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Public Act 102-0598 | ||||
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AN ACT concerning substance use disorders.
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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 Substance Use Disorder Act is amended by | ||||
changing Sections 5-23 and 20-10 as follows: | ||||
(20 ILCS 301/5-23) | ||||
Sec. 5-23. Drug Overdose Prevention Program. | ||||
(a) Reports. | ||||
(1) The Department may publish annually a report on | ||||
drug overdose trends statewide that reviews State death | ||||
rates from available data to ascertain changes in the | ||||
causes or rates of fatal and nonfatal drug overdose. The | ||||
report shall also provide information on interventions | ||||
that would be effective in reducing the rate of fatal or | ||||
nonfatal drug overdose and on the current substance use | ||||
disorder treatment capacity within the State. The report | ||||
shall include an analysis of drug overdose information | ||||
reported to the Department of Public Health pursuant to | ||||
subsection (e) of Section 3-3013 of the Counties Code, | ||||
Section 6.14g of the Hospital Licensing Act, and | ||||
subsection (j) of Section 22-30 of the School Code. | ||||
(2) The report may include: | ||||
(A) Trends in drug overdose death rates. |
(B) Trends in emergency room utilization related | ||
to drug overdose and the cost impact of emergency room | ||
utilization. | ||
(C) Trends in utilization of pre-hospital and | ||
emergency services and the cost impact of emergency | ||
services utilization. | ||
(D) Suggested improvements in data collection. | ||
(E) A description of other interventions effective | ||
in reducing the rate of fatal or nonfatal drug | ||
overdose. | ||
(F) A description of efforts undertaken to educate | ||
the public about unused medication and about how to | ||
properly dispose of unused medication, including the | ||
number of registered collection receptacles in this | ||
State, mail-back programs, and drug take-back events. | ||
(G) An inventory of the State's substance use | ||
disorder treatment capacity, including, but not | ||
limited to: | ||
(i) The number and type of licensed treatment | ||
programs in each geographic area of the State. | ||
(ii) The availability of medication-assisted | ||
treatment at each licensed program and which types | ||
of medication-assisted treatment are available. | ||
(iii) The number of recovery homes that accept | ||
individuals using medication-assisted treatment in | ||
their recovery. |
(iv) The number of medical professionals | ||
currently authorized to prescribe buprenorphine | ||
and the number of individuals who fill | ||
prescriptions for that medication at retail | ||
pharmacies as prescribed. | ||
(v) Any partnerships between programs licensed | ||
by the Department and other providers of | ||
medication-assisted treatment. | ||
(vi) Any challenges in providing | ||
medication-assisted treatment reported by programs | ||
licensed by the Department and any potential | ||
solutions. | ||
(b) Programs; drug overdose prevention. | ||
(1) The Department may establish a program to provide | ||
for the production and publication, in electronic and | ||
other formats, of drug overdose prevention, recognition, | ||
and response literature. The Department may develop and | ||
disseminate curricula for use by professionals, | ||
organizations, individuals, or committees interested in | ||
the prevention of fatal and nonfatal drug overdose, | ||
including, but not limited to, drug users, jail and prison | ||
personnel, jail and prison inmates, drug treatment | ||
professionals, emergency medical personnel, hospital | ||
staff, families and associates of drug users, peace | ||
officers, firefighters, public safety officers, needle | ||
exchange program staff, and other persons. In addition to |
information regarding drug overdose prevention, | ||
recognition, and response, literature produced by the | ||
Department shall stress that drug use remains illegal and | ||
highly dangerous and that complete abstinence from illegal | ||
drug use is the healthiest choice. The literature shall | ||
provide information and resources for substance use | ||
disorder treatment. | ||
The Department may establish or authorize programs for | ||
prescribing, dispensing, or distributing opioid | ||
antagonists for the treatment of drug overdose. Such | ||
programs may include the prescribing of opioid antagonists | ||
for the treatment of drug overdose to a person who is not | ||
at risk of opioid overdose but who, in the judgment of the | ||
health care professional, may be in a position to assist | ||
another individual during an opioid-related drug overdose | ||
and who has received basic instruction on how to | ||
administer an opioid antagonist. | ||
(2) The Department may provide advice to State and | ||
local officials on the growing drug overdose crisis, | ||
including the prevalence of drug overdose incidents, | ||
programs promoting the disposal of unused prescription | ||
drugs, trends in drug overdose incidents, and solutions to | ||
the drug overdose crisis. | ||
(3) The Department may support drug overdose | ||
prevention, recognition, and response projects by | ||
facilitating the acquisition of opioid antagonist |
medication approved for opioid overdose reversal, | ||
facilitating the acquisition of opioid antagonist | ||
medication approved for opioid overdose reversal, | ||
providing trainings in overdose prevention best practices, | ||
connecting programs to medical resources, establishing a | ||
statewide standing order for the acquisition of needed | ||
medication, establishing learning collaboratives between | ||
localities and programs, and assisting programs in | ||
navigating any regulatory requirements for establishing or | ||
expanding such programs. | ||
(4) In supporting best practices in drug overdose | ||
prevention programming, the Department may promote the | ||
following programmatic elements: | ||
(A) Training individuals who currently use drugs | ||
in the administration of opioid antagonists approved | ||
for the reversal of an opioid overdose. | ||
(B) Directly distributing opioid antagonists | ||
approved for the reversal of an opioid overdose rather | ||
than providing prescriptions to be filled at a | ||
pharmacy. | ||
(C) Conducting street and community outreach to | ||
work directly with individuals who are using drugs. | ||
(D) Employing community health workers or peer | ||
recovery specialists who are familiar with the | ||
communities served and can provide culturally | ||
competent services. |
(E) Collaborating with other community-based | ||
organizations, substance use disorder treatment | ||
centers, or other health care providers engaged in | ||
treating individuals who are using drugs. | ||
(F) Providing linkages for individuals to obtain | ||
evidence-based substance use disorder treatment. | ||
(G) Engaging individuals exiting jails or prisons | ||
who are at a high risk of overdose. | ||
(H) Providing education and training to | ||
community-based organizations who work directly with | ||
individuals who are using drugs and those individuals' | ||
families and communities. | ||
(I) Providing education and training on drug | ||
overdose prevention and response to emergency | ||
personnel and law enforcement. | ||
(J) Informing communities of the important role | ||
emergency personnel play in responding to accidental | ||
overdose. | ||
(K) Producing and distributing targeted mass media | ||
materials on drug overdose prevention and response, | ||
the potential dangers of leaving unused prescription | ||
drugs in the home, and the proper methods for | ||
disposing of unused prescription drugs. | ||
(c) Grants. | ||
(1) The Department may award grants, in accordance | ||
with this subsection, to create or support local drug |
overdose prevention, recognition, and response projects. | ||
Local health departments, correctional institutions, | ||
hospitals, universities, community-based organizations, | ||
and faith-based organizations may apply to the Department | ||
for a grant under this subsection at the time and in the | ||
manner the Department prescribes. Eligible grant | ||
activities include, but are not limited to, purchasing and | ||
distributing opioid antagonists, hiring peer recovery | ||
specialists or other community members to conduct | ||
community outreach, and hosting public health fairs or | ||
events to distribute opioid antagonists, promote harm | ||
reduction activities, and provide linkages to community | ||
partners. | ||
(2) In awarding grants, the Department shall consider | ||
the overall rate of opioid overdose, the rate of increase | ||
in opioid overdose, and racial disparities in opioid | ||
overdose experienced by the communities to be served by | ||
grantees. The Department necessity for overdose prevention | ||
projects in various settings and shall encourage all grant | ||
applicants to develop interventions that will be effective | ||
and viable in their local areas. | ||
(3) (Blank). | ||
(3.5) Any hospital licensed under the Hospital | ||
Licensing Act or organized under the University of | ||
Illinois Hospital Act shall be deemed to
have met the | ||
standards and requirements set forth in this Section to |
enroll in the drug overdose prevention program upon | ||
completion of
the enrollment process except that proof of | ||
a standing order and attestation of programmatic | ||
requirements shall
be waived for enrollment purposes. | ||
Reporting mandated by enrollment
shall be necessary to | ||
carry out or attain eligibility for associated resources | ||
under this Section for drug overdose prevention projects
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operated on the licensed premises of the hospital and | ||
operated by the hospital or its designated agent. The | ||
Department shall streamline hospital enrollment for drug | ||
overdose prevention programs by accepting such deemed | ||
status under this Section
in order to reduce barriers to | ||
hospital participation in drug overdose prevention, | ||
recognition, or response projects. | ||
(4) In addition to moneys appropriated by the General | ||
Assembly, the Department may seek grants from private | ||
foundations, the federal government, and other sources to | ||
fund the grants under this Section and to fund an | ||
evaluation of the programs supported by the grants. | ||
(d) Health care professional prescription of opioid | ||
antagonists. | ||
(1) A health care professional who, acting in good | ||
faith, directly or by standing order, prescribes or | ||
dispenses an opioid antagonist to: (a) a patient who, in | ||
the judgment of the health care professional, is capable | ||
of administering the drug in an emergency, or (b) a person |
who is not at risk of opioid overdose but who, in the | ||
judgment of the health care professional, may be in a | ||
position to assist another individual during an | ||
opioid-related drug overdose and who has received basic | ||
instruction on how to administer an opioid antagonist | ||
shall not, as a result of his or her acts or omissions, be | ||
subject to: (i) any disciplinary or other adverse action | ||
under the Medical Practice Act of 1987, the Physician | ||
Assistant Practice Act of 1987, the Nurse Practice Act, | ||
the Pharmacy Practice Act, or any other professional | ||
licensing statute or (ii) any criminal liability, except | ||
for willful and wanton misconduct. | ||
(1.5) Notwithstanding any provision of or requirement | ||
otherwise imposed by the Pharmacy Practice Act, the | ||
Medical Practice Act of 1987, or any other law or rule, | ||
including, but not limited to, any requirement related to | ||
labeling, storage, or recordkeeping, a health care | ||
professional or other person acting under the direction of | ||
a health care professional may, directly or by standing | ||
order, obtain, store, and dispense an
opioid antagonist to | ||
a patient in a facility that includes, but is not limited | ||
to, a hospital, a hospital affiliate, or a federally
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qualified health center if the patient information | ||
specified in paragraph (4) of this subsection is provided | ||
to the patient. A person acting in accordance with this | ||
paragraph shall not, as a result of his or her acts or |
omissions, be subject to: (i) any disciplinary or other | ||
adverse action under the Medical Practice Act of 1987, the | ||
Physician Assistant Practice Act of 1987, the Nurse | ||
Practice Act, the Pharmacy Practice Act, or any other | ||
professional licensing statute; or (ii) any criminal | ||
liability, except for willful and wanton misconduct. | ||
(2) A person who is not otherwise licensed to | ||
administer an opioid antagonist may in an emergency | ||
administer without fee an opioid antagonist if the person | ||
has received the patient information specified in | ||
paragraph (4) of this subsection and believes in good | ||
faith that another person is experiencing a drug overdose. | ||
The person shall not, as a result of his or her acts or | ||
omissions, be (i) liable for any violation of the Medical | ||
Practice Act of 1987, the Physician Assistant Practice Act | ||
of 1987, the Nurse Practice Act, the Pharmacy Practice | ||
Act, or any other professional licensing statute, or (ii) | ||
subject to any criminal prosecution or civil liability, | ||
except for willful and wanton misconduct. | ||
(3) A health care professional prescribing an opioid | ||
antagonist to a patient shall ensure that the patient | ||
receives the patient information specified in paragraph | ||
(4) of this subsection. Patient information may be | ||
provided by the health care professional or a | ||
community-based organization, substance use disorder | ||
program, or other organization with which the health care |
professional establishes a written agreement that includes | ||
a description of how the organization will provide patient | ||
information, how employees or volunteers providing | ||
information will be trained, and standards for documenting | ||
the provision of patient information to patients. | ||
Provision of patient information shall be documented in | ||
the patient's medical record or through similar means as | ||
determined by agreement between the health care | ||
professional and the organization. The Department, in | ||
consultation with statewide organizations representing | ||
physicians, pharmacists, advanced practice registered | ||
nurses, physician assistants, substance use disorder | ||
programs, and other interested groups, shall develop and | ||
disseminate to health care professionals, community-based | ||
organizations, substance use disorder programs, and other | ||
organizations training materials in video, electronic, or | ||
other formats to facilitate the provision of such patient | ||
information. | ||
(4) For the purposes of this subsection: | ||
"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. | ||
"Health care professional" means a physician licensed | ||
to practice medicine in all its branches, a licensed |
physician assistant with prescriptive authority, a | ||
licensed advanced practice registered nurse with | ||
prescriptive authority, an advanced practice registered | ||
nurse or physician assistant who practices in a hospital, | ||
hospital affiliate, or ambulatory surgical treatment | ||
center and possesses appropriate clinical privileges in | ||
accordance with the Nurse Practice Act, or a pharmacist | ||
licensed to practice pharmacy under the Pharmacy Practice | ||
Act. | ||
"Patient" includes a person who is not at risk of | ||
opioid overdose but who, in the judgment of the physician, | ||
advanced practice registered nurse, or physician | ||
assistant, may be in a position to assist another | ||
individual during an overdose and who has received patient | ||
information as required in paragraph (2) of this | ||
subsection on the indications for and administration of an | ||
opioid antagonist. | ||
"Patient information" includes information provided to | ||
the patient on drug overdose prevention and recognition; | ||
how to perform rescue breathing and resuscitation; opioid | ||
antagonist dosage and administration; the importance of | ||
calling 911; care for the overdose victim after | ||
administration of the overdose antagonist; and other | ||
issues as necessary.
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(e) Drug overdose response policy. | ||
(1) Every State and local government agency that |
employs a law enforcement officer or fireman as those | ||
terms are defined in the Line of Duty Compensation Act | ||
must possess opioid antagonists and must establish a | ||
policy to control the acquisition, storage, | ||
transportation, and administration of such opioid | ||
antagonists and to provide training in the administration | ||
of opioid antagonists. A State or local government agency | ||
that employs a fireman as defined in the Line of Duty | ||
Compensation Act but does not respond to emergency medical | ||
calls or provide medical services shall be exempt from | ||
this subsection. | ||
(2) Every publicly or privately owned ambulance, | ||
special emergency medical services vehicle, non-transport | ||
vehicle, or ambulance assist vehicle, as described in the | ||
Emergency Medical Services (EMS) Systems Act, that | ||
responds to requests for emergency services or transports | ||
patients between hospitals in emergency situations must | ||
possess opioid antagonists. | ||
(3) Entities that are required under paragraphs (1) | ||
and (2) to possess opioid antagonists may also apply to | ||
the Department for a grant to fund the acquisition of | ||
opioid antagonists and training programs on the | ||
administration of opioid antagonists. | ||
(Source: P.A. 100-201, eff. 8-18-17; 100-513, eff. 1-1-18; | ||
100-759, eff. 1-1-19; 101-356, eff. 8-9-19.)
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(20 ILCS 301/20-10)
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Sec. 20-10. Screening, Brief Intervention, and Referral to | ||
Treatment. As used in this Section, "SBIRT" means a | ||
comprehensive, integrated, public health approach to the | ||
delivery of early intervention and treatment
services for | ||
persons who are at risk of developing substance use disorders | ||
or have substance use disorders including, but not limited to, | ||
an addiction to alcohol, opioids,
tobacco, or cannabis.
SBIRT | ||
services include all of the following: | ||
(1) Screening to quickly assess the severity of | ||
substance use and to identify the appropriate level of | ||
treatment. | ||
(2) Brief intervention focused on increasing insight | ||
and awareness regarding substance use and motivation | ||
toward behavioral change. | ||
(3) Referral to treatment provided to those identified | ||
as needing more extensive treatment with access to | ||
specialty care. | ||
SBIRT services may include, but are not limited to, the | ||
following settings and programs: primary care centers, | ||
hospital emergency rooms, hospital in-patient units,
trauma | ||
centers, community behavioral health programs, and other | ||
community settings that provide opportunities for early | ||
intervention with at-risk substance users before more severe
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consequences occur. | ||
(a) As used in this Section, "SBIRT" means the |
identification of individuals, within primary care settings, | ||
who need substance use disorder treatment. Primary care | ||
providers will screen and, based on the results of the screen, | ||
deliver a brief intervention or make referral to a licensed | ||
treatment provider as appropriate. SBIRT is not a licensed | ||
category of service. | ||
(b) The Department may develop policy or best practice | ||
guidelines for identification of at-risk individuals through | ||
SBIRT and contract or billing requirements for SBIRT.
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(Source: P.A. 100-759, eff. 1-1-19 .)
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Section 10. The Illinois Public Aid Code is amended by | ||
changing Section 5-5 and by adding Section 5-41 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
| ||
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
| ||
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:
| ||
(1) dental services provided by or under the | ||
supervision of a dentist; and
| ||
(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. | ||
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.
| ||
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.
| ||
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.
| ||
(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.
| ||
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
| ||
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
| ||
addiction for pregnant recipients in accordance with the | ||
Illinois Medicaid
Program in conjunction with the Department | ||
of Human Services.
| ||
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
| ||
program providing case management services for addicted women,
| ||
including information on appropriate referrals for other | ||
social services
that may be needed by addicted women in | ||
addition to treatment for addiction.
| ||
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
| ||
addiction, prenatal health care, and other pertinent programs | ||
directed at
reducing the number of drug-affected infants born | ||
to recipients of medical
assistance.
| ||
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.
| ||
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
| ||
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.
| ||
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.
| ||
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
| ||
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:
| ||
(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.
| ||
(2) The Department may elect to consider and negotiate | ||
financial
incentives to encourage the development of |
Partnerships and the efficient
delivery of medical care.
| ||
(3) Persons receiving medical services through | ||
Partnerships may receive
medical and case management | ||
services above the level usually offered
through the | ||
medical assistance program.
| ||
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.
| ||
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
| ||
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.
| ||
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.
|
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
| ||
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
| ||
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 or hospital fees related to the dispensing , distribution, | ||
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.) | ||
(305 ILCS 5/5-41 new) | ||
Sec. 5-41. Screening, Brief Intervention, and Referral to | ||
Treatment. | ||
As used in this Section, "SBIRT" means a comprehensive, | ||
integrated, public health approach to the delivery of early | ||
intervention and treatment
services for persons who are at | ||
risk of developing substance use disorders or have substance | ||
use disorders including, but not limited to, an addiction to | ||
alcohol, opioids,
tobacco, or cannabis.
SBIRT services include | ||
all of the following: | ||
(1) Screening to quickly assess the severity of | ||
substance use and to identify the appropriate level of | ||
treatment. | ||
(2) Brief intervention focused on increasing insight |
and awareness regarding substance use and motivation | ||
toward behavioral change. | ||
(3) Referral to treatment provided to those identified | ||
as needing more extensive treatment with access to | ||
specialty care. | ||
SBIRT services may include, but are not limited to, the | ||
following settings and programs: primary care centers, | ||
hospital emergency rooms, hospital in-patient units,
trauma | ||
centers, community behavioral health programs, and other | ||
community settings that provide opportunities for early | ||
intervention with at-risk substance users before more severe
| ||
consequences occur. | ||
The Department of Healthcare and Family Services shall | ||
develop and seek federal approval of a SBIRT benefit for which
| ||
qualified providers shall be reimbursed under the medical | ||
assistance program. | ||
In conjunction with the Department of Human Services' | ||
Division of Substance Use Prevention and Recovery, the | ||
Department of Healthcare and
Family Services may develop a | ||
methodology and reimbursement rate for SBIRT services provided | ||
by qualified providers in approved
settings. | ||
For opioid specific SBIRT services provided in a hospital | ||
emergency department, the Department of Healthcare and
Family | ||
Services shall develop a bundled reimbursement
methodology and | ||
rate for a package of opioid treatment services, which include | ||
initiation of medication for the treatment of opioid use |
disorder in
the emergency department setting, including | ||
assessment, referral to ongoing care, and arranging access to | ||
supportive services when necessary. This
package of opioid | ||
related services shall be billed on a separate claim and shall | ||
be reimbursed outside of the Enhanced Ambulatory Patient
| ||
Grouping system.
|