Illinois General Assembly - Full Text of SB3048
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Full Text of SB3048  100th General Assembly


Rep. Kelly M. Cassidy

Filed: 5/21/2018





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2    AMENDMENT NO. ______. Amend Senate Bill 3048 by replacing
3everything after the enacting clause with the following:
4    "Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5 as follows:
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    Sec. 5-5. Medical services. The Illinois Department, by
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing home,
16or elsewhere; (6) medical care, or any other type of remedial



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



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1in Section 1a of the Sexual Assault Survivors Emergency
2Treatment Act, for injuries sustained as a result of the sexual
3assault, including examinations and laboratory tests to
4discover evidence which may be used in criminal proceedings
5arising from the sexual assault; (16) the diagnosis and
6treatment of sickle cell anemia; and (17) any other medical
7care, and any other type of remedial care recognized under the
8laws of this State. The term "any other type of remedial care"
9shall include nursing care and nursing home service for persons
10who rely on treatment by spiritual means alone through prayer
11for healing.
12    Notwithstanding any other provision of this Section, a
13comprehensive tobacco use cessation program that includes
14purchasing prescription drugs or prescription medical devices
15approved by the Food and Drug Administration shall be covered
16under the medical assistance program under this Article for
17persons who are otherwise eligible for assistance under this
19    Notwithstanding any other provision of this Code,
20reproductive health care that is otherwise legal in Illinois
21shall be covered under the medical assistance program for
22persons who are otherwise eligible for medical assistance under
23this Article.
24    Notwithstanding any other provision of this Code, the
25Illinois Department may not require, as a condition of payment
26for any laboratory test authorized under this Article, that a



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



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



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



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1    All screenings shall include a physical breast exam,
2instruction on self-examination and information regarding the
3frequency of self-examination and its value as a preventative
4tool. For purposes of this Section, "low-dose mammography"
5means the x-ray examination of the breast using equipment
6dedicated specifically for mammography, including the x-ray
7tube, filter, compression device, and image receptor, with an
8average radiation exposure delivery of less than one rad per
9breast for 2 views of an average size breast. The term also
10includes digital mammography and includes breast
11tomosynthesis. As used in this Section, the term "breast
12tomosynthesis" means a radiologic procedure that involves the
13acquisition of projection images over the stationary breast to
14produce cross-sectional digital three-dimensional images of
15the breast. If, at any time, the Secretary of the United States
16Department of Health and Human Services, or its successor
17agency, promulgates rules or regulations to be published in the
18Federal Register or publishes a comment in the Federal Register
19or issues an opinion, guidance, or other action that would
20require the State, pursuant to any provision of the Patient
21Protection and Affordable Care Act (Public Law 111-148),
22including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
23successor provision, to defray the cost of any coverage for
24breast tomosynthesis outlined in this paragraph, then the
25requirement that an insurer cover breast tomosynthesis is
26inoperative other than any such coverage authorized under



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1Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
2the State shall not assume any obligation for the cost of
3coverage for breast tomosynthesis set forth in this paragraph.
4    On and after January 1, 2016, the Department shall ensure
5that all networks of care for adult clients of the Department
6include access to at least one breast imaging Center of Imaging
7Excellence as certified by the American College of Radiology.
8    On and after January 1, 2012, providers participating in a
9quality improvement program approved by the Department shall be
10reimbursed for screening and diagnostic mammography at the same
11rate as the Medicare program's rates, including the increased
12reimbursement for digital mammography.
13    The Department shall convene an expert panel including
14representatives of hospitals, free-standing mammography
15facilities, and doctors, including radiologists, to establish
16quality standards for mammography.
17    On and after January 1, 2017, providers participating in a
18breast cancer treatment quality improvement program approved
19by the Department shall be reimbursed for breast cancer
20treatment at a rate that is no lower than 95% of the Medicare
21program's rates for the data elements included in the breast
22cancer treatment quality program.
23    The Department shall convene an expert panel, including
24representatives of hospitals, free standing breast cancer
25treatment centers, breast cancer quality organizations, and
26doctors, including breast surgeons, reconstructive breast



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



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1cancer. This program shall initially operate as a pilot program
2in areas of the State with the highest incidence of mortality
3related to breast cancer. At least one pilot program site shall
4be in the metropolitan Chicago area and at least one site shall
5be outside the metropolitan Chicago area. On or after July 1,
62016, the pilot program shall be expanded to include one site
7in western Illinois, one site in southern Illinois, one site in
8central Illinois, and 4 sites within metropolitan Chicago. An
9evaluation of the pilot program shall be carried out measuring
10health outcomes and cost of care for those served by the pilot
11program compared to similarly situated patients who are not
12served by the pilot program.
13    The Department shall require all networks of care to
14develop a means either internally or by contract with experts
15in navigation and community outreach to navigate cancer
16patients to comprehensive care in a timely fashion. The
17Department shall require all networks of care to include access
18for patients diagnosed with cancer to at least one academic
19commission on cancer-accredited cancer program as an
20in-network covered benefit.
21    Any medical or health care provider shall immediately
22recommend, to any pregnant woman who is being provided prenatal
23services and is suspected of drug abuse or is addicted as
24defined in the Alcoholism and Other Drug Abuse and Dependency
25Act, referral to a local substance abuse treatment provider
26licensed by the Department of Human Services or to a licensed



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



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



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



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



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1with regulations promulgated by the Illinois Department. The
2rules and regulations shall require that proof of the receipt
3of prescription drugs, dentures, prosthetic devices and
4eyeglasses by eligible persons under this Section accompany
5each claim for reimbursement submitted by the dispenser of such
6medical services. No such claims for reimbursement shall be
7approved for payment by the Illinois Department without such
8proof of receipt, unless the Illinois Department shall have put
9into effect and shall be operating a system of post-payment
10audit and review which shall, on a sampling basis, be deemed
11adequate by the Illinois Department to assure that such drugs,
12dentures, prosthetic devices and eyeglasses for which payment
13is being made are actually being received by eligible
14recipients. Within 90 days after September 16, 1984 (the
15effective date of Public Act 83-1439), the Illinois Department
16shall establish a current list of acquisition costs for all
17prosthetic devices and any other items recognized as medical
18equipment and supplies reimbursable under this Article and
19shall update such list on a quarterly basis, except that the
20acquisition costs of all prescription drugs shall be updated no
21less frequently than every 30 days as required by Section
23    Notwithstanding any other law to the contrary, the Illinois
24Department shall, within 365 days after July 22, 2013 (the
25effective date of Public Act 98-104), establish procedures to
26permit skilled care facilities licensed under the Nursing Home



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



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



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



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1    the Illinois Department that the provider enrollment is
2    complete.
3        (2) In the case of errors attributable to the Illinois
4    Department or any of its claims processing intermediaries
5    which result in an inability to receive, process, or
6    adjudicate a claim, the 180-day period shall not begin
7    until the provider has been notified of the error.
8        (3) In the case of a provider for whom the Illinois
9    Department initiates the monthly billing process.
10        (4) In the case of a provider operated by a unit of
11    local government with a population exceeding 3,000,000
12    when local government funds finance federal participation
13    for claims payments.
14    For claims for services rendered during a period for which
15a recipient received retroactive eligibility, claims must be
16filed within 180 days after the Department determines the
17applicant is eligible. For claims for which the Illinois
18Department is not the primary payer, claims must be submitted
19to the Illinois Department within 180 days after the final
20adjudication by the primary payer.
21    In the case of long term care facilities, within 45
22calendar days of receipt by the facility of required
23prescreening information, new admissions with associated
24admission documents shall be submitted through the Medical
25Electronic Data Interchange (MEDI) or the Recipient
26Eligibility Verification (REV) System or shall be submitted



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



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



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1post-adjudicated predictive modeling with an integrated case
2management system with link analysis. Such a request for
3information shall not be considered as a request for proposal
4or as an obligation on the part of the Illinois Department to
5take any action or acquire any products or services.
6    The Illinois Department shall establish policies,
7procedures, standards and criteria by rule for the acquisition,
8repair and replacement of orthotic and prosthetic devices and
9durable medical equipment. Such rules shall provide, but not be
10limited to, the following services: (1) immediate repair or
11replacement of such devices by recipients; and (2) rental,
12lease, purchase or lease-purchase of durable medical equipment
13in a cost-effective manner, taking into consideration the
14recipient's medical prognosis, the extent of the recipient's
15needs, and the requirements and costs for maintaining such
16equipment. Subject to prior approval, such rules shall enable a
17recipient to temporarily acquire and use alternative or
18substitute devices or equipment pending repairs or
19replacements of any device or equipment previously authorized
20for such recipient by the Department. Notwithstanding any
21provision of Section 5-5f to the contrary, the Department may,
22by rule, exempt certain replacement wheelchair parts from prior
23approval and, for wheelchairs, wheelchair parts, wheelchair
24accessories, and related seating and positioning items,
25determine the wholesale price by methods other than actual
26acquisition costs.



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1    The Department shall require, by rule, all providers of
2durable medical equipment to be accredited by an accreditation
3organization approved by the federal Centers for Medicare and
4Medicaid Services and recognized by the Department in order to
5bill the Department for providing durable medical equipment to
6recipients. No later than 15 months after the effective date of
7the rule adopted pursuant to this paragraph, all providers must
8meet the accreditation requirement.
9    In order to promote environmental responsibility, meet the
10needs of recipients and enrollees, and achieve significant cost
11savings, the Department, or a managed care organization under
12contract with the Department, may provide recipients or managed
13care enrollees who have a prescription or Certificate of
14Medical Necessity access to refurbished durable medical
15equipment under this Section (excluding prosthetic and
16orthotic devices as defined in the Orthotics, Prosthetics, and
17Pedorthics Practice Act and complex rehabilitation technology
18products and associated services) through the State's
19assistive technology program's reutilization program, using
20staff with the Assistive Technology Professional (ATP)
21Certification if the refurbished durable medical equipment:
22(i) is available; (ii) is less expensive, including shipping
23costs, than new durable medical equipment of the same type;
24(iii) is able to withstand at least 3 years of use; (iv) is
25cleaned, disinfected, sterilized, and safe in accordance with
26federal Food and Drug Administration regulations and guidance



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1governing the reprocessing of medical devices in health care
2settings; and (v) equally meets the needs of the recipient or
3enrollee. The reutilization program shall confirm that the
4recipient or enrollee is not already in receipt of same or
5similar equipment from another service provider, and that the
6refurbished durable medical equipment equally meets the needs
7of the recipient or enrollee. Nothing in this paragraph shall
8be construed to limit recipient or enrollee choice to obtain
9new durable medical equipment or place any additional prior
10authorization conditions on enrollees of managed care
12    The Department shall execute, relative to the nursing home
13prescreening project, written inter-agency agreements with the
14Department of Human Services and the Department on Aging, to
15effect the following: (i) intake procedures and common
16eligibility criteria for those persons who are receiving
17non-institutional services; and (ii) the establishment and
18development of non-institutional services in areas of the State
19where they are not currently available or are undeveloped; and
20(iii) notwithstanding any other provision of law, subject to
21federal approval, on and after July 1, 2012, an increase in the
22determination of need (DON) scores from 29 to 37 for applicants
23for institutional and home and community-based long term care;
24if and only if federal approval is not granted, the Department
25may, in conjunction with other affected agencies, implement
26utilization controls or changes in benefit packages to



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1effectuate a similar savings amount for this population; and
2(iv) no later than July 1, 2013, minimum level of care
3eligibility criteria for institutional and home and
4community-based long term care; and (v) no later than October
51, 2013, establish procedures to permit long term care
6providers access to eligibility scores for individuals with an
7admission date who are seeking or receiving services from the
8long term care provider. In order to select the minimum level
9of care eligibility criteria, the Governor shall establish a
10workgroup that includes affected agency representatives and
11stakeholders representing the institutional and home and
12community-based long term care interests. This Section shall
13not restrict the Department from implementing lower level of
14care eligibility criteria for community-based services in
15circumstances where federal approval has been granted.
16    The Illinois Department shall develop and operate, in
17cooperation with other State Departments and agencies and in
18compliance with applicable federal laws and regulations,
19appropriate and effective systems of health care evaluation and
20programs for monitoring of utilization of health care services
21and facilities, as it affects persons eligible for medical
22assistance under this Code.
23    The Illinois Department shall report annually to the
24General Assembly, no later than the second Friday in April of
251979 and each year thereafter, in regard to:
26        (a) actual statistics and trends in utilization of



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



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



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1assistance programs for persons who are otherwise eligible for
2medical assistance under this Article and shall not be subject
3to any (1) utilization control, other than those established
4under the American Society of Addiction Medicine patient
5placement criteria, (2) prior authorization mandate, or (3)
6lifetime restriction limit mandate.
7    On or after July 1, 2015, opioid antagonists prescribed for
8the treatment of an opioid overdose, including the medication
9product, administration devices, and any pharmacy fees related
10to the dispensing and administration of the opioid antagonist,
11shall be covered under the medical assistance program for
12persons who are otherwise eligible for medical assistance under
13this Article. As used in this Section, "opioid antagonist"
14means a drug that binds to opioid receptors and blocks or
15inhibits the effect of opioids acting on those receptors,
16including, but not limited to, naloxone hydrochloride or any
17other similarly acting drug approved by the U.S. Food and Drug
19    Upon federal approval, the Department shall provide
20coverage and reimbursement for all drugs that are approved for
21marketing by the federal Food and Drug Administration and that
22are recommended by the federal Public Health Service or the
23United States Centers for Disease Control and Prevention for
24pre-exposure prophylaxis and related pre-exposure prophylaxis
25services, including, but not limited to, HIV and sexually
26transmitted infection screening, treatment for sexually



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1transmitted infections, medical monitoring, assorted labs, and
2counseling to reduce the likelihood of HIV infection among
3individuals who are not infected with HIV but who are at high
4risk of HIV infection.
5(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
699-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
7the effective date of P.A. 99-407); 99-433, eff. 8-21-15;
899-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
97-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
10eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
11100-538, eff. 1-1-18; revised 10-26-17.)".