Full Text of HB4782 100th General Assembly
HB4782 100TH GENERAL ASSEMBLY |
| | 100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018 HB4782 Introduced , by Rep. Kelly M. Burke SYNOPSIS AS INTRODUCED: |
| 215 ILCS 5/356z.10 | | 305 ILCS 5/5-5 | from Ch. 23, par. 5-5 |
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Amends the Illinois Insurance Code and the Illinois Public Aid Code. In provisions concerning coverage for amino acid-based elemental formulas, provides coverage for the diagnosis and treatment of milk protein allergies and intolerances when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary.
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| | A BILL FOR |
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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 356z.10 as follows: | 6 | | (215 ILCS 5/356z.10) | 7 | | Sec. 356z.10. Amino acid-based elemental formulas. A group | 8 | | or individual major medical accident and health insurance | 9 | | policy or managed care plan amended, delivered, issued, or | 10 | | renewed after the effective date of this amendatory Act of the | 11 | | 100th General Assembly this amendatory Act of the 95th General | 12 | | Assembly must provide coverage and reimbursement for amino | 13 | | acid-based elemental formulas, regardless of delivery method, | 14 | | for the diagnosis and treatment of (i) eosinophilic disorders , | 15 | | and (ii) short bowel syndrome , and (iii) milk protein allergies | 16 | | and intolerances when the prescribing physician has issued a | 17 | | written order stating that the amino acid-based elemental | 18 | | formula is medically necessary.
| 19 | | (Source: P.A. 95-520, eff. 8-28-07; 95-876, eff. 8-21-08.) | 20 | | Section 10. The Illinois Public Aid Code is amended by | 21 | | changing Section 5-5 as follows:
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| 1 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| 2 | | Sec. 5-5. Medical services. The Illinois Department, by | 3 | | rule, shall
determine the quantity and quality of and the rate | 4 | | of reimbursement for the
medical assistance for which
payment | 5 | | will be authorized, and the medical services to be provided,
| 6 | | which may include all or part of the following: (1) inpatient | 7 | | hospital
services; (2) outpatient hospital services; (3) other | 8 | | laboratory and
X-ray services; (4) skilled nursing home | 9 | | services; (5) physicians'
services whether furnished in the | 10 | | office, the patient's home, a
hospital, a skilled nursing home, | 11 | | or elsewhere; (6) medical care, or any
other type of remedial | 12 | | care furnished by licensed practitioners; (7)
home health care | 13 | | services; (8) private duty nursing service; (9) clinic
| 14 | | services; (10) dental services, including prevention and | 15 | | treatment of periodontal disease and dental caries disease for | 16 | | pregnant women, provided by an individual licensed to practice | 17 | | dentistry or dental surgery; for purposes of this item (10), | 18 | | "dental services" means diagnostic, preventive, or corrective | 19 | | procedures provided by or under the supervision of a dentist in | 20 | | the practice of his or her profession; (11) physical therapy | 21 | | and related
services; (12) prescribed drugs, dentures, and | 22 | | prosthetic devices; and
eyeglasses prescribed by a physician | 23 | | skilled in the diseases of the eye,
or by an optometrist, | 24 | | whichever the person may select; (13) other
diagnostic, | 25 | | screening, preventive, and rehabilitative services, including | 26 | | to ensure that the individual's need for intervention or |
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| 1 | | treatment of mental disorders or substance use disorders or | 2 | | co-occurring mental health and substance use disorders is | 3 | | determined using a uniform screening, assessment, and | 4 | | evaluation process inclusive of criteria, for children and | 5 | | adults; for purposes of this item (13), a uniform screening, | 6 | | assessment, and evaluation process refers to a process that | 7 | | includes an appropriate evaluation and, as warranted, a | 8 | | referral; "uniform" does not mean the use of a singular | 9 | | instrument, tool, or process that all must utilize; (14)
| 10 | | transportation and such other expenses as may be necessary; | 11 | | (15) medical
treatment of sexual assault survivors, as defined | 12 | | in
Section 1a of the Sexual Assault Survivors Emergency | 13 | | Treatment Act, for
injuries sustained as a result of the sexual | 14 | | assault, including
examinations and laboratory tests to | 15 | | discover evidence which may be used in
criminal proceedings | 16 | | arising from the sexual assault; (16) the
diagnosis and | 17 | | treatment of sickle cell anemia; and (17)
any other medical | 18 | | care, and any other type of remedial care recognized
under the | 19 | | laws of this State. The term "any other type of remedial care" | 20 | | shall
include nursing care and nursing home service for persons | 21 | | who rely on
treatment by spiritual means alone through prayer | 22 | | 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 under | 8 | | this Article. | 9 | | Notwithstanding any other provision of this Code, the | 10 | | Illinois
Department may not require, as a condition of payment | 11 | | for any laboratory
test authorized under this Article, that a | 12 | | physician's handwritten signature
appear on the laboratory | 13 | | test order form. The Illinois Department may,
however, impose | 14 | | other appropriate requirements regarding laboratory test
order | 15 | | documentation.
| 16 | | Upon receipt of federal approval of an amendment to the | 17 | | Illinois Title XIX State Plan for this purpose, the Department | 18 | | shall authorize the Chicago Public Schools (CPS) to procure a | 19 | | vendor or vendors to manufacture eyeglasses for individuals | 20 | | enrolled in a school within the CPS system. CPS shall ensure | 21 | | that its vendor or vendors are enrolled as providers in the | 22 | | medical assistance program and in any capitated Medicaid | 23 | | managed care entity (MCE) serving individuals enrolled in a | 24 | | school within the CPS system. Under any contract procured under | 25 | | this provision, the vendor or vendors must serve only | 26 | | individuals enrolled in a school within the CPS system. Claims |
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| 1 | | for services provided by CPS's vendor or vendors to recipients | 2 | | of benefits in the medical assistance program under this Code, | 3 | | the Children's Health Insurance Program, or the Covering ALL | 4 | | KIDS Health Insurance Program shall be submitted to the | 5 | | Department or the MCE in which the individual is enrolled for | 6 | | payment and shall be reimbursed at the Department's or the | 7 | | MCE's established rates or rate methodologies for eyeglasses. | 8 | | On and after July 1, 2012, the Department of Healthcare and | 9 | | Family Services may provide the following services to
persons
| 10 | | eligible for assistance under this Article who are | 11 | | participating in
education, training or employment programs | 12 | | operated by the Department of Human
Services as successor to | 13 | | the Department of Public Aid:
| 14 | | (1) dental services provided by or under the | 15 | | supervision of a dentist; and
| 16 | | (2) eyeglasses prescribed by a physician skilled in the | 17 | | diseases of the
eye, or by an optometrist, whichever the | 18 | | person may select.
| 19 | | Notwithstanding any other provision of this Code and | 20 | | subject to federal approval, the Department may adopt rules to | 21 | | allow a dentist who is volunteering his or her service at no | 22 | | cost to render dental services through an enrolled | 23 | | not-for-profit health clinic without the dentist personally | 24 | | enrolling as a participating provider in the medical assistance | 25 | | program. A not-for-profit health clinic shall include a public | 26 | | health clinic or Federally Qualified Health Center or other |
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| 1 | | enrolled provider, as determined by the Department, through | 2 | | which dental services covered under this Section are performed. | 3 | | The Department shall establish a process for payment of claims | 4 | | for reimbursement for covered dental services rendered under | 5 | | this provision. | 6 | | The Illinois Department, by rule, may distinguish and | 7 | | classify the
medical services to be provided only in accordance | 8 | | with the classes of
persons designated in Section 5-2.
| 9 | | The Department of Healthcare and Family Services must | 10 | | provide coverage and reimbursement for amino acid-based | 11 | | elemental formulas, regardless of delivery method, for the | 12 | | diagnosis and treatment of (i) eosinophilic disorders , and (ii) | 13 | | short bowel syndrome , and (iii) milk protein allergies and | 14 | | intolerances when the prescribing physician has issued a | 15 | | written order stating that the amino acid-based elemental | 16 | | formula is medically necessary.
| 17 | | The Illinois Department shall authorize the provision of, | 18 | | and shall
authorize payment for, screening by low-dose | 19 | | mammography for the presence of
occult breast cancer for women | 20 | | 35 years of age or older who are eligible
for medical | 21 | | assistance under this Article, as follows: | 22 | | (A) A baseline
mammogram for women 35 to 39 years of | 23 | | age.
| 24 | | (B) An annual mammogram for women 40 years of age or | 25 | | older. | 26 | | (C) A mammogram at the age and intervals considered |
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| 1 | | medically necessary by the woman's health care provider for | 2 | | women under 40 years of age and having a family history of | 3 | | breast cancer, prior personal history of breast cancer, | 4 | | positive genetic testing, or other risk factors. | 5 | | (D) A comprehensive ultrasound screening and MRI of an | 6 | | entire breast or breasts if a mammogram demonstrates | 7 | | heterogeneous or dense breast tissue, when medically | 8 | | necessary as determined by a physician licensed to practice | 9 | | medicine in all of its branches. | 10 | | (E) A screening MRI when medically necessary, as | 11 | | determined by a physician licensed to practice medicine in | 12 | | all of its branches. | 13 | | All screenings
shall
include a physical breast exam, | 14 | | instruction on self-examination and
information regarding the | 15 | | frequency of self-examination and its value as a
preventative | 16 | | tool. For purposes of this Section, "low-dose mammography" | 17 | | means
the x-ray examination of the breast using equipment | 18 | | dedicated specifically
for mammography, including the x-ray | 19 | | tube, filter, compression device,
and image receptor, with an | 20 | | average radiation exposure delivery
of less than one rad per | 21 | | breast for 2 views of an average size breast.
The term also | 22 | | includes digital mammography and includes breast | 23 | | tomosynthesis. As used in this Section, the term "breast | 24 | | tomosynthesis" means a radiologic procedure that involves the | 25 | | acquisition of projection images over the stationary breast to | 26 | | produce cross-sectional digital three-dimensional images of |
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| 1 | | the breast. If, at any time, the Secretary of the United States | 2 | | Department of Health and Human Services, or its successor | 3 | | agency, promulgates rules or regulations to be published in the | 4 | | Federal Register or publishes a comment in the Federal Register | 5 | | or issues an opinion, guidance, or other action that would | 6 | | require the State, pursuant to any provision of the Patient | 7 | | Protection and Affordable Care Act (Public Law 111-148), | 8 | | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any | 9 | | successor provision, to defray the cost of any coverage for | 10 | | breast tomosynthesis outlined in this paragraph, then the | 11 | | requirement that an insurer cover breast tomosynthesis is | 12 | | inoperative other than any such coverage authorized under | 13 | | Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and | 14 | | the State shall not assume any obligation for the cost of | 15 | | coverage for breast tomosynthesis set forth in this paragraph.
| 16 | | On and after January 1, 2016, the Department shall ensure | 17 | | that all networks of care for adult clients of the Department | 18 | | include access to at least one breast imaging Center of Imaging | 19 | | Excellence as certified by the American College of Radiology. | 20 | | On and after January 1, 2012, providers participating in a | 21 | | quality improvement program approved by the Department shall be | 22 | | reimbursed for screening and diagnostic mammography at the same | 23 | | rate as the Medicare program's rates, including the increased | 24 | | reimbursement for digital mammography. | 25 | | The Department shall convene an expert panel including | 26 | | representatives of hospitals, free-standing mammography |
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| 1 | | facilities, and doctors, including radiologists, to establish | 2 | | quality standards for mammography. | 3 | | On and after January 1, 2017, providers participating in a | 4 | | breast cancer treatment quality improvement program approved | 5 | | by the Department shall be reimbursed for breast cancer | 6 | | treatment at a rate that is no lower than 95% of the Medicare | 7 | | program's rates for the data elements included in the breast | 8 | | cancer treatment quality program. | 9 | | The Department shall convene an expert panel, including | 10 | | representatives of hospitals, free standing breast cancer | 11 | | treatment centers, breast cancer quality organizations, and | 12 | | doctors, including breast surgeons, reconstructive breast | 13 | | surgeons, oncologists, and primary care providers to establish | 14 | | quality standards for breast cancer treatment. | 15 | | Subject to federal approval, the Department shall | 16 | | establish a rate methodology for mammography at federally | 17 | | qualified health centers and other encounter-rate clinics. | 18 | | These clinics or centers may also collaborate with other | 19 | | hospital-based mammography facilities. By January 1, 2016, the | 20 | | Department shall report to the General Assembly on the status | 21 | | of the provision set forth in this paragraph. | 22 | | The Department shall establish a methodology to remind | 23 | | women who are age-appropriate for screening mammography, but | 24 | | who have not received a mammogram within the previous 18 | 25 | | months, of the importance and benefit of screening mammography. | 26 | | The Department shall work with experts in breast cancer |
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| 1 | | outreach and patient navigation to optimize these reminders and | 2 | | shall establish a methodology for evaluating their | 3 | | effectiveness and modifying the methodology based on the | 4 | | evaluation. | 5 | | The Department shall establish a performance goal for | 6 | | primary care providers with respect to their female patients | 7 | | over age 40 receiving an annual mammogram. This performance | 8 | | goal shall be used to provide additional reimbursement in the | 9 | | form of a quality performance bonus to primary care providers | 10 | | who meet that goal. | 11 | | The Department shall devise a means of case-managing or | 12 | | patient navigation for beneficiaries diagnosed with breast | 13 | | cancer. This program shall initially operate as a pilot program | 14 | | in areas of the State with the highest incidence of mortality | 15 | | related to breast cancer. At least one pilot program site shall | 16 | | be in the metropolitan Chicago area and at least one site shall | 17 | | be outside the metropolitan Chicago area. On or after July 1, | 18 | | 2016, the pilot program shall be expanded to include one site | 19 | | in western Illinois, one site in southern Illinois, one site in | 20 | | central Illinois, and 4 sites within metropolitan Chicago. An | 21 | | evaluation of the pilot program shall be carried out measuring | 22 | | health outcomes and cost of care for those served by the pilot | 23 | | program compared to similarly situated patients who are not | 24 | | served by the pilot program. | 25 | | The Department shall require all networks of care to | 26 | | develop a means either internally or by contract with experts |
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| 1 | | in navigation and community outreach to navigate cancer | 2 | | patients to comprehensive care in a timely fashion. The | 3 | | Department shall require all networks of care to include access | 4 | | for patients diagnosed with cancer to at least one academic | 5 | | commission on cancer-accredited cancer program as an | 6 | | in-network covered benefit. | 7 | | Any medical or health care provider shall immediately | 8 | | recommend, to
any pregnant woman who is being provided prenatal | 9 | | services and is suspected
of drug abuse or is addicted as | 10 | | defined in the Alcoholism and Other Drug Abuse
and Dependency | 11 | | Act, referral to a local substance abuse treatment provider
| 12 | | licensed by the Department of Human Services or to a licensed
| 13 | | hospital which provides substance abuse treatment services. | 14 | | The Department of Healthcare and Family Services
shall assure | 15 | | coverage for the cost of treatment of the drug abuse or
| 16 | | addiction for pregnant recipients in accordance with the | 17 | | Illinois Medicaid
Program in conjunction with the Department of | 18 | | Human Services.
| 19 | | All medical providers providing medical assistance to | 20 | | pregnant women
under this Code shall receive information from | 21 | | the Department on the
availability of services under the Drug | 22 | | Free Families with a Future or any
comparable program providing | 23 | | case management services for addicted women,
including | 24 | | information on appropriate referrals for other social services
| 25 | | that may be needed by addicted women in addition to treatment | 26 | | for addiction.
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| 1 | | The Illinois Department, in cooperation with the | 2 | | Departments of Human
Services (as successor to the Department | 3 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 4 | | public awareness campaign, may
provide information concerning | 5 | | treatment for alcoholism and drug abuse and
addiction, prenatal | 6 | | health care, and other pertinent programs directed at
reducing | 7 | | the number of drug-affected infants born to recipients of | 8 | | medical
assistance.
| 9 | | Neither the Department of Healthcare and Family Services | 10 | | nor the Department of Human
Services shall sanction the | 11 | | recipient solely on the basis of
her substance abuse.
| 12 | | The Illinois Department shall establish such regulations | 13 | | governing
the dispensing of health services under this Article | 14 | | as it shall deem
appropriate. The Department
should
seek the | 15 | | advice of formal professional advisory committees appointed by
| 16 | | the Director of the Illinois Department for the purpose of | 17 | | providing regular
advice on policy and administrative matters, | 18 | | information dissemination and
educational activities for | 19 | | medical and health care providers, and
consistency in | 20 | | procedures to the Illinois Department.
| 21 | | The Illinois Department may develop and contract with | 22 | | Partnerships of
medical providers to arrange medical services | 23 | | for persons eligible under
Section 5-2 of this Code. | 24 | | Implementation of this Section may be by
demonstration projects | 25 | | in certain geographic areas. The Partnership shall
be | 26 | | represented by a sponsor organization. The Department, by rule, |
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| 1 | | shall
develop qualifications for sponsors of Partnerships. | 2 | | Nothing in this
Section shall be construed to require that the | 3 | | sponsor organization be a
medical organization.
| 4 | | The sponsor must negotiate formal written contracts with | 5 | | medical
providers for physician services, inpatient and | 6 | | outpatient hospital care,
home health services, treatment for | 7 | | alcoholism and substance abuse, and
other services determined | 8 | | necessary by the Illinois Department by rule for
delivery by | 9 | | Partnerships. Physician services must include prenatal and
| 10 | | obstetrical care. The Illinois Department shall reimburse | 11 | | medical services
delivered by Partnership providers to clients | 12 | | in target areas according to
provisions of this Article and the | 13 | | Illinois Health Finance Reform Act,
except that:
| 14 | | (1) Physicians participating in a Partnership and | 15 | | providing certain
services, which shall be determined by | 16 | | the Illinois Department, to persons
in areas covered by the | 17 | | Partnership may receive an additional surcharge
for such | 18 | | services.
| 19 | | (2) The Department may elect to consider and negotiate | 20 | | financial
incentives to encourage the development of | 21 | | Partnerships and the efficient
delivery of medical care.
| 22 | | (3) Persons receiving medical services through | 23 | | Partnerships may receive
medical and case management | 24 | | services above the level usually offered
through the | 25 | | medical assistance program.
| 26 | | Medical providers shall be required to meet certain |
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| 1 | | qualifications to
participate in Partnerships to ensure the | 2 | | delivery of high quality medical
services. These | 3 | | qualifications shall be determined by rule of the Illinois
| 4 | | Department and may be higher than qualifications for | 5 | | participation in the
medical assistance program. Partnership | 6 | | sponsors may prescribe reasonable
additional qualifications | 7 | | for participation by medical providers, only with
the prior | 8 | | written approval of the Illinois Department.
| 9 | | Nothing in this Section shall limit the free choice of | 10 | | practitioners,
hospitals, and other providers of medical | 11 | | services by clients.
In order to ensure patient freedom of | 12 | | choice, the Illinois Department shall
immediately promulgate | 13 | | all rules and take all other necessary actions so that
provided | 14 | | services may be accessed from therapeutically certified | 15 | | optometrists
to the full extent of the Illinois Optometric | 16 | | Practice Act of 1987 without
discriminating between service | 17 | | providers.
| 18 | | The Department shall apply for a waiver from the United | 19 | | States Health
Care Financing Administration to allow for the | 20 | | implementation of
Partnerships under this Section.
| 21 | | The Illinois Department shall require health care | 22 | | providers to maintain
records that document the medical care | 23 | | and services provided to recipients
of Medical Assistance under | 24 | | this Article. Such records must be retained for a period of not | 25 | | less than 6 years from the date of service or as provided by | 26 | | applicable State law, whichever period is longer, except that |
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| 1 | | if an audit is initiated within the required retention period | 2 | | then the records must be retained until the audit is completed | 3 | | and every exception is resolved. The Illinois Department shall
| 4 | | require health care providers to make available, when | 5 | | authorized by the
patient, in writing, the medical records in a | 6 | | timely fashion to other
health care providers who are treating | 7 | | or serving persons eligible for
Medical Assistance under this | 8 | | Article. All dispensers of medical services
shall be required | 9 | | to maintain and retain business and professional records
| 10 | | sufficient to fully and accurately document the nature, scope, | 11 | | details and
receipt of the health care provided to persons | 12 | | eligible for medical
assistance under this Code, in accordance | 13 | | with regulations promulgated by
the Illinois Department. The | 14 | | rules and regulations shall require that proof
of the receipt | 15 | | of prescription drugs, dentures, prosthetic devices and
| 16 | | eyeglasses by eligible persons under this Section accompany | 17 | | each claim
for reimbursement submitted by the dispenser of such | 18 | | medical services.
No such claims for reimbursement shall be | 19 | | approved for payment by the Illinois
Department without such | 20 | | proof of receipt, unless the Illinois Department
shall have put | 21 | | into effect and shall be operating a system of post-payment
| 22 | | audit and review which shall, on a sampling basis, be deemed | 23 | | adequate by
the Illinois Department to assure that such drugs, | 24 | | dentures, prosthetic
devices and eyeglasses for which payment | 25 | | is being made are actually being
received by eligible | 26 | | recipients. Within 90 days after September 16, 1984 (the |
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| 1 | | effective date of Public Act 83-1439), the Illinois Department | 2 | | shall establish a
current list of acquisition costs for all | 3 | | prosthetic devices and any
other items recognized as medical | 4 | | equipment and supplies reimbursable under
this Article and | 5 | | shall update such list on a quarterly basis, except that
the | 6 | | acquisition costs of all prescription drugs shall be updated no
| 7 | | less frequently than every 30 days as required by Section | 8 | | 5-5.12.
| 9 | | Notwithstanding any other law to the contrary, the Illinois | 10 | | Department shall, within 365 days after July 22, 2013 (the | 11 | | effective date of Public Act 98-104), establish procedures to | 12 | | permit skilled care facilities licensed under the Nursing Home | 13 | | Care Act to submit monthly billing claims for reimbursement | 14 | | purposes. Following development of these procedures, the | 15 | | Department shall, by July 1, 2016, test the viability of the | 16 | | new system and implement any necessary operational or | 17 | | structural changes to its information technology platforms in | 18 | | order to allow for the direct acceptance and payment of nursing | 19 | | home claims. | 20 | | Notwithstanding any other law to the contrary, the Illinois | 21 | | Department shall, within 365 days after August 15, 2014 (the | 22 | | effective date of Public Act 98-963), establish procedures to | 23 | | permit ID/DD facilities licensed under the ID/DD Community Care | 24 | | Act and MC/DD facilities licensed under the MC/DD Act to submit | 25 | | monthly billing claims for reimbursement purposes. Following | 26 | | development of these procedures, the Department shall have an |
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| 1 | | additional 365 days to test the viability of the new system and | 2 | | to ensure that any necessary operational or structural changes | 3 | | to its information technology platforms are implemented. | 4 | | The Illinois Department shall require all dispensers of | 5 | | medical
services, other than an individual practitioner or | 6 | | group of practitioners,
desiring to participate in the Medical | 7 | | Assistance program
established under this Article to disclose | 8 | | all financial, beneficial,
ownership, equity, surety or other | 9 | | interests in any and all firms,
corporations, partnerships, | 10 | | associations, business enterprises, joint
ventures, agencies, | 11 | | institutions or other legal entities providing any
form of | 12 | | health care services in this State under this Article.
| 13 | | The Illinois Department may require that all dispensers of | 14 | | medical
services desiring to participate in the medical | 15 | | assistance program
established under this Article disclose, | 16 | | under such terms and conditions as
the Illinois Department may | 17 | | by rule establish, all inquiries from clients
and attorneys | 18 | | regarding medical bills paid by the Illinois Department, which
| 19 | | inquiries could indicate potential existence of claims or liens | 20 | | for the
Illinois Department.
| 21 | | Enrollment of a vendor
shall be
subject to a provisional | 22 | | period and shall be conditional for one year. During the period | 23 | | of conditional enrollment, the Department may
terminate the | 24 | | vendor's eligibility to participate in, or may disenroll the | 25 | | vendor from, the medical assistance
program without cause. | 26 | | Unless otherwise specified, such termination of eligibility or |
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| 1 | | disenrollment is not subject to the
Department's hearing | 2 | | process.
However, a disenrolled vendor may reapply without | 3 | | penalty.
| 4 | | The Department has the discretion to limit the conditional | 5 | | enrollment period for vendors based upon category of risk of | 6 | | the vendor. | 7 | | Prior to enrollment and during the conditional enrollment | 8 | | period in the medical assistance program, all vendors shall be | 9 | | subject to enhanced oversight, screening, and review based on | 10 | | the risk of fraud, waste, and abuse that is posed by the | 11 | | category of risk of the vendor. The Illinois Department shall | 12 | | establish the procedures for oversight, screening, and review, | 13 | | which may include, but need not be limited to: criminal and | 14 | | financial background checks; fingerprinting; license, | 15 | | certification, and authorization verifications; unscheduled or | 16 | | unannounced site visits; database checks; prepayment audit | 17 | | reviews; audits; payment caps; payment suspensions; and other | 18 | | screening as required by federal or State law. | 19 | | The Department shall define or specify the following: (i) | 20 | | by provider notice, the "category of risk of the vendor" for | 21 | | each type of vendor, which shall take into account the level of | 22 | | screening applicable to a particular category of vendor under | 23 | | federal law and regulations; (ii) by rule or provider notice, | 24 | | the maximum length of the conditional enrollment period for | 25 | | each category of risk of the vendor; and (iii) by rule, the | 26 | | hearing rights, if any, afforded to a vendor in each category |
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| 1 | | of risk of the vendor that is terminated or disenrolled during | 2 | | the conditional enrollment period. | 3 | | To be eligible for payment consideration, a vendor's | 4 | | payment claim or bill, either as an initial claim or as a | 5 | | resubmitted claim following prior rejection, must be received | 6 | | by the Illinois Department, or its fiscal intermediary, no | 7 | | later than 180 days after the latest date on the claim on which | 8 | | medical goods or services were provided, with the following | 9 | | exceptions: | 10 | | (1) In the case of a provider whose enrollment is in | 11 | | process by the Illinois Department, the 180-day period | 12 | | shall not begin until the date on the written notice from | 13 | | the Illinois Department that the provider enrollment is | 14 | | complete. | 15 | | (2) In the case of errors attributable to the Illinois | 16 | | Department or any of its claims processing intermediaries | 17 | | which result in an inability to receive, process, or | 18 | | adjudicate a claim, the 180-day period shall not begin | 19 | | until the provider has been notified of the error. | 20 | | (3) In the case of a provider for whom the Illinois | 21 | | Department initiates the monthly billing process. | 22 | | (4) In the case of a provider operated by a unit of | 23 | | local government with a population exceeding 3,000,000 | 24 | | when local government funds finance federal participation | 25 | | for claims payments. | 26 | | For claims for services rendered during a period for which |
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| 1 | | a recipient received retroactive eligibility, claims must be | 2 | | filed within 180 days after the Department determines the | 3 | | applicant is eligible. For claims for which the Illinois | 4 | | Department is not the primary payer, claims must be submitted | 5 | | to the Illinois Department within 180 days after the final | 6 | | adjudication by the primary payer. | 7 | | In the case of long term care facilities, within 45 | 8 | | calendar days of receipt by the facility of required | 9 | | prescreening information, new admissions with associated | 10 | | admission documents shall be submitted through the Medical | 11 | | Electronic Data Interchange (MEDI) or the Recipient | 12 | | Eligibility Verification (REV) System or shall be submitted | 13 | | directly to the Department of Human Services using required | 14 | | admission forms. Effective September
1, 2014, admission | 15 | | documents, including all prescreening
information, must be | 16 | | submitted through MEDI or REV. Confirmation numbers assigned to | 17 | | an accepted transaction shall be retained by a facility to | 18 | | verify timely submittal. Once an admission transaction has been | 19 | | completed, all resubmitted claims following prior rejection | 20 | | are subject to receipt no later than 180 days after the | 21 | | admission transaction has been completed. | 22 | | Claims that are not submitted and received in compliance | 23 | | with the foregoing requirements shall not be eligible for | 24 | | payment under the medical assistance program, and the State | 25 | | shall have no liability for payment of those claims. | 26 | | To the extent consistent with applicable information and |
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| 1 | | privacy, security, and disclosure laws, State and federal | 2 | | agencies and departments shall provide the Illinois Department | 3 | | access to confidential and other information and data necessary | 4 | | to perform eligibility and payment verifications and other | 5 | | Illinois Department functions. This includes, but is not | 6 | | limited to: information pertaining to licensure; | 7 | | certification; earnings; immigration status; citizenship; wage | 8 | | reporting; unearned and earned income; pension income; | 9 | | employment; supplemental security income; social security | 10 | | numbers; National Provider Identifier (NPI) numbers; the | 11 | | National Practitioner Data Bank (NPDB); program and agency | 12 | | exclusions; taxpayer identification numbers; tax delinquency; | 13 | | corporate information; and death records. | 14 | | The Illinois Department shall enter into agreements with | 15 | | State agencies and departments, and is authorized to enter into | 16 | | agreements with federal agencies and departments, under which | 17 | | such agencies and departments shall share data necessary for | 18 | | medical assistance program integrity functions and oversight. | 19 | | The Illinois Department shall develop, in cooperation with | 20 | | other State departments and agencies, and in compliance with | 21 | | applicable federal laws and regulations, appropriate and | 22 | | effective methods to share such data. At a minimum, and to the | 23 | | extent necessary to provide data sharing, the Illinois | 24 | | Department shall enter into agreements with State agencies and | 25 | | departments, and is authorized to enter into agreements with | 26 | | federal agencies and departments, including but not limited to: |
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| 1 | | the Secretary of State; the Department of Revenue; the | 2 | | Department of Public Health; the Department of Human Services; | 3 | | and the Department of Financial and Professional Regulation. | 4 | | Beginning in fiscal year 2013, the Illinois Department | 5 | | shall set forth a request for information to identify the | 6 | | benefits of a pre-payment, post-adjudication, and post-edit | 7 | | claims system with the goals of streamlining claims processing | 8 | | and provider reimbursement, reducing the number of pending or | 9 | | rejected claims, and helping to ensure a more transparent | 10 | | adjudication process through the utilization of: (i) provider | 11 | | data verification and provider screening technology; and (ii) | 12 | | clinical code editing; and (iii) pre-pay, pre- or | 13 | | post-adjudicated predictive modeling with an integrated case | 14 | | management system with link analysis. Such a request for | 15 | | information shall not be considered as a request for proposal | 16 | | or as an obligation on the part of the Illinois Department to | 17 | | take any action or acquire any products or services. | 18 | | The Illinois Department shall establish policies, | 19 | | procedures,
standards and criteria by rule for the acquisition, | 20 | | repair and replacement
of orthotic and prosthetic devices and | 21 | | durable medical equipment. Such
rules shall provide, but not be | 22 | | limited to, the following services: (1)
immediate repair or | 23 | | replacement of such devices by recipients; and (2) rental, | 24 | | lease, purchase or lease-purchase of
durable medical equipment | 25 | | in a cost-effective manner, taking into
consideration the | 26 | | recipient's medical prognosis, the extent of the
recipient's |
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| 1 | | needs, and the requirements and costs for maintaining such
| 2 | | equipment. Subject to prior approval, such rules shall enable a | 3 | | recipient to temporarily acquire and
use alternative or | 4 | | substitute devices or equipment pending repairs or
| 5 | | replacements of any device or equipment previously authorized | 6 | | for such
recipient by the Department. Notwithstanding any | 7 | | provision of Section 5-5f to the contrary, the Department may, | 8 | | by rule, exempt certain replacement wheelchair parts from prior | 9 | | approval and, for wheelchairs, wheelchair parts, wheelchair | 10 | | accessories, and related seating and positioning items, | 11 | | determine the wholesale price by methods other than actual | 12 | | acquisition costs. | 13 | | The Department shall require, by rule, all providers of | 14 | | durable medical equipment to be accredited by an accreditation | 15 | | organization approved by the federal Centers for Medicare and | 16 | | Medicaid Services and recognized by the Department in order to | 17 | | bill the Department for providing durable medical equipment to | 18 | | recipients. No later than 15 months after the effective date of | 19 | | the rule adopted pursuant to this paragraph, all providers must | 20 | | meet the accreditation requirement.
| 21 | | The Department shall execute, relative to the nursing home | 22 | | prescreening
project, written inter-agency agreements with the | 23 | | Department of Human
Services and the Department on Aging, to | 24 | | effect the following: (i) intake
procedures and common | 25 | | eligibility criteria for those persons who are receiving
| 26 | | non-institutional services; and (ii) the establishment and |
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| 1 | | development of
non-institutional services in areas of the State | 2 | | where they are not currently
available or are undeveloped; and | 3 | | (iii) notwithstanding any other provision of law, subject to | 4 | | federal approval, on and after July 1, 2012, an increase in the | 5 | | determination of need (DON) scores from 29 to 37 for applicants | 6 | | for institutional and home and community-based long term care; | 7 | | if and only if federal approval is not granted, the Department | 8 | | may, in conjunction with other affected agencies, implement | 9 | | utilization controls or changes in benefit packages to | 10 | | effectuate a similar savings amount for this population; and | 11 | | (iv) no later than July 1, 2013, minimum level of care | 12 | | eligibility criteria for institutional and home and | 13 | | community-based long term care; and (v) no later than October | 14 | | 1, 2013, establish procedures to permit long term care | 15 | | providers access to eligibility scores for individuals with an | 16 | | admission date who are seeking or receiving services from the | 17 | | long term care provider. In order to select the minimum level | 18 | | of care eligibility criteria, the Governor shall establish a | 19 | | workgroup that includes affected agency representatives and | 20 | | stakeholders representing the institutional and home and | 21 | | community-based long term care interests. This Section shall | 22 | | not restrict the Department from implementing lower level of | 23 | | care eligibility criteria for community-based services in | 24 | | circumstances where federal approval has been granted.
| 25 | | The Illinois Department shall develop and operate, in | 26 | | cooperation
with other State Departments and agencies and in |
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| 1 | | compliance with
applicable federal laws and regulations, | 2 | | appropriate and effective
systems of health care evaluation and | 3 | | programs for monitoring of
utilization of health care services | 4 | | and facilities, as it affects
persons eligible for medical | 5 | | assistance under this Code.
| 6 | | The Illinois Department shall report annually to the | 7 | | General Assembly,
no later than the second Friday in April of | 8 | | 1979 and each year
thereafter, in regard to:
| 9 | | (a) actual statistics and trends in utilization of | 10 | | medical services by
public aid recipients;
| 11 | | (b) actual statistics and trends in the provision of | 12 | | the various medical
services by medical vendors;
| 13 | | (c) current rate structures and proposed changes in | 14 | | those rate structures
for the various medical vendors; and
| 15 | | (d) efforts at utilization review and control by the | 16 | | Illinois Department.
| 17 | | The period covered by each report shall be the 3 years | 18 | | ending on the June
30 prior to the report. The report shall | 19 | | include suggested legislation
for consideration by the General | 20 | | Assembly. The filing of one copy of the
report with the | 21 | | Speaker, one copy with the Minority Leader and one copy
with | 22 | | the Clerk of the House of Representatives, one copy with the | 23 | | President,
one copy with the Minority Leader and one copy with | 24 | | the Secretary of the
Senate, one copy with the Legislative | 25 | | Research Unit, and such additional
copies
with the State | 26 | | Government Report Distribution Center for the General
Assembly |
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| 1 | | as is required under paragraph (t) of Section 7 of the State
| 2 | | Library Act shall be deemed sufficient to comply with this | 3 | | Section.
| 4 | | Rulemaking authority to implement Public Act 95-1045, if | 5 | | any, is conditioned on the rules being adopted in accordance | 6 | | with all provisions of the Illinois Administrative Procedure | 7 | | Act and all rules and procedures of the Joint Committee on | 8 | | Administrative Rules; any purported rule not so adopted, for | 9 | | whatever reason, is unauthorized. | 10 | | On and after July 1, 2012, the Department shall reduce any | 11 | | rate of reimbursement for services or other payments or alter | 12 | | any methodologies authorized by this Code to reduce any rate of | 13 | | reimbursement for services or other payments in accordance with | 14 | | Section 5-5e. | 15 | | Because kidney transplantation can be an appropriate, cost | 16 | | effective
alternative to renal dialysis when medically | 17 | | necessary and notwithstanding the provisions of Section 1-11 of | 18 | | this Code, beginning October 1, 2014, the Department shall | 19 | | cover kidney transplantation for noncitizens with end-stage | 20 | | renal disease who are not eligible for comprehensive medical | 21 | | benefits, who meet the residency requirements of Section 5-3 of | 22 | | this Code, and who would otherwise meet the financial | 23 | | requirements of the appropriate class of eligible persons under | 24 | | Section 5-2 of this Code. To qualify for coverage of kidney | 25 | | transplantation, such person must be receiving emergency renal | 26 | | dialysis services covered by the Department. Providers under |
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| 1 | | this Section shall be prior approved and certified by the | 2 | | Department to perform kidney transplantation and the services | 3 | | under this Section shall be limited to services associated with | 4 | | kidney transplantation. | 5 | | Notwithstanding any other provision of this Code to the | 6 | | contrary, on or after July 1, 2015, all FDA approved forms of | 7 | | medication assisted treatment prescribed for the treatment of | 8 | | alcohol dependence or treatment of opioid dependence shall be | 9 | | covered under both fee for service and managed care medical | 10 | | assistance programs for persons who are otherwise eligible for | 11 | | medical assistance under this Article and shall not be subject | 12 | | to any (1) utilization control, other than those established | 13 | | under the American Society of Addiction Medicine patient | 14 | | placement criteria,
(2) prior authorization mandate, or (3) | 15 | | lifetime restriction limit
mandate. | 16 | | On or after July 1, 2015, opioid antagonists prescribed for | 17 | | the treatment of an opioid overdose, including the medication | 18 | | product, administration devices, and any pharmacy fees related | 19 | | to the dispensing and administration of the opioid antagonist, | 20 | | shall be covered under the medical assistance program for | 21 | | persons who are otherwise eligible for medical assistance under | 22 | | this Article. As used in this Section, "opioid antagonist" | 23 | | means a drug that binds to opioid receptors and blocks or | 24 | | inhibits the effect of opioids acting on those receptors, | 25 | | including, but not limited to, naloxone hydrochloride or any | 26 | | other similarly acting drug approved by the U.S. Food and Drug |
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| 1 | | Administration. | 2 | | Upon federal approval, the Department shall provide | 3 | | coverage and reimbursement for all drugs that are approved for | 4 | | marketing by the federal Food and Drug Administration and that | 5 | | are recommended by the federal Public Health Service or the | 6 | | United States Centers for Disease Control and Prevention for | 7 | | pre-exposure prophylaxis and related pre-exposure prophylaxis | 8 | | services, including, but not limited to, HIV and sexually | 9 | | transmitted infection screening, treatment for sexually | 10 | | transmitted infections, medical monitoring, assorted labs, and | 11 | | counseling to reduce the likelihood of HIV infection among | 12 | | individuals who are not infected with HIV but who are at high | 13 | | risk of HIV infection. | 14 | | (Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15; | 15 | | 99-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for | 16 | | the effective date of P.A. 99-407); 99-433, eff. 8-21-15; | 17 | | 99-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff. | 18 | | 7-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201, | 19 | | eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18; | 20 | | 100-538, eff. 1-1-18; revised 10-26-17.)
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