Full Text of HB5273 101st General Assembly
HB5273 101ST GENERAL ASSEMBLY |
| | 101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020 HB5273 Introduced , by Rep. Sonya M. Harper SYNOPSIS AS INTRODUCED: |
| 305 ILCS 5/5-5 | from Ch. 23, par. 5-5 |
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Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that social and emotional screenings for children that are conducted during a health examination shall be covered under the medical assistance program, subject to appropriations. Effective immediately.
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| | | FISCAL NOTE ACT MAY APPLY | |
| | A BILL FOR |
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| 1 | | AN ACT concerning public aid.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Public Aid Code is amended by | 5 | | changing Section 5-5 as follows:
| 6 | | (305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
| 7 | | Sec. 5-5. Medical services. The Illinois Department, by | 8 | | rule, shall
determine the quantity and quality of and the rate | 9 | | of reimbursement for the
medical assistance for which
payment | 10 | | will be authorized, and the medical services to be provided,
| 11 | | which may include all or part of the following: (1) inpatient | 12 | | hospital
services; (2) outpatient hospital services; (3) other | 13 | | laboratory and
X-ray services; (4) skilled nursing home | 14 | | services; (5) physicians'
services whether furnished in the | 15 | | office, the patient's home, a
hospital, a skilled nursing home, | 16 | | or elsewhere; (6) medical care, or any
other type of remedial | 17 | | care furnished by licensed practitioners; (7)
home health care | 18 | | services; (8) private duty nursing service; (9) clinic
| 19 | | services; (10) dental services, including prevention and | 20 | | treatment of periodontal disease and dental caries disease for | 21 | | pregnant women, provided by an individual licensed to practice | 22 | | dentistry or dental surgery; for purposes of this item (10), | 23 | | "dental services" means diagnostic, preventive, or corrective |
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| 1 | | procedures provided by or under the supervision of a dentist in | 2 | | the practice of his or her profession; (11) physical therapy | 3 | | and related
services; (12) prescribed drugs, dentures, and | 4 | | prosthetic devices; and
eyeglasses prescribed by a physician | 5 | | skilled in the diseases of the eye,
or by an optometrist, | 6 | | whichever the person may select; (13) other
diagnostic, | 7 | | screening, preventive, and rehabilitative services, including | 8 | | to ensure that the individual's need for intervention or | 9 | | treatment of mental disorders or substance use disorders or | 10 | | co-occurring mental health and substance use disorders is | 11 | | determined using a uniform screening, assessment, and | 12 | | evaluation process inclusive of criteria, for children and | 13 | | adults; for purposes of this item (13), a uniform screening, | 14 | | assessment, and evaluation process refers to a process that | 15 | | includes an appropriate evaluation and, as warranted, a | 16 | | referral; "uniform" does not mean the use of a singular | 17 | | instrument, tool, or process that all must utilize; (14)
| 18 | | transportation and such other expenses as may be necessary; | 19 | | (15) medical
treatment of sexual assault survivors, as defined | 20 | | in
Section 1a of the Sexual Assault Survivors Emergency | 21 | | Treatment Act, for
injuries sustained as a result of the sexual | 22 | | assault, including
examinations and laboratory tests to | 23 | | discover evidence which may be used in
criminal proceedings | 24 | | arising from the sexual assault; (16) the
diagnosis and | 25 | | treatment of sickle cell anemia; and (17)
any other medical | 26 | | care, and any other type of remedial care recognized
under the |
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| 1 | | laws of this State. The term "any other type of remedial care" | 2 | | shall
include nursing care and nursing home service for persons | 3 | | who rely on
treatment by spiritual means alone through prayer | 4 | | for healing.
| 5 | | Notwithstanding any other provision of this Section, a | 6 | | comprehensive
tobacco use cessation program that includes | 7 | | purchasing prescription drugs or
prescription medical devices | 8 | | approved by the Food and Drug Administration shall
be covered | 9 | | under the medical assistance
program under this Article for | 10 | | persons who are otherwise eligible for
assistance under this | 11 | | Article.
| 12 | | Notwithstanding any other provision of this Code, | 13 | | reproductive health care that is otherwise legal in Illinois | 14 | | shall be covered under the medical assistance program for | 15 | | persons who are otherwise eligible for medical assistance under | 16 | | this Article. | 17 | | Notwithstanding any other provision of this Code, the | 18 | | Illinois
Department may not require, as a condition of payment | 19 | | for any laboratory
test authorized under this Article, that a | 20 | | physician's handwritten signature
appear on the laboratory | 21 | | test order form. The Illinois Department may,
however, impose | 22 | | other appropriate requirements regarding laboratory test
order | 23 | | documentation.
| 24 | | Upon receipt of federal approval of an amendment to the | 25 | | Illinois Title XIX State Plan for this purpose, the Department | 26 | | shall authorize the Chicago Public Schools (CPS) to procure a |
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| 1 | | vendor or vendors to manufacture eyeglasses for individuals | 2 | | enrolled in a school within the CPS system. CPS shall ensure | 3 | | that its vendor or vendors are enrolled as providers in the | 4 | | medical assistance program and in any capitated Medicaid | 5 | | managed care entity (MCE) serving individuals enrolled in a | 6 | | school within the CPS system. Under any contract procured under | 7 | | this provision, the vendor or vendors must serve only | 8 | | individuals enrolled in a school within the CPS system. Claims | 9 | | for services provided by CPS's vendor or vendors to recipients | 10 | | of benefits in the medical assistance program under this Code, | 11 | | the Children's Health Insurance Program, or the Covering ALL | 12 | | KIDS Health Insurance Program shall be submitted to the | 13 | | Department or the MCE in which the individual is enrolled for | 14 | | payment and shall be reimbursed at the Department's or the | 15 | | MCE's established rates or rate methodologies for eyeglasses. | 16 | | On and after July 1, 2012, the Department of Healthcare and | 17 | | Family Services may provide the following services to
persons
| 18 | | eligible for assistance under this Article who are | 19 | | participating in
education, training or employment programs | 20 | | operated by the Department of Human
Services as successor to | 21 | | the Department of Public Aid:
| 22 | | (1) dental services provided by or under the | 23 | | supervision of a dentist; and
| 24 | | (2) eyeglasses prescribed by a physician skilled in the | 25 | | diseases of the
eye, or by an optometrist, whichever the | 26 | | person may select.
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| 1 | | On and after July 1, 2018, the Department of Healthcare and | 2 | | Family Services shall provide dental services to any adult who | 3 | | is otherwise eligible for assistance under the medical | 4 | | assistance program. As used in this paragraph, "dental | 5 | | services" means diagnostic, preventative, restorative, or | 6 | | corrective procedures, including procedures and services for | 7 | | the prevention and treatment of periodontal disease and dental | 8 | | caries disease, provided by an individual who is licensed to | 9 | | practice dentistry or dental surgery or who is under the | 10 | | supervision of a dentist in the practice of his or her | 11 | | profession. | 12 | | On and after July 1, 2018, targeted dental services, as set | 13 | | forth in Exhibit D of the Consent Decree entered by the United | 14 | | States District Court for the Northern District of Illinois, | 15 | | Eastern Division, in the matter of Memisovski v. Maram, Case | 16 | | No. 92 C 1982, that are provided to adults under the medical | 17 | | assistance program shall be established at no less than the | 18 | | rates set forth in the "New Rate" column in Exhibit D of the | 19 | | Consent Decree for targeted dental services that are provided | 20 | | to persons under the age of 18 under the medical assistance | 21 | | program. | 22 | | Notwithstanding any other provision of this Code and | 23 | | subject to federal approval, the Department may adopt rules to | 24 | | allow a dentist who is volunteering his or her service at no | 25 | | cost to render dental services through an enrolled | 26 | | not-for-profit health clinic without the dentist personally |
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| 1 | | enrolling as a participating provider in the medical assistance | 2 | | program. A not-for-profit health clinic shall include a public | 3 | | health clinic or Federally Qualified Health Center or other | 4 | | enrolled provider, as determined by the Department, through | 5 | | which dental services covered under this Section are performed. | 6 | | The Department shall establish a process for payment of claims | 7 | | for reimbursement for covered dental services rendered under | 8 | | this provision. | 9 | | The Illinois Department, by rule, may distinguish and | 10 | | classify the
medical services to be provided only in accordance | 11 | | with the classes of
persons designated in Section 5-2.
| 12 | | The Department of Healthcare and Family Services must | 13 | | provide coverage and reimbursement for amino acid-based | 14 | | elemental formulas, regardless of delivery method, for the | 15 | | diagnosis and treatment of (i) eosinophilic disorders and (ii) | 16 | | short bowel syndrome when the prescribing physician has issued | 17 | | a written order stating that the amino acid-based elemental | 18 | | formula is medically necessary.
| 19 | | The Illinois Department shall authorize the provision of, | 20 | | and shall
authorize payment for, screening by low-dose | 21 | | mammography for the presence of
occult breast cancer for women | 22 | | 35 years of age or older who are eligible
for medical | 23 | | assistance under this Article, as follows: | 24 | | (A) A baseline
mammogram for women 35 to 39 years of | 25 | | age.
| 26 | | (B) An annual mammogram for women 40 years of age or |
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| 1 | | older. | 2 | | (C) A mammogram at the age and intervals considered | 3 | | medically necessary by the woman's health care provider for | 4 | | women under 40 years of age and having a family history of | 5 | | breast cancer, prior personal history of breast cancer, | 6 | | positive genetic testing, or other risk factors. | 7 | | (D) A comprehensive ultrasound screening and MRI of an | 8 | | entire breast or breasts if a mammogram demonstrates | 9 | | heterogeneous or dense breast tissue or when medically | 10 | | necessary as determined by a physician licensed to practice | 11 | | medicine in all of its branches. | 12 | | (E) A screening MRI when medically necessary, as | 13 | | determined by a physician licensed to practice medicine in | 14 | | all of its branches. | 15 | | (F) A diagnostic mammogram when medically necessary, | 16 | | as determined by a physician licensed to practice medicine | 17 | | in all its branches, advanced practice registered nurse, or | 18 | | physician assistant. | 19 | | The Department shall not impose a deductible, coinsurance, | 20 | | copayment, or any other cost-sharing requirement on the | 21 | | coverage provided under this paragraph; except that this | 22 | | sentence does not apply to coverage of diagnostic mammograms to | 23 | | the extent such coverage would disqualify a high-deductible | 24 | | health plan from eligibility for a health savings account | 25 | | pursuant to Section 223 of the Internal Revenue Code (26 U.S.C. | 26 | | 223). |
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| 1 | | All screenings
shall
include a physical breast exam, | 2 | | instruction on self-examination and
information regarding the | 3 | | frequency of self-examination and its value as a
preventative | 4 | | tool. | 5 | | For purposes of this Section: | 6 | | "Diagnostic
mammogram" means a mammogram obtained using | 7 | | diagnostic mammography. | 8 | | "Diagnostic
mammography" means a method of screening that | 9 | | is designed to
evaluate an abnormality in a breast, including | 10 | | an abnormality seen
or suspected on a screening mammogram or a | 11 | | subjective or objective
abnormality otherwise detected in the | 12 | | breast. | 13 | | "Low-dose mammography" means
the x-ray examination of the | 14 | | breast using equipment dedicated specifically
for mammography, | 15 | | including the x-ray tube, filter, compression device,
and image | 16 | | receptor, with an average radiation exposure delivery
of less | 17 | | than one rad per breast for 2 views of an average size breast.
| 18 | | The term also includes digital mammography and includes breast | 19 | | tomosynthesis. | 20 | | "Breast tomosynthesis" means a radiologic procedure that | 21 | | involves the acquisition of projection images over the | 22 | | stationary breast to produce cross-sectional digital | 23 | | three-dimensional images of the breast. | 24 | | If, at any time, the Secretary of the United States | 25 | | Department of Health and Human Services, or its successor | 26 | | agency, promulgates rules or regulations to be published in the |
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| 1 | | Federal Register or publishes a comment in the Federal Register | 2 | | or issues an opinion, guidance, or other action that would | 3 | | require the State, pursuant to any provision of the Patient | 4 | | Protection and Affordable Care Act (Public Law 111-148), | 5 | | including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any | 6 | | successor provision, to defray the cost of any coverage for | 7 | | breast tomosynthesis outlined in this paragraph, then the | 8 | | requirement that an insurer cover breast tomosynthesis is | 9 | | inoperative other than any such coverage authorized under | 10 | | Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and | 11 | | the State shall not assume any obligation for the cost of | 12 | | coverage for breast tomosynthesis set forth in this paragraph.
| 13 | | On and after January 1, 2016, the Department shall ensure | 14 | | that all networks of care for adult clients of the Department | 15 | | include access to at least one breast imaging Center of Imaging | 16 | | Excellence as certified by the American College of Radiology. | 17 | | On and after January 1, 2012, providers participating in a | 18 | | quality improvement program approved by the Department shall be | 19 | | reimbursed for screening and diagnostic mammography at the same | 20 | | rate as the Medicare program's rates, including the increased | 21 | | reimbursement for digital mammography. | 22 | | The Department shall convene an expert panel including | 23 | | representatives of hospitals, free-standing mammography | 24 | | facilities, and doctors, including radiologists, to establish | 25 | | quality standards for mammography. | 26 | | On and after January 1, 2017, providers participating in a |
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| 1 | | breast cancer treatment quality improvement program approved | 2 | | by the Department shall be reimbursed for breast cancer | 3 | | treatment at a rate that is no lower than 95% of the Medicare | 4 | | program's rates for the data elements included in the breast | 5 | | cancer treatment quality program. | 6 | | The Department shall convene an expert panel, including | 7 | | representatives of hospitals, free-standing breast cancer | 8 | | treatment centers, breast cancer quality organizations, and | 9 | | doctors, including breast surgeons, reconstructive breast | 10 | | surgeons, oncologists, and primary care providers to establish | 11 | | quality standards for breast cancer treatment. | 12 | | Subject to federal approval, the Department shall | 13 | | establish a rate methodology for mammography at federally | 14 | | qualified health centers and other encounter-rate clinics. | 15 | | These clinics or centers may also collaborate with other | 16 | | hospital-based mammography facilities. By January 1, 2016, the | 17 | | Department shall report to the General Assembly on the status | 18 | | of the provision set forth in this paragraph. | 19 | | The Department shall establish a methodology to remind | 20 | | women who are age-appropriate for screening mammography, but | 21 | | who have not received a mammogram within the previous 18 | 22 | | months, of the importance and benefit of screening mammography. | 23 | | The Department shall work with experts in breast cancer | 24 | | outreach and patient navigation to optimize these reminders and | 25 | | shall establish a methodology for evaluating their | 26 | | effectiveness and modifying the methodology based on the |
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| 1 | | evaluation. | 2 | | The Department shall establish a performance goal for | 3 | | primary care providers with respect to their female patients | 4 | | over age 40 receiving an annual mammogram. This performance | 5 | | goal shall be used to provide additional reimbursement in the | 6 | | form of a quality performance bonus to primary care providers | 7 | | who meet that goal. | 8 | | The Department shall devise a means of case-managing or | 9 | | patient navigation for beneficiaries diagnosed with breast | 10 | | cancer. This program shall initially operate as a pilot program | 11 | | in areas of the State with the highest incidence of mortality | 12 | | related to breast cancer. At least one pilot program site shall | 13 | | be in the metropolitan Chicago area and at least one site shall | 14 | | be outside the metropolitan Chicago area. On or after July 1, | 15 | | 2016, the pilot program shall be expanded to include one site | 16 | | in western Illinois, one site in southern Illinois, one site in | 17 | | central Illinois, and 4 sites within metropolitan Chicago. An | 18 | | evaluation of the pilot program shall be carried out measuring | 19 | | health outcomes and cost of care for those served by the pilot | 20 | | program compared to similarly situated patients who are not | 21 | | served by the pilot program. | 22 | | The Department shall require all networks of care to | 23 | | develop a means either internally or by contract with experts | 24 | | in navigation and community outreach to navigate cancer | 25 | | patients to comprehensive care in a timely fashion. The | 26 | | Department shall require all networks of care to include access |
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| 1 | | for patients diagnosed with cancer to at least one academic | 2 | | commission on cancer-accredited cancer program as an | 3 | | in-network covered benefit. | 4 | | Any medical or health care provider shall immediately | 5 | | recommend, to
any pregnant woman who is being provided prenatal | 6 | | services and is suspected
of having a substance use disorder as | 7 | | defined in the Substance Use Disorder Act, referral to a local | 8 | | substance use disorder treatment program licensed by the | 9 | | Department of Human Services or to a licensed
hospital which | 10 | | provides substance abuse treatment services. The Department of | 11 | | Healthcare and Family Services
shall assure coverage for the | 12 | | cost of treatment of the drug abuse or
addiction for pregnant | 13 | | recipients in accordance with the Illinois Medicaid
Program in | 14 | | conjunction with the Department of Human Services.
| 15 | | All medical providers providing medical assistance to | 16 | | pregnant women
under this Code shall receive information from | 17 | | the Department on the
availability of services under any
| 18 | | program providing case management services for addicted women,
| 19 | | including information on appropriate referrals for other | 20 | | social services
that may be needed by addicted women in | 21 | | addition to treatment for addiction.
| 22 | | The Illinois Department, in cooperation with the | 23 | | Departments of Human
Services (as successor to the Department | 24 | | of Alcoholism and Substance
Abuse) and Public Health, through a | 25 | | public awareness campaign, may
provide information concerning | 26 | | treatment for alcoholism and drug abuse and
addiction, prenatal |
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| 1 | | health care, and other pertinent programs directed at
reducing | 2 | | the number of drug-affected infants born to recipients of | 3 | | medical
assistance.
| 4 | | Neither the Department of Healthcare and Family Services | 5 | | nor the Department of Human
Services shall sanction the | 6 | | recipient solely on the basis of
her substance abuse.
| 7 | | The Illinois Department shall establish such regulations | 8 | | governing
the dispensing of health services under this Article | 9 | | as it shall deem
appropriate. The Department
should
seek the | 10 | | advice of formal professional advisory committees appointed by
| 11 | | the Director of the Illinois Department for the purpose of | 12 | | providing regular
advice on policy and administrative matters, | 13 | | information dissemination and
educational activities for | 14 | | medical and health care providers, and
consistency in | 15 | | procedures to the Illinois Department.
| 16 | | The Illinois Department may develop and contract with | 17 | | Partnerships of
medical providers to arrange medical services | 18 | | for persons eligible under
Section 5-2 of this Code. | 19 | | Implementation of this Section may be by
demonstration projects | 20 | | in certain geographic areas. The Partnership shall
be | 21 | | represented by a sponsor organization. The Department, by rule, | 22 | | shall
develop qualifications for sponsors of Partnerships. | 23 | | Nothing in this
Section shall be construed to require that the | 24 | | sponsor organization be a
medical organization.
| 25 | | The sponsor must negotiate formal written contracts with | 26 | | medical
providers for physician services, inpatient and |
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| 1 | | outpatient hospital care,
home health services, treatment for | 2 | | alcoholism and substance abuse, and
other services determined | 3 | | necessary by the Illinois Department by rule for
delivery by | 4 | | Partnerships. Physician services must include prenatal and
| 5 | | obstetrical care. The Illinois Department shall reimburse | 6 | | medical services
delivered by Partnership providers to clients | 7 | | in target areas according to
provisions of this Article and the | 8 | | Illinois Health Finance Reform Act,
except that:
| 9 | | (1) Physicians participating in a Partnership and | 10 | | providing certain
services, which shall be determined by | 11 | | the Illinois Department, to persons
in areas covered by the | 12 | | Partnership may receive an additional surcharge
for such | 13 | | services.
| 14 | | (2) The Department may elect to consider and negotiate | 15 | | financial
incentives to encourage the development of | 16 | | Partnerships and the efficient
delivery of medical care.
| 17 | | (3) Persons receiving medical services through | 18 | | Partnerships may receive
medical and case management | 19 | | services above the level usually offered
through the | 20 | | medical assistance program.
| 21 | | Medical providers shall be required to meet certain | 22 | | qualifications to
participate in Partnerships to ensure the | 23 | | delivery of high quality medical
services. These | 24 | | qualifications shall be determined by rule of the Illinois
| 25 | | Department and may be higher than qualifications for | 26 | | participation in the
medical assistance program. Partnership |
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| 1 | | sponsors may prescribe reasonable
additional qualifications | 2 | | for participation by medical providers, only with
the prior | 3 | | written approval of the Illinois Department.
| 4 | | Nothing in this Section shall limit the free choice of | 5 | | practitioners,
hospitals, and other providers of medical | 6 | | services by clients.
In order to ensure patient freedom of | 7 | | choice, the Illinois Department shall
immediately promulgate | 8 | | all rules and take all other necessary actions so that
provided | 9 | | services may be accessed from therapeutically certified | 10 | | optometrists
to the full extent of the Illinois Optometric | 11 | | Practice Act of 1987 without
discriminating between service | 12 | | providers.
| 13 | | The Department shall apply for a waiver from the United | 14 | | States Health
Care Financing Administration to allow for the | 15 | | implementation of
Partnerships under this Section.
| 16 | | The Illinois Department shall require health care | 17 | | providers to maintain
records that document the medical care | 18 | | and services provided to recipients
of Medical Assistance under | 19 | | this Article. Such records must be retained for a period of not | 20 | | less than 6 years from the date of service or as provided by | 21 | | applicable State law, whichever period is longer, except that | 22 | | if an audit is initiated within the required retention period | 23 | | then the records must be retained until the audit is completed | 24 | | and every exception is resolved. The Illinois Department shall
| 25 | | require health care providers to make available, when | 26 | | authorized by the
patient, in writing, the medical records in a |
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| 1 | | timely fashion to other
health care providers who are treating | 2 | | or serving persons eligible for
Medical Assistance under this | 3 | | Article. All dispensers of medical services
shall be required | 4 | | to maintain and retain business and professional records
| 5 | | sufficient to fully and accurately document the nature, scope, | 6 | | details and
receipt of the health care provided to persons | 7 | | eligible for medical
assistance under this Code, in accordance | 8 | | with regulations promulgated by
the Illinois Department. The | 9 | | rules and regulations shall require that proof
of the receipt | 10 | | of prescription drugs, dentures, prosthetic devices and
| 11 | | eyeglasses by eligible persons under this Section accompany | 12 | | each claim
for reimbursement submitted by the dispenser of such | 13 | | medical services.
No such claims for reimbursement shall be | 14 | | approved for payment by the Illinois
Department without such | 15 | | proof of receipt, unless the Illinois Department
shall have put | 16 | | into effect and shall be operating a system of post-payment
| 17 | | audit and review which shall, on a sampling basis, be deemed | 18 | | adequate by
the Illinois Department to assure that such drugs, | 19 | | dentures, prosthetic
devices and eyeglasses for which payment | 20 | | is being made are actually being
received by eligible | 21 | | recipients. Within 90 days after September 16, 1984 (the | 22 | | effective date of Public Act 83-1439), the Illinois Department | 23 | | shall establish a
current list of acquisition costs for all | 24 | | prosthetic devices and any
other items recognized as medical | 25 | | equipment and supplies reimbursable under
this Article and | 26 | | shall update such list on a quarterly basis, except that
the |
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| 1 | | acquisition costs of all prescription drugs shall be updated no
| 2 | | less frequently than every 30 days as required by Section | 3 | | 5-5.12.
| 4 | | Notwithstanding any other law to the contrary, the Illinois | 5 | | Department shall, within 365 days after July 22, 2013 (the | 6 | | effective date of Public Act 98-104), establish procedures to | 7 | | permit skilled care facilities licensed under the Nursing Home | 8 | | Care Act to submit monthly billing claims for reimbursement | 9 | | purposes. Following development of these procedures, the | 10 | | Department shall, by July 1, 2016, test the viability of the | 11 | | new system and implement any necessary operational or | 12 | | structural changes to its information technology platforms in | 13 | | order to allow for the direct acceptance and payment of nursing | 14 | | home claims. | 15 | | Notwithstanding any other law to the contrary, the Illinois | 16 | | Department shall, within 365 days after August 15, 2014 (the | 17 | | effective date of Public Act 98-963), establish procedures to | 18 | | permit ID/DD facilities licensed under the ID/DD Community Care | 19 | | Act and MC/DD facilities licensed under the MC/DD Act to submit | 20 | | monthly billing claims for reimbursement purposes. Following | 21 | | development of these procedures, the Department shall have an | 22 | | additional 365 days to test the viability of the new system and | 23 | | to ensure that any necessary operational or structural changes | 24 | | to its information technology platforms are implemented. | 25 | | The Illinois Department shall require all dispensers of | 26 | | medical
services, other than an individual practitioner or |
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| 1 | | group of practitioners,
desiring to participate in the Medical | 2 | | Assistance program
established under this Article to disclose | 3 | | all financial, beneficial,
ownership, equity, surety or other | 4 | | interests in any and all firms,
corporations, partnerships, | 5 | | associations, business enterprises, joint
ventures, agencies, | 6 | | institutions or other legal entities providing any
form of | 7 | | health care services in this State under this Article.
| 8 | | The Illinois Department may require that all dispensers of | 9 | | medical
services desiring to participate in the medical | 10 | | assistance program
established under this Article disclose, | 11 | | under such terms and conditions as
the Illinois Department may | 12 | | by rule establish, all inquiries from clients
and attorneys | 13 | | regarding medical bills paid by the Illinois Department, which
| 14 | | inquiries could indicate potential existence of claims or liens | 15 | | for the
Illinois Department.
| 16 | | Enrollment of a vendor
shall be
subject to a provisional | 17 | | period and shall be conditional for one year. During the period | 18 | | of conditional enrollment, the Department may
terminate the | 19 | | vendor's eligibility to participate in, or may disenroll the | 20 | | vendor from, the medical assistance
program without cause. | 21 | | Unless otherwise specified, such termination of eligibility or | 22 | | disenrollment is not subject to the
Department's hearing | 23 | | process.
However, a disenrolled vendor may reapply without | 24 | | penalty.
| 25 | | The Department has the discretion to limit the conditional | 26 | | enrollment period for vendors based upon category of risk of |
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| 1 | | the vendor. | 2 | | Prior to enrollment and during the conditional enrollment | 3 | | period in the medical assistance program, all vendors shall be | 4 | | subject to enhanced oversight, screening, and review based on | 5 | | the risk of fraud, waste, and abuse that is posed by the | 6 | | category of risk of the vendor. The Illinois Department shall | 7 | | establish the procedures for oversight, screening, and review, | 8 | | which may include, but need not be limited to: criminal and | 9 | | financial background checks; fingerprinting; license, | 10 | | certification, and authorization verifications; unscheduled or | 11 | | unannounced site visits; database checks; prepayment audit | 12 | | reviews; audits; payment caps; payment suspensions; and other | 13 | | screening as required by federal or State law. | 14 | | The Department shall define or specify the following: (i) | 15 | | by provider notice, the "category of risk of the vendor" for | 16 | | each type of vendor, which shall take into account the level of | 17 | | screening applicable to a particular category of vendor under | 18 | | federal law and regulations; (ii) by rule or provider notice, | 19 | | the maximum length of the conditional enrollment period for | 20 | | each category of risk of the vendor; and (iii) by rule, the | 21 | | hearing rights, if any, afforded to a vendor in each category | 22 | | of risk of the vendor that is terminated or disenrolled during | 23 | | the conditional enrollment period. | 24 | | To be eligible for payment consideration, a vendor's | 25 | | payment claim or bill, either as an initial claim or as a | 26 | | resubmitted claim following prior rejection, must be received |
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| 1 | | by the Illinois Department, or its fiscal intermediary, no | 2 | | later than 180 days after the latest date on the claim on which | 3 | | medical goods or services were provided, with the following | 4 | | exceptions: | 5 | | (1) In the case of a provider whose enrollment is in | 6 | | process by the Illinois Department, the 180-day period | 7 | | shall not begin until the date on the written notice from | 8 | | the Illinois Department that the provider enrollment is | 9 | | complete. | 10 | | (2) In the case of errors attributable to the Illinois | 11 | | Department or any of its claims processing intermediaries | 12 | | which result in an inability to receive, process, or | 13 | | adjudicate a claim, the 180-day period shall not begin | 14 | | until the provider has been notified of the error. | 15 | | (3) In the case of a provider for whom the Illinois | 16 | | Department initiates the monthly billing process. | 17 | | (4) In the case of a provider operated by a unit of | 18 | | local government with a population exceeding 3,000,000 | 19 | | when local government funds finance federal participation | 20 | | for claims payments. | 21 | | For claims for services rendered during a period for which | 22 | | a recipient received retroactive eligibility, claims must be | 23 | | filed within 180 days after the Department determines the | 24 | | applicant is eligible. For claims for which the Illinois | 25 | | Department is not the primary payer, claims must be submitted | 26 | | to the Illinois Department within 180 days after the final |
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| 1 | | adjudication by the primary payer. | 2 | | In the case of long term care facilities, within 45 | 3 | | calendar days of receipt by the facility of required | 4 | | prescreening information, new admissions with associated | 5 | | admission documents shall be submitted through the Medical | 6 | | Electronic Data Interchange (MEDI) or the Recipient | 7 | | Eligibility Verification (REV) System or shall be submitted | 8 | | directly to the Department of Human Services using required | 9 | | admission forms. Effective September
1, 2014, admission | 10 | | documents, including all prescreening
information, must be | 11 | | submitted through MEDI or REV. Confirmation numbers assigned to | 12 | | an accepted transaction shall be retained by a facility to | 13 | | verify timely submittal. Once an admission transaction has been | 14 | | completed, all resubmitted claims following prior rejection | 15 | | are subject to receipt no later than 180 days after the | 16 | | admission transaction has been completed. | 17 | | Claims that are not submitted and received in compliance | 18 | | with the foregoing requirements shall not be eligible for | 19 | | payment under the medical assistance program, and the State | 20 | | shall have no liability for payment of those claims. | 21 | | To the extent consistent with applicable information and | 22 | | privacy, security, and disclosure laws, State and federal | 23 | | agencies and departments shall provide the Illinois Department | 24 | | access to confidential and other information and data necessary | 25 | | to perform eligibility and payment verifications and other | 26 | | Illinois Department functions. This includes, but is not |
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| 1 | | limited to: information pertaining to licensure; | 2 | | certification; earnings; immigration status; citizenship; wage | 3 | | reporting; unearned and earned income; pension income; | 4 | | employment; supplemental security income; social security | 5 | | numbers; National Provider Identifier (NPI) numbers; the | 6 | | National Practitioner Data Bank (NPDB); program and agency | 7 | | exclusions; taxpayer identification numbers; tax delinquency; | 8 | | corporate information; and death records. | 9 | | The Illinois Department shall enter into agreements with | 10 | | State agencies and departments, and is authorized to enter into | 11 | | agreements with federal agencies and departments, under which | 12 | | such agencies and departments shall share data necessary for | 13 | | medical assistance program integrity functions and oversight. | 14 | | The Illinois Department shall develop, in cooperation with | 15 | | other State departments and agencies, and in compliance with | 16 | | applicable federal laws and regulations, appropriate and | 17 | | effective methods to share such data. At a minimum, and to the | 18 | | extent necessary to provide data sharing, the Illinois | 19 | | Department shall enter into agreements with State agencies and | 20 | | departments, and is authorized to enter into agreements with | 21 | | federal agencies and departments, including , but not limited | 22 | | to: the Secretary of State; the Department of Revenue; the | 23 | | Department of Public Health; the Department of Human Services; | 24 | | and the Department of Financial and Professional Regulation. | 25 | | Beginning in fiscal year 2013, the Illinois Department | 26 | | shall set forth a request for information to identify the |
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| 1 | | benefits of a pre-payment, post-adjudication, and post-edit | 2 | | claims system with the goals of streamlining claims processing | 3 | | and provider reimbursement, reducing the number of pending or | 4 | | rejected claims, and helping to ensure a more transparent | 5 | | adjudication process through the utilization of: (i) provider | 6 | | data verification and provider screening technology; and (ii) | 7 | | clinical code editing; and (iii) pre-pay, pre- or | 8 | | post-adjudicated predictive modeling with an integrated case | 9 | | management system with link analysis. Such a request for | 10 | | information shall not be considered as a request for proposal | 11 | | or as an obligation on the part of the Illinois Department to | 12 | | take any action or acquire any products or services. | 13 | | The Illinois Department shall establish policies, | 14 | | procedures,
standards and criteria by rule for the acquisition, | 15 | | repair and replacement
of orthotic and prosthetic devices and | 16 | | durable medical equipment. Such
rules shall provide, but not be | 17 | | limited to, the following services: (1)
immediate repair or | 18 | | replacement of such devices by recipients; and (2) rental, | 19 | | lease, purchase or lease-purchase of
durable medical equipment | 20 | | in a cost-effective manner, taking into
consideration the | 21 | | recipient's medical prognosis, the extent of the
recipient's | 22 | | needs, and the requirements and costs for maintaining such
| 23 | | equipment. Subject to prior approval, such rules shall enable a | 24 | | recipient to temporarily acquire and
use alternative or | 25 | | substitute devices or equipment pending repairs or
| 26 | | replacements of any device or equipment previously authorized |
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| 1 | | for such
recipient by the Department. Notwithstanding any | 2 | | provision of Section 5-5f to the contrary, the Department may, | 3 | | by rule, exempt certain replacement wheelchair parts from prior | 4 | | approval and, for wheelchairs, wheelchair parts, wheelchair | 5 | | accessories, and related seating and positioning items, | 6 | | determine the wholesale price by methods other than actual | 7 | | acquisition costs. | 8 | | The Department shall require, by rule, all providers of | 9 | | durable medical equipment to be accredited by an accreditation | 10 | | organization approved by the federal Centers for Medicare and | 11 | | Medicaid Services and recognized by the Department in order to | 12 | | bill the Department for providing durable medical equipment to | 13 | | recipients. No later than 15 months after the effective date of | 14 | | the rule adopted pursuant to this paragraph, all providers must | 15 | | meet the accreditation requirement.
| 16 | | In order to promote environmental responsibility, meet the | 17 | | needs of recipients and enrollees, and achieve significant cost | 18 | | savings, the Department, or a managed care organization under | 19 | | contract with the Department, may provide recipients or managed | 20 | | care enrollees who have a prescription or Certificate of | 21 | | Medical Necessity access to refurbished durable medical | 22 | | equipment under this Section (excluding prosthetic and | 23 | | orthotic devices as defined in the Orthotics, Prosthetics, and | 24 | | Pedorthics Practice Act and complex rehabilitation technology | 25 | | products and associated services) through the State's | 26 | | assistive technology program's reutilization program, using |
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| 1 | | staff with the Assistive Technology Professional (ATP) | 2 | | Certification if the refurbished durable medical equipment: | 3 | | (i) is available; (ii) is less expensive, including shipping | 4 | | costs, than new durable medical equipment of the same type; | 5 | | (iii) is able to withstand at least 3 years of use; (iv) is | 6 | | cleaned, disinfected, sterilized, and safe in accordance with | 7 | | federal Food and Drug Administration regulations and guidance | 8 | | governing the reprocessing of medical devices in health care | 9 | | settings; and (v) equally meets the needs of the recipient or | 10 | | enrollee. The reutilization program shall confirm that the | 11 | | recipient or enrollee is not already in receipt of same or | 12 | | similar equipment from another service provider, and that the | 13 | | refurbished durable medical equipment equally meets the needs | 14 | | of the recipient or enrollee. Nothing in this paragraph shall | 15 | | be construed to limit recipient or enrollee choice to obtain | 16 | | new durable medical equipment or place any additional prior | 17 | | authorization conditions on enrollees of managed care | 18 | | organizations. | 19 | | The Department shall execute, relative to the nursing home | 20 | | prescreening
project, written inter-agency agreements with the | 21 | | Department of Human
Services and the Department on Aging, to | 22 | | effect the following: (i) intake
procedures and common | 23 | | eligibility criteria for those persons who are receiving
| 24 | | non-institutional services; and (ii) the establishment and | 25 | | development of
non-institutional services in areas of the State | 26 | | where they are not currently
available or are undeveloped; and |
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| 1 | | (iii) notwithstanding any other provision of law, subject to | 2 | | federal approval, on and after July 1, 2012, an increase in the | 3 | | determination of need (DON) scores from 29 to 37 for applicants | 4 | | for institutional and home and community-based long term care; | 5 | | if and only if federal approval is not granted, the Department | 6 | | may, in conjunction with other affected agencies, implement | 7 | | utilization controls or changes in benefit packages to | 8 | | effectuate a similar savings amount for this population; and | 9 | | (iv) no later than July 1, 2013, minimum level of care | 10 | | eligibility criteria for institutional and home and | 11 | | community-based long term care; and (v) no later than October | 12 | | 1, 2013, establish procedures to permit long term care | 13 | | providers access to eligibility scores for individuals with an | 14 | | admission date who are seeking or receiving services from the | 15 | | long term care provider. In order to select the minimum level | 16 | | of care eligibility criteria, the Governor shall establish a | 17 | | workgroup that includes affected agency representatives and | 18 | | stakeholders representing the institutional and home and | 19 | | community-based long term care interests. This Section shall | 20 | | not restrict the Department from implementing lower level of | 21 | | care eligibility criteria for community-based services in | 22 | | circumstances where federal approval has been granted.
| 23 | | The Illinois Department shall develop and operate, in | 24 | | cooperation
with other State Departments and agencies and in | 25 | | compliance with
applicable federal laws and regulations, | 26 | | appropriate and effective
systems of health care evaluation and |
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| 1 | | programs for monitoring of
utilization of health care services | 2 | | and facilities, as it affects
persons eligible for medical | 3 | | assistance under this Code.
| 4 | | The Illinois Department shall report annually to the | 5 | | General Assembly,
no later than the second Friday in April of | 6 | | 1979 and each year
thereafter, in regard to:
| 7 | | (a) actual statistics and trends in utilization of | 8 | | medical services by
public aid recipients;
| 9 | | (b) actual statistics and trends in the provision of | 10 | | the various medical
services by medical vendors;
| 11 | | (c) current rate structures and proposed changes in | 12 | | those rate structures
for the various medical vendors; and
| 13 | | (d) efforts at utilization review and control by the | 14 | | Illinois Department.
| 15 | | The period covered by each report shall be the 3 years | 16 | | ending on the June
30 prior to the report. The report shall | 17 | | include suggested legislation
for consideration by the General | 18 | | Assembly. The requirement for reporting to the General Assembly | 19 | | shall be satisfied
by filing copies of the report as required | 20 | | by Section 3.1 of the General Assembly Organization Act, and | 21 | | filing such additional
copies
with the State Government Report | 22 | | Distribution Center for the General
Assembly as is required | 23 | | under paragraph (t) of Section 7 of the State
Library Act.
| 24 | | Rulemaking authority to implement Public Act 95-1045, if | 25 | | any, is conditioned on the rules being adopted in accordance | 26 | | with all provisions of the Illinois Administrative Procedure |
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| 1 | | Act and all rules and procedures of the Joint Committee on | 2 | | Administrative Rules; any purported rule not so adopted, for | 3 | | whatever reason, is unauthorized. | 4 | | On and after July 1, 2012, the Department shall reduce any | 5 | | rate of reimbursement for services or other payments or alter | 6 | | any methodologies authorized by this Code to reduce any rate of | 7 | | reimbursement for services or other payments in accordance with | 8 | | Section 5-5e. | 9 | | Because kidney transplantation can be an appropriate, | 10 | | cost-effective
alternative to renal dialysis when medically | 11 | | necessary and notwithstanding the provisions of Section 1-11 of | 12 | | this Code, beginning October 1, 2014, the Department shall | 13 | | cover kidney transplantation for noncitizens with end-stage | 14 | | renal disease who are not eligible for comprehensive medical | 15 | | benefits, who meet the residency requirements of Section 5-3 of | 16 | | this Code, and who would otherwise meet the financial | 17 | | requirements of the appropriate class of eligible persons under | 18 | | Section 5-2 of this Code. To qualify for coverage of kidney | 19 | | transplantation, such person must be receiving emergency renal | 20 | | dialysis services covered by the Department. Providers under | 21 | | this Section shall be prior approved and certified by the | 22 | | Department to perform kidney transplantation and the services | 23 | | under this Section shall be limited to services associated with | 24 | | kidney transplantation. | 25 | | Notwithstanding any other provision of this Code to the | 26 | | contrary, on or after July 1, 2015, all FDA approved forms of |
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| 1 | | medication assisted treatment prescribed for the treatment of | 2 | | alcohol dependence or treatment of opioid dependence shall be | 3 | | covered under both fee for service and managed care medical | 4 | | assistance programs for persons who are otherwise eligible for | 5 | | medical assistance under this Article and shall not be subject | 6 | | to any (1) utilization control, other than those established | 7 | | under the American Society of Addiction Medicine patient | 8 | | placement criteria,
(2) prior authorization mandate, or (3) | 9 | | lifetime restriction limit
mandate. | 10 | | On or after July 1, 2015, opioid antagonists prescribed for | 11 | | the treatment of an opioid overdose, including the medication | 12 | | product, administration devices, and any pharmacy fees related | 13 | | to the dispensing and administration of the opioid antagonist, | 14 | | shall be covered under the medical assistance program for | 15 | | persons who are otherwise eligible for medical assistance under | 16 | | this Article. As used in this Section, "opioid antagonist" | 17 | | means a drug that binds to opioid receptors and blocks or | 18 | | inhibits the effect of opioids acting on those receptors, | 19 | | including, but not limited to, naloxone hydrochloride or any | 20 | | other similarly acting drug approved by the U.S. Food and Drug | 21 | | Administration. | 22 | | Upon federal approval, the Department shall provide | 23 | | coverage and reimbursement for all drugs that are approved for | 24 | | marketing by the federal Food and Drug Administration and that | 25 | | are recommended by the federal Public Health Service or the | 26 | | United States Centers for Disease Control and Prevention for |
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| 1 | | pre-exposure prophylaxis and related pre-exposure prophylaxis | 2 | | services, including, but not limited to, HIV and sexually | 3 | | transmitted infection screening, treatment for sexually | 4 | | transmitted infections, medical monitoring, assorted labs, and | 5 | | counseling to reduce the likelihood of HIV infection among | 6 | | individuals who are not infected with HIV but who are at high | 7 | | risk of HIV infection. | 8 | | A federally qualified health center, as defined in Section | 9 | | 1905(l)(2)(B) of the federal
Social Security Act, shall be | 10 | | reimbursed by the Department in accordance with the federally | 11 | | qualified health center's encounter rate for services provided | 12 | | to medical assistance recipients that are performed by a dental | 13 | | hygienist, as defined under the Illinois Dental Practice Act, | 14 | | working under the general supervision of a dentist and employed | 15 | | by a federally qualified health center. | 16 | | Subject to appropriations, social and emotional screenings | 17 | | for children that are conducted during a health examination | 18 | | shall be covered under the medical assistance program. | 19 | | (Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18; | 20 | | 100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff. | 21 | | 6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974, | 22 | | eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; | 23 | | 100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff. | 24 | | 1-1-20; revised 9-18-19.)
| 25 | | Section 99. Effective date. This Act takes effect upon | 26 | | becoming law.
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