Illinois General Assembly - Full Text of SB0466
Illinois General Assembly

Previous General Assemblies

Full Text of SB0466  99th General Assembly

SB0466eng 99TH GENERAL ASSEMBLY

  
  
  

 


 
SB0466 EngrossedLRB099 03184 MGM 23192 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 356g as follows:
 
6    (215 ILCS 5/356g)  (from Ch. 73, par. 968g)
7    (Text of Section before amendment by P.A. 99-407)
8    Sec. 356g. Mammograms; mastectomies.
9    (a) Every insurer shall provide in each group or individual
10policy, contract, or certificate of insurance issued or renewed
11for persons who are residents of this State, coverage for
12screening by low-dose mammography for all women 35 years of age
13or older for the presence of occult breast cancer within the
14provisions of the policy, contract, or certificate. The
15coverage shall be as follows:
16         (1) A baseline mammogram for women 35 to 39 years of
17    age.
18         (2) An annual mammogram for women 40 years of age or
19    older.
20         (3) A mammogram at the age and intervals considered
21    medically necessary by the woman's health care provider for
22    women under 40 years of age and having a family history of
23    breast cancer, prior personal history of breast cancer,

 

 

SB0466 Engrossed- 2 -LRB099 03184 MGM 23192 b

1    positive genetic testing, or other risk factors.
2        (4) A comprehensive ultrasound screening of an entire
3    breast or breasts if a mammogram demonstrates
4    heterogeneous or dense breast tissue, when medically
5    necessary as determined by a physician licensed to practice
6    medicine in all of its branches.
7        (5) A screening MRI when medically necessary, as
8    determined by a physician licensed to practice medicine in
9    all of its branches.
10    For purposes of this Section, "low-dose mammography" means
11the x-ray examination of the breast using equipment dedicated
12specifically for mammography, including the x-ray tube,
13filter, compression device, and image receptor, with radiation
14exposure delivery of less than 1 rad per breast for 2 views of
15an average size breast. The term also includes digital
16mammography.
17    (a-5) Coverage as described by subsection (a) shall be
18provided at no cost to the insured and shall not be applied to
19an annual or lifetime maximum benefit.
20    (a-10) When health care services are available through
21contracted providers and a person does not comply with plan
22provisions specific to the use of contracted providers, the
23requirements of subsection (a-5) are not applicable. When a
24person does not comply with plan provisions specific to the use
25of contracted providers, plan provisions specific to the use of
26non-contracted providers must be applied without distinction

 

 

SB0466 Engrossed- 3 -LRB099 03184 MGM 23192 b

1for coverage required by this Section and shall be at least as
2favorable as for other radiological examinations covered by the
3policy or contract.
4    (b) No policy of accident or health insurance that provides
5for the surgical procedure known as a mastectomy shall be
6issued, amended, delivered, or renewed in this State unless
7that coverage also provides for prosthetic devices or
8reconstructive surgery incident to the mastectomy. Coverage
9for breast reconstruction in connection with a mastectomy shall
10include:
11        (1) reconstruction of the breast upon which the
12    mastectomy has been performed;
13        (2) surgery and reconstruction of the other breast to
14    produce a symmetrical appearance; and
15        (3) prostheses and treatment for physical
16    complications at all stages of mastectomy, including
17    lymphedemas.
18Care shall be determined in consultation with the attending
19physician and the patient. The offered coverage for prosthetic
20devices and reconstructive surgery shall be subject to the
21deductible and coinsurance conditions applied to the
22mastectomy, and all other terms and conditions applicable to
23other benefits. When a mastectomy is performed and there is no
24evidence of malignancy then the offered coverage may be limited
25to the provision of prosthetic devices and reconstructive
26surgery to within 2 years after the date of the mastectomy. As

 

 

SB0466 Engrossed- 4 -LRB099 03184 MGM 23192 b

1used in this Section, "mastectomy" means the removal of all or
2part of the breast for medically necessary reasons, as
3determined by a licensed physician.
4    Written notice of the availability of coverage under this
5Section shall be delivered to the insured upon enrollment and
6annually thereafter. An insurer may not deny to an insured
7eligibility, or continued eligibility, to enroll or to renew
8coverage under the terms of the plan solely for the purpose of
9avoiding the requirements of this Section. An insurer may not
10penalize or reduce or limit the reimbursement of an attending
11provider or provide incentives (monetary or otherwise) to an
12attending provider to induce the provider to provide care to an
13insured in a manner inconsistent with this Section.
14    (c) Rulemaking authority to implement Public Act 95-1045
15this amendatory Act of the 95th General Assembly, if any, is
16conditioned on the rules being adopted in accordance with all
17provisions of the Illinois Administrative Procedure Act and all
18rules and procedures of the Joint Committee on Administrative
19Rules; any purported rule not so adopted, for whatever reason,
20is unauthorized.
21(Source: P.A. 99-433, eff. 8-21-15; revised 10-20-15.)
 
22    (Text of Section after amendment by P.A. 99-407)
23    Sec. 356g. Mammograms; mastectomies.
24    (a) Every insurer shall provide in each group or individual
25policy, contract, or certificate of insurance issued or renewed

 

 

SB0466 Engrossed- 5 -LRB099 03184 MGM 23192 b

1for persons who are residents of this State, coverage for
2screening by low-dose mammography for all women 35 years of age
3or older for the presence of occult breast cancer within the
4provisions of the policy, contract, or certificate. The
5coverage shall be as follows:
6         (1) A baseline mammogram for women 35 to 39 years of
7    age.
8         (2) An annual mammogram for women 40 years of age or
9    older.
10         (3) A mammogram at the age and intervals considered
11    medically necessary by the woman's health care provider for
12    women under 40 years of age and having a family history of
13    breast cancer, prior personal history of breast cancer,
14    positive genetic testing, or other risk factors.
15        (4) A comprehensive ultrasound screening of an entire
16    breast or breasts if a mammogram demonstrates
17    heterogeneous or dense breast tissue, when medically
18    necessary as determined by a physician licensed to practice
19    medicine in all of its branches.
20        (5) A screening MRI when medically necessary, as
21    determined by a physician licensed to practice medicine in
22    all of its branches.
23    For purposes of this Section, "low-dose mammography" means
24the x-ray examination of the breast using equipment dedicated
25specifically for mammography, including the x-ray tube,
26filter, compression device, and image receptor, with radiation

 

 

SB0466 Engrossed- 6 -LRB099 03184 MGM 23192 b

1exposure delivery of less than 1 rad per breast for 2 views of
2an average size breast. The term also includes digital
3mammography and includes breast tomosynthesis. As used in this
4Section, the term "breast tomosynthesis" means a radiologic
5procedure that involves the acquisition of projection images
6over the stationary breast to produce cross-sectional digital
7three-dimensional images of the breast.
8    If, at any time, the Secretary of the United States
9Department of Health and Human Services, or its successor
10agency, promulgates rules or regulations to be published in the
11Federal Register or publishes a comment in the Federal Register
12or issues an opinion, guidance, or other action that would
13require the State, pursuant to any provision of the Patient
14Protection and Affordable Care Act (Public Law 111-148),
15including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
16successor provision, to defray the cost of any coverage for
17breast tomosynthesis outlined in this subsection, then the
18requirement that an insurer cover breast tomosynthesis is
19inoperative other than any such coverage authorized under
20Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
21the State shall not assume any obligation for the cost of
22coverage for breast tomosynthesis set forth in this subsection.
23    (a-5) Coverage as described by subsection (a) shall be
24provided at no cost to the insured and shall not be applied to
25an annual or lifetime maximum benefit.
26    (a-10) When health care services are available through

 

 

SB0466 Engrossed- 7 -LRB099 03184 MGM 23192 b

1contracted providers and a person does not comply with plan
2provisions specific to the use of contracted providers, the
3requirements of subsection (a-5) are not applicable. When a
4person does not comply with plan provisions specific to the use
5of contracted providers, plan provisions specific to the use of
6non-contracted providers must be applied without distinction
7for coverage required by this Section and shall be at least as
8favorable as for other radiological examinations covered by the
9policy or contract.
10    (b) No policy of accident or health insurance that provides
11for the surgical procedure known as a mastectomy shall be
12issued, amended, delivered, or renewed in this State unless
13that coverage also provides for prosthetic devices or
14reconstructive surgery incident to the mastectomy. Coverage
15for breast reconstruction in connection with a mastectomy shall
16include:
17        (1) reconstruction of the breast upon which the
18    mastectomy has been performed;
19        (2) surgery and reconstruction of the other breast to
20    produce a symmetrical appearance; and
21        (3) prostheses and treatment for physical
22    complications at all stages of mastectomy, including
23    lymphedemas.
24Care shall be determined in consultation with the attending
25physician and the patient. The offered coverage for prosthetic
26devices and reconstructive surgery shall be subject to the

 

 

SB0466 Engrossed- 8 -LRB099 03184 MGM 23192 b

1deductible and coinsurance conditions applied to the
2mastectomy, and all other terms and conditions applicable to
3other benefits. When a mastectomy is performed and there is no
4evidence of malignancy then the offered coverage may be limited
5to the provision of prosthetic devices and reconstructive
6surgery to within 2 years after the date of the mastectomy. As
7used in this Section, "mastectomy" means the removal of all or
8part of the breast for medically necessary reasons, as
9determined by a licensed physician.
10    Written notice of the availability of coverage under this
11Section shall be delivered to the insured upon enrollment and
12annually thereafter. An insurer may not deny to an insured
13eligibility, or continued eligibility, to enroll or to renew
14coverage under the terms of the plan solely for the purpose of
15avoiding the requirements of this Section. An insurer may not
16penalize or reduce or limit the reimbursement of an attending
17provider or provide incentives (monetary or otherwise) to an
18attending provider to induce the provider to provide care to an
19insured in a manner inconsistent with this Section.
20    (c) Rulemaking authority to implement Public Act 95-1045
21this amendatory Act of the 95th General Assembly, if any, is
22conditioned on the rules being adopted in accordance with all
23provisions of the Illinois Administrative Procedure Act and all
24rules and procedures of the Joint Committee on Administrative
25Rules; any purported rule not so adopted, for whatever reason,
26is unauthorized.

 

 

SB0466 Engrossed- 9 -LRB099 03184 MGM 23192 b

1(Source: P.A. 99-407 (see Section 99 of P.A. 99-407 for its
2effective date); 99-433, eff. 8-21-15; revised 10-20-15.)
 
3    Section 10. The Health Maintenance Organization Act is
4amended by changing Section 4-6.1 as follows:
 
5    (215 ILCS 125/4-6.1)  (from Ch. 111 1/2, par. 1408.7)
6    (Text of Section before amendment by P.A. 99-407)
7    Sec. 4-6.1. Mammograms; mastectomies.
8    (a) Every contract or evidence of coverage issued by a
9Health Maintenance Organization for persons who are residents
10of this State shall contain coverage for screening by low-dose
11mammography for all women 35 years of age or older for the
12presence of occult breast cancer. The coverage shall be as
13follows:
14        (1) A baseline mammogram for women 35 to 39 years of
15    age.
16        (2) An annual mammogram for women 40 years of age or
17    older.
18        (3) A mammogram at the age and intervals considered
19    medically necessary by the woman's health care provider for
20    women under 40 years of age and having a family history of
21    breast cancer, prior personal history of breast cancer,
22    positive genetic testing, or other risk factors.
23        (4) A comprehensive ultrasound screening of an entire
24    breast or breasts if a mammogram demonstrates

 

 

SB0466 Engrossed- 10 -LRB099 03184 MGM 23192 b

1    heterogeneous or dense breast tissue, when medically
2    necessary as determined by a physician licensed to practice
3    medicine in all of its branches.
4    For purposes of this Section, "low-dose mammography" means
5the x-ray examination of the breast using equipment dedicated
6specifically for mammography, including the x-ray tube,
7filter, compression device, and image receptor, with radiation
8exposure delivery of less than 1 rad per breast for 2 views of
9an average size breast. The term also includes digital
10mammography.
11    (a-5) Coverage as described in subsection (a) shall be
12provided at no cost to the enrollee and shall not be applied to
13an annual or lifetime maximum benefit.
14    (b) No contract or evidence of coverage issued by a health
15maintenance organization that provides for the surgical
16procedure known as a mastectomy shall be issued, amended,
17delivered, or renewed in this State on or after the effective
18date of this amendatory Act of the 92nd General Assembly unless
19that coverage also provides for prosthetic devices or
20reconstructive surgery incident to the mastectomy, providing
21that the mastectomy is performed after the effective date of
22this amendatory Act. Coverage for breast reconstruction in
23connection with a mastectomy shall include:
24        (1) reconstruction of the breast upon which the
25    mastectomy has been performed;
26        (2) surgery and reconstruction of the other breast to

 

 

SB0466 Engrossed- 11 -LRB099 03184 MGM 23192 b

1    produce a symmetrical appearance; and
2        (3) prostheses and treatment for physical
3    complications at all stages of mastectomy, including
4    lymphedemas.
5Care shall be determined in consultation with the attending
6physician and the patient. The offered coverage for prosthetic
7devices and reconstructive surgery shall be subject to the
8deductible and coinsurance conditions applied to the
9mastectomy and all other terms and conditions applicable to
10other benefits. When a mastectomy is performed and there is no
11evidence of malignancy, then the offered coverage may be
12limited to the provision of prosthetic devices and
13reconstructive surgery to within 2 years after the date of the
14mastectomy. As used in this Section, "mastectomy" means the
15removal of all or part of the breast for medically necessary
16reasons, as determined by a licensed physician.
17    Written notice of the availability of coverage under this
18Section shall be delivered to the enrollee upon enrollment and
19annually thereafter. A health maintenance organization may not
20deny to an enrollee eligibility, or continued eligibility, to
21enroll or to renew coverage under the terms of the plan solely
22for the purpose of avoiding the requirements of this Section. A
23health maintenance organization may not penalize or reduce or
24limit the reimbursement of an attending provider or provide
25incentives (monetary or otherwise) to an attending provider to
26induce the provider to provide care to an insured in a manner

 

 

SB0466 Engrossed- 12 -LRB099 03184 MGM 23192 b

1inconsistent with this Section.
2    (c) Rulemaking authority to implement this amendatory Act
3of the 95th General Assembly, if any, is conditioned on the
4rules being adopted in accordance with all provisions of the
5Illinois Administrative Procedure Act and all rules and
6procedures of the Joint Committee on Administrative Rules; any
7purported rule not so adopted, for whatever reason, is
8unauthorized.
9(Source: P.A. 94-121, eff. 7-6-05; 95-431, eff. 8-24-07;
1095-1045, eff. 3-27-09.)
 
11    (Text of Section after amendment by P.A. 99-407)
12    Sec. 4-6.1. Mammograms; mastectomies.
13    (a) Every contract or evidence of coverage issued by a
14Health Maintenance Organization for persons who are residents
15of this State shall contain coverage for screening by low-dose
16mammography for all women 35 years of age or older for the
17presence of occult breast cancer. The coverage shall be as
18follows:
19        (1) A baseline mammogram for women 35 to 39 years of
20    age.
21        (2) An annual mammogram for women 40 years of age or
22    older.
23        (3) A mammogram at the age and intervals considered
24    medically necessary by the woman's health care provider for
25    women under 40 years of age and having a family history of

 

 

SB0466 Engrossed- 13 -LRB099 03184 MGM 23192 b

1    breast cancer, prior personal history of breast cancer,
2    positive genetic testing, or other risk factors.
3        (4) A comprehensive ultrasound screening of an entire
4    breast or breasts if a mammogram demonstrates
5    heterogeneous or dense breast tissue, when medically
6    necessary as determined by a physician licensed to practice
7    medicine in all of its branches.
8    For purposes of this Section, "low-dose mammography" means
9the x-ray examination of the breast using equipment dedicated
10specifically for mammography, including the x-ray tube,
11filter, compression device, and image receptor, with radiation
12exposure delivery of less than 1 rad per breast for 2 views of
13an average size breast. The term also includes digital
14mammography and includes breast tomosynthesis. As used in this
15Section, the term "breast tomosynthesis" means a radiologic
16procedure that involves the acquisition of projection images
17over the stationary breast to produce cross-sectional digital
18three-dimensional images of the breast.
19    If, at any time, the Secretary of the United States
20Department of Health and Human Services, or its successor
21agency, promulgates rules or regulations to be published in the
22Federal Register or publishes a comment in the Federal Register
23or issues an opinion, guidance, or other action that would
24require the State, pursuant to any provision of the Patient
25Protection and Affordable Care Act (Public Law 111-148),
26including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any

 

 

SB0466 Engrossed- 14 -LRB099 03184 MGM 23192 b

1successor provision, to defray the cost of any coverage for
2breast tomosynthesis outlined in this subsection, then the
3requirement that an insurer cover breast tomosynthesis is
4inoperative other than any such coverage authorized under
5Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
6the State shall not assume any obligation for the cost of
7coverage for breast tomosynthesis set forth in this subsection.
8    (a-5) Coverage as described in subsection (a) shall be
9provided at no cost to the enrollee and shall not be applied to
10an annual or lifetime maximum benefit.
11    (b) No contract or evidence of coverage issued by a health
12maintenance organization that provides for the surgical
13procedure known as a mastectomy shall be issued, amended,
14delivered, or renewed in this State on or after the effective
15date of this amendatory Act of the 92nd General Assembly unless
16that coverage also provides for prosthetic devices or
17reconstructive surgery incident to the mastectomy, providing
18that the mastectomy is performed after the effective date of
19this amendatory Act. Coverage for breast reconstruction in
20connection with a mastectomy shall include:
21        (1) reconstruction of the breast upon which the
22    mastectomy has been performed;
23        (2) surgery and reconstruction of the other breast to
24    produce a symmetrical appearance; and
25        (3) prostheses and treatment for physical
26    complications at all stages of mastectomy, including

 

 

SB0466 Engrossed- 15 -LRB099 03184 MGM 23192 b

1    lymphedemas.
2Care shall be determined in consultation with the attending
3physician and the patient. The offered coverage for prosthetic
4devices and reconstructive surgery shall be subject to the
5deductible and coinsurance conditions applied to the
6mastectomy and all other terms and conditions applicable to
7other benefits. When a mastectomy is performed and there is no
8evidence of malignancy, then the offered coverage may be
9limited to the provision of prosthetic devices and
10reconstructive surgery to within 2 years after the date of the
11mastectomy. As used in this Section, "mastectomy" means the
12removal of all or part of the breast for medically necessary
13reasons, as determined by a licensed physician.
14    Written notice of the availability of coverage under this
15Section shall be delivered to the enrollee upon enrollment and
16annually thereafter. A health maintenance organization may not
17deny to an enrollee eligibility, or continued eligibility, to
18enroll or to renew coverage under the terms of the plan solely
19for the purpose of avoiding the requirements of this Section. A
20health maintenance organization may not penalize or reduce or
21limit the reimbursement of an attending provider or provide
22incentives (monetary or otherwise) to an attending provider to
23induce the provider to provide care to an insured in a manner
24inconsistent with this Section.
25    (c) Rulemaking authority to implement this amendatory Act
26of the 95th General Assembly, if any, is conditioned on the

 

 

SB0466 Engrossed- 16 -LRB099 03184 MGM 23192 b

1rules being adopted in accordance with all provisions of the
2Illinois Administrative Procedure Act and all rules and
3procedures of the Joint Committee on Administrative Rules; any
4purported rule not so adopted, for whatever reason, is
5unauthorized.
6(Source: P.A. 99-407 (see Section 99 of P.A. 99-407 for its
7effective date).)
 
8    Section 15. The Illinois Public Aid Code is amended by
9changing Section 5-5 as follows:
 
10    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
11    (Text of Section before amendment by P.A. 99-407)
12    Sec. 5-5. Medical services. The Illinois Department, by
13rule, shall determine the quantity and quality of and the rate
14of reimbursement for the medical assistance for which payment
15will be authorized, and the medical services to be provided,
16which may include all or part of the following: (1) inpatient
17hospital services; (2) outpatient hospital services; (3) other
18laboratory and X-ray services; (4) skilled nursing home
19services; (5) physicians' services whether furnished in the
20office, the patient's home, a hospital, a skilled nursing home,
21or elsewhere; (6) medical care, or any other type of remedial
22care furnished by licensed practitioners; (7) home health care
23services; (8) private duty nursing service; (9) clinic
24services; (10) dental services, including prevention and

 

 

SB0466 Engrossed- 17 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 18 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 19 -LRB099 03184 MGM 23192 b

1    Notwithstanding any other provision of this Code, the
2Illinois Department may not require, as a condition of payment
3for any laboratory test authorized under this Article, that a
4physician's handwritten signature appear on the laboratory
5test order form. The Illinois Department may, however, impose
6other appropriate requirements regarding laboratory test order
7documentation.
8    Upon receipt of federal approval of an amendment to the
9Illinois Title XIX State Plan for this purpose, the Department
10shall authorize the Chicago Public Schools (CPS) to procure a
11vendor or vendors to manufacture eyeglasses for individuals
12enrolled in a school within the CPS system. CPS shall ensure
13that its vendor or vendors are enrolled as providers in the
14medical assistance program and in any capitated Medicaid
15managed care entity (MCE) serving individuals enrolled in a
16school within the CPS system. Under any contract procured under
17this provision, the vendor or vendors must serve only
18individuals enrolled in a school within the CPS system. Claims
19for services provided by CPS's vendor or vendors to recipients
20of benefits in the medical assistance program under this Code,
21the Children's Health Insurance Program, or the Covering ALL
22KIDS Health Insurance Program shall be submitted to the
23Department or the MCE in which the individual is enrolled for
24payment and shall be reimbursed at the Department's or the
25MCE's established rates or rate methodologies for eyeglasses.
26    On and after July 1, 2012, the Department of Healthcare and

 

 

SB0466 Engrossed- 20 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 21 -LRB099 03184 MGM 23192 b

1    The Department of Healthcare and Family Services must
2provide coverage and reimbursement for amino acid-based
3elemental formulas, regardless of delivery method, for the
4diagnosis and treatment of (i) eosinophilic disorders and (ii)
5short bowel syndrome when the prescribing physician has issued
6a written order stating that the amino acid-based elemental
7formula is medically necessary.
8    The Illinois Department shall authorize the provision of,
9and shall authorize payment for, screening by low-dose
10mammography for the presence of occult breast cancer for women
1135 years of age or older who are eligible for medical
12assistance under this Article, as follows:
13        (A) A baseline mammogram for women 35 to 39 years of
14    age.
15        (B) An annual mammogram for women 40 years of age or
16    older.
17        (C) A mammogram at the age and intervals considered
18    medically necessary by the woman's health care provider for
19    women under 40 years of age and having a family history of
20    breast cancer, prior personal history of breast cancer,
21    positive genetic testing, or other risk factors.
22        (D) A comprehensive ultrasound screening of an entire
23    breast or breasts if a mammogram demonstrates
24    heterogeneous or dense breast tissue, when medically
25    necessary as determined by a physician licensed to practice
26    medicine in all of its branches.

 

 

SB0466 Engrossed- 22 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 23 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 24 -LRB099 03184 MGM 23192 b

1effectiveness and modifying the methodology based on the
2evaluation.
3    The Department shall establish a performance goal for
4primary care providers with respect to their female patients
5over age 40 receiving an annual mammogram. This performance
6goal shall be used to provide additional reimbursement in the
7form of a quality performance bonus to primary care providers
8who meet that goal.
9    The Department shall devise a means of case-managing or
10patient navigation for beneficiaries diagnosed with breast
11cancer. This program shall initially operate as a pilot program
12in areas of the State with the highest incidence of mortality
13related to breast cancer. At least one pilot program site shall
14be in the metropolitan Chicago area and at least one site shall
15be outside the metropolitan Chicago area. On or after July 1,
162016, the pilot program shall be expanded to include one site
17in western Illinois, one site in southern Illinois, one site in
18central Illinois, and 4 sites within metropolitan Chicago. An
19evaluation of the pilot program shall be carried out measuring
20health outcomes and cost of care for those served by the pilot
21program compared to similarly situated patients who are not
22served by the pilot program.
23    The Department shall require all networks of care to
24develop a means either internally or by contract with experts
25in navigation and community outreach to navigate cancer
26patients to comprehensive care in a timely fashion. The

 

 

SB0466 Engrossed- 25 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 26 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 27 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 28 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 29 -LRB099 03184 MGM 23192 b

1and every exception is resolved. The Illinois Department shall
2require health care providers to make available, when
3authorized by the patient, in writing, the medical records in a
4timely fashion to other health care providers who are treating
5or serving persons eligible for Medical Assistance under this
6Article. All dispensers of medical services shall be required
7to maintain and retain business and professional records
8sufficient to fully and accurately document the nature, scope,
9details and receipt of the health care provided to persons
10eligible for medical assistance under this Code, in accordance
11with regulations promulgated by the Illinois Department. The
12rules and regulations shall require that proof of the receipt
13of prescription drugs, dentures, prosthetic devices and
14eyeglasses by eligible persons under this Section accompany
15each claim for reimbursement submitted by the dispenser of such
16medical services. No such claims for reimbursement shall be
17approved for payment by the Illinois Department without such
18proof of receipt, unless the Illinois Department shall have put
19into effect and shall be operating a system of post-payment
20audit and review which shall, on a sampling basis, be deemed
21adequate by the Illinois Department to assure that such drugs,
22dentures, prosthetic devices and eyeglasses for which payment
23is being made are actually being received by eligible
24recipients. Within 90 days after September 16, 1984 (the
25effective date of Public Act 83-1439) this amendatory Act of
261984, the Illinois Department shall establish a current list of

 

 

SB0466 Engrossed- 30 -LRB099 03184 MGM 23192 b

1acquisition costs for all prosthetic devices and any other
2items recognized as medical equipment and supplies
3reimbursable under this Article and shall update such list on a
4quarterly basis, except that the acquisition costs of all
5prescription drugs shall be updated no less frequently than
6every 30 days as required by Section 5-5.12.
7    The rules and regulations of the Illinois Department shall
8require that a written statement including the required opinion
9of a physician shall accompany any claim for reimbursement for
10abortions, or induced miscarriages or premature births. This
11statement shall indicate what procedures were used in providing
12such medical services.
13    Notwithstanding any other law to the contrary, the Illinois
14Department shall, within 365 days after July 22, 2013 (the
15effective date of Public Act 98-104), establish procedures to
16permit skilled care facilities licensed under the Nursing Home
17Care Act to submit monthly billing claims for reimbursement
18purposes. Following development of these procedures, the
19Department shall, by July 1, 2016, test the viability of the
20new system and implement any necessary operational or
21structural changes to its information technology platforms in
22order to allow for the direct acceptance and payment of nursing
23home claims.
24    Notwithstanding any other law to the contrary, the Illinois
25Department shall, within 365 days after August 15, 2014 (the
26effective date of Public Act 98-963), establish procedures to

 

 

SB0466 Engrossed- 31 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 32 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 33 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 34 -LRB099 03184 MGM 23192 b

1    local government with a population exceeding 3,000,000
2    when local government funds finance federal participation
3    for claims payments.
4    For claims for services rendered during a period for which
5a recipient received retroactive eligibility, claims must be
6filed within 180 days after the Department determines the
7applicant is eligible. For claims for which the Illinois
8Department is not the primary payer, claims must be submitted
9to the Illinois Department within 180 days after the final
10adjudication by the primary payer.
11    In the case of long term care facilities, within 5 days of
12receipt by the facility of required prescreening information,
13data for new admissions shall be entered into the Medical
14Electronic Data Interchange (MEDI) or the Recipient
15Eligibility Verification (REV) System or successor system, and
16within 15 days of receipt by the facility of required
17prescreening information, admission documents shall be
18submitted through MEDI or REV or shall be submitted directly to
19the Department of Human Services using required admission
20forms. Effective September 1, 2014, admission documents,
21including all prescreening information, must be submitted
22through MEDI or REV. Confirmation numbers assigned to an
23accepted transaction shall be retained by a facility to verify
24timely submittal. Once an admission transaction has been
25completed, all resubmitted claims following prior rejection
26are subject to receipt no later than 180 days after the

 

 

SB0466 Engrossed- 35 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 36 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 37 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 38 -LRB099 03184 MGM 23192 b

1utilization controls or changes in benefit packages to
2effectuate a similar savings amount for this population; and
3(iv) no later than July 1, 2013, minimum level of care
4eligibility criteria for institutional and home and
5community-based long term care; and (v) no later than October
61, 2013, establish procedures to permit long term care
7providers access to eligibility scores for individuals with an
8admission date who are seeking or receiving services from the
9long term care provider. In order to select the minimum level
10of care eligibility criteria, the Governor shall establish a
11workgroup that includes affected agency representatives and
12stakeholders representing the institutional and home and
13community-based long term care interests. This Section shall
14not restrict the Department from implementing lower level of
15care eligibility criteria for community-based services in
16circumstances where federal approval has been granted.
17    The Illinois Department shall develop and operate, in
18cooperation with other State Departments and agencies and in
19compliance with applicable federal laws and regulations,
20appropriate and effective systems of health care evaluation and
21programs for monitoring of utilization of health care services
22and facilities, as it affects persons eligible for medical
23assistance under this Code.
24    The Illinois Department shall report annually to the
25General Assembly, no later than the second Friday in April of
261979 and each year thereafter, in regard to:

 

 

SB0466 Engrossed- 39 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 40 -LRB099 03184 MGM 23192 b

1whatever reason, is unauthorized.
2    On and after July 1, 2012, the Department shall reduce any
3rate of reimbursement for services or other payments or alter
4any methodologies authorized by this Code to reduce any rate of
5reimbursement for services or other payments in accordance with
6Section 5-5e.
7    Because kidney transplantation can be an appropriate, cost
8effective alternative to renal dialysis when medically
9necessary and notwithstanding the provisions of Section 1-11 of
10this Code, beginning October 1, 2014, the Department shall
11cover kidney transplantation for noncitizens with end-stage
12renal disease who are not eligible for comprehensive medical
13benefits, who meet the residency requirements of Section 5-3 of
14this Code, and who would otherwise meet the financial
15requirements of the appropriate class of eligible persons under
16Section 5-2 of this Code. To qualify for coverage of kidney
17transplantation, such person must be receiving emergency renal
18dialysis services covered by the Department. Providers under
19this Section shall be prior approved and certified by the
20Department to perform kidney transplantation and the services
21under this Section shall be limited to services associated with
22kidney transplantation.
23    Notwithstanding any other provision of this Code to the
24contrary, on or after July 1, 2015, all FDA approved forms of
25medication assisted treatment prescribed for the treatment of
26alcohol dependence or treatment of opioid dependence shall be

 

 

SB0466 Engrossed- 41 -LRB099 03184 MGM 23192 b

1covered under both fee for service and managed care medical
2assistance programs for persons who are otherwise eligible for
3medical assistance under this Article and shall not be subject
4to any (1) utilization control, other than those established
5under the American Society of Addiction Medicine patient
6placement criteria, (2) prior authorization mandate, or (3)
7lifetime restriction limit mandate.
8    On or after July 1, 2015, opioid antagonists prescribed for
9the treatment of an opioid overdose, including the medication
10product, administration devices, and any pharmacy fees related
11to the dispensing and administration of the opioid antagonist,
12shall be covered under the medical assistance program for
13persons who are otherwise eligible for medical assistance under
14this Article. As used in this Section, "opioid antagonist"
15means a drug that binds to opioid receptors and blocks or
16inhibits the effect of opioids acting on those receptors,
17including, but not limited to, naloxone hydrochloride or any
18other similarly acting drug approved by the U.S. Food and Drug
19Administration.
20(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
2198-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
228-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
23eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
2499-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-433, eff.
258-21-15; 99-480, eff. 9-9-15; revised 10-13-15.)
 

 

 

SB0466 Engrossed- 42 -LRB099 03184 MGM 23192 b

1    (Text of Section after amendment by P.A. 99-407)
2    Sec. 5-5. Medical services. The Illinois Department, by
3rule, shall determine the quantity and quality of and the rate
4of reimbursement for the medical assistance for which payment
5will be authorized, and the medical services to be provided,
6which may include all or part of the following: (1) inpatient
7hospital services; (2) outpatient hospital services; (3) other
8laboratory and X-ray services; (4) skilled nursing home
9services; (5) physicians' services whether furnished in the
10office, the patient's home, a hospital, a skilled nursing home,
11or elsewhere; (6) medical care, or any other type of remedial
12care furnished by licensed practitioners; (7) home health care
13services; (8) private duty nursing service; (9) clinic
14services; (10) dental services, including prevention and
15treatment of periodontal disease and dental caries disease for
16pregnant women, provided by an individual licensed to practice
17dentistry or dental surgery; for purposes of this item (10),
18"dental services" means diagnostic, preventive, or corrective
19procedures provided by or under the supervision of a dentist in
20the practice of his or her profession; (11) physical therapy
21and related services; (12) prescribed drugs, dentures, and
22prosthetic devices; and eyeglasses prescribed by a physician
23skilled in the diseases of the eye, or by an optometrist,
24whichever the person may select; (13) other diagnostic,
25screening, preventive, and rehabilitative services, including
26to ensure that the individual's need for intervention or

 

 

SB0466 Engrossed- 43 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 44 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 45 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 46 -LRB099 03184 MGM 23192 b

1allow a dentist who is volunteering his or her service at no
2cost to render dental services through an enrolled
3not-for-profit health clinic without the dentist personally
4enrolling as a participating provider in the medical assistance
5program. A not-for-profit health clinic shall include a public
6health clinic or Federally Qualified Health Center or other
7enrolled provider, as determined by the Department, through
8which dental services covered under this Section are performed.
9The Department shall establish a process for payment of claims
10for reimbursement for covered dental services rendered under
11this provision.
12    The Illinois Department, by rule, may distinguish and
13classify the medical services to be provided only in accordance
14with the classes of persons designated in Section 5-2.
15    The Department of Healthcare and Family Services must
16provide coverage and reimbursement for amino acid-based
17elemental formulas, regardless of delivery method, for the
18diagnosis and treatment of (i) eosinophilic disorders and (ii)
19short bowel syndrome when the prescribing physician has issued
20a written order stating that the amino acid-based elemental
21formula is medically necessary.
22    The Illinois Department shall authorize the provision of,
23and shall authorize payment for, screening by low-dose
24mammography for the presence of occult breast cancer for women
2535 years of age or older who are eligible for medical
26assistance under this Article, as follows:

 

 

SB0466 Engrossed- 47 -LRB099 03184 MGM 23192 b

1        (A) A baseline mammogram for women 35 to 39 years of
2    age.
3        (B) An annual mammogram for women 40 years of age or
4    older.
5        (C) A mammogram at the age and intervals considered
6    medically necessary by the woman's health care provider for
7    women under 40 years of age and having a family history of
8    breast cancer, prior personal history of breast cancer,
9    positive genetic testing, or other risk factors.
10        (D) A comprehensive ultrasound screening of an entire
11    breast or breasts if a mammogram demonstrates
12    heterogeneous or dense breast tissue, when medically
13    necessary as determined by a physician licensed to practice
14    medicine in all of its branches.
15        (E) A screening MRI when medically necessary, as
16    determined by a physician licensed to practice medicine in
17    all of its branches.
18    All screenings shall include a physical breast exam,
19instruction on self-examination and information regarding the
20frequency of self-examination and its value as a preventative
21tool. For purposes of this Section, "low-dose mammography"
22means the x-ray examination of the breast using equipment
23dedicated specifically for mammography, including the x-ray
24tube, filter, compression device, and image receptor, with an
25average radiation exposure delivery of less than one rad per
26breast for 2 views of an average size breast. The term also

 

 

SB0466 Engrossed- 48 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 49 -LRB099 03184 MGM 23192 b

1reimbursed for screening and diagnostic mammography at the same
2rate as the Medicare program's rates, including the increased
3reimbursement for digital mammography.
4    The Department shall convene an expert panel including
5representatives of hospitals, free-standing mammography
6facilities, and doctors, including radiologists, to establish
7quality standards for mammography.
8    On and after January 1, 2017, providers participating in a
9breast cancer treatment quality improvement program approved
10by the Department shall be reimbursed for breast cancer
11treatment at a rate that is no lower than 95% of the Medicare
12program's rates for the data elements included in the breast
13cancer treatment quality program.
14    The Department shall convene an expert panel, including
15representatives of hospitals, free standing breast cancer
16treatment centers, breast cancer quality organizations, and
17doctors, including breast surgeons, reconstructive breast
18surgeons, oncologists, and primary care providers to establish
19quality standards for breast cancer treatment.
20    Subject to federal approval, the Department shall
21establish a rate methodology for mammography at federally
22qualified health centers and other encounter-rate clinics.
23These clinics or centers may also collaborate with other
24hospital-based mammography facilities. By January 1, 2016, the
25Department shall report to the General Assembly on the status
26of the provision set forth in this paragraph.

 

 

SB0466 Engrossed- 50 -LRB099 03184 MGM 23192 b

1    The Department shall establish a methodology to remind
2women who are age-appropriate for screening mammography, but
3who have not received a mammogram within the previous 18
4months, of the importance and benefit of screening mammography.
5The Department shall work with experts in breast cancer
6outreach and patient navigation to optimize these reminders and
7shall establish a methodology for evaluating their
8effectiveness and modifying the methodology based on the
9evaluation.
10    The Department shall establish a performance goal for
11primary care providers with respect to their female patients
12over age 40 receiving an annual mammogram. This performance
13goal shall be used to provide additional reimbursement in the
14form of a quality performance bonus to primary care providers
15who meet that goal.
16    The Department shall devise a means of case-managing or
17patient navigation for beneficiaries diagnosed with breast
18cancer. This program shall initially operate as a pilot program
19in areas of the State with the highest incidence of mortality
20related to breast cancer. At least one pilot program site shall
21be in the metropolitan Chicago area and at least one site shall
22be outside the metropolitan Chicago area. On or after July 1,
232016, the pilot program shall be expanded to include one site
24in western Illinois, one site in southern Illinois, one site in
25central Illinois, and 4 sites within metropolitan Chicago. An
26evaluation of the pilot program shall be carried out measuring

 

 

SB0466 Engrossed- 51 -LRB099 03184 MGM 23192 b

1health outcomes and cost of care for those served by the pilot
2program compared to similarly situated patients who are not
3served by the pilot program.
4    The Department shall require all networks of care to
5develop a means either internally or by contract with experts
6in navigation and community outreach to navigate cancer
7patients to comprehensive care in a timely fashion. The
8Department shall require all networks of care to include access
9for patients diagnosed with cancer to at least one academic
10commission on cancer-accredited cancer program as an
11in-network covered benefit.
12    Any medical or health care provider shall immediately
13recommend, to any pregnant woman who is being provided prenatal
14services and is suspected of drug abuse or is addicted as
15defined in the Alcoholism and Other Drug Abuse and Dependency
16Act, referral to a local substance abuse treatment provider
17licensed by the Department of Human Services or to a licensed
18hospital which provides substance abuse treatment services.
19The Department of Healthcare and Family Services shall assure
20coverage for the cost of treatment of the drug abuse or
21addiction for pregnant recipients in accordance with the
22Illinois Medicaid Program in conjunction with the Department of
23Human Services.
24    All medical providers providing medical assistance to
25pregnant women under this Code shall receive information from
26the Department on the availability of services under the Drug

 

 

SB0466 Engrossed- 52 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 53 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 54 -LRB099 03184 MGM 23192 b

1        (3) Persons receiving medical services through
2    Partnerships may receive medical and case management
3    services above the level usually offered through the
4    medical assistance program.
5    Medical providers shall be required to meet certain
6qualifications to participate in Partnerships to ensure the
7delivery of high quality medical services. These
8qualifications shall be determined by rule of the Illinois
9Department and may be higher than qualifications for
10participation in the medical assistance program. Partnership
11sponsors may prescribe reasonable additional qualifications
12for participation by medical providers, only with the prior
13written approval of the Illinois Department.
14    Nothing in this Section shall limit the free choice of
15practitioners, hospitals, and other providers of medical
16services by clients. In order to ensure patient freedom of
17choice, the Illinois Department shall immediately promulgate
18all rules and take all other necessary actions so that provided
19services may be accessed from therapeutically certified
20optometrists to the full extent of the Illinois Optometric
21Practice Act of 1987 without discriminating between service
22providers.
23    The Department shall apply for a waiver from the United
24States Health Care Financing Administration to allow for the
25implementation of Partnerships under this Section.
26    The Illinois Department shall require health care

 

 

SB0466 Engrossed- 55 -LRB099 03184 MGM 23192 b

1providers to maintain records that document the medical care
2and services provided to recipients of Medical Assistance under
3this Article. Such records must be retained for a period of not
4less than 6 years from the date of service or as provided by
5applicable State law, whichever period is longer, except that
6if an audit is initiated within the required retention period
7then the records must be retained until the audit is completed
8and every exception is resolved. The Illinois Department shall
9require health care providers to make available, when
10authorized by the patient, in writing, the medical records in a
11timely fashion to other health care providers who are treating
12or serving persons eligible for Medical Assistance under this
13Article. All dispensers of medical services shall be required
14to maintain and retain business and professional records
15sufficient to fully and accurately document the nature, scope,
16details and receipt of the health care provided to persons
17eligible for medical assistance under this Code, in accordance
18with regulations promulgated by the Illinois Department. The
19rules and regulations shall require that proof of the receipt
20of prescription drugs, dentures, prosthetic devices and
21eyeglasses by eligible persons under this Section accompany
22each claim for reimbursement submitted by the dispenser of such
23medical services. No such claims for reimbursement shall be
24approved for payment by the Illinois Department without such
25proof of receipt, unless the Illinois Department shall have put
26into effect and shall be operating a system of post-payment

 

 

SB0466 Engrossed- 56 -LRB099 03184 MGM 23192 b

1audit and review which shall, on a sampling basis, be deemed
2adequate by the Illinois Department to assure that such drugs,
3dentures, prosthetic devices and eyeglasses for which payment
4is being made are actually being received by eligible
5recipients. Within 90 days after September 16, 1984 (the
6effective date of Public Act 83-1439) this amendatory Act of
71984, the Illinois Department shall establish a current list of
8acquisition costs for all prosthetic devices and any other
9items recognized as medical equipment and supplies
10reimbursable under this Article and shall update such list on a
11quarterly basis, except that the acquisition costs of all
12prescription drugs shall be updated no less frequently than
13every 30 days as required by Section 5-5.12.
14    The rules and regulations of the Illinois Department shall
15require that a written statement including the required opinion
16of a physician shall accompany any claim for reimbursement for
17abortions, or induced miscarriages or premature births. This
18statement shall indicate what procedures were used in providing
19such medical services.
20    Notwithstanding any other law to the contrary, the Illinois
21Department shall, within 365 days after July 22, 2013 (the
22effective date of Public Act 98-104), establish procedures to
23permit skilled care facilities licensed under the Nursing Home
24Care Act to submit monthly billing claims for reimbursement
25purposes. Following development of these procedures, the
26Department shall, by July 1, 2016, test the viability of the

 

 

SB0466 Engrossed- 57 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 58 -LRB099 03184 MGM 23192 b

1under such terms and conditions as the Illinois Department may
2by rule establish, all inquiries from clients and attorneys
3regarding medical bills paid by the Illinois Department, which
4inquiries could indicate potential existence of claims or liens
5for the Illinois Department.
6    Enrollment of a vendor shall be subject to a provisional
7period and shall be conditional for one year. During the period
8of conditional enrollment, the Department may terminate the
9vendor's eligibility to participate in, or may disenroll the
10vendor from, the medical assistance program without cause.
11Unless otherwise specified, such termination of eligibility or
12disenrollment is not subject to the Department's hearing
13process. However, a disenrolled vendor may reapply without
14penalty.
15    The Department has the discretion to limit the conditional
16enrollment period for vendors based upon category of risk of
17the vendor.
18    Prior to enrollment and during the conditional enrollment
19period in the medical assistance program, all vendors shall be
20subject to enhanced oversight, screening, and review based on
21the risk of fraud, waste, and abuse that is posed by the
22category of risk of the vendor. The Illinois Department shall
23establish the procedures for oversight, screening, and review,
24which may include, but need not be limited to: criminal and
25financial background checks; fingerprinting; license,
26certification, and authorization verifications; unscheduled or

 

 

SB0466 Engrossed- 59 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 60 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 61 -LRB099 03184 MGM 23192 b

1forms. Effective September 1, 2014, admission documents,
2including all prescreening information, must be submitted
3through MEDI or REV. Confirmation numbers assigned to an
4accepted transaction shall be retained by a facility to verify
5timely submittal. Once an admission transaction has been
6completed, all resubmitted claims following prior rejection
7are subject to receipt no later than 180 days after the
8admission transaction has been completed.
9    Claims that are not submitted and received in compliance
10with the foregoing requirements shall not be eligible for
11payment under the medical assistance program, and the State
12shall have no liability for payment of those claims.
13    To the extent consistent with applicable information and
14privacy, security, and disclosure laws, State and federal
15agencies and departments shall provide the Illinois Department
16access to confidential and other information and data necessary
17to perform eligibility and payment verifications and other
18Illinois Department functions. This includes, but is not
19limited to: information pertaining to licensure;
20certification; earnings; immigration status; citizenship; wage
21reporting; unearned and earned income; pension income;
22employment; supplemental security income; social security
23numbers; National Provider Identifier (NPI) numbers; the
24National Practitioner Data Bank (NPDB); program and agency
25exclusions; taxpayer identification numbers; tax delinquency;
26corporate information; and death records.

 

 

SB0466 Engrossed- 62 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 63 -LRB099 03184 MGM 23192 b

1management system with link analysis. Such a request for
2information shall not be considered as a request for proposal
3or as an obligation on the part of the Illinois Department to
4take any action or acquire any products or services.
5    The Illinois Department shall establish policies,
6procedures, standards and criteria by rule for the acquisition,
7repair and replacement of orthotic and prosthetic devices and
8durable medical equipment. Such rules shall provide, but not be
9limited to, the following services: (1) immediate repair or
10replacement of such devices by recipients; and (2) rental,
11lease, purchase or lease-purchase of durable medical equipment
12in a cost-effective manner, taking into consideration the
13recipient's medical prognosis, the extent of the recipient's
14needs, and the requirements and costs for maintaining such
15equipment. Subject to prior approval, such rules shall enable a
16recipient to temporarily acquire and use alternative or
17substitute devices or equipment pending repairs or
18replacements of any device or equipment previously authorized
19for such recipient by the Department.
20    The Department shall execute, relative to the nursing home
21prescreening project, written inter-agency agreements with the
22Department of Human Services and the Department on Aging, to
23effect the following: (i) intake procedures and common
24eligibility criteria for those persons who are receiving
25non-institutional services; and (ii) the establishment and
26development of non-institutional services in areas of the State

 

 

SB0466 Engrossed- 64 -LRB099 03184 MGM 23192 b

1where they are not currently available or are undeveloped; and
2(iii) notwithstanding any other provision of law, subject to
3federal approval, on and after July 1, 2012, an increase in the
4determination of need (DON) scores from 29 to 37 for applicants
5for institutional and home and community-based long term care;
6if and only if federal approval is not granted, the Department
7may, in conjunction with other affected agencies, implement
8utilization controls or changes in benefit packages to
9effectuate a similar savings amount for this population; and
10(iv) no later than July 1, 2013, minimum level of care
11eligibility criteria for institutional and home and
12community-based long term care; and (v) no later than October
131, 2013, establish procedures to permit long term care
14providers access to eligibility scores for individuals with an
15admission date who are seeking or receiving services from the
16long term care provider. In order to select the minimum level
17of care eligibility criteria, the Governor shall establish a
18workgroup that includes affected agency representatives and
19stakeholders representing the institutional and home and
20community-based long term care interests. This Section shall
21not restrict the Department from implementing lower level of
22care eligibility criteria for community-based services in
23circumstances where federal approval has been granted.
24    The Illinois Department shall develop and operate, in
25cooperation with other State Departments and agencies and in
26compliance with applicable federal laws and regulations,

 

 

SB0466 Engrossed- 65 -LRB099 03184 MGM 23192 b

1appropriate and effective systems of health care evaluation and
2programs for monitoring of utilization of health care services
3and facilities, as it affects persons eligible for medical
4assistance under this Code.
5    The Illinois Department shall report annually to the
6General Assembly, no later than the second Friday in April of
71979 and each year thereafter, in regard to:
8        (a) actual statistics and trends in utilization of
9    medical services by public aid recipients;
10        (b) actual statistics and trends in the provision of
11    the various medical services by medical vendors;
12        (c) current rate structures and proposed changes in
13    those rate structures for the various medical vendors; and
14        (d) efforts at utilization review and control by the
15    Illinois Department.
16    The period covered by each report shall be the 3 years
17ending on the June 30 prior to the report. The report shall
18include suggested legislation for consideration by the General
19Assembly. The filing of one copy of the report with the
20Speaker, one copy with the Minority Leader and one copy with
21the Clerk of the House of Representatives, one copy with the
22President, one copy with the Minority Leader and one copy with
23the Secretary of the Senate, one copy with the Legislative
24Research Unit, and such additional copies with the State
25Government Report Distribution Center for the General Assembly
26as is required under paragraph (t) of Section 7 of the State

 

 

SB0466 Engrossed- 66 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 67 -LRB099 03184 MGM 23192 b

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

 

 

SB0466 Engrossed- 68 -LRB099 03184 MGM 23192 b

1(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
298-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
38-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
4eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
599-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
699 of P.A. 99-407 for its effective date); 99-433, eff.
78-21-15; 99-480, eff. 9-9-15; revised 10-13-15.)
 
8    Section 20. "An Act concerning regulation", approved
9August 19, 2015, Public Act 99-407, is amended by changing
10Section 99 as follows:
 
11    (P.A. 99-407, Sec. 99)
12    Sec. 99. Effective date. This Act takes effect on July 1,
132016. , if and only if on or before July 1, 2016:
14    (1) the Secretary of the United States Department of Health
15and Human Services, or its successor agency, promulgates rules
16or regulations published in the Federal Register or publishes a
17comment in the Federal Register:
18         (A) repealing, amending, or reinterpreting 45 CFR
19    155.170 to eliminate the State's responsibility to defray
20    the cost of a state-mandated benefit enacted on or after
21    January 1, 2012;
22        (B) requiring qualified health plans, as defined in the
23    federal Patient Protection and Affordable Care Act, as
24    amended by the Health Care and Education Reconciliation Act

 

 

SB0466 Engrossed- 69 -LRB099 03184 MGM 23192 b

1    of 2010 and any subsequent amendatory Acts, rules, or
2    regulations issued pursuant thereto, to cover breast
3    tomosynthesis as an essential health benefit; or
4        (C) including breast tomosynthesis as a standard as
5    part of the essential health benefits required of benchmark
6    plans under 45 CFR 156.110; or
7    (2) the federal Patient Protection and Affordable Care Act
8is repealed by an Act of Congress or is invalidated by a
9decision of the U.S. Supreme Court.
10(Source: P.A. 99-407, eff. (see Section 99 of P.A. 99-407 for
11its effective date).)
 
12    Section 95. No acceleration or delay. Where this Act makes
13changes in a statute that is represented in this Act by text
14that is not yet or no longer in effect (for example, a Section
15represented by multiple versions), the use of that text does
16not accelerate or delay the taking effect of (i) the changes
17made by this Act or (ii) provisions derived from any other
18Public Act.
 
19    Section 99. Effective date. This Act takes effect on July
201, 2016.