Illinois General Assembly - Full Text of HB5068
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Full Text of HB5068  101st General Assembly




State of Illinois
2019 and 2020


Introduced 2/18/2020, by Rep. Norine K. Hammond


305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that within 120 calendar days (rather than 45 calendar days) of receipt by a long-term care facility of required prescreening information, new admissions with associated admission documents shall be submitted through the Medical Electronic Data Interchange or the Recipient Eligibility Verification System or shall be submitted directly to the Department of Human Services using required admission forms.

LRB101 17974 KTG 67412 b






HB5068LRB101 17974 KTG 67412 b

1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5 as follows:
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    Sec. 5-5. Medical services. The Illinois Department, by
8rule, shall determine the quantity and quality of and the rate
9of reimbursement for the medical assistance for which payment
10will be authorized, and the medical services to be provided,
11which may include all or part of the following: (1) inpatient
12hospital services; (2) outpatient hospital services; (3) other
13laboratory and X-ray services; (4) skilled nursing home
14services; (5) physicians' services whether furnished in the
15office, the patient's home, a hospital, a skilled nursing home,
16or elsewhere; (6) medical care, or any other type of remedial
17care furnished by licensed practitioners; (7) home health care
18services; (8) private duty nursing service; (9) clinic
19services; (10) dental services, including prevention and
20treatment of periodontal disease and dental caries disease for
21pregnant women, provided by an individual licensed to practice
22dentistry or dental surgery; for purposes of this item (10),
23"dental services" means diagnostic, preventive, or corrective



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1procedures provided by or under the supervision of a dentist in
2the practice of his or her profession; (11) physical therapy
3and related services; (12) prescribed drugs, dentures, and
4prosthetic devices; and eyeglasses prescribed by a physician
5skilled in the diseases of the eye, or by an optometrist,
6whichever the person may select; (13) other diagnostic,
7screening, preventive, and rehabilitative services, including
8to ensure that the individual's need for intervention or
9treatment of mental disorders or substance use disorders or
10co-occurring mental health and substance use disorders is
11determined using a uniform screening, assessment, and
12evaluation process inclusive of criteria, for children and
13adults; for purposes of this item (13), a uniform screening,
14assessment, and evaluation process refers to a process that
15includes an appropriate evaluation and, as warranted, a
16referral; "uniform" does not mean the use of a singular
17instrument, tool, or process that all must utilize; (14)
18transportation and such other expenses as may be necessary;
19(15) medical treatment of sexual assault survivors, as defined
20in Section 1a of the Sexual Assault Survivors Emergency
21Treatment Act, for injuries sustained as a result of the sexual
22assault, including examinations and laboratory tests to
23discover evidence which may be used in criminal proceedings
24arising from the sexual assault; (16) the diagnosis and
25treatment of sickle cell anemia; and (17) any other medical
26care, and any other type of remedial care recognized under the



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1laws of this State. The term "any other type of remedial care"
2shall include nursing care and nursing home service for persons
3who rely on treatment by spiritual means alone through prayer
4for healing.
5    Notwithstanding any other provision of this Section, a
6comprehensive tobacco use cessation program that includes
7purchasing prescription drugs or prescription medical devices
8approved by the Food and Drug Administration shall be covered
9under the medical assistance program under this Article for
10persons who are otherwise eligible for assistance under this
12    Notwithstanding any other provision of this Code,
13reproductive health care that is otherwise legal in Illinois
14shall be covered under the medical assistance program for
15persons who are otherwise eligible for medical assistance under
16this Article.
17    Notwithstanding any other provision of this Code, the
18Illinois Department may not require, as a condition of payment
19for any laboratory test authorized under this Article, that a
20physician's handwritten signature appear on the laboratory
21test order form. The Illinois Department may, however, impose
22other appropriate requirements regarding laboratory test order
24    Upon receipt of federal approval of an amendment to the
25Illinois Title XIX State Plan for this purpose, the Department
26shall authorize the Chicago Public Schools (CPS) to procure a



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1vendor or vendors to manufacture eyeglasses for individuals
2enrolled in a school within the CPS system. CPS shall ensure
3that its vendor or vendors are enrolled as providers in the
4medical assistance program and in any capitated Medicaid
5managed care entity (MCE) serving individuals enrolled in a
6school within the CPS system. Under any contract procured under
7this provision, the vendor or vendors must serve only
8individuals enrolled in a school within the CPS system. Claims
9for services provided by CPS's vendor or vendors to recipients
10of benefits in the medical assistance program under this Code,
11the Children's Health Insurance Program, or the Covering ALL
12KIDS Health Insurance Program shall be submitted to the
13Department or the MCE in which the individual is enrolled for
14payment and shall be reimbursed at the Department's or the
15MCE's established rates or rate methodologies for eyeglasses.
16    On and after July 1, 2012, the Department of Healthcare and
17Family Services may provide the following services to persons
18eligible for assistance under this Article who are
19participating in education, training or employment programs
20operated by the Department of Human Services as successor to
21the 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
2Family Services shall provide dental services to any adult who
3is otherwise eligible for assistance under the medical
4assistance program. As used in this paragraph, "dental
5services" means diagnostic, preventative, restorative, or
6corrective procedures, including procedures and services for
7the prevention and treatment of periodontal disease and dental
8caries disease, provided by an individual who is licensed to
9practice dentistry or dental surgery or who is under the
10supervision of a dentist in the practice of his or her
12    On and after July 1, 2018, targeted dental services, as set
13forth in Exhibit D of the Consent Decree entered by the United
14States District Court for the Northern District of Illinois,
15Eastern Division, in the matter of Memisovski v. Maram, Case
16No. 92 C 1982, that are provided to adults under the medical
17assistance program shall be established at no less than the
18rates set forth in the "New Rate" column in Exhibit D of the
19Consent Decree for targeted dental services that are provided
20to persons under the age of 18 under the medical assistance
22    Notwithstanding any other provision of this Code and
23subject to federal approval, the Department may adopt rules to
24allow a dentist who is volunteering his or her service at no
25cost to render dental services through an enrolled
26not-for-profit health clinic without the dentist personally



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1enrolling as a participating provider in the medical assistance
2program. A not-for-profit health clinic shall include a public
3health clinic or Federally Qualified Health Center or other
4enrolled provider, as determined by the Department, through
5which dental services covered under this Section are performed.
6The Department shall establish a process for payment of claims
7for reimbursement for covered dental services rendered under
8this provision.
9    The Illinois Department, by rule, may distinguish and
10classify the medical services to be provided only in accordance
11with the classes of persons designated in Section 5-2.
12    The Department of Healthcare and Family Services must
13provide coverage and reimbursement for amino acid-based
14elemental formulas, regardless of delivery method, for the
15diagnosis and treatment of (i) eosinophilic disorders and (ii)
16short bowel syndrome when the prescribing physician has issued
17a written order stating that the amino acid-based elemental
18formula is medically necessary.
19    The Illinois Department shall authorize the provision of,
20and shall authorize payment for, screening by low-dose
21mammography for the presence of occult breast cancer for women
2235 years of age or older who are eligible for medical
23assistance 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,
20copayment, or any other cost-sharing requirement on the
21coverage provided under this paragraph; except that this
22sentence does not apply to coverage of diagnostic mammograms to
23the extent such coverage would disqualify a high-deductible
24health plan from eligibility for a health savings account
25pursuant to Section 223 of the Internal Revenue Code (26 U.S.C.



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1    All screenings shall include a physical breast exam,
2instruction on self-examination and information regarding the
3frequency of self-examination and its value as a preventative
5     For purposes of this Section:
6    "Diagnostic mammogram" means a mammogram obtained using
7diagnostic mammography.
8    "Diagnostic mammography" means a method of screening that
9is designed to evaluate an abnormality in a breast, including
10an abnormality seen or suspected on a screening mammogram or a
11subjective or objective abnormality otherwise detected in the
13    "Low-dose mammography" means the x-ray examination of the
14breast using equipment dedicated specifically for mammography,
15including the x-ray tube, filter, compression device, and image
16receptor, with an average radiation exposure delivery of less
17than one rad per breast for 2 views of an average size breast.
18The term also includes digital mammography and includes breast
20    "Breast tomosynthesis" means a radiologic procedure that
21involves the acquisition of projection images over the
22stationary breast to produce cross-sectional digital
23three-dimensional images of the breast.
24    If, at any time, the Secretary of the United States
25Department of Health and Human Services, or its successor
26agency, promulgates rules or regulations to be published in the



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1Federal Register or publishes a comment in the Federal Register
2or issues an opinion, guidance, or other action that would
3require the State, pursuant to any provision of the Patient
4Protection and Affordable Care Act (Public Law 111-148),
5including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
6successor provision, to defray the cost of any coverage for
7breast tomosynthesis outlined in this paragraph, then the
8requirement that an insurer cover breast tomosynthesis is
9inoperative other than any such coverage authorized under
10Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
11the State shall not assume any obligation for the cost of
12coverage for breast tomosynthesis set forth in this paragraph.
13    On and after January 1, 2016, the Department shall ensure
14that all networks of care for adult clients of the Department
15include access to at least one breast imaging Center of Imaging
16Excellence as certified by the American College of Radiology.
17    On and after January 1, 2012, providers participating in a
18quality improvement program approved by the Department shall be
19reimbursed for screening and diagnostic mammography at the same
20rate as the Medicare program's rates, including the increased
21reimbursement for digital mammography.
22    The Department shall convene an expert panel including
23representatives of hospitals, free-standing mammography
24facilities, and doctors, including radiologists, to establish
25quality standards for mammography.
26    On and after January 1, 2017, providers participating in a



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1breast cancer treatment quality improvement program approved
2by the Department shall be reimbursed for breast cancer
3treatment at a rate that is no lower than 95% of the Medicare
4program's rates for the data elements included in the breast
5cancer treatment quality program.
6    The Department shall convene an expert panel, including
7representatives of hospitals, free-standing breast cancer
8treatment centers, breast cancer quality organizations, and
9doctors, including breast surgeons, reconstructive breast
10surgeons, oncologists, and primary care providers to establish
11quality standards for breast cancer treatment.
12    Subject to federal approval, the Department shall
13establish a rate methodology for mammography at federally
14qualified health centers and other encounter-rate clinics.
15These clinics or centers may also collaborate with other
16hospital-based mammography facilities. By January 1, 2016, the
17Department shall report to the General Assembly on the status
18of the provision set forth in this paragraph.
19    The Department shall establish a methodology to remind
20women who are age-appropriate for screening mammography, but
21who have not received a mammogram within the previous 18
22months, of the importance and benefit of screening mammography.
23The Department shall work with experts in breast cancer
24outreach and patient navigation to optimize these reminders and
25shall establish a methodology for evaluating their
26effectiveness and modifying the methodology based on the



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2    The Department shall establish a performance goal for
3primary care providers with respect to their female patients
4over age 40 receiving an annual mammogram. This performance
5goal shall be used to provide additional reimbursement in the
6form of a quality performance bonus to primary care providers
7who meet that goal.
8    The Department shall devise a means of case-managing or
9patient navigation for beneficiaries diagnosed with breast
10cancer. This program shall initially operate as a pilot program
11in areas of the State with the highest incidence of mortality
12related to breast cancer. At least one pilot program site shall
13be in the metropolitan Chicago area and at least one site shall
14be outside the metropolitan Chicago area. On or after July 1,
152016, the pilot program shall be expanded to include one site
16in western Illinois, one site in southern Illinois, one site in
17central Illinois, and 4 sites within metropolitan Chicago. An
18evaluation of the pilot program shall be carried out measuring
19health outcomes and cost of care for those served by the pilot
20program compared to similarly situated patients who are not
21served by the pilot program.
22    The Department shall require all networks of care to
23develop a means either internally or by contract with experts
24in navigation and community outreach to navigate cancer
25patients to comprehensive care in a timely fashion. The
26Department shall require all networks of care to include access



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1for patients diagnosed with cancer to at least one academic
2commission on cancer-accredited cancer program as an
3in-network covered benefit.
4    Any medical or health care provider shall immediately
5recommend, to any pregnant woman who is being provided prenatal
6services and is suspected of having a substance use disorder as
7defined in the Substance Use Disorder Act, referral to a local
8substance use disorder treatment program licensed by the
9Department of Human Services or to a licensed hospital which
10provides substance abuse treatment services. The Department of
11Healthcare and Family Services shall assure coverage for the
12cost of treatment of the drug abuse or addiction for pregnant
13recipients in accordance with the Illinois Medicaid Program in
14conjunction with the Department of Human Services.
15    All medical providers providing medical assistance to
16pregnant women under this Code shall receive information from
17the Department on the availability of services under any
18program providing case management services for addicted women,
19including information on appropriate referrals for other
20social services that may be needed by addicted women in
21addition to treatment for addiction.
22    The Illinois Department, in cooperation with the
23Departments of Human Services (as successor to the Department
24of Alcoholism and Substance Abuse) and Public Health, through a
25public awareness campaign, may provide information concerning
26treatment for alcoholism and drug abuse and addiction, prenatal



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1health care, and other pertinent programs directed at reducing
2the number of drug-affected infants born to recipients of
3medical assistance.
4    Neither the Department of Healthcare and Family Services
5nor the Department of Human Services shall sanction the
6recipient solely on the basis of her substance abuse.
7    The Illinois Department shall establish such regulations
8governing the dispensing of health services under this Article
9as it shall deem appropriate. The Department should seek the
10advice of formal professional advisory committees appointed by
11the Director of the Illinois Department for the purpose of
12providing regular advice on policy and administrative matters,
13information dissemination and educational activities for
14medical and health care providers, and consistency in
15procedures to the Illinois Department.
16    The Illinois Department may develop and contract with
17Partnerships of medical providers to arrange medical services
18for persons eligible under Section 5-2 of this Code.
19Implementation of this Section may be by demonstration projects
20in certain geographic areas. The Partnership shall be
21represented by a sponsor organization. The Department, by rule,
22shall develop qualifications for sponsors of Partnerships.
23Nothing in this Section shall be construed to require that the
24sponsor organization be a medical organization.
25    The sponsor must negotiate formal written contracts with
26medical providers for physician services, inpatient and



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1outpatient hospital care, home health services, treatment for
2alcoholism and substance abuse, and other services determined
3necessary by the Illinois Department by rule for delivery by
4Partnerships. Physician services must include prenatal and
5obstetrical care. The Illinois Department shall reimburse
6medical services delivered by Partnership providers to clients
7in target areas according to provisions of this Article and the
8Illinois 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
22qualifications to participate in Partnerships to ensure the
23delivery of high quality medical services. These
24qualifications shall be determined by rule of the Illinois
25Department and may be higher than qualifications for
26participation in the medical assistance program. Partnership



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1sponsors may prescribe reasonable additional qualifications
2for participation by medical providers, only with the prior
3written approval of the Illinois Department.
4    Nothing in this Section shall limit the free choice of
5practitioners, hospitals, and other providers of medical
6services by clients. In order to ensure patient freedom of
7choice, the Illinois Department shall immediately promulgate
8all rules and take all other necessary actions so that provided
9services may be accessed from therapeutically certified
10optometrists to the full extent of the Illinois Optometric
11Practice Act of 1987 without discriminating between service
13    The Department shall apply for a waiver from the United
14States Health Care Financing Administration to allow for the
15implementation of Partnerships under this Section.
16    The Illinois Department shall require health care
17providers to maintain records that document the medical care
18and services provided to recipients of Medical Assistance under
19this Article. Such records must be retained for a period of not
20less than 6 years from the date of service or as provided by
21applicable State law, whichever period is longer, except that
22if an audit is initiated within the required retention period
23then the records must be retained until the audit is completed
24and every exception is resolved. The Illinois Department shall
25require health care providers to make available, when
26authorized by the patient, in writing, the medical records in a



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1timely fashion to other health care providers who are treating
2or serving persons eligible for Medical Assistance under this
3Article. All dispensers of medical services shall be required
4to maintain and retain business and professional records
5sufficient to fully and accurately document the nature, scope,
6details and receipt of the health care provided to persons
7eligible for medical assistance under this Code, in accordance
8with regulations promulgated by the Illinois Department. The
9rules and regulations shall require that proof of the receipt
10of prescription drugs, dentures, prosthetic devices and
11eyeglasses by eligible persons under this Section accompany
12each claim for reimbursement submitted by the dispenser of such
13medical services. No such claims for reimbursement shall be
14approved for payment by the Illinois Department without such
15proof of receipt, unless the Illinois Department shall have put
16into effect and shall be operating a system of post-payment
17audit and review which shall, on a sampling basis, be deemed
18adequate by the Illinois Department to assure that such drugs,
19dentures, prosthetic devices and eyeglasses for which payment
20is being made are actually being received by eligible
21recipients. Within 90 days after September 16, 1984 (the
22effective date of Public Act 83-1439), the Illinois Department
23shall establish a current list of acquisition costs for all
24prosthetic devices and any other items recognized as medical
25equipment and supplies reimbursable under this Article and
26shall update such list on a quarterly basis, except that the



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1acquisition costs of all prescription drugs shall be updated no
2less frequently than every 30 days as required by Section
4    Notwithstanding any other law to the contrary, the Illinois
5Department shall, within 365 days after July 22, 2013 (the
6effective date of Public Act 98-104), establish procedures to
7permit skilled care facilities licensed under the Nursing Home
8Care Act to submit monthly billing claims for reimbursement
9purposes. Following development of these procedures, the
10Department shall, by July 1, 2016, test the viability of the
11new system and implement any necessary operational or
12structural changes to its information technology platforms in
13order to allow for the direct acceptance and payment of nursing
14home claims.
15    Notwithstanding any other law to the contrary, the Illinois
16Department shall, within 365 days after August 15, 2014 (the
17effective date of Public Act 98-963), establish procedures to
18permit ID/DD facilities licensed under the ID/DD Community Care
19Act and MC/DD facilities licensed under the MC/DD Act to submit
20monthly billing claims for reimbursement purposes. Following
21development of these procedures, the Department shall have an
22additional 365 days to test the viability of the new system and
23to ensure that any necessary operational or structural changes
24to its information technology platforms are implemented.
25    The Illinois Department shall require all dispensers of
26medical services, other than an individual practitioner or



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1group of practitioners, desiring to participate in the Medical
2Assistance program established under this Article to disclose
3all financial, beneficial, ownership, equity, surety or other
4interests in any and all firms, corporations, partnerships,
5associations, business enterprises, joint ventures, agencies,
6institutions or other legal entities providing any form of
7health care services in this State under this Article.
8    The Illinois Department may require that all dispensers of
9medical services desiring to participate in the medical
10assistance program established under this Article disclose,
11under such terms and conditions as the Illinois Department may
12by rule establish, all inquiries from clients and attorneys
13regarding medical bills paid by the Illinois Department, which
14inquiries could indicate potential existence of claims or liens
15for the Illinois Department.
16    Enrollment of a vendor shall be subject to a provisional
17period and shall be conditional for one year. During the period
18of conditional enrollment, the Department may terminate the
19vendor's eligibility to participate in, or may disenroll the
20vendor from, the medical assistance program without cause.
21Unless otherwise specified, such termination of eligibility or
22disenrollment is not subject to the Department's hearing
23process. However, a disenrolled vendor may reapply without
25    The Department has the discretion to limit the conditional
26enrollment period for vendors based upon category of risk of



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1the vendor.
2    Prior to enrollment and during the conditional enrollment
3period in the medical assistance program, all vendors shall be
4subject to enhanced oversight, screening, and review based on
5the risk of fraud, waste, and abuse that is posed by the
6category of risk of the vendor. The Illinois Department shall
7establish the procedures for oversight, screening, and review,
8which may include, but need not be limited to: criminal and
9financial background checks; fingerprinting; license,
10certification, and authorization verifications; unscheduled or
11unannounced site visits; database checks; prepayment audit
12reviews; audits; payment caps; payment suspensions; and other
13screening as required by federal or State law.
14    The Department shall define or specify the following: (i)
15by provider notice, the "category of risk of the vendor" for
16each type of vendor, which shall take into account the level of
17screening applicable to a particular category of vendor under
18federal law and regulations; (ii) by rule or provider notice,
19the maximum length of the conditional enrollment period for
20each category of risk of the vendor; and (iii) by rule, the
21hearing rights, if any, afforded to a vendor in each category
22of risk of the vendor that is terminated or disenrolled during
23the conditional enrollment period.
24    To be eligible for payment consideration, a vendor's
25payment claim or bill, either as an initial claim or as a
26resubmitted claim following prior rejection, must be received



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1by the Illinois Department, or its fiscal intermediary, no
2later than 180 days after the latest date on the claim on which
3medical goods or services were provided, with the following
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
22a recipient received retroactive eligibility, claims must be
23filed within 180 days after the Department determines the
24applicant is eligible. For claims for which the Illinois
25Department is not the primary payer, claims must be submitted
26to the Illinois Department within 180 days after the final



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1adjudication by the primary payer.
2    In the case of long term care facilities, within 120 45
3calendar days of receipt by the facility of required
4prescreening information, new admissions with associated
5admission documents shall be submitted through the Medical
6Electronic Data Interchange (MEDI) or the Recipient
7Eligibility Verification (REV) System or shall be submitted
8directly to the Department of Human Services using required
9admission forms. Effective September 1, 2014, admission
10documents, including all prescreening information, must be
11submitted through MEDI or REV. Confirmation numbers assigned to
12an accepted transaction shall be retained by a facility to
13verify timely submittal. Once an admission transaction has been
14completed, all resubmitted claims following prior rejection
15are subject to receipt no later than 180 days after the
16admission transaction has been completed.
17    Claims that are not submitted and received in compliance
18with the foregoing requirements shall not be eligible for
19payment under the medical assistance program, and the State
20shall have no liability for payment of those claims.
21    To the extent consistent with applicable information and
22privacy, security, and disclosure laws, State and federal
23agencies and departments shall provide the Illinois Department
24access to confidential and other information and data necessary
25to perform eligibility and payment verifications and other
26Illinois Department functions. This includes, but is not



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1limited to: information pertaining to licensure;
2certification; earnings; immigration status; citizenship; wage
3reporting; unearned and earned income; pension income;
4employment; supplemental security income; social security
5numbers; National Provider Identifier (NPI) numbers; the
6National Practitioner Data Bank (NPDB); program and agency
7exclusions; taxpayer identification numbers; tax delinquency;
8corporate information; and death records.
9    The Illinois Department shall enter into agreements with
10State agencies and departments, and is authorized to enter into
11agreements with federal agencies and departments, under which
12such agencies and departments shall share data necessary for
13medical assistance program integrity functions and oversight.
14The Illinois Department shall develop, in cooperation with
15other State departments and agencies, and in compliance with
16applicable federal laws and regulations, appropriate and
17effective methods to share such data. At a minimum, and to the
18extent necessary to provide data sharing, the Illinois
19Department shall enter into agreements with State agencies and
20departments, and is authorized to enter into agreements with
21federal agencies and departments, including, but not limited
22to: the Secretary of State; the Department of Revenue; the
23Department of Public Health; the Department of Human Services;
24and the Department of Financial and Professional Regulation.
25    Beginning in fiscal year 2013, the Illinois Department
26shall set forth a request for information to identify the



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1benefits of a pre-payment, post-adjudication, and post-edit
2claims system with the goals of streamlining claims processing
3and provider reimbursement, reducing the number of pending or
4rejected claims, and helping to ensure a more transparent
5adjudication process through the utilization of: (i) provider
6data verification and provider screening technology; and (ii)
7clinical code editing; and (iii) pre-pay, pre- or
8post-adjudicated predictive modeling with an integrated case
9management system with link analysis. Such a request for
10information shall not be considered as a request for proposal
11or as an obligation on the part of the Illinois Department to
12take any action or acquire any products or services.
13    The Illinois Department shall establish policies,
14procedures, standards and criteria by rule for the acquisition,
15repair and replacement of orthotic and prosthetic devices and
16durable medical equipment. Such rules shall provide, but not be
17limited to, the following services: (1) immediate repair or
18replacement of such devices by recipients; and (2) rental,
19lease, purchase or lease-purchase of durable medical equipment
20in a cost-effective manner, taking into consideration the
21recipient's medical prognosis, the extent of the recipient's
22needs, and the requirements and costs for maintaining such
23equipment. Subject to prior approval, such rules shall enable a
24recipient to temporarily acquire and use alternative or
25substitute devices or equipment pending repairs or
26replacements of any device or equipment previously authorized



HB5068- 24 -LRB101 17974 KTG 67412 b

1for such recipient by the Department. Notwithstanding any
2provision of Section 5-5f to the contrary, the Department may,
3by rule, exempt certain replacement wheelchair parts from prior
4approval and, for wheelchairs, wheelchair parts, wheelchair
5accessories, and related seating and positioning items,
6determine the wholesale price by methods other than actual
7acquisition costs.
8    The Department shall require, by rule, all providers of
9durable medical equipment to be accredited by an accreditation
10organization approved by the federal Centers for Medicare and
11Medicaid Services and recognized by the Department in order to
12bill the Department for providing durable medical equipment to
13recipients. No later than 15 months after the effective date of
14the rule adopted pursuant to this paragraph, all providers must
15meet the accreditation requirement.
16    In order to promote environmental responsibility, meet the
17needs of recipients and enrollees, and achieve significant cost
18savings, the Department, or a managed care organization under
19contract with the Department, may provide recipients or managed
20care enrollees who have a prescription or Certificate of
21Medical Necessity access to refurbished durable medical
22equipment under this Section (excluding prosthetic and
23orthotic devices as defined in the Orthotics, Prosthetics, and
24Pedorthics Practice Act and complex rehabilitation technology
25products and associated services) through the State's
26assistive technology program's reutilization program, using



HB5068- 25 -LRB101 17974 KTG 67412 b

1staff with the Assistive Technology Professional (ATP)
2Certification if the refurbished durable medical equipment:
3(i) is available; (ii) is less expensive, including shipping
4costs, than new durable medical equipment of the same type;
5(iii) is able to withstand at least 3 years of use; (iv) is
6cleaned, disinfected, sterilized, and safe in accordance with
7federal Food and Drug Administration regulations and guidance
8governing the reprocessing of medical devices in health care
9settings; and (v) equally meets the needs of the recipient or
10enrollee. The reutilization program shall confirm that the
11recipient or enrollee is not already in receipt of same or
12similar equipment from another service provider, and that the
13refurbished durable medical equipment equally meets the needs
14of the recipient or enrollee. Nothing in this paragraph shall
15be construed to limit recipient or enrollee choice to obtain
16new durable medical equipment or place any additional prior
17authorization conditions on enrollees of managed care
19    The Department shall execute, relative to the nursing home
20prescreening project, written inter-agency agreements with the
21Department of Human Services and the Department on Aging, to
22effect the following: (i) intake procedures and common
23eligibility criteria for those persons who are receiving
24non-institutional services; and (ii) the establishment and
25development of non-institutional services in areas of the State
26where they are not currently available or are undeveloped; and



HB5068- 26 -LRB101 17974 KTG 67412 b

1(iii) notwithstanding any other provision of law, subject to
2federal approval, on and after July 1, 2012, an increase in the
3determination of need (DON) scores from 29 to 37 for applicants
4for institutional and home and community-based long term care;
5if and only if federal approval is not granted, the Department
6may, in conjunction with other affected agencies, implement
7utilization controls or changes in benefit packages to
8effectuate a similar savings amount for this population; and
9(iv) no later than July 1, 2013, minimum level of care
10eligibility criteria for institutional and home and
11community-based long term care; and (v) no later than October
121, 2013, establish procedures to permit long term care
13providers access to eligibility scores for individuals with an
14admission date who are seeking or receiving services from the
15long term care provider. In order to select the minimum level
16of care eligibility criteria, the Governor shall establish a
17workgroup that includes affected agency representatives and
18stakeholders representing the institutional and home and
19community-based long term care interests. This Section shall
20not restrict the Department from implementing lower level of
21care eligibility criteria for community-based services in
22circumstances where federal approval has been granted.
23    The Illinois Department shall develop and operate, in
24cooperation with other State Departments and agencies and in
25compliance with applicable federal laws and regulations,
26appropriate and effective systems of health care evaluation and



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1programs for monitoring of utilization of health care services
2and facilities, as it affects persons eligible for medical
3assistance under this Code.
4    The Illinois Department shall report annually to the
5General Assembly, no later than the second Friday in April of
61979 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
16ending on the June 30 prior to the report. The report shall
17include suggested legislation for consideration by the General
18Assembly. The requirement for reporting to the General Assembly
19shall be satisfied by filing copies of the report as required
20by Section 3.1 of the General Assembly Organization Act, and
21filing such additional copies with the State Government Report
22Distribution Center for the General Assembly as is required
23under paragraph (t) of Section 7 of the State Library Act.
24    Rulemaking authority to implement Public Act 95-1045, if
25any, is conditioned on the rules being adopted in accordance
26with all provisions of the Illinois Administrative Procedure



HB5068- 28 -LRB101 17974 KTG 67412 b

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



HB5068- 29 -LRB101 17974 KTG 67412 b

1medication assisted treatment prescribed for the treatment of
2alcohol dependence or treatment of opioid dependence shall be
3covered under both fee for service and managed care medical
4assistance programs for persons who are otherwise eligible for
5medical assistance under this Article and shall not be subject
6to any (1) utilization control, other than those established
7under the American Society of Addiction Medicine patient
8placement criteria, (2) prior authorization mandate, or (3)
9lifetime restriction limit mandate.
10    On or after July 1, 2015, opioid antagonists prescribed for
11the treatment of an opioid overdose, including the medication
12product, administration devices, and any pharmacy fees related
13to the dispensing and administration of the opioid antagonist,
14shall be covered under the medical assistance program for
15persons who are otherwise eligible for medical assistance under
16this Article. As used in this Section, "opioid antagonist"
17means a drug that binds to opioid receptors and blocks or
18inhibits the effect of opioids acting on those receptors,
19including, but not limited to, naloxone hydrochloride or any
20other similarly acting drug approved by the U.S. Food and Drug
22    Upon federal approval, the Department shall provide
23coverage and reimbursement for all drugs that are approved for
24marketing by the federal Food and Drug Administration and that
25are recommended by the federal Public Health Service or the
26United States Centers for Disease Control and Prevention for



HB5068- 30 -LRB101 17974 KTG 67412 b

1pre-exposure prophylaxis and related pre-exposure prophylaxis
2services, including, but not limited to, HIV and sexually
3transmitted infection screening, treatment for sexually
4transmitted infections, medical monitoring, assorted labs, and
5counseling to reduce the likelihood of HIV infection among
6individuals who are not infected with HIV but who are at high
7risk of HIV infection.
8    A federally qualified health center, as defined in Section
91905(l)(2)(B) of the federal Social Security Act, shall be
10reimbursed by the Department in accordance with the federally
11qualified health center's encounter rate for services provided
12to medical assistance recipients that are performed by a dental
13hygienist, as defined under the Illinois Dental Practice Act,
14working under the general supervision of a dentist and employed
15by a federally qualified health center.
16(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
17100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
186-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
19eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
20100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
211-1-20; revised 9-18-19.)