Illinois General Assembly - Full Text of HB0004
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Full Text of HB0004  101st General Assembly




State of Illinois
2019 and 2020


Introduced 1/9/2019___________, by


305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that doula services shall be covered under the medical assistance program. Sets forth certain certification and training requirements a doula must satisfy to qualify for reimbursement under the medical assistance program.

LRB101 04058 KTG 49066 b






HB0004LRB101 04058 KTG 49066 b

1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5 as follows:
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    Sec. 5-5. Medical services. The Illinois Department, by
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing home,
16or elsewhere; (6) medical care, or any other type of remedial
17care furnished by licensed practitioners; (7) home health care
18services; (8) private duty nursing service; (9) clinic
19services; (10) dental services, including prevention and
20treatment of periodontal disease and dental caries disease for
21pregnant women, provided by an individual licensed to practice
22dentistry or dental surgery; for purposes of this item (10),
23"dental services" means diagnostic, preventive, or corrective



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



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



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1vendor or vendors to manufacture eyeglasses for individuals
2enrolled in a school within the CPS system. CPS shall ensure
3that its vendor or vendors are enrolled as providers in the
4medical assistance program and in any capitated Medicaid
5managed care entity (MCE) serving individuals enrolled in a
6school within the CPS system. Under any contract procured under
7this provision, the vendor or vendors must serve only
8individuals enrolled in a school within the CPS system. Claims
9for services provided by CPS's vendor or vendors to recipients
10of benefits in the medical assistance program under this Code,
11the Children's Health Insurance Program, or the Covering ALL
12KIDS Health Insurance Program shall be submitted to the
13Department or the MCE in which the individual is enrolled for
14payment and shall be reimbursed at the Department's or the
15MCE's established rates or rate methodologies for eyeglasses.
16    On and after July 1, 2012, the Department of Healthcare and
17Family Services may provide the following services to persons
18eligible for assistance under this Article who are
19participating in education, training or employment programs
20operated by the Department of Human Services as successor to
21the Department of Public Aid:
22        (1) dental services provided by or under the
23    supervision of a dentist; and
24        (2) eyeglasses prescribed by a physician skilled in the
25    diseases of the eye, or by an optometrist, whichever the
26    person may select.



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1    On and after July 1, 2018, the Department of Healthcare and
2Family Services shall provide dental services to any adult who
3is otherwise eligible for assistance under the medical
4assistance program. As used in this paragraph, "dental
5services" means diagnostic, preventative, restorative, or
6corrective procedures, including procedures and services for
7the prevention and treatment of periodontal disease and dental
8caries disease, provided by an individual who is licensed to
9practice dentistry or dental surgery or who is under the
10supervision of a dentist in the practice of his or her
12    On and after July 1, 2018, targeted dental services, as set
13forth in Exhibit D of the Consent Decree entered by the United
14States District Court for the Northern District of Illinois,
15Eastern Division, in the matter of Memisovski v. Maram, Case
16No. 92 C 1982, that are provided to adults under the medical
17assistance program shall be established at no less than the
18rates set forth in the "New Rate" column in Exhibit D of the
19Consent Decree for targeted dental services that are provided
20to persons under the age of 18 under the medical assistance
22    Notwithstanding any other provision of this Code and
23subject to federal approval, the Department may adopt rules to
24allow a dentist who is volunteering his or her service at no
25cost to render dental services through an enrolled
26not-for-profit health clinic without the dentist personally



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1enrolling as a participating provider in the medical assistance
2program. A not-for-profit health clinic shall include a public
3health clinic or Federally Qualified Health Center or other
4enrolled provider, as determined by the Department, through
5which dental services covered under this Section are performed.
6The Department shall establish a process for payment of claims
7for reimbursement for covered dental services rendered under
8this provision.
9    The Illinois Department, by rule, may distinguish and
10classify the medical services to be provided only in accordance
11with the classes of persons designated in Section 5-2.
12    The Department of Healthcare and Family Services must
13provide coverage and reimbursement for amino acid-based
14elemental formulas, regardless of delivery method, for the
15diagnosis and treatment of (i) eosinophilic disorders and (ii)
16short bowel syndrome when the prescribing physician has issued
17a written order stating that the amino acid-based elemental
18formula is medically necessary.
19    The Illinois Department shall authorize the provision of,
20and shall authorize payment for, screening by low-dose
21mammography for the presence of occult breast cancer for women
2235 years of age or older who are eligible for medical
23assistance under this Article, as follows:
24        (A) A baseline mammogram for women 35 to 39 years of
25    age.
26        (B) An annual mammogram for women 40 years of age or



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1    older.
2        (C) 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        (D) A comprehensive ultrasound screening and MRI of an
8    entire 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        (E) A screening MRI when medically necessary, as
13    determined by a physician licensed to practice medicine in
14    all of its branches.
15    All screenings shall include a physical breast exam,
16instruction on self-examination and information regarding the
17frequency of self-examination and its value as a preventative
18tool. For purposes of this Section, "low-dose mammography"
19means the x-ray examination of the breast using equipment
20dedicated specifically for mammography, including the x-ray
21tube, filter, compression device, and image receptor, with an
22average radiation exposure delivery of less than one rad per
23breast for 2 views of an average size breast. The term also
24includes digital mammography and includes breast
25tomosynthesis. As used in this Section, the term "breast
26tomosynthesis" means a radiologic procedure that involves the



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1acquisition of projection images over the stationary breast to
2produce cross-sectional digital three-dimensional images of
3the breast. If, at any time, the Secretary of the United States
4Department of Health and Human Services, or its successor
5agency, promulgates rules or regulations to be published in the
6Federal Register or publishes a comment in the Federal Register
7or issues an opinion, guidance, or other action that would
8require the State, pursuant to any provision of the Patient
9Protection and Affordable Care Act (Public Law 111-148),
10including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
11successor provision, to defray the cost of any coverage for
12breast tomosynthesis outlined in this paragraph, then the
13requirement that an insurer cover breast tomosynthesis is
14inoperative other than any such coverage authorized under
15Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
16the State shall not assume any obligation for the cost of
17coverage for breast tomosynthesis set forth in this paragraph.
18    On and after January 1, 2016, the Department shall ensure
19that all networks of care for adult clients of the Department
20include access to at least one breast imaging Center of Imaging
21Excellence as certified by the American College of Radiology.
22    On and after January 1, 2012, providers participating in a
23quality improvement program approved by the Department shall be
24reimbursed for screening and diagnostic mammography at the same
25rate as the Medicare program's rates, including the increased
26reimbursement for digital mammography.



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



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1who have not received a mammogram within the previous 18
2months, of the importance and benefit of screening mammography.
3The Department shall work with experts in breast cancer
4outreach and patient navigation to optimize these reminders and
5shall establish a methodology for evaluating their
6effectiveness and modifying the methodology based on the
8    The Department shall establish a performance goal for
9primary care providers with respect to their female patients
10over age 40 receiving an annual mammogram. This performance
11goal shall be used to provide additional reimbursement in the
12form of a quality performance bonus to primary care providers
13who meet that goal.
14    The Department shall devise a means of case-managing or
15patient navigation for beneficiaries diagnosed with breast
16cancer. This program shall initially operate as a pilot program
17in areas of the State with the highest incidence of mortality
18related to breast cancer. At least one pilot program site shall
19be in the metropolitan Chicago area and at least one site shall
20be outside the metropolitan Chicago area. On or after July 1,
212016, the pilot program shall be expanded to include one site
22in western Illinois, one site in southern Illinois, one site in
23central Illinois, and 4 sites within metropolitan Chicago. An
24evaluation of the pilot program shall be carried out measuring
25health outcomes and cost of care for those served by the pilot
26program compared to similarly situated patients who are not



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1served by the pilot program.
2    The Department shall require all networks of care to
3develop a means either internally or by contract with experts
4in navigation and community outreach to navigate cancer
5patients to comprehensive care in a timely fashion. The
6Department shall require all networks of care to include access
7for patients diagnosed with cancer to at least one academic
8commission on cancer-accredited cancer program as an
9in-network covered benefit.
10    Any medical or health care provider shall immediately
11recommend, to any pregnant woman who is being provided prenatal
12services and is suspected of having a substance use disorder as
13defined in the Substance Use Disorder Act, referral to a local
14substance use disorder treatment program licensed by the
15Department of Human Services or to a licensed hospital which
16provides substance abuse treatment services. The Department of
17Healthcare and Family Services shall assure coverage for the
18cost of treatment of the drug abuse or addiction for pregnant
19recipients in accordance with the Illinois Medicaid Program in
20conjunction with the Department of Human Services.
21    All medical providers providing medical assistance to
22pregnant women under this Code shall receive information from
23the Department on the availability of services under any
24program providing case management services for addicted women,
25including information on appropriate referrals for other
26social services that may be needed by addicted women in



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



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



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1    Medical providers shall be required to meet certain
2qualifications to participate in Partnerships to ensure the
3delivery of high quality medical services. These
4qualifications shall be determined by rule of the Illinois
5Department and may be higher than qualifications for
6participation in the medical assistance program. Partnership
7sponsors may prescribe reasonable additional qualifications
8for participation by medical providers, only with the prior
9written approval of the Illinois Department.
10    Nothing in this Section shall limit the free choice of
11practitioners, hospitals, and other providers of medical
12services by clients. In order to ensure patient freedom of
13choice, the Illinois Department shall immediately promulgate
14all rules and take all other necessary actions so that provided
15services may be accessed from therapeutically certified
16optometrists to the full extent of the Illinois Optometric
17Practice Act of 1987 without discriminating between service
19    The Department shall apply for a waiver from the United
20States Health Care Financing Administration to allow for the
21implementation of Partnerships under this Section.
22    The Illinois Department shall require health care
23providers to maintain records that document the medical care
24and services provided to recipients of Medical Assistance under
25this Article. Such records must be retained for a period of not
26less than 6 years from the date of service or as provided by



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1applicable State law, whichever period is longer, except that
2if an audit is initiated within the required retention period
3then the records must be retained until the audit is completed
4and every exception is resolved. The Illinois Department shall
5require health care providers to make available, when
6authorized by the patient, in writing, the medical records in a
7timely fashion to other health care providers who are treating
8or serving persons eligible for Medical Assistance under this
9Article. All dispensers of medical services shall be required
10to maintain and retain business and professional records
11sufficient to fully and accurately document the nature, scope,
12details and receipt of the health care provided to persons
13eligible for medical assistance under this Code, in accordance
14with regulations promulgated by the Illinois Department. The
15rules and regulations shall require that proof of the receipt
16of prescription drugs, dentures, prosthetic devices and
17eyeglasses by eligible persons under this Section accompany
18each claim for reimbursement submitted by the dispenser of such
19medical services. No such claims for reimbursement shall be
20approved for payment by the Illinois Department without such
21proof of receipt, unless the Illinois Department shall have put
22into effect and shall be operating a system of post-payment
23audit and review which shall, on a sampling basis, be deemed
24adequate by the Illinois Department to assure that such drugs,
25dentures, prosthetic devices and eyeglasses for which payment
26is being made are actually being received by eligible



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1recipients. Within 90 days after September 16, 1984 (the
2effective date of Public Act 83-1439), the Illinois Department
3shall establish a current list of acquisition costs for all
4prosthetic devices and any other items recognized as medical
5equipment and supplies reimbursable under this Article and
6shall update such list on a quarterly basis, except that the
7acquisition costs of all prescription drugs shall be updated no
8less frequently than every 30 days as required by Section
10    Notwithstanding any other law to the contrary, the Illinois
11Department shall, within 365 days after July 22, 2013 (the
12effective date of Public Act 98-104), establish procedures to
13permit skilled care facilities licensed under the Nursing Home
14Care Act to submit monthly billing claims for reimbursement
15purposes. Following development of these procedures, the
16Department shall, by July 1, 2016, test the viability of the
17new system and implement any necessary operational or
18structural changes to its information technology platforms in
19order to allow for the direct acceptance and payment of nursing
20home claims.
21    Notwithstanding any other law to the contrary, the Illinois
22Department shall, within 365 days after August 15, 2014 (the
23effective date of Public Act 98-963), establish procedures to
24permit ID/DD facilities licensed under the ID/DD Community Care
25Act and MC/DD facilities licensed under the MC/DD Act to submit
26monthly billing claims for reimbursement purposes. Following



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1development of these procedures, the Department shall have an
2additional 365 days to test the viability of the new system and
3to ensure that any necessary operational or structural changes
4to its information technology platforms are implemented.
5    The Illinois Department shall require all dispensers of
6medical services, other than an individual practitioner or
7group of practitioners, desiring to participate in the Medical
8Assistance program established under this Article to disclose
9all financial, beneficial, ownership, equity, surety or other
10interests in any and all firms, corporations, partnerships,
11associations, business enterprises, joint ventures, agencies,
12institutions or other legal entities providing any form of
13health care services in this State under this Article.
14    The Illinois Department may require that all dispensers of
15medical services desiring to participate in the medical
16assistance program established under this Article disclose,
17under such terms and conditions as the Illinois Department may
18by rule establish, all inquiries from clients and attorneys
19regarding medical bills paid by the Illinois Department, which
20inquiries could indicate potential existence of claims or liens
21for the Illinois Department.
22    Enrollment of a vendor shall be subject to a provisional
23period and shall be conditional for one year. During the period
24of conditional enrollment, the Department may terminate the
25vendor's eligibility to participate in, or may disenroll the
26vendor from, the medical assistance program without cause.



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1Unless otherwise specified, such termination of eligibility or
2disenrollment is not subject to the Department's hearing
3process. However, a disenrolled vendor may reapply without
5    The Department has the discretion to limit the conditional
6enrollment period for vendors based upon category of risk of
7the vendor.
8    Prior to enrollment and during the conditional enrollment
9period in the medical assistance program, all vendors shall be
10subject to enhanced oversight, screening, and review based on
11the risk of fraud, waste, and abuse that is posed by the
12category of risk of the vendor. The Illinois Department shall
13establish the procedures for oversight, screening, and review,
14which may include, but need not be limited to: criminal and
15financial background checks; fingerprinting; license,
16certification, and authorization verifications; unscheduled or
17unannounced site visits; database checks; prepayment audit
18reviews; audits; payment caps; payment suspensions; and other
19screening as required by federal or State law.
20    The Department shall define or specify the following: (i)
21by provider notice, the "category of risk of the vendor" for
22each type of vendor, which shall take into account the level of
23screening applicable to a particular category of vendor under
24federal law and regulations; (ii) by rule or provider notice,
25the maximum length of the conditional enrollment period for
26each category of risk of the vendor; and (iii) by rule, the



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1hearing rights, if any, afforded to a vendor in each category
2of risk of the vendor that is terminated or disenrolled during
3the conditional enrollment period.
4    To be eligible for payment consideration, a vendor's
5payment claim or bill, either as an initial claim or as a
6resubmitted claim following prior rejection, must be received
7by the Illinois Department, or its fiscal intermediary, no
8later than 180 days after the latest date on the claim on which
9medical goods or services were provided, with the following
11        (1) In the case of a provider whose enrollment is in
12    process by the Illinois Department, the 180-day period
13    shall not begin until the date on the written notice from
14    the Illinois Department that the provider enrollment is
15    complete.
16        (2) In the case of errors attributable to the Illinois
17    Department or any of its claims processing intermediaries
18    which result in an inability to receive, process, or
19    adjudicate a claim, the 180-day period shall not begin
20    until the provider has been notified of the error.
21        (3) In the case of a provider for whom the Illinois
22    Department initiates the monthly billing process.
23        (4) In the case of a provider operated by a unit of
24    local government with a population exceeding 3,000,000
25    when local government funds finance federal participation
26    for claims payments.



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1    For claims for services rendered during a period for which
2a recipient received retroactive eligibility, claims must be
3filed within 180 days after the Department determines the
4applicant is eligible. For claims for which the Illinois
5Department is not the primary payer, claims must be submitted
6to the Illinois Department within 180 days after the final
7adjudication by the primary payer.
8    In the case of long term care facilities, within 45
9calendar days of receipt by the facility of required
10prescreening information, new admissions with associated
11admission documents shall be submitted through the Medical
12Electronic Data Interchange (MEDI) or the Recipient
13Eligibility Verification (REV) System or shall be submitted
14directly to the Department of Human Services using required
15admission forms. Effective September 1, 2014, admission
16documents, including all prescreening information, must be
17submitted through MEDI or REV. Confirmation numbers assigned to
18an accepted transaction shall be retained by a facility to
19verify timely submittal. Once an admission transaction has been
20completed, all resubmitted claims following prior rejection
21are subject to receipt no later than 180 days after the
22admission transaction has been completed.
23    Claims that are not submitted and received in compliance
24with the foregoing requirements shall not be eligible for
25payment under the medical assistance program, and the State
26shall have no liability for payment of those claims.



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



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



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1recipient's medical prognosis, the extent of the recipient's
2needs, and the requirements and costs for maintaining such
3equipment. Subject to prior approval, such rules shall enable a
4recipient to temporarily acquire and use alternative or
5substitute devices or equipment pending repairs or
6replacements of any device or equipment previously authorized
7for such recipient by the Department. Notwithstanding any
8provision of Section 5-5f to the contrary, the Department may,
9by rule, exempt certain replacement wheelchair parts from prior
10approval and, for wheelchairs, wheelchair parts, wheelchair
11accessories, and related seating and positioning items,
12determine the wholesale price by methods other than actual
13acquisition costs.
14    The Department shall require, by rule, all providers of
15durable medical equipment to be accredited by an accreditation
16organization approved by the federal Centers for Medicare and
17Medicaid Services and recognized by the Department in order to
18bill the Department for providing durable medical equipment to
19recipients. No later than 15 months after the effective date of
20the rule adopted pursuant to this paragraph, all providers must
21meet the accreditation requirement.
22    In order to promote environmental responsibility, meet the
23needs of recipients and enrollees, and achieve significant cost
24savings, the Department, or a managed care organization under
25contract with the Department, may provide recipients or managed
26care enrollees who have a prescription or Certificate of



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1Medical Necessity access to refurbished durable medical
2equipment under this Section (excluding prosthetic and
3orthotic devices as defined in the Orthotics, Prosthetics, and
4Pedorthics Practice Act and complex rehabilitation technology
5products and associated services) through the State's
6assistive technology program's reutilization program, using
7staff with the Assistive Technology Professional (ATP)
8Certification if the refurbished durable medical equipment:
9(i) is available; (ii) is less expensive, including shipping
10costs, than new durable medical equipment of the same type;
11(iii) is able to withstand at least 3 years of use; (iv) is
12cleaned, disinfected, sterilized, and safe in accordance with
13federal Food and Drug Administration regulations and guidance
14governing the reprocessing of medical devices in health care
15settings; and (v) equally meets the needs of the recipient or
16enrollee. The reutilization program shall confirm that the
17recipient or enrollee is not already in receipt of same or
18similar equipment from another service provider, and that the
19refurbished durable medical equipment equally meets the needs
20of the recipient or enrollee. Nothing in this paragraph shall
21be construed to limit recipient or enrollee choice to obtain
22new durable medical equipment or place any additional prior
23authorization conditions on enrollees of managed care
25    The Department shall execute, relative to the nursing home
26prescreening project, written inter-agency agreements with the



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1Department of Human Services and the Department on Aging, to
2effect the following: (i) intake procedures and common
3eligibility criteria for those persons who are receiving
4non-institutional services; and (ii) the establishment and
5development of non-institutional services in areas of the State
6where they are not currently available or are undeveloped; and
7(iii) notwithstanding any other provision of law, subject to
8federal approval, on and after July 1, 2012, an increase in the
9determination of need (DON) scores from 29 to 37 for applicants
10for institutional and home and community-based long term care;
11if and only if federal approval is not granted, the Department
12may, in conjunction with other affected agencies, implement
13utilization controls or changes in benefit packages to
14effectuate a similar savings amount for this population; and
15(iv) no later than July 1, 2013, minimum level of care
16eligibility criteria for institutional and home and
17community-based long term care; and (v) no later than October
181, 2013, establish procedures to permit long term care
19providers access to eligibility scores for individuals with an
20admission date who are seeking or receiving services from the
21long term care provider. In order to select the minimum level
22of care eligibility criteria, the Governor shall establish a
23workgroup that includes affected agency representatives and
24stakeholders representing the institutional and home and
25community-based long term care interests. This Section shall
26not restrict the Department from implementing lower level of



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1care eligibility criteria for community-based services in
2circumstances where federal approval has been granted.
3    The Illinois Department shall develop and operate, in
4cooperation with other State Departments and agencies and in
5compliance with applicable federal laws and regulations,
6appropriate and effective systems of health care evaluation and
7programs for monitoring of utilization of health care services
8and facilities, as it affects persons eligible for medical
9assistance under this Code.
10    The Illinois Department shall report annually to the
11General Assembly, no later than the second Friday in April of
121979 and each year thereafter, in regard to:
13        (a) actual statistics and trends in utilization of
14    medical services by public aid recipients;
15        (b) actual statistics and trends in the provision of
16    the various medical services by medical vendors;
17        (c) current rate structures and proposed changes in
18    those rate structures for the various medical vendors; and
19        (d) efforts at utilization review and control by the
20    Illinois Department.
21    The period covered by each report shall be the 3 years
22ending on the June 30 prior to the report. The report shall
23include suggested legislation for consideration by the General
24Assembly. The filing of one copy of the report with the
25Speaker, one copy with the Minority Leader and one copy with
26the Clerk of the House of Representatives, one copy with the



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



HB0004- 28 -LRB101 04058 KTG 49066 b

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



HB0004- 29 -LRB101 04058 KTG 49066 b

1means a drug that binds to opioid receptors and blocks or
2inhibits the effect of opioids acting on those receptors,
3including, but not limited to, naloxone hydrochloride or any
4other similarly acting drug approved by the U.S. Food and Drug
6    Upon federal approval, the Department shall provide
7coverage and reimbursement for all drugs that are approved for
8marketing by the federal Food and Drug Administration and that
9are recommended by the federal Public Health Service or the
10United States Centers for Disease Control and Prevention for
11pre-exposure prophylaxis and related pre-exposure prophylaxis
12services, including, but not limited to, HIV and sexually
13transmitted infection screening, treatment for sexually
14transmitted infections, medical monitoring, assorted labs, and
15counseling to reduce the likelihood of HIV infection among
16individuals who are not infected with HIV but who are at high
17risk of HIV infection.
18    A federally qualified health center, as defined in Section
191905(l)(2)(B) of the federal Social Security Act, shall be
20reimbursed by the Department in accordance with the federally
21qualified health center's encounter rate for services provided
22to medical assistance recipients that are performed by a dental
23hygienist, as defined under the Illinois Dental Practice Act,
24working under the general supervision of a dentist and employed
25by a federally qualified health center.
26    Notwithstanding any other provision of this Code, the



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1Illinois Department shall authorize licensed dietitian
2nutritionists and certified diabetes educators to counsel
3senior diabetes patients in the senior diabetes patients' homes
4to remove the hurdle of transportation for senior diabetes
5patients to receive treatment.
6    Notwithstanding any other provision of this Code, doula
7services shall be covered under the medical assistance program
8for persons who are otherwise eligible for medical assistance
9under this Article. To be eligible for reimbursement under this
10paragraph, the individual providing doula services must: (i) be
11certified by an entity that is nationally recognized for
12training and certifying doulas and that is approved by the
13Department; (ii) have completed a cultural competency course;
14(iii) have completed a course on Health Insurance Portability
15and Accountability Act compliance; (iv) be certified to perform
16cardiopulmonary resuscitation; and (v) be willing to submit to
17a federal and State criminal history background check. As used
18in this paragraph, "cultural competency course" means training
19in cultural sensitivity, cultural respect, and cultural
20humility that instructs a doula on how to acquire and use
21knowledge of the health-related beliefs, attitudes, practices,
22and communication patterns of clients and their families to
23improve services, strengthen programs, increase community
24participation, and close the gaps in health status among
25diverse population groups.
26(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;



HB0004- 31 -LRB101 04058 KTG 49066 b

199-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
2the effective date of P.A. 99-407); 99-433, eff. 8-21-15;
399-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
47-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
5eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
6100-538, eff. 1-1-18; 100-587, eff. 6-4-18; 100-759, eff.
71-1-19; 100-863, eff. 8-14-18; 100-974, eff. 8-19-18;
8100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; revised