|
regulations thereunder for Federal Drug |
Administration-cleared or in-house developed methods, |
performed under an institutional review board approved |
protocol, if required. |
(4) The availability of quality assurance testing and |
comparative threshold values for metachromatic |
leukodystrophy screening tests. |
(5) The acquisition and installation by the Department |
of equipment necessary to implement metachromatic |
leukodystrophy screening tests. |
(6) The establishment of precise threshold values |
ensuring defined disorder identification of metachromatic |
leukodystrophy. |
(7) The authentication of pilot testing indicating |
that each milestone described in paragraphs (1) through |
(6) has been achieved. |
(8) The authentication of achieving the potential of |
high throughput standards for statewide volume of each |
metachromatic leukodystrophy screening test concomitant |
with each milestone described in paragraphs (1) through |
(4). |
(b) To accumulate the resources for the costs, including |
start-up costs, associated with metachromatic leukodystrophy |
screening tests and any follow-up programs, the Department may |
require payment of an additional fee for administering a |
metachromatic leukodystrophy screening test under this |
|
Section. The Department may not require the payment of the |
additional fee prior to 6 months before the Department |
administers metachromatic leukodystrophy screening tests under |
this Section.
|
Section 10. The Illinois Public Aid Code is amended by |
changing Section 5-5 as follows:
|
(305 ILCS 5/5-5) (from Ch. 23, par. 5-5)
|
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,
|
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 individuals, 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)
|
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; (16.5) services performed by |
a chiropractic physician licensed under the Medical Practice |
|
Act of 1987 and acting within the scope of his or her license, |
including, but not limited to, chiropractic manipulative |
treatment; 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.
|
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.
|
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 Section, all |
tobacco cessation medications approved by the United States |
Food and Drug Administration and all individual and group |
tobacco cessation counseling services and telephone-based |
counseling services and tobacco cessation medications provided |
through the Illinois Tobacco Quitline shall be covered under |
the medical assistance program for persons who are otherwise |
|
eligible for assistance under this Article. The Department |
shall comply with all federal requirements necessary to obtain |
federal financial participation, as specified in 42 CFR |
433.15(b)(7), for telephone-based counseling services provided |
through the Illinois Tobacco Quitline, including, but not |
limited to: (i) entering into a memorandum of understanding or |
interagency agreement with the Department of Public Health, as |
administrator of the Illinois Tobacco Quitline; and (ii) |
developing a cost allocation plan for Medicaid-allowable |
Illinois Tobacco Quitline services in accordance with 45 CFR |
95.507. The Department shall submit the memorandum of |
understanding or interagency agreement, the cost allocation |
plan, and all other necessary documentation to the Centers for |
Medicare and Medicaid Services for review and approval. |
Coverage under this paragraph shall be contingent upon federal |
approval. |
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.
|
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.
|
|
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.
|
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 |
individuals 35 years of age or older who are eligible
for |
medical assistance under this Article, as follows: |
(A) A baseline
mammogram for individuals 35 to 39 |
years of age.
|
(B) An annual mammogram for individuals 40 years of |
age or older. |
(C) A mammogram at the age and intervals considered |
medically necessary by the individual's health care |
|
provider for individuals 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 and, after |
January 1, 2023 (the effective date of Public Act 102-1018) |
this amendatory Act of the 102nd General Assembly, breast |
tomosynthesis. |
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 |
individuals 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. |
The Department shall provide coverage and reimbursement |
for a human papillomavirus (HPV) vaccine that is approved for |
marketing by the federal Food and Drug Administration for all |
persons between the ages of 9 and 45 and persons of the age of |
46 and above who have been diagnosed with cervical dysplasia |
with a high risk of recurrence or progression. The Department |
shall disallow any preauthorization requirements for the |
administration of the human papillomavirus (HPV) vaccine. |
On or after July 1, 2022, individuals who are otherwise |
eligible for medical assistance under this Article shall |
receive coverage for perinatal depression screenings for the |
12-month period beginning on the last day of their pregnancy. |
Medical assistance coverage under this paragraph shall be |
conditioned on the use of a screening instrument approved by |
the Department. |
Any medical or health care provider shall immediately |
recommend, to
any pregnant individual 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 individuals
under this Code shall receive information |
from the Department on the
availability of services under any
|
program providing case management services for addicted |
individuals,
including information on appropriate referrals |
for other social services
that may be needed by addicted |
individuals 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 the recipient's
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 the 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 120 |
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-adjudicated 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 the 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. The |
Department shall not impose a copayment on the coverage |
provided for naloxone hydrochloride under the medical |
assistance program. |
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. |
Within 90 days after October 8, 2021 (the effective date |
of Public Act 102-665), the Department shall seek federal |
approval of a State Plan amendment to expand coverage for |
family planning services that includes presumptive eligibility |
to individuals whose income is at or below 208% of the federal |
poverty level. Coverage under this Section shall be effective |
beginning no later than December 1, 2022. |
Subject to approval by the federal Centers for Medicare |
|
and Medicaid Services of a Title XIX State Plan amendment |
electing the Program of All-Inclusive Care for the Elderly |
(PACE) as a State Medicaid option, as provided for by Subtitle |
I (commencing with Section 4801) of Title IV of the Balanced |
Budget Act of 1997 (Public Law 105-33) and Part 460 |
(commencing with Section 460.2) of Subchapter E of Title 42 of |
the Code of Federal Regulations, PACE program services shall |
become a covered benefit of the medical assistance program, |
subject to criteria established in accordance with all |
applicable laws. |
Notwithstanding any other provision of this Code, |
community-based pediatric palliative care from a trained |
interdisciplinary team shall be covered under the medical |
assistance program as provided in Section 15 of the Pediatric |
Palliative
Care Act. |
Notwithstanding any other provision of this Code, within |
12 months after June 2, 2022 (the effective date of Public Act |
102-1037) this amendatory Act of the 102nd General Assembly |
and subject to federal approval, acupuncture services |
performed by an acupuncturist licensed under the Acupuncture |
Practice Act who is acting within the scope of his or her |
license shall be covered under the medical assistance program. |
The Department shall apply for any federal waiver or State |
Plan amendment, if required, to implement this paragraph. The |
Department may adopt any rules, including standards and |
criteria, necessary to implement this paragraph. |
|
Notwithstanding any other provision of this Code, the |
medical assistance program shall, subject to appropriation and |
federal approval, reimburse hospitals for costs associated |
with a newborn screening test for the presence of |
metachromatic leukodystrophy, as required under the Newborn |
Metabolic Screening Act, at a rate not less than the fee |
charged by the Department of Public Health. The Department |
shall seek federal approval before the implementation of the |
newborn screening test fees by the Department of Public |
Health. |
(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20; |
102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article |
35, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section |
55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22; |
102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff. |
1-1-22; 102-665, eff. 10-8-21; 102-813, eff. 5-13-22; |
102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22; 102-1038 eff. |
1-1-23; revised 2-5-23.) |