Full Text of SB1040 102nd General Assembly
SB1040sam001 102ND GENERAL ASSEMBLY | Sen. Ann Gillespie Filed: 4/16/2021
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| 1 | | AMENDMENT TO SENATE BILL 1040
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 1040 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 12-4.45 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 | 16 | | home, or elsewhere; (6) medical care, or any
other type of |
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| 1 | | remedial care furnished by licensed practitioners; (7)
home | 2 | | health care services; (8) private duty nursing service; (9) | 3 | | clinic
services; (10) dental services, including prevention | 4 | | and treatment of periodontal disease and dental caries disease | 5 | | for pregnant women, provided by an individual licensed to | 6 | | practice dentistry or dental surgery; for purposes of this | 7 | | item (10), "dental services" means diagnostic, preventive, or | 8 | | corrective procedures provided by or under the supervision of | 9 | | a dentist in the practice of his or her profession; (11) | 10 | | physical therapy and related
services; (12) prescribed drugs, | 11 | | dentures, and prosthetic devices; and
eyeglasses prescribed by | 12 | | a physician skilled in the diseases of the eye,
or by an | 13 | | optometrist, whichever the person may select; (13) other
| 14 | | diagnostic, screening, preventive, and rehabilitative | 15 | | services, including to ensure that the individual's need for | 16 | | intervention or treatment of mental disorders or substance use | 17 | | disorders or co-occurring mental health and substance use | 18 | | disorders is determined using a uniform screening, assessment, | 19 | | and 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 | 3 | | sexual 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 | 10 | | persons who rely on
treatment by spiritual means alone through | 11 | | prayer 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 | 23 | | under 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 | 14 | | under 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 | 24 | | and Family Services may provide the following services to
| 25 | | persons
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 | 6 | | the diseases of the
eye, or by an optometrist, whichever | 7 | | the person may select.
| 8 | | On and after July 1, 2018, the Department of Healthcare | 9 | | and Family Services shall provide dental services to any adult | 10 | | who 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 | 20 | | set forth in Exhibit D of the Consent Decree entered by the | 21 | | United States District Court for the Northern District of | 22 | | Illinois, Eastern Division, in the matter of Memisovski v. | 23 | | Maram, Case No. 92 C 1982, that are provided to adults under | 24 | | the medical assistance program shall be established at no less | 25 | | than the rates set forth in the "New Rate" column in Exhibit D | 26 | | of the Consent Decree for targeted dental services that are |
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| 1 | | provided to persons under the age of 18 under the medical | 2 | | assistance program. | 3 | | Notwithstanding any other provision of this Code and | 4 | | subject to federal approval, the Department may adopt rules to | 5 | | allow a dentist who is volunteering his or her service at no | 6 | | cost to render dental services through an enrolled | 7 | | not-for-profit health clinic without the dentist personally | 8 | | enrolling as a participating provider in the medical | 9 | | assistance program. A not-for-profit health clinic shall | 10 | | include a public health clinic or Federally Qualified Health | 11 | | Center or other enrolled provider, as determined by the | 12 | | Department, through which dental services covered under this | 13 | | Section are performed. The Department shall establish a | 14 | | process for payment of claims for reimbursement for covered | 15 | | dental services rendered under this provision. | 16 | | The Illinois Department, by rule, may distinguish and | 17 | | classify the
medical services to be provided only in | 18 | | accordance with the classes of
persons designated in Section | 19 | | 5-2.
| 20 | | The Department of Healthcare and Family Services must | 21 | | provide coverage and reimbursement for amino acid-based | 22 | | elemental formulas, regardless of delivery method, for the | 23 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 24 | | short bowel syndrome when the prescribing physician has issued | 25 | | a written order stating that the amino acid-based elemental | 26 | | formula is medically necessary.
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| 1 | | The Illinois Department shall authorize the provision of, | 2 | | and shall
authorize payment for, screening by low-dose | 3 | | mammography for the presence of
occult breast cancer for women | 4 | | 35 years of age or older who are eligible
for medical | 5 | | assistance under this Article, as follows: | 6 | | (A) A baseline
mammogram for women 35 to 39 years of | 7 | | age.
| 8 | | (B) An annual mammogram for women 40 years of age or | 9 | | older. | 10 | | (C) A mammogram at the age and intervals considered | 11 | | medically necessary by the woman's health care provider | 12 | | for women under 40 years of age and having a family history | 13 | | of breast cancer, prior personal history of breast cancer, | 14 | | positive genetic testing, or other risk factors. | 15 | | (D) A comprehensive ultrasound screening and MRI of an | 16 | | entire breast or breasts if a mammogram demonstrates | 17 | | heterogeneous or dense breast tissue or when medically | 18 | | necessary as determined by a physician licensed to | 19 | | practice medicine in all of its branches. | 20 | | (E) A screening MRI when medically necessary, as | 21 | | determined by a physician licensed to practice medicine in | 22 | | all of its branches. | 23 | | (F) A diagnostic mammogram when medically necessary, | 24 | | as determined by a physician licensed to practice medicine | 25 | | in all its branches, advanced practice registered nurse, | 26 | | or physician assistant. |
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| 1 | | The Department shall not impose a deductible, coinsurance, | 2 | | copayment, or any other cost-sharing requirement on the | 3 | | coverage provided under this paragraph; except that this | 4 | | sentence does not apply to coverage of diagnostic mammograms | 5 | | to the extent such coverage would disqualify a high-deductible | 6 | | health plan from eligibility for a health savings account | 7 | | pursuant to Section 223 of the Internal Revenue Code (26 | 8 | | U.S.C. 223). | 9 | | All screenings
shall
include a physical breast exam, | 10 | | instruction on self-examination and
information regarding the | 11 | | frequency of self-examination and its value as a
preventative | 12 | | tool. | 13 | | For purposes of this Section: | 14 | | "Diagnostic
mammogram" means a mammogram obtained using | 15 | | diagnostic mammography. | 16 | | "Diagnostic
mammography" means a method of screening that | 17 | | is designed to
evaluate an abnormality in a breast, including | 18 | | an abnormality seen
or suspected on a screening mammogram or a | 19 | | subjective or objective
abnormality otherwise detected in the | 20 | | breast. | 21 | | "Low-dose mammography" means
the x-ray examination of the | 22 | | breast using equipment dedicated specifically
for mammography, | 23 | | including the x-ray tube, filter, compression device,
and | 24 | | image receptor, with an average radiation exposure delivery
of | 25 | | less than one rad per breast for 2 views of an average size | 26 | | breast.
The term also includes digital mammography and |
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| 1 | | includes breast tomosynthesis. | 2 | | "Breast tomosynthesis" means a radiologic procedure that | 3 | | involves the acquisition of projection images over the | 4 | | stationary breast to produce cross-sectional digital | 5 | | three-dimensional images of the breast. | 6 | | If, at any time, the Secretary of the United States | 7 | | Department of Health and Human Services, or its successor | 8 | | agency, promulgates rules or regulations to be published in | 9 | | the Federal Register or publishes a comment in the Federal | 10 | | Register or issues an opinion, guidance, or other action that | 11 | | would require the State, pursuant to any provision of the | 12 | | Patient Protection and Affordable Care Act (Public Law | 13 | | 111-148), including, but not limited to, 42 U.S.C. | 14 | | 18031(d)(3)(B) or any successor provision, to defray the cost | 15 | | of any coverage for breast tomosynthesis outlined in this | 16 | | paragraph, then the requirement that an insurer cover breast | 17 | | tomosynthesis is inoperative other than any such coverage | 18 | | authorized under Section 1902 of the Social Security Act, 42 | 19 | | U.S.C. 1396a, and the State shall not assume any obligation | 20 | | for the cost of coverage for breast tomosynthesis set forth in | 21 | | this paragraph.
| 22 | | On and after January 1, 2016, the Department shall ensure | 23 | | that all networks of care for adult clients of the Department | 24 | | include access to at least one breast imaging Center of | 25 | | Imaging Excellence as certified by the American College of | 26 | | Radiology. |
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| 1 | | On and after January 1, 2012, providers participating in a | 2 | | quality improvement program approved by the Department shall | 3 | | be reimbursed for screening and diagnostic mammography at the | 4 | | same rate as the Medicare program's rates, including the | 5 | | increased reimbursement for digital mammography. | 6 | | The Department shall convene an expert panel including | 7 | | representatives of hospitals, free-standing mammography | 8 | | facilities, and doctors, including radiologists, to establish | 9 | | quality standards for mammography. | 10 | | On and after January 1, 2017, providers participating in a | 11 | | breast cancer treatment quality improvement program approved | 12 | | by the Department shall be reimbursed for breast cancer | 13 | | treatment at a rate that is no lower than 95% of the Medicare | 14 | | program's rates for the data elements included in the breast | 15 | | cancer treatment quality program. | 16 | | The Department shall convene an expert panel, including | 17 | | representatives of hospitals, free-standing breast cancer | 18 | | treatment centers, breast cancer quality organizations, and | 19 | | doctors, including breast surgeons, reconstructive breast | 20 | | surgeons, oncologists, and primary care providers to establish | 21 | | quality standards for breast cancer treatment. | 22 | | Subject to federal approval, the Department shall | 23 | | establish a rate methodology for mammography at federally | 24 | | qualified health centers and other encounter-rate clinics. | 25 | | These clinics or centers may also collaborate with other | 26 | | hospital-based mammography facilities. By January 1, 2016, the |
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| 1 | | Department shall report to the General Assembly on the status | 2 | | of the provision set forth in this paragraph. | 3 | | The Department shall establish a methodology to remind | 4 | | women who are age-appropriate for screening mammography, but | 5 | | who have not received a mammogram within the previous 18 | 6 | | months, of the importance and benefit of screening | 7 | | mammography. The Department shall work with experts in breast | 8 | | cancer outreach and patient navigation to optimize these | 9 | | reminders and shall establish a methodology for evaluating | 10 | | their effectiveness and modifying the methodology based on the | 11 | | evaluation. | 12 | | The Department shall establish a performance goal for | 13 | | primary care providers with respect to their female patients | 14 | | over age 40 receiving an annual mammogram. This performance | 15 | | goal shall be used to provide additional reimbursement in the | 16 | | form of a quality performance bonus to primary care providers | 17 | | who meet that goal. | 18 | | The Department shall devise a means of case-managing or | 19 | | patient navigation for beneficiaries diagnosed with breast | 20 | | cancer. This program shall initially operate as a pilot | 21 | | program in areas of the State with the highest incidence of | 22 | | mortality related to breast cancer. At least one pilot program | 23 | | site shall be in the metropolitan Chicago area and at least one | 24 | | site shall be outside the metropolitan Chicago area. On or | 25 | | after July 1, 2016, the pilot program shall be expanded to | 26 | | include one site in western Illinois, one site in southern |
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| 1 | | Illinois, one site in central Illinois, and 4 sites within | 2 | | metropolitan Chicago. An evaluation of the pilot program shall | 3 | | be carried out measuring health outcomes and cost of care for | 4 | | those served by the pilot program compared to similarly | 5 | | situated patients who are not served by the pilot program. | 6 | | The Department shall require all networks of care to | 7 | | develop a means either internally or by contract with experts | 8 | | in navigation and community outreach to navigate cancer | 9 | | patients to comprehensive care in a timely fashion. The | 10 | | Department shall require all networks of care to include | 11 | | access for patients diagnosed with cancer to at least one | 12 | | academic commission on cancer-accredited cancer program as an | 13 | | in-network covered benefit. | 14 | | Any medical or health care provider shall immediately | 15 | | recommend, to
any pregnant woman who is being provided | 16 | | prenatal services and is suspected
of having a substance use | 17 | | disorder as defined in the Substance Use Disorder Act, | 18 | | referral to a local substance use disorder treatment program | 19 | | licensed by the Department of Human Services or to a licensed
| 20 | | hospital which provides substance abuse treatment services. | 21 | | The Department of Healthcare and Family Services
shall assure | 22 | | coverage for the cost of treatment of the drug abuse or
| 23 | | addiction for pregnant recipients in accordance with the | 24 | | Illinois Medicaid
Program in conjunction with the Department | 25 | | of Human Services.
| 26 | | All medical providers providing medical assistance to |
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| 1 | | pregnant women
under this Code shall receive information from | 2 | | the Department on the
availability of services under any
| 3 | | program providing case management services for addicted women,
| 4 | | including information on appropriate referrals for other | 5 | | social services
that may be needed by addicted women in | 6 | | addition to treatment for addiction.
| 7 | | The Illinois Department, in cooperation with the | 8 | | Departments of Human
Services (as successor to the Department | 9 | | of Alcoholism and Substance
Abuse) and Public Health, through | 10 | | a public awareness campaign, may
provide information | 11 | | concerning treatment for alcoholism and drug abuse and
| 12 | | addiction, prenatal health care, and other pertinent programs | 13 | | directed at
reducing the number of drug-affected infants born | 14 | | to recipients of medical
assistance.
| 15 | | Neither the Department of Healthcare and Family Services | 16 | | nor the Department of Human
Services shall sanction the | 17 | | recipient solely on the basis of
her substance abuse.
| 18 | | The Illinois Department shall establish such regulations | 19 | | governing
the dispensing of health services under this Article | 20 | | as it shall deem
appropriate. The Department
should
seek the | 21 | | advice of formal professional advisory committees appointed by
| 22 | | the Director of the Illinois Department for the purpose of | 23 | | providing regular
advice on policy and administrative matters, | 24 | | information dissemination and
educational activities for | 25 | | medical and health care providers, and
consistency in | 26 | | procedures to the Illinois Department.
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| 1 | | The Illinois Department may develop and contract with | 2 | | Partnerships of
medical providers to arrange medical services | 3 | | for persons eligible under
Section 5-2 of this Code. | 4 | | Implementation of this Section may be by
demonstration | 5 | | projects in certain geographic areas. The Partnership shall
be | 6 | | represented by a sponsor organization. The Department, by | 7 | | rule, shall
develop qualifications for sponsors of | 8 | | Partnerships. Nothing in this
Section shall be construed to | 9 | | require that the sponsor organization be a
medical | 10 | | organization.
| 11 | | The sponsor must negotiate formal written contracts with | 12 | | medical
providers for physician services, inpatient and | 13 | | outpatient hospital care,
home health services, treatment for | 14 | | alcoholism and substance abuse, and
other services determined | 15 | | necessary by the Illinois Department by rule for
delivery by | 16 | | Partnerships. Physician services must include prenatal and
| 17 | | obstetrical care. The Illinois Department shall reimburse | 18 | | medical services
delivered by Partnership providers to clients | 19 | | in target areas according to
provisions of this Article and | 20 | | the Illinois Health Finance Reform Act,
except that:
| 21 | | (1) Physicians participating in a Partnership and | 22 | | providing certain
services, which shall be determined by | 23 | | the Illinois Department, to persons
in areas covered by | 24 | | the Partnership may receive an additional surcharge
for | 25 | | such services.
| 26 | | (2) The Department may elect to consider and negotiate |
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| 1 | | financial
incentives to encourage the development of | 2 | | Partnerships and the efficient
delivery of medical care.
| 3 | | (3) Persons receiving medical services through | 4 | | Partnerships may receive
medical and case management | 5 | | services above the level usually offered
through the | 6 | | medical assistance program.
| 7 | | Medical providers shall be required to meet certain | 8 | | qualifications to
participate in Partnerships to ensure the | 9 | | delivery of high quality medical
services. These | 10 | | qualifications shall be determined by rule of the Illinois
| 11 | | Department and may be higher than qualifications for | 12 | | participation in the
medical assistance program. Partnership | 13 | | sponsors may prescribe reasonable
additional qualifications | 14 | | for participation by medical providers, only with
the prior | 15 | | written approval of the Illinois Department.
| 16 | | Nothing in this Section shall limit the free choice of | 17 | | practitioners,
hospitals, and other providers of medical | 18 | | services by clients.
In order to ensure patient freedom of | 19 | | choice, the Illinois Department shall
immediately promulgate | 20 | | all rules and take all other necessary actions so that
| 21 | | provided services may be accessed from therapeutically | 22 | | certified optometrists
to the full extent of the Illinois | 23 | | Optometric Practice Act of 1987 without
discriminating between | 24 | | service providers.
| 25 | | The Department shall apply for a waiver from the United | 26 | | States Health
Care Financing Administration to allow for the |
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| 1 | | implementation of
Partnerships under this Section.
| 2 | | The Illinois Department shall require health care | 3 | | providers to maintain
records that document the medical care | 4 | | and services provided to recipients
of Medical Assistance | 5 | | under this Article. Such records must be retained for a period | 6 | | of not less than 6 years from the date of service or as | 7 | | provided by applicable State law, whichever period is longer, | 8 | | except that if an audit is initiated within the required | 9 | | retention period then the records must be retained until the | 10 | | audit is completed and every exception is resolved. The | 11 | | Illinois Department shall
require health care providers to | 12 | | make available, when authorized by the
patient, in writing, | 13 | | the medical records in a timely fashion to other
health care | 14 | | providers who are treating or serving persons eligible for
| 15 | | Medical Assistance under this Article. All dispensers of | 16 | | medical services
shall be required to maintain and retain | 17 | | business and professional records
sufficient to fully and | 18 | | accurately document the nature, scope, details and
receipt of | 19 | | the health care provided to persons eligible for medical
| 20 | | assistance under this Code, in accordance with regulations | 21 | | promulgated by
the Illinois Department. The rules and | 22 | | regulations shall require that proof
of the receipt of | 23 | | 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 | 26 | | such medical services.
No such claims for reimbursement shall |
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| 1 | | be approved for payment by the Illinois
Department without | 2 | | such proof of receipt, unless the Illinois Department
shall | 3 | | have put into effect and shall be operating a system of | 4 | | post-payment
audit and review which shall, on a sampling | 5 | | basis, be deemed adequate by
the Illinois Department to assure | 6 | | that such drugs, dentures, prosthetic
devices and eyeglasses | 7 | | for which payment is being made are actually being
received by | 8 | | eligible recipients. Within 90 days after September 16, 1984 | 9 | | (the effective date of Public Act 83-1439), the Illinois | 10 | | Department shall establish a
current list of acquisition costs | 11 | | for all prosthetic devices and any
other items recognized as | 12 | | medical equipment and supplies reimbursable under
this Article | 13 | | and shall update such list on a quarterly basis, except that
| 14 | | the acquisition costs of all prescription drugs shall be | 15 | | updated no
less frequently than every 30 days as required by | 16 | | Section 5-5.12.
| 17 | | Notwithstanding any other law to the contrary, the | 18 | | Illinois Department shall, within 365 days after July 22, 2013 | 19 | | (the effective date of Public Act 98-104), establish | 20 | | procedures to permit skilled care facilities licensed under | 21 | | the Nursing Home Care Act to submit monthly billing claims for | 22 | | reimbursement purposes. Following development of these | 23 | | procedures, the Department shall, by July 1, 2016, test the | 24 | | viability of the new system and implement any necessary | 25 | | operational or structural changes to its information | 26 | | technology platforms in order to allow for the direct |
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| 1 | | acceptance and payment of nursing home claims. | 2 | | Notwithstanding any other law to the contrary, the | 3 | | Illinois Department shall, within 365 days after August 15, | 4 | | 2014 (the effective date of Public Act 98-963), establish | 5 | | procedures to permit ID/DD facilities licensed under the ID/DD | 6 | | Community Care Act and MC/DD facilities licensed under the | 7 | | MC/DD Act to submit monthly billing claims for reimbursement | 8 | | purposes. Following development of these procedures, the | 9 | | Department shall have an additional 365 days to test the | 10 | | viability of the new system and to ensure that any necessary | 11 | | operational or structural changes to its information | 12 | | technology platforms are implemented. | 13 | | The Illinois Department shall require all dispensers of | 14 | | medical
services, other than an individual practitioner or | 15 | | group of practitioners,
desiring to participate in the Medical | 16 | | Assistance program
established under this Article to disclose | 17 | | all financial, beneficial,
ownership, equity, surety or other | 18 | | interests in any and all firms,
corporations, partnerships, | 19 | | associations, business enterprises, joint
ventures, agencies, | 20 | | institutions or other legal entities providing any
form of | 21 | | health care services in this State under this Article.
| 22 | | The Illinois Department may require that all dispensers of | 23 | | medical
services desiring to participate in the medical | 24 | | assistance program
established under this Article disclose, | 25 | | under such terms and conditions as
the Illinois Department may | 26 | | by rule establish, all inquiries from clients
and attorneys |
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| 1 | | regarding medical bills paid by the Illinois Department, which
| 2 | | inquiries could indicate potential existence of claims or | 3 | | liens for the
Illinois Department.
| 4 | | Enrollment of a vendor
shall be
subject to a provisional | 5 | | period and shall be conditional for one year. During the | 6 | | period of conditional enrollment, the Department may
terminate | 7 | | the vendor's eligibility to participate in, or may disenroll | 8 | | the vendor from, the medical assistance
program without cause. | 9 | | Unless otherwise specified, such termination of eligibility or | 10 | | disenrollment is not subject to the
Department's hearing | 11 | | process.
However, a disenrolled vendor may reapply without | 12 | | penalty.
| 13 | | The Department has the discretion to limit the conditional | 14 | | enrollment period for vendors based upon category of risk of | 15 | | the vendor. | 16 | | Prior to enrollment and during the conditional enrollment | 17 | | period in the medical assistance program, all vendors shall be | 18 | | subject to enhanced oversight, screening, and review based on | 19 | | the risk of fraud, waste, and abuse that is posed by the | 20 | | category of risk of the vendor. The Illinois Department shall | 21 | | establish the procedures for oversight, screening, and review, | 22 | | which may include, but need not be limited to: criminal and | 23 | | financial background checks; fingerprinting; license, | 24 | | certification, and authorization verifications; unscheduled or | 25 | | unannounced site visits; database checks; prepayment audit | 26 | | reviews; audits; payment caps; payment suspensions; and other |
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| 1 | | screening as required by federal or State law. | 2 | | The Department shall define or specify the following: (i) | 3 | | by provider notice, the "category of risk of the vendor" for | 4 | | each type of vendor, which shall take into account the level of | 5 | | screening applicable to a particular category of vendor under | 6 | | federal law and regulations; (ii) by rule or provider notice, | 7 | | the maximum length of the conditional enrollment period for | 8 | | each category of risk of the vendor; and (iii) by rule, the | 9 | | hearing rights, if any, afforded to a vendor in each category | 10 | | of risk of the vendor that is terminated or disenrolled during | 11 | | the conditional enrollment period. | 12 | | To be eligible for payment consideration, a vendor's | 13 | | payment claim or bill, either as an initial claim or as a | 14 | | resubmitted claim following prior rejection, must be received | 15 | | by the Illinois Department, or its fiscal intermediary, no | 16 | | later than 180 days after the latest date on the claim on which | 17 | | medical goods or services were provided, with the following | 18 | | exceptions: | 19 | | (1) In the case of a provider whose enrollment is in | 20 | | process by the Illinois Department, the 180-day period | 21 | | shall not begin until the date on the written notice from | 22 | | the Illinois Department that the provider enrollment is | 23 | | complete. | 24 | | (2) In the case of errors attributable to the Illinois | 25 | | Department or any of its claims processing intermediaries | 26 | | which result in an inability to receive, process, or |
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| 1 | | adjudicate a claim, the 180-day period shall not begin | 2 | | until the provider has been notified of the error. | 3 | | (3) In the case of a provider for whom the Illinois | 4 | | Department initiates the monthly billing process. | 5 | | (4) In the case of a provider operated by a unit of | 6 | | local government with a population exceeding 3,000,000 | 7 | | when local government funds finance federal participation | 8 | | for claims payments. | 9 | | (5) In cases established by Department rule or | 10 | | provider notice. | 11 | | For claims for services rendered during a period for which | 12 | | a recipient received retroactive eligibility, claims must be | 13 | | filed within 180 days after the Department determines the | 14 | | applicant is eligible. For claims for which the Illinois | 15 | | Department is not the primary payer, claims must be submitted | 16 | | to the Illinois Department within 180 days after the final | 17 | | adjudication by the primary payer. | 18 | | In the case of long term care facilities, within 45 | 19 | | calendar days of receipt by the facility of required | 20 | | prescreening information, new admissions with associated | 21 | | admission documents shall be submitted through the Medical | 22 | | Electronic Data Interchange (MEDI) or the Recipient | 23 | | Eligibility Verification (REV) System or shall be submitted | 24 | | directly to the Department of Human Services using required | 25 | | admission forms. Effective September
1, 2014, admission | 26 | | documents, including all prescreening
information, must be |
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| 1 | | submitted through MEDI or REV. Confirmation numbers assigned | 2 | | to an accepted transaction shall be retained by a facility to | 3 | | verify timely submittal. Once an admission transaction has | 4 | | been completed, all resubmitted claims following prior | 5 | | rejection are subject to receipt no later than 180 days after | 6 | | the admission transaction has been completed. | 7 | | Claims that are not submitted and received in compliance | 8 | | with the foregoing requirements shall not be eligible for | 9 | | payment under the medical assistance program, and the State | 10 | | shall have no liability for payment of those claims. | 11 | | To the extent consistent with applicable information and | 12 | | privacy, security, and disclosure laws, State and federal | 13 | | agencies and departments shall provide the Illinois Department | 14 | | access to confidential and other information and data | 15 | | necessary to perform eligibility and payment verifications and | 16 | | other Illinois Department functions. This includes, but is not | 17 | | limited to: information pertaining to licensure; | 18 | | certification; earnings; immigration status; citizenship; wage | 19 | | reporting; unearned and earned income; pension income; | 20 | | employment; supplemental security income; social security | 21 | | numbers; National Provider Identifier (NPI) numbers; the | 22 | | National Practitioner Data Bank (NPDB); program and agency | 23 | | exclusions; taxpayer identification numbers; tax delinquency; | 24 | | corporate information; and death records. | 25 | | The Illinois Department shall enter into agreements with | 26 | | State agencies and departments, and is authorized to enter |
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| 1 | | into agreements with federal agencies and departments, under | 2 | | which such agencies and departments shall share data necessary | 3 | | for medical assistance program integrity functions and | 4 | | oversight. The Illinois Department shall develop, in | 5 | | cooperation with other State departments and agencies, and in | 6 | | compliance with applicable federal laws and regulations, | 7 | | appropriate and effective methods to share such data. At a | 8 | | minimum, and to the extent necessary to provide data sharing, | 9 | | the Illinois Department shall enter into agreements with State | 10 | | agencies and departments, and is authorized to enter into | 11 | | agreements with federal agencies and departments, including , | 12 | | but not limited to: the Secretary of State; the Department of | 13 | | Revenue; the Department of Public Health; the Department of | 14 | | Human Services; and the Department of Financial and | 15 | | Professional Regulation. | 16 | | Beginning in fiscal year 2013, the Illinois Department | 17 | | shall set forth a request for information to identify the | 18 | | benefits of a pre-payment, post-adjudication, and post-edit | 19 | | claims system with the goals of streamlining claims processing | 20 | | and provider reimbursement, reducing the number of pending or | 21 | | rejected claims, and helping to ensure a more transparent | 22 | | adjudication process through the utilization of: (i) provider | 23 | | data verification and provider screening technology; and (ii) | 24 | | clinical code editing; and (iii) pre-pay, pre- or | 25 | | post-adjudicated predictive modeling with an integrated case | 26 | | management system with link analysis. Such a request for |
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| 1 | | information shall not be considered as a request for proposal | 2 | | or as an obligation on the part of the Illinois Department to | 3 | | take any action or acquire any products or services. | 4 | | The Illinois Department shall establish policies, | 5 | | procedures,
standards and criteria by rule for the | 6 | | acquisition, repair and replacement
of orthotic and prosthetic | 7 | | devices and durable medical equipment. Such
rules shall | 8 | | provide, but not be limited to, the following services: (1)
| 9 | | immediate repair or replacement of such devices by recipients; | 10 | | and (2) rental, lease, purchase or lease-purchase of
durable | 11 | | medical equipment in a cost-effective manner, taking into
| 12 | | consideration the recipient's medical prognosis, the extent of | 13 | | the
recipient's needs, and the requirements and costs for | 14 | | maintaining such
equipment. Subject to prior approval, such | 15 | | rules shall enable a recipient to temporarily acquire and
use | 16 | | alternative or substitute devices or equipment pending repairs | 17 | | or
replacements of any device or equipment previously | 18 | | authorized for such
recipient by the Department. | 19 | | Notwithstanding any provision of Section 5-5f to the contrary, | 20 | | the Department may, by rule, exempt certain replacement | 21 | | wheelchair parts from prior approval and, for wheelchairs, | 22 | | wheelchair parts, wheelchair accessories, and related seating | 23 | | and positioning items, determine the wholesale price by | 24 | | methods other than actual acquisition costs. | 25 | | The Department shall require, by rule, all providers of | 26 | | durable medical equipment to be accredited by an accreditation |
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| 1 | | organization approved by the federal Centers for Medicare and | 2 | | Medicaid Services and recognized by the Department in order to | 3 | | bill the Department for providing durable medical equipment to | 4 | | recipients. No later than 15 months after the effective date | 5 | | of the rule adopted pursuant to this paragraph, all providers | 6 | | must meet the accreditation requirement.
| 7 | | In order to promote environmental responsibility, meet the | 8 | | needs of recipients and enrollees, and achieve significant | 9 | | cost savings, the Department, or a managed care organization | 10 | | under contract with the Department, may provide recipients or | 11 | | managed care enrollees who have a prescription or Certificate | 12 | | of Medical Necessity access to refurbished durable medical | 13 | | equipment under this Section (excluding prosthetic and | 14 | | orthotic devices as defined in the Orthotics, Prosthetics, and | 15 | | Pedorthics Practice Act and complex rehabilitation technology | 16 | | products and associated services) through the State's | 17 | | assistive technology program's reutilization program, using | 18 | | staff with the Assistive Technology Professional (ATP) | 19 | | Certification if the refurbished durable medical equipment: | 20 | | (i) is available; (ii) is less expensive, including shipping | 21 | | costs, than new durable medical equipment of the same type; | 22 | | (iii) is able to withstand at least 3 years of use; (iv) is | 23 | | cleaned, disinfected, sterilized, and safe in accordance with | 24 | | federal Food and Drug Administration regulations and guidance | 25 | | governing the reprocessing of medical devices in health care | 26 | | settings; and (v) equally meets the needs of the recipient or |
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| 1 | | enrollee. The reutilization program shall confirm that the | 2 | | recipient or enrollee is not already in receipt of same or | 3 | | similar equipment from another service provider, and that the | 4 | | refurbished durable medical equipment equally meets the needs | 5 | | of the recipient or enrollee. Nothing in this paragraph shall | 6 | | be construed to limit recipient or enrollee choice to obtain | 7 | | new durable medical equipment or place any additional prior | 8 | | authorization conditions on enrollees of managed care | 9 | | organizations. | 10 | | The Department shall execute, relative to the nursing home | 11 | | prescreening
project, written inter-agency agreements with the | 12 | | Department of Human
Services and the Department on Aging, to | 13 | | effect the following: (i) intake
procedures and common | 14 | | eligibility criteria for those persons who are receiving
| 15 | | non-institutional services; and (ii) the establishment and | 16 | | development of
non-institutional services in areas of the | 17 | | State where they are not currently
available or are | 18 | | undeveloped; and (iii) notwithstanding any other provision of | 19 | | law, subject to federal approval, on and after July 1, 2012, an | 20 | | increase in the determination of need (DON) scores from 29 to | 21 | | 37 for applicants for institutional and home and | 22 | | community-based long term care; if and only if federal | 23 | | approval is not granted, the Department may, in conjunction | 24 | | with other affected agencies, implement utilization controls | 25 | | or changes in benefit packages to effectuate a similar savings | 26 | | amount for this population; and (iv) no later than July 1, |
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| 1 | | 2013, minimum level of care eligibility criteria for | 2 | | institutional and home and community-based long term care; and | 3 | | (v) no later than October 1, 2013, establish procedures to | 4 | | permit long term care providers access to eligibility scores | 5 | | for individuals with an admission date who are seeking or | 6 | | receiving services from the long term care provider. In order | 7 | | to select the minimum level of care eligibility criteria, the | 8 | | Governor shall establish a workgroup that includes affected | 9 | | agency representatives and stakeholders representing the | 10 | | institutional and home and community-based long term care | 11 | | interests. This Section shall not restrict the Department from | 12 | | implementing lower level of care eligibility criteria for | 13 | | community-based services in circumstances where federal | 14 | | approval has been granted.
| 15 | | The Illinois Department shall develop and operate, in | 16 | | cooperation
with other State Departments and agencies and in | 17 | | compliance with
applicable federal laws and regulations, | 18 | | appropriate and effective
systems of health care evaluation | 19 | | and programs for monitoring of
utilization of health care | 20 | | services and facilities, as it affects
persons eligible for | 21 | | medical assistance under this Code.
| 22 | | The Illinois Department shall report annually to the | 23 | | General Assembly,
no later than the second Friday in April of | 24 | | 1979 and each year
thereafter, in regard to:
| 25 | | (a) actual statistics and trends in utilization of | 26 | | medical services by
public aid recipients;
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| 1 | | (b) actual statistics and trends in the provision of | 2 | | the various medical
services by medical vendors;
| 3 | | (c) current rate structures and proposed changes in | 4 | | those rate structures
for the various medical vendors; and
| 5 | | (d) efforts at utilization review and control by the | 6 | | Illinois Department.
| 7 | | The period covered by each report shall be the 3 years | 8 | | ending on the June
30 prior to the report. The report shall | 9 | | include suggested legislation
for consideration by the General | 10 | | Assembly. The requirement for reporting to the General | 11 | | Assembly shall be satisfied
by filing copies of the report as | 12 | | required by Section 3.1 of the General Assembly Organization | 13 | | Act, and filing such additional
copies
with the State | 14 | | Government Report Distribution Center for the General
Assembly | 15 | | as is required under paragraph (t) of Section 7 of the State
| 16 | | Library Act.
| 17 | | Rulemaking authority to implement Public Act 95-1045, if | 18 | | any, is conditioned on the rules being adopted in accordance | 19 | | with all provisions of the Illinois Administrative Procedure | 20 | | Act and all rules and procedures of the Joint Committee on | 21 | | Administrative Rules; any purported rule not so adopted, for | 22 | | whatever reason, is unauthorized. | 23 | | On and after July 1, 2012, the Department shall reduce any | 24 | | rate of reimbursement for services or other payments or alter | 25 | | any methodologies authorized by this Code to reduce any rate | 26 | | of reimbursement for services or other payments in accordance |
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| 1 | | with Section 5-5e. | 2 | | Because kidney transplantation can be an appropriate, | 3 | | cost-effective
alternative to renal dialysis when medically | 4 | | necessary and notwithstanding the provisions of Section 1-11 | 5 | | of this Code, beginning October 1, 2014, the Department shall | 6 | | cover kidney transplantation for noncitizens with end-stage | 7 | | renal disease who are not eligible for comprehensive medical | 8 | | benefits, who meet the residency requirements of Section 5-3 | 9 | | of this Code, and who would otherwise meet the financial | 10 | | requirements of the appropriate class of eligible persons | 11 | | under Section 5-2 of this Code. To qualify for coverage of | 12 | | kidney transplantation, such person must be receiving | 13 | | emergency renal dialysis services covered by the Department. | 14 | | Providers under this Section shall be prior approved and | 15 | | certified by the Department to perform kidney transplantation | 16 | | and the services under this Section shall be limited to | 17 | | services associated with kidney transplantation. | 18 | | Notwithstanding any other provision of this Code to the | 19 | | contrary, on or after July 1, 2015, all FDA approved forms of | 20 | | medication assisted treatment prescribed for the treatment of | 21 | | alcohol dependence or treatment of opioid dependence shall be | 22 | | covered under both fee for service and managed care medical | 23 | | assistance programs for persons who are otherwise eligible for | 24 | | medical assistance under this Article and shall not be subject | 25 | | to any (1) utilization control, other than those established | 26 | | under the American Society of Addiction Medicine patient |
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| 1 | | placement criteria,
(2) prior authorization mandate, or (3) | 2 | | lifetime restriction limit
mandate. | 3 | | On or after July 1, 2015, opioid antagonists prescribed | 4 | | for the treatment of an opioid overdose, including the | 5 | | medication product, administration devices, and any pharmacy | 6 | | fees related to the dispensing and administration of the | 7 | | opioid antagonist, shall be covered under the medical | 8 | | assistance program for persons who are otherwise eligible for | 9 | | medical assistance under this Article. As used in this | 10 | | Section, "opioid antagonist" means a drug that binds to opioid | 11 | | receptors and blocks or inhibits the effect of opioids acting | 12 | | on those receptors, including, but not limited to, naloxone | 13 | | hydrochloride or any other similarly acting drug approved by | 14 | | the U.S. Food and Drug Administration. | 15 | | Upon federal approval, the Department shall provide | 16 | | coverage and reimbursement for all drugs that are approved for | 17 | | marketing by the federal Food and Drug Administration and that | 18 | | are recommended by the federal Public Health Service or the | 19 | | United States Centers for Disease Control and Prevention for | 20 | | pre-exposure prophylaxis and related pre-exposure prophylaxis | 21 | | services, including, but not limited to, HIV and sexually | 22 | | transmitted infection screening, treatment for sexually | 23 | | transmitted infections, medical monitoring, assorted labs, and | 24 | | counseling to reduce the likelihood of HIV infection among | 25 | | individuals who are not infected with HIV but who are at high | 26 | | risk of HIV infection. |
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| 1 | | A federally qualified health center, as defined in Section | 2 | | 1905(l)(2)(B) of the federal
Social Security Act, shall be | 3 | | reimbursed by the Department in accordance with the federally | 4 | | qualified health center's encounter rate for services provided | 5 | | to medical assistance recipients that are performed by a | 6 | | dental hygienist, as defined under the Illinois Dental | 7 | | Practice Act, working under the general supervision of a | 8 | | dentist and employed by a federally qualified health center. | 9 | | (Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18; | 10 | | 100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff. | 11 | | 6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974, | 12 | | eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; | 13 | | 100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff. | 14 | | 1-1-20; revised 9-18-19.) | 15 | | (305 ILCS 5/12-4.45) | 16 | | Sec. 12-4.45. Third party liability. | 17 | | (a) To the extent authorized under federal law, the | 18 | | Department of Healthcare and Family Services shall identify | 19 | | individuals receiving services under medical assistance | 20 | | programs funded or partially funded by the State who may be or | 21 | | may have been covered by a third party health insurer, the | 22 | | period of coverage for such individuals, and the nature of | 23 | | coverage. A company, as defined in Section 5.5 of the Illinois | 24 | | Insurance Code and Section 2 of the Comprehensive Health | 25 | | Insurance Plan Act, must provide the Department eligibility |
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| 1 | | information in a federally recommended or Department | 2 | | prescribed mutually agreed-upon format that includes at a | 3 | | minimum: | 4 | | (1) The names, addresses, dates, and sex of primary | 5 | | covered persons. | 6 | | (2) The policy group numbers of the covered persons. | 7 | | (3) The names, dates of birth, and sex of covered | 8 | | dependents, and the relationship of dependents to the | 9 | | primary covered person. | 10 | | (4) The effective dates of coverage for each covered | 11 | | person. | 12 | | (5) The generally defined covered services | 13 | | information, such as drugs, medical, or any other similar | 14 | | description of services covered. | 15 | | (b) The Department may impose an administrative penalty on | 16 | | a company that does not comply with the request for | 17 | | information made under Section 5.5 of the Illinois Insurance | 18 | | Code and paragraph (3) of subsection (a) of Section 20 of the | 19 | | Covering ALL KIDS Health Insurance Act. The amount of the | 20 | | penalty shall not exceed $10,000 per day for each day of | 21 | | noncompliance that occurs after the 90th day 180th day after | 22 | | the date of the request. The first day of the 90-day 180-day | 23 | | period commences on the business day following the date of the | 24 | | correspondence requesting the information sent by the | 25 | | Department to the company. The amount shall be based on: | 26 | | (1) The seriousness of the violation, including the |
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| 1 | | nature, circumstances, extent, and gravity of the | 2 | | violation. | 3 | | (2) The economic harm caused by the violation. | 4 | | (3) The history of previous violations. | 5 | | (4) The amount necessary to deter a future violation. | 6 | | (5) Efforts to correct the violation. | 7 | | (6) Any other matter that justice may require. | 8 | | (c) The enforcement of the penalty may be stayed during | 9 | | the time the order is under administrative review if the | 10 | | company files an appeal. | 11 | | (d) The Attorney General may bring suit on behalf of the | 12 | | Department to collect the penalty. | 13 | | (e) Recoveries made by the Department in connection with | 14 | | the imposition of an administrative penalty as provided under | 15 | | this Section shall be deposited into the Public Aid Recoveries | 16 | | Trust Fund created under Section 12-9.
| 17 | | (Source: P.A. 98-130, eff. 8-2-13; 98-756, eff. 7-16-14.)
| 18 | | Section 99. Effective date. This Act takes effect upon | 19 | | becoming law, except that the changes to Section 12-4.45 of | 20 | | the Illinois Public Aid Code take effect July 1, 2021.".
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