apply for a waiver from the United
8States Health Care Financing Administration to allow for the
9implementation of Partnerships under this Section.
10    The Illinois Department shall require health care
11providers to maintain records that document the medical care
12and services provided to recipients of Medical Assistance under
13this Article. Such records must be retained for a period of not
14less than 6 years from the date of service or as provided by
15applicable State law, whichever period is longer, except that
16if an audit is initiated within the required retention period
17then the records must be retained until the audit is completed
18and every exception is resolved. The Illinois Department shall
19require health care providers to make available, when
20authorized by the patient, in writing, the medical records in a
21timely fashion to other health care providers who are treating
22or serving persons eligible for Medical Assistance under this
23Article. All dispensers of medical services shall be required
24to maintain and retain business and professional records
25sufficient to fully and accurately document the nature, scope,
26details and receipt of the health care provided to persons

 

 

09900SB0466sam001- 56 -LRB099 03184 EGJ 47643 a

1eligible for medical assistance under this Code, in accordance
2with regulations promulgated by the Illinois Department. The
3rules and regulations shall require that proof of the receipt
4of prescription drugs, dentures, prosthetic devices and
5eyeglasses by eligible persons under this Section accompany
6each claim for reimbursement submitted by the dispenser of such
7medical services. No such claims for reimbursement shall be
8approved for payment by the Illinois Department without such
9proof of receipt, unless the Illinois Department shall have put
10into effect and shall be operating a system of post-payment
11audit and review which shall, on a sampling basis, be deemed
12adequate by the Illinois Department to assure that such drugs,
13dentures, prosthetic devices and eyeglasses for which payment
14is being made are actually being received by eligible
15recipients. Within 90 days after September 16, 1984 (the
16effective date of Public Act 83-1439) this amendatory Act of
171984, the Illinois Department shall establish a current list of
18acquisition costs for all prosthetic devices and any other
19items recognized as medical equipment and supplies
20reimbursable under this Article and shall update such list on a
21quarterly basis, except that the acquisition costs of all
22prescription drugs shall be updated no less frequently than
23every 30 days as required by Section 5-5.12.
24    The rules and regulations of the Illinois Department shall
25require that a written statement including the required opinion
26of a physician shall accompany any claim for reimbursement for

 

 

09900SB0466sam001- 57 -LRB099 03184 EGJ 47643 a

1abortions, or induced miscarriages or premature births. This
2statement shall indicate what procedures were used in providing
3such medical services.
4    Notwithstanding any other law to the contrary, the Illinois
5Department shall, within 365 days after July 22, 2013 (the
6effective date of Public Act 98-104), establish procedures to
7permit skilled care facilities licensed under the Nursing Home
8Care Act to submit monthly billing claims for reimbursement
9purposes. Following development of these procedures, the
10Department shall, by July 1, 2016, test the viability of the
11new system and implement any necessary operational or
12structural changes to its information technology platforms in
13order to allow for the direct acceptance and payment of nursing
14home claims.
15    Notwithstanding any other law to the contrary, the Illinois
16Department shall, within 365 days after August 15, 2014 (the
17effective date of Public Act 98-963), establish procedures to
18permit ID/DD facilities licensed under the ID/DD Community Care
19Act and MC/DD facilities licensed under the MC/DD Act to submit
20monthly billing claims for reimbursement purposes. Following
21development of these procedures, the Department shall have an
22additional 365 days to test the viability of the new system and
23to ensure that any necessary operational or structural changes
24to its information technology platforms are implemented.
25    The Illinois Department shall require all dispensers of
26medical services, other than an individual practitioner or

 

 

09900SB0466sam001- 58 -LRB099 03184 EGJ 47643 a

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 liens
15for the Illinois Department.
16    Enrollment of a vendor shall be subject to a provisional
17period and shall be conditional for one year. During the period
18of conditional enrollment, the Department may terminate the
19vendor's eligibility to participate in, or may disenroll the
20vendor 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

 

 

09900SB0466sam001- 59 -LRB099 03184 EGJ 47643 a

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

 

 

09900SB0466sam001- 60 -LRB099 03184 EGJ 47643 a

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

 

 

09900SB0466sam001- 61 -LRB099 03184 EGJ 47643 a

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

 

 

09900SB0466sam001- 62 -LRB099 03184 EGJ 47643 a

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

 

 

09900SB0466sam001- 63 -LRB099 03184 EGJ 47643 a

1    Beginning in fiscal year 2013, the Illinois Department
2shall set forth a request for information to identify the
3benefits of a pre-payment, post-adjudication, and post-edit
4claims system with the goals of streamlining claims processing
5and provider reimbursement, reducing the number of pending or
6rejected claims, and helping to ensure a more transparent
7adjudication process through the utilization of: (i) provider
8data verification and provider screening technology; and (ii)
9clinical code editing; and (iii) pre-pay, pre- or
10post-adjudicated predictive modeling with an integrated case
11management system with link analysis. Such a request for
12information shall not be considered as a request for proposal
13or as an obligation on the part of the Illinois Department to
14take any action or acquire any products or services.
15    The Illinois Department shall establish policies,
16procedures, standards and criteria by rule for the acquisition,
17repair and replacement of orthotic and prosthetic devices and
18durable medical equipment. Such rules shall provide, but not be
19limited to, the following services: (1) immediate repair or
20replacement of such devices by recipients; and (2) rental,
21lease, purchase or lease-purchase of durable medical equipment
22in a cost-effective manner, taking into consideration the
23recipient's medical prognosis, the extent of the recipient's
24needs, and the requirements and costs for maintaining such
25equipment. Subject to prior approval, such rules shall enable a
26recipient to temporarily acquire and use alternative or

 

 

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1substitute devices or equipment pending repairs or
2replacements of any device or equipment previously authorized
3for such recipient by the Department.
4    The Department shall execute, relative to the nursing home
5prescreening project, written inter-agency agreements with the
6Department of Human Services and the Department on Aging, to
7effect the following: (i) intake procedures and common
8eligibility criteria for those persons who are receiving
9non-institutional services; and (ii) the establishment and
10development of non-institutional services in areas of the State
11where they are not currently available or are undeveloped; and
12(iii) notwithstanding any other provision of law, subject to
13federal approval, on and after July 1, 2012, an increase in the
14determination of need (DON) scores from 29 to 37 for applicants
15for institutional and home and community-based long term care;
16if and only if federal approval is not granted, the Department
17may, in conjunction with other affected agencies, implement
18utilization controls or changes in benefit packages to
19effectuate a similar savings amount for this population; and
20(iv) no later than July 1, 2013, minimum level of care
21eligibility criteria for institutional and home and
22community-based long term care; and (v) no later than October
231, 2013, establish procedures to permit long term care
24providers access to eligibility scores for individuals with an
25admission date who are seeking or receiving services from the
26long term care provider. In order to select the minimum level

 

 

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1of care eligibility criteria, the Governor shall establish a
2workgroup that includes affected agency representatives and
3stakeholders representing the institutional and home and
4community-based long term care interests. This Section shall
5not restrict the Department from implementing lower level of
6care eligibility criteria for community-based services in
7circumstances where federal approval has been granted.
8    The Illinois Department shall develop and operate, in
9cooperation with other State Departments and agencies and in
10compliance with applicable federal laws and regulations,
11appropriate and effective systems of health care evaluation and
12programs for monitoring of utilization of health care services
13and facilities, as it affects persons eligible for medical
14assistance under this Code.
15    The Illinois Department shall report annually to the
16General Assembly, no later than the second Friday in April of
171979 and each year thereafter, in regard to:
18        (a) actual statistics and trends in utilization of
19    medical services by public aid recipients;
20        (b) actual statistics and trends in the provision of
21    the various medical services by medical vendors;
22        (c) current rate structures and proposed changes in
23    those rate structures for the various medical vendors; and
24        (d) efforts at utilization review and control by the
25    Illinois Department.
26    The period covered by each report shall be the 3 years

 

 

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1ending on the June 30 prior to the report. The report shall
2include suggested legislation for consideration by the General
3Assembly. The filing of one copy of the report with the
4Speaker, one copy with the Minority Leader and one copy with
5the Clerk of the House of Representatives, one copy with the
6President, one copy with the Minority Leader and one copy with
7the Secretary of the Senate, one copy with the Legislative
8Research Unit, and such additional copies with the State
9Government Report Distribution Center for the General Assembly
10as is required under paragraph (t) of Section 7 of the State
11Library Act shall be deemed sufficient to comply with this
12Section.
13    Rulemaking authority to implement Public Act 95-1045, if
14any, is conditioned on the rules being adopted in accordance
15with all provisions of the Illinois Administrative Procedure
16Act and all rules and procedures of the Joint Committee on
17Administrative Rules; any purported rule not so adopted, for
18whatever reason, is unauthorized.
19    On and after July 1, 2012, the Department shall reduce any
20rate of reimbursement for services or other payments or alter
21any methodologies authorized by this Code to reduce any rate of
22reimbursement for services or other payments in accordance with
23Section 5-5e.
24    Because kidney transplantation can be an appropriate, cost
25effective alternative to renal dialysis when medically
26necessary and notwithstanding the provisions of Section 1-11 of

 

 

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

 

 

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1product, administration devices, and any pharmacy fees related
2to the dispensing and administration of the opioid antagonist,
3shall be covered under the medical assistance program for
4persons who are otherwise eligible for medical assistance under
5this Article. As used in this Section, "opioid antagonist"
6means a drug that binds to opioid receptors and blocks or
7inhibits the effect of opioids acting on those receptors,
8including, but not limited to, naloxone hydrochloride or any
9other similarly acting drug approved by the U.S. Food and Drug
10Administration.
11(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
1298-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
138-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
14eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
1599-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
1699 of P.A. 99-407 for its effective date); 99-433, eff.
178-21-15; 99-480, eff. 9-9-15; revised 10-13-15.)
 
18    Section 20. "An Act concerning regulation", approved
19August 19, 2015, Public Act 99-407, is amended by changing
20Section 99 as follows:
 
21    (P.A. 99-407, Sec. 99)
22    Sec. 99. Effective date. This Act takes effect on July 1,
232016. , if and only if on or before July 1, 2016:
24    (1) the Secretary of the United States Department of Health

 

 

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1and Human Services, or its successor agency, promulgates rules
2or regulations published in the Federal Register or publishes a
3comment in the Federal Register:
4         (A) repealing, amending, or reinterpreting 45 CFR
5    155.170 to eliminate the State's responsibility to defray
6    the cost of a state-mandated benefit enacted on or after
7    January 1, 2012;
8        (B) requiring qualified health plans, as defined in the
9    federal Patient Protection and Affordable Care Act, as
10    amended by the Health Care and Education Reconciliation Act
11    of 2010 and any subsequent amendatory Acts, rules, or
12    regulations issued pursuant thereto, to cover breast
13    tomosynthesis as an essential health benefit; or
14        (C) including breast tomosynthesis as a standard as
15    part of the essential health benefits required of benchmark
16    plans under 45 CFR 156.110; or
17    (2) the federal Patient Protection and Affordable Care Act
18is repealed by an Act of Congress or is invalidated by a
19decision of the U.S. Supreme Court.
20(Source: P.A. 99-407, eff. (see Section 99 of P.A. 99-407 for
21its effective date).)
 
22    Section 95. No acceleration or delay. Where this Act makes
23changes in a statute that is represented in this Act by text
24that is not yet or no longer in effect (for example, a Section
25represented by multiple versions), the use of that text does

 

 

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1not accelerate or delay the taking effect of (i) the changes
2made by this Act or (ii) provisions derived from any other
3Public Act.
 
4    Section 99. Effective date. This Act takes effect upon
5becoming law.".