Full Text of SB2429 100th General Assembly
SB2429sam001 100TH GENERAL ASSEMBLY | Sen. Omar Aquino Filed: 2/22/2018
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| 1 | | AMENDMENT TO SENATE BILL 2429
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 2429 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Illinois Public Aid Code is amended by | 5 | | changing Sections 5-5 and 5-30 as follows:
| 6 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| 7 | | Sec. 5-5. Medical services. The Illinois Department, by | 8 | | rule, shall
determine the quantity and quality of and the rate | 9 | | of reimbursement for the
medical assistance for which
payment | 10 | | will be authorized, and the medical services to be provided,
| 11 | | which may include all or part of the following: (1) inpatient | 12 | | hospital
services; (2) outpatient hospital services; (3) other | 13 | | laboratory and
X-ray services; (4) skilled nursing home | 14 | | services; (5) physicians'
services whether furnished in the | 15 | | office, the patient's home, a
hospital, a skilled nursing home, | 16 | | or elsewhere; (6) medical care, or any
other type of remedial |
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| 1 | | care furnished by licensed practitioners; (7)
home health care | 2 | | services; (8) private duty nursing service; (9) clinic
| 3 | | services; (10) dental services, including prevention and | 4 | | treatment of periodontal disease and dental caries disease for | 5 | | pregnant women, provided by an individual licensed to practice | 6 | | dentistry or dental surgery; for purposes of this item (10), | 7 | | "dental services" means diagnostic, preventive, or corrective | 8 | | procedures provided by or under the supervision of a dentist in | 9 | | the practice of his or her profession; (11) physical therapy | 10 | | and related
services; (12) prescribed drugs, dentures, and | 11 | | prosthetic devices; and
eyeglasses prescribed by a physician | 12 | | skilled in the diseases of the eye,
or by an optometrist, | 13 | | whichever the person may select; (13) other
diagnostic, | 14 | | screening, preventive, and rehabilitative services, including | 15 | | to ensure that the individual's need for intervention or | 16 | | treatment of mental disorders or substance use disorders or | 17 | | co-occurring mental health and substance use disorders is | 18 | | determined using a uniform screening, assessment, and | 19 | | evaluation process inclusive of criteria, for children and | 20 | | adults; for purposes of this item (13), a uniform screening, | 21 | | assessment, and evaluation process refers to a process that | 22 | | includes an appropriate evaluation and, as warranted, a | 23 | | referral; "uniform" does not mean the use of a singular | 24 | | instrument, tool, or process that all must utilize; (14)
| 25 | | transportation and such other expenses as may be necessary; | 26 | | (15) medical
treatment of sexual assault survivors, as defined |
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| 1 | | in
Section 1a of the Sexual Assault Survivors Emergency | 2 | | Treatment Act, for
injuries sustained as a result of the sexual | 3 | | assault, including
examinations and laboratory tests to | 4 | | discover evidence which may be used in
criminal proceedings | 5 | | arising from the sexual assault; (16) the
diagnosis and | 6 | | treatment of sickle cell anemia; and (17)
any other medical | 7 | | care, and any other type of remedial care recognized
under the | 8 | | laws of this State. The term "any other type of remedial care" | 9 | | shall
include nursing care and nursing home service for persons | 10 | | who rely on
treatment by spiritual means alone through prayer | 11 | | for healing.
| 12 | | Notwithstanding any other provision of this Section, a | 13 | | comprehensive
tobacco use cessation program that includes | 14 | | purchasing prescription drugs or
prescription medical devices | 15 | | approved by the Food and Drug Administration shall
be covered | 16 | | under the medical assistance
program under this Article for | 17 | | persons who are otherwise eligible for
assistance under this | 18 | | Article.
| 19 | | Notwithstanding any other provision of this Code, | 20 | | reproductive health care that is otherwise legal in Illinois | 21 | | shall be covered under the medical assistance program for | 22 | | persons who are otherwise eligible for medical assistance under | 23 | | this Article. | 24 | | Notwithstanding any other provision of this Code, the | 25 | | Illinois
Department may not require, as a condition of payment | 26 | | for any laboratory
test authorized under this Article, that a |
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| 1 | | physician's handwritten signature
appear on the laboratory | 2 | | test order form. The Illinois Department may,
however, impose | 3 | | other appropriate requirements regarding laboratory test
order | 4 | | documentation.
| 5 | | Upon receipt of federal approval of an amendment to the | 6 | | Illinois Title XIX State Plan for this purpose, the Department | 7 | | shall authorize the Chicago Public Schools (CPS) to procure a | 8 | | vendor or vendors to manufacture eyeglasses for individuals | 9 | | enrolled in a school within the CPS system. CPS shall ensure | 10 | | that its vendor or vendors are enrolled as providers in the | 11 | | medical assistance program and in any capitated Medicaid | 12 | | managed care entity (MCE) serving individuals enrolled in a | 13 | | school within the CPS system. Under any contract procured under | 14 | | this provision, the vendor or vendors must serve only | 15 | | individuals enrolled in a school within the CPS system. Claims | 16 | | for services provided by CPS's vendor or vendors to recipients | 17 | | of benefits in the medical assistance program under this Code, | 18 | | the Children's Health Insurance Program, or the Covering ALL | 19 | | KIDS Health Insurance Program shall be submitted to the | 20 | | Department or the MCE in which the individual is enrolled for | 21 | | payment and shall be reimbursed at the Department's or the | 22 | | MCE's established rates or rate methodologies for eyeglasses. | 23 | | On and after July 1, 2012, the Department of Healthcare and | 24 | | Family Services may provide the following services to
persons
| 25 | | eligible for assistance under this Article who are | 26 | | participating in
education, training or employment programs |
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| 1 | | operated by the Department of Human
Services as successor to | 2 | | the Department of Public Aid:
| 3 | | (1) dental services provided by or under the | 4 | | supervision of a dentist; and
| 5 | | (2) eyeglasses prescribed by a physician skilled in the | 6 | | diseases of the
eye, or by an optometrist, whichever the | 7 | | person may select.
| 8 | | On and after July 1, 2018, the Department of Healthcare and | 9 | | Family Services shall provide dental services to any adult who | 10 | | is otherwise eligible for assistance under the medical | 11 | | assistance program. As used in this paragraph, "dental | 12 | | services" means diagnostic, preventative, restorative, or | 13 | | corrective procedures, including procedures and services for | 14 | | the prevention and treatment of periodontal disease and dental | 15 | | caries disease, provided by an individual who is licensed to | 16 | | practice dentistry or dental surgery or who is under the | 17 | | supervision of a dentist in the practice of his or her | 18 | | profession. | 19 | | On and after July 1, 2018, targeted dental services, as set | 20 | | forth in Exhibit D of the Consent Decree entered by the United | 21 | | States District Court for the Northern District of Illinois, | 22 | | Eastern Division, in the matter of Memisovski v. Maram, Case | 23 | | No. 92 C 1982, that are provided to adults under the medical | 24 | | assistance program shall be reimbursed at the rates set forth | 25 | | in the "New Rate" column in Exhibit D of the Consent Decree for | 26 | | targeted dental services that are provided to persons under the |
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| 1 | | age of 18 under the medical assistance program. | 2 | | Notwithstanding any other provision of this Code and | 3 | | subject to federal approval, the Department may adopt rules to | 4 | | allow a dentist who is volunteering his or her service at no | 5 | | cost to render dental services through an enrolled | 6 | | not-for-profit health clinic without the dentist personally | 7 | | enrolling as a participating provider in the medical assistance | 8 | | program. A not-for-profit health clinic shall include a public | 9 | | health clinic or Federally Qualified Health Center or other | 10 | | enrolled provider, as determined by the Department, through | 11 | | which dental services covered under this Section are performed. | 12 | | The Department shall establish a process for payment of claims | 13 | | for reimbursement for covered dental services rendered under | 14 | | this provision. | 15 | | The Illinois Department, by rule, may distinguish and | 16 | | classify the
medical services to be provided only in accordance | 17 | | with the classes of
persons designated in Section 5-2.
| 18 | | The Department of Healthcare and Family Services must | 19 | | provide coverage and reimbursement for amino acid-based | 20 | | elemental formulas, regardless of delivery method, for the | 21 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 22 | | short bowel syndrome when the prescribing physician has issued | 23 | | a written order stating that the amino acid-based elemental | 24 | | formula is medically necessary.
| 25 | | The Illinois Department shall authorize the provision of, | 26 | | and shall
authorize payment for, screening by low-dose |
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| 1 | | mammography for the presence of
occult breast cancer for women | 2 | | 35 years of age or older who are eligible
for medical | 3 | | assistance under this Article, as follows: | 4 | | (A) A baseline
mammogram for women 35 to 39 years of | 5 | | age.
| 6 | | (B) An annual mammogram for women 40 years of age or | 7 | | older. | 8 | | (C) A mammogram at the age and intervals considered | 9 | | medically necessary by the woman's health care provider for | 10 | | women under 40 years of age and having a family history of | 11 | | breast cancer, prior personal history of breast cancer, | 12 | | positive genetic testing, or other risk factors. | 13 | | (D) A comprehensive ultrasound screening and MRI of an | 14 | | entire breast or breasts if a mammogram demonstrates | 15 | | heterogeneous or dense breast tissue, when medically | 16 | | necessary as determined by a physician licensed to practice | 17 | | medicine in all of its branches. | 18 | | (E) A screening MRI when medically necessary, as | 19 | | determined by a physician licensed to practice medicine in | 20 | | all of its branches. | 21 | | All screenings
shall
include a physical breast exam, | 22 | | instruction on self-examination and
information regarding the | 23 | | frequency of self-examination and its value as a
preventative | 24 | | tool. For purposes of this Section, "low-dose mammography" | 25 | | means
the x-ray examination of the breast using equipment | 26 | | dedicated specifically
for mammography, including the x-ray |
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| 1 | | tube, filter, compression device,
and image receptor, with an | 2 | | average radiation exposure delivery
of less than one rad per | 3 | | breast for 2 views of an average size breast.
The term also | 4 | | includes digital mammography and includes breast | 5 | | tomosynthesis. As used in this Section, the term "breast | 6 | | tomosynthesis" means a radiologic procedure that involves the | 7 | | acquisition of projection images over the stationary breast to | 8 | | produce cross-sectional digital three-dimensional images of | 9 | | the breast. If, at any time, the Secretary of the United States | 10 | | Department of Health and Human Services, or its successor | 11 | | agency, promulgates rules or regulations to be published in the | 12 | | Federal Register or publishes a comment in the Federal Register | 13 | | or issues an opinion, guidance, or other action that would | 14 | | require the State, pursuant to any provision of the Patient | 15 | | Protection and Affordable Care Act (Public Law 111-148), | 16 | | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any | 17 | | successor provision, to defray the cost of any coverage for | 18 | | breast tomosynthesis outlined in this paragraph, then the | 19 | | requirement that an insurer cover breast tomosynthesis is | 20 | | inoperative other than any such coverage authorized under | 21 | | Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and | 22 | | the State shall not assume any obligation for the cost of | 23 | | coverage for breast tomosynthesis set forth in this paragraph.
| 24 | | On and after January 1, 2016, the Department shall ensure | 25 | | that all networks of care for adult clients of the Department | 26 | | include access to at least one breast imaging Center of Imaging |
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| 1 | | Excellence as certified by the American College of Radiology. | 2 | | On and after January 1, 2012, providers participating in a | 3 | | quality improvement program approved by the Department shall be | 4 | | reimbursed for screening and diagnostic mammography at the same | 5 | | rate as the Medicare program's rates, including the increased | 6 | | reimbursement for digital mammography. | 7 | | The Department shall convene an expert panel including | 8 | | representatives of hospitals, free-standing mammography | 9 | | facilities, and doctors, including radiologists, to establish | 10 | | quality standards for mammography. | 11 | | On and after January 1, 2017, providers participating in a | 12 | | breast cancer treatment quality improvement program approved | 13 | | by the Department shall be reimbursed for breast cancer | 14 | | treatment at a rate that is no lower than 95% of the Medicare | 15 | | program's rates for the data elements included in the breast | 16 | | cancer treatment quality program. | 17 | | The Department shall convene an expert panel, including | 18 | | representatives of hospitals, free standing breast cancer | 19 | | treatment centers, breast cancer quality organizations, and | 20 | | doctors, including breast surgeons, reconstructive breast | 21 | | surgeons, oncologists, and primary care providers to establish | 22 | | quality standards for breast cancer treatment. | 23 | | Subject to federal approval, the Department shall | 24 | | establish a rate methodology for mammography at federally | 25 | | qualified health centers and other encounter-rate clinics. | 26 | | These clinics or centers may also collaborate with other |
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| 1 | | hospital-based mammography facilities. By January 1, 2016, the | 2 | | Department shall report to the General Assembly on the status | 3 | | of the provision set forth in this paragraph. | 4 | | The Department shall establish a methodology to remind | 5 | | women who are age-appropriate for screening mammography, but | 6 | | who have not received a mammogram within the previous 18 | 7 | | months, of the importance and benefit of screening mammography. | 8 | | The Department shall work with experts in breast cancer | 9 | | outreach and patient navigation to optimize these reminders and | 10 | | shall establish a methodology for evaluating their | 11 | | effectiveness and modifying the methodology based on the | 12 | | evaluation. | 13 | | The Department shall establish a performance goal for | 14 | | primary care providers with respect to their female patients | 15 | | over age 40 receiving an annual mammogram. This performance | 16 | | goal shall be used to provide additional reimbursement in the | 17 | | form of a quality performance bonus to primary care providers | 18 | | who meet that goal. | 19 | | The Department shall devise a means of case-managing or | 20 | | patient navigation for beneficiaries diagnosed with breast | 21 | | cancer. This program shall initially operate as a pilot program | 22 | | in areas of the State with the highest incidence of mortality | 23 | | related to breast cancer. At least one pilot program site shall | 24 | | be in the metropolitan Chicago area and at least one site shall | 25 | | be outside the metropolitan Chicago area. On or after July 1, | 26 | | 2016, the pilot program shall be expanded to include one site |
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| 1 | | in western Illinois, one site in southern Illinois, one site in | 2 | | central Illinois, and 4 sites within metropolitan Chicago. An | 3 | | evaluation of the pilot program shall be carried out measuring | 4 | | health outcomes and cost of care for those served by the pilot | 5 | | program compared to similarly situated patients who are not | 6 | | served by the pilot program. | 7 | | The Department shall require all networks of care to | 8 | | develop a means either internally or by contract with experts | 9 | | in navigation and community outreach to navigate cancer | 10 | | patients to comprehensive care in a timely fashion. The | 11 | | Department shall require all networks of care to include access | 12 | | for patients diagnosed with cancer to at least one academic | 13 | | commission on cancer-accredited cancer program as an | 14 | | in-network covered benefit. | 15 | | Any medical or health care provider shall immediately | 16 | | recommend, to
any pregnant woman who is being provided prenatal | 17 | | services and is suspected
of drug abuse or is addicted as | 18 | | defined in the Alcoholism and Other Drug Abuse
and Dependency | 19 | | Act, referral to a local substance abuse treatment provider
| 20 | | licensed by the Department of Human Services or to a licensed
| 21 | | hospital which provides substance abuse treatment services. | 22 | | The Department of Healthcare and Family Services
shall assure | 23 | | coverage for the cost of treatment of the drug abuse or
| 24 | | addiction for pregnant recipients in accordance with the | 25 | | Illinois Medicaid
Program in conjunction with the Department of | 26 | | Human Services.
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| 1 | | All medical providers providing medical assistance to | 2 | | pregnant women
under this Code shall receive information from | 3 | | the Department on the
availability of services under the Drug | 4 | | Free Families with a Future or any
comparable program providing | 5 | | case management services for addicted women,
including | 6 | | information on appropriate referrals for other social services
| 7 | | that may be needed by addicted women in addition to treatment | 8 | | for addiction.
| 9 | | The Illinois Department, in cooperation with the | 10 | | Departments of Human
Services (as successor to the Department | 11 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 12 | | public awareness campaign, may
provide information concerning | 13 | | treatment for alcoholism and drug abuse and
addiction, prenatal | 14 | | health care, and other pertinent programs directed at
reducing | 15 | | the number of drug-affected infants born to recipients of | 16 | | medical
assistance.
| 17 | | Neither the Department of Healthcare and Family Services | 18 | | nor the Department of Human
Services shall sanction the | 19 | | recipient solely on the basis of
her substance abuse.
| 20 | | The Illinois Department shall establish such regulations | 21 | | governing
the dispensing of health services under this Article | 22 | | as it shall deem
appropriate. The Department
should
seek the | 23 | | advice of formal professional advisory committees appointed by
| 24 | | the Director of the Illinois Department for the purpose of | 25 | | providing regular
advice on policy and administrative matters, | 26 | | information dissemination and
educational activities for |
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| 1 | | medical and health care providers, and
consistency in | 2 | | procedures to the Illinois Department.
| 3 | | The Illinois Department may develop and contract with | 4 | | Partnerships of
medical providers to arrange medical services | 5 | | for persons eligible under
Section 5-2 of this Code. | 6 | | Implementation of this Section may be by
demonstration projects | 7 | | in certain geographic areas. The Partnership shall
be | 8 | | represented by a sponsor organization. The Department, by rule, | 9 | | shall
develop qualifications for sponsors of Partnerships. | 10 | | Nothing in this
Section shall be construed to require that the | 11 | | sponsor organization be a
medical organization.
| 12 | | The sponsor must negotiate formal written contracts with | 13 | | medical
providers for physician services, inpatient and | 14 | | outpatient hospital care,
home health services, treatment for | 15 | | alcoholism and substance abuse, and
other services determined | 16 | | necessary by the Illinois Department by rule for
delivery by | 17 | | Partnerships. Physician services must include prenatal and
| 18 | | obstetrical care. The Illinois Department shall reimburse | 19 | | medical services
delivered by Partnership providers to clients | 20 | | in target areas according to
provisions of this Article and the | 21 | | Illinois Health Finance Reform Act,
except that:
| 22 | | (1) Physicians participating in a Partnership and | 23 | | providing certain
services, which shall be determined by | 24 | | the Illinois Department, to persons
in areas covered by the | 25 | | Partnership may receive an additional surcharge
for such | 26 | | services.
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| 1 | | (2) The Department may elect to consider and negotiate | 2 | | financial
incentives to encourage the development of | 3 | | Partnerships and the efficient
delivery of medical care.
| 4 | | (3) Persons receiving medical services through | 5 | | Partnerships may receive
medical and case management | 6 | | services above the level usually offered
through the | 7 | | medical assistance program.
| 8 | | Medical providers shall be required to meet certain | 9 | | qualifications to
participate in Partnerships to ensure the | 10 | | delivery of high quality medical
services. These | 11 | | qualifications shall be determined by rule of the Illinois
| 12 | | Department and may be higher than qualifications for | 13 | | participation in the
medical assistance program. Partnership | 14 | | sponsors may prescribe reasonable
additional qualifications | 15 | | for participation by medical providers, only with
the prior | 16 | | written approval of the Illinois Department.
| 17 | | Nothing in this Section shall limit the free choice of | 18 | | practitioners,
hospitals, and other providers of medical | 19 | | services by clients.
In order to ensure patient freedom of | 20 | | choice, the Illinois Department shall
immediately promulgate | 21 | | all rules and take all other necessary actions so that
provided | 22 | | services may be accessed from therapeutically certified | 23 | | optometrists
to the full extent of the Illinois Optometric | 24 | | Practice Act of 1987 without
discriminating between service | 25 | | providers.
| 26 | | The Department shall apply for a waiver from the United |
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| 1 | | States Health
Care Financing Administration to allow for the | 2 | | implementation of
Partnerships under this Section.
| 3 | | The Illinois Department shall require health care | 4 | | providers to maintain
records that document the medical care | 5 | | and services provided to recipients
of Medical Assistance under | 6 | | this Article. Such records must be retained for a period of not | 7 | | less than 6 years from the date of service or as provided by | 8 | | applicable State law, whichever period is longer, except that | 9 | | if an audit is initiated within the required retention period | 10 | | then the records must be retained until the audit is completed | 11 | | and every exception is resolved. The Illinois Department shall
| 12 | | require health care providers to make available, when | 13 | | authorized by the
patient, in writing, the medical records in a | 14 | | timely fashion to other
health care providers who are treating | 15 | | or serving persons eligible for
Medical Assistance under this | 16 | | Article. All dispensers of medical services
shall be required | 17 | | to maintain and retain business and professional records
| 18 | | sufficient to fully and accurately document the nature, scope, | 19 | | details and
receipt of the health care provided to persons | 20 | | eligible for medical
assistance under this Code, in accordance | 21 | | with regulations promulgated by
the Illinois Department. The | 22 | | rules and regulations shall require that proof
of the receipt | 23 | | of prescription drugs, dentures, prosthetic devices and
| 24 | | eyeglasses by eligible persons under this Section accompany | 25 | | each claim
for reimbursement submitted by the dispenser of such | 26 | | medical services.
No such claims for reimbursement shall be |
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| 1 | | approved for payment by the Illinois
Department without such | 2 | | proof of receipt, unless the Illinois Department
shall have put | 3 | | into effect and shall be operating a system of post-payment
| 4 | | audit and review which shall, on a sampling basis, be deemed | 5 | | adequate by
the Illinois Department to assure that such drugs, | 6 | | dentures, prosthetic
devices and eyeglasses for which payment | 7 | | is being made are actually being
received by eligible | 8 | | recipients. Within 90 days after September 16, 1984 (the | 9 | | effective date of Public Act 83-1439), the Illinois Department | 10 | | shall establish a
current list of acquisition costs for all | 11 | | prosthetic devices and any
other items recognized as medical | 12 | | equipment and supplies reimbursable under
this Article and | 13 | | shall update such list on a quarterly basis, except that
the | 14 | | acquisition costs of all prescription drugs shall be updated no
| 15 | | less frequently than every 30 days as required by Section | 16 | | 5-5.12.
| 17 | | Notwithstanding any other law to the contrary, the Illinois | 18 | | Department shall, within 365 days after July 22, 2013 (the | 19 | | effective date of Public Act 98-104), establish procedures to | 20 | | permit skilled care facilities licensed under the Nursing Home | 21 | | Care Act to submit monthly billing claims for reimbursement | 22 | | purposes. Following development of these procedures, the | 23 | | Department shall, by July 1, 2016, test the viability of the | 24 | | new system and implement any necessary operational or | 25 | | structural changes to its information technology platforms in | 26 | | order to allow for the direct acceptance and payment of nursing |
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| 1 | | home claims. | 2 | | Notwithstanding any other law to the contrary, the Illinois | 3 | | Department shall, within 365 days after August 15, 2014 (the | 4 | | effective date of Public Act 98-963), establish procedures to | 5 | | permit ID/DD facilities licensed under the ID/DD Community Care | 6 | | Act and MC/DD facilities licensed under the MC/DD Act to submit | 7 | | monthly billing claims for reimbursement purposes. Following | 8 | | development of these procedures, the Department shall have an | 9 | | additional 365 days to test the viability of the new system and | 10 | | to ensure that any necessary operational or structural changes | 11 | | to its information technology platforms are implemented. | 12 | | The Illinois Department shall require all dispensers of | 13 | | medical
services, other than an individual practitioner or | 14 | | group of practitioners,
desiring to participate in the Medical | 15 | | Assistance program
established under this Article to disclose | 16 | | all financial, beneficial,
ownership, equity, surety or other | 17 | | interests in any and all firms,
corporations, partnerships, | 18 | | associations, business enterprises, joint
ventures, agencies, | 19 | | institutions or other legal entities providing any
form of | 20 | | health care services in this State under this Article.
| 21 | | The Illinois Department may require that all dispensers of | 22 | | medical
services desiring to participate in the medical | 23 | | assistance program
established under this Article disclose, | 24 | | under such terms and conditions as
the Illinois Department may | 25 | | by rule establish, all inquiries from clients
and attorneys | 26 | | regarding medical bills paid by the Illinois Department, which
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| 1 | | inquiries could indicate potential existence of claims or liens | 2 | | for the
Illinois Department.
| 3 | | Enrollment of a vendor
shall be
subject to a provisional | 4 | | period and shall be conditional for one year. During the period | 5 | | of conditional enrollment, the Department may
terminate the | 6 | | vendor's eligibility to participate in, or may disenroll the | 7 | | vendor from, the medical assistance
program without cause. | 8 | | Unless otherwise specified, such termination of eligibility or | 9 | | disenrollment is not subject to the
Department's hearing | 10 | | process.
However, a disenrolled vendor may reapply without | 11 | | penalty.
| 12 | | The Department has the discretion to limit the conditional | 13 | | enrollment period for vendors based upon category of risk of | 14 | | the vendor. | 15 | | Prior to enrollment and during the conditional enrollment | 16 | | period in the medical assistance program, all vendors shall be | 17 | | subject to enhanced oversight, screening, and review based on | 18 | | the risk of fraud, waste, and abuse that is posed by the | 19 | | category of risk of the vendor. The Illinois Department shall | 20 | | establish the procedures for oversight, screening, and review, | 21 | | which may include, but need not be limited to: criminal and | 22 | | financial background checks; fingerprinting; license, | 23 | | certification, and authorization verifications; unscheduled or | 24 | | unannounced site visits; database checks; prepayment audit | 25 | | reviews; audits; payment caps; payment suspensions; and other | 26 | | screening as required by federal or State law. |
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| 1 | | The Department shall define or specify the following: (i) | 2 | | by provider notice, the "category of risk of the vendor" for | 3 | | each type of vendor, which shall take into account the level of | 4 | | screening applicable to a particular category of vendor under | 5 | | federal law and regulations; (ii) by rule or provider notice, | 6 | | the maximum length of the conditional enrollment period for | 7 | | each category of risk of the vendor; and (iii) by rule, the | 8 | | hearing rights, if any, afforded to a vendor in each category | 9 | | of risk of the vendor that is terminated or disenrolled during | 10 | | the conditional enrollment period. | 11 | | To be eligible for payment consideration, a vendor's | 12 | | payment claim or bill, either as an initial claim or as a | 13 | | resubmitted claim following prior rejection, must be received | 14 | | by the Illinois Department, or its fiscal intermediary, no | 15 | | later than 180 days after the latest date on the claim on which | 16 | | medical goods or services were provided, with the following | 17 | | exceptions: | 18 | | (1) In the case of a provider whose enrollment is in | 19 | | process by the Illinois Department, the 180-day period | 20 | | shall not begin until the date on the written notice from | 21 | | the Illinois Department that the provider enrollment is | 22 | | complete. | 23 | | (2) In the case of errors attributable to the Illinois | 24 | | Department or any of its claims processing intermediaries | 25 | | which result in an inability to receive, process, or | 26 | | adjudicate a claim, the 180-day period shall not begin |
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| 1 | | until the provider has been notified of the error. | 2 | | (3) In the case of a provider for whom the Illinois | 3 | | Department initiates the monthly billing process. | 4 | | (4) In the case of a provider operated by a unit of | 5 | | local government with a population exceeding 3,000,000 | 6 | | when local government funds finance federal participation | 7 | | for claims payments. | 8 | | For claims for services rendered during a period for which | 9 | | a recipient received retroactive eligibility, claims must be | 10 | | filed within 180 days after the Department determines the | 11 | | applicant is eligible. For claims for which the Illinois | 12 | | Department is not the primary payer, claims must be submitted | 13 | | to the Illinois Department within 180 days after the final | 14 | | adjudication by the primary payer. | 15 | | In the case of long term care facilities, within 45 | 16 | | calendar days of receipt by the facility of required | 17 | | prescreening information, new admissions with associated | 18 | | admission documents shall be submitted through the Medical | 19 | | Electronic Data Interchange (MEDI) or the Recipient | 20 | | Eligibility Verification (REV) System or shall be submitted | 21 | | directly to the Department of Human Services using required | 22 | | admission forms. Effective September
1, 2014, admission | 23 | | documents, including all prescreening
information, must be | 24 | | submitted through MEDI or REV. Confirmation numbers assigned to | 25 | | an accepted transaction shall be retained by a facility to | 26 | | verify timely submittal. Once an admission transaction has been |
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| 1 | | completed, all resubmitted claims following prior rejection | 2 | | are subject to receipt no later than 180 days after the | 3 | | admission transaction has been completed. | 4 | | Claims that are not submitted and received in compliance | 5 | | with the foregoing requirements shall not be eligible for | 6 | | payment under the medical assistance program, and the State | 7 | | shall have no liability for payment of those claims. | 8 | | To the extent consistent with applicable information and | 9 | | privacy, security, and disclosure laws, State and federal | 10 | | agencies and departments shall provide the Illinois Department | 11 | | access to confidential and other information and data necessary | 12 | | to perform eligibility and payment verifications and other | 13 | | Illinois Department functions. This includes, but is not | 14 | | limited to: information pertaining to licensure; | 15 | | certification; earnings; immigration status; citizenship; wage | 16 | | reporting; unearned and earned income; pension income; | 17 | | employment; supplemental security income; social security | 18 | | numbers; National Provider Identifier (NPI) numbers; the | 19 | | National Practitioner Data Bank (NPDB); program and agency | 20 | | exclusions; taxpayer identification numbers; tax delinquency; | 21 | | corporate information; and death records. | 22 | | The Illinois Department shall enter into agreements with | 23 | | State agencies and departments, and is authorized to enter into | 24 | | agreements with federal agencies and departments, under which | 25 | | such agencies and departments shall share data necessary for | 26 | | medical assistance program integrity functions and oversight. |
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| 1 | | The Illinois Department shall develop, in cooperation with | 2 | | other State departments and agencies, and in compliance with | 3 | | applicable federal laws and regulations, appropriate and | 4 | | effective methods to share such data. At a minimum, and to the | 5 | | extent necessary to provide data sharing, the Illinois | 6 | | Department shall enter into agreements with State agencies and | 7 | | departments, and is authorized to enter into agreements with | 8 | | federal agencies and departments, including but not limited to: | 9 | | the Secretary of State; the Department of Revenue; the | 10 | | Department of Public Health; the Department of Human Services; | 11 | | and the Department of Financial and Professional Regulation. | 12 | | Beginning in fiscal year 2013, the Illinois Department | 13 | | shall set forth a request for information to identify the | 14 | | benefits of a pre-payment, post-adjudication, and post-edit | 15 | | claims system with the goals of streamlining claims processing | 16 | | and provider reimbursement, reducing the number of pending or | 17 | | rejected claims, and helping to ensure a more transparent | 18 | | adjudication process through the utilization of: (i) provider | 19 | | data verification and provider screening technology; and (ii) | 20 | | clinical code editing; and (iii) pre-pay, pre- or | 21 | | post-adjudicated predictive modeling with an integrated case | 22 | | management system with link analysis. Such a request for | 23 | | information shall not be considered as a request for proposal | 24 | | or as an obligation on the part of the Illinois Department to | 25 | | take any action or acquire any products or services. | 26 | | The Illinois Department shall establish policies, |
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| 1 | | procedures,
standards and criteria by rule for the acquisition, | 2 | | repair and replacement
of orthotic and prosthetic devices and | 3 | | durable medical equipment. Such
rules shall provide, but not be | 4 | | limited to, the following services: (1)
immediate repair or | 5 | | replacement of such devices by recipients; and (2) rental, | 6 | | lease, purchase or lease-purchase of
durable medical equipment | 7 | | in a cost-effective manner, taking into
consideration the | 8 | | recipient's medical prognosis, the extent of the
recipient's | 9 | | needs, and the requirements and costs for maintaining such
| 10 | | equipment. Subject to prior approval, such rules shall enable a | 11 | | recipient to temporarily acquire and
use alternative or | 12 | | substitute devices or equipment pending repairs or
| 13 | | replacements of any device or equipment previously authorized | 14 | | for such
recipient by the Department. Notwithstanding any | 15 | | provision of Section 5-5f to the contrary, the Department may, | 16 | | by rule, exempt certain replacement wheelchair parts from prior | 17 | | approval and, for wheelchairs, wheelchair parts, wheelchair | 18 | | accessories, and related seating and positioning items, | 19 | | determine the wholesale price by methods other than actual | 20 | | acquisition costs. | 21 | | The Department shall require, by rule, all providers of | 22 | | durable medical equipment to be accredited by an accreditation | 23 | | organization approved by the federal Centers for Medicare and | 24 | | Medicaid Services and recognized by the Department in order to | 25 | | bill the Department for providing durable medical equipment to | 26 | | recipients. No later than 15 months after the effective date of |
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| 1 | | the rule adopted pursuant to this paragraph, all providers must | 2 | | meet the accreditation requirement.
| 3 | | The Department shall execute, relative to the nursing home | 4 | | prescreening
project, written inter-agency agreements with the | 5 | | Department of Human
Services and the Department on Aging, to | 6 | | effect the following: (i) intake
procedures and common | 7 | | eligibility criteria for those persons who are receiving
| 8 | | non-institutional services; and (ii) the establishment and | 9 | | development of
non-institutional services in areas of the State | 10 | | where they are not currently
available or are undeveloped; and | 11 | | (iii) notwithstanding any other provision of law, subject to | 12 | | federal approval, on and after July 1, 2012, an increase in the | 13 | | determination of need (DON) scores from 29 to 37 for applicants | 14 | | for institutional and home and community-based long term care; | 15 | | if and only if federal approval is not granted, the Department | 16 | | may, in conjunction with other affected agencies, implement | 17 | | utilization controls or changes in benefit packages to | 18 | | effectuate a similar savings amount for this population; and | 19 | | (iv) no later than July 1, 2013, minimum level of care | 20 | | eligibility criteria for institutional and home and | 21 | | community-based long term care; and (v) no later than October | 22 | | 1, 2013, establish procedures to permit long term care | 23 | | providers access to eligibility scores for individuals with an | 24 | | admission date who are seeking or receiving services from the | 25 | | long term care provider. In order to select the minimum level | 26 | | of care eligibility criteria, the Governor shall establish a |
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| 1 | | workgroup that includes affected agency representatives and | 2 | | stakeholders representing the institutional and home and | 3 | | community-based long term care interests. This Section shall | 4 | | not restrict the Department from implementing lower level of | 5 | | care eligibility criteria for community-based services in | 6 | | circumstances where federal approval has been granted.
| 7 | | The Illinois Department shall develop and operate, in | 8 | | cooperation
with other State Departments and agencies and in | 9 | | compliance with
applicable federal laws and regulations, | 10 | | appropriate and effective
systems of health care evaluation and | 11 | | programs for monitoring of
utilization of health care services | 12 | | and facilities, as it affects
persons eligible for medical | 13 | | assistance under this Code.
| 14 | | The Illinois Department shall report annually to the | 15 | | General Assembly,
no later than the second Friday in April of | 16 | | 1979 and each year
thereafter, in regard to:
| 17 | | (a) actual statistics and trends in utilization of | 18 | | medical services by
public aid recipients;
| 19 | | (b) actual statistics and trends in the provision of | 20 | | the various medical
services by medical vendors;
| 21 | | (c) current rate structures and proposed changes in | 22 | | those rate structures
for the various medical vendors; and
| 23 | | (d) efforts at utilization review and control by the | 24 | | Illinois Department.
| 25 | | The period covered by each report shall be the 3 years | 26 | | ending on the June
30 prior to the report. The report shall |
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| 1 | | include suggested legislation
for consideration by the General | 2 | | Assembly. The filing of one copy of the
report with the | 3 | | Speaker, one copy with the Minority Leader and one copy
with | 4 | | the Clerk of the House of Representatives, one copy with the | 5 | | President,
one copy with the Minority Leader and one copy with | 6 | | the Secretary of the
Senate, one copy with the Legislative | 7 | | Research Unit, and such additional
copies
with the State | 8 | | Government Report Distribution Center for the General
Assembly | 9 | | as is required under paragraph (t) of Section 7 of the State
| 10 | | Library Act shall be deemed sufficient to comply with this | 11 | | Section.
| 12 | | Rulemaking authority to implement Public Act 95-1045, if | 13 | | any, is conditioned on the rules being adopted in accordance | 14 | | with all provisions of the Illinois Administrative Procedure | 15 | | Act and all rules and procedures of the Joint Committee on | 16 | | Administrative Rules; any purported rule not so adopted, for | 17 | | whatever reason, is unauthorized. | 18 | | On and after July 1, 2012, the Department shall reduce any | 19 | | rate of reimbursement for services or other payments or alter | 20 | | any methodologies authorized by this Code to reduce any rate of | 21 | | reimbursement for services or other payments in accordance with | 22 | | Section 5-5e. | 23 | | Because kidney transplantation can be an appropriate, cost | 24 | | effective
alternative to renal dialysis when medically | 25 | | necessary and notwithstanding the provisions of Section 1-11 of | 26 | | this Code, beginning October 1, 2014, the Department shall |
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| 1 | | cover kidney transplantation for noncitizens with end-stage | 2 | | renal disease who are not eligible for comprehensive medical | 3 | | benefits, who meet the residency requirements of Section 5-3 of | 4 | | this Code, and who would otherwise meet the financial | 5 | | requirements of the appropriate class of eligible persons under | 6 | | Section 5-2 of this Code. To qualify for coverage of kidney | 7 | | transplantation, such person must be receiving emergency renal | 8 | | dialysis services covered by the Department. Providers under | 9 | | this Section shall be prior approved and certified by the | 10 | | Department to perform kidney transplantation and the services | 11 | | under this Section shall be limited to services associated with | 12 | | kidney transplantation. | 13 | | Notwithstanding any other provision of this Code to the | 14 | | contrary, on or after July 1, 2015, all FDA approved forms of | 15 | | medication assisted treatment prescribed for the treatment of | 16 | | alcohol dependence or treatment of opioid dependence shall be | 17 | | covered under both fee for service and managed care medical | 18 | | assistance programs for persons who are otherwise eligible for | 19 | | medical assistance under this Article and shall not be subject | 20 | | to any (1) utilization control, other than those established | 21 | | under the American Society of Addiction Medicine patient | 22 | | placement criteria,
(2) prior authorization mandate, or (3) | 23 | | lifetime restriction limit
mandate. | 24 | | On or after July 1, 2015, opioid antagonists prescribed for | 25 | | the treatment of an opioid overdose, including the medication | 26 | | product, administration devices, and any pharmacy fees related |
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| 1 | | to the dispensing and administration of the opioid antagonist, | 2 | | shall be covered under the medical assistance program for | 3 | | persons who are otherwise eligible for medical assistance under | 4 | | this Article. As used in this Section, "opioid antagonist" | 5 | | means a drug that binds to opioid receptors and blocks or | 6 | | inhibits the effect of opioids acting on those receptors, | 7 | | including, but not limited to, naloxone hydrochloride or any | 8 | | other similarly acting drug approved by the U.S. Food and Drug | 9 | | Administration. | 10 | | Upon federal approval, the Department shall provide | 11 | | coverage and reimbursement for all drugs that are approved for | 12 | | marketing by the federal Food and Drug Administration and that | 13 | | are recommended by the federal Public Health Service or the | 14 | | United States Centers for Disease Control and Prevention for | 15 | | pre-exposure prophylaxis and related pre-exposure prophylaxis | 16 | | services, including, but not limited to, HIV and sexually | 17 | | transmitted infection screening, treatment for sexually | 18 | | transmitted infections, medical monitoring, assorted labs, and | 19 | | counseling to reduce the likelihood of HIV infection among | 20 | | individuals who are not infected with HIV but who are at high | 21 | | risk of HIV infection. | 22 | | Notwithstanding any other law to the contrary, the | 23 | | Department shall not adopt any rule or enter into any contract | 24 | | that prohibits reimbursement under the medical assistance | 25 | | program to an eligible clinic for a dental encounter for | 26 | | services performed by an individual licensed to practice |
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| 1 | | dentistry or dental hygiene under the Illinois Dental Practice | 2 | | Act. | 3 | | (Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15; | 4 | | 99-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for | 5 | | the effective date of P.A. 99-407); 99-433, eff. 8-21-15; | 6 | | 99-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff. | 7 | | 7-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201, | 8 | | eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18; | 9 | | 100-538, eff. 1-1-18; revised 10-26-17.) | 10 | | (305 ILCS 5/5-30) | 11 | | Sec. 5-30. Care coordination. | 12 | | (a) At least 50% of recipients eligible for comprehensive | 13 | | medical benefits in all medical assistance programs or other | 14 | | health benefit programs administered by the Department, | 15 | | including the Children's Health Insurance Program Act and the | 16 | | Covering ALL KIDS Health Insurance Act, shall be enrolled in a | 17 | | care coordination program by no later than January 1, 2015. For | 18 | | purposes of this Section, "coordinated care" or "care | 19 | | coordination" means delivery systems where recipients will | 20 | | receive their care from providers who participate under | 21 | | contract in integrated delivery systems that are responsible | 22 | | for providing or arranging the majority of care, including | 23 | | primary care physician services, referrals from primary care | 24 | | physicians, diagnostic and treatment services, behavioral | 25 | | health services, in-patient and outpatient hospital services, |
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| 1 | | dental services, and rehabilitation and long-term care | 2 | | services. The Department shall designate or contract for such | 3 | | integrated delivery systems (i) to ensure enrollees have a | 4 | | choice of systems and of primary care providers within such | 5 | | systems; (ii) to ensure that enrollees receive quality care in | 6 | | a culturally and linguistically appropriate manner; and (iii) | 7 | | to ensure that coordinated care programs meet the diverse needs | 8 | | of enrollees with developmental, mental health, physical, and | 9 | | age-related disabilities. When the integrated delivery system | 10 | | requires the subcontracting of a dental administrator to | 11 | | provide dental services, care coordination shall include, but | 12 | | not be limited to, providing the dental administrator with the | 13 | | health status of medically compromised enrollees such as | 14 | | pregnant women and diabetic enrollees so that the dental | 15 | | administrator can actively promote and arrange for the | 16 | | enrollees to obtain the necessary dental services. | 17 | | (b) Payment for such coordinated care shall be based on | 18 | | arrangements where the State pays for performance related to | 19 | | health care outcomes, the use of evidence-based practices, the | 20 | | use of primary care delivered through comprehensive medical | 21 | | homes, the use of electronic medical records, and the | 22 | | appropriate exchange of health information electronically made | 23 | | either on a capitated basis in which a fixed monthly premium | 24 | | per recipient is paid and full financial risk is assumed for | 25 | | the delivery of services, or through other risk-based payment | 26 | | arrangements. |
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| 1 | | (c) To qualify for compliance with this Section, the 50% | 2 | | goal shall be achieved by enrolling medical assistance | 3 | | enrollees from each medical assistance enrollment category, | 4 | | including parents, children, seniors, and people with | 5 | | disabilities to the extent that current State Medicaid payment | 6 | | laws would not limit federal matching funds for recipients in | 7 | | care coordination programs. In addition, services must be more | 8 | | comprehensively defined and more risk shall be assumed than in | 9 | | the Department's primary care case management program as of | 10 | | January 25, 2011 (the effective date of Public Act 96-1501). | 11 | | (d) The Department shall report to the General Assembly in | 12 | | a separate part of its annual medical assistance program | 13 | | report, beginning April, 2012 until April, 2016, on the | 14 | | progress and implementation of the care coordination program | 15 | | initiatives established by the provisions of Public Act | 16 | | 96-1501. The Department shall include in its April 2011 report | 17 | | a full analysis of federal laws or regulations regarding upper | 18 | | payment limitations to providers and the necessary revisions or | 19 | | adjustments in rate methodologies and payments to providers | 20 | | under this Code that would be necessary to implement | 21 | | coordinated care with full financial risk by a party other than | 22 | | the Department.
| 23 | | (e) Integrated Care Program for individuals with chronic | 24 | | mental health conditions. | 25 | | (1) The Integrated Care Program shall encompass | 26 | | services administered to recipients of medical assistance |
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| 1 | | under this Article to prevent exacerbations and | 2 | | complications using cost-effective, evidence-based | 3 | | practice guidelines and mental health management | 4 | | strategies. | 5 | | (2) The Department may utilize and expand upon existing | 6 | | contractual arrangements with integrated care plans under | 7 | | the Integrated Care Program for providing the coordinated | 8 | | care provisions of this Section. | 9 | | (3) Payment for such coordinated care shall be based on | 10 | | arrangements where the State pays for performance related | 11 | | to mental health outcomes on a capitated basis in which a | 12 | | fixed monthly premium per recipient is paid and full | 13 | | financial risk is assumed for the delivery of services, or | 14 | | through other risk-based payment arrangements such as | 15 | | provider-based care coordination. | 16 | | (4) The Department shall examine whether chronic | 17 | | mental health management programs and services for | 18 | | recipients with specific chronic mental health conditions | 19 | | do any or all of the following: | 20 | | (A) Improve the patient's overall mental health in | 21 | | a more expeditious and cost-effective manner. | 22 | | (B) Lower costs in other aspects of the medical | 23 | | assistance program, such as hospital admissions, | 24 | | emergency room visits, or more frequent and | 25 | | inappropriate psychotropic drug use. | 26 | | (5) The Department shall work with the facilities and |
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| 1 | | any integrated care plan participating in the program to | 2 | | identify and correct barriers to the successful | 3 | | implementation of this subsection (e) prior to and during | 4 | | the implementation to best facilitate the goals and | 5 | | objectives of this subsection (e). | 6 | | (f) A hospital that is located in a county of the State in | 7 | | which the Department mandates some or all of the beneficiaries | 8 | | of the Medical Assistance Program residing in the county to | 9 | | enroll in a Care Coordination Program, as set forth in Section | 10 | | 5-30 of this Code, shall not be eligible for any non-claims | 11 | | based payments not mandated by Article V-A of this Code for | 12 | | which it would otherwise be qualified to receive, unless the | 13 | | hospital is a Coordinated Care Participating Hospital no later | 14 | | than 60 days after June 14, 2012 (the effective date of Public | 15 | | Act 97-689) or 60 days after the first mandatory enrollment of | 16 | | a beneficiary in a Coordinated Care program. For purposes of | 17 | | this subsection, "Coordinated Care Participating Hospital" | 18 | | means a hospital that meets one of the following criteria: | 19 | | (1) The hospital has entered into a contract to provide | 20 | | hospital services with one or more MCOs to enrollees of the | 21 | | care coordination program. | 22 | | (2) The hospital has not been offered a contract by a | 23 | | care coordination plan that the Department has determined | 24 | | to be a good faith offer and that pays at least as much as | 25 | | the Department would pay, on a fee-for-service basis, not | 26 | | including disproportionate share hospital adjustment |
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| 1 | | payments or any other supplemental adjustment or add-on | 2 | | payment to the base fee-for-service rate, except to the | 3 | | extent such adjustments or add-on payments are | 4 | | incorporated into the development of the applicable MCO | 5 | | capitated rates. | 6 | | As used in this subsection (f), "MCO" means any entity | 7 | | which contracts with the Department to provide services where | 8 | | payment for medical services is made on a capitated basis. | 9 | | (g) No later than August 1, 2013, the Department shall | 10 | | issue a purchase of care solicitation for Accountable Care | 11 | | Entities (ACE) to serve any children and parents or caretaker | 12 | | relatives of children eligible for medical assistance under | 13 | | this Article. An ACE may be a single corporate structure or a | 14 | | network of providers organized through contractual | 15 | | relationships with a single corporate entity. The solicitation | 16 | | shall require that: | 17 | | (1) An ACE operating in Cook County be capable of | 18 | | serving at least 40,000 eligible individuals in that | 19 | | county; an ACE operating in Lake, Kane, DuPage, or Will | 20 | | Counties be capable of serving at least 20,000 eligible | 21 | | individuals in those counties and an ACE operating in other | 22 | | regions of the State be capable of serving at least 10,000 | 23 | | eligible individuals in the region in which it operates. | 24 | | During initial periods of mandatory enrollment, the | 25 | | Department shall require its enrollment services | 26 | | contractor to use a default assignment algorithm that |
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| 1 | | ensures if possible an ACE reaches the minimum enrollment | 2 | | levels set forth in this paragraph. | 3 | | (2) An ACE must include at a minimum the following | 4 | | types of providers: primary care, specialty care, | 5 | | hospitals, and behavioral healthcare. | 6 | | (3) An ACE shall have a governance structure that | 7 | | includes the major components of the health care delivery | 8 | | system, including one representative from each of the | 9 | | groups listed in paragraph (2). | 10 | | (4) An ACE must be an integrated delivery system, | 11 | | including a network able to provide the full range of | 12 | | services needed by Medicaid beneficiaries and system | 13 | | capacity to securely pass clinical information across | 14 | | participating entities and to aggregate and analyze that | 15 | | data in order to coordinate care. | 16 | | (5) An ACE must be capable of providing both care | 17 | | coordination and complex case management, as necessary, to | 18 | | beneficiaries. To be responsive to the solicitation, a | 19 | | potential ACE must outline its care coordination and | 20 | | complex case management model and plan to reduce the cost | 21 | | of care. | 22 | | (6) In the first 18 months of operation, unless the ACE | 23 | | selects a shorter period, an ACE shall be paid care | 24 | | coordination fees on a per member per month basis that are | 25 | | projected to be cost neutral to the State during the term | 26 | | of their payment and, subject to federal approval, be |
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| 1 | | eligible to share in additional savings generated by their | 2 | | care coordination. | 3 | | (7) In months 19 through 36 of operation, unless the | 4 | | ACE selects a shorter period, an ACE shall be paid on a | 5 | | pre-paid capitation basis for all medical assistance | 6 | | covered services, under contract terms similar to Managed | 7 | | Care Organizations (MCO), with the Department sharing the | 8 | | risk through either stop-loss insurance for extremely high | 9 | | cost individuals or corridors of shared risk based on the | 10 | | overall cost of the total enrollment in the ACE. The ACE | 11 | | shall be responsible for claims processing, encounter data | 12 | | submission, utilization control, and quality assurance. | 13 | | (8) In the fourth and subsequent years of operation, an | 14 | | ACE shall convert to a Managed Care Community Network | 15 | | (MCCN), as defined in this Article, or Health Maintenance | 16 | | Organization pursuant to the Illinois Insurance Code, | 17 | | accepting full-risk capitation payments. | 18 | | The Department shall allow potential ACE entities 5 months | 19 | | from the date of the posting of the solicitation to submit | 20 | | proposals. After the solicitation is released, in addition to | 21 | | the MCO rate development data available on the Department's | 22 | | website, subject to federal and State confidentiality and | 23 | | privacy laws and regulations, the Department shall provide 2 | 24 | | years of de-identified summary service data on the targeted | 25 | | population, split between children and adults, showing the | 26 | | historical type and volume of services received and the cost of |
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| 1 | | those services to those potential bidders that sign a data use | 2 | | agreement. The Department may add up to 2 non-state government | 3 | | employees with expertise in creating integrated delivery | 4 | | systems to its review team for the purchase of care | 5 | | solicitation described in this subsection. Any such | 6 | | individuals must sign a no-conflict disclosure and | 7 | | confidentiality agreement and agree to act in accordance with | 8 | | all applicable State laws. | 9 | | During the first 2 years of an ACE's operation, the | 10 | | Department shall provide claims data to the ACE on its | 11 | | enrollees on a periodic basis no less frequently than monthly. | 12 | | Nothing in this subsection shall be construed to limit the | 13 | | Department's mandate to enroll 50% of its beneficiaries into | 14 | | care coordination systems by January 1, 2015, using all | 15 | | available care coordination delivery systems, including Care | 16 | | Coordination Entities (CCE), MCCNs, or MCOs, nor be construed | 17 | | to affect the current CCEs, MCCNs, and MCOs selected to serve | 18 | | seniors and persons with disabilities prior to that date. | 19 | | Nothing in this subsection precludes the Department from | 20 | | considering future proposals for new ACEs or expansion of | 21 | | existing ACEs at the discretion of the Department. | 22 | | (h) Department contracts with MCOs and other entities | 23 | | reimbursed by risk based capitation shall have a minimum | 24 | | medical loss ratio of 85%, shall require the entity to | 25 | | establish an appeals and grievances process for consumers and | 26 | | providers, and shall require the entity to provide a quality |
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| 1 | | assurance and utilization review program. Entities contracted | 2 | | with the Department to coordinate healthcare regardless of risk | 3 | | shall be measured utilizing the same quality metrics. The | 4 | | quality metrics may be population specific. Any contracted | 5 | | entity serving at least 5,000 seniors or people with | 6 | | disabilities or 15,000 individuals in other populations | 7 | | covered by the Medical Assistance Program that has been | 8 | | receiving full-risk capitation for a year shall be accredited | 9 | | by a national accreditation organization authorized by the | 10 | | Department within 2 years after the date it is eligible to | 11 | | become accredited. The requirements of this subsection shall | 12 | | apply to contracts with MCOs entered into or renewed or | 13 | | extended after June 1, 2013. | 14 | | (h-5) The Department shall monitor and enforce compliance | 15 | | by MCOs with agreements they have entered into with providers | 16 | | on issues that include, but are not limited to, timeliness of | 17 | | payment, payment rates, and processes for obtaining prior | 18 | | approval. The Department may impose sanctions on MCOs for | 19 | | violating provisions of those agreements that include, but are | 20 | | not limited to, financial penalties, suspension of enrollment | 21 | | of new enrollees, and termination of the MCO's contract with | 22 | | the Department. As used in this subsection (h-5), "MCO" has the | 23 | | meaning ascribed to that term in Section 5-30.1 of this Code. | 24 | | (h-6) With respect to the managed care organizations and | 25 | | their subcontracted dental administrator's provider agreements | 26 | | with dentists, the level of reimbursement to dentists for |
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| 1 | | providing dental services shall be equal to at least the | 2 | | fee-for-service dental program administered by the Department. | 3 | | (i) Unless otherwise required by federal law, Medicaid | 4 | | Managed Care Entities and their respective business associates | 5 | | shall not disclose, directly or indirectly, including by | 6 | | sending a bill or explanation of benefits, information | 7 | | concerning the sensitive health services received by enrollees | 8 | | of the Medicaid Managed Care Entity to any person other than | 9 | | covered entities and business associates, which may receive, | 10 | | use, and further disclose such information solely for the | 11 | | purposes permitted under applicable federal and State laws and | 12 | | regulations if such use and further disclosure satisfies all | 13 | | applicable requirements of such laws and regulations. The | 14 | | Medicaid Managed Care Entity or its respective business | 15 | | associates may disclose information concerning the sensitive | 16 | | health services if the enrollee who received the sensitive | 17 | | health services requests the information from the Medicaid | 18 | | Managed Care Entity or its respective business associates and | 19 | | authorized the sending of a bill or explanation of benefits. | 20 | | Communications including, but not limited to, statements of | 21 | | care received or appointment reminders either directly or | 22 | | indirectly to the enrollee from the health care provider, | 23 | | health care professional, and care coordinators, remain | 24 | | permissible. Medicaid Managed Care Entities or their | 25 | | respective business associates may communicate directly with | 26 | | their enrollees regarding care coordination activities for |
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| 1 | | those enrollees. | 2 | | For the purposes of this subsection, the term "Medicaid | 3 | | Managed Care Entity" includes Care Coordination Entities, | 4 | | Accountable Care Entities, Managed Care Organizations, and | 5 | | Managed Care Community Networks. | 6 | | For purposes of this subsection, the term "sensitive health | 7 | | services" means mental health services, substance abuse | 8 | | treatment services, reproductive health services, family | 9 | | planning services, services for sexually transmitted | 10 | | infections and sexually transmitted diseases, and services for | 11 | | sexual assault or domestic abuse. Services include prevention, | 12 | | screening, consultation, examination, treatment, or follow-up. | 13 | | For purposes of this subsection, "business associate", | 14 | | "covered entity", "disclosure", and "use" have the meanings | 15 | | ascribed to those terms in 45 CFR 160.103. | 16 | | Nothing in this subsection shall be construed to relieve a | 17 | | Medicaid Managed Care Entity or the Department of any duty to | 18 | | report incidents of sexually transmitted infections to the | 19 | | Department of Public Health or to the local board of health in | 20 | | accordance with regulations adopted under a statute or | 21 | | ordinance or to report incidents of sexually transmitted | 22 | | infections as necessary to comply with the requirements under | 23 | | Section 5 of the Abused and Neglected Child Reporting Act or as | 24 | | otherwise required by State or federal law. | 25 | | The Department shall create policy in order to implement | 26 | | the requirements in this subsection. |
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| 1 | | (j) Managed Care Entities (MCEs), including MCOs and all | 2 | | other care coordination organizations, shall develop and | 3 | | maintain a written language access policy that sets forth the | 4 | | standards, guidelines, and operational plan to ensure language | 5 | | appropriate services and that is consistent with the standard | 6 | | of meaningful access for populations with limited English | 7 | | proficiency. The language access policy shall describe how the | 8 | | MCEs will provide all of the following required services: | 9 | | (1) Translation (the written replacement of text from | 10 | | one language into another) of all vital documents and forms | 11 | | as identified by the Department. | 12 | | (2) Qualified interpreter services (the oral | 13 | | communication of a message from one language into another | 14 | | by a qualified interpreter). | 15 | | (3) Staff training on the language access policy, | 16 | | including how to identify language needs, access and | 17 | | provide language assistance services, work with | 18 | | interpreters, request translations, and track the use of | 19 | | language assistance services. | 20 | | (4) Data tracking that identifies the language need. | 21 | | (5) Notification to participants on the availability | 22 | | of language access services and on how to access such | 23 | | services. | 24 | | (k) The Department shall actively monitor the contractual | 25 | | relationship between Managed Care Organizations (MCOs) and any | 26 | | dental administrator contracted by an MCO to provide dental |
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| 1 | | services. The Department shall adopt appropriate dental | 2 | | Healthcare Effectiveness Data and Information Set measures or | 3 | | other dental quality performance measures as part of its | 4 | | monitoring and shall include additional specific dental | 5 | | performance measurers in its Health Plan Comparison Tool and | 6 | | Illinois Medicaid Plan Report Card that is available on the | 7 | | Department's website for enrolled individuals. | 8 | | The Department shall collect from each MCO specific | 9 | | information about the types of contracted, broad-based care | 10 | | coordination occurring between the MCO and any dental | 11 | | administrator, including, but not limited to, pregnant women | 12 | | and diabetic patients in need of oral care. | 13 | | (l) No health plan or its subcontractors by contract, | 14 | | written policy, or procedure shall contain any clause | 15 | | attempting to limit the right of medical assistance recipients | 16 | | under any medical assistance program administered by the | 17 | | Department to obtain dental services from any qualified | 18 | | Medicaid provider who undertakes to provide those services. | 19 | | (m) Notwithstanding any other law to the contrary, the | 20 | | Department shall not adopt any rule or enter into any contract | 21 | | that prohibits reimbursement under the medical assistance | 22 | | program to an eligible clinic for a dental encounter for | 23 | | services performed by an individual licensed to practice | 24 | | dentistry or dental hygiene under the Illinois Dental Practice | 25 | | Act. | 26 | | (Source: P.A. 98-104, eff. 7-22-13; 98-651, eff. 6-16-14; |
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| 1 | | 99-106, eff. 1-1-16; 99-181, eff. 7-29-15; 99-566, eff. 1-1-17; | 2 | | 99-642, eff. 7-28-16 .)
| 3 | | Section 99. Effective date. This Act takes effect upon | 4 | | becoming law.".
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