Illinois General Assembly - Full Text of HB4351
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Full Text of HB4351  99th General Assembly

HB4351enr 99TH GENERAL ASSEMBLY

  
  
  

 


 
HB4351 EnrolledLRB099 15530 KTG 39820 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 Act on the Aging is amended by
5changing Section 4.02 as follows:
 
6    (20 ILCS 105/4.02)  (from Ch. 23, par. 6104.02)
7    Sec. 4.02. Community Care Program. The Department shall
8establish a program of services to prevent unnecessary
9institutionalization of persons age 60 and older in need of
10long term care or who are established as persons who suffer
11from Alzheimer's disease or a related disorder under the
12Alzheimer's Disease Assistance Act, thereby enabling them to
13remain in their own homes or in other living arrangements. Such
14preventive services, which may be coordinated with other
15programs for the aged and monitored by area agencies on aging
16in cooperation with the Department, may include, but are not
17limited to, any or all of the following:
18        (a) (blank);
19        (b) (blank);
20        (c) home care aide services;
21        (d) personal assistant services;
22        (e) adult day services;
23        (f) home-delivered meals;

 

 

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1        (g) education in self-care;
2        (h) personal care services;
3        (i) adult day health services;
4        (j) habilitation services;
5        (k) respite care;
6        (k-5) community reintegration services;
7        (k-6) flexible senior services;
8        (k-7) medication management;
9        (k-8) emergency home response;
10        (l) other nonmedical social services that may enable
11    the person to become self-supporting; or
12        (m) clearinghouse for information provided by senior
13    citizen home owners who want to rent rooms to or share
14    living space with other senior citizens.
15    Individuals who meet the following criteria shall have
16equal access to services under the Community Care Program: The
17Department shall establish eligibility standards for such
18services.
19        (a) are 60 years old or older;
20        (b) are U.S. citizens or legal aliens;
21        (c) are residents of Illinois;
22        (d) have non-exempt assets of $17,500 or less;
23    non-exempt assets do not include home, car, or personal
24    furnishings; and
25        (e) have an assessed need for long term care, as
26    provided in this Section, and are at risk for nursing

 

 

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1    facility placement as measured by the determination of need
2    assessment tool or a future updated assessment tool.
3In determining the amount and nature of services for which a
4person may qualify, consideration shall not be given to the
5value of cash, property or other assets held in the name of the
6person's spouse pursuant to a written agreement dividing
7marital property into equal but separate shares or pursuant to
8a transfer of the person's interest in a home to his spouse,
9provided that the spouse's share of the marital property is not
10made available to the person seeking such services.
11    Need for long term care shall be determined as follows:
12    Individuals with a score of 29 or higher based on the
13determination of need (DON) assessment tool shall be eligible
14to receive institutional and home and community-based long term
15care services until such time that the State receives federal
16approval and implements an updated assessment tool, and those
17individuals are found to be ineligible under that updated
18assessment tool. Anyone determined to be ineligible for
19services due to the updated assessment tool shall continue to
20be eligible for services for at least one year following that
21determination and must be reassessed no earlier than 11 months
22after that determination. The Department must adopt rules
23through the regular rulemaking process regarding the updated
24assessment tool, and shall not adopt emergency or peremptory
25rules regarding the updated assessment tool. The State shall
26not implement an updated assessment tool that causes more than

 

 

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11% of then-current recipients to lose eligibility.
2    Service cost maximums shall be set at levels no lower than
3the service cost maximums that were in effect as of January 1,
42016. Service cost maximums shall be increased accordingly to
5reflect any rate increases.
6    Beginning January 1, 2008, the Department shall require as
7a condition of eligibility that all new financially eligible
8applicants apply for and enroll in medical assistance under
9Article V of the Illinois Public Aid Code in accordance with
10rules promulgated by the Department.
11    The Department shall, in conjunction with the Department of
12Public Aid (now Department of Healthcare and Family Services),
13seek appropriate amendments under Sections 1915 and 1924 of the
14Social Security Act. The purpose of the amendments shall be to
15extend eligibility for home and community based services under
16Sections 1915 and 1924 of the Social Security Act to persons
17who transfer to or for the benefit of a spouse those amounts of
18income and resources allowed under Section 1924 of the Social
19Security Act. Subject to the approval of such amendments, the
20Department shall extend the provisions of Section 5-4 of the
21Illinois Public Aid Code to persons who, but for the provision
22of home or community-based services, would require the level of
23care provided in an institution, as is provided for in federal
24law. Those persons no longer found to be eligible for receiving
25noninstitutional services due to changes in the eligibility
26criteria shall be given 45 days notice prior to actual

 

 

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1termination. Those persons receiving notice of termination may
2contact the Department and request the determination be
3appealed at any time during the 45 day notice period. The
4target population identified for the purposes of this Section
5are persons age 60 and older with an identified service need.
6Priority shall be given to those who are at imminent risk of
7institutionalization. The services shall be provided to
8eligible persons age 60 and older to the extent that the cost
9of the services together with the other personal maintenance
10expenses of the persons are reasonably related to the standards
11established for care in a group facility appropriate to the
12person's condition. These non-institutional services, pilot
13projects or experimental facilities may be provided as part of
14or in addition to those authorized by federal law or those
15funded and administered by the Department of Human Services.
16The Departments of Human Services, Healthcare and Family
17Services, Public Health, Veterans' Affairs, and Commerce and
18Economic Opportunity and other appropriate agencies of State,
19federal and local governments shall cooperate with the
20Department on Aging in the establishment and development of the
21non-institutional services. The Department shall require an
22annual audit from all personal assistant and home care aide
23vendors contracting with the Department under this Section. The
24annual audit shall assure that each audited vendor's procedures
25are in compliance with Department's financial reporting
26guidelines requiring an administrative and employee wage and

 

 

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1benefits cost split as defined in administrative rules. The
2audit is a public record under the Freedom of Information Act.
3The Department shall execute, relative to the nursing home
4prescreening project, written inter-agency agreements with the
5Department of Human Services and the Department of Healthcare
6and Family Services, to effect the following: (1) intake
7procedures and common eligibility criteria for those persons
8who are receiving non-institutional services; and (2) the
9establishment and development of non-institutional services in
10areas of the State where they are not currently available or
11are undeveloped. On and after July 1, 1996, all nursing home
12prescreenings for individuals 60 years of age or older shall be
13conducted by the Department.
14    As part of the Department on Aging's routine training of
15case managers and case manager supervisors, the Department may
16include information on family futures planning for persons who
17are age 60 or older and who are caregivers of their adult
18children with developmental disabilities. The content of the
19training shall be at the Department's discretion.
20    The Department is authorized to establish a system of
21recipient copayment for services provided under this Section,
22such copayment to be based upon the recipient's ability to pay
23but in no case to exceed the actual cost of the services
24provided. Additionally, any portion of a person's income which
25is equal to or less than the federal poverty standard shall not
26be considered by the Department in determining the copayment.

 

 

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1The level of such copayment shall be adjusted whenever
2necessary to reflect any change in the officially designated
3federal poverty standard.
4    The Department, or the Department's authorized
5representative, may recover the amount of moneys expended for
6services provided to or in behalf of a person under this
7Section by a claim against the person's estate or against the
8estate of the person's surviving spouse, but no recovery may be
9had until after the death of the surviving spouse, if any, and
10then only at such time when there is no surviving child who is
11under age 21 or blind or who has a permanent and total
12disability. This paragraph, however, shall not bar recovery, at
13the death of the person, of moneys for services provided to the
14person or in behalf of the person under this Section to which
15the person was not entitled; provided that such recovery shall
16not be enforced against any real estate while it is occupied as
17a homestead by the surviving spouse or other dependent, if no
18claims by other creditors have been filed against the estate,
19or, if such claims have been filed, they remain dormant for
20failure of prosecution or failure of the claimant to compel
21administration of the estate for the purpose of payment. This
22paragraph shall not bar recovery from the estate of a spouse,
23under Sections 1915 and 1924 of the Social Security Act and
24Section 5-4 of the Illinois Public Aid Code, who precedes a
25person receiving services under this Section in death. All
26moneys for services paid to or in behalf of the person under

 

 

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1this Section shall be claimed for recovery from the deceased
2spouse's estate. "Homestead", as used in this paragraph, means
3the dwelling house and contiguous real estate occupied by a
4surviving spouse or relative, as defined by the rules and
5regulations of the Department of Healthcare and Family
6Services, regardless of the value of the property.
7    The Department shall increase the effectiveness of the
8existing Community Care Program by:
9        (1) ensuring that in-home services included in the care
10    plan are available on evenings and weekends;
11        (2) ensuring that care plans contain the services that
12    eligible participants need based on the number of days in a
13    month, not limited to specific blocks of time, as
14    identified by the comprehensive assessment tool selected
15    by the Department for use statewide, not to exceed the
16    total monthly service cost maximum allowed for each
17    service; the Department shall develop administrative rules
18    to implement this item (2);
19        (3) ensuring that the participants have the right to
20    choose the services contained in their care plan and to
21    direct how those services are provided, based on
22    administrative rules established by the Department;
23        (4) ensuring that the determination of need tool is
24    accurate in determining the participants' level of need; to
25    achieve this, the Department, in conjunction with the Older
26    Adult Services Advisory Committee, shall institute a study

 

 

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1    of the relationship between the Determination of Need
2    scores, level of need, service cost maximums, and the
3    development and utilization of service plans no later than
4    May 1, 2008; findings and recommendations shall be
5    presented to the Governor and the General Assembly no later
6    than January 1, 2009; recommendations shall include all
7    needed changes to the service cost maximums schedule and
8    additional covered services;
9        (5) ensuring that homemakers can provide personal care
10    services that may or may not involve contact with clients,
11    including but not limited to:
12            (A) bathing;
13            (B) grooming;
14            (C) toileting;
15            (D) nail care;
16            (E) transferring;
17            (F) respiratory services;
18            (G) exercise; or
19            (H) positioning;
20        (6) ensuring that homemaker program vendors are not
21    restricted from hiring homemakers who are family members of
22    clients or recommended by clients; the Department may not,
23    by rule or policy, require homemakers who are family
24    members of clients or recommended by clients to accept
25    assignments in homes other than the client;
26        (7) ensuring that the State may access maximum federal

 

 

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1    matching funds by seeking approval for the Centers for
2    Medicare and Medicaid Services for modifications to the
3    State's home and community based services waiver and
4    additional waiver opportunities, including applying for
5    enrollment in the Balance Incentive Payment Program by May
6    1, 2013, in order to maximize federal matching funds; this
7    shall include, but not be limited to, modification that
8    reflects all changes in the Community Care Program services
9    and all increases in the services cost maximum;
10        (8) ensuring that the determination of need tool
11    accurately reflects the service needs of individuals with
12    Alzheimer's disease and related dementia disorders;
13        (9) ensuring that services are authorized accurately
14    and consistently for the Community Care Program (CCP); the
15    Department shall implement a Service Authorization policy
16    directive; the purpose shall be to ensure that eligibility
17    and services are authorized accurately and consistently in
18    the CCP program; the policy directive shall clarify service
19    authorization guidelines to Care Coordination Units and
20    Community Care Program providers no later than May 1, 2013;
21        (10) working in conjunction with Care Coordination
22    Units, the Department of Healthcare and Family Services,
23    the Department of Human Services, Community Care Program
24    providers, and other stakeholders to make improvements to
25    the Medicaid claiming processes and the Medicaid
26    enrollment procedures or requirements as needed,

 

 

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1    including, but not limited to, specific policy changes or
2    rules to improve the up-front enrollment of participants in
3    the Medicaid program and specific policy changes or rules
4    to insure more prompt submission of bills to the federal
5    government to secure maximum federal matching dollars as
6    promptly as possible; the Department on Aging shall have at
7    least 3 meetings with stakeholders by January 1, 2014 in
8    order to address these improvements;
9        (11) requiring home care service providers to comply
10    with the rounding of hours worked provisions under the
11    federal Fair Labor Standards Act (FLSA) and as set forth in
12    29 CFR 785.48(b) by May 1, 2013;
13        (12) implementing any necessary policy changes or
14    promulgating any rules, no later than January 1, 2014, to
15    assist the Department of Healthcare and Family Services in
16    moving as many participants as possible, consistent with
17    federal regulations, into coordinated care plans if a care
18    coordination plan that covers long term care is available
19    in the recipient's area; and
20        (13) maintaining fiscal year 2014 rates at the same
21    level established on January 1, 2013.
22    By January 1, 2009 or as soon after the end of the Cash and
23Counseling Demonstration Project as is practicable, the
24Department may, based on its evaluation of the demonstration
25project, promulgate rules concerning personal assistant
26services, to include, but need not be limited to,

 

 

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1qualifications, employment screening, rights under fair labor
2standards, training, fiduciary agent, and supervision
3requirements. All applicants shall be subject to the provisions
4of the Health Care Worker Background Check Act.
5    The Department shall develop procedures to enhance
6availability of services on evenings, weekends, and on an
7emergency basis to meet the respite needs of caregivers.
8Procedures shall be developed to permit the utilization of
9services in successive blocks of 24 hours up to the monthly
10maximum established by the Department. Workers providing these
11services shall be appropriately trained.
12    Beginning on the effective date of this amendatory Act of
131991, no person may perform chore/housekeeping and home care
14aide services under a program authorized by this Section unless
15that person has been issued a certificate of pre-service to do
16so by his or her employing agency. Information gathered to
17effect such certification shall include (i) the person's name,
18(ii) the date the person was hired by his or her current
19employer, and (iii) the training, including dates and levels.
20Persons engaged in the program authorized by this Section
21before the effective date of this amendatory Act of 1991 shall
22be issued a certificate of all pre- and in-service training
23from his or her employer upon submitting the necessary
24information. The employing agency shall be required to retain
25records of all staff pre- and in-service training, and shall
26provide such records to the Department upon request and upon

 

 

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1termination of the employer's contract with the Department. In
2addition, the employing agency is responsible for the issuance
3of certifications of in-service training completed to their
4employees.
5    The Department is required to develop a system to ensure
6that persons working as home care aides and personal assistants
7receive increases in their wages when the federal minimum wage
8is increased by requiring vendors to certify that they are
9meeting the federal minimum wage statute for home care aides
10and personal assistants. An employer that cannot ensure that
11the minimum wage increase is being given to home care aides and
12personal assistants shall be denied any increase in
13reimbursement costs.
14    The Community Care Program Advisory Committee is created in
15the Department on Aging. The Director shall appoint individuals
16to serve in the Committee, who shall serve at their own
17expense. Members of the Committee must abide by all applicable
18ethics laws. The Committee shall advise the Department on
19issues related to the Department's program of services to
20prevent unnecessary institutionalization. The Committee shall
21meet on a bi-monthly basis and shall serve to identify and
22advise the Department on present and potential issues affecting
23the service delivery network, the program's clients, and the
24Department and to recommend solution strategies. Persons
25appointed to the Committee shall be appointed on, but not
26limited to, their own and their agency's experience with the

 

 

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1program, geographic representation, and willingness to serve.
2The Director shall appoint members to the Committee to
3represent provider, advocacy, policy research, and other
4constituencies committed to the delivery of high quality home
5and community-based services to older adults. Representatives
6shall be appointed to ensure representation from community care
7providers including, but not limited to, adult day service
8providers, homemaker providers, case coordination and case
9management units, emergency home response providers, statewide
10trade or labor unions that represent home care aides and direct
11care staff, area agencies on aging, adults over age 60,
12membership organizations representing older adults, and other
13organizational entities, providers of care, or individuals
14with demonstrated interest and expertise in the field of home
15and community care as determined by the Director.
16    Nominations may be presented from any agency or State
17association with interest in the program. The Director, or his
18or her designee, shall serve as the permanent co-chair of the
19advisory committee. One other co-chair shall be nominated and
20approved by the members of the committee on an annual basis.
21Committee members' terms of appointment shall be for 4 years
22with one-quarter of the appointees' terms expiring each year. A
23member shall continue to serve until his or her replacement is
24named. The Department shall fill vacancies that have a
25remaining term of over one year, and this replacement shall
26occur through the annual replacement of expiring terms. The

 

 

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1Director shall designate Department staff to provide technical
2assistance and staff support to the committee. Department
3representation shall not constitute membership of the
4committee. All Committee papers, issues, recommendations,
5reports, and meeting memoranda are advisory only. The Director,
6or his or her designee, shall make a written report, as
7requested by the Committee, regarding issues before the
8Committee.
9    The Department on Aging and the Department of Human
10Services shall cooperate in the development and submission of
11an annual report on programs and services provided under this
12Section. Such joint report shall be filed with the Governor and
13the General Assembly on or before September 30 each year.
14    The requirement for reporting to the General Assembly shall
15be satisfied by filing copies of the report with the Speaker,
16the Minority Leader and the Clerk of the House of
17Representatives and the President, the Minority Leader and the
18Secretary of the Senate and the Legislative Research Unit, as
19required by Section 3.1 of the General Assembly Organization
20Act and filing such additional copies with the State Government
21Report Distribution Center for the General Assembly as is
22required under paragraph (t) of Section 7 of the State Library
23Act.
24    Those persons previously found eligible for receiving
25non-institutional services whose services were discontinued
26under the Emergency Budget Act of Fiscal Year 1992, and who do

 

 

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1not meet the eligibility standards in effect on or after July
21, 1992, shall remain ineligible on and after July 1, 1992.
3Those persons previously not required to cost-share and who
4were required to cost-share effective March 1, 1992, shall
5continue to meet cost-share requirements on and after July 1,
61992. Beginning July 1, 1992, all clients will be required to
7meet eligibility, cost-share, and other requirements and will
8have services discontinued or altered when they fail to meet
9these requirements.
10    For the purposes of this Section, "flexible senior
11services" refers to services that require one-time or periodic
12expenditures including, but not limited to, respite care, home
13modification, assistive technology, housing assistance, and
14transportation.
15    The Department shall implement an electronic service
16verification based on global positioning systems or other
17cost-effective technology for the Community Care Program no
18later than January 1, 2014.
19    The Department shall require, as a condition of
20eligibility, enrollment in the medical assistance program
21under Article V of the Illinois Public Aid Code (i) beginning
22August 1, 2013, if the Auditor General has reported that the
23Department has failed to comply with the reporting requirements
24of Section 2-27 of the Illinois State Auditing Act; or (ii)
25beginning June 1, 2014, if the Auditor General has reported
26that the Department has not undertaken the required actions

 

 

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1listed in the report required by subsection (a) of Section 2-27
2of the Illinois State Auditing Act.
3    The Department shall delay Community Care Program services
4until an applicant is determined eligible for medical
5assistance under Article V of the Illinois Public Aid Code (i)
6beginning August 1, 2013, if the Auditor General has reported
7that the Department has failed to comply with the reporting
8requirements of Section 2-27 of the Illinois State Auditing
9Act; or (ii) beginning June 1, 2014, if the Auditor General has
10reported that the Department has not undertaken the required
11actions listed in the report required by subsection (a) of
12Section 2-27 of the Illinois State Auditing Act.
13    The Department shall implement co-payments for the
14Community Care Program at the federally allowable maximum level
15(i) beginning August 1, 2013, if the Auditor General has
16reported that the Department has failed to comply with the
17reporting requirements of Section 2-27 of the Illinois State
18Auditing Act; or (ii) beginning June 1, 2014, if the Auditor
19General has reported that the Department has not undertaken the
20required actions listed in the report required by subsection
21(a) of Section 2-27 of the Illinois State Auditing Act.
22    The Department shall provide a bi-monthly report on the
23progress of the Community Care Program reforms set forth in
24this amendatory Act of the 98th General Assembly to the
25Governor, the Speaker of the House of Representatives, the
26Minority Leader of the House of Representatives, the President

 

 

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1of the Senate, and the Minority Leader of the Senate.
2    The Department shall conduct a quarterly review of Care
3Coordination Unit performance and adherence to service
4guidelines. The quarterly review shall be reported to the
5Speaker of the House of Representatives, the Minority Leader of
6the House of Representatives, the President of the Senate, and
7the Minority Leader of the Senate. The Department shall collect
8and report longitudinal data on the performance of each care
9coordination unit. Nothing in this paragraph shall be construed
10to require the Department to identify specific care
11coordination units.
12    In regard to community care providers, failure to comply
13with Department on Aging policies shall be cause for
14disciplinary action, including, but not limited to,
15disqualification from serving Community Care Program clients.
16Each provider, upon submission of any bill or invoice to the
17Department for payment for services rendered, shall include a
18notarized statement, under penalty of perjury pursuant to
19Section 1-109 of the Code of Civil Procedure, that the provider
20has complied with all Department policies.
21    The Director of the Department on Aging shall make
22information available to the State Board of Elections as may be
23required by an agreement the State Board of Elections has
24entered into with a multi-state voter registration list
25maintenance system.
26(Source: P.A. 98-8, eff. 5-3-13; 98-1171, eff. 6-1-15; 99-143,

 

 

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1eff. 7-27-15.)
 
2    Section 10. The Rehabilitation of Persons with
3Disabilities Act is amended by changing Section 3 as follows:
 
4    (20 ILCS 2405/3)  (from Ch. 23, par. 3434)
5    Sec. 3. Powers and duties. The Department shall have the
6powers and duties enumerated herein:
7    (a) To co-operate with the federal government in the
8administration of the provisions of the federal Rehabilitation
9Act of 1973, as amended, of the Workforce Investment Act of
101998, and of the federal Social Security Act to the extent and
11in the manner provided in these Acts.
12    (b) To prescribe and supervise such courses of vocational
13training and provide such other services as may be necessary
14for the habilitation and rehabilitation of persons with one or
15more disabilities, including the administrative activities
16under subsection (e) of this Section, and to co-operate with
17State and local school authorities and other recognized
18agencies engaged in habilitation, rehabilitation and
19comprehensive rehabilitation services; and to cooperate with
20the Department of Children and Family Services regarding the
21care and education of children with one or more disabilities.
22    (c) (Blank).
23    (d) To report in writing, to the Governor, annually on or
24before the first day of December, and at such other times and

 

 

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1in such manner and upon such subjects as the Governor may
2require. The annual report shall contain (1) a statement of the
3existing condition of comprehensive rehabilitation services,
4habilitation and rehabilitation in the State; (2) a statement
5of suggestions and recommendations with reference to the
6development of comprehensive rehabilitation services,
7habilitation and rehabilitation in the State; and (3) an
8itemized statement of the amounts of money received from
9federal, State and other sources, and of the objects and
10purposes to which the respective items of these several amounts
11have been devoted.
12    (e) (Blank).
13    (f) To establish a program of services to prevent the
14unnecessary institutionalization of persons in need of long
15term care and who meet the criteria for blindness or disability
16as defined by the Social Security Act, thereby enabling them to
17remain in their own homes. Such preventive services include any
18or all of the following:
19        (1) personal assistant services;
20        (2) homemaker services;
21        (3) home-delivered meals;
22        (4) adult day care services;
23        (5) respite care;
24        (6) home modification or assistive equipment;
25        (7) home health services;
26        (8) electronic home response;

 

 

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1        (9) brain injury behavioral/cognitive services;
2        (10) brain injury habilitation;
3        (11) brain injury pre-vocational services; or
4        (12) brain injury supported employment.
5    The Department shall establish eligibility standards for
6such services taking into consideration the unique economic and
7social needs of the population for whom they are to be
8provided. Such eligibility standards may be based on the
9recipient's ability to pay for services; provided, however,
10that any portion of a person's income that is equal to or less
11than the "protected income" level shall not be considered by
12the Department in determining eligibility. The "protected
13income" level shall be determined by the Department, shall
14never be less than the federal poverty standard, and shall be
15adjusted each year to reflect changes in the Consumer Price
16Index For All Urban Consumers as determined by the United
17States Department of Labor. The standards must provide that a
18person may not have more than $10,000 in assets to be eligible
19for the services, and the Department may increase or decrease
20the asset limitation by rule. The Department may not decrease
21the asset level below $10,000.
22    Individuals with a score of 29 or higher based on the
23determination of need (DON) assessment tool shall be eligible
24to receive institutional and home and community-based long term
25care services until such time that the State receives federal
26approval and implements an updated assessment tool, and those

 

 

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1individuals are found to be ineligible under that updated
2assessment tool. Anyone determined to be ineligible for
3services due to the updated assessment tool shall continue to
4be eligible for services for at least one year following that
5determination and must be reassessed no earlier than 11 months
6after that determination. The Department must adopt rules
7through the regular rulemaking process regarding the updated
8assessment tool, and shall not adopt emergency or peremptory
9rules regarding the updated assessment tool. The State shall
10not implement an updated assessment tool that causes more than
111% of then-current recipients to lose eligibility.
12    Service cost maximums shall be set at levels no lower than
13the service cost maximums that were in effect as of January 1,
142016. Service cost maximums shall be increased accordingly to
15reflect any rate increases.
16    The services shall be provided, as established by the
17Department by rule, to eligible persons to prevent unnecessary
18or premature institutionalization, to the extent that the cost
19of the services, together with the other personal maintenance
20expenses of the persons, are reasonably related to the
21standards established for care in a group facility appropriate
22to their condition. These non-institutional services, pilot
23projects or experimental facilities may be provided as part of
24or in addition to those authorized by federal law or those
25funded and administered by the Illinois Department on Aging.
26The Department shall set rates and fees for services in a fair

 

 

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1and equitable manner. Services identical to those offered by
2the Department on Aging shall be paid at the same rate.
3    Personal assistants shall be paid at a rate negotiated
4between the State and an exclusive representative of personal
5assistants under a collective bargaining agreement. In no case
6shall the Department pay personal assistants an hourly wage
7that is less than the federal minimum wage.
8    Solely for the purposes of coverage under the Illinois
9Public Labor Relations Act (5 ILCS 315/), personal assistants
10providing services under the Department's Home Services
11Program shall be considered to be public employees and the
12State of Illinois shall be considered to be their employer as
13of the effective date of this amendatory Act of the 93rd
14General Assembly, but not before. Solely for the purposes of
15coverage under the Illinois Public Labor Relations Act, home
16care and home health workers who function as personal
17assistants and individual maintenance home health workers and
18who also provide services under the Department's Home Services
19Program shall be considered to be public employees, no matter
20whether the State provides such services through direct
21fee-for-service arrangements, with the assistance of a managed
22care organization or other intermediary, or otherwise, and the
23State of Illinois shall be considered to be the employer of
24those persons as of January 29, 2013 (the effective date of
25Public Act 97-1158), but not before except as otherwise
26provided under this subsection (f). The State shall engage in

 

 

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1collective bargaining with an exclusive representative of home
2care and home health workers who function as personal
3assistants and individual maintenance home health workers
4working under the Home Services Program concerning their terms
5and conditions of employment that are within the State's
6control. Nothing in this paragraph shall be understood to limit
7the right of the persons receiving services defined in this
8Section to hire and fire home care and home health workers who
9function as personal assistants and individual maintenance
10home health workers working under the Home Services Program or
11to supervise them within the limitations set by the Home
12Services Program. The State shall not be considered to be the
13employer of home care and home health workers who function as
14personal assistants and individual maintenance home health
15workers working under the Home Services Program for any
16purposes not specifically provided in Public Act 93-204 or
17Public Act 97-1158, including but not limited to, purposes of
18vicarious liability in tort and purposes of statutory
19retirement or health insurance benefits. Home care and home
20health workers who function as personal assistants and
21individual maintenance home health workers and who also provide
22services under the Department's Home Services Program shall not
23be covered by the State Employees Group Insurance Act of 1971
24(5 ILCS 375/).
25    The Department shall execute, relative to nursing home
26prescreening, as authorized by Section 4.03 of the Illinois Act

 

 

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1on the Aging, written inter-agency agreements with the
2Department on Aging and the Department of Healthcare and Family
3Services, to effect the intake procedures and eligibility
4criteria for those persons who may need long term care. On and
5after July 1, 1996, all nursing home prescreenings for
6individuals 18 through 59 years of age shall be conducted by
7the Department, or a designee of the Department.
8    The Department is authorized to establish a system of
9recipient cost-sharing for services provided under this
10Section. The cost-sharing shall be based upon the recipient's
11ability to pay for services, but in no case shall the
12recipient's share exceed the actual cost of the services
13provided. Protected income shall not be considered by the
14Department in its determination of the recipient's ability to
15pay a share of the cost of services. The level of cost-sharing
16shall be adjusted each year to reflect changes in the
17"protected income" level. The Department shall deduct from the
18recipient's share of the cost of services any money expended by
19the recipient for disability-related expenses.
20    To the extent permitted under the federal Social Security
21Act, the Department, or the Department's authorized
22representative, may recover the amount of moneys expended for
23services provided to or in behalf of a person under this
24Section by a claim against the person's estate or against the
25estate of the person's surviving spouse, but no recovery may be
26had until after the death of the surviving spouse, if any, and

 

 

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1then only at such time when there is no surviving child who is
2under age 21 or blind or who has a permanent and total
3disability. This paragraph, however, shall not bar recovery, at
4the death of the person, of moneys for services provided to the
5person or in behalf of the person under this Section to which
6the person was not entitled; provided that such recovery shall
7not be enforced against any real estate while it is occupied as
8a homestead by the surviving spouse or other dependent, if no
9claims by other creditors have been filed against the estate,
10or, if such claims have been filed, they remain dormant for
11failure of prosecution or failure of the claimant to compel
12administration of the estate for the purpose of payment. This
13paragraph shall not bar recovery from the estate of a spouse,
14under Sections 1915 and 1924 of the Social Security Act and
15Section 5-4 of the Illinois Public Aid Code, who precedes a
16person receiving services under this Section in death. All
17moneys for services paid to or in behalf of the person under
18this Section shall be claimed for recovery from the deceased
19spouse's estate. "Homestead", as used in this paragraph, means
20the dwelling house and contiguous real estate occupied by a
21surviving spouse or relative, as defined by the rules and
22regulations of the Department of Healthcare and Family
23Services, regardless of the value of the property.
24    The Department shall submit an annual report on programs
25and services provided under this Section. The report shall be
26filed with the Governor and the General Assembly on or before

 

 

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1March 30 each year.
2    The requirement for reporting to the General Assembly shall
3be satisfied by filing copies of the report with the Speaker,
4the Minority Leader and the Clerk of the House of
5Representatives and the President, the Minority Leader and the
6Secretary of the Senate and the Legislative Research Unit, as
7required by Section 3.1 of the General Assembly Organization
8Act, and filing additional copies with the State Government
9Report Distribution Center for the General Assembly as required
10under paragraph (t) of Section 7 of the State Library Act.
11    (g) To establish such subdivisions of the Department as
12shall be desirable and assign to the various subdivisions the
13responsibilities and duties placed upon the Department by law.
14    (h) To cooperate and enter into any necessary agreements
15with the Department of Employment Security for the provision of
16job placement and job referral services to clients of the
17Department, including job service registration of such clients
18with Illinois Employment Security offices and making job
19listings maintained by the Department of Employment Security
20available to such clients.
21    (i) To possess all powers reasonable and necessary for the
22exercise and administration of the powers, duties and
23responsibilities of the Department which are provided for by
24law.
25    (j) (Blank).
26    (k) (Blank).

 

 

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1    (l) To establish, operate and maintain a Statewide Housing
2Clearinghouse of information on available, government
3subsidized housing accessible to persons with disabilities and
4available privately owned housing accessible to persons with
5disabilities. The information shall include but not be limited
6to the location, rental requirements, access features and
7proximity to public transportation of available housing. The
8Clearinghouse shall consist of at least a computerized database
9for the storage and retrieval of information and a separate or
10shared toll free telephone number for use by those seeking
11information from the Clearinghouse. Department offices and
12personnel throughout the State shall also assist in the
13operation of the Statewide Housing Clearinghouse. Cooperation
14with local, State and federal housing managers shall be sought
15and extended in order to frequently and promptly update the
16Clearinghouse's information.
17    (m) To assure that the names and case records of persons
18who received or are receiving services from the Department,
19including persons receiving vocational rehabilitation, home
20services, or other services, and those attending one of the
21Department's schools or other supervised facility shall be
22confidential and not be open to the general public. Those case
23records and reports or the information contained in those
24records and reports shall be disclosed by the Director only to
25proper law enforcement officials, individuals authorized by a
26court, the General Assembly or any committee or commission of

 

 

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1the General Assembly, and other persons and for reasons as the
2Director designates by rule. Disclosure by the Director may be
3only in accordance with other applicable law.
4(Source: P.A. 98-1004, eff. 8-18-14; 99-143, eff. 7-27-15.)
 
5    Section 13. The Nursing Home Care Act is amended by
6changing Section 3-402 as follows:
 
7    (210 ILCS 45/3-402)  (from Ch. 111 1/2, par. 4153-402)
8    Sec. 3-402. Involuntary transfer or discharge.
9    Involuntary transfer or discharge of a resident from a
10facility shall be preceded by the discussion required under
11Section 3-408 and by a minimum written notice of 21 days,
12except in one of the following instances:
13        (a) When an emergency transfer or discharge is ordered
14    by the resident's attending physician because of the
15    resident's health care needs.
16        (b) When the transfer or discharge is mandated by the
17    physical safety of other residents, the facility staff, or
18    facility visitors, as documented in the clinical record.
19    The Department shall be notified prior to any such
20    involuntary transfer or discharge. The Department shall
21    immediately offer transfer, or discharge and relocation
22    assistance to residents transferred or discharged under
23    this subparagraph (b), and the Department may place
24    relocation teams as provided in Section 3-419 of this Act.

 

 

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1        (c) When an identified offender is within the
2    provisional admission period defined in Section 1-120.3.
3    If the Identified Offender Report and Recommendation
4    prepared under Section 2-201.6 shows that the identified
5    offender poses a serious threat or danger to the physical
6    safety of other residents, the facility staff, or facility
7    visitors in the admitting facility and the facility
8    determines that it is unable to provide a safe environment
9    for the other residents, the facility staff, or facility
10    visitors, the facility shall transfer or discharge the
11    identified offender within 3 days after its receipt of the
12    Identified Offender Report and Recommendation.
13    No individual receiving care in an institutional setting
14shall be involuntarily discharged as the result of the updated
15determination of need (DON) assessment tool as provided in
16Section 5-5 of the Illinois Public Aid Code until a transition
17plan has been developed by the Department on Aging or its
18designee and all care identified in the transition plan is
19available to the resident immediately upon discharge.
20(Source: P.A. 96-1372, eff. 7-29-10.)
 
21    Section 15. The Illinois Public Aid Code is amended by
22changing Sections 5-5 and 5-5.01a as follows:
 
23    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
24    (Text of Section before amendment by P.A. 99-407)

 

 

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

 

 

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

 

 

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

 

 

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1medical assistance program and in any capitated Medicaid
2managed care entity (MCE) serving individuals enrolled in a
3school within the CPS system. Under any contract procured under
4this provision, the vendor or vendors must serve only
5individuals enrolled in a school within the CPS system. Claims
6for services provided by CPS's vendor or vendors to recipients
7of benefits in the medical assistance program under this Code,
8the Children's Health Insurance Program, or the Covering ALL
9KIDS Health Insurance Program shall be submitted to the
10Department or the MCE in which the individual is enrolled for
11payment and shall be reimbursed at the Department's or the
12MCE's established rates or rate methodologies for eyeglasses.
13    On and after July 1, 2012, the Department of Healthcare and
14Family Services may provide the following services to persons
15eligible for assistance under this Article who are
16participating in education, training or employment programs
17operated by the Department of Human Services as successor to
18the Department of Public Aid:
19        (1) dental services provided by or under the
20    supervision of a dentist; and
21        (2) eyeglasses prescribed by a physician skilled in the
22    diseases of the eye, or by an optometrist, whichever the
23    person may select.
24    Notwithstanding any other provision of this Code and
25subject to federal approval, the Department may adopt rules to
26allow a dentist who is volunteering his or her service at no

 

 

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1cost to render dental services through an enrolled
2not-for-profit health clinic without the dentist personally
3enrolling as a participating provider in the medical assistance
4program. A not-for-profit health clinic shall include a public
5health clinic or Federally Qualified Health Center or other
6enrolled provider, as determined by the Department, through
7which dental services covered under this Section are performed.
8The Department shall establish a process for payment of claims
9for reimbursement for covered dental services rendered under
10this provision.
11    The Illinois Department, by rule, may distinguish and
12classify the medical services to be provided only in accordance
13with the classes of persons designated in Section 5-2.
14    The Department of Healthcare and Family Services must
15provide coverage and reimbursement for amino acid-based
16elemental formulas, regardless of delivery method, for the
17diagnosis and treatment of (i) eosinophilic disorders and (ii)
18short bowel syndrome when the prescribing physician has issued
19a written order stating that the amino acid-based elemental
20formula is medically necessary.
21    The Illinois Department shall authorize the provision of,
22and shall authorize payment for, screening by low-dose
23mammography for the presence of occult breast cancer for women
2435 years of age or older who are eligible for medical
25assistance under this Article, as follows:
26        (A) A baseline mammogram for women 35 to 39 years of

 

 

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

 

 

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1    On and after January 1, 2016, the Department shall ensure
2that all networks of care for adult clients of the Department
3include access to at least one breast imaging Center of Imaging
4Excellence as certified by the American College of Radiology.
5    On and after January 1, 2012, providers participating in a
6quality improvement program approved by the Department shall be
7reimbursed for screening and diagnostic mammography at the same
8rate as the Medicare program's rates, including the increased
9reimbursement for digital mammography.
10    The Department shall convene an expert panel including
11representatives of hospitals, free-standing mammography
12facilities, and doctors, including radiologists, to establish
13quality standards for mammography.
14    On and after January 1, 2017, providers participating in a
15breast cancer treatment quality improvement program approved
16by the Department shall be reimbursed for breast cancer
17treatment at a rate that is no lower than 95% of the Medicare
18program's rates for the data elements included in the breast
19cancer treatment quality program.
20    The Department shall convene an expert panel, including
21representatives of hospitals, free standing breast cancer
22treatment centers, breast cancer quality organizations, and
23doctors, including breast surgeons, reconstructive breast
24surgeons, oncologists, and primary care providers to establish
25quality standards for breast cancer treatment.
26    Subject to federal approval, the Department shall

 

 

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

 

 

HB4351 Enrolled- 39 -LRB099 15530 KTG 39820 b

1be in the metropolitan Chicago area and at least one site shall
2be outside the metropolitan Chicago area. On or after July 1,
32016, the pilot program shall be expanded to include one site
4in western Illinois, one site in southern Illinois, one site in
5central Illinois, and 4 sites within metropolitan Chicago. An
6evaluation of the pilot program shall be carried out measuring
7health outcomes and cost of care for those served by the pilot
8program compared to similarly situated patients who are not
9served by the pilot program.
10    The Department shall require all networks of care to
11develop a means either internally or by contract with experts
12in navigation and community outreach to navigate cancer
13patients to comprehensive care in a timely fashion. The
14Department shall require all networks of care to include access
15for patients diagnosed with cancer to at least one academic
16commission on cancer-accredited cancer program as an
17in-network covered benefit.
18    Any medical or health care provider shall immediately
19recommend, to any pregnant woman who is being provided prenatal
20services and is suspected of drug abuse or is addicted as
21defined in the Alcoholism and Other Drug Abuse and Dependency
22Act, referral to a local substance abuse treatment provider
23licensed by the Department of Human Services or to a licensed
24hospital which provides substance abuse treatment services.
25The Department of Healthcare and Family Services shall assure
26coverage for the cost of treatment of the drug abuse or

 

 

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

 

 

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

 

 

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1    the Illinois Department, to persons in areas covered by the
2    Partnership may receive an additional surcharge for such
3    services.
4        (2) The Department may elect to consider and negotiate
5    financial incentives to encourage the development of
6    Partnerships and the efficient delivery of medical care.
7        (3) Persons receiving medical services through
8    Partnerships may receive medical and case management
9    services above the level usually offered through the
10    medical assistance program.
11    Medical providers shall be required to meet certain
12qualifications to participate in Partnerships to ensure the
13delivery of high quality medical services. These
14qualifications shall be determined by rule of the Illinois
15Department and may be higher than qualifications for
16participation in the medical assistance program. Partnership
17sponsors may prescribe reasonable additional qualifications
18for participation by medical providers, only with the prior
19written approval of the Illinois Department.
20    Nothing in this Section shall limit the free choice of
21practitioners, hospitals, and other providers of medical
22services by clients. In order to ensure patient freedom of
23choice, the Illinois Department shall immediately promulgate
24all rules and take all other necessary actions so that provided
25services may be accessed from therapeutically certified
26optometrists to the full extent of the Illinois Optometric

 

 

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

 

 

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1eyeglasses by eligible persons under this Section accompany
2each claim for reimbursement submitted by the dispenser of such
3medical services. No such claims for reimbursement shall be
4approved for payment by the Illinois Department without such
5proof of receipt, unless the Illinois Department shall have put
6into effect and shall be operating a system of post-payment
7audit and review which shall, on a sampling basis, be deemed
8adequate by the Illinois Department to assure that such drugs,
9dentures, prosthetic devices and eyeglasses for which payment
10is being made are actually being received by eligible
11recipients. Within 90 days after September 16, 1984 (the
12effective date of Public Act 83-1439) this amendatory Act of
131984, the Illinois Department shall establish a current list of
14acquisition costs for all prosthetic devices and any other
15items recognized as medical equipment and supplies
16reimbursable under this Article and shall update such list on a
17quarterly basis, except that the acquisition costs of all
18prescription drugs shall be updated no less frequently than
19every 30 days as required by Section 5-5.12.
20    The rules and regulations of the Illinois Department shall
21require that a written statement including the required opinion
22of a physician shall accompany any claim for reimbursement for
23abortions, or induced miscarriages or premature births. This
24statement shall indicate what procedures were used in providing
25such medical services.
26    Notwithstanding any other law to the contrary, the Illinois

 

 

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1Department shall, within 365 days after July 22, 2013 (the
2effective date of Public Act 98-104), establish procedures to
3permit skilled care facilities licensed under the Nursing Home
4Care Act to submit monthly billing claims for reimbursement
5purposes. Following development of these procedures, the
6Department shall, by July 1, 2016, test the viability of the
7new system and implement any necessary operational or
8structural changes to its information technology platforms in
9order to allow for the direct acceptance and payment of nursing
10home claims.
11    Notwithstanding any other law to the contrary, the Illinois
12Department shall, within 365 days after August 15, 2014 (the
13effective date of Public Act 98-963), establish procedures to
14permit ID/DD facilities licensed under the ID/DD Community Care
15Act and MC/DD facilities licensed under the MC/DD Act to submit
16monthly billing claims for reimbursement purposes. Following
17development of these procedures, the Department shall have an
18additional 365 days to test the viability of the new system and
19to ensure that any necessary operational or structural changes
20to its information technology platforms are implemented.
21    The Illinois Department shall require all dispensers of
22medical services, other than an individual practitioner or
23group of practitioners, desiring to participate in the Medical
24Assistance program established under this Article to disclose
25all financial, beneficial, ownership, equity, surety or other
26interests in any and all firms, corporations, partnerships,

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1reporting; unearned and earned income; pension income;
2employment; supplemental security income; social security
3numbers; National Provider Identifier (NPI) numbers; the
4National Practitioner Data Bank (NPDB); program and agency
5exclusions; taxpayer identification numbers; tax delinquency;
6corporate information; and death records.
7    The Illinois Department shall enter into agreements with
8State agencies and departments, and is authorized to enter into
9agreements with federal agencies and departments, under which
10such agencies and departments shall share data necessary for
11medical assistance program integrity functions and oversight.
12The Illinois Department shall develop, in cooperation with
13other State departments and agencies, and in compliance with
14applicable federal laws and regulations, appropriate and
15effective methods to share such data. At a minimum, and to the
16extent necessary to provide data sharing, the Illinois
17Department shall enter into agreements with State agencies and
18departments, and is authorized to enter into agreements with
19federal agencies and departments, including but not limited to:
20the Secretary of State; the Department of Revenue; the
21Department of Public Health; the Department of Human Services;
22and the Department of Financial and Professional Regulation.
23    Beginning in fiscal year 2013, the Illinois Department
24shall set forth a request for information to identify the
25benefits of a pre-payment, post-adjudication, and post-edit
26claims system with the goals of streamlining claims processing

 

 

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

 

 

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1prescreening project, written inter-agency agreements with the
2Department of Human Services and the Department on Aging, to
3effect the following: (i) intake procedures and common
4eligibility criteria for those persons who are receiving
5non-institutional services; and (ii) the establishment and
6development of non-institutional services in areas of the State
7where they are not currently available or are undeveloped; and
8(iii) (iii) notwithstanding any other provision of law, subject
9to federal approval, on and after July 1, 2012, an increase in
10the determination of need (DON) scores from 29 to 37 for
11applicants for institutional and home and community-based long
12term care; if and only if federal approval is not granted, the
13Department may, in conjunction with other affected agencies,
14implement utilization controls or changes in benefit packages
15to effectuate a similar savings amount for this population; and
16(iv) no later than July 1, 2013, minimum level of care
17eligibility criteria for institutional and home and
18community-based long term care; and (iv) (v) no later than
19October 1, 2013, establish procedures to permit long term care
20providers access to eligibility scores for individuals with an
21admission date who are seeking or receiving services from the
22long term care provider. In order to select the minimum level
23of care eligibility criteria, the Governor shall establish a
24workgroup that includes affected agency representatives and
25stakeholders representing the institutional and home and
26community-based long term care interests. This Section shall

 

 

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1not restrict the Department from implementing lower level of
2care eligibility criteria for community-based services in
3circumstances where federal approval has been granted.
4Individuals with a score of 29 or higher based on the
5determination of need (DON) assessment tool shall be eligible
6to receive institutional and home and community-based long term
7care services until such time that the State receives federal
8approval and implements an updated assessment tool, and those
9individuals are found to be ineligible under that updated
10assessment tool. Anyone determined to be ineligible for
11services due to the updated assessment tool shall continue to
12be eligible for services for at least one year following that
13determination and must be reassessed no earlier than 11 months
14after that determination. The Department must adopt rules
15through the regular rulemaking process regarding the updated
16assessment tool, and shall not adopt emergency or peremptory
17rules regarding the updated assessment tool. The State shall
18not implement an updated assessment tool that causes more than
191% of then-current recipients to lose eligibility. No
20individual receiving care in an institutional setting shall be
21involuntarily discharged as the result of the updated
22assessment tool until a transition plan has been developed by
23the Department on Aging or its designee and all care identified
24in the transition plan is available to the resident immediately
25upon discharge.
26    The Illinois Department shall develop and operate, in

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1    All screenings shall include a physical breast exam,
2instruction on self-examination and information regarding the
3frequency of self-examination and its value as a preventative
4tool. For purposes of this Section, "low-dose mammography"
5means the x-ray examination of the breast using equipment
6dedicated specifically for mammography, including the x-ray
7tube, filter, compression device, and image receptor, with an
8average radiation exposure delivery of less than one rad per
9breast for 2 views of an average size breast. The term also
10includes digital mammography and includes breast
11tomosynthesis. As used in this Section, the term "breast
12tomosynthesis" means a radiologic procedure that involves the
13acquisition of projection images over the stationary breast to
14produce cross-sectional digital three-dimensional images of
15the breast.
16    On and after January 1, 2016, the Department shall ensure
17that all networks of care for adult clients of the Department
18include access to at least one breast imaging Center of Imaging
19Excellence as certified by the American College of Radiology.
20    On and after January 1, 2012, providers participating in a
21quality improvement program approved by the Department shall be
22reimbursed for screening and diagnostic mammography at the same
23rate as the Medicare program's rates, including the increased
24reimbursement for digital mammography.
25    The Department shall convene an expert panel including
26representatives of hospitals, free-standing mammography

 

 

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1facilities, and doctors, including radiologists, to establish
2quality standards for mammography.
3    On and after January 1, 2017, providers participating in a
4breast cancer treatment quality improvement program approved
5by the Department shall be reimbursed for breast cancer
6treatment at a rate that is no lower than 95% of the Medicare
7program's rates for the data elements included in the breast
8cancer treatment quality program.
9    The Department shall convene an expert panel, including
10representatives of hospitals, free standing breast cancer
11treatment centers, breast cancer quality organizations, and
12doctors, including breast surgeons, reconstructive breast
13surgeons, oncologists, and primary care providers to establish
14quality standards for breast cancer treatment.
15    Subject to federal approval, the Department shall
16establish a rate methodology for mammography at federally
17qualified health centers and other encounter-rate clinics.
18These clinics or centers may also collaborate with other
19hospital-based mammography facilities. By January 1, 2016, the
20Department shall report to the General Assembly on the status
21of the provision set forth in this paragraph.
22    The Department shall establish a methodology to remind
23women who are age-appropriate for screening mammography, but
24who have not received a mammogram within the previous 18
25months, of the importance and benefit of screening mammography.
26The Department shall work with experts in breast cancer

 

 

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1outreach and patient navigation to optimize these reminders and
2shall establish a methodology for evaluating their
3effectiveness and modifying the methodology based on the
4evaluation.
5    The Department shall establish a performance goal for
6primary care providers with respect to their female patients
7over age 40 receiving an annual mammogram. This performance
8goal shall be used to provide additional reimbursement in the
9form of a quality performance bonus to primary care providers
10who meet that goal.
11    The Department shall devise a means of case-managing or
12patient navigation for beneficiaries diagnosed with breast
13cancer. This program shall initially operate as a pilot program
14in areas of the State with the highest incidence of mortality
15related to breast cancer. At least one pilot program site shall
16be in the metropolitan Chicago area and at least one site shall
17be outside the metropolitan Chicago area. On or after July 1,
182016, the pilot program shall be expanded to include one site
19in western Illinois, one site in southern Illinois, one site in
20central Illinois, and 4 sites within metropolitan Chicago. An
21evaluation of the pilot program shall be carried out measuring
22health outcomes and cost of care for those served by the pilot
23program compared to similarly situated patients who are not
24served by the pilot program.
25    The Department shall require all networks of care to
26develop a means either internally or by contract with experts

 

 

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

 

 

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

 

 

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1shall develop qualifications for sponsors of Partnerships.
2Nothing in this Section shall be construed to require that the
3sponsor organization be a medical organization.
4    The sponsor must negotiate formal written contracts with
5medical providers for physician services, inpatient and
6outpatient hospital care, home health services, treatment for
7alcoholism and substance abuse, and other services determined
8necessary by the Illinois Department by rule for delivery by
9Partnerships. Physician services must include prenatal and
10obstetrical care. The Illinois Department shall reimburse
11medical services delivered by Partnership providers to clients
12in target areas according to provisions of this Article and the
13Illinois 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 the
17    Partnership may receive an additional surcharge for such
18    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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1qualifications to participate in Partnerships to ensure the
2delivery of high quality medical services. These
3qualifications shall be determined by rule of the Illinois
4Department and may be higher than qualifications for
5participation in the medical assistance program. Partnership
6sponsors may prescribe reasonable additional qualifications
7for participation by medical providers, only with the prior
8written approval of the Illinois Department.
9    Nothing in this Section shall limit the free choice of
10practitioners, hospitals, and other providers of medical
11services by clients. In order to ensure patient freedom of
12choice, the Illinois Department shall immediately promulgate
13all rules and take all other necessary actions so that provided
14services may be accessed from therapeutically certified
15optometrists to the full extent of the Illinois Optometric
16Practice Act of 1987 without discriminating between service
17providers.
18    The Department shall apply for a waiver from the United
19States Health Care Financing Administration to allow for the
20implementation of Partnerships under this Section.
21    The Illinois Department shall require health care
22providers to maintain records that document the medical care
23and services provided to recipients of Medical Assistance under
24this Article. Such records must be retained for a period of not
25less than 6 years from the date of service or as provided by
26applicable State law, whichever period is longer, except that

 

 

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

 

 

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1effective date of Public Act 83-1439) this amendatory Act of
21984, the Illinois Department shall establish a current list of
3acquisition costs for all prosthetic devices and any other
4items recognized as medical equipment and supplies
5reimbursable under this Article and shall update such list on a
6quarterly basis, except that the acquisition costs of all
7prescription drugs shall be updated no less frequently than
8every 30 days as required by Section 5-5.12.
9    The rules and regulations of the Illinois Department shall
10require that a written statement including the required opinion
11of a physician shall accompany any claim for reimbursement for
12abortions, or induced miscarriages or premature births. This
13statement shall indicate what procedures were used in providing
14such medical services.
15    Notwithstanding any other law to the contrary, the Illinois
16Department shall, within 365 days after July 22, 2013 (the
17effective date of Public Act 98-104), establish procedures to
18permit skilled care facilities licensed under the Nursing Home
19Care Act to submit monthly billing claims for reimbursement
20purposes. Following development of these procedures, the
21Department shall, by July 1, 2016, test the viability of the
22new system and implement any necessary operational or
23structural changes to its information technology platforms in
24order to allow for the direct acceptance and payment of nursing
25home claims.
26    Notwithstanding any other law to the contrary, the Illinois

 

 

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

 

 

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1    Enrollment of a vendor shall be subject to a provisional
2period and shall be conditional for one year. During the period
3of conditional enrollment, the Department may terminate the
4vendor's eligibility to participate in, or may disenroll the
5vendor from, the medical assistance program without cause.
6Unless otherwise specified, such termination of eligibility or
7disenrollment is not subject to the Department's hearing
8process. However, a disenrolled vendor may reapply without
9penalty.
10    The Department has the discretion to limit the conditional
11enrollment period for vendors based upon category of risk of
12the vendor.
13    Prior to enrollment and during the conditional enrollment
14period in the medical assistance program, all vendors shall be
15subject to enhanced oversight, screening, and review based on
16the risk of fraud, waste, and abuse that is posed by the
17category of risk of the vendor. The Illinois Department shall
18establish the procedures for oversight, screening, and review,
19which may include, but need not be limited to: criminal and
20financial background checks; fingerprinting; license,
21certification, and authorization verifications; unscheduled or
22unannounced site visits; database checks; prepayment audit
23reviews; audits; payment caps; payment suspensions; and other
24screening as required by federal or State law.
25    The Department shall define or specify the following: (i)
26by provider notice, the "category of risk of the vendor" for

 

 

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1each type of vendor, which shall take into account the level of
2screening applicable to a particular category of vendor under
3federal law and regulations; (ii) by rule or provider notice,
4the maximum length of the conditional enrollment period for
5each category of risk of the vendor; and (iii) by rule, the
6hearing rights, if any, afforded to a vendor in each category
7of risk of the vendor that is terminated or disenrolled during
8the conditional enrollment period.
9    To be eligible for payment consideration, a vendor's
10payment claim or bill, either as an initial claim or as a
11resubmitted claim following prior rejection, must be received
12by the Illinois Department, or its fiscal intermediary, no
13later than 180 days after the latest date on the claim on which
14medical goods or services were provided, with the following
15exceptions:
16        (1) In the case of a provider whose enrollment is in
17    process by the Illinois Department, the 180-day period
18    shall not begin until the date on the written notice from
19    the Illinois Department that the provider enrollment is
20    complete.
21        (2) In the case of errors attributable to the Illinois
22    Department or any of its claims processing intermediaries
23    which result in an inability to receive, process, or
24    adjudicate a claim, the 180-day period shall not begin
25    until the provider has been notified of the error.
26        (3) In the case of a provider for whom the Illinois

 

 

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1    Department initiates the monthly billing process.
2        (4) In the case of a provider operated by a unit of
3    local government with a population exceeding 3,000,000
4    when local government funds finance federal participation
5    for claims payments.
6    For claims for services rendered during a period for which
7a recipient received retroactive eligibility, claims must be
8filed within 180 days after the Department determines the
9applicant is eligible. For claims for which the Illinois
10Department is not the primary payer, claims must be submitted
11to the Illinois Department within 180 days after the final
12adjudication by the primary payer.
13    In the case of long term care facilities, within 5 days of
14receipt by the facility of required prescreening information,
15data for new admissions shall be entered into the Medical
16Electronic Data Interchange (MEDI) or the Recipient
17Eligibility Verification (REV) System or successor system, and
18within 15 days of receipt by the facility of required
19prescreening information, admission documents shall be
20submitted through MEDI or REV or shall be submitted directly to
21the Department of Human Services using required admission
22forms. Effective September 1, 2014, admission documents,
23including all prescreening information, must be submitted
24through MEDI or REV. Confirmation numbers assigned to an
25accepted transaction shall be retained by a facility to verify
26timely submittal. Once an admission transaction has been

 

 

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1completed, all resubmitted claims following prior rejection
2are subject to receipt no later than 180 days after the
3admission transaction has been completed.
4    Claims that are not submitted and received in compliance
5with the foregoing requirements shall not be eligible for
6payment under the medical assistance program, and the State
7shall have no liability for payment of those claims.
8    To the extent consistent with applicable information and
9privacy, security, and disclosure laws, State and federal
10agencies and departments shall provide the Illinois Department
11access to confidential and other information and data necessary
12to perform eligibility and payment verifications and other
13Illinois Department functions. This includes, but is not
14limited to: information pertaining to licensure;
15certification; earnings; immigration status; citizenship; wage
16reporting; unearned and earned income; pension income;
17employment; supplemental security income; social security
18numbers; National Provider Identifier (NPI) numbers; the
19National Practitioner Data Bank (NPDB); program and agency
20exclusions; taxpayer identification numbers; tax delinquency;
21corporate information; and death records.
22    The Illinois Department shall enter into agreements with
23State agencies and departments, and is authorized to enter into
24agreements with federal agencies and departments, under which
25such agencies and departments shall share data necessary for
26medical assistance program integrity functions and oversight.

 

 

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1The Illinois Department shall develop, in cooperation with
2other State departments and agencies, and in compliance with
3applicable federal laws and regulations, appropriate and
4effective methods to share such data. At a minimum, and to the
5extent necessary to provide data sharing, the Illinois
6Department shall enter into agreements with State agencies and
7departments, and is authorized to enter into agreements with
8federal agencies and departments, including but not limited to:
9the Secretary of State; the Department of Revenue; the
10Department of Public Health; the Department of Human Services;
11and the Department of Financial and Professional Regulation.
12    Beginning in fiscal year 2013, the Illinois Department
13shall set forth a request for information to identify the
14benefits of a pre-payment, post-adjudication, and post-edit
15claims system with the goals of streamlining claims processing
16and provider reimbursement, reducing the number of pending or
17rejected claims, and helping to ensure a more transparent
18adjudication process through the utilization of: (i) provider
19data verification and provider screening technology; and (ii)
20clinical code editing; and (iii) pre-pay, pre- or
21post-adjudicated predictive modeling with an integrated case
22management system with link analysis. Such a request for
23information shall not be considered as a request for proposal
24or as an obligation on the part of the Illinois Department to
25take any action or acquire any products or services.
26    The Illinois Department shall establish policies,

 

 

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1procedures, standards and criteria by rule for the acquisition,
2repair and replacement of orthotic and prosthetic devices and
3durable medical equipment. Such rules shall provide, but not be
4limited to, the following services: (1) immediate repair or
5replacement of such devices by recipients; and (2) rental,
6lease, purchase or lease-purchase of durable medical equipment
7in a cost-effective manner, taking into consideration the
8recipient's medical prognosis, the extent of the recipient's
9needs, and the requirements and costs for maintaining such
10equipment. Subject to prior approval, such rules shall enable a
11recipient to temporarily acquire and use alternative or
12substitute devices or equipment pending repairs or
13replacements of any device or equipment previously authorized
14for such recipient by the Department.
15    The Department shall execute, relative to the nursing home
16prescreening project, written inter-agency agreements with the
17Department of Human Services and the Department on Aging, to
18effect the following: (i) intake procedures and common
19eligibility criteria for those persons who are receiving
20non-institutional services; and (ii) the establishment and
21development of non-institutional services in areas of the State
22where they are not currently available or are undeveloped; and
23(iii) (iii) notwithstanding any other provision of law, subject
24to federal approval, on and after July 1, 2012, an increase in
25the determination of need (DON) scores from 29 to 37 for
26applicants for institutional and home and community-based long

 

 

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1term care; if and only if federal approval is not granted, the
2Department may, in conjunction with other affected agencies,
3implement utilization controls or changes in benefit packages
4to effectuate a similar savings amount for this population; and
5(iv) no later than July 1, 2013, minimum level of care
6eligibility criteria for institutional and home and
7community-based long term care; and (iv) (v) no later than
8October 1, 2013, establish procedures to permit long term care
9providers access to eligibility scores for individuals with an
10admission date who are seeking or receiving services from the
11long term care provider. In order to select the minimum level
12of care eligibility criteria, the Governor shall establish a
13workgroup that includes affected agency representatives and
14stakeholders representing the institutional and home and
15community-based long term care interests. This Section shall
16not restrict the Department from implementing lower level of
17care eligibility criteria for community-based services in
18circumstances where federal approval has been granted.
19Individuals with a score of 29 or higher based on the
20determination of need (DON) assessment tool shall be eligible
21to receive institutional and home and community-based long term
22care services until such time that the State receives federal
23approval and implements an updated assessment tool, and those
24individuals are found to be ineligible under that updated
25assessment tool. Anyone determined to be ineligible for
26services due to the updated assessment tool shall continue to

 

 

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1be eligible for services for at least one year following that
2determination and must be reassessed no earlier than 11 months
3after that determination. The Department must adopt rules
4through the regular rulemaking process regarding the updated
5assessment tool, and shall not adopt emergency or peremptory
6rules regarding the updated assessment tool. The State shall
7not implement an updated assessment tool that causes more than
81% of then-current recipients to lose eligibility. No
9individual receiving care in an institutional setting shall be
10involuntarily discharged as the result of the updated
11assessment tool until a transition plan has been developed by
12the Department on Aging or its designee and all care identified
13in the transition plan is available to the resident immediately
14upon discharge.
15    The Illinois Department shall develop and operate, in
16cooperation with other State Departments and agencies and in
17compliance with applicable federal laws and regulations,
18appropriate and effective systems of health care evaluation and
19programs for monitoring of utilization of health care services
20and facilities, as it affects persons eligible for medical
21assistance under this Code.
22    The Illinois Department shall report annually to the
23General Assembly, no later than the second Friday in April of
241979 and each year thereafter, in regard to:
25        (a) actual statistics and trends in utilization of
26    medical services by public aid recipients;

 

 

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1        (b) actual statistics and trends in the provision of
2    the various medical services by medical vendors;
3        (c) current rate structures and proposed changes in
4    those rate structures for the various medical vendors; and
5        (d) efforts at utilization review and control by the
6    Illinois Department.
7    The period covered by each report shall be the 3 years
8ending on the June 30 prior to the report. The report shall
9include suggested legislation for consideration by the General
10Assembly. The filing of one copy of the report with the
11Speaker, one copy with the Minority Leader and one copy with
12the Clerk of the House of Representatives, one copy with the
13President, one copy with the Minority Leader and one copy with
14the Secretary of the Senate, one copy with the Legislative
15Research Unit, and such additional copies with the State
16Government Report Distribution Center for the General Assembly
17as is required under paragraph (t) of Section 7 of the State
18Library Act shall be deemed sufficient to comply with this
19Section.
20    Rulemaking authority to implement Public Act 95-1045, if
21any, is conditioned on the rules being adopted in accordance
22with all provisions of the Illinois Administrative Procedure
23Act and all rules and procedures of the Joint Committee on
24Administrative Rules; any purported rule not so adopted, for
25whatever reason, is unauthorized.
26    On and after July 1, 2012, the Department shall reduce any

 

 

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1rate of reimbursement for services or other payments or alter
2any methodologies authorized by this Code to reduce any rate of
3reimbursement for services or other payments in accordance with
4Section 5-5e.
5    Because kidney transplantation can be an appropriate, cost
6effective alternative to renal dialysis when medically
7necessary and notwithstanding the provisions of Section 1-11 of
8this Code, beginning October 1, 2014, the Department shall
9cover kidney transplantation for noncitizens with end-stage
10renal disease who are not eligible for comprehensive medical
11benefits, who meet the residency requirements of Section 5-3 of
12this Code, and who would otherwise meet the financial
13requirements of the appropriate class of eligible persons under
14Section 5-2 of this Code. To qualify for coverage of kidney
15transplantation, such person must be receiving emergency renal
16dialysis services covered by the Department. Providers under
17this Section shall be prior approved and certified by the
18Department to perform kidney transplantation and the services
19under this Section shall be limited to services associated with
20kidney transplantation.
21    Notwithstanding any other provision of this Code to the
22contrary, on or after July 1, 2015, all FDA approved forms of
23medication assisted treatment prescribed for the treatment of
24alcohol dependence or treatment of opioid dependence shall be
25covered under both fee for service and managed care medical
26assistance programs for persons who are otherwise eligible for

 

 

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1medical assistance under this Article and shall not be subject
2to any (1) utilization control, other than those established
3under the American Society of Addiction Medicine patient
4placement criteria, (2) prior authorization mandate, or (3)
5lifetime restriction limit mandate.
6    On or after July 1, 2015, opioid antagonists prescribed for
7the treatment of an opioid overdose, including the medication
8product, administration devices, and any pharmacy fees related
9to the dispensing and administration of the opioid antagonist,
10shall be covered under the medical assistance program for
11persons who are otherwise eligible for medical assistance under
12this Article. As used in this Section, "opioid antagonist"
13means a drug that binds to opioid receptors and blocks or
14inhibits the effect of opioids acting on those receptors,
15including, but not limited to, naloxone hydrochloride or any
16other similarly acting drug approved by the U.S. Food and Drug
17Administration.
18(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
1998-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
208-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
21eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
2299-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
2399 of P.A. 99-407 for its effective date); 99-433, eff.
248-21-15; 99-480, eff. 9-9-15; revised 10-13-15.)
 
25    (305 ILCS 5/5-5.01a)

 

 

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1    Sec. 5-5.01a. Supportive living facilities program. The
2Department shall establish and provide oversight for a program
3of supportive living facilities that seek to promote resident
4independence, dignity, respect, and well-being in the most
5cost-effective manner.
6    A supportive living facility is either a free-standing
7facility or a distinct physical and operational entity within a
8nursing facility. A supportive living facility integrates
9housing with health, personal care, and supportive services and
10is a designated setting that offers residents their own
11separate, private, and distinct living units.
12    Sites for the operation of the program shall be selected by
13the Department based upon criteria that may include the need
14for services in a geographic area, the availability of funding,
15and the site's ability to meet the standards.
16    Beginning July 1, 2014, subject to federal approval, the
17Medicaid rates for supportive living facilities shall be equal
18to the supportive living facility Medicaid rate effective on
19June 30, 2014 increased by 8.85%. Once the assessment imposed
20at Article V-G of this Code is determined to be a permissible
21tax under Title XIX of the Social Security Act, the Department
22shall increase the Medicaid rates for supportive living
23facilities effective on July 1, 2014 by 9.09%. The Department
24shall apply this increase retroactively to coincide with the
25imposition of the assessment in Article V-G of this Code in
26accordance with the approval for federal financial

 

 

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1participation by the Centers for Medicare and Medicaid
2Services.
3    The Department may adopt rules to implement this Section.
4Rules that establish or modify the services, standards, and
5conditions for participation in the program shall be adopted by
6the Department in consultation with the Department on Aging,
7the Department of Rehabilitation Services, and the Department
8of Mental Health and Developmental Disabilities (or their
9successor agencies).
10    Facilities or distinct parts of facilities which are
11selected as supportive living facilities and are in good
12standing with the Department's rules are exempt from the
13provisions of the Nursing Home Care Act and the Illinois Health
14Facilities Planning Act.
15    Individuals with a score of 29 or higher based on the
16determination of need (DON) assessment tool shall be eligible
17to receive institutional and home and community-based long term
18care services until such time that the State receives federal
19approval and implements an updated assessment tool, and those
20individuals are found to be ineligible under that updated
21assessment tool. Anyone determined to be ineligible for
22services due to the updated assessment tool shall continue to
23be eligible for services for at least one year following that
24determination and must be reassessed no earlier than 11 months
25after that determination. The Department must adopt rules
26through the regular rulemaking process regarding the updated

 

 

HB4351 Enrolled- 86 -LRB099 15530 KTG 39820 b

1assessment tool, and shall not adopt emergency or peremptory
2rules regarding the updated assessment tool. The State shall
3not implement an updated assessment tool that causes more than
41% of then-current recipients to lose eligibility. No
5individual receiving care in an institutional setting shall be
6involuntarily discharged as the result of the updated
7assessment tool until a transition plan has been developed by
8the Department on Aging or its designee and all care identified
9in the transition plan is available to the resident immediately
10upon discharge.
11(Source: P.A. 98-651, eff. 6-16-14.)
 
12    Section 95. No acceleration or delay. Where this Act makes
13changes in a statute that is represented in this Act by text
14that is not yet or no longer in effect (for example, a Section
15represented by multiple versions), the use of that text does
16not accelerate or delay the taking effect of (i) the changes
17made by this Act or (ii) provisions derived from any other
18Public Act.
 
19    Section 99. Effective date. This Act takes effect upon
20becoming law.