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Public Act 102-0095 | ||||
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AN ACT concerning public aid.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Illinois Public Aid Code is amended by | ||||
changing Section 5-5 as follows:
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(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
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Sec. 5-5. Medical services. The Illinois Department, by | ||||
rule, shall
determine the quantity and quality of and the rate | ||||
of reimbursement for the
medical assistance for which
payment | ||||
will be authorized, and the medical services to be provided,
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which may include all or part of the following: (1) inpatient | ||||
hospital
services; (2) outpatient hospital services; (3) other | ||||
laboratory and
X-ray services; (4) skilled nursing home | ||||
services; (5) physicians'
services whether furnished in the | ||||
office, the patient's home, a
hospital, a skilled nursing | ||||
home, or elsewhere; (6) medical care, or any
other type of | ||||
remedial care furnished by licensed practitioners; (7)
home | ||||
health care services; (8) private duty nursing service; (9) | ||||
clinic
services; (10) dental services, including prevention | ||||
and treatment of periodontal disease and dental caries disease | ||||
for pregnant women, provided by an individual licensed to | ||||
practice dentistry or dental surgery; for purposes of this | ||||
item (10), "dental services" means diagnostic, preventive, or |
corrective procedures provided by or under the supervision of | ||
a dentist in the practice of his or her profession; (11) | ||
physical therapy and related
services; (12) prescribed drugs, | ||
dentures, and prosthetic devices; and
eyeglasses prescribed by | ||
a physician skilled in the diseases of the eye,
or by an | ||
optometrist, whichever the person may select; (13) other
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diagnostic, screening, preventive, and rehabilitative | ||
services, including to ensure that the individual's need for | ||
intervention or treatment of mental disorders or substance use | ||
disorders or co-occurring mental health and substance use | ||
disorders is determined using a uniform screening, assessment, | ||
and evaluation process inclusive of criteria, for children and | ||
adults; for purposes of this item (13), a uniform screening, | ||
assessment, and evaluation process refers to a process that | ||
includes an appropriate evaluation and, as warranted, a | ||
referral; "uniform" does not mean the use of a singular | ||
instrument, tool, or process that all must utilize; (14)
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transportation and such other expenses as may be necessary; | ||
(15) medical
treatment of sexual assault survivors, as defined | ||
in
Section 1a of the Sexual Assault Survivors Emergency | ||
Treatment Act, for
injuries sustained as a result of the | ||
sexual assault, including
examinations and laboratory tests to | ||
discover evidence which may be used in
criminal proceedings | ||
arising from the sexual assault; (16) the
diagnosis and | ||
treatment of sickle cell anemia; and (17)
any other medical | ||
care, and any other type of remedial care recognized
under the |
laws of this State. The term "any other type of remedial care" | ||
shall
include nursing care and nursing home service for | ||
persons who rely on
treatment by spiritual means alone through | ||
prayer for healing.
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Notwithstanding any other provision of this Section, a | ||
comprehensive
tobacco use cessation program that includes | ||
purchasing prescription drugs or
prescription medical devices | ||
approved by the Food and Drug Administration shall
be covered | ||
under the medical assistance
program under this Article for | ||
persons who are otherwise eligible for
assistance under this | ||
Article.
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Notwithstanding any other provision of this Code, | ||
reproductive health care that is otherwise legal in Illinois | ||
shall be covered under the medical assistance program for | ||
persons who are otherwise eligible for medical assistance | ||
under this Article. | ||
Notwithstanding any other provision of this Code, the | ||
Illinois
Department may not require, as a condition of payment | ||
for any laboratory
test authorized under this Article, that a | ||
physician's handwritten signature
appear on the laboratory | ||
test order form. The Illinois Department may,
however, impose | ||
other appropriate requirements regarding laboratory test
order | ||
documentation.
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Upon receipt of federal approval of an amendment to the | ||
Illinois Title XIX State Plan for this purpose, the Department | ||
shall authorize the Chicago Public Schools (CPS) to procure a |
vendor or vendors to manufacture eyeglasses for individuals | ||
enrolled in a school within the CPS system. CPS shall ensure | ||
that its vendor or vendors are enrolled as providers in the | ||
medical assistance program and in any capitated Medicaid | ||
managed care entity (MCE) serving individuals enrolled in a | ||
school within the CPS system. Under any contract procured | ||
under this provision, the vendor or vendors must serve only | ||
individuals enrolled in a school within the CPS system. Claims | ||
for services provided by CPS's vendor or vendors to recipients | ||
of benefits in the medical assistance program under this Code, | ||
the Children's Health Insurance Program, or the Covering ALL | ||
KIDS Health Insurance Program shall be submitted to the | ||
Department or the MCE in which the individual is enrolled for | ||
payment and shall be reimbursed at the Department's or the | ||
MCE's established rates or rate methodologies for eyeglasses. | ||
On and after July 1, 2012, the Department of Healthcare | ||
and Family Services may provide the following services to
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persons
eligible for assistance under this Article who are | ||
participating in
education, training or employment programs | ||
operated by the Department of Human
Services as successor to | ||
the Department of Public Aid:
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(1) dental services provided by or under the | ||
supervision of a dentist; and
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(2) eyeglasses prescribed by a physician skilled in | ||
the diseases of the
eye, or by an optometrist, whichever | ||
the person may select.
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On and after July 1, 2018, the Department of Healthcare | ||
and Family Services shall provide dental services to any adult | ||
who is otherwise eligible for assistance under the medical | ||
assistance program. As used in this paragraph, "dental | ||
services" means diagnostic, preventative, restorative, or | ||
corrective procedures, including procedures and services for | ||
the prevention and treatment of periodontal disease and dental | ||
caries disease, provided by an individual who is licensed to | ||
practice dentistry or dental surgery or who is under the | ||
supervision of a dentist in the practice of his or her | ||
profession. | ||
On and after July 1, 2018, targeted dental services, as | ||
set forth in Exhibit D of the Consent Decree entered by the | ||
United States District Court for the Northern District of | ||
Illinois, Eastern Division, in the matter of Memisovski v. | ||
Maram, Case No. 92 C 1982, that are provided to adults under | ||
the medical assistance program shall be established at no less | ||
than the rates set forth in the "New Rate" column in Exhibit D | ||
of the Consent Decree for targeted dental services that are | ||
provided to persons under the age of 18 under the medical | ||
assistance program. | ||
Notwithstanding any other provision of this Code and | ||
subject to federal approval, the Department may adopt rules to | ||
allow a dentist who is volunteering his or her service at no | ||
cost to render dental services through an enrolled | ||
not-for-profit health clinic without the dentist personally |
enrolling as a participating provider in the medical | ||
assistance program. A not-for-profit health clinic shall | ||
include a public health clinic or Federally Qualified Health | ||
Center or other enrolled provider, as determined by the | ||
Department, through which dental services covered under this | ||
Section are performed. The Department shall establish a | ||
process for payment of claims for reimbursement for covered | ||
dental services rendered under this provision. | ||
On and after January 1, 2022, the Department of Healthcare | ||
and Family Services shall administer and regulate a | ||
school-based dental program that allows for the out-of-office | ||
delivery of preventative dental services in a school setting | ||
to children under 19 years of age. The Department shall | ||
establish, by rule, guidelines for participation by providers | ||
and set requirements for follow-up referral care based on the | ||
requirements established in the Dental Office Reference Manual | ||
published by the Department that establishes the requirements | ||
for dentists participating in the All Kids Dental School | ||
Program. Every effort shall be made by the Department when | ||
developing the program requirements to consider the different | ||
geographic differences of both urban and rural areas of the | ||
State for initial treatment and necessary follow-up care. No | ||
provider shall be charged a fee by any unit of local government | ||
to participate in the school-based dental program administered | ||
by the Department. Nothing in this paragraph shall be | ||
construed to limit or preempt a home rule unit's or school |
district's authority to establish, change, or administer a | ||
school-based dental program in addition to, or independent of, | ||
the school-based dental program administered by the | ||
Department. | ||
The Illinois Department, by rule, may distinguish and | ||
classify the
medical services to be provided only in | ||
accordance with the classes of
persons designated in Section | ||
5-2.
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The Department of Healthcare and Family Services must | ||
provide coverage and reimbursement for amino acid-based | ||
elemental formulas, regardless of delivery method, for the | ||
diagnosis and treatment of (i) eosinophilic disorders and (ii) | ||
short bowel syndrome when the prescribing physician has issued | ||
a written order stating that the amino acid-based elemental | ||
formula is medically necessary.
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The Illinois Department shall authorize the provision of, | ||
and shall
authorize payment for, screening by low-dose | ||
mammography for the presence of
occult breast cancer for women | ||
35 years of age or older who are eligible
for medical | ||
assistance under this Article, as follows: | ||
(A) A baseline
mammogram for women 35 to 39 years of | ||
age.
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(B) An annual mammogram for women 40 years of age or | ||
older. | ||
(C) A mammogram at the age and intervals considered | ||
medically necessary by the woman's health care provider |
for women under 40 years of age and having a family history | ||
of breast cancer, prior personal history of breast cancer, | ||
positive genetic testing, or other risk factors. | ||
(D) A comprehensive ultrasound screening and MRI of an | ||
entire breast or breasts if a mammogram demonstrates | ||
heterogeneous or dense breast tissue or when medically | ||
necessary as determined by a physician licensed to | ||
practice medicine in all of its branches. | ||
(E) A screening MRI when medically necessary, as | ||
determined by a physician licensed to practice medicine in | ||
all of its branches. | ||
(F) A diagnostic mammogram when medically necessary, | ||
as determined by a physician licensed to practice medicine | ||
in all its branches, advanced practice registered nurse, | ||
or physician assistant. | ||
The Department shall not impose a deductible, coinsurance, | ||
copayment, or any other cost-sharing requirement on the | ||
coverage provided under this paragraph; except that this | ||
sentence does not apply to coverage of diagnostic mammograms | ||
to the extent such coverage would disqualify a high-deductible | ||
health plan from eligibility for a health savings account | ||
pursuant to Section 223 of the Internal Revenue Code (26 | ||
U.S.C. 223). | ||
All screenings
shall
include a physical breast exam, | ||
instruction on self-examination and
information regarding the | ||
frequency of self-examination and its value as a
preventative |
tool. | ||
For purposes of this Section: | ||
"Diagnostic
mammogram" means a mammogram obtained using | ||
diagnostic mammography. | ||
"Diagnostic
mammography" means a method of screening that | ||
is designed to
evaluate an abnormality in a breast, including | ||
an abnormality seen
or suspected on a screening mammogram or a | ||
subjective or objective
abnormality otherwise detected in the | ||
breast. | ||
"Low-dose mammography" means
the x-ray examination of the | ||
breast using equipment dedicated specifically
for mammography, | ||
including the x-ray tube, filter, compression device,
and | ||
image receptor, with an average radiation exposure delivery
of | ||
less than one rad per breast for 2 views of an average size | ||
breast.
The term also includes digital mammography and | ||
includes breast tomosynthesis. | ||
"Breast tomosynthesis" means a radiologic procedure that | ||
involves the acquisition of projection images over the | ||
stationary breast to produce cross-sectional digital | ||
three-dimensional images of the breast. | ||
If, at any time, the Secretary of the United States | ||
Department of Health and Human Services, or its successor | ||
agency, promulgates rules or regulations to be published in | ||
the Federal Register or publishes a comment in the Federal | ||
Register or issues an opinion, guidance, or other action that | ||
would require the State, pursuant to any provision of the |
Patient Protection and Affordable Care Act (Public Law | ||
111-148), including, but not limited to, 42 U.S.C. | ||
18031(d)(3)(B) or any successor provision, to defray the cost | ||
of any coverage for breast tomosynthesis outlined in this | ||
paragraph, then the requirement that an insurer cover breast | ||
tomosynthesis is inoperative other than any such coverage | ||
authorized under Section 1902 of the Social Security Act, 42 | ||
U.S.C. 1396a, and the State shall not assume any obligation | ||
for the cost of coverage for breast tomosynthesis set forth in | ||
this paragraph.
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On and after January 1, 2016, the Department shall ensure | ||
that all networks of care for adult clients of the Department | ||
include access to at least one breast imaging Center of | ||
Imaging Excellence as certified by the American College of | ||
Radiology. | ||
On and after January 1, 2012, providers participating in a | ||
quality improvement program approved by the Department shall | ||
be reimbursed for screening and diagnostic mammography at the | ||
same rate as the Medicare program's rates, including the | ||
increased reimbursement for digital mammography. | ||
The Department shall convene an expert panel including | ||
representatives of hospitals, free-standing mammography | ||
facilities, and doctors, including radiologists, to establish | ||
quality standards for mammography. | ||
On and after January 1, 2017, providers participating in a | ||
breast cancer treatment quality improvement program approved |
by the Department shall be reimbursed for breast cancer | ||
treatment at a rate that is no lower than 95% of the Medicare | ||
program's rates for the data elements included in the breast | ||
cancer treatment quality program. | ||
The Department shall convene an expert panel, including | ||
representatives of hospitals, free-standing breast cancer | ||
treatment centers, breast cancer quality organizations, and | ||
doctors, including breast surgeons, reconstructive breast | ||
surgeons, oncologists, and primary care providers to establish | ||
quality standards for breast cancer treatment. | ||
Subject to federal approval, the Department shall | ||
establish a rate methodology for mammography at federally | ||
qualified health centers and other encounter-rate clinics. | ||
These clinics or centers may also collaborate with other | ||
hospital-based mammography facilities. By January 1, 2016, the | ||
Department shall report to the General Assembly on the status | ||
of the provision set forth in this paragraph. | ||
The Department shall establish a methodology to remind | ||
women who are age-appropriate for screening mammography, but | ||
who have not received a mammogram within the previous 18 | ||
months, of the importance and benefit of screening | ||
mammography. The Department shall work with experts in breast | ||
cancer outreach and patient navigation to optimize these | ||
reminders and shall establish a methodology for evaluating | ||
their effectiveness and modifying the methodology based on the | ||
evaluation. |
The Department shall establish a performance goal for | ||
primary care providers with respect to their female patients | ||
over age 40 receiving an annual mammogram. This performance | ||
goal shall be used to provide additional reimbursement in the | ||
form of a quality performance bonus to primary care providers | ||
who meet that goal. | ||
The Department shall devise a means of case-managing or | ||
patient navigation for beneficiaries diagnosed with breast | ||
cancer. This program shall initially operate as a pilot | ||
program in areas of the State with the highest incidence of | ||
mortality related to breast cancer. At least one pilot program | ||
site shall be in the metropolitan Chicago area and at least one | ||
site shall be outside the metropolitan Chicago area. On or | ||
after July 1, 2016, the pilot program shall be expanded to | ||
include one site in western Illinois, one site in southern | ||
Illinois, one site in central Illinois, and 4 sites within | ||
metropolitan Chicago. An evaluation of the pilot program shall | ||
be carried out measuring health outcomes and cost of care for | ||
those served by the pilot program compared to similarly | ||
situated patients who are not served by the pilot program. | ||
The Department shall require all networks of care to | ||
develop a means either internally or by contract with experts | ||
in navigation and community outreach to navigate cancer | ||
patients to comprehensive care in a timely fashion. The | ||
Department shall require all networks of care to include | ||
access for patients diagnosed with cancer to at least one |
academic commission on cancer-accredited cancer program as an | ||
in-network covered benefit. | ||
Any medical or health care provider shall immediately | ||
recommend, to
any pregnant woman who is being provided | ||
prenatal services and is suspected
of having a substance use | ||
disorder as defined in the Substance Use Disorder Act, | ||
referral to a local substance use disorder treatment program | ||
licensed by the Department of Human Services or to a licensed
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hospital which provides substance abuse treatment services. | ||
The Department of Healthcare and Family Services
shall assure | ||
coverage for the cost of treatment of the drug abuse or
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addiction for pregnant recipients in accordance with the | ||
Illinois Medicaid
Program in conjunction with the Department | ||
of Human Services.
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All medical providers providing medical assistance to | ||
pregnant women
under this Code shall receive information from | ||
the Department on the
availability of services under any
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program providing case management services for addicted women,
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including information on appropriate referrals for other | ||
social services
that may be needed by addicted women in | ||
addition to treatment for addiction.
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The Illinois Department, in cooperation with the | ||
Departments of Human
Services (as successor to the Department | ||
of Alcoholism and Substance
Abuse) and Public Health, through | ||
a public awareness campaign, may
provide information | ||
concerning treatment for alcoholism and drug abuse and
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addiction, prenatal health care, and other pertinent programs | ||
directed at
reducing the number of drug-affected infants born | ||
to recipients of medical
assistance.
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Neither the Department of Healthcare and Family Services | ||
nor the Department of Human
Services shall sanction the | ||
recipient solely on the basis of
her substance abuse.
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The Illinois Department shall establish such regulations | ||
governing
the dispensing of health services under this Article | ||
as it shall deem
appropriate. The Department
should
seek the | ||
advice of formal professional advisory committees appointed by
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the Director of the Illinois Department for the purpose of | ||
providing regular
advice on policy and administrative matters, | ||
information dissemination and
educational activities for | ||
medical and health care providers, and
consistency in | ||
procedures to the Illinois Department.
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The Illinois Department may develop and contract with | ||
Partnerships of
medical providers to arrange medical services | ||
for persons eligible under
Section 5-2 of this Code. | ||
Implementation of this Section may be by
demonstration | ||
projects in certain geographic areas. The Partnership shall
be | ||
represented by a sponsor organization. The Department, by | ||
rule, shall
develop qualifications for sponsors of | ||
Partnerships. Nothing in this
Section shall be construed to | ||
require that the sponsor organization be a
medical | ||
organization.
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The sponsor must negotiate formal written contracts with |
medical
providers for physician services, inpatient and | ||
outpatient hospital care,
home health services, treatment for | ||
alcoholism and substance abuse, and
other services determined | ||
necessary by the Illinois Department by rule for
delivery by | ||
Partnerships. Physician services must include prenatal and
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obstetrical care. The Illinois Department shall reimburse | ||
medical services
delivered by Partnership providers to clients | ||
in target areas according to
provisions of this Article and | ||
the Illinois Health Finance Reform Act,
except that:
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(1) Physicians participating in a Partnership and | ||
providing certain
services, which shall be determined by | ||
the Illinois Department, to persons
in areas covered by | ||
the Partnership may receive an additional surcharge
for | ||
such services.
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(2) The Department may elect to consider and negotiate | ||
financial
incentives to encourage the development of | ||
Partnerships and the efficient
delivery of medical care.
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(3) Persons receiving medical services through | ||
Partnerships may receive
medical and case management | ||
services above the level usually offered
through the | ||
medical assistance program.
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Medical providers shall be required to meet certain | ||
qualifications to
participate in Partnerships to ensure the | ||
delivery of high quality medical
services. These | ||
qualifications shall be determined by rule of the Illinois
| ||
Department and may be higher than qualifications for |
participation in the
medical assistance program. Partnership | ||
sponsors may prescribe reasonable
additional qualifications | ||
for participation by medical providers, only with
the prior | ||
written approval of the Illinois Department.
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Nothing in this Section shall limit the free choice of | ||
practitioners,
hospitals, and other providers of medical | ||
services by clients.
In order to ensure patient freedom of | ||
choice, the Illinois Department shall
immediately promulgate | ||
all rules and take all other necessary actions so that
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provided services may be accessed from therapeutically | ||
certified optometrists
to the full extent of the Illinois | ||
Optometric Practice Act of 1987 without
discriminating between | ||
service providers.
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The Department shall apply for a waiver from the United | ||
States Health
Care Financing Administration to allow for the | ||
implementation of
Partnerships under this Section.
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The Illinois Department shall require health care | ||
providers to maintain
records that document the medical care | ||
and services provided to recipients
of Medical Assistance | ||
under this Article. Such records must be retained for a period | ||
of not less than 6 years from the date of service or as | ||
provided by applicable State law, whichever period is longer, | ||
except that if an audit is initiated within the required | ||
retention period then the records must be retained until the | ||
audit is completed and every exception is resolved. The | ||
Illinois Department shall
require health care providers to |
make available, when authorized by the
patient, in writing, | ||
the medical records in a timely fashion to other
health care | ||
providers who are treating or serving persons eligible for
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Medical Assistance under this Article. All dispensers of | ||
medical services
shall be required to maintain and retain | ||
business and professional records
sufficient to fully and | ||
accurately document the nature, scope, details and
receipt of | ||
the health care provided to persons eligible for medical
| ||
assistance under this Code, in accordance with regulations | ||
promulgated by
the Illinois Department. The rules and | ||
regulations shall require that proof
of the receipt of | ||
prescription drugs, dentures, prosthetic devices and
| ||
eyeglasses by eligible persons under this Section accompany | ||
each claim
for reimbursement submitted by the dispenser of | ||
such medical services.
No such claims for reimbursement shall | ||
be approved for payment by the Illinois
Department without | ||
such proof of receipt, unless the Illinois Department
shall | ||
have put into effect and shall be operating a system of | ||
post-payment
audit and review which shall, on a sampling | ||
basis, be deemed adequate by
the Illinois Department to assure | ||
that such drugs, dentures, prosthetic
devices and eyeglasses | ||
for which payment is being made are actually being
received by | ||
eligible recipients. Within 90 days after September 16, 1984 | ||
(the effective date of Public Act 83-1439), the Illinois | ||
Department shall establish a
current list of acquisition costs | ||
for all prosthetic devices and any
other items recognized as |
medical equipment and supplies reimbursable under
this Article | ||
and shall update such list on a quarterly basis, except that
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the acquisition costs of all prescription drugs shall be | ||
updated no
less frequently than every 30 days as required by | ||
Section 5-5.12.
| ||
Notwithstanding any other law to the contrary, the | ||
Illinois Department shall, within 365 days after July 22, 2013 | ||
(the effective date of Public Act 98-104), establish | ||
procedures to permit skilled care facilities licensed under | ||
the Nursing Home Care Act to submit monthly billing claims for | ||
reimbursement purposes. Following development of these | ||
procedures, the Department shall, by July 1, 2016, test the | ||
viability of the new system and implement any necessary | ||
operational or structural changes to its information | ||
technology platforms in order to allow for the direct | ||
acceptance and payment of nursing home claims. | ||
Notwithstanding any other law to the contrary, the | ||
Illinois Department shall, within 365 days after August 15, | ||
2014 (the effective date of Public Act 98-963), establish | ||
procedures to permit ID/DD facilities licensed under the ID/DD | ||
Community Care Act and MC/DD facilities licensed under the | ||
MC/DD Act to submit monthly billing claims for reimbursement | ||
purposes. Following development of these procedures, the | ||
Department shall have an additional 365 days to test the | ||
viability of the new system and to ensure that any necessary | ||
operational or structural changes to its information |
technology platforms are implemented. | ||
The Illinois Department shall require all dispensers of | ||
medical
services, other than an individual practitioner or | ||
group of practitioners,
desiring to participate in the Medical | ||
Assistance program
established under this Article to disclose | ||
all financial, beneficial,
ownership, equity, surety or other | ||
interests in any and all firms,
corporations, partnerships, | ||
associations, business enterprises, joint
ventures, agencies, | ||
institutions or other legal entities providing any
form of | ||
health care services in this State under this Article.
| ||
The Illinois Department may require that all dispensers of | ||
medical
services desiring to participate in the medical | ||
assistance program
established under this Article disclose, | ||
under such terms and conditions as
the Illinois Department may | ||
by rule establish, all inquiries from clients
and attorneys | ||
regarding medical bills paid by the Illinois Department, which
| ||
inquiries could indicate potential existence of claims or | ||
liens for the
Illinois Department.
| ||
Enrollment of a vendor
shall be
subject to a provisional | ||
period and shall be conditional for one year. During the | ||
period of conditional enrollment, the Department may
terminate | ||
the vendor's eligibility to participate in, or may disenroll | ||
the vendor from, the medical assistance
program without cause. | ||
Unless otherwise specified, such termination of eligibility or | ||
disenrollment is not subject to the
Department's hearing | ||
process.
However, a disenrolled vendor may reapply without |
penalty.
| ||
The Department has the discretion to limit the conditional | ||
enrollment period for vendors based upon category of risk of | ||
the vendor. | ||
Prior to enrollment and during the conditional enrollment | ||
period in the medical assistance program, all vendors shall be | ||
subject to enhanced oversight, screening, and review based on | ||
the risk of fraud, waste, and abuse that is posed by the | ||
category of risk of the vendor. The Illinois Department shall | ||
establish the procedures for oversight, screening, and review, | ||
which may include, but need not be limited to: criminal and | ||
financial background checks; fingerprinting; license, | ||
certification, and authorization verifications; unscheduled or | ||
unannounced site visits; database checks; prepayment audit | ||
reviews; audits; payment caps; payment suspensions; and other | ||
screening as required by federal or State law. | ||
The Department shall define or specify the following: (i) | ||
by provider notice, the "category of risk of the vendor" for | ||
each type of vendor, which shall take into account the level of | ||
screening applicable to a particular category of vendor under | ||
federal law and regulations; (ii) by rule or provider notice, | ||
the maximum length of the conditional enrollment period for | ||
each category of risk of the vendor; and (iii) by rule, the | ||
hearing rights, if any, afforded to a vendor in each category | ||
of risk of the vendor that is terminated or disenrolled during | ||
the conditional enrollment period. |
To be eligible for payment consideration, a vendor's | ||
payment claim or bill, either as an initial claim or as a | ||
resubmitted claim following prior rejection, must be received | ||
by the Illinois Department, or its fiscal intermediary, no | ||
later than 180 days after the latest date on the claim on which | ||
medical goods or services were provided, with the following | ||
exceptions: | ||
(1) In the case of a provider whose enrollment is in | ||
process by the Illinois Department, the 180-day period | ||
shall not begin until the date on the written notice from | ||
the Illinois Department that the provider enrollment is | ||
complete. | ||
(2) In the case of errors attributable to the Illinois | ||
Department or any of its claims processing intermediaries | ||
which result in an inability to receive, process, or | ||
adjudicate a claim, the 180-day period shall not begin | ||
until the provider has been notified of the error. | ||
(3) In the case of a provider for whom the Illinois | ||
Department initiates the monthly billing process. | ||
(4) In the case of a provider operated by a unit of | ||
local government with a population exceeding 3,000,000 | ||
when local government funds finance federal participation | ||
for claims payments. | ||
For claims for services rendered during a period for which | ||
a recipient received retroactive eligibility, claims must be | ||
filed within 180 days after the Department determines the |
applicant is eligible. For claims for which the Illinois | ||
Department is not the primary payer, claims must be submitted | ||
to the Illinois Department within 180 days after the final | ||
adjudication by the primary payer. | ||
In the case of long term care facilities, within 45 | ||
calendar days of receipt by the facility of required | ||
prescreening information, new admissions with associated | ||
admission documents shall be submitted through the Medical | ||
Electronic Data Interchange (MEDI) or the Recipient | ||
Eligibility Verification (REV) System or shall be submitted | ||
directly to the Department of Human Services using required | ||
admission forms. Effective September
1, 2014, admission | ||
documents, including all prescreening
information, must be | ||
submitted through MEDI or REV. Confirmation numbers assigned | ||
to an accepted transaction shall be retained by a facility to | ||
verify timely submittal. Once an admission transaction has | ||
been completed, all resubmitted claims following prior | ||
rejection are subject to receipt no later than 180 days after | ||
the admission transaction has been completed. | ||
Claims that are not submitted and received in compliance | ||
with the foregoing requirements shall not be eligible for | ||
payment under the medical assistance program, and the State | ||
shall have no liability for payment of those claims. | ||
To the extent consistent with applicable information and | ||
privacy, security, and disclosure laws, State and federal | ||
agencies and departments shall provide the Illinois Department |
access to confidential and other information and data | ||
necessary to perform eligibility and payment verifications and | ||
other Illinois Department functions. This includes, but is not | ||
limited to: information pertaining to licensure; | ||
certification; earnings; immigration status; citizenship; wage | ||
reporting; unearned and earned income; pension income; | ||
employment; supplemental security income; social security | ||
numbers; National Provider Identifier (NPI) numbers; the | ||
National Practitioner Data Bank (NPDB); program and agency | ||
exclusions; taxpayer identification numbers; tax delinquency; | ||
corporate information; and death records. | ||
The Illinois Department shall enter into agreements with | ||
State agencies and departments, and is authorized to enter | ||
into agreements with federal agencies and departments, under | ||
which such agencies and departments shall share data necessary | ||
for medical assistance program integrity functions and | ||
oversight. The Illinois Department shall develop, in | ||
cooperation with other State departments and agencies, and in | ||
compliance with applicable federal laws and regulations, | ||
appropriate and effective methods to share such data. At a | ||
minimum, and to the extent necessary to provide data sharing, | ||
the Illinois Department shall enter into agreements with State | ||
agencies and departments, and is authorized to enter into | ||
agreements with federal agencies and departments, including , | ||
but not limited to: the Secretary of State; the Department of | ||
Revenue; the Department of Public Health; the Department of |
Human Services; and the Department of Financial and | ||
Professional Regulation. | ||
Beginning in fiscal year 2013, the Illinois Department | ||
shall set forth a request for information to identify the | ||
benefits of a pre-payment, post-adjudication, and post-edit | ||
claims system with the goals of streamlining claims processing | ||
and provider reimbursement, reducing the number of pending or | ||
rejected claims, and helping to ensure a more transparent | ||
adjudication process through the utilization of: (i) provider | ||
data verification and provider screening technology; and (ii) | ||
clinical code editing; and (iii) pre-pay, pre- or | ||
post-adjudicated predictive modeling with an integrated case | ||
management system with link analysis. Such a request for | ||
information shall not be considered as a request for proposal | ||
or as an obligation on the part of the Illinois Department to | ||
take any action or acquire any products or services. | ||
The Illinois Department shall establish policies, | ||
procedures,
standards and criteria by rule for the | ||
acquisition, repair and replacement
of orthotic and prosthetic | ||
devices and durable medical equipment. Such
rules shall | ||
provide, but not be limited to, the following services: (1)
| ||
immediate repair or replacement of such devices by recipients; | ||
and (2) rental, lease, purchase or lease-purchase of
durable | ||
medical equipment in a cost-effective manner, taking into
| ||
consideration the recipient's medical prognosis, the extent of | ||
the
recipient's needs, and the requirements and costs for |
maintaining such
equipment. Subject to prior approval, such | ||
rules shall enable a recipient to temporarily acquire and
use | ||
alternative or substitute devices or equipment pending repairs | ||
or
replacements of any device or equipment previously | ||
authorized for such
recipient by the Department. | ||
Notwithstanding any provision of Section 5-5f to the contrary, | ||
the Department may, by rule, exempt certain replacement | ||
wheelchair parts from prior approval and, for wheelchairs, | ||
wheelchair parts, wheelchair accessories, and related seating | ||
and positioning items, determine the wholesale price by | ||
methods other than actual acquisition costs. | ||
The Department shall require, by rule, all providers of | ||
durable medical equipment to be accredited by an accreditation | ||
organization approved by the federal Centers for Medicare and | ||
Medicaid Services and recognized by the Department in order to | ||
bill the Department for providing durable medical equipment to | ||
recipients. No later than 15 months after the effective date | ||
of the rule adopted pursuant to this paragraph, all providers | ||
must meet the accreditation requirement.
| ||
In order to promote environmental responsibility, meet the | ||
needs of recipients and enrollees, and achieve significant | ||
cost savings, the Department, or a managed care organization | ||
under contract with the Department, may provide recipients or | ||
managed care enrollees who have a prescription or Certificate | ||
of Medical Necessity access to refurbished durable medical | ||
equipment under this Section (excluding prosthetic and |
orthotic devices as defined in the Orthotics, Prosthetics, and | ||
Pedorthics Practice Act and complex rehabilitation technology | ||
products and associated services) through the State's | ||
assistive technology program's reutilization program, using | ||
staff with the Assistive Technology Professional (ATP) | ||
Certification if the refurbished durable medical equipment: | ||
(i) is available; (ii) is less expensive, including shipping | ||
costs, than new durable medical equipment of the same type; | ||
(iii) is able to withstand at least 3 years of use; (iv) is | ||
cleaned, disinfected, sterilized, and safe in accordance with | ||
federal Food and Drug Administration regulations and guidance | ||
governing the reprocessing of medical devices in health care | ||
settings; and (v) equally meets the needs of the recipient or | ||
enrollee. The reutilization program shall confirm that the | ||
recipient or enrollee is not already in receipt of same or | ||
similar equipment from another service provider, and that the | ||
refurbished durable medical equipment equally meets the needs | ||
of the recipient or enrollee. Nothing in this paragraph shall | ||
be construed to limit recipient or enrollee choice to obtain | ||
new durable medical equipment or place any additional prior | ||
authorization conditions on enrollees of managed care | ||
organizations. | ||
The Department shall execute, relative to the nursing home | ||
prescreening
project, written inter-agency agreements with the | ||
Department of Human
Services and the Department on Aging, to | ||
effect the following: (i) intake
procedures and common |
eligibility criteria for those persons who are receiving
| ||
non-institutional services; and (ii) the establishment and | ||
development of
non-institutional services in areas of the | ||
State where they are not currently
available or are | ||
undeveloped; and (iii) notwithstanding any other provision of | ||
law, subject to federal approval, on and after July 1, 2012, an | ||
increase in the determination of need (DON) scores from 29 to | ||
37 for applicants for institutional and home and | ||
community-based long term care; if and only if federal | ||
approval is not granted, the Department may, in conjunction | ||
with other affected agencies, implement utilization controls | ||
or changes in benefit packages to effectuate a similar savings | ||
amount for this population; and (iv) no later than July 1, | ||
2013, minimum level of care eligibility criteria for | ||
institutional and home and community-based long term care; and | ||
(v) no later than October 1, 2013, establish procedures to | ||
permit long term care providers access to eligibility scores | ||
for individuals with an admission date who are seeking or | ||
receiving services from the long term care provider. In order | ||
to select the minimum level of care eligibility criteria, the | ||
Governor shall establish a workgroup that includes affected | ||
agency representatives and stakeholders representing the | ||
institutional and home and community-based long term care | ||
interests. This Section shall not restrict the Department from | ||
implementing lower level of care eligibility criteria for | ||
community-based services in circumstances where federal |
approval has been granted.
| ||
The Illinois Department shall develop and operate, in | ||
cooperation
with other State Departments and agencies and in | ||
compliance with
applicable federal laws and regulations, | ||
appropriate and effective
systems of health care evaluation | ||
and programs for monitoring of
utilization of health care | ||
services and facilities, as it affects
persons eligible for | ||
medical assistance under this Code.
| ||
The Illinois Department shall report annually to the | ||
General Assembly,
no later than the second Friday in April of | ||
1979 and each year
thereafter, in regard to:
| ||
(a) actual statistics and trends in utilization of | ||
medical services by
public aid recipients;
| ||
(b) actual statistics and trends in the provision of | ||
the various medical
services by medical vendors;
| ||
(c) current rate structures and proposed changes in | ||
those rate structures
for the various medical vendors; and
| ||
(d) efforts at utilization review and control by the | ||
Illinois Department.
| ||
The period covered by each report shall be the 3 years | ||
ending on the June
30 prior to the report. The report shall | ||
include suggested legislation
for consideration by the General | ||
Assembly. The requirement for reporting to the General | ||
Assembly shall be satisfied
by filing copies of the report as | ||
required by Section 3.1 of the General Assembly Organization | ||
Act, and filing such additional
copies
with the State |
Government Report Distribution Center for the General
Assembly | ||
as is required under paragraph (t) of Section 7 of the State
| ||
Library Act.
| ||
Rulemaking authority to implement Public Act 95-1045, if | ||
any, is conditioned on the rules being adopted in accordance | ||
with all provisions of the Illinois Administrative Procedure | ||
Act and all rules and procedures of the Joint Committee on | ||
Administrative Rules; any purported rule not so adopted, for | ||
whatever reason, is unauthorized. | ||
On and after July 1, 2012, the Department shall reduce any | ||
rate of reimbursement for services or other payments or alter | ||
any methodologies authorized by this Code to reduce any rate | ||
of reimbursement for services or other payments in accordance | ||
with Section 5-5e. | ||
Because kidney transplantation can be an appropriate, | ||
cost-effective
alternative to renal dialysis when medically | ||
necessary and notwithstanding the provisions of Section 1-11 | ||
of this Code, beginning October 1, 2014, the Department shall | ||
cover kidney transplantation for noncitizens with end-stage | ||
renal disease who are not eligible for comprehensive medical | ||
benefits, who meet the residency requirements of Section 5-3 | ||
of this Code, and who would otherwise meet the financial | ||
requirements of the appropriate class of eligible persons | ||
under Section 5-2 of this Code. To qualify for coverage of | ||
kidney transplantation, such person must be receiving | ||
emergency renal dialysis services covered by the Department. |
Providers under this Section shall be prior approved and | ||
certified by the Department to perform kidney transplantation | ||
and the services under this Section shall be limited to | ||
services associated with kidney transplantation. | ||
Notwithstanding any other provision of this Code to the | ||
contrary, on or after July 1, 2015, all FDA approved forms of | ||
medication assisted treatment prescribed for the treatment of | ||
alcohol dependence or treatment of opioid dependence shall be | ||
covered under both fee for service and managed care medical | ||
assistance programs for persons who are otherwise eligible for | ||
medical assistance under this Article and shall not be subject | ||
to any (1) utilization control, other than those established | ||
under the American Society of Addiction Medicine patient | ||
placement criteria,
(2) prior authorization mandate, or (3) | ||
lifetime restriction limit
mandate. | ||
On or after July 1, 2015, opioid antagonists prescribed | ||
for the treatment of an opioid overdose, including the | ||
medication product, administration devices, and any pharmacy | ||
fees related to the dispensing and administration of the | ||
opioid antagonist, shall be covered under the medical | ||
assistance program for persons who are otherwise eligible for | ||
medical assistance under this Article. As used in this | ||
Section, "opioid antagonist" means a drug that binds to opioid | ||
receptors and blocks or inhibits the effect of opioids acting | ||
on those receptors, including, but not limited to, naloxone | ||
hydrochloride or any other similarly acting drug approved by |
the U.S. Food and Drug Administration. | ||
Upon federal approval, the Department shall provide | ||
coverage and reimbursement for all drugs that are approved for | ||
marketing by the federal Food and Drug Administration and that | ||
are recommended by the federal Public Health Service or the | ||
United States Centers for Disease Control and Prevention for | ||
pre-exposure prophylaxis and related pre-exposure prophylaxis | ||
services, including, but not limited to, HIV and sexually | ||
transmitted infection screening, treatment for sexually | ||
transmitted infections, medical monitoring, assorted labs, and | ||
counseling to reduce the likelihood of HIV infection among | ||
individuals who are not infected with HIV but who are at high | ||
risk of HIV infection. | ||
A federally qualified health center, as defined in Section | ||
1905(l)(2)(B) of the federal
Social Security Act, shall be | ||
reimbursed by the Department in accordance with the federally | ||
qualified health center's encounter rate for services provided | ||
to medical assistance recipients that are performed by a | ||
dental hygienist, as defined under the Illinois Dental | ||
Practice Act, working under the general supervision of a | ||
dentist and employed by a federally qualified health center. | ||
(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18; | ||
100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff. | ||
6-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974, | ||
eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19; | ||
100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff. |
1-1-20; revised 9-18-19.) | ||
Section 99. Effective date. This Act takes effect January | ||
1, 2022.
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