Full Text of SB3741 103rd General Assembly
SB3741eng 103RD GENERAL ASSEMBLY | | | SB3741 Engrossed | | LRB103 37781 RPS 67910 b |
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| 1 | | AN ACT concerning regulation. | 2 | | Be it enacted by the People of the State of Illinois, | 3 | | represented in the General Assembly: | 4 | | Section 5. The Illinois Insurance Code is amended by | 5 | | changing Section 370c as follows: | 6 | | (215 ILCS 5/370c) (from Ch. 73, par. 982c) | 7 | | Sec. 370c. Mental and emotional disorders. | 8 | | (a)(1) On and after January 1, 2022 (the effective date of | 9 | | Public Act 102-579), every insurer that amends, delivers, | 10 | | issues, or renews group accident and health policies providing | 11 | | coverage for hospital or medical treatment or services for | 12 | | illness on an expense-incurred basis shall provide coverage | 13 | | for the medically necessary treatment of mental, emotional, | 14 | | nervous, or substance use disorders or conditions consistent | 15 | | with the parity requirements of Section 370c.1 of this Code. | 16 | | (2) Each insured that is covered for mental, emotional, | 17 | | nervous, or substance use disorders or conditions shall be | 18 | | free to select the physician licensed to practice medicine in | 19 | | all its branches, licensed clinical psychologist, licensed | 20 | | clinical social worker, licensed clinical professional | 21 | | counselor, licensed marriage and family therapist, licensed | 22 | | speech-language pathologist, or other licensed or certified | 23 | | professional at a program licensed pursuant to the Substance |
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| 1 | | Use Disorder Act of his or her choice to treat such disorders, | 2 | | and the insurer shall pay the covered charges of such | 3 | | physician licensed to practice medicine in all its branches, | 4 | | licensed clinical psychologist, licensed clinical social | 5 | | worker, licensed clinical professional counselor, licensed | 6 | | marriage and family therapist, licensed speech-language | 7 | | pathologist, or other licensed or certified professional at a | 8 | | program licensed pursuant to the Substance Use Disorder Act up | 9 | | to the limits of coverage, provided (i) the disorder or | 10 | | condition treated is covered by the policy, and (ii) the | 11 | | physician, licensed psychologist, licensed clinical social | 12 | | worker, licensed clinical professional counselor, licensed | 13 | | marriage and family therapist, licensed speech-language | 14 | | pathologist, or other licensed or certified professional at a | 15 | | program licensed pursuant to the Substance Use Disorder Act is | 16 | | authorized to provide said services under the statutes of this | 17 | | State and in accordance with accepted principles of his or her | 18 | | profession. | 19 | | (3) Insofar as this Section applies solely to licensed | 20 | | clinical social workers, licensed clinical professional | 21 | | counselors, licensed marriage and family therapists, licensed | 22 | | speech-language pathologists, and other licensed or certified | 23 | | professionals at programs licensed pursuant to the Substance | 24 | | Use Disorder Act, those persons who may provide services to | 25 | | individuals shall do so after the licensed clinical social | 26 | | worker, licensed clinical professional counselor, licensed |
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| 1 | | marriage and family therapist, licensed speech-language | 2 | | pathologist, or other licensed or certified professional at a | 3 | | program licensed pursuant to the Substance Use Disorder Act | 4 | | has informed the patient of the desirability of the patient | 5 | | conferring with the patient's primary care physician. | 6 | | (4) "Mental, emotional, nervous, or substance use disorder | 7 | | or condition" means a condition or disorder that involves a | 8 | | mental health condition or substance use disorder that falls | 9 | | under any of the diagnostic categories listed in the mental | 10 | | and behavioral disorders chapter of the current edition of the | 11 | | World Health Organization's International Classification of | 12 | | Disease or that is listed in the most recent version of the | 13 | | American Psychiatric Association's Diagnostic and Statistical | 14 | | Manual of Mental Disorders. "Mental, emotional, nervous, or | 15 | | substance use disorder or condition" includes any mental | 16 | | health condition that occurs during pregnancy or during the | 17 | | postpartum period and includes, but is not limited to, | 18 | | postpartum depression. | 19 | | (5) Medically necessary treatment and medical necessity | 20 | | determinations shall be interpreted and made in a manner that | 21 | | is consistent with and pursuant to subsections (h) through | 22 | | (t). | 23 | | (b)(1) (Blank). | 24 | | (2) (Blank). | 25 | | (2.5) (Blank). | 26 | | (3) Unless otherwise prohibited by federal law and |
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| 1 | | consistent with the parity requirements of Section 370c.1 of | 2 | | this Code, the reimbursing insurer that amends, delivers, | 3 | | issues, or renews a group or individual policy of accident and | 4 | | health insurance, a qualified health plan offered through the | 5 | | health insurance marketplace, or a provider of treatment of | 6 | | mental, emotional, nervous, or substance use disorders or | 7 | | conditions shall furnish medical records or other necessary | 8 | | data that substantiate that initial or continued treatment is | 9 | | at all times medically necessary. An insurer shall provide a | 10 | | mechanism for the timely review by a provider holding the same | 11 | | license and practicing in the same specialty as the patient's | 12 | | provider, who is unaffiliated with the insurer, jointly | 13 | | selected by the patient (or the patient's next of kin or legal | 14 | | representative if the patient is unable to act for himself or | 15 | | herself), the patient's provider, and the insurer in the event | 16 | | of a dispute between the insurer and patient's provider | 17 | | regarding the medical necessity of a treatment proposed by a | 18 | | patient's provider. If the reviewing provider determines the | 19 | | treatment to be medically necessary, the insurer shall provide | 20 | | reimbursement for the treatment. Future contractual or | 21 | | employment actions by the insurer regarding the patient's | 22 | | provider may not be based on the provider's participation in | 23 | | this procedure. Nothing prevents the insured from agreeing in | 24 | | writing to continue treatment at his or her expense. When | 25 | | making a determination of the medical necessity for a | 26 | | treatment modality for mental, emotional, nervous, or |
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| 1 | | substance use disorders or conditions, an insurer must make | 2 | | the determination in a manner that is consistent with the | 3 | | manner used to make that determination with respect to other | 4 | | diseases or illnesses covered under the policy, including an | 5 | | appeals process. Medical necessity determinations for | 6 | | substance use disorders shall be made in accordance with | 7 | | appropriate patient placement criteria established by the | 8 | | American Society of Addiction Medicine. No additional criteria | 9 | | may be used to make medical necessity determinations for | 10 | | substance use disorders. | 11 | | (4) A group health benefit plan amended, delivered, | 12 | | issued, or renewed on or after January 1, 2019 (the effective | 13 | | date of Public Act 100-1024) or an individual policy of | 14 | | accident and health insurance or a qualified health plan | 15 | | offered through the health insurance marketplace amended, | 16 | | delivered, issued, or renewed on or after January 1, 2019 (the | 17 | | effective date of Public Act 100-1024): | 18 | | (A) shall provide coverage based upon medical | 19 | | necessity for the treatment of a mental, emotional, | 20 | | nervous, or substance use disorder or condition consistent | 21 | | with the parity requirements of Section 370c.1 of this | 22 | | Code; provided, however, that in each calendar year | 23 | | coverage shall not be less than the following: | 24 | | (i) 45 days of inpatient treatment; and | 25 | | (ii) beginning on June 26, 2006 (the effective | 26 | | date of Public Act 94-921), 60 visits for outpatient |
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| 1 | | treatment including group and individual outpatient | 2 | | treatment; and | 3 | | (iii) for plans or policies delivered, issued for | 4 | | delivery, renewed, or modified after January 1, 2007 | 5 | | (the effective date of Public Act 94-906), 20 | 6 | | additional outpatient visits for speech therapy for | 7 | | treatment of pervasive developmental disorders that | 8 | | will be in addition to speech therapy provided | 9 | | pursuant to item (ii) of this subparagraph (A); and | 10 | | (B) may not include a lifetime limit on the number of | 11 | | days of inpatient treatment or the number of outpatient | 12 | | visits covered under the plan. | 13 | | (C) (Blank). | 14 | | (5) An issuer of a group health benefit plan or an | 15 | | individual policy of accident and health insurance or a | 16 | | qualified health plan offered through the health insurance | 17 | | marketplace may not count toward the number of outpatient | 18 | | visits required to be covered under this Section an outpatient | 19 | | visit for the purpose of medication management and shall cover | 20 | | the outpatient visits under the same terms and conditions as | 21 | | it covers outpatient visits for the treatment of physical | 22 | | illness. | 23 | | (5.5) An individual or group health benefit plan amended, | 24 | | delivered, issued, or renewed on or after September 9, 2015 | 25 | | (the effective date of Public Act 99-480) shall offer coverage | 26 | | for medically necessary acute treatment services and medically |
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| 1 | | necessary clinical stabilization services. The treating | 2 | | provider shall base all treatment recommendations and the | 3 | | health benefit plan shall base all medical necessity | 4 | | determinations for substance use disorders in accordance with | 5 | | the most current edition of the Treatment Criteria for | 6 | | Addictive, Substance-Related, and Co-Occurring Conditions | 7 | | established by the American Society of Addiction Medicine. The | 8 | | treating provider shall base all treatment recommendations and | 9 | | the health benefit plan shall base all medical necessity | 10 | | determinations for medication-assisted treatment in accordance | 11 | | with the most current Treatment Criteria for Addictive, | 12 | | Substance-Related, and Co-Occurring Conditions established by | 13 | | the American Society of Addiction Medicine. | 14 | | As used in this subsection: | 15 | | "Acute treatment services" means 24-hour medically | 16 | | supervised addiction treatment that provides evaluation and | 17 | | withdrawal management and may include biopsychosocial | 18 | | assessment, individual and group counseling, psychoeducational | 19 | | groups, and discharge planning. | 20 | | "Clinical stabilization services" means 24-hour treatment, | 21 | | usually following acute treatment services for substance | 22 | | abuse, which may include intensive education and counseling | 23 | | regarding the nature of addiction and its consequences, | 24 | | relapse prevention, outreach to families and significant | 25 | | others, and aftercare planning for individuals beginning to | 26 | | engage in recovery from addiction. |
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| 1 | | (6) An issuer of a group health benefit plan may provide or | 2 | | offer coverage required under this Section through a managed | 3 | | care plan. | 4 | | (6.5) An individual or group health benefit plan amended, | 5 | | delivered, issued, or renewed on or after January 1, 2019 (the | 6 | | effective date of Public Act 100-1024): | 7 | | (A) shall not impose prior authorization requirements, | 8 | | including limitations on dosage, other than those | 9 | | established under the Treatment Criteria for Addictive, | 10 | | Substance-Related, and Co-Occurring Conditions | 11 | | established by the American Society of Addiction Medicine, | 12 | | on a prescription medication approved by the United States | 13 | | Food and Drug Administration that is prescribed or | 14 | | administered for the treatment of substance use disorders; | 15 | | (B) shall not impose any step therapy requirements, | 16 | | other than those established under the Treatment Criteria | 17 | | for Addictive, Substance-Related, and Co-Occurring | 18 | | Conditions established by the American Society of | 19 | | Addiction Medicine, before authorizing coverage for a | 20 | | prescription medication approved by the United States Food | 21 | | and Drug Administration that is prescribed or administered | 22 | | for the treatment of substance use disorders; | 23 | | (C) shall place all prescription medications approved | 24 | | by the United States Food and Drug Administration | 25 | | prescribed or administered for the treatment of substance | 26 | | use disorders on, for brand medications, the lowest tier |
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| 1 | | of the drug formulary developed and maintained by the | 2 | | individual or group health benefit plan that covers brand | 3 | | medications and, for generic medications, the lowest tier | 4 | | of the drug formulary developed and maintained by the | 5 | | individual or group health benefit plan that covers | 6 | | generic medications; and | 7 | | (D) shall not exclude coverage for a prescription | 8 | | medication approved by the United States Food and Drug | 9 | | Administration for the treatment of substance use | 10 | | disorders and any associated counseling or wraparound | 11 | | services on the grounds that such medications and services | 12 | | were court ordered. | 13 | | (7) (Blank). | 14 | | (8) (Blank). | 15 | | (9) With respect to all mental, emotional, nervous, or | 16 | | substance use disorders or conditions, coverage for inpatient | 17 | | treatment shall include coverage for treatment in a | 18 | | residential treatment center certified or licensed by the | 19 | | Department of Public Health or the Department of Human | 20 | | Services. | 21 | | (c) This Section shall not be interpreted to require | 22 | | coverage for speech therapy or other habilitative services for | 23 | | those individuals covered under Section 356z.15 of this Code. | 24 | | (d) With respect to a group or individual policy of | 25 | | accident and health insurance or a qualified health plan | 26 | | offered through the health insurance marketplace, the |
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| 1 | | Department and, with respect to medical assistance, the | 2 | | Department of Healthcare and Family Services shall each | 3 | | enforce the requirements of this Section and Sections 356z.23 | 4 | | and 370c.1 of this Code, the Paul Wellstone and Pete Domenici | 5 | | Mental Health Parity and Addiction Equity Act of 2008, 42 | 6 | | U.S.C. 18031(j), and any amendments to, and federal guidance | 7 | | or regulations issued under, those Acts, including, but not | 8 | | limited to, final regulations issued under the Paul Wellstone | 9 | | and Pete Domenici Mental Health Parity and Addiction Equity | 10 | | Act of 2008 and final regulations applying the Paul Wellstone | 11 | | and Pete Domenici Mental Health Parity and Addiction Equity | 12 | | Act of 2008 to Medicaid managed care organizations, the | 13 | | Children's Health Insurance Program, and alternative benefit | 14 | | plans. Specifically, the Department and the Department of | 15 | | Healthcare and Family Services shall take action: | 16 | | (1) proactively ensuring compliance by individual and | 17 | | group policies, including by requiring that insurers | 18 | | submit comparative analyses, as set forth in paragraph (6) | 19 | | of subsection (k) of Section 370c.1, demonstrating how | 20 | | they design and apply nonquantitative treatment | 21 | | limitations, both as written and in operation, for mental, | 22 | | emotional, nervous, or substance use disorder or condition | 23 | | benefits as compared to how they design and apply | 24 | | nonquantitative treatment limitations, as written and in | 25 | | operation, for medical and surgical benefits; | 26 | | (2) evaluating all consumer or provider complaints |
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| 1 | | regarding mental, emotional, nervous, or substance use | 2 | | disorder or condition coverage for possible parity | 3 | | violations; | 4 | | (3) performing parity compliance market conduct | 5 | | examinations or, in the case of the Department of | 6 | | Healthcare and Family Services, parity compliance audits | 7 | | of individual and group plans and policies, including, but | 8 | | not limited to, reviews of: | 9 | | (A) nonquantitative treatment limitations, | 10 | | including, but not limited to, prior authorization | 11 | | requirements, concurrent review, retrospective review, | 12 | | step therapy, network admission standards, | 13 | | reimbursement rates, and geographic restrictions; | 14 | | (B) denials of authorization, payment, and | 15 | | coverage; and | 16 | | (C) other specific criteria as may be determined | 17 | | by the Department. | 18 | | The findings and the conclusions of the parity compliance | 19 | | market conduct examinations and audits shall be made public. | 20 | | The Director may adopt rules to effectuate any provisions | 21 | | of the Paul Wellstone and Pete Domenici Mental Health Parity | 22 | | and Addiction Equity Act of 2008 that relate to the business of | 23 | | insurance. | 24 | | (e) Availability of plan information. | 25 | | (1) The criteria for medical necessity determinations | 26 | | made under a group health plan, an individual policy of |
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| 1 | | accident and health insurance, or a qualified health plan | 2 | | offered through the health insurance marketplace with | 3 | | respect to mental health or substance use disorder | 4 | | benefits (or health insurance coverage offered in | 5 | | connection with the plan with respect to such benefits) | 6 | | must be made available by the plan administrator (or the | 7 | | health insurance issuer offering such coverage) to any | 8 | | current or potential participant, beneficiary, or | 9 | | contracting provider upon request. | 10 | | (2) The reason for any denial under a group health | 11 | | benefit plan, an individual policy of accident and health | 12 | | insurance, or a qualified health plan offered through the | 13 | | health insurance marketplace (or health insurance coverage | 14 | | offered in connection with such plan or policy) of | 15 | | reimbursement or payment for services with respect to | 16 | | mental, emotional, nervous, or substance use disorders or | 17 | | conditions benefits in the case of any participant or | 18 | | beneficiary must be made available within a reasonable | 19 | | time and in a reasonable manner and in readily | 20 | | understandable language by the plan administrator (or the | 21 | | health insurance issuer offering such coverage) to the | 22 | | participant or beneficiary upon request. | 23 | | (f) As used in this Section, "group policy of accident and | 24 | | health insurance" and "group health benefit plan" includes (1) | 25 | | State-regulated employer-sponsored group health insurance | 26 | | plans written in Illinois or which purport to provide coverage |
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| 1 | | for a resident of this State; and (2) State employee health | 2 | | plans. | 3 | | (g) (1) As used in this subsection: | 4 | | "Benefits", with respect to insurers, means the benefits | 5 | | provided for treatment services for inpatient and outpatient | 6 | | treatment of substance use disorders or conditions at American | 7 | | Society of Addiction Medicine levels of treatment 2.1 | 8 | | (Intensive Outpatient), 2.5 (Partial Hospitalization), 3.1 | 9 | | (Clinically Managed Low-Intensity Residential), 3.3 | 10 | | (Clinically Managed Population-Specific High-Intensity | 11 | | Residential), 3.5 (Clinically Managed High-Intensity | 12 | | Residential), and 3.7 (Medically Monitored Intensive | 13 | | Inpatient) and OMT (Opioid Maintenance Therapy) services. | 14 | | "Benefits", with respect to managed care organizations, | 15 | | means the benefits provided for treatment services for | 16 | | inpatient and outpatient treatment of substance use disorders | 17 | | or conditions at American Society of Addiction Medicine levels | 18 | | of treatment 2.1 (Intensive Outpatient), 2.5 (Partial | 19 | | Hospitalization), 3.5 (Clinically Managed High-Intensity | 20 | | Residential), and 3.7 (Medically Monitored Intensive | 21 | | Inpatient) and OMT (Opioid Maintenance Therapy) services. | 22 | | "Substance use disorder treatment provider or facility" | 23 | | means a licensed physician, licensed psychologist, licensed | 24 | | psychiatrist, licensed advanced practice registered nurse, or | 25 | | licensed, certified, or otherwise State-approved facility or | 26 | | provider of substance use disorder treatment. |
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| 1 | | (2) A group health insurance policy, an individual health | 2 | | benefit plan, or qualified health plan that is offered through | 3 | | the health insurance marketplace, small employer group health | 4 | | plan, and large employer group health plan that is amended, | 5 | | delivered, issued, executed, or renewed in this State, or | 6 | | approved for issuance or renewal in this State, on or after | 7 | | January 1, 2019 (the effective date of Public Act 100-1023) | 8 | | shall comply with the requirements of this Section and Section | 9 | | 370c.1. The services for the treatment and the ongoing | 10 | | assessment of the patient's progress in treatment shall follow | 11 | | the requirements of 77 Ill. Adm. Code 2060. | 12 | | (3) Prior authorization shall not be utilized for the | 13 | | benefits under this subsection. The substance use disorder | 14 | | treatment provider or facility shall notify the insurer of the | 15 | | initiation of treatment. For an insurer that is not a managed | 16 | | care organization, the substance use disorder treatment | 17 | | provider or facility notification shall occur for the | 18 | | initiation of treatment of the covered person within 2 | 19 | | business days. For managed care organizations, the substance | 20 | | use disorder treatment provider or facility notification shall | 21 | | occur in accordance with the protocol set forth in the | 22 | | provider agreement for initiation of treatment within 24 | 23 | | hours. If the managed care organization is not capable of | 24 | | accepting the notification in accordance with the contractual | 25 | | protocol during the 24-hour period following admission, the | 26 | | substance use disorder treatment provider or facility shall |
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| 1 | | have one additional business day to provide the notification | 2 | | to the appropriate managed care organization. Treatment plans | 3 | | shall be developed in accordance with the requirements and | 4 | | timeframes established in 77 Ill. Adm. Code 2060. If the | 5 | | substance use disorder treatment provider or facility fails to | 6 | | notify the insurer of the initiation of treatment in | 7 | | accordance with these provisions, the insurer may follow its | 8 | | normal prior authorization processes. | 9 | | (4) For an insurer that is not a managed care | 10 | | organization, if an insurer determines that benefits are no | 11 | | longer medically necessary, the insurer shall notify the | 12 | | covered person, the covered person's authorized | 13 | | representative, if any, and the covered person's health care | 14 | | provider in writing of the covered person's right to request | 15 | | an external review pursuant to the Health Carrier External | 16 | | Review Act. The notification shall occur within 24 hours | 17 | | following the adverse determination. | 18 | | Pursuant to the requirements of the Health Carrier | 19 | | External Review Act, the covered person or the covered | 20 | | person's authorized representative may request an expedited | 21 | | external review. An expedited external review may not occur if | 22 | | the substance use disorder treatment provider or facility | 23 | | determines that continued treatment is no longer medically | 24 | | necessary. | 25 | | If an expedited external review request meets the criteria | 26 | | of the Health Carrier External Review Act, an independent |
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| 1 | | review organization shall make a final determination of | 2 | | medical necessity within 72 hours. If an independent review | 3 | | organization upholds an adverse determination, an insurer | 4 | | shall remain responsible to provide coverage of benefits | 5 | | through the day following the determination of the independent | 6 | | review organization. A decision to reverse an adverse | 7 | | determination shall comply with the Health Carrier External | 8 | | Review Act. | 9 | | (5) The substance use disorder treatment provider or | 10 | | facility shall provide the insurer with 7 business days' | 11 | | advance notice of the planned discharge of the patient from | 12 | | the substance use disorder treatment provider or facility and | 13 | | notice on the day that the patient is discharged from the | 14 | | substance use disorder treatment provider or facility. | 15 | | (6) The benefits required by this subsection shall be | 16 | | provided to all covered persons with a diagnosis of substance | 17 | | use disorder or conditions. The presence of additional related | 18 | | or unrelated diagnoses shall not be a basis to reduce or deny | 19 | | the benefits required by this subsection. | 20 | | (7) Nothing in this subsection shall be construed to | 21 | | require an insurer to provide coverage for any of the benefits | 22 | | in this subsection. | 23 | | (h) As used in this Section: | 24 | | "Generally accepted standards of mental, emotional, | 25 | | nervous, or substance use disorder or condition care" means | 26 | | standards of care and clinical practice that are generally |
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| 1 | | recognized by health care providers practicing in relevant | 2 | | clinical specialties such as psychiatry, psychology, clinical | 3 | | sociology, social work, addiction medicine and counseling, and | 4 | | behavioral health treatment. Valid, evidence-based sources | 5 | | reflecting generally accepted standards of mental, emotional, | 6 | | nervous, or substance use disorder or condition care include | 7 | | peer-reviewed scientific studies and medical literature, | 8 | | recommendations of nonprofit health care provider professional | 9 | | associations and specialty societies, including, but not | 10 | | limited to, patient placement criteria and clinical practice | 11 | | guidelines, recommendations of federal government agencies, | 12 | | and drug labeling approved by the United States Food and Drug | 13 | | Administration. | 14 | | "Medically necessary treatment of mental, emotional, | 15 | | nervous, or substance use disorders or conditions" means a | 16 | | service or product addressing the specific needs of that | 17 | | patient, for the purpose of screening, preventing, diagnosing, | 18 | | managing, or treating an illness, injury, or condition or its | 19 | | symptoms and comorbidities, including minimizing the | 20 | | progression of an illness, injury, or condition or its | 21 | | symptoms and comorbidities in a manner that is all of the | 22 | | following: | 23 | | (1) in accordance with the generally accepted | 24 | | standards of mental, emotional, nervous, or substance use | 25 | | disorder or condition care; | 26 | | (2) clinically appropriate in terms of type, |
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| 1 | | frequency, extent, site, and duration; and | 2 | | (3) not primarily for the economic benefit of the | 3 | | insurer, purchaser, or for the convenience of the patient, | 4 | | treating physician, or other health care provider. | 5 | | "Utilization review" means either of the following: | 6 | | (1) prospectively, retrospectively, or concurrently | 7 | | reviewing and approving, modifying, delaying, or denying, | 8 | | based in whole or in part on medical necessity, requests | 9 | | by health care providers, insureds, or their authorized | 10 | | representatives for coverage of health care services | 11 | | before, retrospectively, or concurrently with the | 12 | | provision of health care services to insureds. | 13 | | (2) evaluating the medical necessity, appropriateness, | 14 | | level of care, service intensity, efficacy, or efficiency | 15 | | of health care services, benefits, procedures, or | 16 | | settings, under any circumstances, to determine whether a | 17 | | health care service or benefit subject to a medical | 18 | | necessity coverage requirement in an insurance policy is | 19 | | covered as medically necessary for an insured. | 20 | | "Utilization review criteria" means patient placement | 21 | | criteria or any criteria, standards, protocols, or guidelines | 22 | | used by an insurer to conduct utilization review. | 23 | | (i)(1) Every insurer that amends, delivers, issues, or | 24 | | renews a group or individual policy of accident and health | 25 | | insurance or a qualified health plan offered through the | 26 | | health insurance marketplace in this State and Medicaid |
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| 1 | | managed care organizations providing coverage for hospital or | 2 | | medical treatment on or after January 1, 2023 shall, pursuant | 3 | | to subsections (h) through (s), provide coverage for medically | 4 | | necessary treatment of mental, emotional, nervous, or | 5 | | substance use disorders or conditions. | 6 | | (2) An insurer shall not set a specific limit on the | 7 | | duration of benefits or coverage of medically necessary | 8 | | treatment of mental, emotional, nervous, or substance use | 9 | | disorders or conditions or limit coverage only to alleviation | 10 | | of the insured's current symptoms. | 11 | | (3) All medical necessity determinations made by the | 12 | | insurer concerning service intensity, level of care placement, | 13 | | continued stay, and transfer or discharge of insureds | 14 | | diagnosed with mental, emotional, nervous, or substance use | 15 | | disorders or conditions shall be conducted in accordance with | 16 | | the requirements of subsections (k) through (u). | 17 | | (4) An insurer that authorizes a specific type of | 18 | | treatment by a provider pursuant to this Section shall not | 19 | | rescind or modify the authorization after that provider | 20 | | renders the health care service in good faith and pursuant to | 21 | | this authorization for any reason, including, but not limited | 22 | | to, the insurer's subsequent cancellation or modification of | 23 | | the insured's or policyholder's contract, or the insured's or | 24 | | policyholder's eligibility. Nothing in this Section shall | 25 | | require the insurer to cover a treatment when the | 26 | | authorization was granted based on a material |
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| 1 | | misrepresentation by the insured, the policyholder, or the | 2 | | provider. Nothing in this Section shall require Medicaid | 3 | | managed care organizations to pay for services if the | 4 | | individual was not eligible for Medicaid at the time the | 5 | | service was rendered. Nothing in this Section shall require an | 6 | | insurer to pay for services if the individual was not the | 7 | | insurer's enrollee at the time services were rendered. As used | 8 | | in this paragraph, "material" means a fact or situation that | 9 | | is not merely technical in nature and results in or could | 10 | | result in a substantial change in the situation. | 11 | | (j) An insurer shall not limit benefits or coverage for | 12 | | medically necessary services on the basis that those services | 13 | | should be or could be covered by a public entitlement program, | 14 | | including, but not limited to, special education or an | 15 | | individualized education program, Medicaid, Medicare, | 16 | | Supplemental Security Income, or Social Security Disability | 17 | | Insurance, and shall not include or enforce a contract term | 18 | | that excludes otherwise covered benefits on the basis that | 19 | | those services should be or could be covered by a public | 20 | | entitlement program. Nothing in this subsection shall be | 21 | | construed to require an insurer to cover benefits that have | 22 | | been authorized and provided for a covered person by a public | 23 | | entitlement program. Medicaid managed care organizations are | 24 | | not subject to this subsection. | 25 | | (k) An insurer shall base any medical necessity | 26 | | determination or the utilization review criteria that the |
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| 1 | | insurer, and any entity acting on the insurer's behalf, | 2 | | applies to determine the medical necessity of health care | 3 | | services and benefits for the diagnosis, prevention, and | 4 | | treatment of mental, emotional, nervous, or substance use | 5 | | disorders or conditions on current generally accepted | 6 | | standards of mental, emotional, nervous, or substance use | 7 | | disorder or condition care. All denials and appeals shall be | 8 | | reviewed by a professional with experience or expertise | 9 | | comparable to the provider requesting the authorization. | 10 | | (l) For medical necessity determinations relating to level | 11 | | of care placement, continued stay, and transfer or discharge | 12 | | of insureds diagnosed with mental, emotional, and nervous | 13 | | disorders or conditions, an insurer shall apply the patient | 14 | | placement criteria set forth in the most recent version of the | 15 | | treatment criteria developed by an unaffiliated nonprofit | 16 | | professional association for the relevant clinical specialty | 17 | | or, for Medicaid managed care organizations, patient placement | 18 | | criteria determined by the Department of Healthcare and Family | 19 | | Services that are consistent with generally accepted standards | 20 | | of mental, emotional, nervous or substance use disorder or | 21 | | condition care. Pursuant to subsection (b), in conducting | 22 | | utilization review of all covered services and benefits for | 23 | | the diagnosis, prevention, and treatment of substance use | 24 | | disorders an insurer shall use the most recent edition of the | 25 | | patient placement criteria established by the American Society | 26 | | of Addiction Medicine. |
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| 1 | | (m) For medical necessity determinations relating to level | 2 | | of care placement, continued stay, and transfer or discharge | 3 | | that are within the scope of the sources specified in | 4 | | subsection (l), an insurer shall not apply different, | 5 | | additional, conflicting, or more restrictive utilization | 6 | | review criteria than the criteria set forth in those sources. | 7 | | For all level of care placement decisions, the insurer shall | 8 | | authorize placement at the level of care consistent with the | 9 | | assessment of the insured using the relevant patient placement | 10 | | criteria as specified in subsection (l). If that level of | 11 | | placement is not available, the insurer shall authorize the | 12 | | next higher level of care. In the event of disagreement, the | 13 | | insurer shall provide full detail of its assessment using the | 14 | | relevant criteria as specified in subsection (l) to the | 15 | | provider of the service and the patient. | 16 | | Nothing in this subsection or subsection (l) prohibits an | 17 | | insurer from applying utilization review criteria that were | 18 | | developed in accordance with subsection (k) to health care | 19 | | services and benefits for mental, emotional, and nervous | 20 | | disorders or conditions that are not related to medical | 21 | | necessity determinations for level of care placement, | 22 | | continued stay, and transfer or discharge. If an insurer | 23 | | purchases or licenses utilization review criteria pursuant to | 24 | | this subsection, the insurer shall verify and document before | 25 | | use that the criteria were developed in accordance with | 26 | | subsection (k). |
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| 1 | | (n) In conducting utilization review that is outside the | 2 | | scope of the criteria as specified in subsection (l) or | 3 | | relates to the advancements in technology or in the types or | 4 | | levels of care that are not addressed in the most recent | 5 | | versions of the sources specified in subsection (l), an | 6 | | insurer shall conduct utilization review in accordance with | 7 | | subsection (k). | 8 | | (o) This Section does not in any way limit the rights of a | 9 | | patient under the Medical Patient Rights Act. | 10 | | (p) This Section does not in any way limit early and | 11 | | periodic screening, diagnostic, and treatment benefits as | 12 | | defined under 42 U.S.C. 1396d(r). | 13 | | (q) To ensure the proper use of the criteria described in | 14 | | subsection (l), every insurer shall do all of the following: | 15 | | (1) Educate the insurer's staff, including any third | 16 | | parties contracted with the insurer to review claims, | 17 | | conduct utilization reviews, or make medical necessity | 18 | | determinations about the utilization review criteria. | 19 | | (2) Make the educational program available to other | 20 | | stakeholders, including the insurer's participating or | 21 | | contracted providers and potential participants, | 22 | | beneficiaries, or covered lives. The education program | 23 | | must be provided at least once a year, in-person or | 24 | | digitally, or recordings of the education program must be | 25 | | made available to the aforementioned stakeholders. | 26 | | (3) Provide, at no cost, the utilization review |
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| 1 | | criteria and any training material or resources to | 2 | | providers and insured patients upon request. For | 3 | | utilization review criteria not concerning level of care | 4 | | placement, continued stay, and transfer or discharge used | 5 | | by the insurer pursuant to subsection (m), the insurer may | 6 | | place the criteria on a secure, password-protected website | 7 | | so long as the access requirements of the website do not | 8 | | unreasonably restrict access to insureds or their | 9 | | providers. No restrictions shall be placed upon the | 10 | | insured's or treating provider's access right to | 11 | | utilization review criteria obtained under this paragraph | 12 | | at any point in time, including before an initial request | 13 | | for authorization. | 14 | | (4) Track, identify, and analyze how the utilization | 15 | | review criteria are used to certify care, deny care, and | 16 | | support the appeals process. | 17 | | (5) Conduct interrater reliability testing to ensure | 18 | | consistency in utilization review decision making that | 19 | | covers how medical necessity decisions are made; this | 20 | | assessment shall cover all aspects of utilization review | 21 | | as defined in subsection (h). | 22 | | (6) Run interrater reliability reports about how the | 23 | | clinical guidelines are used in conjunction with the | 24 | | utilization review process and parity compliance | 25 | | activities. | 26 | | (7) Achieve interrater reliability pass rates of at |
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| 1 | | least 90% and, if this threshold is not met, immediately | 2 | | provide for the remediation of poor interrater reliability | 3 | | and interrater reliability testing for all new staff | 4 | | before they can conduct utilization review without | 5 | | supervision. | 6 | | (8) Maintain documentation of interrater reliability | 7 | | testing and the remediation actions taken for those with | 8 | | pass rates lower than 90% and submit to the Department of | 9 | | Insurance or, in the case of Medicaid managed care | 10 | | organizations, the Department of Healthcare and Family | 11 | | Services the testing results and a summary of remedial | 12 | | actions as part of parity compliance reporting set forth | 13 | | in subsection (k) of Section 370c.1. | 14 | | (r) This Section applies to all health care services and | 15 | | benefits for the diagnosis, prevention, and treatment of | 16 | | mental, emotional, nervous, or substance use disorders or | 17 | | conditions covered by an insurance policy, including | 18 | | prescription drugs. | 19 | | (s) This Section applies to an insurer that amends, | 20 | | delivers, issues, or renews a group or individual policy of | 21 | | accident and health insurance or a qualified health plan | 22 | | offered through the health insurance marketplace in this State | 23 | | providing coverage for hospital or medical treatment and | 24 | | conducts utilization review as defined in this Section, | 25 | | including Medicaid managed care organizations, and any entity | 26 | | or contracting provider that performs utilization review or |
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| 1 | | utilization management functions on an insurer's behalf. | 2 | | (t) If the Director determines that an insurer has | 3 | | violated this Section, the Director may, after appropriate | 4 | | notice and opportunity for hearing, by order, assess a civil | 5 | | penalty between $1,000 and $5,000 for each violation. Moneys | 6 | | collected from penalties shall be deposited into the Parity | 7 | | Advancement Fund established in subsection (i) of Section | 8 | | 370c.1. | 9 | | (u) An insurer shall not adopt, impose, or enforce terms | 10 | | in its policies or provider agreements, in writing or in | 11 | | operation, that undermine, alter, or conflict with the | 12 | | requirements of this Section. | 13 | | (v) The provisions of this Section are severable. If any | 14 | | provision of this Section or its application is held invalid, | 15 | | that invalidity shall not affect other provisions or | 16 | | applications that can be given effect without the invalid | 17 | | provision or application. | 18 | | (Source: P.A. 102-558, eff. 8-20-21; 102-579, eff. 1-1-22; | 19 | | 102-813, eff. 5-13-22; 103-426, eff. 8-4-23.) | 20 | | Section 10. The Illinois Public Aid Code is amended by | 21 | | changing Section 5-5 as follows: | 22 | | (305 ILCS 5/5-5) | 23 | | Sec. 5-5. Medical services. The Illinois Department, by | 24 | | rule, shall determine the quantity and quality of and the rate |
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| 1 | | of reimbursement for the medical assistance for which payment | 2 | | will be authorized, and the medical services to be provided, | 3 | | which may include all or part of the following: (1) inpatient | 4 | | hospital services; (2) outpatient hospital services; (3) other | 5 | | laboratory and X-ray services; (4) skilled nursing home | 6 | | services; (5) physicians' services whether furnished in the | 7 | | office, the patient's home, a hospital, a skilled nursing | 8 | | home, or elsewhere; (6) medical care, or any other type of | 9 | | remedial care furnished by licensed practitioners; (7) home | 10 | | health care services; (8) private duty nursing service; (9) | 11 | | clinic services; (10) dental services, including prevention | 12 | | and treatment of periodontal disease and dental caries disease | 13 | | for pregnant individuals, provided by an individual licensed | 14 | | to practice dentistry or dental surgery; for purposes of this | 15 | | item (10), "dental services" means diagnostic, preventive, or | 16 | | corrective procedures provided by or under the supervision of | 17 | | a dentist in the practice of his or her profession; (11) | 18 | | physical therapy and related services; (12) prescribed drugs, | 19 | | dentures, and prosthetic devices; and eyeglasses prescribed by | 20 | | a physician skilled in the diseases of the eye, or by an | 21 | | optometrist, whichever the person may select; (13) other | 22 | | diagnostic, screening, preventive, and rehabilitative | 23 | | services, including to ensure that the individual's need for | 24 | | intervention or treatment of mental disorders or substance use | 25 | | disorders or co-occurring mental health and substance use | 26 | | disorders is determined using a uniform screening, assessment, |
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| 1 | | and evaluation process inclusive of criteria, for children and | 2 | | adults; for purposes of this item (13), a uniform screening, | 3 | | assessment, and evaluation process refers to a process that | 4 | | includes an appropriate evaluation and, as warranted, a | 5 | | referral; "uniform" does not mean the use of a singular | 6 | | instrument, tool, or process that all must utilize; (14) | 7 | | transportation and such other expenses as may be necessary; | 8 | | (15) medical treatment of sexual assault survivors, as defined | 9 | | in Section 1a of the Sexual Assault Survivors Emergency | 10 | | Treatment Act, for injuries sustained as a result of the | 11 | | sexual assault, including examinations and laboratory tests to | 12 | | discover evidence which may be used in criminal proceedings | 13 | | arising from the sexual assault; (16) the diagnosis and | 14 | | treatment of sickle cell anemia; (16.5) services performed by | 15 | | a chiropractic physician licensed under the Medical Practice | 16 | | Act of 1987 and acting within the scope of his or her license, | 17 | | including, but not limited to, chiropractic manipulative | 18 | | treatment; and (17) any other medical care, and any other type | 19 | | of remedial care recognized under the laws of this State. The | 20 | | term "any other type of remedial care" shall include nursing | 21 | | care and nursing home service for persons who rely on | 22 | | treatment by spiritual means alone through prayer for healing. | 23 | | Notwithstanding any other provision of this Section, a | 24 | | comprehensive tobacco use cessation program that includes | 25 | | purchasing prescription drugs or prescription medical devices | 26 | | approved by the Food and Drug Administration shall be covered |
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| 1 | | under the medical assistance program under this Article for | 2 | | persons who are otherwise eligible for assistance under this | 3 | | Article. | 4 | | Notwithstanding any other provision of this Code, | 5 | | reproductive health care that is otherwise legal in Illinois | 6 | | shall be covered under the medical assistance program for | 7 | | persons who are otherwise eligible for medical assistance | 8 | | under this Article. | 9 | | Notwithstanding any other provision of this Section, all | 10 | | tobacco cessation medications approved by the United States | 11 | | Food and Drug Administration and all individual and group | 12 | | tobacco cessation counseling services and telephone-based | 13 | | counseling services and tobacco cessation medications provided | 14 | | through the Illinois Tobacco Quitline shall be covered under | 15 | | the medical assistance program for persons who are otherwise | 16 | | eligible for assistance under this Article. The Department | 17 | | shall comply with all federal requirements necessary to obtain | 18 | | federal financial participation, as specified in 42 CFR | 19 | | 433.15(b)(7), for telephone-based counseling services provided | 20 | | through the Illinois Tobacco Quitline, including, but not | 21 | | limited to: (i) entering into a memorandum of understanding or | 22 | | interagency agreement with the Department of Public Health, as | 23 | | administrator of the Illinois Tobacco Quitline; and (ii) | 24 | | developing a cost allocation plan for Medicaid-allowable | 25 | | Illinois Tobacco Quitline services in accordance with 45 CFR | 26 | | 95.507. The Department shall submit the memorandum of |
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| 1 | | understanding or interagency agreement, the cost allocation | 2 | | plan, and all other necessary documentation to the Centers for | 3 | | Medicare and Medicaid Services for review and approval. | 4 | | Coverage under this paragraph shall be contingent upon federal | 5 | | approval. | 6 | | Notwithstanding any other provision of this Code, the | 7 | | Illinois Department may not require, as a condition of payment | 8 | | for any laboratory test authorized under this Article, that a | 9 | | physician's handwritten signature appear on the laboratory | 10 | | test order form. The Illinois Department may, however, impose | 11 | | other appropriate requirements regarding laboratory test order | 12 | | documentation. | 13 | | Upon receipt of federal approval of an amendment to the | 14 | | Illinois Title XIX State Plan for this purpose, the Department | 15 | | shall authorize the Chicago Public Schools (CPS) to procure a | 16 | | vendor or vendors to manufacture eyeglasses for individuals | 17 | | enrolled in a school within the CPS system. CPS shall ensure | 18 | | that its vendor or vendors are enrolled as providers in the | 19 | | medical assistance program and in any capitated Medicaid | 20 | | managed care entity (MCE) serving individuals enrolled in a | 21 | | school within the CPS system. Under any contract procured | 22 | | under this provision, the vendor or vendors must serve only | 23 | | individuals enrolled in a school within the CPS system. Claims | 24 | | for services provided by CPS's vendor or vendors to recipients | 25 | | of benefits in the medical assistance program under this Code, | 26 | | the Children's Health Insurance Program, or the Covering ALL |
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| 1 | | KIDS Health Insurance Program shall be submitted to the | 2 | | Department or the MCE in which the individual is enrolled for | 3 | | payment and shall be reimbursed at the Department's or the | 4 | | MCE's established rates or rate methodologies for eyeglasses. | 5 | | On and after July 1, 2012, the Department of Healthcare | 6 | | and Family Services may provide the following services to | 7 | | persons eligible for assistance under this Article who are | 8 | | participating in education, training or employment programs | 9 | | operated by the Department of Human Services as successor to | 10 | | the Department of Public Aid: | 11 | | (1) dental services provided by or under the | 12 | | supervision of a dentist; and | 13 | | (2) eyeglasses prescribed by a physician skilled in | 14 | | the diseases of the eye, or by an optometrist, whichever | 15 | | the person may select. | 16 | | On and after July 1, 2018, the Department of Healthcare | 17 | | and Family Services shall provide dental services to any adult | 18 | | who is otherwise eligible for assistance under the medical | 19 | | assistance program. As used in this paragraph, "dental | 20 | | services" means diagnostic, preventative, restorative, or | 21 | | corrective procedures, including procedures and services for | 22 | | the prevention and treatment of periodontal disease and dental | 23 | | caries disease, provided by an individual who is licensed to | 24 | | practice dentistry or dental surgery or who is under the | 25 | | supervision of a dentist in the practice of his or her | 26 | | profession. |
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| 1 | | On and after July 1, 2018, targeted dental services, as | 2 | | set forth in Exhibit D of the Consent Decree entered by the | 3 | | United States District Court for the Northern District of | 4 | | Illinois, Eastern Division, in the matter of Memisovski v. | 5 | | Maram, Case No. 92 C 1982, that are provided to adults under | 6 | | the medical assistance program shall be established at no less | 7 | | than the rates set forth in the "New Rate" column in Exhibit D | 8 | | of the Consent Decree for targeted dental services that are | 9 | | provided to persons under the age of 18 under the medical | 10 | | assistance program. | 11 | | Notwithstanding any other provision of this Code and | 12 | | subject to federal approval, the Department may adopt rules to | 13 | | allow a dentist who is volunteering his or her service at no | 14 | | cost to render dental services through an enrolled | 15 | | not-for-profit health clinic without the dentist personally | 16 | | enrolling as a participating provider in the medical | 17 | | assistance program. A not-for-profit health clinic shall | 18 | | include a public health clinic or Federally Qualified Health | 19 | | Center or other enrolled provider, as determined by the | 20 | | Department, through which dental services covered under this | 21 | | Section are performed. The Department shall establish a | 22 | | process for payment of claims for reimbursement for covered | 23 | | dental services rendered under this provision. | 24 | | On and after January 1, 2022, the Department of Healthcare | 25 | | and Family Services shall administer and regulate a | 26 | | school-based dental program that allows for the out-of-office |
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| 1 | | delivery of preventative dental services in a school setting | 2 | | to children under 19 years of age. The Department shall | 3 | | establish, by rule, guidelines for participation by providers | 4 | | and set requirements for follow-up referral care based on the | 5 | | requirements established in the Dental Office Reference Manual | 6 | | published by the Department that establishes the requirements | 7 | | for dentists participating in the All Kids Dental School | 8 | | Program. Every effort shall be made by the Department when | 9 | | developing the program requirements to consider the different | 10 | | geographic differences of both urban and rural areas of the | 11 | | State for initial treatment and necessary follow-up care. No | 12 | | provider shall be charged a fee by any unit of local government | 13 | | to participate in the school-based dental program administered | 14 | | by the Department. Nothing in this paragraph shall be | 15 | | construed to limit or preempt a home rule unit's or school | 16 | | district's authority to establish, change, or administer a | 17 | | school-based dental program in addition to, or independent of, | 18 | | the school-based dental program administered by the | 19 | | Department. | 20 | | The Illinois Department, by rule, may distinguish and | 21 | | classify the medical services to be provided only in | 22 | | accordance with the classes of persons designated in Section | 23 | | 5-2. | 24 | | The Department of Healthcare and Family Services must | 25 | | provide coverage and reimbursement for amino acid-based | 26 | | elemental formulas, regardless of delivery method, for the |
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| 1 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 2 | | short bowel syndrome when the prescribing physician has issued | 3 | | a written order stating that the amino acid-based elemental | 4 | | formula is medically necessary. | 5 | | The Illinois Department shall authorize the provision of, | 6 | | and shall authorize payment for, screening by low-dose | 7 | | mammography for the presence of occult breast cancer for | 8 | | individuals 35 years of age or older who are eligible for | 9 | | medical assistance under this Article, as follows: | 10 | | (A) A baseline mammogram for individuals 35 to 39 | 11 | | years of age. | 12 | | (B) An annual mammogram for individuals 40 years of | 13 | | age or older. | 14 | | (C) A mammogram at the age and intervals considered | 15 | | medically necessary by the individual's health care | 16 | | provider for individuals under 40 years of age and having | 17 | | a family history of breast cancer, prior personal history | 18 | | of breast cancer, positive genetic testing, or other risk | 19 | | factors. | 20 | | (D) A comprehensive ultrasound screening and MRI of an | 21 | | entire breast or breasts if a mammogram demonstrates | 22 | | heterogeneous or dense breast tissue or when medically | 23 | | necessary as determined by a physician licensed to | 24 | | practice medicine in all of its branches. | 25 | | (E) A screening MRI when medically necessary, as | 26 | | determined by a physician licensed to practice medicine in |
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| 1 | | all of its branches. | 2 | | (F) A diagnostic mammogram when medically necessary, | 3 | | as determined by a physician licensed to practice medicine | 4 | | in all its branches, advanced practice registered nurse, | 5 | | or physician assistant. | 6 | | The Department shall not impose a deductible, coinsurance, | 7 | | copayment, or any other cost-sharing requirement on the | 8 | | coverage provided under this paragraph; except that this | 9 | | sentence does not apply to coverage of diagnostic mammograms | 10 | | to the extent such coverage would disqualify a high-deductible | 11 | | health plan from eligibility for a health savings account | 12 | | pursuant to Section 223 of the Internal Revenue Code (26 | 13 | | U.S.C. 223). | 14 | | All screenings shall include a physical breast exam, | 15 | | instruction on self-examination and information regarding the | 16 | | frequency of self-examination and its value as a preventative | 17 | | tool. | 18 | | For purposes of this Section: | 19 | | "Diagnostic mammogram" means a mammogram obtained using | 20 | | diagnostic mammography. | 21 | | "Diagnostic mammography" means a method of screening that | 22 | | is designed to evaluate an abnormality in a breast, including | 23 | | an abnormality seen or suspected on a screening mammogram or a | 24 | | subjective or objective abnormality otherwise detected in the | 25 | | breast. | 26 | | "Low-dose mammography" means the x-ray examination of the |
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| 1 | | breast using equipment dedicated specifically for mammography, | 2 | | including the x-ray tube, filter, compression device, and | 3 | | image receptor, with an average radiation exposure delivery of | 4 | | less than one rad per breast for 2 views of an average size | 5 | | breast. The term also includes digital mammography and | 6 | | includes breast tomosynthesis. | 7 | | "Breast tomosynthesis" means a radiologic procedure that | 8 | | involves the acquisition of projection images over the | 9 | | stationary breast to produce cross-sectional digital | 10 | | three-dimensional images of the breast. | 11 | | If, at any time, the Secretary of the United States | 12 | | Department of Health and Human Services, or its successor | 13 | | agency, promulgates rules or regulations to be published in | 14 | | the Federal Register or publishes a comment in the Federal | 15 | | Register or issues an opinion, guidance, or other action that | 16 | | would require the State, pursuant to any provision of the | 17 | | Patient Protection and Affordable Care Act (Public Law | 18 | | 111-148), including, but not limited to, 42 U.S.C. | 19 | | 18031(d)(3)(B) or any successor provision, to defray the cost | 20 | | of any coverage for breast tomosynthesis outlined in this | 21 | | paragraph, then the requirement that an insurer cover breast | 22 | | tomosynthesis is inoperative other than any such coverage | 23 | | authorized under Section 1902 of the Social Security Act, 42 | 24 | | U.S.C. 1396a, and the State shall not assume any obligation | 25 | | for the cost of coverage for breast tomosynthesis set forth in | 26 | | this paragraph. |
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| 1 | | On and after January 1, 2016, the Department shall ensure | 2 | | that all networks of care for adult clients of the Department | 3 | | include access to at least one breast imaging Center of | 4 | | Imaging Excellence as certified by the American College of | 5 | | Radiology. | 6 | | On and after January 1, 2012, providers participating in a | 7 | | quality improvement program approved by the Department shall | 8 | | be reimbursed for screening and diagnostic mammography at the | 9 | | same rate as the Medicare program's rates, including the | 10 | | increased reimbursement for digital mammography and, after | 11 | | January 1, 2023 (the effective date of Public Act 102-1018), | 12 | | breast tomosynthesis. | 13 | | The Department shall convene an expert panel including | 14 | | representatives of hospitals, free-standing mammography | 15 | | facilities, and doctors, including radiologists, to establish | 16 | | quality standards for mammography. | 17 | | On and after January 1, 2017, providers participating in a | 18 | | breast cancer treatment quality improvement program approved | 19 | | by the Department shall be reimbursed for breast cancer | 20 | | treatment at a rate that is no lower than 95% of the Medicare | 21 | | program's rates for the data elements included in the breast | 22 | | cancer treatment quality program. | 23 | | The Department shall convene an expert panel, including | 24 | | representatives of hospitals, free-standing breast cancer | 25 | | treatment centers, breast cancer quality organizations, and | 26 | | doctors, including breast surgeons, reconstructive breast |
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| 1 | | surgeons, oncologists, and primary care providers to establish | 2 | | quality standards for breast cancer treatment. | 3 | | Subject to federal approval, the Department shall | 4 | | establish a rate methodology for mammography at federally | 5 | | qualified health centers and other encounter-rate clinics. | 6 | | These clinics or centers may also collaborate with other | 7 | | hospital-based mammography facilities. By January 1, 2016, the | 8 | | Department shall report to the General Assembly on the status | 9 | | of the provision set forth in this paragraph. | 10 | | The Department shall establish a methodology to remind | 11 | | individuals who are age-appropriate for screening mammography, | 12 | | but who have not received a mammogram within the previous 18 | 13 | | months, of the importance and benefit of screening | 14 | | mammography. The Department shall work with experts in breast | 15 | | cancer outreach and patient navigation to optimize these | 16 | | reminders and shall establish a methodology for evaluating | 17 | | their effectiveness and modifying the methodology based on the | 18 | | evaluation. | 19 | | The Department shall establish a performance goal for | 20 | | primary care providers with respect to their female patients | 21 | | over age 40 receiving an annual mammogram. This performance | 22 | | goal shall be used to provide additional reimbursement in the | 23 | | form of a quality performance bonus to primary care providers | 24 | | who meet that goal. | 25 | | The Department shall devise a means of case-managing or | 26 | | patient navigation for beneficiaries diagnosed with breast |
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| 1 | | cancer. This program shall initially operate as a pilot | 2 | | program in areas of the State with the highest incidence of | 3 | | mortality related to breast cancer. At least one pilot program | 4 | | site shall be in the metropolitan Chicago area and at least one | 5 | | site shall be outside the metropolitan Chicago area. On or | 6 | | after July 1, 2016, the pilot program shall be expanded to | 7 | | include one site in western Illinois, one site in southern | 8 | | Illinois, one site in central Illinois, and 4 sites within | 9 | | metropolitan Chicago. An evaluation of the pilot program shall | 10 | | be carried out measuring health outcomes and cost of care for | 11 | | those served by the pilot program compared to similarly | 12 | | situated patients who are not served by the pilot program. | 13 | | The Department shall require all networks of care to | 14 | | develop a means either internally or by contract with experts | 15 | | in navigation and community outreach to navigate cancer | 16 | | patients to comprehensive care in a timely fashion. The | 17 | | Department shall require all networks of care to include | 18 | | access for patients diagnosed with cancer to at least one | 19 | | academic commission on cancer-accredited cancer program as an | 20 | | in-network covered benefit. | 21 | | The Department shall provide coverage and reimbursement | 22 | | for a human papillomavirus (HPV) vaccine that is approved for | 23 | | marketing by the federal Food and Drug Administration for all | 24 | | persons between the ages of 9 and 45. Subject to federal | 25 | | approval, the Department shall provide coverage and | 26 | | reimbursement for a human papillomavirus (HPV) vaccine for |
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| 1 | | persons of the age of 46 and above who have been diagnosed with | 2 | | cervical dysplasia with a high risk of recurrence or | 3 | | progression. The Department shall disallow any | 4 | | preauthorization requirements for the administration of the | 5 | | human papillomavirus (HPV) vaccine. | 6 | | On or after July 1, 2022, individuals who are otherwise | 7 | | eligible for medical assistance under this Article shall | 8 | | receive coverage for perinatal depression screenings for the | 9 | | 12-month period beginning on the last day of their pregnancy. | 10 | | Medical assistance coverage under this paragraph shall be | 11 | | conditioned on the use of a screening instrument approved by | 12 | | the Department. | 13 | | Any medical or health care provider shall immediately | 14 | | recommend, to any pregnant individual who is being provided | 15 | | prenatal services and is suspected of having a substance use | 16 | | disorder as defined in the Substance Use Disorder Act, | 17 | | referral to a local substance use disorder treatment program | 18 | | licensed by the Department of Human Services or to a licensed | 19 | | hospital which provides substance abuse treatment services. | 20 | | The Department of Healthcare and Family Services shall assure | 21 | | coverage for the cost of treatment of the drug abuse or | 22 | | addiction for pregnant recipients in accordance with the | 23 | | Illinois Medicaid Program in conjunction with the Department | 24 | | of Human Services. | 25 | | All medical providers providing medical assistance to | 26 | | pregnant individuals under this Code shall receive information |
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| 1 | | from the Department on the availability of services under any | 2 | | program providing case management services for addicted | 3 | | individuals, including information on appropriate referrals | 4 | | for other social services that may be needed by addicted | 5 | | individuals in addition to treatment for addiction. | 6 | | The Illinois Department, in cooperation with the | 7 | | Departments of Human Services (as successor to the Department | 8 | | of Alcoholism and Substance Abuse) and Public Health, through | 9 | | a public awareness campaign, may provide information | 10 | | concerning treatment for alcoholism and drug abuse and | 11 | | addiction, prenatal health care, and other pertinent programs | 12 | | directed at reducing the number of drug-affected infants born | 13 | | to recipients of medical assistance. | 14 | | Neither the Department of Healthcare and Family Services | 15 | | nor the Department of Human Services shall sanction the | 16 | | recipient solely on the basis of the recipient's substance | 17 | | 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 the category of risk | 15 | | of 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 | | For claims for services rendered during a period for which | 10 | | a recipient received retroactive eligibility, claims must be | 11 | | filed within 180 days after the Department determines the | 12 | | applicant is eligible. For claims for which the Illinois | 13 | | Department is not the primary payer, claims must be submitted | 14 | | to the Illinois Department within 180 days after the final | 15 | | adjudication by the primary payer. | 16 | | In the case of long term care facilities, within 120 | 17 | | calendar days of receipt by the facility of required | 18 | | prescreening information, new admissions with associated | 19 | | admission documents shall be submitted through the Medical | 20 | | Electronic Data Interchange (MEDI) or the Recipient | 21 | | Eligibility Verification (REV) System or shall be submitted | 22 | | directly to the Department of Human Services using required | 23 | | admission forms. Effective September 1, 2014, admission | 24 | | documents, including all prescreening information, must be | 25 | | submitted through MEDI or REV. Confirmation numbers assigned | 26 | | to an accepted transaction shall be retained by a facility to |
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| 1 | | verify timely submittal. Once an admission transaction has | 2 | | been completed, all resubmitted claims following prior | 3 | | rejection are subject to receipt no later than 180 days after | 4 | | the admission transaction has been completed. | 5 | | Claims that are not submitted and received in compliance | 6 | | with the foregoing requirements shall not be eligible for | 7 | | payment under the medical assistance program, and the State | 8 | | shall have no liability for payment of those claims. | 9 | | To the extent consistent with applicable information and | 10 | | privacy, security, and disclosure laws, State and federal | 11 | | agencies and departments shall provide the Illinois Department | 12 | | access to confidential and other information and data | 13 | | necessary to perform eligibility and payment verifications and | 14 | | other Illinois Department functions. This includes, but is not | 15 | | limited to: information pertaining to licensure; | 16 | | certification; earnings; immigration status; citizenship; wage | 17 | | reporting; unearned and earned income; pension income; | 18 | | employment; supplemental security income; social security | 19 | | numbers; National Provider Identifier (NPI) numbers; the | 20 | | National Practitioner Data Bank (NPDB); program and agency | 21 | | exclusions; taxpayer identification numbers; tax delinquency; | 22 | | corporate information; and death records. | 23 | | The Illinois Department shall enter into agreements with | 24 | | State agencies and departments, and is authorized to enter | 25 | | into agreements with federal agencies and departments, under | 26 | | which such agencies and departments shall share data necessary |
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| 1 | | for medical assistance program integrity functions and | 2 | | oversight. The Illinois Department shall develop, in | 3 | | cooperation with other State departments and agencies, and in | 4 | | compliance with applicable federal laws and regulations, | 5 | | appropriate and effective methods to share such data. At a | 6 | | minimum, and to the extent necessary to provide data sharing, | 7 | | the Illinois Department shall enter into agreements with State | 8 | | agencies and departments, and is authorized to enter into | 9 | | agreements with federal agencies and departments, including, | 10 | | but not limited to: the Secretary of State; the Department of | 11 | | Revenue; the Department of Public Health; the Department of | 12 | | Human Services; and the Department of Financial and | 13 | | Professional Regulation. | 14 | | Beginning in fiscal year 2013, the Illinois Department | 15 | | shall set forth a request for information to identify the | 16 | | benefits of a pre-payment, post-adjudication, and post-edit | 17 | | claims system with the goals of streamlining claims processing | 18 | | and provider reimbursement, reducing the number of pending or | 19 | | rejected claims, and helping to ensure a more transparent | 20 | | adjudication process through the utilization of: (i) provider | 21 | | data verification and provider screening technology; and (ii) | 22 | | clinical code editing; and (iii) pre-pay, pre-adjudicated , or | 23 | | post-adjudicated predictive modeling with an integrated case | 24 | | management system with link analysis. Such a request for | 25 | | information shall not be considered as a request for proposal | 26 | | or as an obligation on the part of the Illinois Department to |
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| 1 | | take any action or acquire any products or services. | 2 | | The Illinois Department shall establish policies, | 3 | | procedures, standards and criteria by rule for the | 4 | | acquisition, repair and replacement of orthotic and prosthetic | 5 | | devices and durable medical equipment. Such rules shall | 6 | | provide, but not be limited to, the following services: (1) | 7 | | immediate repair or replacement of such devices by recipients; | 8 | | and (2) rental, lease, purchase or lease-purchase of durable | 9 | | medical equipment in a cost-effective manner, taking into | 10 | | consideration the recipient's medical prognosis, the extent of | 11 | | the recipient's needs, and the requirements and costs for | 12 | | maintaining such equipment. Subject to prior approval, such | 13 | | rules shall enable a recipient to temporarily acquire and use | 14 | | alternative or substitute devices or equipment pending repairs | 15 | | or replacements of any device or equipment previously | 16 | | authorized for such recipient by the Department. | 17 | | Notwithstanding any provision of Section 5-5f to the contrary, | 18 | | the Department may, by rule, exempt certain replacement | 19 | | wheelchair parts from prior approval and, for wheelchairs, | 20 | | wheelchair parts, wheelchair accessories, and related seating | 21 | | and positioning items, determine the wholesale price by | 22 | | methods other than actual acquisition costs. | 23 | | The Department shall require, by rule, all providers of | 24 | | durable medical equipment to be accredited by an accreditation | 25 | | organization approved by the federal Centers for Medicare and | 26 | | Medicaid Services and recognized by the Department in order to |
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| 1 | | bill the Department for providing durable medical equipment to | 2 | | recipients. No later than 15 months after the effective date | 3 | | of the rule adopted pursuant to this paragraph, all providers | 4 | | must meet the accreditation requirement. | 5 | | In order to promote environmental responsibility, meet the | 6 | | needs of recipients and enrollees, and achieve significant | 7 | | cost savings, the Department, or a managed care organization | 8 | | under contract with the Department, may provide recipients or | 9 | | managed care enrollees who have a prescription or Certificate | 10 | | of Medical Necessity access to refurbished durable medical | 11 | | equipment under this Section (excluding prosthetic and | 12 | | orthotic devices as defined in the Orthotics, Prosthetics, and | 13 | | Pedorthics Practice Act and complex rehabilitation technology | 14 | | products and associated services) through the State's | 15 | | assistive technology program's reutilization program, using | 16 | | staff with the Assistive Technology Professional (ATP) | 17 | | Certification if the refurbished durable medical equipment: | 18 | | (i) is available; (ii) is less expensive, including shipping | 19 | | costs, than new durable medical equipment of the same type; | 20 | | (iii) is able to withstand at least 3 years of use; (iv) is | 21 | | cleaned, disinfected, sterilized, and safe in accordance with | 22 | | federal Food and Drug Administration regulations and guidance | 23 | | governing the reprocessing of medical devices in health care | 24 | | settings; and (v) equally meets the needs of the recipient or | 25 | | enrollee. The reutilization program shall confirm that the | 26 | | recipient or enrollee is not already in receipt of the same or |
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| 1 | | similar equipment from another service provider, and that the | 2 | | refurbished durable medical equipment equally meets the needs | 3 | | of the recipient or enrollee. Nothing in this paragraph shall | 4 | | be construed to limit recipient or enrollee choice to obtain | 5 | | new durable medical equipment or place any additional prior | 6 | | authorization conditions on enrollees of managed care | 7 | | organizations. | 8 | | The Department shall execute, relative to the nursing home | 9 | | prescreening project, written inter-agency agreements with the | 10 | | Department of Human Services and the Department on Aging, to | 11 | | effect the following: (i) intake procedures and common | 12 | | eligibility criteria for those persons who are receiving | 13 | | non-institutional services; and (ii) the establishment and | 14 | | development of non-institutional services in areas of the | 15 | | State where they are not currently available or are | 16 | | undeveloped; and (iii) notwithstanding any other provision of | 17 | | law, subject to federal approval, on and after July 1, 2012, an | 18 | | increase in the determination of need (DON) scores from 29 to | 19 | | 37 for applicants for institutional and home and | 20 | | community-based long term care; if and only if federal | 21 | | approval is not granted, the Department may, in conjunction | 22 | | with other affected agencies, implement utilization controls | 23 | | or changes in benefit packages to effectuate a similar savings | 24 | | amount for this population; and (iv) no later than July 1, | 25 | | 2013, minimum level of care eligibility criteria for | 26 | | institutional and home and community-based long term care; and |
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| 1 | | (v) no later than October 1, 2013, establish procedures to | 2 | | permit long term care providers access to eligibility scores | 3 | | for individuals with an admission date who are seeking or | 4 | | receiving services from the long term care provider. In order | 5 | | to select the minimum level of care eligibility criteria, the | 6 | | Governor shall establish a workgroup that includes affected | 7 | | agency representatives and stakeholders representing the | 8 | | institutional and home and community-based long term care | 9 | | interests. This Section shall not restrict the Department from | 10 | | implementing lower level of care eligibility criteria for | 11 | | community-based services in circumstances where federal | 12 | | approval has been granted. | 13 | | The Illinois Department shall develop and operate, in | 14 | | cooperation with other State Departments and agencies and in | 15 | | compliance with applicable federal laws and regulations, | 16 | | appropriate and effective systems of health care evaluation | 17 | | and programs for monitoring of utilization of health care | 18 | | services and facilities, as it affects persons eligible for | 19 | | medical assistance under this Code. | 20 | | The Illinois Department shall report annually to the | 21 | | General Assembly, no later than the second Friday in April of | 22 | | 1979 and each year thereafter, in regard to: | 23 | | (a) actual statistics and trends in utilization of | 24 | | medical services by public aid recipients; | 25 | | (b) actual statistics and trends in the provision of | 26 | | the various medical services by medical vendors; |
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| 1 | | (c) current rate structures and proposed changes in | 2 | | those rate structures for the various medical vendors; and | 3 | | (d) efforts at utilization review and control by the | 4 | | Illinois Department. | 5 | | The period covered by each report shall be the 3 years | 6 | | ending on the June 30 prior to the report. The report shall | 7 | | include suggested legislation for consideration by the General | 8 | | Assembly. The requirement for reporting to the General | 9 | | Assembly shall be satisfied by filing copies of the report as | 10 | | required by Section 3.1 of the General Assembly Organization | 11 | | Act, and filing such additional copies with the State | 12 | | Government Report Distribution Center for the General Assembly | 13 | | as is required under paragraph (t) of Section 7 of the State | 14 | | Library Act. | 15 | | Rulemaking authority to implement Public Act 95-1045, if | 16 | | any, is conditioned on the rules being adopted in accordance | 17 | | with all provisions of the Illinois Administrative Procedure | 18 | | Act and all rules and procedures of the Joint Committee on | 19 | | Administrative Rules; any purported rule not so adopted, for | 20 | | whatever reason, is unauthorized. | 21 | | On and after July 1, 2012, the Department shall reduce any | 22 | | rate of reimbursement for services or other payments or alter | 23 | | any methodologies authorized by this Code to reduce any rate | 24 | | of reimbursement for services or other payments in accordance | 25 | | with Section 5-5e. | 26 | | Because kidney transplantation can be an appropriate, |
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| 1 | | cost-effective alternative to renal dialysis when medically | 2 | | necessary and notwithstanding the provisions of Section 1-11 | 3 | | of this Code, beginning October 1, 2014, the Department shall | 4 | | cover kidney transplantation for noncitizens with end-stage | 5 | | renal disease who are not eligible for comprehensive medical | 6 | | benefits, who meet the residency requirements of Section 5-3 | 7 | | of this Code, and who would otherwise meet the financial | 8 | | requirements of the appropriate class of eligible persons | 9 | | under Section 5-2 of this Code. To qualify for coverage of | 10 | | kidney transplantation, such person must be receiving | 11 | | emergency renal dialysis services covered by the Department. | 12 | | Providers under this Section shall be prior approved and | 13 | | certified by the Department to perform kidney transplantation | 14 | | and the services under this Section shall be limited to | 15 | | services associated with kidney transplantation. | 16 | | Notwithstanding any other provision of this Code to the | 17 | | contrary, on or after July 1, 2015, all FDA approved forms of | 18 | | medication assisted treatment prescribed for the treatment of | 19 | | alcohol dependence or treatment of opioid dependence shall be | 20 | | covered under both fee-for-service fee for service and managed | 21 | | care medical assistance programs for persons who are otherwise | 22 | | eligible for medical assistance under this Article and shall | 23 | | not be subject to any (1) utilization control, other than | 24 | | those established under the American Society of Addiction | 25 | | Medicine patient placement criteria, (2) prior authorization | 26 | | mandate, or (3) lifetime restriction limit mandate , or (4) |
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| 1 | | limitations on dosage . | 2 | | On or after July 1, 2015, opioid antagonists prescribed | 3 | | for the treatment of an opioid overdose, including the | 4 | | medication product, administration devices, and any pharmacy | 5 | | fees or hospital fees related to the dispensing, distribution, | 6 | | and administration of the opioid antagonist, shall be covered | 7 | | under the medical assistance program for persons who are | 8 | | otherwise eligible for medical assistance under this Article. | 9 | | As used in this Section, "opioid antagonist" means a drug that | 10 | | binds to opioid receptors and blocks or inhibits the effect of | 11 | | opioids acting on those receptors, including, but not limited | 12 | | to, naloxone hydrochloride or any other similarly acting drug | 13 | | approved by the U.S. Food and Drug Administration. The | 14 | | Department shall not impose a copayment on the coverage | 15 | | provided for naloxone hydrochloride under the medical | 16 | | assistance program. | 17 | | Upon federal approval, the Department shall provide | 18 | | coverage and reimbursement for all drugs that are approved for | 19 | | marketing by the federal Food and Drug Administration and that | 20 | | are recommended by the federal Public Health Service or the | 21 | | United States Centers for Disease Control and Prevention for | 22 | | pre-exposure prophylaxis and related pre-exposure prophylaxis | 23 | | services, including, but not limited to, HIV and sexually | 24 | | transmitted infection screening, treatment for sexually | 25 | | transmitted infections, medical monitoring, assorted labs, and | 26 | | counseling to reduce the likelihood of HIV infection among |
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| 1 | | individuals who are not infected with HIV but who are at high | 2 | | risk of HIV infection. | 3 | | A federally qualified health center, as defined in Section | 4 | | 1905(l)(2)(B) of the federal Social Security Act, shall be | 5 | | reimbursed by the Department in accordance with the federally | 6 | | qualified health center's encounter rate for services provided | 7 | | to medical assistance recipients that are performed by a | 8 | | dental hygienist, as defined under the Illinois Dental | 9 | | Practice Act, working under the general supervision of a | 10 | | dentist and employed by a federally qualified health center. | 11 | | Within 90 days after October 8, 2021 (the effective date | 12 | | of Public Act 102-665), the Department shall seek federal | 13 | | approval of a State Plan amendment to expand coverage for | 14 | | family planning services that includes presumptive eligibility | 15 | | to individuals whose income is at or below 208% of the federal | 16 | | poverty level. Coverage under this Section shall be effective | 17 | | beginning no later than December 1, 2022. | 18 | | Subject to approval by the federal Centers for Medicare | 19 | | and Medicaid Services of a Title XIX State Plan amendment | 20 | | electing the Program of All-Inclusive Care for the Elderly | 21 | | (PACE) as a State Medicaid option, as provided for by Subtitle | 22 | | I (commencing with Section 4801) of Title IV of the Balanced | 23 | | Budget Act of 1997 (Public Law 105-33) and Part 460 | 24 | | (commencing with Section 460.2) of Subchapter E of Title 42 of | 25 | | the Code of Federal Regulations, PACE program services shall | 26 | | become a covered benefit of the medical assistance program, |
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| 1 | | subject to criteria established in accordance with all | 2 | | applicable laws. | 3 | | Notwithstanding any other provision of this Code, | 4 | | community-based pediatric palliative care from a trained | 5 | | interdisciplinary team shall be covered under the medical | 6 | | assistance program as provided in Section 15 of the Pediatric | 7 | | Palliative Care Act. | 8 | | Notwithstanding any other provision of this Code, within | 9 | | 12 months after June 2, 2022 (the effective date of Public Act | 10 | | 102-1037) and subject to federal approval, acupuncture | 11 | | services performed by an acupuncturist licensed under the | 12 | | Acupuncture Practice Act who is acting within the scope of his | 13 | | or her license shall be covered under the medical assistance | 14 | | program. The Department shall apply for any federal waiver or | 15 | | State Plan amendment, if required, to implement this | 16 | | paragraph. The Department may adopt any rules, including | 17 | | standards and criteria, necessary to implement this paragraph. | 18 | | Notwithstanding any other provision of this Code, the | 19 | | medical assistance program shall, subject to appropriation and | 20 | | federal approval, reimburse hospitals for costs associated | 21 | | with a newborn screening test for the presence of | 22 | | metachromatic leukodystrophy, as required under the Newborn | 23 | | Metabolic Screening Act, at a rate not less than the fee | 24 | | charged by the Department of Public Health. The Department | 25 | | shall seek federal approval before the implementation of the | 26 | | newborn screening test fees by the Department of Public |
| | | SB3741 Engrossed | - 61 - | LRB103 37781 RPS 67910 b |
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| 1 | | Health. | 2 | | Notwithstanding any other provision of this Code, | 3 | | beginning on January 1, 2024, subject to federal approval, | 4 | | cognitive assessment and care planning services provided to a | 5 | | person who experiences signs or symptoms of cognitive | 6 | | impairment, as defined by the Diagnostic and Statistical | 7 | | Manual of Mental Disorders, Fifth Edition, shall be covered | 8 | | under the medical assistance program for persons who are | 9 | | otherwise eligible for medical assistance under this Article. | 10 | | Notwithstanding any other provision of this Code, | 11 | | medically necessary reconstructive services that are intended | 12 | | to restore physical appearance shall be covered under the | 13 | | medical assistance program for persons who are otherwise | 14 | | eligible for medical assistance under this Article. As used in | 15 | | this paragraph, "reconstructive services" means treatments | 16 | | performed on structures of the body damaged by trauma to | 17 | | restore physical appearance. | 18 | | (Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21; | 19 | | 102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article | 20 | | 55, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, | 21 | | eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22; | 22 | | 102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff. | 23 | | 5-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; | 24 | | 102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff. | 25 | | 1-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24; | 26 | | 103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff. |
| | | SB3741 Engrossed | - 62 - | LRB103 37781 RPS 67910 b |
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| 1 | | 1-1-24; revised 12-15-23.) | 2 | | Section 99. Effective date. This Act takes effect upon | 3 | | becoming law. |
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