| |||||||||||||||||||||||||||
| |||||||||||||||||||||||||||
| |||||||||||||||||||||||||||
| |||||||||||||||||||||||||||
| |||||||||||||||||||||||||||
1 | AN ACT concerning regulation.
| ||||||||||||||||||||||||||
2 | Be it enacted by the People of the State of Illinois,
| ||||||||||||||||||||||||||
3 | represented in the General Assembly:
| ||||||||||||||||||||||||||
4 | Section 5. The Illinois Insurance Code is amended by adding | ||||||||||||||||||||||||||
5 | Section 356z.24 as follows: | ||||||||||||||||||||||||||
6 | (215 ILCS 5/356z.24 new) | ||||||||||||||||||||||||||
7 | Sec. 356z.24. HIV pre-exposure prophylaxis coverage. | ||||||||||||||||||||||||||
8 | (a) An individual or group policy of accident and health | ||||||||||||||||||||||||||
9 | insurance amended, delivered, issued, or renewed in this State | ||||||||||||||||||||||||||
10 | after the effective date of this amendatory Act of the 99th | ||||||||||||||||||||||||||
11 | General Assembly shall provide coverage for all drugs that are | ||||||||||||||||||||||||||
12 | approved for marketing by the federal Food and Drug | ||||||||||||||||||||||||||
13 | Administration and that are recommended by the federal Public | ||||||||||||||||||||||||||
14 | Health Service or the United States Centers for Disease Control | ||||||||||||||||||||||||||
15 | and Prevention for pre-exposure prophylaxis and related | ||||||||||||||||||||||||||
16 | pre-exposure prophylaxis services, including, but not limited | ||||||||||||||||||||||||||
17 | to, HIV and sexually transmitted infection screening, | ||||||||||||||||||||||||||
18 | treatment for sexually transmitted infections, medical | ||||||||||||||||||||||||||
19 | monitoring, assorted labs, and counseling to reduce the | ||||||||||||||||||||||||||
20 | likelihood of HIV infection among individuals who are not | ||||||||||||||||||||||||||
21 | infected with HIV but who are at high risk of HIV infection. | ||||||||||||||||||||||||||
22 | (b) This Section does not require a policy of accident and | ||||||||||||||||||||||||||
23 | health insurance to provide coverage for any clinical trials |
| |||||||
| |||||||
1 | relating to any drug that is for pre-exposure prophylaxis for | ||||||
2 | HIV for that has been approved by the federal Food and Drug | ||||||
3 | Administration in the form of an investigational new drug | ||||||
4 | application. | ||||||
5 | Section 10. The Illinois Public Aid Code is amended by | ||||||
6 | changing Section 5-5 as follows:
| ||||||
7 | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| ||||||
8 | (Text of Section before amendment by P.A. 99-407 ) | ||||||
9 | Sec. 5-5. Medical services. The Illinois Department, by | ||||||
10 | rule, shall
determine the quantity and quality of and the rate | ||||||
11 | of reimbursement for the
medical assistance for which
payment | ||||||
12 | will be authorized, and the medical services to be provided,
| ||||||
13 | which may include all or part of the following: (1) inpatient | ||||||
14 | hospital
services; (2) outpatient hospital services; (3) other | ||||||
15 | laboratory and
X-ray services; (4) skilled nursing home | ||||||
16 | services; (5) physicians'
services whether furnished in the | ||||||
17 | office, the patient's home, a
hospital, a skilled nursing home, | ||||||
18 | or elsewhere; (6) medical care, or any
other type of remedial | ||||||
19 | care furnished by licensed practitioners; (7)
home health care | ||||||
20 | services; (8) private duty nursing service; (9) clinic
| ||||||
21 | services; (10) dental services, including prevention and | ||||||
22 | treatment of periodontal disease and dental caries disease for | ||||||
23 | pregnant women, provided by an individual licensed to practice | ||||||
24 | dentistry or dental surgery; for purposes of this item (10), |
| |||||||
| |||||||
1 | "dental services" means diagnostic, preventive, or corrective | ||||||
2 | procedures provided by or under the supervision of a dentist in | ||||||
3 | the practice of his or her profession; (11) physical therapy | ||||||
4 | and related
services; (12) prescribed drugs, dentures, and | ||||||
5 | prosthetic devices; and
eyeglasses prescribed by a physician | ||||||
6 | skilled in the diseases of the eye,
or by an optometrist, | ||||||
7 | whichever the person may select; (13) other
diagnostic, | ||||||
8 | screening, preventive, and rehabilitative services, including | ||||||
9 | to ensure that the individual's need for intervention or | ||||||
10 | treatment of mental disorders or substance use disorders or | ||||||
11 | co-occurring mental health and substance use disorders is | ||||||
12 | determined using a uniform screening, assessment, and | ||||||
13 | evaluation process inclusive of criteria, for children and | ||||||
14 | adults; for purposes of this item (13), a uniform screening, | ||||||
15 | assessment, and evaluation process refers to a process that | ||||||
16 | includes an appropriate evaluation and, as warranted, a | ||||||
17 | referral; "uniform" does not mean the use of a singular | ||||||
18 | instrument, tool, or process that all must utilize; (14)
| ||||||
19 | transportation and such other expenses as may be necessary; | ||||||
20 | (15) medical
treatment of sexual assault survivors, as defined | ||||||
21 | in
Section 1a of the Sexual Assault Survivors Emergency | ||||||
22 | Treatment Act, for
injuries sustained as a result of the sexual | ||||||
23 | assault, including
examinations and laboratory tests to | ||||||
24 | discover evidence which may be used in
criminal proceedings | ||||||
25 | arising from the sexual assault; (16) the
diagnosis and | ||||||
26 | treatment of sickle cell anemia; and (17)
any other medical |
| |||||||
| |||||||
1 | care, and any other type of remedial care recognized
under the | ||||||
2 | laws of this State, but not including abortions, or induced
| ||||||
3 | miscarriages or premature births, unless, in the opinion of a | ||||||
4 | physician,
such procedures are necessary for the preservation | ||||||
5 | of the life of the
woman seeking such treatment, or except an | ||||||
6 | induced premature birth
intended to produce a live viable child | ||||||
7 | and such procedure is necessary
for the health of the mother or | ||||||
8 | her unborn child. The Illinois Department,
by rule, shall | ||||||
9 | prohibit any physician from providing medical assistance
to | ||||||
10 | anyone eligible therefor under this Code where such physician | ||||||
11 | has been
found guilty of performing an abortion procedure in a | ||||||
12 | wilful and wanton
manner upon a woman who was not pregnant at | ||||||
13 | the time such abortion
procedure was performed. The term "any | ||||||
14 | other type of remedial care" shall
include nursing care and | ||||||
15 | nursing home service for persons who rely on
treatment by | ||||||
16 | spiritual means alone through prayer for healing.
| ||||||
17 | Notwithstanding any other provision of this Section, a | ||||||
18 | comprehensive
tobacco use cessation program that includes | ||||||
19 | purchasing prescription drugs or
prescription medical devices | ||||||
20 | approved by the Food and Drug Administration shall
be covered | ||||||
21 | under the medical assistance
program under this Article for | ||||||
22 | persons who are otherwise eligible for
assistance under this | ||||||
23 | Article.
| ||||||
24 | Notwithstanding any other provision of this Code, the | ||||||
25 | Illinois
Department may not require, as a condition of payment | ||||||
26 | for any laboratory
test authorized under this Article, that a |
| |||||||
| |||||||
1 | physician's handwritten signature
appear on the laboratory | ||||||
2 | test order form. The Illinois Department may,
however, impose | ||||||
3 | other appropriate requirements regarding laboratory test
order | ||||||
4 | documentation.
| ||||||
5 | Upon receipt of federal approval of an amendment to the | ||||||
6 | Illinois Title XIX State Plan for this purpose, the Department | ||||||
7 | shall authorize the Chicago Public Schools (CPS) to procure a | ||||||
8 | vendor or vendors to manufacture eyeglasses for individuals | ||||||
9 | enrolled in a school within the CPS system. CPS shall ensure | ||||||
10 | that its vendor or vendors are enrolled as providers in the | ||||||
11 | medical assistance program and in any capitated Medicaid | ||||||
12 | managed care entity (MCE) serving individuals enrolled in a | ||||||
13 | school within the CPS system. Under any contract procured under | ||||||
14 | this provision, the vendor or vendors must serve only | ||||||
15 | individuals enrolled in a school within the CPS system. Claims | ||||||
16 | for services provided by CPS's vendor or vendors to recipients | ||||||
17 | of benefits in the medical assistance program under this Code, | ||||||
18 | the Children's Health Insurance Program, or the Covering ALL | ||||||
19 | KIDS Health Insurance Program shall be submitted to the | ||||||
20 | Department or the MCE in which the individual is enrolled for | ||||||
21 | payment and shall be reimbursed at the Department's or the | ||||||
22 | MCE's established rates or rate methodologies for eyeglasses. | ||||||
23 | On and after July 1, 2012, the Department of Healthcare and | ||||||
24 | Family Services may provide the following services to
persons
| ||||||
25 | eligible for assistance under this Article who are | ||||||
26 | participating in
education, training or employment programs |
| |||||||
| |||||||
1 | operated by the Department of Human
Services as successor to | ||||||
2 | the 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 | ||||||
9 | subject to federal approval, the Department may adopt rules to | ||||||
10 | allow a dentist who is volunteering his or her service at no | ||||||
11 | cost to render dental services through an enrolled | ||||||
12 | not-for-profit health clinic without the dentist personally | ||||||
13 | enrolling as a participating provider in the medical assistance | ||||||
14 | program. A not-for-profit health clinic shall include a public | ||||||
15 | health clinic or Federally Qualified Health Center or other | ||||||
16 | enrolled provider, as determined by the Department, through | ||||||
17 | which dental services covered under this Section are performed. | ||||||
18 | The Department shall establish a process for payment of claims | ||||||
19 | for reimbursement for covered dental services rendered under | ||||||
20 | this provision. | ||||||
21 | The Illinois Department, by rule, may distinguish and | ||||||
22 | classify the
medical services to be provided only in accordance | ||||||
23 | with the classes of
persons designated in Section 5-2.
| ||||||
24 | The Department of Healthcare and Family Services must | ||||||
25 | provide coverage and reimbursement for amino acid-based | ||||||
26 | elemental formulas, regardless of delivery method, for the |
| |||||||
| |||||||
1 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
2 | short bowel syndrome when the prescribing physician has issued | ||||||
3 | a written order stating that the amino acid-based elemental | ||||||
4 | formula is medically necessary.
| ||||||
5 | The Illinois Department shall authorize the provision of, | ||||||
6 | and shall
authorize payment for, screening by low-dose | ||||||
7 | mammography for the presence of
occult breast cancer for women | ||||||
8 | 35 years of age or older who are eligible
for medical | ||||||
9 | assistance 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. |
| |||||||
| |||||||
1 | All screenings
shall
include a physical breast exam, | ||||||
2 | instruction on self-examination and
information regarding the | ||||||
3 | frequency of self-examination and its value as a
preventative | ||||||
4 | tool. For purposes of this Section, "low-dose mammography" | ||||||
5 | means
the x-ray examination of the breast using equipment | ||||||
6 | dedicated specifically
for mammography, including the x-ray | ||||||
7 | tube, filter, compression device,
and image receptor, with an | ||||||
8 | average radiation exposure delivery
of less than one rad per | ||||||
9 | breast for 2 views of an average size breast.
The term also | ||||||
10 | includes digital mammography.
| ||||||
11 | On and after January 1, 2016, the Department shall ensure | ||||||
12 | that all networks of care for adult clients of the Department | ||||||
13 | include access to at least one breast imaging Center of Imaging | ||||||
14 | Excellence as certified by the American College of Radiology. | ||||||
15 | On and after January 1, 2012, providers participating in a | ||||||
16 | quality improvement program approved by the Department shall be | ||||||
17 | reimbursed for screening and diagnostic mammography at the same | ||||||
18 | rate as the Medicare program's rates, including the increased | ||||||
19 | reimbursement for digital mammography. | ||||||
20 | The Department shall convene an expert panel including | ||||||
21 | representatives of hospitals, free-standing mammography | ||||||
22 | facilities, and doctors, including radiologists, to establish | ||||||
23 | quality standards for mammography. | ||||||
24 | On and after January 1, 2017, providers participating in a | ||||||
25 | breast cancer treatment quality improvement program approved | ||||||
26 | by the Department shall be reimbursed for breast cancer |
| |||||||
| |||||||
1 | treatment at a rate that is no lower than 95% of the Medicare | ||||||
2 | program's rates for the data elements included in the breast | ||||||
3 | cancer treatment quality program. | ||||||
4 | The Department shall convene an expert panel, including | ||||||
5 | representatives of hospitals, free standing breast cancer | ||||||
6 | treatment centers, breast cancer quality organizations, and | ||||||
7 | doctors, including breast surgeons, reconstructive breast | ||||||
8 | surgeons, oncologists, and primary care providers to establish | ||||||
9 | quality standards for breast cancer treatment. | ||||||
10 | Subject to federal approval, the Department shall | ||||||
11 | establish a rate methodology for mammography at federally | ||||||
12 | qualified health centers and other encounter-rate clinics. | ||||||
13 | These clinics or centers may also collaborate with other | ||||||
14 | hospital-based mammography facilities. By January 1, 2016, the | ||||||
15 | Department shall report to the General Assembly on the status | ||||||
16 | of the provision set forth in this paragraph. | ||||||
17 | The Department shall establish a methodology to remind | ||||||
18 | women who are age-appropriate for screening mammography, but | ||||||
19 | who have not received a mammogram within the previous 18 | ||||||
20 | months, of the importance and benefit of screening mammography. | ||||||
21 | The Department shall work with experts in breast cancer | ||||||
22 | outreach and patient navigation to optimize these reminders and | ||||||
23 | shall establish a methodology for evaluating their | ||||||
24 | effectiveness and modifying the methodology based on the | ||||||
25 | evaluation. | ||||||
26 | The Department shall establish a performance goal for |
| |||||||
| |||||||
1 | primary care providers with respect to their female patients | ||||||
2 | over age 40 receiving an annual mammogram. This performance | ||||||
3 | goal shall be used to provide additional reimbursement in the | ||||||
4 | form of a quality performance bonus to primary care providers | ||||||
5 | who meet that goal. | ||||||
6 | The Department shall devise a means of case-managing or | ||||||
7 | patient navigation for beneficiaries diagnosed with breast | ||||||
8 | cancer. This program shall initially operate as a pilot program | ||||||
9 | in areas of the State with the highest incidence of mortality | ||||||
10 | related to breast cancer. At least one pilot program site shall | ||||||
11 | be in the metropolitan Chicago area and at least one site shall | ||||||
12 | be outside the metropolitan Chicago area. On or after July 1, | ||||||
13 | 2016, the pilot program shall be expanded to include one site | ||||||
14 | in western Illinois, one site in southern Illinois, one site in | ||||||
15 | central Illinois, and 4 sites within metropolitan Chicago. An | ||||||
16 | evaluation of the pilot program shall be carried out measuring | ||||||
17 | health outcomes and cost of care for those served by the pilot | ||||||
18 | program compared to similarly situated patients who are not | ||||||
19 | served by the pilot program. | ||||||
20 | The Department shall require all networks of care to | ||||||
21 | develop a means either internally or by contract with experts | ||||||
22 | in navigation and community outreach to navigate cancer | ||||||
23 | patients to comprehensive care in a timely fashion. The | ||||||
24 | Department shall require all networks of care to include access | ||||||
25 | for patients diagnosed with cancer to at least one academic | ||||||
26 | commission on cancer-accredited cancer program as an |
| |||||||
| |||||||
1 | in-network covered benefit. | ||||||
2 | Any medical or health care provider shall immediately | ||||||
3 | recommend, to
any pregnant woman who is being provided prenatal | ||||||
4 | services and is suspected
of drug abuse or is addicted as | ||||||
5 | defined in the Alcoholism and Other Drug Abuse
and Dependency | ||||||
6 | Act, referral to a local substance abuse treatment provider
| ||||||
7 | licensed by the Department of Human Services or to a licensed
| ||||||
8 | hospital which provides substance abuse treatment services. | ||||||
9 | The Department of Healthcare and Family Services
shall assure | ||||||
10 | coverage for the cost of treatment of the drug abuse or
| ||||||
11 | addiction for pregnant recipients in accordance with the | ||||||
12 | Illinois Medicaid
Program in conjunction with the Department of | ||||||
13 | Human Services.
| ||||||
14 | All medical providers providing medical assistance to | ||||||
15 | pregnant women
under this Code shall receive information from | ||||||
16 | the Department on the
availability of services under the Drug | ||||||
17 | Free Families with a Future or any
comparable program providing | ||||||
18 | case management services for addicted women,
including | ||||||
19 | information on appropriate referrals for other social services
| ||||||
20 | that may be needed by addicted women in addition to treatment | ||||||
21 | for addiction.
| ||||||
22 | The Illinois Department, in cooperation with the | ||||||
23 | Departments of Human
Services (as successor to the Department | ||||||
24 | of Alcoholism and Substance
Abuse) and Public Health, through a | ||||||
25 | public awareness campaign, may
provide information concerning | ||||||
26 | treatment for alcoholism and drug abuse and
addiction, prenatal |
| |||||||
| |||||||
1 | health care, and other pertinent programs directed at
reducing | ||||||
2 | the number of drug-affected infants born to recipients of | ||||||
3 | medical
assistance.
| ||||||
4 | Neither the Department of Healthcare and Family Services | ||||||
5 | nor the Department of Human
Services shall sanction the | ||||||
6 | recipient solely on the basis of
her substance abuse.
| ||||||
7 | The Illinois Department shall establish such regulations | ||||||
8 | governing
the dispensing of health services under this Article | ||||||
9 | as it shall deem
appropriate. The Department
should
seek the | ||||||
10 | advice of formal professional advisory committees appointed by
| ||||||
11 | the Director of the Illinois Department for the purpose of | ||||||
12 | providing regular
advice on policy and administrative matters, | ||||||
13 | information dissemination and
educational activities for | ||||||
14 | medical and health care providers, and
consistency in | ||||||
15 | procedures to the Illinois Department.
| ||||||
16 | The Illinois Department may develop and contract with | ||||||
17 | Partnerships of
medical providers to arrange medical services | ||||||
18 | for persons eligible under
Section 5-2 of this Code. | ||||||
19 | Implementation of this Section may be by
demonstration projects | ||||||
20 | in certain geographic areas. The Partnership shall
be | ||||||
21 | represented by a sponsor organization. The Department, by rule, | ||||||
22 | shall
develop qualifications for sponsors of Partnerships. | ||||||
23 | Nothing in this
Section shall be construed to require that the | ||||||
24 | sponsor organization be a
medical organization.
| ||||||
25 | The sponsor must negotiate formal written contracts with | ||||||
26 | medical
providers for physician services, inpatient and |
| |||||||
| |||||||
1 | outpatient hospital care,
home health services, treatment for | ||||||
2 | alcoholism and substance abuse, and
other services determined | ||||||
3 | necessary by the Illinois Department by rule for
delivery by | ||||||
4 | Partnerships. Physician services must include prenatal and
| ||||||
5 | obstetrical care. The Illinois Department shall reimburse | ||||||
6 | medical services
delivered by Partnership providers to clients | ||||||
7 | in target areas according to
provisions of this Article and the | ||||||
8 | Illinois Health Finance Reform Act,
except that:
| ||||||
9 | (1) Physicians participating in a Partnership and | ||||||
10 | providing certain
services, which shall be determined by | ||||||
11 | the Illinois Department, to persons
in areas covered by the | ||||||
12 | Partnership may receive an additional surcharge
for such | ||||||
13 | services.
| ||||||
14 | (2) The Department may elect to consider and negotiate | ||||||
15 | financial
incentives to encourage the development of | ||||||
16 | Partnerships and the efficient
delivery of medical care.
| ||||||
17 | (3) Persons receiving medical services through | ||||||
18 | Partnerships may receive
medical and case management | ||||||
19 | services above the level usually offered
through the | ||||||
20 | medical assistance program.
| ||||||
21 | Medical providers shall be required to meet certain | ||||||
22 | qualifications to
participate in Partnerships to ensure the | ||||||
23 | delivery of high quality medical
services. These | ||||||
24 | qualifications shall be determined by rule of the Illinois
| ||||||
25 | Department and may be higher than qualifications for | ||||||
26 | participation in the
medical assistance program. Partnership |
| |||||||
| |||||||
1 | sponsors may prescribe reasonable
additional qualifications | ||||||
2 | for participation by medical providers, only with
the prior | ||||||
3 | written approval of the Illinois Department.
| ||||||
4 | Nothing in this Section shall limit the free choice of | ||||||
5 | practitioners,
hospitals, and other providers of medical | ||||||
6 | services by clients.
In order to ensure patient freedom of | ||||||
7 | choice, the Illinois Department shall
immediately promulgate | ||||||
8 | all rules and take all other necessary actions so that
provided | ||||||
9 | services may be accessed from therapeutically certified | ||||||
10 | optometrists
to the full extent of the Illinois Optometric | ||||||
11 | Practice Act of 1987 without
discriminating between service | ||||||
12 | providers.
| ||||||
13 | The Department shall apply for a waiver from the United | ||||||
14 | States Health
Care Financing Administration to allow for the | ||||||
15 | implementation of
Partnerships under this Section.
| ||||||
16 | The Illinois Department shall require health care | ||||||
17 | providers to maintain
records that document the medical care | ||||||
18 | and services provided to recipients
of Medical Assistance under | ||||||
19 | this Article. Such records must be retained for a period of not | ||||||
20 | less than 6 years from the date of service or as provided by | ||||||
21 | applicable State law, whichever period is longer, except that | ||||||
22 | if an audit is initiated within the required retention period | ||||||
23 | then the records must be retained until the audit is completed | ||||||
24 | and every exception is resolved. The Illinois Department shall
| ||||||
25 | require health care providers to make available, when | ||||||
26 | authorized by the
patient, in writing, the medical records in a |
| |||||||
| |||||||
1 | timely fashion to other
health care providers who are treating | ||||||
2 | or serving persons eligible for
Medical Assistance under this | ||||||
3 | Article. All dispensers of medical services
shall be required | ||||||
4 | to maintain and retain business and professional records
| ||||||
5 | sufficient to fully and accurately document the nature, scope, | ||||||
6 | details and
receipt of the health care provided to persons | ||||||
7 | eligible for medical
assistance under this Code, in accordance | ||||||
8 | with regulations promulgated by
the Illinois Department. The | ||||||
9 | rules and regulations shall require that proof
of the receipt | ||||||
10 | of prescription drugs, dentures, prosthetic devices and
| ||||||
11 | eyeglasses by eligible persons under this Section accompany | ||||||
12 | each claim
for reimbursement submitted by the dispenser of such | ||||||
13 | medical services.
No such claims for reimbursement shall be | ||||||
14 | approved for payment by the Illinois
Department without such | ||||||
15 | proof of receipt, unless the Illinois Department
shall have put | ||||||
16 | into effect and shall be operating a system of post-payment
| ||||||
17 | audit and review which shall, on a sampling basis, be deemed | ||||||
18 | adequate by
the Illinois Department to assure that such drugs, | ||||||
19 | dentures, prosthetic
devices and eyeglasses for which payment | ||||||
20 | is being made are actually being
received by eligible | ||||||
21 | recipients. Within 90 days after September 16, 1984 ( the | ||||||
22 | effective date of Public Act 83-1439)
this amendatory Act of | ||||||
23 | 1984 , the Illinois Department shall establish a
current list of | ||||||
24 | acquisition costs for all prosthetic devices and any
other | ||||||
25 | items recognized as medical equipment and supplies | ||||||
26 | reimbursable under
this Article and shall update such list on a |
| |||||||
| |||||||
1 | quarterly basis, except that
the acquisition costs of all | ||||||
2 | prescription drugs shall be updated no
less frequently than | ||||||
3 | every 30 days as required by Section 5-5.12.
| ||||||
4 | The rules and regulations of the Illinois Department shall | ||||||
5 | require
that a written statement including the required opinion | ||||||
6 | of a physician
shall accompany any claim for reimbursement for | ||||||
7 | abortions, or induced
miscarriages or premature births. This | ||||||
8 | statement shall indicate what
procedures were used in providing | ||||||
9 | such medical services.
| ||||||
10 | Notwithstanding any other law to the contrary, the Illinois | ||||||
11 | Department shall, within 365 days after July 22, 2013 (the | ||||||
12 | effective date of Public Act 98-104), establish procedures to | ||||||
13 | permit skilled care facilities licensed under the Nursing Home | ||||||
14 | Care Act to submit monthly billing claims for reimbursement | ||||||
15 | purposes. Following development of these procedures, the | ||||||
16 | Department shall, by July 1, 2016, test the viability of the | ||||||
17 | new system and implement any necessary operational or | ||||||
18 | structural changes to its information technology platforms in | ||||||
19 | order to allow for the direct acceptance and payment of nursing | ||||||
20 | home claims. | ||||||
21 | Notwithstanding any other law to the contrary, the Illinois | ||||||
22 | Department shall, within 365 days after August 15, 2014 (the | ||||||
23 | effective date of Public Act 98-963), establish procedures to | ||||||
24 | permit ID/DD facilities licensed under the ID/DD Community Care | ||||||
25 | Act and MC/DD facilities licensed under the MC/DD Act to submit | ||||||
26 | monthly billing claims for reimbursement purposes. Following |
| |||||||
| |||||||
1 | development of these procedures, the Department shall have an | ||||||
2 | additional 365 days to test the viability of the new system and | ||||||
3 | to ensure that any necessary operational or structural changes | ||||||
4 | to its information technology platforms are implemented. | ||||||
5 | The Illinois Department shall require all dispensers of | ||||||
6 | medical
services, other than an individual practitioner or | ||||||
7 | group of practitioners,
desiring to participate in the Medical | ||||||
8 | Assistance program
established under this Article to disclose | ||||||
9 | all financial, beneficial,
ownership, equity, surety or other | ||||||
10 | interests in any and all firms,
corporations, partnerships, | ||||||
11 | associations, business enterprises, joint
ventures, agencies, | ||||||
12 | institutions or other legal entities providing any
form of | ||||||
13 | health care services in this State under this Article.
| ||||||
14 | The Illinois Department may require that all dispensers of | ||||||
15 | medical
services desiring to participate in the medical | ||||||
16 | assistance program
established under this Article disclose, | ||||||
17 | under such terms and conditions as
the Illinois Department may | ||||||
18 | by rule establish, all inquiries from clients
and attorneys | ||||||
19 | regarding medical bills paid by the Illinois Department, which
| ||||||
20 | inquiries could indicate potential existence of claims or liens | ||||||
21 | for the
Illinois Department.
| ||||||
22 | Enrollment of a vendor
shall be
subject to a provisional | ||||||
23 | period and shall be conditional for one year. During the period | ||||||
24 | of conditional enrollment, the Department may
terminate the | ||||||
25 | vendor's eligibility to participate in, or may disenroll the | ||||||
26 | vendor from, the medical assistance
program without cause. |
| |||||||
| |||||||
1 | Unless otherwise specified, such termination of eligibility or | ||||||
2 | disenrollment is not subject to the
Department's hearing | ||||||
3 | process.
However, a disenrolled vendor may reapply without | ||||||
4 | penalty.
| ||||||
5 | The Department has the discretion to limit the conditional | ||||||
6 | enrollment period for vendors based upon category of risk of | ||||||
7 | the vendor. | ||||||
8 | Prior to enrollment and during the conditional enrollment | ||||||
9 | period in the medical assistance program, all vendors shall be | ||||||
10 | subject to enhanced oversight, screening, and review based on | ||||||
11 | the risk of fraud, waste, and abuse that is posed by the | ||||||
12 | category of risk of the vendor. The Illinois Department shall | ||||||
13 | establish the procedures for oversight, screening, and review, | ||||||
14 | which may include, but need not be limited to: criminal and | ||||||
15 | financial background checks; fingerprinting; license, | ||||||
16 | certification, and authorization verifications; unscheduled or | ||||||
17 | unannounced site visits; database checks; prepayment audit | ||||||
18 | reviews; audits; payment caps; payment suspensions; and other | ||||||
19 | screening as required by federal or State law. | ||||||
20 | The Department shall define or specify the following: (i) | ||||||
21 | by provider notice, the "category of risk of the vendor" for | ||||||
22 | each type of vendor, which shall take into account the level of | ||||||
23 | screening applicable to a particular category of vendor under | ||||||
24 | federal law and regulations; (ii) by rule or provider notice, | ||||||
25 | the maximum length of the conditional enrollment period for | ||||||
26 | each category of risk of the vendor; and (iii) by rule, the |
| |||||||
| |||||||
1 | hearing rights, if any, afforded to a vendor in each category | ||||||
2 | of risk of the vendor that is terminated or disenrolled during | ||||||
3 | the conditional enrollment period. | ||||||
4 | To be eligible for payment consideration, a vendor's | ||||||
5 | payment claim or bill, either as an initial claim or as a | ||||||
6 | resubmitted claim following prior rejection, must be received | ||||||
7 | by the Illinois Department, or its fiscal intermediary, no | ||||||
8 | later than 180 days after the latest date on the claim on which | ||||||
9 | medical goods or services were provided, with the following | ||||||
10 | exceptions: | ||||||
11 | (1) In the case of a provider whose enrollment is in | ||||||
12 | process by the Illinois Department, the 180-day period | ||||||
13 | shall not begin until the date on the written notice from | ||||||
14 | the Illinois Department that the provider enrollment is | ||||||
15 | complete. | ||||||
16 | (2) In the case of errors attributable to the Illinois | ||||||
17 | Department or any of its claims processing intermediaries | ||||||
18 | which result in an inability to receive, process, or | ||||||
19 | adjudicate a claim, the 180-day period shall not begin | ||||||
20 | until the provider has been notified of the error. | ||||||
21 | (3) In the case of a provider for whom the Illinois | ||||||
22 | Department initiates the monthly billing process. | ||||||
23 | (4) In the case of a provider operated by a unit of | ||||||
24 | local government with a population exceeding 3,000,000 | ||||||
25 | when local government funds finance federal participation | ||||||
26 | for claims payments. |
| |||||||
| |||||||
1 | For claims for services rendered during a period for which | ||||||
2 | a recipient received retroactive eligibility, claims must be | ||||||
3 | filed within 180 days after the Department determines the | ||||||
4 | applicant is eligible. For claims for which the Illinois | ||||||
5 | Department is not the primary payer, claims must be submitted | ||||||
6 | to the Illinois Department within 180 days after the final | ||||||
7 | adjudication by the primary payer. | ||||||
8 | In the case of long term care facilities, within 5 days of | ||||||
9 | receipt by the facility of required prescreening information, | ||||||
10 | data for new admissions shall be entered into the Medical | ||||||
11 | Electronic Data Interchange (MEDI) or the Recipient | ||||||
12 | Eligibility Verification (REV) System or successor system, and | ||||||
13 | within 15 days of receipt by the facility of required | ||||||
14 | prescreening information, admission documents shall be | ||||||
15 | submitted through MEDI or REV or shall be submitted directly to | ||||||
16 | the Department of Human Services using required admission | ||||||
17 | forms. Effective September
1, 2014, admission documents, | ||||||
18 | including all prescreening
information, must be submitted | ||||||
19 | through MEDI or REV. Confirmation numbers assigned to an | ||||||
20 | accepted transaction shall be retained by a facility to verify | ||||||
21 | timely submittal. Once an admission transaction has been | ||||||
22 | completed, all resubmitted claims following prior rejection | ||||||
23 | are subject to receipt no later than 180 days after the | ||||||
24 | admission transaction has been completed. | ||||||
25 | Claims that are not submitted and received in compliance | ||||||
26 | with the foregoing requirements shall not be eligible for |
| |||||||
| |||||||
1 | payment under the medical assistance program, and the State | ||||||
2 | shall have no liability for payment of those claims. | ||||||
3 | To the extent consistent with applicable information and | ||||||
4 | privacy, security, and disclosure laws, State and federal | ||||||
5 | agencies and departments shall provide the Illinois Department | ||||||
6 | access to confidential and other information and data necessary | ||||||
7 | to perform eligibility and payment verifications and other | ||||||
8 | Illinois Department functions. This includes, but is not | ||||||
9 | limited to: information pertaining to licensure; | ||||||
10 | certification; earnings; immigration status; citizenship; wage | ||||||
11 | reporting; unearned and earned income; pension income; | ||||||
12 | employment; supplemental security income; social security | ||||||
13 | numbers; National Provider Identifier (NPI) numbers; the | ||||||
14 | National Practitioner Data Bank (NPDB); program and agency | ||||||
15 | exclusions; taxpayer identification numbers; tax delinquency; | ||||||
16 | corporate information; and death records. | ||||||
17 | The Illinois Department shall enter into agreements with | ||||||
18 | State agencies and departments, and is authorized to enter into | ||||||
19 | agreements with federal agencies and departments, under which | ||||||
20 | such agencies and departments shall share data necessary for | ||||||
21 | medical assistance program integrity functions and oversight. | ||||||
22 | The Illinois Department shall develop, in cooperation with | ||||||
23 | other State departments and agencies, and in compliance with | ||||||
24 | applicable federal laws and regulations, appropriate and | ||||||
25 | effective methods to share such data. At a minimum, and to the | ||||||
26 | extent necessary to provide data sharing, the Illinois |
| |||||||
| |||||||
1 | Department shall enter into agreements with State agencies and | ||||||
2 | departments, and is authorized to enter into agreements with | ||||||
3 | federal agencies and departments, including but not limited to: | ||||||
4 | the Secretary of State; the Department of Revenue; the | ||||||
5 | Department of Public Health; the Department of Human Services; | ||||||
6 | and the Department of Financial and Professional Regulation. | ||||||
7 | Beginning in fiscal year 2013, the Illinois Department | ||||||
8 | shall set forth a request for information to identify the | ||||||
9 | benefits of a pre-payment, post-adjudication, and post-edit | ||||||
10 | claims system with the goals of streamlining claims processing | ||||||
11 | and provider reimbursement, reducing the number of pending or | ||||||
12 | rejected claims, and helping to ensure a more transparent | ||||||
13 | adjudication process through the utilization of: (i) provider | ||||||
14 | data verification and provider screening technology; and (ii) | ||||||
15 | clinical code editing; and (iii) pre-pay, pre- or | ||||||
16 | post-adjudicated predictive modeling with an integrated case | ||||||
17 | management system with link analysis. Such a request for | ||||||
18 | information shall not be considered as a request for proposal | ||||||
19 | or as an obligation on the part of the Illinois Department to | ||||||
20 | take any action or acquire any products or services. | ||||||
21 | The Illinois Department shall establish policies, | ||||||
22 | procedures,
standards and criteria by rule for the acquisition, | ||||||
23 | repair and replacement
of orthotic and prosthetic devices and | ||||||
24 | durable medical equipment. Such
rules shall provide, but not be | ||||||
25 | limited to, the following services: (1)
immediate repair or | ||||||
26 | replacement of such devices by recipients; and (2) rental, |
| |||||||
| |||||||
1 | lease, purchase or lease-purchase of
durable medical equipment | ||||||
2 | in a cost-effective manner, taking into
consideration the | ||||||
3 | recipient's medical prognosis, the extent of the
recipient's | ||||||
4 | needs, and the requirements and costs for maintaining such
| ||||||
5 | equipment. Subject to prior approval, such rules shall enable a | ||||||
6 | recipient to temporarily acquire and
use alternative or | ||||||
7 | substitute devices or equipment pending repairs or
| ||||||
8 | replacements of any device or equipment previously authorized | ||||||
9 | for such
recipient by the Department.
| ||||||
10 | The Department shall execute, relative to the nursing home | ||||||
11 | prescreening
project, written inter-agency agreements with the | ||||||
12 | Department of Human
Services and the Department on Aging, to | ||||||
13 | effect the following: (i) intake
procedures and common | ||||||
14 | eligibility criteria for those persons who are receiving
| ||||||
15 | non-institutional services; and (ii) the establishment and | ||||||
16 | development of
non-institutional services in areas of the State | ||||||
17 | where they are not currently
available or are undeveloped; and | ||||||
18 | (iii) notwithstanding any other provision of law, subject to | ||||||
19 | federal approval, on and after July 1, 2012, an increase in the | ||||||
20 | determination of need (DON) scores from 29 to 37 for applicants | ||||||
21 | for institutional and home and community-based long term care; | ||||||
22 | if and only if federal approval is not granted, the Department | ||||||
23 | may, in conjunction with other affected agencies, implement | ||||||
24 | utilization controls or changes in benefit packages to | ||||||
25 | effectuate a similar savings amount for this population; and | ||||||
26 | (iv) no later than July 1, 2013, minimum level of care |
| |||||||
| |||||||
1 | eligibility criteria for institutional and home and | ||||||
2 | community-based long term care; and (v) no later than October | ||||||
3 | 1, 2013, establish procedures to permit long term care | ||||||
4 | providers access to eligibility scores for individuals with an | ||||||
5 | admission date who are seeking or receiving services from the | ||||||
6 | long term care provider. In order to select the minimum level | ||||||
7 | of care eligibility criteria, the Governor shall establish a | ||||||
8 | workgroup that includes affected agency representatives and | ||||||
9 | stakeholders representing the institutional and home and | ||||||
10 | community-based long term care interests. This Section shall | ||||||
11 | not restrict the Department from implementing lower level of | ||||||
12 | care eligibility criteria for community-based services in | ||||||
13 | circumstances where federal approval has been granted.
| ||||||
14 | The Illinois Department shall develop and operate, in | ||||||
15 | cooperation
with other State Departments and agencies and in | ||||||
16 | compliance with
applicable federal laws and regulations, | ||||||
17 | appropriate and effective
systems of health care evaluation and | ||||||
18 | programs for monitoring of
utilization of health care services | ||||||
19 | and facilities, as it affects
persons eligible for medical | ||||||
20 | assistance under this Code.
| ||||||
21 | The Illinois Department shall report annually to the | ||||||
22 | General Assembly,
no later than the second Friday in April of | ||||||
23 | 1979 and each year
thereafter, in regard to:
| ||||||
24 | (a) actual statistics and trends in utilization of | ||||||
25 | medical services by
public aid recipients;
| ||||||
26 | (b) actual statistics and trends in the provision of |
| |||||||
| |||||||
1 | the various medical
services by medical vendors;
| ||||||
2 | (c) current rate structures and proposed changes in | ||||||
3 | those rate structures
for the various medical vendors; and
| ||||||
4 | (d) efforts at utilization review and control by the | ||||||
5 | Illinois Department.
| ||||||
6 | The period covered by each report shall be the 3 years | ||||||
7 | ending on the June
30 prior to the report. The report shall | ||||||
8 | include suggested legislation
for consideration by the General | ||||||
9 | Assembly. The filing of one copy of the
report with the | ||||||
10 | Speaker, one copy with the Minority Leader and one copy
with | ||||||
11 | the Clerk of the House of Representatives, one copy with the | ||||||
12 | President,
one copy with the Minority Leader and one copy with | ||||||
13 | the Secretary of the
Senate, one copy with the Legislative | ||||||
14 | Research Unit, and such additional
copies
with the State | ||||||
15 | Government Report Distribution Center for the General
Assembly | ||||||
16 | as is required under paragraph (t) of Section 7 of the State
| ||||||
17 | Library Act shall be deemed sufficient to comply with this | ||||||
18 | Section.
| ||||||
19 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
20 | any, is conditioned on the rules being adopted in accordance | ||||||
21 | with all provisions of the Illinois Administrative Procedure | ||||||
22 | Act and all rules and procedures of the Joint Committee on | ||||||
23 | Administrative Rules; any purported rule not so adopted, for | ||||||
24 | whatever reason, is unauthorized. | ||||||
25 | On and after July 1, 2012, the Department shall reduce any | ||||||
26 | rate of reimbursement for services or other payments or alter |
| |||||||
| |||||||
1 | any methodologies authorized by this Code to reduce any rate of | ||||||
2 | reimbursement for services or other payments in accordance with | ||||||
3 | Section 5-5e. | ||||||
4 | Because kidney transplantation can be an appropriate, cost | ||||||
5 | effective
alternative to renal dialysis when medically | ||||||
6 | necessary and notwithstanding the provisions of Section 1-11 of | ||||||
7 | this Code, beginning October 1, 2014, the Department shall | ||||||
8 | cover kidney transplantation for noncitizens with end-stage | ||||||
9 | renal disease who are not eligible for comprehensive medical | ||||||
10 | benefits, who meet the residency requirements of Section 5-3 of | ||||||
11 | this Code, and who would otherwise meet the financial | ||||||
12 | requirements of the appropriate class of eligible persons under | ||||||
13 | Section 5-2 of this Code. To qualify for coverage of kidney | ||||||
14 | transplantation, such person must be receiving emergency renal | ||||||
15 | dialysis services covered by the Department. Providers under | ||||||
16 | this Section shall be prior approved and certified by the | ||||||
17 | Department to perform kidney transplantation and the services | ||||||
18 | under this Section shall be limited to services associated with | ||||||
19 | kidney transplantation. | ||||||
20 | Notwithstanding any other provision of this Code to the | ||||||
21 | contrary, on or after July 1, 2015, all FDA approved forms of | ||||||
22 | medication assisted treatment prescribed for the treatment of | ||||||
23 | alcohol dependence or treatment of opioid dependence shall be | ||||||
24 | covered under both fee for service and managed care medical | ||||||
25 | assistance programs for persons who are otherwise eligible for | ||||||
26 | medical assistance under this Article and shall not be subject |
| |||||||
| |||||||
1 | to any (1) utilization control, other than those established | ||||||
2 | under the American Society of Addiction Medicine patient | ||||||
3 | placement criteria,
(2) prior authorization mandate, or (3) | ||||||
4 | lifetime restriction limit
mandate. | ||||||
5 | On or after July 1, 2015, opioid antagonists prescribed for | ||||||
6 | the treatment of an opioid overdose, including the medication | ||||||
7 | product, administration devices, and any pharmacy fees related | ||||||
8 | to the dispensing and administration of the opioid antagonist, | ||||||
9 | shall be covered under the medical assistance program for | ||||||
10 | persons who are otherwise eligible for medical assistance under | ||||||
11 | this Article. As used in this Section, "opioid antagonist" | ||||||
12 | means a drug that binds to opioid receptors and blocks or | ||||||
13 | inhibits the effect of opioids acting on those receptors, | ||||||
14 | including, but not limited to, naloxone hydrochloride or any | ||||||
15 | other similarly acting drug approved by the U.S. Food and Drug | ||||||
16 | Administration. | ||||||
17 | Upon federal approval, the Department shall provide | ||||||
18 | coverage and reimbursement for all drugs that are approved for | ||||||
19 | marketing by the federal Food and Drug Administration and that | ||||||
20 | are recommended by the federal Public Health Service or the | ||||||
21 | United States Centers for Disease Control and Prevention for | ||||||
22 | pre-exposure prophylaxis and related pre-exposure prophylaxis | ||||||
23 | services, including, but not limited to, HIV and sexually | ||||||
24 | transmitted infection screening, treatment for sexually | ||||||
25 | transmitted infections, medical monitoring, assorted labs, and | ||||||
26 | counseling to reduce the likelihood of HIV infection among |
| |||||||
| |||||||
1 | individuals who are not infected with HIV but who are at high | ||||||
2 | risk of HIV infection. | ||||||
3 | (Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13; | ||||||
4 | 98-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff. | ||||||
5 | 8-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756, | ||||||
6 | eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15; | ||||||
7 | 99-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-433, eff. | ||||||
8 | 8-21-15; 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 | ||||||
11 | rule, shall
determine the quantity and quality of and the rate | ||||||
12 | of reimbursement for the
medical assistance for which
payment | ||||||
13 | will be authorized, and the medical services to be provided,
| ||||||
14 | which may include all or part of the following: (1) inpatient | ||||||
15 | hospital
services; (2) outpatient hospital services; (3) other | ||||||
16 | laboratory and
X-ray services; (4) skilled nursing home | ||||||
17 | services; (5) physicians'
services whether furnished in the | ||||||
18 | office, the patient's home, a
hospital, a skilled nursing home, | ||||||
19 | or elsewhere; (6) medical care, or any
other type of remedial | ||||||
20 | care furnished by licensed practitioners; (7)
home health care | ||||||
21 | services; (8) private duty nursing service; (9) clinic
| ||||||
22 | services; (10) dental services, including prevention and | ||||||
23 | treatment of periodontal disease and dental caries disease for | ||||||
24 | pregnant women, provided by an individual licensed to practice | ||||||
25 | dentistry or dental surgery; for purposes of this item (10), |
| |||||||
| |||||||
1 | "dental services" means diagnostic, preventive, or corrective | ||||||
2 | procedures provided by or under the supervision of a dentist in | ||||||
3 | the practice of his or her profession; (11) physical therapy | ||||||
4 | and related
services; (12) prescribed drugs, dentures, and | ||||||
5 | prosthetic devices; and
eyeglasses prescribed by a physician | ||||||
6 | skilled in the diseases of the eye,
or by an optometrist, | ||||||
7 | whichever the person may select; (13) other
diagnostic, | ||||||
8 | screening, preventive, and rehabilitative services, including | ||||||
9 | to ensure that the individual's need for intervention or | ||||||
10 | treatment of mental disorders or substance use disorders or | ||||||
11 | co-occurring mental health and substance use disorders is | ||||||
12 | determined using a uniform screening, assessment, and | ||||||
13 | evaluation process inclusive of criteria, for children and | ||||||
14 | adults; for purposes of this item (13), a uniform screening, | ||||||
15 | assessment, and evaluation process refers to a process that | ||||||
16 | includes an appropriate evaluation and, as warranted, a | ||||||
17 | referral; "uniform" does not mean the use of a singular | ||||||
18 | instrument, tool, or process that all must utilize; (14)
| ||||||
19 | transportation and such other expenses as may be necessary; | ||||||
20 | (15) medical
treatment of sexual assault survivors, as defined | ||||||
21 | in
Section 1a of the Sexual Assault Survivors Emergency | ||||||
22 | Treatment Act, for
injuries sustained as a result of the sexual | ||||||
23 | assault, including
examinations and laboratory tests to | ||||||
24 | discover evidence which may be used in
criminal proceedings | ||||||
25 | arising from the sexual assault; (16) the
diagnosis and | ||||||
26 | treatment of sickle cell anemia; and (17)
any other medical |
| |||||||
| |||||||
1 | care, and any other type of remedial care recognized
under the | ||||||
2 | laws of this State, but not including abortions, or induced
| ||||||
3 | miscarriages or premature births, unless, in the opinion of a | ||||||
4 | physician,
such procedures are necessary for the preservation | ||||||
5 | of the life of the
woman seeking such treatment, or except an | ||||||
6 | induced premature birth
intended to produce a live viable child | ||||||
7 | and such procedure is necessary
for the health of the mother or | ||||||
8 | her unborn child. The Illinois Department,
by rule, shall | ||||||
9 | prohibit any physician from providing medical assistance
to | ||||||
10 | anyone eligible therefor under this Code where such physician | ||||||
11 | has been
found guilty of performing an abortion procedure in a | ||||||
12 | wilful and wanton
manner upon a woman who was not pregnant at | ||||||
13 | the time such abortion
procedure was performed. The term "any | ||||||
14 | other type of remedial care" shall
include nursing care and | ||||||
15 | nursing home service for persons who rely on
treatment by | ||||||
16 | spiritual means alone through prayer for healing.
| ||||||
17 | Notwithstanding any other provision of this Section, a | ||||||
18 | comprehensive
tobacco use cessation program that includes | ||||||
19 | purchasing prescription drugs or
prescription medical devices | ||||||
20 | approved by the Food and Drug Administration shall
be covered | ||||||
21 | under the medical assistance
program under this Article for | ||||||
22 | persons who are otherwise eligible for
assistance under this | ||||||
23 | Article.
| ||||||
24 | Notwithstanding any other provision of this Code, the | ||||||
25 | Illinois
Department may not require, as a condition of payment | ||||||
26 | for any laboratory
test authorized under this Article, that a |
| |||||||
| |||||||
1 | physician's handwritten signature
appear on the laboratory | ||||||
2 | test order form. The Illinois Department may,
however, impose | ||||||
3 | other appropriate requirements regarding laboratory test
order | ||||||
4 | documentation.
| ||||||
5 | Upon receipt of federal approval of an amendment to the | ||||||
6 | Illinois Title XIX State Plan for this purpose, the Department | ||||||
7 | shall authorize the Chicago Public Schools (CPS) to procure a | ||||||
8 | vendor or vendors to manufacture eyeglasses for individuals | ||||||
9 | enrolled in a school within the CPS system. CPS shall ensure | ||||||
10 | that its vendor or vendors are enrolled as providers in the | ||||||
11 | medical assistance program and in any capitated Medicaid | ||||||
12 | managed care entity (MCE) serving individuals enrolled in a | ||||||
13 | school within the CPS system. Under any contract procured under | ||||||
14 | this provision, the vendor or vendors must serve only | ||||||
15 | individuals enrolled in a school within the CPS system. Claims | ||||||
16 | for services provided by CPS's vendor or vendors to recipients | ||||||
17 | of benefits in the medical assistance program under this Code, | ||||||
18 | the Children's Health Insurance Program, or the Covering ALL | ||||||
19 | KIDS Health Insurance Program shall be submitted to the | ||||||
20 | Department or the MCE in which the individual is enrolled for | ||||||
21 | payment and shall be reimbursed at the Department's or the | ||||||
22 | MCE's established rates or rate methodologies for eyeglasses. | ||||||
23 | On and after July 1, 2012, the Department of Healthcare and | ||||||
24 | Family Services may provide the following services to
persons
| ||||||
25 | eligible for assistance under this Article who are | ||||||
26 | participating in
education, training or employment programs |
| |||||||
| |||||||
1 | operated by the Department of Human
Services as successor to | ||||||
2 | the 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 | ||||||
9 | subject to federal approval, the Department may adopt rules to | ||||||
10 | allow a dentist who is volunteering his or her service at no | ||||||
11 | cost to render dental services through an enrolled | ||||||
12 | not-for-profit health clinic without the dentist personally | ||||||
13 | enrolling as a participating provider in the medical assistance | ||||||
14 | program. A not-for-profit health clinic shall include a public | ||||||
15 | health clinic or Federally Qualified Health Center or other | ||||||
16 | enrolled provider, as determined by the Department, through | ||||||
17 | which dental services covered under this Section are performed. | ||||||
18 | The Department shall establish a process for payment of claims | ||||||
19 | for reimbursement for covered dental services rendered under | ||||||
20 | this provision. | ||||||
21 | The Illinois Department, by rule, may distinguish and | ||||||
22 | classify the
medical services to be provided only in accordance | ||||||
23 | with the classes of
persons designated in Section 5-2.
| ||||||
24 | The Department of Healthcare and Family Services must | ||||||
25 | provide coverage and reimbursement for amino acid-based | ||||||
26 | elemental formulas, regardless of delivery method, for the |
| |||||||
| |||||||
1 | diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||||||
2 | short bowel syndrome when the prescribing physician has issued | ||||||
3 | a written order stating that the amino acid-based elemental | ||||||
4 | formula is medically necessary.
| ||||||
5 | The Illinois Department shall authorize the provision of, | ||||||
6 | and shall
authorize payment for, screening by low-dose | ||||||
7 | mammography for the presence of
occult breast cancer for women | ||||||
8 | 35 years of age or older who are eligible
for medical | ||||||
9 | assistance 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. |
| |||||||
| |||||||
1 | All screenings
shall
include a physical breast exam, | ||||||
2 | instruction on self-examination and
information regarding the | ||||||
3 | frequency of self-examination and its value as a
preventative | ||||||
4 | tool. For purposes of this Section, "low-dose mammography" | ||||||
5 | means
the x-ray examination of the breast using equipment | ||||||
6 | dedicated specifically
for mammography, including the x-ray | ||||||
7 | tube, filter, compression device,
and image receptor, with an | ||||||
8 | average radiation exposure delivery
of less than one rad per | ||||||
9 | breast for 2 views of an average size breast.
The term also | ||||||
10 | includes digital mammography and includes breast | ||||||
11 | tomosynthesis. As used in this Section, the term "breast | ||||||
12 | tomosynthesis" means a radiologic procedure that involves the | ||||||
13 | acquisition of projection images over the stationary breast to | ||||||
14 | produce cross-sectional digital three-dimensional images of | ||||||
15 | the breast.
| ||||||
16 | On and after January 1, 2016, the Department shall ensure | ||||||
17 | that all networks of care for adult clients of the Department | ||||||
18 | include access to at least one breast imaging Center of Imaging | ||||||
19 | Excellence as certified by the American College of Radiology. | ||||||
20 | On and after January 1, 2012, providers participating in a | ||||||
21 | quality improvement program approved by the Department shall be | ||||||
22 | reimbursed for screening and diagnostic mammography at the same | ||||||
23 | rate as the Medicare program's rates, including the increased | ||||||
24 | reimbursement for digital mammography. | ||||||
25 | The Department shall convene an expert panel including | ||||||
26 | representatives of hospitals, free-standing mammography |
| |||||||
| |||||||
1 | facilities, and doctors, including radiologists, to establish | ||||||
2 | quality standards for mammography. | ||||||
3 | On and after January 1, 2017, providers participating in a | ||||||
4 | breast cancer treatment quality improvement program approved | ||||||
5 | by the Department shall be reimbursed for breast cancer | ||||||
6 | treatment at a rate that is no lower than 95% of the Medicare | ||||||
7 | program's rates for the data elements included in the breast | ||||||
8 | cancer treatment quality program. | ||||||
9 | The Department shall convene an expert panel, including | ||||||
10 | representatives of hospitals, free standing breast cancer | ||||||
11 | treatment centers, breast cancer quality organizations, and | ||||||
12 | doctors, including breast surgeons, reconstructive breast | ||||||
13 | surgeons, oncologists, and primary care providers to establish | ||||||
14 | quality standards for breast cancer treatment. | ||||||
15 | Subject to federal approval, the Department shall | ||||||
16 | establish a rate methodology for mammography at federally | ||||||
17 | qualified health centers and other encounter-rate clinics. | ||||||
18 | These clinics or centers may also collaborate with other | ||||||
19 | hospital-based mammography facilities. By January 1, 2016, the | ||||||
20 | Department shall report to the General Assembly on the status | ||||||
21 | of the provision set forth in this paragraph. | ||||||
22 | The Department shall establish a methodology to remind | ||||||
23 | women who are age-appropriate for screening mammography, but | ||||||
24 | who have not received a mammogram within the previous 18 | ||||||
25 | months, of the importance and benefit of screening mammography. | ||||||
26 | The Department shall work with experts in breast cancer |
| |||||||
| |||||||
1 | outreach and patient navigation to optimize these reminders and | ||||||
2 | shall establish a methodology for evaluating their | ||||||
3 | effectiveness and modifying the methodology based on the | ||||||
4 | evaluation. | ||||||
5 | The Department shall establish a performance goal for | ||||||
6 | primary care providers with respect to their female patients | ||||||
7 | over age 40 receiving an annual mammogram. This performance | ||||||
8 | goal shall be used to provide additional reimbursement in the | ||||||
9 | form of a quality performance bonus to primary care providers | ||||||
10 | who meet that goal. | ||||||
11 | The Department shall devise a means of case-managing or | ||||||
12 | patient navigation for beneficiaries diagnosed with breast | ||||||
13 | cancer. This program shall initially operate as a pilot program | ||||||
14 | in areas of the State with the highest incidence of mortality | ||||||
15 | related to breast cancer. At least one pilot program site shall | ||||||
16 | be in the metropolitan Chicago area and at least one site shall | ||||||
17 | be outside the metropolitan Chicago area. On or after July 1, | ||||||
18 | 2016, the pilot program shall be expanded to include one site | ||||||
19 | in western Illinois, one site in southern Illinois, one site in | ||||||
20 | central Illinois, and 4 sites within metropolitan Chicago. An | ||||||
21 | evaluation of the pilot program shall be carried out measuring | ||||||
22 | health outcomes and cost of care for those served by the pilot | ||||||
23 | program compared to similarly situated patients who are not | ||||||
24 | served by the pilot program. | ||||||
25 | The Department shall require all networks of care to | ||||||
26 | develop a means either internally or by contract with experts |
| |||||||
| |||||||
1 | in navigation and community outreach to navigate cancer | ||||||
2 | patients to comprehensive care in a timely fashion. The | ||||||
3 | Department shall require all networks of care to include access | ||||||
4 | for patients diagnosed with cancer to at least one academic | ||||||
5 | commission on cancer-accredited cancer program as an | ||||||
6 | in-network covered benefit. | ||||||
7 | Any medical or health care provider shall immediately | ||||||
8 | recommend, to
any pregnant woman who is being provided prenatal | ||||||
9 | services and is suspected
of drug abuse or is addicted as | ||||||
10 | defined in the Alcoholism and Other Drug Abuse
and Dependency | ||||||
11 | Act, referral to a local substance abuse treatment provider
| ||||||
12 | licensed by the Department of Human Services or to a licensed
| ||||||
13 | hospital which provides substance abuse treatment services. | ||||||
14 | The Department of Healthcare and Family Services
shall assure | ||||||
15 | coverage for the cost of treatment of the drug abuse or
| ||||||
16 | addiction for pregnant recipients in accordance with the | ||||||
17 | Illinois Medicaid
Program in conjunction with the Department of | ||||||
18 | Human Services.
| ||||||
19 | All medical providers providing medical assistance to | ||||||
20 | pregnant women
under this Code shall receive information from | ||||||
21 | the Department on the
availability of services under the Drug | ||||||
22 | Free Families with a Future or any
comparable program providing | ||||||
23 | case management services for addicted women,
including | ||||||
24 | information on appropriate referrals for other social services
| ||||||
25 | that may be needed by addicted women in addition to treatment | ||||||
26 | for addiction.
|
| |||||||
| |||||||
1 | The Illinois Department, in cooperation with the | ||||||
2 | Departments of Human
Services (as successor to the Department | ||||||
3 | of Alcoholism and Substance
Abuse) and Public Health, through a | ||||||
4 | public awareness campaign, may
provide information concerning | ||||||
5 | treatment for alcoholism and drug abuse and
addiction, prenatal | ||||||
6 | health care, and other pertinent programs directed at
reducing | ||||||
7 | the number of drug-affected infants born to recipients of | ||||||
8 | medical
assistance.
| ||||||
9 | Neither the Department of Healthcare and Family Services | ||||||
10 | nor the Department of Human
Services shall sanction the | ||||||
11 | recipient solely on the basis of
her substance abuse.
| ||||||
12 | The Illinois Department shall establish such regulations | ||||||
13 | governing
the dispensing of health services under this Article | ||||||
14 | as it shall deem
appropriate. The Department
should
seek the | ||||||
15 | advice of formal professional advisory committees appointed by
| ||||||
16 | the Director of the Illinois Department for the purpose of | ||||||
17 | providing regular
advice on policy and administrative matters, | ||||||
18 | information dissemination and
educational activities for | ||||||
19 | medical and health care providers, and
consistency in | ||||||
20 | procedures to the Illinois Department.
| ||||||
21 | The Illinois Department may develop and contract with | ||||||
22 | Partnerships of
medical providers to arrange medical services | ||||||
23 | for persons eligible under
Section 5-2 of this Code. | ||||||
24 | Implementation of this Section may be by
demonstration projects | ||||||
25 | in certain geographic areas. The Partnership shall
be | ||||||
26 | represented by a sponsor organization. The Department, by rule, |
| |||||||
| |||||||
1 | shall
develop qualifications for sponsors of Partnerships. | ||||||
2 | Nothing in this
Section shall be construed to require that the | ||||||
3 | sponsor organization be a
medical organization.
| ||||||
4 | The sponsor must negotiate formal written contracts with | ||||||
5 | medical
providers for physician services, inpatient and | ||||||
6 | outpatient hospital care,
home health services, treatment for | ||||||
7 | alcoholism and substance abuse, and
other services determined | ||||||
8 | necessary by the Illinois Department by rule for
delivery by | ||||||
9 | Partnerships. Physician services must include prenatal and
| ||||||
10 | obstetrical care. The Illinois Department shall reimburse | ||||||
11 | medical services
delivered by Partnership providers to clients | ||||||
12 | in target areas according to
provisions of this Article and the | ||||||
13 | Illinois Health Finance Reform Act,
except that:
| ||||||
14 | (1) Physicians participating in a Partnership and | ||||||
15 | providing certain
services, which shall be determined by | ||||||
16 | the Illinois Department, to persons
in areas covered by 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 |
| |||||||
| |||||||
1 | qualifications to
participate in Partnerships to ensure the | ||||||
2 | delivery of high quality medical
services. These | ||||||
3 | qualifications shall be determined by rule of the Illinois
| ||||||
4 | Department and may be higher than qualifications for | ||||||
5 | participation in the
medical assistance program. Partnership | ||||||
6 | sponsors may prescribe reasonable
additional qualifications | ||||||
7 | for participation by medical providers, only with
the prior | ||||||
8 | written approval of the Illinois Department.
| ||||||
9 | Nothing in this Section shall limit the free choice of | ||||||
10 | practitioners,
hospitals, and other providers of medical | ||||||
11 | services by clients.
In order to ensure patient freedom of | ||||||
12 | choice, the Illinois Department shall
immediately promulgate | ||||||
13 | all rules and take all other necessary actions so that
provided | ||||||
14 | services may be accessed from therapeutically certified | ||||||
15 | optometrists
to the full extent of the Illinois Optometric | ||||||
16 | Practice Act of 1987 without
discriminating between service | ||||||
17 | providers.
| ||||||
18 | The Department shall apply for a waiver from the United | ||||||
19 | States Health
Care Financing Administration to allow for the | ||||||
20 | implementation of
Partnerships under this Section.
| ||||||
21 | The Illinois Department shall require health care | ||||||
22 | providers to maintain
records that document the medical care | ||||||
23 | and services provided to recipients
of Medical Assistance under | ||||||
24 | this Article. Such records must be retained for a period of not | ||||||
25 | less than 6 years from the date of service or as provided by | ||||||
26 | applicable State law, whichever period is longer, except that |
| |||||||
| |||||||
1 | if an audit is initiated within the required retention period | ||||||
2 | then the records must be retained until the audit is completed | ||||||
3 | and every exception is resolved. The Illinois Department shall
| ||||||
4 | require health care providers to make available, when | ||||||
5 | authorized by the
patient, in writing, the medical records in a | ||||||
6 | timely fashion to other
health care providers who are treating | ||||||
7 | or serving persons eligible for
Medical Assistance under this | ||||||
8 | Article. All dispensers of medical services
shall be required | ||||||
9 | to maintain and retain business and professional records
| ||||||
10 | sufficient to fully and accurately document the nature, scope, | ||||||
11 | details and
receipt of the health care provided to persons | ||||||
12 | eligible for medical
assistance under this Code, in accordance | ||||||
13 | with regulations promulgated by
the Illinois Department. The | ||||||
14 | rules and regulations shall require that proof
of the receipt | ||||||
15 | of prescription drugs, dentures, prosthetic devices and
| ||||||
16 | eyeglasses by eligible persons under this Section accompany | ||||||
17 | each claim
for reimbursement submitted by the dispenser of such | ||||||
18 | medical services.
No such claims for reimbursement shall be | ||||||
19 | approved for payment by the Illinois
Department without such | ||||||
20 | proof of receipt, unless the Illinois Department
shall have put | ||||||
21 | into effect and shall be operating a system of post-payment
| ||||||
22 | audit and review which shall, on a sampling basis, be deemed | ||||||
23 | adequate by
the Illinois Department to assure that such drugs, | ||||||
24 | dentures, prosthetic
devices and eyeglasses for which payment | ||||||
25 | is being made are actually being
received by eligible | ||||||
26 | recipients. Within 90 days after September 16, 1984 ( the |
| |||||||
| |||||||
1 | effective date of Public Act 83-1439)
this amendatory Act of | ||||||
2 | 1984 , the Illinois Department shall establish a
current list of | ||||||
3 | acquisition costs for all prosthetic devices and any
other | ||||||
4 | items recognized as medical equipment and supplies | ||||||
5 | reimbursable under
this Article and shall update such list on a | ||||||
6 | quarterly basis, except that
the acquisition costs of all | ||||||
7 | prescription drugs shall be updated no
less frequently than | ||||||
8 | every 30 days as required by Section 5-5.12.
| ||||||
9 | The rules and regulations of the Illinois Department shall | ||||||
10 | require
that a written statement including the required opinion | ||||||
11 | of a physician
shall accompany any claim for reimbursement for | ||||||
12 | abortions, or induced
miscarriages or premature births. This | ||||||
13 | statement shall indicate what
procedures were used in providing | ||||||
14 | such medical services.
| ||||||
15 | Notwithstanding any other law to the contrary, the Illinois | ||||||
16 | Department shall, within 365 days after July 22, 2013 (the | ||||||
17 | effective date of Public Act 98-104), establish procedures to | ||||||
18 | permit skilled care facilities licensed under the Nursing Home | ||||||
19 | Care Act to submit monthly billing claims for reimbursement | ||||||
20 | purposes. Following development of these procedures, the | ||||||
21 | Department shall, by July 1, 2016, test the viability of the | ||||||
22 | new system and implement any necessary operational or | ||||||
23 | structural changes to its information technology platforms in | ||||||
24 | order to allow for the direct acceptance and payment of nursing | ||||||
25 | home claims. | ||||||
26 | Notwithstanding any other law to the contrary, the Illinois |
| |||||||
| |||||||
1 | Department shall, within 365 days after August 15, 2014 (the | ||||||
2 | effective date of Public Act 98-963), establish procedures to | ||||||
3 | permit ID/DD facilities licensed under the ID/DD Community Care | ||||||
4 | Act and MC/DD facilities licensed under the MC/DD Act to submit | ||||||
5 | monthly billing claims for reimbursement purposes. Following | ||||||
6 | development of these procedures, the Department shall have an | ||||||
7 | additional 365 days to test the viability of the new system and | ||||||
8 | to ensure that any necessary operational or structural changes | ||||||
9 | to its information technology platforms are implemented. | ||||||
10 | The Illinois Department shall require all dispensers of | ||||||
11 | medical
services, other than an individual practitioner or | ||||||
12 | group of practitioners,
desiring to participate in the Medical | ||||||
13 | Assistance program
established under this Article to disclose | ||||||
14 | all financial, beneficial,
ownership, equity, surety or other | ||||||
15 | interests in any and all firms,
corporations, partnerships, | ||||||
16 | associations, business enterprises, joint
ventures, agencies, | ||||||
17 | institutions or other legal entities providing any
form of | ||||||
18 | health care services in this State under this Article.
| ||||||
19 | The Illinois Department may require that all dispensers of | ||||||
20 | medical
services desiring to participate in the medical | ||||||
21 | assistance program
established under this Article disclose, | ||||||
22 | under such terms and conditions as
the Illinois Department may | ||||||
23 | by rule establish, all inquiries from clients
and attorneys | ||||||
24 | regarding medical bills paid by the Illinois Department, which
| ||||||
25 | inquiries could indicate potential existence of claims or liens | ||||||
26 | for the
Illinois Department.
|
| |||||||
| |||||||
1 | Enrollment of a vendor
shall be
subject to a provisional | ||||||
2 | period and shall be conditional for one year. During the period | ||||||
3 | of conditional enrollment, the Department may
terminate the | ||||||
4 | vendor's eligibility to participate in, or may disenroll the | ||||||
5 | vendor from, the medical assistance
program without cause. | ||||||
6 | Unless otherwise specified, such termination of eligibility or | ||||||
7 | disenrollment is not subject to the
Department's hearing | ||||||
8 | process.
However, a disenrolled vendor may reapply without | ||||||
9 | penalty.
| ||||||
10 | The Department has the discretion to limit the conditional | ||||||
11 | enrollment period for vendors based upon category of risk of | ||||||
12 | the vendor. | ||||||
13 | Prior to enrollment and during the conditional enrollment | ||||||
14 | period in the medical assistance program, all vendors shall be | ||||||
15 | subject to enhanced oversight, screening, and review based on | ||||||
16 | the risk of fraud, waste, and abuse that is posed by the | ||||||
17 | category of risk of the vendor. The Illinois Department shall | ||||||
18 | establish the procedures for oversight, screening, and review, | ||||||
19 | which may include, but need not be limited to: criminal and | ||||||
20 | financial background checks; fingerprinting; license, | ||||||
21 | certification, and authorization verifications; unscheduled or | ||||||
22 | unannounced site visits; database checks; prepayment audit | ||||||
23 | reviews; audits; payment caps; payment suspensions; and other | ||||||
24 | screening as required by federal or State law. | ||||||
25 | The Department shall define or specify the following: (i) | ||||||
26 | by provider notice, the "category of risk of the vendor" for |
| |||||||
| |||||||
1 | each type of vendor, which shall take into account the level of | ||||||
2 | screening applicable to a particular category of vendor under | ||||||
3 | federal law and regulations; (ii) by rule or provider notice, | ||||||
4 | the maximum length of the conditional enrollment period for | ||||||
5 | each category of risk of the vendor; and (iii) by rule, the | ||||||
6 | hearing rights, if any, afforded to a vendor in each category | ||||||
7 | of risk of the vendor that is terminated or disenrolled during | ||||||
8 | the conditional enrollment period. | ||||||
9 | To be eligible for payment consideration, a vendor's | ||||||
10 | payment claim or bill, either as an initial claim or as a | ||||||
11 | resubmitted claim following prior rejection, must be received | ||||||
12 | by the Illinois Department, or its fiscal intermediary, no | ||||||
13 | later than 180 days after the latest date on the claim on which | ||||||
14 | medical goods or services were provided, with the following | ||||||
15 | exceptions: | ||||||
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 |
| |||||||
| |||||||
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 | ||||||
7 | a recipient received retroactive eligibility, claims must be | ||||||
8 | filed within 180 days after the Department determines the | ||||||
9 | applicant is eligible. For claims for which the Illinois | ||||||
10 | Department is not the primary payer, claims must be submitted | ||||||
11 | to the Illinois Department within 180 days after the final | ||||||
12 | adjudication by the primary payer. | ||||||
13 | In the case of long term care facilities, within 5 days of | ||||||
14 | receipt by the facility of required prescreening information, | ||||||
15 | data for new admissions shall be entered into the Medical | ||||||
16 | Electronic Data Interchange (MEDI) or the Recipient | ||||||
17 | Eligibility Verification (REV) System or successor system, and | ||||||
18 | within 15 days of receipt by the facility of required | ||||||
19 | prescreening information, admission documents shall be | ||||||
20 | submitted through MEDI or REV or shall be submitted directly to | ||||||
21 | the Department of Human Services using required admission | ||||||
22 | forms. Effective September
1, 2014, admission documents, | ||||||
23 | including all prescreening
information, must be submitted | ||||||
24 | through MEDI or REV. Confirmation numbers assigned to an | ||||||
25 | accepted transaction shall be retained by a facility to verify | ||||||
26 | timely submittal. Once an admission transaction has been |
| |||||||
| |||||||
1 | completed, all resubmitted claims following prior rejection | ||||||
2 | are subject to receipt no later than 180 days after the | ||||||
3 | admission transaction has been completed. | ||||||
4 | Claims that are not submitted and received in compliance | ||||||
5 | with the foregoing requirements shall not be eligible for | ||||||
6 | payment under the medical assistance program, and the State | ||||||
7 | shall have no liability for payment of those claims. | ||||||
8 | To the extent consistent with applicable information and | ||||||
9 | privacy, security, and disclosure laws, State and federal | ||||||
10 | agencies and departments shall provide the Illinois Department | ||||||
11 | access to confidential and other information and data necessary | ||||||
12 | to perform eligibility and payment verifications and other | ||||||
13 | Illinois Department functions. This includes, but is not | ||||||
14 | limited to: information pertaining to licensure; | ||||||
15 | certification; earnings; immigration status; citizenship; wage | ||||||
16 | reporting; unearned and earned income; pension income; | ||||||
17 | employment; supplemental security income; social security | ||||||
18 | numbers; National Provider Identifier (NPI) numbers; the | ||||||
19 | National Practitioner Data Bank (NPDB); program and agency | ||||||
20 | exclusions; taxpayer identification numbers; tax delinquency; | ||||||
21 | corporate information; and death records. | ||||||
22 | The Illinois Department shall enter into agreements with | ||||||
23 | State agencies and departments, and is authorized to enter into | ||||||
24 | agreements with federal agencies and departments, under which | ||||||
25 | such agencies and departments shall share data necessary for | ||||||
26 | medical assistance program integrity functions and oversight. |
| |||||||
| |||||||
1 | The Illinois Department shall develop, in cooperation with | ||||||
2 | other State departments and agencies, and in compliance with | ||||||
3 | applicable federal laws and regulations, appropriate and | ||||||
4 | effective methods to share such data. At a minimum, and to the | ||||||
5 | extent necessary to provide data sharing, the Illinois | ||||||
6 | Department shall enter into agreements with State agencies and | ||||||
7 | departments, and is authorized to enter into agreements with | ||||||
8 | federal agencies and departments, including but not limited to: | ||||||
9 | the Secretary of State; the Department of Revenue; the | ||||||
10 | Department of Public Health; the Department of Human Services; | ||||||
11 | and the Department of Financial and Professional Regulation. | ||||||
12 | Beginning in fiscal year 2013, the Illinois Department | ||||||
13 | shall set forth a request for information to identify the | ||||||
14 | benefits of a pre-payment, post-adjudication, and post-edit | ||||||
15 | claims system with the goals of streamlining claims processing | ||||||
16 | and provider reimbursement, reducing the number of pending or | ||||||
17 | rejected claims, and helping to ensure a more transparent | ||||||
18 | adjudication process through the utilization of: (i) provider | ||||||
19 | data verification and provider screening technology; and (ii) | ||||||
20 | clinical code editing; and (iii) pre-pay, pre- or | ||||||
21 | post-adjudicated predictive modeling with an integrated case | ||||||
22 | management system with link analysis. Such a request for | ||||||
23 | information shall not be considered as a request for proposal | ||||||
24 | or as an obligation on the part of the Illinois Department to | ||||||
25 | take any action or acquire any products or services. | ||||||
26 | The Illinois Department shall establish policies, |
| |||||||
| |||||||
1 | procedures,
standards and criteria by rule for the acquisition, | ||||||
2 | repair and replacement
of orthotic and prosthetic devices and | ||||||
3 | durable medical equipment. Such
rules shall provide, but not be | ||||||
4 | limited to, the following services: (1)
immediate repair or | ||||||
5 | replacement of such devices by recipients; and (2) rental, | ||||||
6 | lease, purchase or lease-purchase of
durable medical equipment | ||||||
7 | in a cost-effective manner, taking into
consideration the | ||||||
8 | recipient's medical prognosis, the extent of the
recipient's | ||||||
9 | needs, and the requirements and costs for maintaining such
| ||||||
10 | equipment. Subject to prior approval, such rules shall enable a | ||||||
11 | recipient to temporarily acquire and
use alternative or | ||||||
12 | substitute devices or equipment pending repairs or
| ||||||
13 | replacements of any device or equipment previously authorized | ||||||
14 | for such
recipient by the Department.
| ||||||
15 | The Department shall execute, relative to the nursing home | ||||||
16 | prescreening
project, written inter-agency agreements with the | ||||||
17 | Department of Human
Services and the Department on Aging, to | ||||||
18 | effect the following: (i) intake
procedures and common | ||||||
19 | eligibility criteria for those persons who are receiving
| ||||||
20 | non-institutional services; and (ii) the establishment and | ||||||
21 | development of
non-institutional services in areas of the State | ||||||
22 | where they are not currently
available or are undeveloped; and | ||||||
23 | (iii) notwithstanding any other provision of law, subject to | ||||||
24 | federal approval, on and after July 1, 2012, an increase in the | ||||||
25 | determination of need (DON) scores from 29 to 37 for applicants | ||||||
26 | for institutional and home and community-based long term care; |
| |||||||
| |||||||
1 | if and only if federal approval is not granted, the Department | ||||||
2 | may, in conjunction with other affected agencies, implement | ||||||
3 | utilization controls or changes in benefit packages to | ||||||
4 | effectuate a similar savings amount for this population; and | ||||||
5 | (iv) no later than July 1, 2013, minimum level of care | ||||||
6 | eligibility criteria for institutional and home and | ||||||
7 | community-based long term care; and (v) no later than October | ||||||
8 | 1, 2013, establish procedures to permit long term care | ||||||
9 | providers access to eligibility scores for individuals with an | ||||||
10 | admission date who are seeking or receiving services from the | ||||||
11 | long term care provider. In order to select the minimum level | ||||||
12 | of care eligibility criteria, the Governor shall establish a | ||||||
13 | workgroup that includes affected agency representatives and | ||||||
14 | stakeholders representing the institutional and home and | ||||||
15 | community-based long term care interests. This Section shall | ||||||
16 | not restrict the Department from implementing lower level of | ||||||
17 | care eligibility criteria for community-based services in | ||||||
18 | circumstances where federal approval has been granted.
| ||||||
19 | The Illinois Department shall develop and operate, in | ||||||
20 | cooperation
with other State Departments and agencies and in | ||||||
21 | compliance with
applicable federal laws and regulations, | ||||||
22 | appropriate and effective
systems of health care evaluation and | ||||||
23 | programs for monitoring of
utilization of health care services | ||||||
24 | and facilities, as it affects
persons eligible for medical | ||||||
25 | assistance under this Code.
| ||||||
26 | The Illinois Department shall report annually to the |
| |||||||
| |||||||
1 | General Assembly,
no later than the second Friday in April of | ||||||
2 | 1979 and each year
thereafter, in regard to:
| ||||||
3 | (a) actual statistics and trends in utilization of | ||||||
4 | medical services by
public aid recipients;
| ||||||
5 | (b) actual statistics and trends in the provision of | ||||||
6 | the various medical
services by medical vendors;
| ||||||
7 | (c) current rate structures and proposed changes in | ||||||
8 | those rate structures
for the various medical vendors; and
| ||||||
9 | (d) efforts at utilization review and control by the | ||||||
10 | Illinois Department.
| ||||||
11 | The period covered by each report shall be the 3 years | ||||||
12 | ending on the June
30 prior to the report. The report shall | ||||||
13 | include suggested legislation
for consideration by the General | ||||||
14 | Assembly. The filing of one copy of the
report with the | ||||||
15 | Speaker, one copy with the Minority Leader and one copy
with | ||||||
16 | the Clerk of the House of Representatives, one copy with the | ||||||
17 | President,
one copy with the Minority Leader and one copy with | ||||||
18 | the Secretary of the
Senate, one copy with the Legislative | ||||||
19 | Research Unit, and such additional
copies
with the State | ||||||
20 | Government Report Distribution Center for the General
Assembly | ||||||
21 | as is required under paragraph (t) of Section 7 of the State
| ||||||
22 | Library Act shall be deemed sufficient to comply with this | ||||||
23 | Section.
| ||||||
24 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
25 | any, is conditioned on the rules being adopted in accordance | ||||||
26 | with all provisions of the Illinois Administrative Procedure |
| |||||||
| |||||||
1 | Act and all rules and procedures of the Joint Committee on | ||||||
2 | Administrative Rules; any purported rule not so adopted, for | ||||||
3 | whatever reason, is unauthorized. | ||||||
4 | On and after July 1, 2012, the Department shall reduce any | ||||||
5 | rate of reimbursement for services or other payments or alter | ||||||
6 | any methodologies authorized by this Code to reduce any rate of | ||||||
7 | reimbursement for services or other payments in accordance with | ||||||
8 | Section 5-5e. | ||||||
9 | Because kidney transplantation can be an appropriate, cost | ||||||
10 | effective
alternative to renal dialysis when medically | ||||||
11 | necessary and notwithstanding the provisions of Section 1-11 of | ||||||
12 | this Code, beginning October 1, 2014, the Department shall | ||||||
13 | cover kidney transplantation for noncitizens with end-stage | ||||||
14 | renal disease who are not eligible for comprehensive medical | ||||||
15 | benefits, who meet the residency requirements of Section 5-3 of | ||||||
16 | this Code, and who would otherwise meet the financial | ||||||
17 | requirements of the appropriate class of eligible persons under | ||||||
18 | Section 5-2 of this Code. To qualify for coverage of kidney | ||||||
19 | transplantation, such person must be receiving emergency renal | ||||||
20 | dialysis services covered by the Department. Providers under | ||||||
21 | this Section shall be prior approved and certified by the | ||||||
22 | Department to perform kidney transplantation and the services | ||||||
23 | under this Section shall be limited to services associated with | ||||||
24 | kidney transplantation. | ||||||
25 | Notwithstanding any other provision of this Code to the | ||||||
26 | contrary, on or after July 1, 2015, all FDA approved forms of |
| |||||||
| |||||||
1 | medication assisted treatment prescribed for the treatment of | ||||||
2 | alcohol dependence or treatment of opioid dependence shall be | ||||||
3 | covered under both fee for service and managed care medical | ||||||
4 | assistance programs for persons who are otherwise eligible for | ||||||
5 | medical assistance under this Article and shall not be subject | ||||||
6 | to any (1) utilization control, other than those established | ||||||
7 | under the American Society of Addiction Medicine patient | ||||||
8 | placement criteria,
(2) prior authorization mandate, or (3) | ||||||
9 | lifetime restriction limit
mandate. | ||||||
10 | On or after July 1, 2015, opioid antagonists prescribed for | ||||||
11 | the treatment of an opioid overdose, including the medication | ||||||
12 | product, administration devices, and any pharmacy fees related | ||||||
13 | to the dispensing and administration of the opioid antagonist, | ||||||
14 | shall be covered under the medical assistance program for | ||||||
15 | persons who are otherwise eligible for medical assistance under | ||||||
16 | this Article. As used in this Section, "opioid antagonist" | ||||||
17 | means a drug that binds to opioid receptors and blocks or | ||||||
18 | inhibits the effect of opioids acting on those receptors, | ||||||
19 | including, but not limited to, naloxone hydrochloride or any | ||||||
20 | other similarly acting drug approved by the U.S. Food and Drug | ||||||
21 | Administration. | ||||||
22 | Upon federal approval, the Department shall provide | ||||||
23 | coverage and reimbursement for all drugs that are approved for | ||||||
24 | marketing by the federal Food and Drug Administration and that | ||||||
25 | are recommended by the federal Public Health Service or the | ||||||
26 | United States Centers for Disease Control and Prevention for |
| |||||||
| |||||||
1 | pre-exposure prophylaxis and related pre-exposure prophylaxis | ||||||
2 | services, including, but not limited to, HIV and sexually | ||||||
3 | transmitted infection screening, treatment for sexually | ||||||
4 | transmitted infections, medical monitoring, assorted labs, and | ||||||
5 | counseling to reduce the likelihood of HIV infection among | ||||||
6 | individuals who are not infected with HIV but who are at high | ||||||
7 | risk of HIV infection. | ||||||
8 | (Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13; | ||||||
9 | 98-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff. | ||||||
10 | 8-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756, | ||||||
11 | eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15; | ||||||
12 | 99-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section | ||||||
13 | 99 of P.A. 99-407 for its effective date); 99-433, eff. | ||||||
14 | 8-21-15; 99-480, eff. 9-9-15; revised 10-13-15.) | ||||||
15 | Section 95. No acceleration or delay. Where this Act makes | ||||||
16 | changes in a statute that is represented in this Act by text | ||||||
17 | that is not yet or no longer in effect (for example, a Section | ||||||
18 | represented by multiple versions), the use of that text does | ||||||
19 | not accelerate or delay the taking effect of (i) the changes | ||||||
20 | made by this Act or (ii) provisions derived from any other | ||||||
21 | Public Act.
| ||||||
22 | Section 99. Effective date. This Act takes effect January | ||||||
23 | 1, 2017.
|