101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
SB2493

 

Introduced 1/22/2020, by Sen. Julie A. Morrison

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that, on and after July 1, 2020, targeted dental services that are provided to adults and children under the Medical Assistance Program shall be established and paid at no less than the rates established under the State of Illinois Dental Benefit Schedule and shall include specified dental procedures. Sets forth the reimbursement rates for certain anesthesia services. Effective immediately.


LRB101 16152 KTG 65520 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

SB2493LRB101 16152 KTG 65520 b

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

 

 

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

 

 

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1laws of this State. The term "any other type of remedial care"
2shall include nursing care and nursing home service for persons
3who rely on treatment by spiritual means alone through prayer
4for healing.
5    Notwithstanding any other provision of this Section, a
6comprehensive tobacco use cessation program that includes
7purchasing prescription drugs or prescription medical devices
8approved by the Food and Drug Administration shall be covered
9under the medical assistance program under this Article for
10persons who are otherwise eligible for assistance under this
11Article.
12    Notwithstanding any other provision of this Code,
13reproductive health care that is otherwise legal in Illinois
14shall be covered under the medical assistance program for
15persons who are otherwise eligible for medical assistance under
16this Article.
17    Notwithstanding any other provision of this Code, the
18Illinois Department may not require, as a condition of payment
19for any laboratory test authorized under this Article, that a
20physician's handwritten signature appear on the laboratory
21test order form. The Illinois Department may, however, impose
22other appropriate requirements regarding laboratory test order
23documentation.
24    Upon receipt of federal approval of an amendment to the
25Illinois Title XIX State Plan for this purpose, the Department
26shall authorize the Chicago Public Schools (CPS) to procure a

 

 

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1vendor or vendors to manufacture eyeglasses for individuals
2enrolled in a school within the CPS system. CPS shall ensure
3that its vendor or vendors are enrolled as providers in the
4medical assistance program and in any capitated Medicaid
5managed care entity (MCE) serving individuals enrolled in a
6school within the CPS system. Under any contract procured under
7this provision, the vendor or vendors must serve only
8individuals enrolled in a school within the CPS system. Claims
9for services provided by CPS's vendor or vendors to recipients
10of benefits in the medical assistance program under this Code,
11the Children's Health Insurance Program, or the Covering ALL
12KIDS Health Insurance Program shall be submitted to the
13Department or the MCE in which the individual is enrolled for
14payment and shall be reimbursed at the Department's or the
15MCE's established rates or rate methodologies for eyeglasses.
16    On and after July 1, 2012, the Department of Healthcare and
17Family Services may provide the following services to persons
18eligible for assistance under this Article who are
19participating in education, training or employment programs
20operated by the Department of Human Services as successor to
21the Department of Public Aid:
22        (1) dental services provided by or under the
23    supervision of a dentist; and
24        (2) eyeglasses prescribed by a physician skilled in the
25    diseases of the eye, or by an optometrist, whichever the
26    person may select.

 

 

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1    On and after July 1, 2018, the Department of Healthcare and
2Family Services shall provide dental services to any adult who
3is otherwise eligible for assistance under the medical
4assistance program. As used in this paragraph, "dental
5services" means diagnostic, preventative, restorative, or
6corrective procedures, including procedures and services for
7the prevention and treatment of periodontal disease and dental
8caries disease, provided by an individual who is licensed to
9practice dentistry or dental surgery or who is under the
10supervision of a dentist in the practice of his or her
11profession.
12    On and after July 1, 2018, targeted dental services, as set
13forth in Exhibit D of the Consent Decree entered by the United
14States District Court for the Northern District of Illinois,
15Eastern Division, in the matter of Memisovski v. Maram, Case
16No. 92 C 1982, that are provided to adults under the medical
17assistance program shall be established at no less than the
18rates set forth in the "New Rate" column in Exhibit D of the
19Consent Decree for targeted dental services that are provided
20to persons under the age of 18 under the medical assistance
21program.
22    On and after July 1, 2020, targeted dental services that
23are provided to adults and children under the Medical
24Assistance Program shall be established and paid at no less
25than the rates established under the State of Illinois Dental
26Benefit Schedule and shall include the following dental

 

 

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1procedures: D0120, D0150, D0220, D0230, D0272, D1110, D1120,
2D1206, D1351, D2140, D2150, D2160, D2161, D2330, D2331, D2332,
3D2335, D2391, D2392, D2393, D2394, D2751, D2930, D2931, D2950,
4D5110, D5120, D5211, D5212, D5213, D5214, D7140, D7210, D7220.
5The following anesthesia related codes shall be reimbursed as
6follows:
7        (i) D9230 Inhalation of nitrous, $70.00.
8        (ii) D9248 Non-intravenous conscious sedation,
9    $150.00.
10        (iii) D9239 Intravenous moderate sedation, first 15
11    minutes, $181.00.
12        (iv) D9243 Intravenous moderate sedation, each
13    additional 15 minutes, $181.00.
14        (v) D9222 Deep sedation, first 15 minutes, $214.00.
15        (vi) D9223 Deep sedation, each additional 15 minutes,
16    $214.00.
17    Notwithstanding any other provision of this Code and
18subject to federal approval, the Department may adopt rules to
19allow a dentist who is volunteering his or her service at no
20cost to render dental services through an enrolled
21not-for-profit health clinic without the dentist personally
22enrolling as a participating provider in the medical assistance
23program. A not-for-profit health clinic shall include a public
24health clinic or Federally Qualified Health Center or other
25enrolled provider, as determined by the Department, through
26which dental services covered under this Section are performed.

 

 

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1The Department shall establish a process for payment of claims
2for reimbursement for covered dental services rendered under
3this provision.
4    The Illinois Department, by rule, may distinguish and
5classify the medical services to be provided only in accordance
6with the classes of persons designated in Section 5-2.
7    The Department of Healthcare and Family Services must
8provide coverage and reimbursement for amino acid-based
9elemental formulas, regardless of delivery method, for the
10diagnosis and treatment of (i) eosinophilic disorders and (ii)
11short bowel syndrome when the prescribing physician has issued
12a written order stating that the amino acid-based elemental
13formula is medically necessary.
14    The Illinois Department shall authorize the provision of,
15and shall authorize payment for, screening by low-dose
16mammography for the presence of occult breast cancer for women
1735 years of age or older who are eligible for medical
18assistance under this Article, as follows:
19        (A) A baseline mammogram for women 35 to 39 years of
20    age.
21        (B) An annual mammogram for women 40 years of age or
22    older.
23        (C) A mammogram at the age and intervals considered
24    medically necessary by the woman's health care provider for
25    women under 40 years of age and having a family history of
26    breast cancer, prior personal history of breast cancer,

 

 

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1    positive genetic testing, or other risk factors.
2        (D) A comprehensive ultrasound screening and MRI of an
3    entire breast or breasts if a mammogram demonstrates
4    heterogeneous or dense breast tissue or when medically
5    necessary as determined by a physician licensed to practice
6    medicine in all of its branches.
7        (E) A screening MRI when medically necessary, as
8    determined by a physician licensed to practice medicine in
9    all of its branches.
10        (F) A diagnostic mammogram when medically necessary,
11    as determined by a physician licensed to practice medicine
12    in all its branches, advanced practice registered nurse, or
13    physician assistant.
14    The Department shall not impose a deductible, coinsurance,
15copayment, or any other cost-sharing requirement on the
16coverage provided under this paragraph; except that this
17sentence does not apply to coverage of diagnostic mammograms to
18the extent such coverage would disqualify a high-deductible
19health plan from eligibility for a health savings account
20pursuant to Section 223 of the Internal Revenue Code (26 U.S.C.
21223).
22    All screenings shall include a physical breast exam,
23instruction on self-examination and information regarding the
24frequency of self-examination and its value as a preventative
25tool.
26     For purposes of this Section:

 

 

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1    "Diagnostic mammogram" means a mammogram obtained using
2diagnostic mammography.
3    "Diagnostic mammography" means a method of screening that
4is designed to evaluate an abnormality in a breast, including
5an abnormality seen or suspected on a screening mammogram or a
6subjective or objective abnormality otherwise detected in the
7breast.
8    "Low-dose mammography" means the x-ray examination of the
9breast using equipment dedicated specifically for mammography,
10including the x-ray tube, filter, compression device, and image
11receptor, with an average radiation exposure delivery of less
12than one rad per breast for 2 views of an average size breast.
13The term also includes digital mammography and includes breast
14tomosynthesis.
15    "Breast tomosynthesis" means a radiologic procedure that
16involves the acquisition of projection images over the
17stationary breast to produce cross-sectional digital
18three-dimensional images of the breast.
19    If, at any time, the Secretary of the United States
20Department of Health and Human Services, or its successor
21agency, promulgates rules or regulations to be published in the
22Federal Register or publishes a comment in the Federal Register
23or issues an opinion, guidance, or other action that would
24require the State, pursuant to any provision of the Patient
25Protection and Affordable Care Act (Public Law 111-148),
26including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any

 

 

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1successor provision, to defray the cost of any coverage for
2breast tomosynthesis outlined in this paragraph, then the
3requirement that an insurer cover breast tomosynthesis is
4inoperative other than any such coverage authorized under
5Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
6the State shall not assume any obligation for the cost of
7coverage for breast tomosynthesis set forth in this paragraph.
8    On and after January 1, 2016, the Department shall ensure
9that all networks of care for adult clients of the Department
10include access to at least one breast imaging Center of Imaging
11Excellence as certified by the American College of Radiology.
12    On and after January 1, 2012, providers participating in a
13quality improvement program approved by the Department shall be
14reimbursed for screening and diagnostic mammography at the same
15rate as the Medicare program's rates, including the increased
16reimbursement for digital mammography.
17    The Department shall convene an expert panel including
18representatives of hospitals, free-standing mammography
19facilities, and doctors, including radiologists, to establish
20quality standards for mammography.
21    On and after January 1, 2017, providers participating in a
22breast cancer treatment quality improvement program approved
23by the Department shall be reimbursed for breast cancer
24treatment at a rate that is no lower than 95% of the Medicare
25program's rates for the data elements included in the breast
26cancer treatment quality program.

 

 

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1    The Department shall convene an expert panel, including
2representatives of hospitals, free-standing breast cancer
3treatment centers, breast cancer quality organizations, and
4doctors, including breast surgeons, reconstructive breast
5surgeons, oncologists, and primary care providers to establish
6quality standards for breast cancer treatment.
7    Subject to federal approval, the Department shall
8establish a rate methodology for mammography at federally
9qualified health centers and other encounter-rate clinics.
10These clinics or centers may also collaborate with other
11hospital-based mammography facilities. By January 1, 2016, the
12Department shall report to the General Assembly on the status
13of the provision set forth in this paragraph.
14    The Department shall establish a methodology to remind
15women who are age-appropriate for screening mammography, but
16who have not received a mammogram within the previous 18
17months, of the importance and benefit of screening mammography.
18The Department shall work with experts in breast cancer
19outreach and patient navigation to optimize these reminders and
20shall establish a methodology for evaluating their
21effectiveness and modifying the methodology based on the
22evaluation.
23    The Department shall establish a performance goal for
24primary care providers with respect to their female patients
25over age 40 receiving an annual mammogram. This performance
26goal shall be used to provide additional reimbursement in the

 

 

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1form of a quality performance bonus to primary care providers
2who meet that goal.
3    The Department shall devise a means of case-managing or
4patient navigation for beneficiaries diagnosed with breast
5cancer. This program shall initially operate as a pilot program
6in areas of the State with the highest incidence of mortality
7related to breast cancer. At least one pilot program site shall
8be in the metropolitan Chicago area and at least one site shall
9be outside the metropolitan Chicago area. On or after July 1,
102016, the pilot program shall be expanded to include one site
11in western Illinois, one site in southern Illinois, one site in
12central Illinois, and 4 sites within metropolitan Chicago. An
13evaluation of the pilot program shall be carried out measuring
14health outcomes and cost of care for those served by the pilot
15program compared to similarly situated patients who are not
16served by the pilot program.
17    The Department shall require all networks of care to
18develop a means either internally or by contract with experts
19in navigation and community outreach to navigate cancer
20patients to comprehensive care in a timely fashion. The
21Department shall require all networks of care to include access
22for patients diagnosed with cancer to at least one academic
23commission on cancer-accredited cancer program as an
24in-network covered benefit.
25    Any medical or health care provider shall immediately
26recommend, to any pregnant woman who is being provided prenatal

 

 

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1services and is suspected of having a substance use disorder as
2defined in the Substance Use Disorder Act, referral to a local
3substance use disorder treatment program licensed by the
4Department of Human Services or to a licensed hospital which
5provides substance abuse treatment services. The Department of
6Healthcare and Family Services shall assure coverage for the
7cost of treatment of the drug abuse or addiction for pregnant
8recipients in accordance with the Illinois Medicaid Program in
9conjunction with the Department of Human Services.
10    All medical providers providing medical assistance to
11pregnant women under this Code shall receive information from
12the Department on the availability of services under any
13program providing case management services for addicted women,
14including information on appropriate referrals for other
15social services that may be needed by addicted women in
16addition to treatment for addiction.
17    The Illinois Department, in cooperation with the
18Departments of Human Services (as successor to the Department
19of Alcoholism and Substance Abuse) and Public Health, through a
20public awareness campaign, may provide information concerning
21treatment for alcoholism and drug abuse and addiction, prenatal
22health care, and other pertinent programs directed at reducing
23the number of drug-affected infants born to recipients of
24medical assistance.
25    Neither the Department of Healthcare and Family Services
26nor the Department of Human Services shall sanction the

 

 

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1recipient solely on the basis of her substance abuse.
2    The Illinois Department shall establish such regulations
3governing the dispensing of health services under this Article
4as it shall deem appropriate. The Department should seek the
5advice of formal professional advisory committees appointed by
6the Director of the Illinois Department for the purpose of
7providing regular advice on policy and administrative matters,
8information dissemination and educational activities for
9medical and health care providers, and consistency in
10procedures to the Illinois Department.
11    The Illinois Department may develop and contract with
12Partnerships of medical providers to arrange medical services
13for persons eligible under Section 5-2 of this Code.
14Implementation of this Section may be by demonstration projects
15in certain geographic areas. The Partnership shall be
16represented by a sponsor organization. The Department, by rule,
17shall develop qualifications for sponsors of Partnerships.
18Nothing in this Section shall be construed to require that the
19sponsor organization be a medical organization.
20    The sponsor must negotiate formal written contracts with
21medical providers for physician services, inpatient and
22outpatient hospital care, home health services, treatment for
23alcoholism and substance abuse, and other services determined
24necessary by the Illinois Department by rule for delivery by
25Partnerships. Physician services must include prenatal and
26obstetrical care. The Illinois Department shall reimburse

 

 

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1medical services delivered by Partnership providers to clients
2in target areas according to provisions of this Article and the
3Illinois Health Finance Reform Act, except that:
4        (1) Physicians participating in a Partnership and
5    providing certain services, which shall be determined by
6    the Illinois Department, to persons in areas covered by the
7    Partnership may receive an additional surcharge for such
8    services.
9        (2) The Department may elect to consider and negotiate
10    financial incentives to encourage the development of
11    Partnerships and the efficient delivery of medical care.
12        (3) Persons receiving medical services through
13    Partnerships may receive medical and case management
14    services above the level usually offered through the
15    medical assistance program.
16    Medical providers shall be required to meet certain
17qualifications to participate in Partnerships to ensure the
18delivery of high quality medical services. These
19qualifications shall be determined by rule of the Illinois
20Department and may be higher than qualifications for
21participation in the medical assistance program. Partnership
22sponsors may prescribe reasonable additional qualifications
23for participation by medical providers, only with the prior
24written approval of the Illinois Department.
25    Nothing in this Section shall limit the free choice of
26practitioners, hospitals, and other providers of medical

 

 

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1services by clients. In order to ensure patient freedom of
2choice, the Illinois Department shall immediately promulgate
3all rules and take all other necessary actions so that provided
4services may be accessed from therapeutically certified
5optometrists to the full extent of the Illinois Optometric
6Practice Act of 1987 without discriminating between service
7providers.
8    The Department shall apply for a waiver from the United
9States Health Care Financing Administration to allow for the
10implementation of Partnerships under this Section.
11    The Illinois Department shall require health care
12providers to maintain records that document the medical care
13and services provided to recipients of Medical Assistance under
14this Article. Such records must be retained for a period of not
15less than 6 years from the date of service or as provided by
16applicable State law, whichever period is longer, except that
17if an audit is initiated within the required retention period
18then the records must be retained until the audit is completed
19and every exception is resolved. The Illinois Department shall
20require health care providers to make available, when
21authorized by the patient, in writing, the medical records in a
22timely fashion to other health care providers who are treating
23or serving persons eligible for Medical Assistance under this
24Article. All dispensers of medical services shall be required
25to maintain and retain business and professional records
26sufficient to fully and accurately document the nature, scope,

 

 

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1details and receipt of the health care provided to persons
2eligible for medical assistance under this Code, in accordance
3with regulations promulgated by the Illinois Department. The
4rules and regulations shall require that proof of the receipt
5of prescription drugs, dentures, prosthetic devices and
6eyeglasses by eligible persons under this Section accompany
7each claim for reimbursement submitted by the dispenser of such
8medical services. No such claims for reimbursement shall be
9approved for payment by the Illinois Department without such
10proof of receipt, unless the Illinois Department shall have put
11into effect and shall be operating a system of post-payment
12audit and review which shall, on a sampling basis, be deemed
13adequate by the Illinois Department to assure that such drugs,
14dentures, prosthetic devices and eyeglasses for which payment
15is being made are actually being received by eligible
16recipients. Within 90 days after September 16, 1984 (the
17effective date of Public Act 83-1439), the Illinois Department
18shall establish a current list of acquisition costs for all
19prosthetic devices and any other items recognized as medical
20equipment and supplies reimbursable under this Article and
21shall update such list on a quarterly basis, except that the
22acquisition costs of all prescription drugs shall be updated no
23less frequently than every 30 days as required by Section
245-5.12.
25    Notwithstanding any other law to the contrary, the Illinois
26Department shall, within 365 days after July 22, 2013 (the

 

 

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1effective date of Public Act 98-104), establish procedures to
2permit skilled care facilities licensed under the Nursing Home
3Care Act to submit monthly billing claims for reimbursement
4purposes. Following development of these procedures, the
5Department shall, by July 1, 2016, test the viability of the
6new system and implement any necessary operational or
7structural changes to its information technology platforms in
8order to allow for the direct acceptance and payment of nursing
9home claims.
10    Notwithstanding any other law to the contrary, the Illinois
11Department shall, within 365 days after August 15, 2014 (the
12effective date of Public Act 98-963), establish procedures to
13permit ID/DD facilities licensed under the ID/DD Community Care
14Act and MC/DD facilities licensed under the MC/DD Act to submit
15monthly billing claims for reimbursement purposes. Following
16development of these procedures, the Department shall have an
17additional 365 days to test the viability of the new system and
18to ensure that any necessary operational or structural changes
19to its information technology platforms are implemented.
20    The Illinois Department shall require all dispensers of
21medical services, other than an individual practitioner or
22group of practitioners, desiring to participate in the Medical
23Assistance program established under this Article to disclose
24all financial, beneficial, ownership, equity, surety or other
25interests in any and all firms, corporations, partnerships,
26associations, business enterprises, joint ventures, agencies,

 

 

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1institutions or other legal entities providing any form of
2health care services in this State under this Article.
3    The Illinois Department may require that all dispensers of
4medical services desiring to participate in the medical
5assistance program established under this Article disclose,
6under such terms and conditions as the Illinois Department may
7by rule establish, all inquiries from clients and attorneys
8regarding medical bills paid by the Illinois Department, which
9inquiries could indicate potential existence of claims or liens
10for the Illinois Department.
11    Enrollment of a vendor shall be subject to a provisional
12period and shall be conditional for one year. During the period
13of conditional enrollment, the Department may terminate the
14vendor's eligibility to participate in, or may disenroll the
15vendor from, the medical assistance program without cause.
16Unless otherwise specified, such termination of eligibility or
17disenrollment is not subject to the Department's hearing
18process. However, a disenrolled vendor may reapply without
19penalty.
20    The Department has the discretion to limit the conditional
21enrollment period for vendors based upon category of risk of
22the vendor.
23    Prior to enrollment and during the conditional enrollment
24period in the medical assistance program, all vendors shall be
25subject to enhanced oversight, screening, and review based on
26the risk of fraud, waste, and abuse that is posed by the

 

 

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1category of risk of the vendor. The Illinois Department shall
2establish the procedures for oversight, screening, and review,
3which may include, but need not be limited to: criminal and
4financial background checks; fingerprinting; license,
5certification, and authorization verifications; unscheduled or
6unannounced site visits; database checks; prepayment audit
7reviews; audits; payment caps; payment suspensions; and other
8screening as required by federal or State law.
9    The Department shall define or specify the following: (i)
10by provider notice, the "category of risk of the vendor" for
11each type of vendor, which shall take into account the level of
12screening applicable to a particular category of vendor under
13federal law and regulations; (ii) by rule or provider notice,
14the maximum length of the conditional enrollment period for
15each category of risk of the vendor; and (iii) by rule, the
16hearing rights, if any, afforded to a vendor in each category
17of risk of the vendor that is terminated or disenrolled during
18the conditional enrollment period.
19    To be eligible for payment consideration, a vendor's
20payment claim or bill, either as an initial claim or as a
21resubmitted claim following prior rejection, must be received
22by the Illinois Department, or its fiscal intermediary, no
23later than 180 days after the latest date on the claim on which
24medical goods or services were provided, with the following
25exceptions:
26        (1) In the case of a provider whose enrollment is in

 

 

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1    process by the Illinois Department, the 180-day period
2    shall not begin until the date on the written notice from
3    the Illinois Department that the provider enrollment is
4    complete.
5        (2) In the case of errors attributable to the Illinois
6    Department or any of its claims processing intermediaries
7    which result in an inability to receive, process, or
8    adjudicate a claim, the 180-day period shall not begin
9    until the provider has been notified of the error.
10        (3) In the case of a provider for whom the Illinois
11    Department initiates the monthly billing process.
12        (4) In the case of a provider operated by a unit of
13    local government with a population exceeding 3,000,000
14    when local government funds finance federal participation
15    for claims payments.
16    For claims for services rendered during a period for which
17a recipient received retroactive eligibility, claims must be
18filed within 180 days after the Department determines the
19applicant is eligible. For claims for which the Illinois
20Department is not the primary payer, claims must be submitted
21to the Illinois Department within 180 days after the final
22adjudication by the primary payer.
23    In the case of long term care facilities, within 45
24calendar days of receipt by the facility of required
25prescreening information, new admissions with associated
26admission documents shall be submitted through the Medical

 

 

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1Electronic Data Interchange (MEDI) or the Recipient
2Eligibility Verification (REV) System or shall be submitted
3directly to the Department of Human Services using required
4admission forms. Effective September 1, 2014, admission
5documents, including all prescreening information, must be
6submitted through MEDI or REV. Confirmation numbers assigned to
7an accepted transaction shall be retained by a facility to
8verify timely submittal. Once an admission transaction has been
9completed, all resubmitted claims following prior rejection
10are subject to receipt no later than 180 days after the
11admission transaction has been completed.
12    Claims that are not submitted and received in compliance
13with the foregoing requirements shall not be eligible for
14payment under the medical assistance program, and the State
15shall have no liability for payment of those claims.
16    To the extent consistent with applicable information and
17privacy, security, and disclosure laws, State and federal
18agencies and departments shall provide the Illinois Department
19access to confidential and other information and data necessary
20to perform eligibility and payment verifications and other
21Illinois Department functions. This includes, but is not
22limited to: information pertaining to licensure;
23certification; earnings; immigration status; citizenship; wage
24reporting; unearned and earned income; pension income;
25employment; supplemental security income; social security
26numbers; National Provider Identifier (NPI) numbers; the

 

 

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1National Practitioner Data Bank (NPDB); program and agency
2exclusions; taxpayer identification numbers; tax delinquency;
3corporate information; and death records.
4    The Illinois Department shall enter into agreements with
5State agencies and departments, and is authorized to enter into
6agreements with federal agencies and departments, under which
7such agencies and departments shall share data necessary for
8medical assistance program integrity functions and oversight.
9The Illinois Department shall develop, in cooperation with
10other State departments and agencies, and in compliance with
11applicable federal laws and regulations, appropriate and
12effective methods to share such data. At a minimum, and to the
13extent necessary to provide data sharing, the Illinois
14Department shall enter into agreements with State agencies and
15departments, and is authorized to enter into agreements with
16federal agencies and departments, including, but not limited
17to: the Secretary of State; the Department of Revenue; the
18Department of Public Health; the Department of Human Services;
19and the Department of Financial and Professional Regulation.
20    Beginning in fiscal year 2013, the Illinois Department
21shall set forth a request for information to identify the
22benefits of a pre-payment, post-adjudication, and post-edit
23claims system with the goals of streamlining claims processing
24and provider reimbursement, reducing the number of pending or
25rejected claims, and helping to ensure a more transparent
26adjudication process through the utilization of: (i) provider

 

 

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1data verification and provider screening technology; and (ii)
2clinical code editing; and (iii) pre-pay, pre- or
3post-adjudicated predictive modeling with an integrated case
4management system with link analysis. Such a request for
5information shall not be considered as a request for proposal
6or as an obligation on the part of the Illinois Department to
7take any action or acquire any products or services.
8    The Illinois Department shall establish policies,
9procedures, standards and criteria by rule for the acquisition,
10repair and replacement of orthotic and prosthetic devices and
11durable medical equipment. Such rules shall provide, but not be
12limited to, the following services: (1) immediate repair or
13replacement of such devices by recipients; and (2) rental,
14lease, purchase or lease-purchase of durable medical equipment
15in a cost-effective manner, taking into consideration the
16recipient's medical prognosis, the extent of the recipient's
17needs, and the requirements and costs for maintaining such
18equipment. Subject to prior approval, such rules shall enable a
19recipient to temporarily acquire and use alternative or
20substitute devices or equipment pending repairs or
21replacements of any device or equipment previously authorized
22for such recipient by the Department. Notwithstanding any
23provision of Section 5-5f to the contrary, the Department may,
24by rule, exempt certain replacement wheelchair parts from prior
25approval and, for wheelchairs, wheelchair parts, wheelchair
26accessories, and related seating and positioning items,

 

 

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1determine the wholesale price by methods other than actual
2acquisition costs.
3    The Department shall require, by rule, all providers of
4durable medical equipment to be accredited by an accreditation
5organization approved by the federal Centers for Medicare and
6Medicaid Services and recognized by the Department in order to
7bill the Department for providing durable medical equipment to
8recipients. No later than 15 months after the effective date of
9the rule adopted pursuant to this paragraph, all providers must
10meet the accreditation requirement.
11    In order to promote environmental responsibility, meet the
12needs of recipients and enrollees, and achieve significant cost
13savings, the Department, or a managed care organization under
14contract with the Department, may provide recipients or managed
15care enrollees who have a prescription or Certificate of
16Medical Necessity access to refurbished durable medical
17equipment under this Section (excluding prosthetic and
18orthotic devices as defined in the Orthotics, Prosthetics, and
19Pedorthics Practice Act and complex rehabilitation technology
20products and associated services) through the State's
21assistive technology program's reutilization program, using
22staff with the Assistive Technology Professional (ATP)
23Certification if the refurbished durable medical equipment:
24(i) is available; (ii) is less expensive, including shipping
25costs, than new durable medical equipment of the same type;
26(iii) is able to withstand at least 3 years of use; (iv) is

 

 

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1cleaned, disinfected, sterilized, and safe in accordance with
2federal Food and Drug Administration regulations and guidance
3governing the reprocessing of medical devices in health care
4settings; and (v) equally meets the needs of the recipient or
5enrollee. The reutilization program shall confirm that the
6recipient or enrollee is not already in receipt of same or
7similar equipment from another service provider, and that the
8refurbished durable medical equipment equally meets the needs
9of the recipient or enrollee. Nothing in this paragraph shall
10be construed to limit recipient or enrollee choice to obtain
11new durable medical equipment or place any additional prior
12authorization conditions on enrollees of managed care
13organizations.
14    The Department shall execute, relative to the nursing home
15prescreening project, written inter-agency agreements with the
16Department of Human Services and the Department on Aging, to
17effect the following: (i) intake procedures and common
18eligibility criteria for those persons who are receiving
19non-institutional services; and (ii) the establishment and
20development of non-institutional services in areas of the State
21where they are not currently available or are undeveloped; and
22(iii) notwithstanding any other provision of law, subject to
23federal approval, on and after July 1, 2012, an increase in the
24determination of need (DON) scores from 29 to 37 for applicants
25for institutional and home and community-based long term care;
26if and only if federal approval is not granted, the Department

 

 

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1may, in conjunction with other affected agencies, implement
2utilization controls or changes in benefit packages to
3effectuate a similar savings amount for this population; and
4(iv) no later than July 1, 2013, minimum level of care
5eligibility criteria for institutional and home and
6community-based long term care; and (v) no later than October
71, 2013, establish procedures to permit long term care
8providers access to eligibility scores for individuals with an
9admission date who are seeking or receiving services from the
10long term care provider. In order to select the minimum level
11of care eligibility criteria, the Governor shall establish a
12workgroup that includes affected agency representatives and
13stakeholders representing the institutional and home and
14community-based long term care interests. This Section shall
15not restrict the Department from implementing lower level of
16care eligibility criteria for community-based services in
17circumstances where federal approval has been granted.
18    The Illinois Department shall develop and operate, in
19cooperation with other State Departments and agencies and in
20compliance with applicable federal laws and regulations,
21appropriate and effective systems of health care evaluation and
22programs for monitoring of utilization of health care services
23and facilities, as it affects persons eligible for medical
24assistance under this Code.
25    The Illinois Department shall report annually to the
26General Assembly, no later than the second Friday in April of

 

 

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11979 and each year thereafter, in regard to:
2        (a) actual statistics and trends in utilization of
3    medical services by public aid recipients;
4        (b) actual statistics and trends in the provision of
5    the various medical services by medical vendors;
6        (c) current rate structures and proposed changes in
7    those rate structures for the various medical vendors; and
8        (d) efforts at utilization review and control by the
9    Illinois Department.
10    The period covered by each report shall be the 3 years
11ending on the June 30 prior to the report. The report shall
12include suggested legislation for consideration by the General
13Assembly. The requirement for reporting to the General Assembly
14shall be satisfied by filing copies of the report as required
15by Section 3.1 of the General Assembly Organization Act, and
16filing such additional copies with the State Government Report
17Distribution Center for the General Assembly as is required
18under paragraph (t) of Section 7 of the State Library Act.
19    Rulemaking authority to implement Public Act 95-1045, if
20any, is conditioned on the rules being adopted in accordance
21with all provisions of the Illinois Administrative Procedure
22Act and all rules and procedures of the Joint Committee on
23Administrative Rules; any purported rule not so adopted, for
24whatever reason, is unauthorized.
25    On and after July 1, 2012, the Department shall reduce any
26rate of reimbursement for services or other payments or alter

 

 

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1any methodologies authorized by this Code to reduce any rate of
2reimbursement for services or other payments in accordance with
3Section 5-5e.
4    Because kidney transplantation can be an appropriate,
5cost-effective alternative to renal dialysis when medically
6necessary and notwithstanding the provisions of Section 1-11 of
7this Code, beginning October 1, 2014, the Department shall
8cover kidney transplantation for noncitizens with end-stage
9renal disease who are not eligible for comprehensive medical
10benefits, who meet the residency requirements of Section 5-3 of
11this Code, and who would otherwise meet the financial
12requirements of the appropriate class of eligible persons under
13Section 5-2 of this Code. To qualify for coverage of kidney
14transplantation, such person must be receiving emergency renal
15dialysis services covered by the Department. Providers under
16this Section shall be prior approved and certified by the
17Department to perform kidney transplantation and the services
18under this Section shall be limited to services associated with
19kidney transplantation.
20    Notwithstanding any other provision of this Code to the
21contrary, on or after July 1, 2015, all FDA approved forms of
22medication assisted treatment prescribed for the treatment of
23alcohol dependence or treatment of opioid dependence shall be
24covered under both fee for service and managed care medical
25assistance programs for persons who are otherwise eligible for
26medical assistance under this Article and shall not be subject

 

 

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1to any (1) utilization control, other than those established
2under the American Society of Addiction Medicine patient
3placement criteria, (2) prior authorization mandate, or (3)
4lifetime restriction limit mandate.
5    On or after July 1, 2015, opioid antagonists prescribed for
6the treatment of an opioid overdose, including the medication
7product, administration devices, and any pharmacy fees related
8to the dispensing and administration of the opioid antagonist,
9shall be covered under the medical assistance program for
10persons who are otherwise eligible for medical assistance under
11this Article. As used in this Section, "opioid antagonist"
12means a drug that binds to opioid receptors and blocks or
13inhibits the effect of opioids acting on those receptors,
14including, but not limited to, naloxone hydrochloride or any
15other similarly acting drug approved by the U.S. Food and Drug
16Administration.
17    Upon federal approval, the Department shall provide
18coverage and reimbursement for all drugs that are approved for
19marketing by the federal Food and Drug Administration and that
20are recommended by the federal Public Health Service or the
21United States Centers for Disease Control and Prevention for
22pre-exposure prophylaxis and related pre-exposure prophylaxis
23services, including, but not limited to, HIV and sexually
24transmitted infection screening, treatment for sexually
25transmitted infections, medical monitoring, assorted labs, and
26counseling to reduce the likelihood of HIV infection among

 

 

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1individuals who are not infected with HIV but who are at high
2risk of HIV infection.
3    A federally qualified health center, as defined in Section
41905(l)(2)(B) of the federal Social Security Act, shall be
5reimbursed by the Department in accordance with the federally
6qualified health center's encounter rate for services provided
7to medical assistance recipients that are performed by a dental
8hygienist, as defined under the Illinois Dental Practice Act,
9working under the general supervision of a dentist and employed
10by a federally qualified health center.
11(Source: P.A. 100-201, eff. 8-18-17; 100-395, eff. 1-1-18;
12100-449, eff. 1-1-18; 100-538, eff. 1-1-18; 100-587, eff.
136-4-18; 100-759, eff. 1-1-19; 100-863, eff. 8-14-18; 100-974,
14eff. 8-19-18; 100-1009, eff. 1-1-19; 100-1018, eff. 1-1-19;
15100-1148, eff. 12-10-18; 101-209, eff. 8-5-19; 101-580, eff.
161-1-20; revised 9-18-19.)
 
17    Section 99. Effective date. This Act takes effect upon
18becoming law.