Full Text of HB0357 102nd General Assembly
HB0357enr 102ND GENERAL ASSEMBLY |
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| 1 | | AN ACT concerning public aid.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Public Aid Code is amended by | 5 | | changing 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 | 8 | | rule, shall
determine the quantity and quality of and the rate | 9 | | of reimbursement for the
medical assistance for which
payment | 10 | | will be authorized, and the medical services to be provided,
| 11 | | which may include all or part of the following: (1) inpatient | 12 | | hospital
services; (2) outpatient hospital services; (3) other | 13 | | laboratory and
X-ray services; (4) skilled nursing home | 14 | | services; (5) physicians'
services whether furnished in the | 15 | | office, the patient's home, a
hospital, a skilled nursing | 16 | | home, or elsewhere; (6) medical care, or any
other type of | 17 | | remedial care furnished by licensed practitioners; (7)
home | 18 | | health care services; (8) private duty nursing service; (9) | 19 | | clinic
services; (10) dental services, including prevention | 20 | | and treatment of periodontal disease and dental caries disease | 21 | | for pregnant women, provided by an individual licensed to | 22 | | practice dentistry or dental surgery; for purposes of this | 23 | | item (10), "dental services" means diagnostic, preventive, or |
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| 1 | | corrective procedures provided by or under the supervision of | 2 | | a dentist in the practice of his or her profession; (11) | 3 | | physical therapy and related
services; (12) prescribed drugs, | 4 | | dentures, and prosthetic devices; and
eyeglasses prescribed by | 5 | | a physician skilled in the diseases of the eye,
or by an | 6 | | optometrist, whichever the person may select; (13) other
| 7 | | diagnostic, screening, preventive, and rehabilitative | 8 | | services, including to ensure that the individual's need for | 9 | | intervention or treatment of mental disorders or substance use | 10 | | disorders or co-occurring mental health and substance use | 11 | | disorders is determined using a uniform screening, assessment, | 12 | | and evaluation process inclusive of criteria, for children and | 13 | | adults; for purposes of this item (13), a uniform screening, | 14 | | assessment, and evaluation process refers to a process that | 15 | | includes an appropriate evaluation and, as warranted, a | 16 | | referral; "uniform" does not mean the use of a singular | 17 | | instrument, tool, or process that all must utilize; (14)
| 18 | | transportation and such other expenses as may be necessary; | 19 | | (15) medical
treatment of sexual assault survivors, as defined | 20 | | in
Section 1a of the Sexual Assault Survivors Emergency | 21 | | Treatment Act, for
injuries sustained as a result of the | 22 | | sexual assault, including
examinations and laboratory tests to | 23 | | discover evidence which may be used in
criminal proceedings | 24 | | arising from the sexual assault; (16) the
diagnosis and | 25 | | treatment of sickle cell anemia; and (17)
any other medical | 26 | | care, and any other type of remedial care recognized
under the |
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| 1 | | laws of this State. The term "any other type of remedial care" | 2 | | shall
include nursing care and nursing home service for | 3 | | persons who rely on
treatment by spiritual means alone through | 4 | | prayer for healing.
| 5 | | Notwithstanding any other provision of this Section, a | 6 | | comprehensive
tobacco use cessation program that includes | 7 | | purchasing prescription drugs or
prescription medical devices | 8 | | approved by the Food and Drug Administration shall
be covered | 9 | | under the medical assistance
program under this Article for | 10 | | persons who are otherwise eligible for
assistance under this | 11 | | Article.
| 12 | | Notwithstanding any other provision of this Code, | 13 | | reproductive health care that is otherwise legal in Illinois | 14 | | shall be covered under the medical assistance program for | 15 | | persons who are otherwise eligible for medical assistance | 16 | | under this Article. | 17 | | Notwithstanding any other provision of this Code, the | 18 | | Illinois
Department may not require, as a condition of payment | 19 | | for any laboratory
test authorized under this Article, that a | 20 | | physician's handwritten signature
appear on the laboratory | 21 | | test order form. The Illinois Department may,
however, impose | 22 | | other appropriate requirements regarding laboratory test
order | 23 | | documentation.
| 24 | | Upon receipt of federal approval of an amendment to the | 25 | | Illinois Title XIX State Plan for this purpose, the Department | 26 | | shall authorize the Chicago Public Schools (CPS) to procure a |
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| 1 | | vendor or vendors to manufacture eyeglasses for individuals | 2 | | enrolled in a school within the CPS system. CPS shall ensure | 3 | | that its vendor or vendors are enrolled as providers in the | 4 | | medical assistance program and in any capitated Medicaid | 5 | | managed care entity (MCE) serving individuals enrolled in a | 6 | | school within the CPS system. Under any contract procured | 7 | | under this provision, the vendor or vendors must serve only | 8 | | individuals enrolled in a school within the CPS system. Claims | 9 | | for services provided by CPS's vendor or vendors to recipients | 10 | | of benefits in the medical assistance program under this Code, | 11 | | the Children's Health Insurance Program, or the Covering ALL | 12 | | KIDS Health Insurance Program shall be submitted to the | 13 | | Department or the MCE in which the individual is enrolled for | 14 | | payment and shall be reimbursed at the Department's or the | 15 | | MCE's established rates or rate methodologies for eyeglasses. | 16 | | On and after July 1, 2012, the Department of Healthcare | 17 | | and Family Services may provide the following services to
| 18 | | persons
eligible for assistance under this Article who are | 19 | | participating in
education, training or employment programs | 20 | | operated by the Department of Human
Services as successor to | 21 | | the Department of Public Aid:
| 22 | | (1) dental services provided by or under the | 23 | | supervision of a dentist; and
| 24 | | (2) eyeglasses prescribed by a physician skilled in | 25 | | the diseases of the
eye, or by an optometrist, whichever | 26 | | the person may select.
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| 1 | | On and after July 1, 2018, the Department of Healthcare | 2 | | and Family Services shall provide dental services to any adult | 3 | | who is otherwise eligible for assistance under the medical | 4 | | assistance program. As used in this paragraph, "dental | 5 | | services" means diagnostic, preventative, restorative, or | 6 | | corrective procedures, including procedures and services for | 7 | | the prevention and treatment of periodontal disease and dental | 8 | | caries disease, provided by an individual who is licensed to | 9 | | practice dentistry or dental surgery or who is under the | 10 | | supervision of a dentist in the practice of his or her | 11 | | profession. | 12 | | On and after July 1, 2018, targeted dental services, as | 13 | | set forth in Exhibit D of the Consent Decree entered by the | 14 | | United States District Court for the Northern District of | 15 | | Illinois, Eastern Division, in the matter of Memisovski v. | 16 | | Maram, Case No. 92 C 1982, that are provided to adults under | 17 | | the medical assistance program shall be established at no less | 18 | | than the rates set forth in the "New Rate" column in Exhibit D | 19 | | of the Consent Decree for targeted dental services that are | 20 | | provided to persons under the age of 18 under the medical | 21 | | assistance program. | 22 | | Notwithstanding any other provision of this Code and | 23 | | subject to federal approval, the Department may adopt rules to | 24 | | allow a dentist who is volunteering his or her service at no | 25 | | cost to render dental services through an enrolled | 26 | | not-for-profit health clinic without the dentist personally |
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| 1 | | enrolling as a participating provider in the medical | 2 | | assistance program. A not-for-profit health clinic shall | 3 | | include a public health clinic or Federally Qualified Health | 4 | | Center or other enrolled provider, as determined by the | 5 | | Department, through which dental services covered under this | 6 | | Section are performed. The Department shall establish a | 7 | | process for payment of claims for reimbursement for covered | 8 | | dental services rendered under this provision. | 9 | | The Illinois Department, by rule, may distinguish and | 10 | | classify the
medical services to be provided only in | 11 | | accordance with the classes of
persons designated in Section | 12 | | 5-2.
| 13 | | The Department of Healthcare and Family Services must | 14 | | provide coverage and reimbursement for amino acid-based | 15 | | elemental formulas, regardless of delivery method, for the | 16 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 17 | | short bowel syndrome when the prescribing physician has issued | 18 | | a written order stating that the amino acid-based elemental | 19 | | formula is medically necessary.
| 20 | | The Illinois Department shall authorize the provision of, | 21 | | and shall
authorize payment for, screening by low-dose | 22 | | mammography for the presence of
occult breast cancer for women | 23 | | 35 years of age or older who are eligible
for medical | 24 | | assistance under this Article, as follows: | 25 | | (A) A baseline
mammogram for women 35 to 39 years of | 26 | | age.
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| 1 | | (B) An annual mammogram for women 40 years of age or | 2 | | older. | 3 | | (C) A mammogram at the age and intervals considered | 4 | | medically necessary by the woman's health care provider | 5 | | for women under 40 years of age and having a family history | 6 | | of breast cancer, prior personal history of breast cancer, | 7 | | positive genetic testing, or other risk factors. | 8 | | (D) A comprehensive ultrasound screening and MRI of an | 9 | | entire breast or breasts if a mammogram demonstrates | 10 | | heterogeneous or dense breast tissue or when medically | 11 | | necessary as determined by a physician licensed to | 12 | | practice medicine in all of its branches. | 13 | | (E) A screening MRI when medically necessary, as | 14 | | determined by a physician licensed to practice medicine in | 15 | | all of its branches. | 16 | | (F) A diagnostic mammogram when medically necessary, | 17 | | as determined by a physician licensed to practice medicine | 18 | | in all its branches, advanced practice registered nurse, | 19 | | or physician assistant. | 20 | | The Department shall not impose a deductible, coinsurance, | 21 | | copayment, or any other cost-sharing requirement on the | 22 | | coverage provided under this paragraph; except that this | 23 | | sentence does not apply to coverage of diagnostic mammograms | 24 | | to the extent such coverage would disqualify a high-deductible | 25 | | health plan from eligibility for a health savings account | 26 | | pursuant to Section 223 of the Internal Revenue Code (26 |
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| 1 | | U.S.C. 223). | 2 | | All screenings
shall
include a physical breast exam, | 3 | | instruction on self-examination and
information regarding the | 4 | | frequency of self-examination and its value as a
preventative | 5 | | tool. | 6 | | For purposes of this Section: | 7 | | "Diagnostic
mammogram" means a mammogram obtained using | 8 | | diagnostic mammography. | 9 | | "Diagnostic
mammography" means a method of screening that | 10 | | is designed to
evaluate an abnormality in a breast, including | 11 | | an abnormality seen
or suspected on a screening mammogram or a | 12 | | subjective or objective
abnormality otherwise detected in the | 13 | | breast. | 14 | | "Low-dose mammography" means
the x-ray examination of the | 15 | | breast using equipment dedicated specifically
for mammography, | 16 | | including the x-ray tube, filter, compression device,
and | 17 | | image receptor, with an average radiation exposure delivery
of | 18 | | less than one rad per breast for 2 views of an average size | 19 | | breast.
The term also includes digital mammography and | 20 | | includes breast tomosynthesis. | 21 | | "Breast tomosynthesis" means a radiologic procedure that | 22 | | involves the acquisition of projection images over the | 23 | | stationary breast to produce cross-sectional digital | 24 | | three-dimensional images of the breast. | 25 | | If, at any time, the Secretary of the United States | 26 | | Department of Health and Human Services, or its successor |
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| 1 | | agency, promulgates rules or regulations to be published in | 2 | | the Federal Register or publishes a comment in the Federal | 3 | | Register or issues an opinion, guidance, or other action that | 4 | | would require the State, pursuant to any provision of the | 5 | | Patient Protection and Affordable Care Act (Public Law | 6 | | 111-148), including, but not limited to, 42 U.S.C. | 7 | | 18031(d)(3)(B) or any successor provision, to defray the cost | 8 | | of any coverage for breast tomosynthesis outlined in this | 9 | | paragraph, then the requirement that an insurer cover breast | 10 | | tomosynthesis is inoperative other than any such coverage | 11 | | authorized under Section 1902 of the Social Security Act, 42 | 12 | | U.S.C. 1396a, and the State shall not assume any obligation | 13 | | for the cost of coverage for breast tomosynthesis set forth in | 14 | | this paragraph.
| 15 | | On and after January 1, 2016, the Department shall ensure | 16 | | that all networks of care for adult clients of the Department | 17 | | include access to at least one breast imaging Center of | 18 | | Imaging Excellence as certified by the American College of | 19 | | Radiology. | 20 | | On and after January 1, 2012, providers participating in a | 21 | | quality improvement program approved by the Department shall | 22 | | be reimbursed for screening and diagnostic mammography at the | 23 | | same rate as the Medicare program's rates, including the | 24 | | increased reimbursement for digital mammography. | 25 | | The Department shall convene an expert panel including | 26 | | representatives of hospitals, free-standing mammography |
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| 1 | | facilities, and doctors, including radiologists, to establish | 2 | | quality standards for mammography. | 3 | | On and after January 1, 2017, providers participating in a | 4 | | breast cancer treatment quality improvement program approved | 5 | | by the Department shall be reimbursed for breast cancer | 6 | | treatment at a rate that is no lower than 95% of the Medicare | 7 | | program's rates for the data elements included in the breast | 8 | | cancer treatment quality program. | 9 | | The Department shall convene an expert panel, including | 10 | | representatives of hospitals, free-standing breast cancer | 11 | | treatment centers, breast cancer quality organizations, and | 12 | | doctors, including breast surgeons, reconstructive breast | 13 | | surgeons, oncologists, and primary care providers to establish | 14 | | quality standards for breast cancer treatment. | 15 | | Subject to federal approval, the Department shall | 16 | | establish a rate methodology for mammography at federally | 17 | | qualified health centers and other encounter-rate clinics. | 18 | | These clinics or centers may also collaborate with other | 19 | | hospital-based mammography facilities. By January 1, 2016, the | 20 | | Department shall report to the General Assembly on the status | 21 | | of the provision set forth in this paragraph. | 22 | | The Department shall establish a methodology to remind | 23 | | women who are age-appropriate for screening mammography, but | 24 | | who have not received a mammogram within the previous 18 | 25 | | months, of the importance and benefit of screening | 26 | | mammography. The Department shall work with experts in breast |
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| 1 | | cancer outreach and patient navigation to optimize these | 2 | | reminders and shall establish a methodology for evaluating | 3 | | their effectiveness and modifying the methodology based on the | 4 | | evaluation. | 5 | | The Department shall establish a performance goal for | 6 | | primary care providers with respect to their female patients | 7 | | over age 40 receiving an annual mammogram. This performance | 8 | | goal shall be used to provide additional reimbursement in the | 9 | | form of a quality performance bonus to primary care providers | 10 | | who meet that goal. | 11 | | The Department shall devise a means of case-managing or | 12 | | patient navigation for beneficiaries diagnosed with breast | 13 | | cancer. This program shall initially operate as a pilot | 14 | | program in areas of the State with the highest incidence of | 15 | | mortality related to breast cancer. At least one pilot program | 16 | | site shall be in the metropolitan Chicago area and at least one | 17 | | site shall be outside the metropolitan Chicago area. On or | 18 | | after July 1, 2016, the pilot program shall be expanded to | 19 | | include one site in western Illinois, one site in southern | 20 | | Illinois, one site in central Illinois, and 4 sites within | 21 | | metropolitan Chicago. An evaluation of the pilot program shall | 22 | | be carried out measuring health outcomes and cost of care for | 23 | | those served by the pilot program compared to similarly | 24 | | situated patients who are not served by the pilot program. | 25 | | The Department shall require all networks of care to | 26 | | develop a means either internally or by contract with experts |
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| 1 | | in navigation and community outreach to navigate cancer | 2 | | patients to comprehensive care in a timely fashion. The | 3 | | Department shall require all networks of care to include | 4 | | access for patients diagnosed with cancer to at least one | 5 | | academic commission on cancer-accredited cancer program as an | 6 | | in-network covered benefit. | 7 | | Any medical or health care provider shall immediately | 8 | | recommend, to
any pregnant woman who is being provided | 9 | | prenatal services and is suspected
of having a substance use | 10 | | disorder as defined in the Substance Use Disorder Act, | 11 | | referral to a local substance use disorder treatment program | 12 | | licensed by the Department of Human Services or to a licensed
| 13 | | hospital which provides substance abuse treatment services. | 14 | | The Department of Healthcare and Family Services
shall assure | 15 | | coverage for the cost of treatment of the drug abuse or
| 16 | | addiction for pregnant recipients in accordance with the | 17 | | Illinois Medicaid
Program in conjunction with the Department | 18 | | of Human Services.
| 19 | | All medical providers providing medical assistance to | 20 | | pregnant women
under this Code shall receive information from | 21 | | the Department on the
availability of services under any
| 22 | | program providing case management services for addicted women,
| 23 | | including information on appropriate referrals for other | 24 | | social services
that may be needed by addicted women in | 25 | | addition to treatment for addiction.
| 26 | | The Illinois Department, in cooperation with the |
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| 1 | | Departments of Human
Services (as successor to the Department | 2 | | of Alcoholism and Substance
Abuse) and Public Health, through | 3 | | a public awareness campaign, may
provide information | 4 | | concerning treatment for alcoholism and drug abuse and
| 5 | | addiction, prenatal health care, and other pertinent programs | 6 | | directed at
reducing the number of drug-affected infants born | 7 | | to recipients of medical
assistance.
| 8 | | Neither the Department of Healthcare and Family Services | 9 | | nor the Department of Human
Services shall sanction the | 10 | | recipient solely on the basis of
her substance abuse.
| 11 | | The Illinois Department shall establish such regulations | 12 | | governing
the dispensing of health services under this Article | 13 | | as it shall deem
appropriate. The Department
should
seek the | 14 | | advice of formal professional advisory committees appointed by
| 15 | | the Director of the Illinois Department for the purpose of | 16 | | providing regular
advice on policy and administrative matters, | 17 | | information dissemination and
educational activities for | 18 | | medical and health care providers, and
consistency in | 19 | | procedures to the Illinois Department.
| 20 | | The Illinois Department may develop and contract with | 21 | | Partnerships of
medical providers to arrange medical services | 22 | | for persons eligible under
Section 5-2 of this Code. | 23 | | Implementation of this Section may be by
demonstration | 24 | | projects in certain geographic areas. The Partnership shall
be | 25 | | represented by a sponsor organization. The Department, by | 26 | | rule, shall
develop qualifications for sponsors of |
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| 1 | | Partnerships. Nothing in this
Section shall be construed to | 2 | | require that the sponsor organization be a
medical | 3 | | organization.
| 4 | | The sponsor must negotiate formal written contracts with | 5 | | medical
providers for physician services, inpatient and | 6 | | outpatient hospital care,
home health services, treatment for | 7 | | alcoholism and substance abuse, and
other services determined | 8 | | necessary by the Illinois Department by rule for
delivery by | 9 | | Partnerships. Physician services must include prenatal and
| 10 | | obstetrical care. The Illinois Department shall reimburse | 11 | | medical services
delivered by Partnership providers to clients | 12 | | in target areas according to
provisions of this Article and | 13 | | the Illinois Health Finance Reform Act,
except that:
| 14 | | (1) Physicians participating in a Partnership and | 15 | | providing certain
services, which shall be determined by | 16 | | the Illinois Department, to persons
in areas covered by | 17 | | the Partnership may receive an additional surcharge
for | 18 | | such services.
| 19 | | (2) The Department may elect to consider and negotiate | 20 | | financial
incentives to encourage the development of | 21 | | Partnerships and the efficient
delivery of medical care.
| 22 | | (3) Persons receiving medical services through | 23 | | Partnerships may receive
medical and case management | 24 | | services above the level usually offered
through the | 25 | | medical assistance program.
| 26 | | Medical providers shall be required to meet certain |
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| 1 | | qualifications to
participate in Partnerships to ensure the | 2 | | delivery of high quality medical
services. These | 3 | | qualifications shall be determined by rule of the Illinois
| 4 | | Department and may be higher than qualifications for | 5 | | participation in the
medical assistance program. Partnership | 6 | | sponsors may prescribe reasonable
additional qualifications | 7 | | for participation by medical providers, only with
the prior | 8 | | written approval of the Illinois Department.
| 9 | | Nothing in this Section shall limit the free choice of | 10 | | practitioners,
hospitals, and other providers of medical | 11 | | services by clients.
In order to ensure patient freedom of | 12 | | choice, the Illinois Department shall
immediately promulgate | 13 | | all rules and take all other necessary actions so that
| 14 | | provided services may be accessed from therapeutically | 15 | | certified optometrists
to the full extent of the Illinois | 16 | | Optometric Practice Act of 1987 without
discriminating between | 17 | | service providers.
| 18 | | The Department shall apply for a waiver from the United | 19 | | States Health
Care Financing Administration to allow for the | 20 | | implementation of
Partnerships under this Section.
| 21 | | The Illinois Department shall require health care | 22 | | providers to maintain
records that document the medical care | 23 | | and services provided to recipients
of Medical Assistance | 24 | | under this Article. Such records must be retained for a period | 25 | | of not less than 6 years from the date of service or as | 26 | | provided by applicable State law, whichever period is longer, |
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| 1 | | except that if an audit is initiated within the required | 2 | | retention period then the records must be retained until the | 3 | | audit is completed and every exception is resolved. The | 4 | | Illinois Department shall
require health care providers to | 5 | | make available, when authorized by the
patient, in writing, | 6 | | the medical records in a timely fashion to other
health care | 7 | | providers who are treating or serving persons eligible for
| 8 | | Medical Assistance under this Article. All dispensers of | 9 | | medical services
shall be required to maintain and retain | 10 | | business and professional records
sufficient to fully and | 11 | | accurately document the nature, scope, details and
receipt of | 12 | | the health care provided to persons eligible for medical
| 13 | | assistance under this Code, in accordance with regulations | 14 | | promulgated by
the Illinois Department. The rules and | 15 | | regulations shall require that proof
of the receipt of | 16 | | prescription drugs, dentures, prosthetic devices and
| 17 | | eyeglasses by eligible persons under this Section accompany | 18 | | each claim
for reimbursement submitted by the dispenser of | 19 | | such medical services.
No such claims for reimbursement shall | 20 | | be approved for payment by the Illinois
Department without | 21 | | such proof of receipt, unless the Illinois Department
shall | 22 | | have put into effect and shall be operating a system of | 23 | | post-payment
audit and review which shall, on a sampling | 24 | | basis, be deemed adequate by
the Illinois Department to assure | 25 | | that such drugs, dentures, prosthetic
devices and eyeglasses | 26 | | for which payment is being made are actually being
received by |
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| 1 | | eligible recipients. Within 90 days after September 16, 1984 | 2 | | (the effective date of Public Act 83-1439), the Illinois | 3 | | Department shall establish a
current list of acquisition costs | 4 | | for all prosthetic devices and any
other items recognized as | 5 | | medical equipment and supplies reimbursable under
this Article | 6 | | and shall update such list on a quarterly basis, except that
| 7 | | the acquisition costs of all prescription drugs shall be | 8 | | updated no
less frequently than every 30 days as required by | 9 | | Section 5-5.12.
| 10 | | Notwithstanding any other law to the contrary, the | 11 | | Illinois Department shall, within 365 days after July 22, 2013 | 12 | | (the effective date of Public Act 98-104), establish | 13 | | procedures to permit skilled care facilities licensed under | 14 | | the Nursing Home Care Act to submit monthly billing claims for | 15 | | reimbursement purposes. Following development of these | 16 | | procedures, the Department shall, by July 1, 2016, test the | 17 | | viability of the new system and implement any necessary | 18 | | operational or structural changes to its information | 19 | | technology platforms in order to allow for the direct | 20 | | acceptance and payment of nursing home claims. | 21 | | Notwithstanding any other law to the contrary, the | 22 | | Illinois Department shall, within 365 days after August 15, | 23 | | 2014 (the effective date of Public Act 98-963), establish | 24 | | procedures to permit ID/DD facilities licensed under the ID/DD | 25 | | Community Care Act and MC/DD facilities licensed under the | 26 | | MC/DD Act to submit monthly billing claims for reimbursement |
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| 1 | | purposes. Following development of these procedures, the | 2 | | Department shall have an additional 365 days to test the | 3 | | viability of the new system and to ensure that any necessary | 4 | | operational or structural changes to its information | 5 | | technology platforms are implemented. | 6 | | The Illinois Department shall require all dispensers of | 7 | | medical
services, other than an individual practitioner or | 8 | | group of practitioners,
desiring to participate in the Medical | 9 | | Assistance program
established under this Article to disclose | 10 | | all financial, beneficial,
ownership, equity, surety or other | 11 | | interests in any and all firms,
corporations, partnerships, | 12 | | associations, business enterprises, joint
ventures, agencies, | 13 | | institutions or other legal entities providing any
form of | 14 | | health care services in this State under this Article.
| 15 | | The Illinois Department may require that all dispensers of | 16 | | medical
services desiring to participate in the medical | 17 | | assistance program
established under this Article disclose, | 18 | | under such terms and conditions as
the Illinois Department may | 19 | | by rule establish, all inquiries from clients
and attorneys | 20 | | regarding medical bills paid by the Illinois Department, which
| 21 | | inquiries could indicate potential existence of claims or | 22 | | liens for the
Illinois Department.
| 23 | | Enrollment of a vendor
shall be
subject to a provisional | 24 | | period and shall be conditional for one year. During the | 25 | | period of conditional enrollment, the Department may
terminate | 26 | | the vendor's eligibility to participate in, or may disenroll |
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| 1 | | the vendor from, the medical assistance
program without cause. | 2 | | Unless otherwise specified, such termination of eligibility or | 3 | | disenrollment is not subject to the
Department's hearing | 4 | | process.
However, a disenrolled vendor may reapply without | 5 | | penalty.
| 6 | | The Department has the discretion to limit the conditional | 7 | | enrollment period for vendors based upon category of risk of | 8 | | the vendor. | 9 | | Prior to enrollment and during the conditional enrollment | 10 | | period in the medical assistance program, all vendors shall be | 11 | | subject to enhanced oversight, screening, and review based on | 12 | | the risk of fraud, waste, and abuse that is posed by the | 13 | | category of risk of the vendor. The Illinois Department shall | 14 | | establish the procedures for oversight, screening, and review, | 15 | | which may include, but need not be limited to: criminal and | 16 | | financial background checks; fingerprinting; license, | 17 | | certification, and authorization verifications; unscheduled or | 18 | | unannounced site visits; database checks; prepayment audit | 19 | | reviews; audits; payment caps; payment suspensions; and other | 20 | | screening as required by federal or State law. | 21 | | The Department shall define or specify the following: (i) | 22 | | by provider notice, the "category of risk of the vendor" for | 23 | | each type of vendor, which shall take into account the level of | 24 | | screening applicable to a particular category of vendor under | 25 | | federal law and regulations; (ii) by rule or provider notice, | 26 | | the maximum length of the conditional enrollment period for |
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| 1 | | each category of risk of the vendor; and (iii) by rule, the | 2 | | hearing rights, if any, afforded to a vendor in each category | 3 | | of risk of the vendor that is terminated or disenrolled during | 4 | | the conditional enrollment period. | 5 | | To be eligible for payment consideration, a vendor's | 6 | | payment claim or bill, either as an initial claim or as a | 7 | | resubmitted claim following prior rejection, must be received | 8 | | by the Illinois Department, or its fiscal intermediary, no | 9 | | later than 180 days after the latest date on the claim on which | 10 | | medical goods or services were provided, with the following | 11 | | exceptions: | 12 | | (1) In the case of a provider whose enrollment is in | 13 | | process by the Illinois Department, the 180-day period | 14 | | shall not begin until the date on the written notice from | 15 | | the Illinois Department that the provider enrollment is | 16 | | complete. | 17 | | (2) In the case of errors attributable to the Illinois | 18 | | Department or any of its claims processing intermediaries | 19 | | which result in an inability to receive, process, or | 20 | | adjudicate a claim, the 180-day period shall not begin | 21 | | until the provider has been notified of the error. | 22 | | (3) In the case of a provider for whom the Illinois | 23 | | Department initiates the monthly billing process. | 24 | | (4) In the case of a provider operated by a unit of | 25 | | local government with a population exceeding 3,000,000 | 26 | | when local government funds finance federal participation |
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| 1 | | for claims payments. | 2 | | For claims for services rendered during a period for which | 3 | | a recipient received retroactive eligibility, claims must be | 4 | | filed within 180 days after the Department determines the | 5 | | applicant is eligible. For claims for which the Illinois | 6 | | Department is not the primary payer, claims must be submitted | 7 | | to the Illinois Department within 180 days after the final | 8 | | adjudication by the primary payer. | 9 | | In the case of long term care facilities, within 120 45 | 10 | | calendar days of receipt by the facility of required | 11 | | prescreening information, new admissions with associated | 12 | | admission documents shall be submitted through the Medical | 13 | | Electronic Data Interchange (MEDI) or the Recipient | 14 | | Eligibility Verification (REV) System or shall be submitted | 15 | | directly to the Department of Human Services using required | 16 | | admission forms. Effective September
1, 2014, admission | 17 | | documents, including all prescreening
information, must be | 18 | | submitted through MEDI or REV. Confirmation numbers assigned | 19 | | to an accepted transaction shall be retained by a facility to | 20 | | verify timely submittal. Once an admission transaction has | 21 | | been completed, all resubmitted claims following prior | 22 | | rejection are subject to receipt no later than 180 days after | 23 | | the admission transaction has been completed. | 24 | | Claims that are not submitted and received in compliance | 25 | | with the foregoing requirements shall not be eligible for | 26 | | payment under the medical assistance program, and the State |
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| 1 | | shall have no liability for payment of those claims. | 2 | | To the extent consistent with applicable information and | 3 | | privacy, security, and disclosure laws, State and federal | 4 | | agencies and departments shall provide the Illinois Department | 5 | | access to confidential and other information and data | 6 | | necessary to perform eligibility and payment verifications and | 7 | | other Illinois Department functions. This includes, but is not | 8 | | limited to: information pertaining to licensure; | 9 | | certification; earnings; immigration status; citizenship; wage | 10 | | reporting; unearned and earned income; pension income; | 11 | | employment; supplemental security income; social security | 12 | | numbers; National Provider Identifier (NPI) numbers; the | 13 | | National Practitioner Data Bank (NPDB); program and agency | 14 | | exclusions; taxpayer identification numbers; tax delinquency; | 15 | | corporate information; and death records. | 16 | | The Illinois Department shall enter into agreements with | 17 | | State agencies and departments, and is authorized to enter | 18 | | into agreements with federal agencies and departments, under | 19 | | which such agencies and departments shall share data necessary | 20 | | for medical assistance program integrity functions and | 21 | | oversight. The Illinois Department shall develop, in | 22 | | cooperation with other State departments and agencies, and in | 23 | | compliance with applicable federal laws and regulations, | 24 | | appropriate and effective methods to share such data. At a | 25 | | minimum, and to the extent necessary to provide data sharing, | 26 | | the Illinois Department shall enter into agreements with State |
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| 1 | | agencies and departments, and is authorized to enter into | 2 | | agreements with federal agencies and departments, including , | 3 | | but not limited to: the Secretary of State; the Department of | 4 | | Revenue; the Department of Public Health; the Department of | 5 | | Human Services; and the Department of Financial and | 6 | | Professional Regulation. | 7 | | Beginning in fiscal year 2013, the Illinois Department | 8 | | shall set forth a request for information to identify the | 9 | | benefits of a pre-payment, post-adjudication, and post-edit | 10 | | claims system with the goals of streamlining claims processing | 11 | | and provider reimbursement, reducing the number of pending or | 12 | | rejected claims, and helping to ensure a more transparent | 13 | | adjudication process through the utilization of: (i) provider | 14 | | data verification and provider screening technology; and (ii) | 15 | | clinical code editing; and (iii) pre-pay, pre- or | 16 | | post-adjudicated predictive modeling with an integrated case | 17 | | management system with link analysis. Such a request for | 18 | | information shall not be considered as a request for proposal | 19 | | or as an obligation on the part of the Illinois Department to | 20 | | take any action or acquire any products or services. | 21 | | The Illinois Department shall establish policies, | 22 | | procedures,
standards and criteria by rule for the | 23 | | acquisition, repair and replacement
of orthotic and prosthetic | 24 | | devices and durable medical equipment. Such
rules shall | 25 | | provide, but not be limited to, the following services: (1)
| 26 | | immediate repair or replacement of such devices by recipients; |
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| 1 | | and (2) rental, lease, purchase or lease-purchase of
durable | 2 | | medical equipment in a cost-effective manner, taking into
| 3 | | consideration the recipient's medical prognosis, the extent of | 4 | | the
recipient's needs, and the requirements and costs for | 5 | | maintaining such
equipment. Subject to prior approval, such | 6 | | rules shall enable a recipient to temporarily acquire and
use | 7 | | alternative or substitute devices or equipment pending repairs | 8 | | or
replacements of any device or equipment previously | 9 | | authorized for such
recipient by the Department. | 10 | | Notwithstanding any provision of Section 5-5f to the contrary, | 11 | | the Department may, by rule, exempt certain replacement | 12 | | wheelchair parts from prior approval and, for wheelchairs, | 13 | | wheelchair parts, wheelchair accessories, and related seating | 14 | | and positioning items, determine the wholesale price by | 15 | | methods other than actual acquisition costs. | 16 | | The Department shall require, by rule, all providers of | 17 | | durable medical equipment to be accredited by an accreditation | 18 | | organization approved by the federal Centers for Medicare and | 19 | | Medicaid Services and recognized by the Department in order to | 20 | | bill the Department for providing durable medical equipment to | 21 | | recipients. No later than 15 months after the effective date | 22 | | of the rule adopted pursuant to this paragraph, all providers | 23 | | must meet the accreditation requirement.
| 24 | | In order to promote environmental responsibility, meet the | 25 | | needs of recipients and enrollees, and achieve significant | 26 | | cost savings, the Department, or a managed care organization |
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| 1 | | under contract with the Department, may provide recipients or | 2 | | managed care enrollees who have a prescription or Certificate | 3 | | of Medical Necessity access to refurbished durable medical | 4 | | equipment under this Section (excluding prosthetic and | 5 | | orthotic devices as defined in the Orthotics, Prosthetics, and | 6 | | Pedorthics Practice Act and complex rehabilitation technology | 7 | | products and associated services) through the State's | 8 | | assistive technology program's reutilization program, using | 9 | | staff with the Assistive Technology Professional (ATP) | 10 | | Certification if the refurbished durable medical equipment: | 11 | | (i) is available; (ii) is less expensive, including shipping | 12 | | costs, than new durable medical equipment of the same type; | 13 | | (iii) is able to withstand at least 3 years of use; (iv) is | 14 | | cleaned, disinfected, sterilized, and safe in accordance with | 15 | | federal Food and Drug Administration regulations and guidance | 16 | | governing the reprocessing of medical devices in health care | 17 | | settings; and (v) equally meets the needs of the recipient or | 18 | | enrollee. The reutilization program shall confirm that the | 19 | | recipient or enrollee is not already in receipt of same or | 20 | | similar equipment from another service provider, and that the | 21 | | refurbished durable medical equipment equally meets the needs | 22 | | of the recipient or enrollee. Nothing in this paragraph shall | 23 | | be construed to limit recipient or enrollee choice to obtain | 24 | | new durable medical equipment or place any additional prior | 25 | | authorization conditions on enrollees of managed care | 26 | | organizations. |
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| 1 | | The Department shall execute, relative to the nursing home | 2 | | prescreening
project, written inter-agency agreements with the | 3 | | Department of Human
Services and the Department on Aging, to | 4 | | effect the following: (i) intake
procedures and common | 5 | | eligibility criteria for those persons who are receiving
| 6 | | non-institutional services; and (ii) the establishment and | 7 | | development of
non-institutional services in areas of the | 8 | | State where they are not currently
available or are | 9 | | undeveloped; and (iii) notwithstanding any other provision of | 10 | | law, subject to federal approval, on and after July 1, 2012, an | 11 | | increase in the determination of need (DON) scores from 29 to | 12 | | 37 for applicants for institutional and home and | 13 | | community-based long term care; if and only if federal | 14 | | approval is not granted, the Department may, in conjunction | 15 | | with other affected agencies, implement utilization controls | 16 | | or changes in benefit packages to effectuate a similar savings | 17 | | amount for this population; and (iv) no later than July 1, | 18 | | 2013, minimum level of care eligibility criteria for | 19 | | institutional and home and community-based long term care; and | 20 | | (v) no later than October 1, 2013, establish procedures to | 21 | | permit long term care providers access to eligibility scores | 22 | | for individuals with an admission date who are seeking or | 23 | | receiving services from the long term care provider. In order | 24 | | to select the minimum level of care eligibility criteria, the | 25 | | Governor shall establish a workgroup that includes affected | 26 | | agency representatives and stakeholders representing the |
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| 1 | | institutional and home and community-based long term care | 2 | | interests. This Section shall not restrict the Department from | 3 | | implementing lower level of care eligibility criteria for | 4 | | community-based services in circumstances where federal | 5 | | approval has been granted.
| 6 | | The Illinois Department shall develop and operate, in | 7 | | cooperation
with other State Departments and agencies and in | 8 | | compliance with
applicable federal laws and regulations, | 9 | | appropriate and effective
systems of health care evaluation | 10 | | and programs for monitoring of
utilization of health care | 11 | | services and facilities, as it affects
persons eligible for | 12 | | medical assistance under this Code.
| 13 | | The Illinois Department shall report annually to the | 14 | | General Assembly,
no later than the second Friday in April of | 15 | | 1979 and each year
thereafter, in regard to:
| 16 | | (a) actual statistics and trends in utilization of | 17 | | medical services by
public aid recipients;
| 18 | | (b) actual statistics and trends in the provision of | 19 | | the various medical
services by medical vendors;
| 20 | | (c) current rate structures and proposed changes in | 21 | | those rate structures
for the various medical vendors; and
| 22 | | (d) efforts at utilization review and control by the | 23 | | Illinois Department.
| 24 | | The period covered by each report shall be the 3 years | 25 | | ending on the June
30 prior to the report. The report shall | 26 | | include suggested legislation
for consideration by the General |
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| 1 | | Assembly. The requirement for reporting to the General | 2 | | Assembly shall be satisfied
by filing copies of the report as | 3 | | required by Section 3.1 of the General Assembly Organization | 4 | | Act, and filing such additional
copies
with the State | 5 | | Government Report Distribution Center for the General
Assembly | 6 | | as is required under paragraph (t) of Section 7 of the State
| 7 | | Library Act.
| 8 | | Rulemaking authority to implement Public Act 95-1045, if | 9 | | any, is conditioned on the rules being adopted in accordance | 10 | | with all provisions of the Illinois Administrative Procedure | 11 | | Act and all rules and procedures of the Joint Committee on | 12 | | Administrative Rules; any purported rule not so adopted, for | 13 | | whatever reason, is unauthorized. | 14 | | On and after July 1, 2012, the Department shall reduce any | 15 | | rate of reimbursement for services or other payments or alter | 16 | | any methodologies authorized by this Code to reduce any rate | 17 | | of reimbursement for services or other payments in accordance | 18 | | with Section 5-5e. | 19 | | Because kidney transplantation can be an appropriate, | 20 | | cost-effective
alternative to renal dialysis when medically | 21 | | necessary and notwithstanding the provisions of Section 1-11 | 22 | | of this Code, beginning October 1, 2014, the Department shall | 23 | | cover kidney transplantation for noncitizens with end-stage | 24 | | renal disease who are not eligible for comprehensive medical | 25 | | benefits, who meet the residency requirements of Section 5-3 | 26 | | of this Code, and who would otherwise meet the financial |
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| 1 | | requirements of the appropriate class of eligible persons | 2 | | under Section 5-2 of this Code. To qualify for coverage of | 3 | | kidney transplantation, such person must be receiving | 4 | | emergency renal dialysis services covered by the Department. | 5 | | Providers under this Section shall be prior approved and | 6 | | certified by the Department to perform kidney transplantation | 7 | | and the services under this Section shall be limited to | 8 | | services associated with kidney transplantation. | 9 | | Notwithstanding any other provision of this Code to the | 10 | | contrary, on or after July 1, 2015, all FDA approved forms of | 11 | | medication assisted treatment prescribed for the treatment of | 12 | | alcohol dependence or treatment of opioid dependence shall be | 13 | | covered under both fee for service and managed care medical | 14 | | assistance programs for persons who are otherwise eligible for | 15 | | medical assistance under this Article and shall not be subject | 16 | | to any (1) utilization control, other than those established | 17 | | under the American Society of Addiction Medicine patient | 18 | | placement criteria,
(2) prior authorization mandate, or (3) | 19 | | lifetime restriction limit
mandate. | 20 | | On or after July 1, 2015, opioid antagonists prescribed | 21 | | for the treatment of an opioid overdose, including the | 22 | | medication product, administration devices, and any pharmacy | 23 | | fees related to the dispensing and administration of the | 24 | | opioid antagonist, shall be covered under the medical | 25 | | assistance program for persons who are otherwise eligible for | 26 | | medical assistance under this Article. As used in this |
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| 1 | | Section, "opioid antagonist" means a drug that binds to opioid | 2 | | receptors and blocks or inhibits the effect of opioids acting | 3 | | on those receptors, including, but not limited to, naloxone | 4 | | hydrochloride or any other similarly acting drug approved by | 5 | | the U.S. Food and Drug Administration. | 6 | | Upon federal approval, the Department shall provide | 7 | | coverage and reimbursement for all drugs that are approved for | 8 | | marketing by the federal Food and Drug Administration and that | 9 | | are recommended by the federal Public Health Service or the | 10 | | United States Centers for Disease Control and Prevention for | 11 | | pre-exposure prophylaxis and related pre-exposure prophylaxis | 12 | | services, including, but not limited to, HIV and sexually | 13 | | transmitted infection screening, treatment for sexually | 14 | | transmitted infections, medical monitoring, assorted labs, and | 15 | | counseling to reduce the likelihood of HIV infection among | 16 | | individuals who are not infected with HIV but who are at high | 17 | | risk of HIV infection. | 18 | | A federally qualified health center, as defined in Section | 19 | | 1905(l)(2)(B) of the federal
Social Security Act, shall be | 20 | | reimbursed by the Department in accordance with the federally | 21 | | qualified health center's encounter rate for services provided | 22 | | to medical assistance recipients that are performed by a | 23 | | dental hygienist, as defined under the Illinois Dental | 24 | | Practice Act, working under the general supervision of a | 25 | | dentist and employed by a federally qualified health center. | 26 | | (Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18; |
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| 1 | | 100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff. | 2 | | 6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974, | 3 | | eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; | 4 | | 100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff. | 5 | | 1-1-20; revised 9-18-19.)
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