Illinois General Assembly - Full Text of SB0346
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Full Text of SB0346  102nd General Assembly

SB0346enr 102ND GENERAL ASSEMBLY

  
  
  

 


 
SB0346 EnrolledLRB102 10839 KTG 16169 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
16home, or elsewhere; (6) medical care, or any other type of
17remedial care furnished by licensed practitioners; (7) home
18health care services; (8) private duty nursing service; (9)
19clinic services; (10) dental services, including prevention
20and treatment of periodontal disease and dental caries disease
21for pregnant women, provided by an individual licensed to
22practice dentistry or dental surgery; for purposes of this
23item (10), "dental services" means diagnostic, preventive, or

 

 

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1corrective procedures provided by or under the supervision of
2a dentist in the practice of his or her profession; (11)
3physical therapy and related services; (12) prescribed drugs,
4dentures, and prosthetic devices; and eyeglasses prescribed by
5a physician skilled in the diseases of the eye, or by an
6optometrist, whichever the person may select; (13) other
7diagnostic, screening, preventive, and rehabilitative
8services, including to ensure that the individual's need for
9intervention or treatment of mental disorders or substance use
10disorders or co-occurring mental health and substance use
11disorders is determined using a uniform screening, assessment,
12and evaluation 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
22sexual assault, 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
3persons who rely on treatment by spiritual means alone through
4prayer for 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
11Article.
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
16under this 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
23documentation.
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
7under this 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
17and Family Services may provide the following services to
18persons eligible 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
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
2and Family Services shall provide dental services to any adult
3who is 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
11profession.
12    On and after July 1, 2018, targeted dental services, as
13set forth in Exhibit D of the Consent Decree entered by the
14United States District Court for the Northern District of
15Illinois, Eastern Division, in the matter of Memisovski v.
16Maram, Case No. 92 C 1982, that are provided to adults under
17the medical assistance program shall be established at no less
18than the rates set forth in the "New Rate" column in Exhibit D
19of the Consent Decree for targeted dental services that are
20provided to persons under the age of 18 under the medical
21assistance program.
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
2assistance program. A not-for-profit health clinic shall
3include a public health clinic or Federally Qualified Health
4Center or other enrolled provider, as determined by the
5Department, through which dental services covered under this
6Section are performed. The Department shall establish a
7process for payment of claims for reimbursement for covered
8dental services rendered under this provision.
9    On and after January 1, 2022, the Department of Healthcare
10and Family Services shall administer and regulate a
11school-based dental program that allows for the out-of-office
12delivery of preventative dental services in a school setting
13to children under 19 years of age. The Department shall
14establish, by rule, guidelines for participation by providers
15and set requirements for follow-up referral care based on the
16requirements established in the Dental Office Reference Manual
17published by the Department that establishes the requirements
18for dentists participating in the All Kids Dental School
19Program. Every effort shall be made by the Department when
20developing the program requirements to consider the different
21geographic differences of both urban and rural areas of the
22State for initial treatment and necessary follow-up care. No
23provider shall be charged a fee by any unit of local government
24to participate in the school-based dental program administered
25by the Department. Nothing in this paragraph shall be
26construed to limit or preempt a home rule unit's or school

 

 

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1district's authority to establish, change, or administer a
2school-based dental program in addition to, or independent of,
3the school-based dental program administered by the
4Department.
5    The Illinois Department, by rule, may distinguish and
6classify the medical services to be provided only in
7accordance with the classes of persons designated in Section
85-2.
9    The Department of Healthcare and Family Services must
10provide coverage and reimbursement for amino acid-based
11elemental formulas, regardless of delivery method, for the
12diagnosis and treatment of (i) eosinophilic disorders and (ii)
13short bowel syndrome when the prescribing physician has issued
14a written order stating that the amino acid-based elemental
15formula is medically necessary.
16    The Illinois Department shall authorize the provision of,
17and shall authorize payment for, screening by low-dose
18mammography for the presence of occult breast cancer for women
1935 years of age or older who are eligible for medical
20assistance under this Article, as follows:
21        (A) A baseline mammogram for women 35 to 39 years of
22    age.
23        (B) An annual mammogram for women 40 years of age or
24    older.
25        (C) A mammogram at the age and intervals considered
26    medically necessary by the woman's health care provider

 

 

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1    for women under 40 years of age and having a family history
2    of breast cancer, prior personal history of breast cancer,
3    positive genetic testing, or other risk factors.
4        (D) A comprehensive ultrasound screening and MRI of an
5    entire breast or breasts if a mammogram demonstrates
6    heterogeneous or dense breast tissue or when medically
7    necessary as determined by a physician licensed to
8    practice medicine in all of its branches.
9        (E) A screening MRI when medically necessary, as
10    determined by a physician licensed to practice medicine in
11    all of its branches.
12        (F) A diagnostic mammogram when medically necessary,
13    as determined by a physician licensed to practice medicine
14    in all its branches, advanced practice registered nurse,
15    or physician assistant.
16    The Department shall not impose a deductible, coinsurance,
17copayment, or any other cost-sharing requirement on the
18coverage provided under this paragraph; except that this
19sentence does not apply to coverage of diagnostic mammograms
20to the extent such coverage would disqualify a high-deductible
21health plan from eligibility for a health savings account
22pursuant to Section 223 of the Internal Revenue Code (26
23U.S.C. 223).
24    All screenings shall include a physical breast exam,
25instruction on self-examination and information regarding the
26frequency of self-examination and its value as a preventative

 

 

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1tool.
2     For purposes of this Section:
3    "Diagnostic mammogram" means a mammogram obtained using
4diagnostic mammography.
5    "Diagnostic mammography" means a method of screening that
6is designed to evaluate an abnormality in a breast, including
7an abnormality seen or suspected on a screening mammogram or a
8subjective or objective abnormality otherwise detected in the
9breast.
10    "Low-dose mammography" means the x-ray examination of the
11breast using equipment dedicated specifically for mammography,
12including the x-ray tube, filter, compression device, and
13image receptor, with an average radiation exposure delivery of
14less than one rad per breast for 2 views of an average size
15breast. The term also includes digital mammography and
16includes breast tomosynthesis.
17    "Breast tomosynthesis" means a radiologic procedure that
18involves the acquisition of projection images over the
19stationary breast to produce cross-sectional digital
20three-dimensional images of the breast.
21    If, at any time, the Secretary of the United States
22Department of Health and Human Services, or its successor
23agency, promulgates rules or regulations to be published in
24the Federal Register or publishes a comment in the Federal
25Register or issues an opinion, guidance, or other action that
26would require the State, pursuant to any provision of the

 

 

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1Patient Protection and Affordable Care Act (Public Law
2111-148), including, but not limited to, 42 U.S.C.
318031(d)(3)(B) or any successor provision, to defray the cost
4of any coverage for breast tomosynthesis outlined in this
5paragraph, then the requirement that an insurer cover breast
6tomosynthesis is inoperative other than any such coverage
7authorized under Section 1902 of the Social Security Act, 42
8U.S.C. 1396a, and the State shall not assume any obligation
9for the cost of coverage for breast tomosynthesis set forth in
10this paragraph.
11    On and after January 1, 2016, the Department shall ensure
12that all networks of care for adult clients of the Department
13include access to at least one breast imaging Center of
14Imaging Excellence as certified by the American College of
15Radiology.
16    On and after January 1, 2012, providers participating in a
17quality improvement program approved by the Department shall
18be reimbursed for screening and diagnostic mammography at the
19same rate as the Medicare program's rates, including the
20increased reimbursement for digital mammography.
21    The Department shall convene an expert panel including
22representatives of hospitals, free-standing mammography
23facilities, and doctors, including radiologists, to establish
24quality standards for mammography.
25    On and after January 1, 2017, providers participating in a
26breast cancer treatment quality improvement program approved

 

 

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1by the Department shall be reimbursed for breast cancer
2treatment at a rate that is no lower than 95% of the Medicare
3program's rates for the data elements included in the breast
4cancer treatment quality program.
5    The Department shall convene an expert panel, including
6representatives of hospitals, free-standing breast cancer
7treatment centers, breast cancer quality organizations, and
8doctors, including breast surgeons, reconstructive breast
9surgeons, oncologists, and primary care providers to establish
10quality standards for breast cancer treatment.
11    Subject to federal approval, the Department shall
12establish a rate methodology for mammography at federally
13qualified health centers and other encounter-rate clinics.
14These clinics or centers may also collaborate with other
15hospital-based mammography facilities. By January 1, 2016, the
16Department shall report to the General Assembly on the status
17of the provision set forth in this paragraph.
18    The Department shall establish a methodology to remind
19women who are age-appropriate for screening mammography, but
20who have not received a mammogram within the previous 18
21months, of the importance and benefit of screening
22mammography. The Department shall work with experts in breast
23cancer outreach and patient navigation to optimize these
24reminders and shall establish a methodology for evaluating
25their effectiveness and modifying the methodology based on the
26evaluation.

 

 

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1    The Department shall establish a performance goal for
2primary care providers with respect to their female patients
3over age 40 receiving an annual mammogram. This performance
4goal shall be used to provide additional reimbursement in the
5form of a quality performance bonus to primary care providers
6who meet that goal.
7    The Department shall devise a means of case-managing or
8patient navigation for beneficiaries diagnosed with breast
9cancer. This program shall initially operate as a pilot
10program in areas of the State with the highest incidence of
11mortality related to breast cancer. At least one pilot program
12site shall be in the metropolitan Chicago area and at least one
13site shall be outside the metropolitan Chicago area. On or
14after July 1, 2016, the pilot program shall be expanded to
15include one site in western Illinois, one site in southern
16Illinois, one site in central Illinois, and 4 sites within
17metropolitan Chicago. An evaluation of the pilot program shall
18be carried out measuring health outcomes and cost of care for
19those served by the pilot program compared to similarly
20situated patients who are not served by the pilot program.
21    The Department shall require all networks of care to
22develop a means either internally or by contract with experts
23in navigation and community outreach to navigate cancer
24patients to comprehensive care in a timely fashion. The
25Department shall require all networks of care to include
26access for patients diagnosed with cancer to at least one

 

 

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1academic commission on cancer-accredited cancer program as an
2in-network covered benefit.
3    Any medical or health care provider shall immediately
4recommend, to any pregnant woman who is being provided
5prenatal services and is suspected of having a substance use
6disorder as defined in the Substance Use Disorder Act,
7referral to a local substance use disorder treatment program
8licensed by the Department of Human Services or to a licensed
9hospital which provides substance abuse treatment services.
10The Department of Healthcare and Family Services shall assure
11coverage for the cost of treatment of the drug abuse or
12addiction for pregnant recipients in accordance with the
13Illinois Medicaid Program in conjunction with the Department
14of Human Services.
15    All medical providers providing medical assistance to
16pregnant women under this Code shall receive information from
17the Department on the availability of services under any
18program providing case management services for addicted women,
19including information on appropriate referrals for other
20social services that may be needed by addicted women in
21addition to treatment for addiction.
22    The Illinois Department, in cooperation with the
23Departments of Human Services (as successor to the Department
24of Alcoholism and Substance Abuse) and Public Health, through
25a public awareness campaign, may provide information
26concerning treatment for alcoholism and drug abuse and

 

 

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1addiction, prenatal health care, and other pertinent programs
2directed at reducing the number of drug-affected infants born
3to recipients of medical assistance.
4    Neither the Department of Healthcare and Family Services
5nor the Department of Human Services shall sanction the
6recipient solely on the basis of her substance abuse.
7    The Illinois Department shall establish such regulations
8governing the dispensing of health services under this Article
9as it shall deem appropriate. The Department should seek the
10advice of formal professional advisory committees appointed by
11the Director of the Illinois Department for the purpose of
12providing regular advice on policy and administrative matters,
13information dissemination and educational activities for
14medical and health care providers, and consistency in
15procedures to the Illinois Department.
16    The Illinois Department may develop and contract with
17Partnerships of medical providers to arrange medical services
18for persons eligible under Section 5-2 of this Code.
19Implementation of this Section may be by demonstration
20projects in certain geographic areas. The Partnership shall be
21represented by a sponsor organization. The Department, by
22rule, shall develop qualifications for sponsors of
23Partnerships. Nothing in this Section shall be construed to
24require that the sponsor organization be a medical
25organization.
26    The sponsor must negotiate formal written contracts with

 

 

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1medical providers for physician services, inpatient and
2outpatient hospital care, home health services, treatment for
3alcoholism and substance abuse, and other services determined
4necessary by the Illinois Department by rule for delivery by
5Partnerships. Physician services must include prenatal and
6obstetrical care. The Illinois Department shall reimburse
7medical services delivered by Partnership providers to clients
8in target areas according to provisions of this Article and
9the Illinois Health Finance Reform Act, except that:
10        (1) Physicians participating in a Partnership and
11    providing certain services, which shall be determined by
12    the Illinois Department, to persons in areas covered by
13    the Partnership may receive an additional surcharge for
14    such services.
15        (2) The Department may elect to consider and negotiate
16    financial incentives to encourage the development of
17    Partnerships and the efficient delivery of medical care.
18        (3) Persons receiving medical services through
19    Partnerships may receive medical and case management
20    services above the level usually offered through the
21    medical assistance program.
22    Medical providers shall be required to meet certain
23qualifications to participate in Partnerships to ensure the
24delivery of high quality medical services. These
25qualifications shall be determined by rule of the Illinois
26Department and may be higher than qualifications for

 

 

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1participation in the medical assistance program. Partnership
2sponsors may prescribe reasonable additional qualifications
3for participation by medical providers, only with the prior
4written approval of the Illinois Department.
5    Nothing in this Section shall limit the free choice of
6practitioners, hospitals, and other providers of medical
7services by clients. In order to ensure patient freedom of
8choice, the Illinois Department shall immediately promulgate
9all rules and take all other necessary actions so that
10provided services may be accessed from therapeutically
11certified optometrists to the full extent of the Illinois
12Optometric Practice Act of 1987 without discriminating between
13service providers.
14    The Department shall apply for a waiver from the United
15States Health Care Financing Administration to allow for the
16implementation of Partnerships under this Section.
17    The Illinois Department shall require health care
18providers to maintain records that document the medical care
19and services provided to recipients of Medical Assistance
20under this Article. Such records must be retained for a period
21of not less than 6 years from the date of service or as
22provided by applicable State law, whichever period is longer,
23except that if an audit is initiated within the required
24retention period then the records must be retained until the
25audit is completed and every exception is resolved. The
26Illinois Department shall require health care providers to

 

 

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1make available, when authorized by the patient, in writing,
2the medical records in a timely fashion to other health care
3providers who are treating or serving persons eligible for
4Medical Assistance under this Article. All dispensers of
5medical services shall be required to maintain and retain
6business and professional records sufficient to fully and
7accurately document the nature, scope, details and receipt of
8the health care provided to persons eligible for medical
9assistance under this Code, in accordance with regulations
10promulgated by the Illinois Department. The rules and
11regulations shall require that proof of the receipt of
12prescription drugs, dentures, prosthetic devices and
13eyeglasses by eligible persons under this Section accompany
14each claim for reimbursement submitted by the dispenser of
15such medical services. No such claims for reimbursement shall
16be approved for payment by the Illinois Department without
17such proof of receipt, unless the Illinois Department shall
18have put into effect and shall be operating a system of
19post-payment audit and review which shall, on a sampling
20basis, be deemed adequate by the Illinois Department to assure
21that such drugs, dentures, prosthetic devices and eyeglasses
22for which payment is being made are actually being received by
23eligible recipients. Within 90 days after September 16, 1984
24(the effective date of Public Act 83-1439), the Illinois
25Department shall establish a current list of acquisition costs
26for all prosthetic devices and any other items recognized as

 

 

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1medical equipment and supplies reimbursable under this Article
2and shall update such list on a quarterly basis, except that
3the acquisition costs of all prescription drugs shall be
4updated no less frequently than every 30 days as required by
5Section 5-5.12.
6    Notwithstanding any other law to the contrary, the
7Illinois Department shall, within 365 days after July 22, 2013
8(the effective date of Public Act 98-104), establish
9procedures to permit skilled care facilities licensed under
10the Nursing Home Care Act to submit monthly billing claims for
11reimbursement purposes. Following development of these
12procedures, the Department shall, by July 1, 2016, test the
13viability of the new system and implement any necessary
14operational or structural changes to its information
15technology platforms in order to allow for the direct
16acceptance and payment of nursing home claims.
17    Notwithstanding any other law to the contrary, the
18Illinois Department shall, within 365 days after August 15,
192014 (the effective date of Public Act 98-963), establish
20procedures to permit ID/DD facilities licensed under the ID/DD
21Community Care Act and MC/DD facilities licensed under the
22MC/DD Act to submit monthly billing claims for reimbursement
23purposes. Following development of these procedures, the
24Department shall have an additional 365 days to test the
25viability of the new system and to ensure that any necessary
26operational or structural changes to its information

 

 

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1technology platforms are implemented.
2    The Illinois Department shall require all dispensers of
3medical services, other than an individual practitioner or
4group of practitioners, desiring to participate in the Medical
5Assistance program established under this Article to disclose
6all financial, beneficial, ownership, equity, surety or other
7interests in any and all firms, corporations, partnerships,
8associations, business enterprises, joint ventures, agencies,
9institutions or other legal entities providing any form of
10health care services in this State under this Article.
11    The Illinois Department may require that all dispensers of
12medical services desiring to participate in the medical
13assistance program established under this Article disclose,
14under such terms and conditions as the Illinois Department may
15by rule establish, all inquiries from clients and attorneys
16regarding medical bills paid by the Illinois Department, which
17inquiries could indicate potential existence of claims or
18liens for the Illinois Department.
19    Enrollment of a vendor shall be subject to a provisional
20period and shall be conditional for one year. During the
21period of conditional enrollment, the Department may terminate
22the vendor's eligibility to participate in, or may disenroll
23the vendor from, the medical assistance program without cause.
24Unless otherwise specified, such termination of eligibility or
25disenrollment is not subject to the Department's hearing
26process. However, a disenrolled vendor may reapply without

 

 

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1penalty.
2    The Department has the discretion to limit the conditional
3enrollment period for vendors based upon category of risk of
4the vendor.
5    Prior to enrollment and during the conditional enrollment
6period in the medical assistance program, all vendors shall be
7subject to enhanced oversight, screening, and review based on
8the risk of fraud, waste, and abuse that is posed by the
9category of risk of the vendor. The Illinois Department shall
10establish the procedures for oversight, screening, and review,
11which may include, but need not be limited to: criminal and
12financial background checks; fingerprinting; license,
13certification, and authorization verifications; unscheduled or
14unannounced site visits; database checks; prepayment audit
15reviews; audits; payment caps; payment suspensions; and other
16screening as required by federal or State law.
17    The Department shall define or specify the following: (i)
18by provider notice, the "category of risk of the vendor" for
19each type of vendor, which shall take into account the level of
20screening applicable to a particular category of vendor under
21federal law and regulations; (ii) by rule or provider notice,
22the maximum length of the conditional enrollment period for
23each category of risk of the vendor; and (iii) by rule, the
24hearing rights, if any, afforded to a vendor in each category
25of risk of the vendor that is terminated or disenrolled during
26the conditional enrollment period.

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1orthotic devices as defined in the Orthotics, Prosthetics, and
2Pedorthics Practice Act and complex rehabilitation technology
3products and associated services) through the State's
4assistive technology program's reutilization program, using
5staff with the Assistive Technology Professional (ATP)
6Certification if the refurbished durable medical equipment:
7(i) is available; (ii) is less expensive, including shipping
8costs, than new durable medical equipment of the same type;
9(iii) is able to withstand at least 3 years of use; (iv) is
10cleaned, disinfected, sterilized, and safe in accordance with
11federal Food and Drug Administration regulations and guidance
12governing the reprocessing of medical devices in health care
13settings; and (v) equally meets the needs of the recipient or
14enrollee. The reutilization program shall confirm that the
15recipient or enrollee is not already in receipt of same or
16similar equipment from another service provider, and that the
17refurbished durable medical equipment equally meets the needs
18of the recipient or enrollee. Nothing in this paragraph shall
19be construed to limit recipient or enrollee choice to obtain
20new durable medical equipment or place any additional prior
21authorization conditions on enrollees of managed care
22organizations.
23    The Department shall execute, relative to the nursing home
24prescreening project, written inter-agency agreements with the
25Department of Human Services and the Department on Aging, to
26effect the following: (i) intake procedures and common

 

 

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1eligibility criteria for those persons who are receiving
2non-institutional services; and (ii) the establishment and
3development of non-institutional services in areas of the
4State where they are not currently available or are
5undeveloped; and (iii) notwithstanding any other provision of
6law, subject to federal approval, on and after July 1, 2012, an
7increase in the determination of need (DON) scores from 29 to
837 for applicants for institutional and home and
9community-based long term care; if and only if federal
10approval is not granted, the Department may, in conjunction
11with other affected agencies, implement utilization controls
12or changes in benefit packages to effectuate a similar savings
13amount for this population; and (iv) no later than July 1,
142013, minimum level of care eligibility criteria for
15institutional and home and community-based long term care; and
16(v) no later than October 1, 2013, establish procedures to
17permit long term care providers access to eligibility scores
18for individuals with an admission date who are seeking or
19receiving services from the long term care provider. In order
20to select the minimum level of care eligibility criteria, the
21Governor shall establish a workgroup that includes affected
22agency representatives and stakeholders representing the
23institutional and home and community-based long term care
24interests. This Section shall not restrict the Department from
25implementing lower level of care eligibility criteria for
26community-based services in circumstances where federal

 

 

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1approval has been granted.
2    The Illinois Department shall develop and operate, in
3cooperation with other State Departments and agencies and in
4compliance with applicable federal laws and regulations,
5appropriate and effective systems of health care evaluation
6and programs for monitoring of utilization of health care
7services and facilities, as it affects persons eligible for
8medical assistance under this Code.
9    The Illinois Department shall report annually to the
10General Assembly, no later than the second Friday in April of
111979 and each year thereafter, in regard to:
12        (a) actual statistics and trends in utilization of
13    medical services by public aid recipients;
14        (b) actual statistics and trends in the provision of
15    the various medical services by medical vendors;
16        (c) current rate structures and proposed changes in
17    those rate structures for the various medical vendors; and
18        (d) efforts at utilization review and control by the
19    Illinois Department.
20    The period covered by each report shall be the 3 years
21ending on the June 30 prior to the report. The report shall
22include suggested legislation for consideration by the General
23Assembly. The requirement for reporting to the General
24Assembly shall be satisfied by filing copies of the report as
25required by Section 3.1 of the General Assembly Organization
26Act, and filing such additional copies with the State

 

 

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

 

 

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

 

 

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1the U.S. Food and Drug Administration.
2    Upon federal approval, the Department shall provide
3coverage and reimbursement for all drugs that are approved for
4marketing by the federal Food and Drug Administration and that
5are recommended by the federal Public Health Service or the
6United States Centers for Disease Control and Prevention for
7pre-exposure prophylaxis and related pre-exposure prophylaxis
8services, including, but not limited to, HIV and sexually
9transmitted infection screening, treatment for sexually
10transmitted infections, medical monitoring, assorted labs, and
11counseling to reduce the likelihood of HIV infection among
12individuals who are not infected with HIV but who are at high
13risk of HIV infection.
14    A federally qualified health center, as defined in Section
151905(l)(2)(B) of the federal Social Security Act, shall be
16reimbursed by the Department in accordance with the federally
17qualified health center's encounter rate for services provided
18to medical assistance recipients that are performed by a
19dental hygienist, as defined under the Illinois Dental
20Practice Act, working under the general supervision of a
21dentist and employed by a federally qualified health center.
22(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
23100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
246-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
25eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
26100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.

 

 

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11-1-20; revised 9-18-19.)
 
2    Section 99. Effective date. This Act takes effect January
31, 2022.