103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB4832

 

Introduced 2/7/2024, by Rep. Dagmara Avelar

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-5

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to file administrative rules updating the Handicapping Labio-Lingual Deviation orthodontic scoring tool by July 1, 2024, or as soon as practicable. Effective immediately.


LRB103 37451 KTG 67573 b

 

 

A BILL FOR

 

HB4832LRB103 37451 KTG 67573 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)
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
16home, or elsewhere; (6) medical care, or any other type of
17remedial care furnished by licensed practitioners; (7) home
18health care services; (8) private duty nursing service; (9)
19clinic services; (10) dental services, including prevention
20and treatment of periodontal disease and dental caries disease
21for pregnant individuals, provided by an individual licensed
22to practice dentistry or dental surgery; for purposes of this
23item (10), "dental services" means diagnostic, preventive, or

 

 

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1corrective procedures provided by or under the supervision of
2a dentist in the practice of his or her profession; (11)
3physical therapy and related services; (12) prescribed drugs,
4dentures, and prosthetic devices; and eyeglasses prescribed by
5a physician skilled in the diseases of the eye, or by an
6optometrist, whichever the person may select; (13) other
7diagnostic, screening, preventive, and rehabilitative
8services, including to ensure that the individual's need for
9intervention or treatment of mental disorders or substance use
10disorders or co-occurring mental health and substance use
11disorders is determined using a uniform screening, assessment,
12and evaluation 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
22sexual assault, 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; (16.5) services performed by
26a chiropractic physician licensed under the Medical Practice

 

 

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1Act of 1987 and acting within the scope of his or her license,
2including, but not limited to, chiropractic manipulative
3treatment; and (17) any other medical care, and any other type
4of remedial care recognized under the laws of this State. The
5term "any other type of remedial care" shall include nursing
6care and nursing home service for persons who rely on
7treatment by spiritual means alone through prayer for healing.
8    Notwithstanding any other provision of this Section, a
9comprehensive tobacco use cessation program that includes
10purchasing prescription drugs or prescription medical devices
11approved by the Food and Drug Administration shall be covered
12under the medical assistance program under this Article for
13persons who are otherwise eligible for assistance under this
14Article.
15    Notwithstanding any other provision of this Code,
16reproductive health care that is otherwise legal in Illinois
17shall be covered under the medical assistance program for
18persons who are otherwise eligible for medical assistance
19under this Article.
20    Notwithstanding any other provision of this Section, all
21tobacco cessation medications approved by the United States
22Food and Drug Administration and all individual and group
23tobacco cessation counseling services and telephone-based
24counseling services and tobacco cessation medications provided
25through the Illinois Tobacco Quitline shall be covered under
26the medical assistance program for persons who are otherwise

 

 

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1eligible for assistance under this Article. The Department
2shall comply with all federal requirements necessary to obtain
3federal financial participation, as specified in 42 CFR
4433.15(b)(7), for telephone-based counseling services provided
5through the Illinois Tobacco Quitline, including, but not
6limited to: (i) entering into a memorandum of understanding or
7interagency agreement with the Department of Public Health, as
8administrator of the Illinois Tobacco Quitline; and (ii)
9developing a cost allocation plan for Medicaid-allowable
10Illinois Tobacco Quitline services in accordance with 45 CFR
1195.507. The Department shall submit the memorandum of
12understanding or interagency agreement, the cost allocation
13plan, and all other necessary documentation to the Centers for
14Medicare and Medicaid Services for review and approval.
15Coverage under this paragraph shall be contingent upon federal
16approval.
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
7under this 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
17and Family Services may provide the following services to
18persons eligible 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
25    the diseases of the eye, or by an optometrist, whichever
26    the person may select.

 

 

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1    On and after July 1, 2018, the Department of Healthcare
2and Family Services shall provide dental services to any adult
3who is 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
13set forth in Exhibit D of the Consent Decree entered by the
14United States District Court for the Northern District of
15Illinois, Eastern Division, in the matter of Memisovski v.
16Maram, Case No. 92 C 1982, that are provided to adults under
17the medical assistance program shall be established at no less
18than the rates set forth in the "New Rate" column in Exhibit D
19of the Consent Decree for targeted dental services that are
20provided to persons under the age of 18 under the medical
21assistance program.
22    Notwithstanding any other provision of this Code and
23subject to federal approval, the Department may adopt rules to
24allow a dentist who is volunteering his or her service at no
25cost to render dental services through an enrolled
26not-for-profit health clinic without the dentist personally

 

 

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1enrolling as a participating provider in the medical
2assistance program. A not-for-profit health clinic shall
3include a public health clinic or Federally Qualified Health
4Center or other enrolled provider, as determined by the
5Department, through which dental services covered under this
6Section are performed. The Department shall establish a
7process for payment of claims for reimbursement for covered
8dental services rendered under this provision.
9    The Department shall file administrative rules updating
10the Handicapping Labio-Lingual Deviation orthodontic scoring
11tool by July 1, 2024, or as soon as practicable.
12    On and after January 1, 2022, the Department of Healthcare
13and Family Services shall administer and regulate a
14school-based dental program that allows for the out-of-office
15delivery of preventative dental services in a school setting
16to children under 19 years of age. The Department shall
17establish, by rule, guidelines for participation by providers
18and set requirements for follow-up referral care based on the
19requirements established in the Dental Office Reference Manual
20published by the Department that establishes the requirements
21for dentists participating in the All Kids Dental School
22Program. Every effort shall be made by the Department when
23developing the program requirements to consider the different
24geographic differences of both urban and rural areas of the
25State for initial treatment and necessary follow-up care. No
26provider shall be charged a fee by any unit of local government

 

 

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1to participate in the school-based dental program administered
2by the Department. Nothing in this paragraph shall be
3construed to limit or preempt a home rule unit's or school
4district's authority to establish, change, or administer a
5school-based dental program in addition to, or independent of,
6the school-based dental program administered by the
7Department.
8    The Illinois Department, by rule, may distinguish and
9classify the medical services to be provided only in
10accordance with the classes of persons designated in Section
115-2.
12    The Department of Healthcare and Family Services must
13provide coverage and reimbursement for amino acid-based
14elemental formulas, regardless of delivery method, for the
15diagnosis and treatment of (i) eosinophilic disorders and (ii)
16short bowel syndrome when the prescribing physician has issued
17a written order stating that the amino acid-based elemental
18formula is medically necessary.
19    The Illinois Department shall authorize the provision of,
20and shall authorize payment for, screening by low-dose
21mammography for the presence of occult breast cancer for
22individuals 35 years of age or older who are eligible for
23medical assistance under this Article, as follows:
24        (A) A baseline mammogram for individuals 35 to 39
25    years of age.
26        (B) An annual mammogram for individuals 40 years of

 

 

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1    age or older.
2        (C) A mammogram at the age and intervals considered
3    medically necessary by the individual's health care
4    provider for individuals under 40 years of age and having
5    a family history of breast cancer, prior personal history
6    of breast cancer, positive genetic testing, or other risk
7    factors.
8        (D) A comprehensive ultrasound screening and MRI of an
9    entire breast or breasts if a mammogram demonstrates
10    heterogeneous or dense breast tissue or when medically
11    necessary as determined by a physician licensed to
12    practice medicine in all of its branches.
13        (E) A screening MRI when medically necessary, as
14    determined by a physician licensed to practice medicine in
15    all of its branches.
16        (F) A diagnostic mammogram when medically necessary,
17    as determined by a physician licensed to practice medicine
18    in all its branches, advanced practice registered nurse,
19    or physician assistant.
20    The Department shall not impose a deductible, coinsurance,
21copayment, or any other cost-sharing requirement on the
22coverage provided under this paragraph; except that this
23sentence does not apply to coverage of diagnostic mammograms
24to the extent such coverage would disqualify a high-deductible
25health plan from eligibility for a health savings account
26pursuant to Section 223 of the Internal Revenue Code (26

 

 

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1U.S.C. 223).
2    All screenings shall include a physical breast exam,
3instruction on self-examination and information regarding the
4frequency of self-examination and its value as a preventative
5tool.
6     For purposes of this Section:
7    "Diagnostic mammogram" means a mammogram obtained using
8diagnostic mammography.
9    "Diagnostic mammography" means a method of screening that
10is designed to evaluate an abnormality in a breast, including
11an abnormality seen or suspected on a screening mammogram or a
12subjective or objective abnormality otherwise detected in the
13breast.
14    "Low-dose mammography" means the x-ray examination of the
15breast using equipment dedicated specifically for mammography,
16including the x-ray tube, filter, compression device, and
17image receptor, with an average radiation exposure delivery of
18less than one rad per breast for 2 views of an average size
19breast. The term also includes digital mammography and
20includes breast tomosynthesis.
21    "Breast tomosynthesis" means a radiologic procedure that
22involves the acquisition of projection images over the
23stationary breast to produce cross-sectional digital
24three-dimensional images of the breast.
25    If, at any time, the Secretary of the United States
26Department of Health and Human Services, or its successor

 

 

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1agency, promulgates rules or regulations to be published in
2the Federal Register or publishes a comment in the Federal
3Register or issues an opinion, guidance, or other action that
4would require the State, pursuant to any provision of the
5Patient Protection and Affordable Care Act (Public Law
6111-148), including, but not limited to, 42 U.S.C.
718031(d)(3)(B) or any successor provision, to defray the cost
8of any coverage for breast tomosynthesis outlined in this
9paragraph, then the requirement that an insurer cover breast
10tomosynthesis is inoperative other than any such coverage
11authorized under Section 1902 of the Social Security Act, 42
12U.S.C. 1396a, and the State shall not assume any obligation
13for the cost of coverage for breast tomosynthesis set forth in
14this paragraph.
15    On and after January 1, 2016, the Department shall ensure
16that all networks of care for adult clients of the Department
17include access to at least one breast imaging Center of
18Imaging Excellence as certified by the American College of
19Radiology.
20    On and after January 1, 2012, providers participating in a
21quality improvement program approved by the Department shall
22be reimbursed for screening and diagnostic mammography at the
23same rate as the Medicare program's rates, including the
24increased reimbursement for digital mammography and, after
25January 1, 2023 (the effective date of Public Act 102-1018),
26breast tomosynthesis.

 

 

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1    The Department shall convene an expert panel including
2representatives of hospitals, free-standing mammography
3facilities, and doctors, including radiologists, to establish
4quality standards for mammography.
5    On and after January 1, 2017, providers participating in a
6breast cancer treatment quality improvement program approved
7by the Department shall be reimbursed for breast cancer
8treatment at a rate that is no lower than 95% of the Medicare
9program's rates for the data elements included in the breast
10cancer treatment quality program.
11    The Department shall convene an expert panel, including
12representatives of hospitals, free-standing breast cancer
13treatment centers, breast cancer quality organizations, and
14doctors, including breast surgeons, reconstructive breast
15surgeons, oncologists, and primary care providers to establish
16quality standards for breast cancer treatment.
17    Subject to federal approval, the Department shall
18establish a rate methodology for mammography at federally
19qualified health centers and other encounter-rate clinics.
20These clinics or centers may also collaborate with other
21hospital-based mammography facilities. By January 1, 2016, the
22Department shall report to the General Assembly on the status
23of the provision set forth in this paragraph.
24    The Department shall establish a methodology to remind
25individuals who are age-appropriate for screening mammography,
26but who have not received a mammogram within the previous 18

 

 

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1months, of the importance and benefit of screening
2mammography. The Department shall work with experts in breast
3cancer outreach and patient navigation to optimize these
4reminders and shall establish a methodology for evaluating
5their effectiveness and modifying the methodology based on the
6evaluation.
7    The Department shall establish a performance goal for
8primary care providers with respect to their female patients
9over age 40 receiving an annual mammogram. This performance
10goal shall be used to provide additional reimbursement in the
11form of a quality performance bonus to primary care providers
12who meet that goal.
13    The Department shall devise a means of case-managing or
14patient navigation for beneficiaries diagnosed with breast
15cancer. This program shall initially operate as a pilot
16program in areas of the State with the highest incidence of
17mortality related to breast cancer. At least one pilot program
18site shall be in the metropolitan Chicago area and at least one
19site shall be outside the metropolitan Chicago area. On or
20after July 1, 2016, the pilot program shall be expanded to
21include one site in western Illinois, one site in southern
22Illinois, one site in central Illinois, and 4 sites within
23metropolitan Chicago. An evaluation of the pilot program shall
24be carried out measuring health outcomes and cost of care for
25those served by the pilot program compared to similarly
26situated patients who are not served by the pilot program.

 

 

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1    The Department shall require all networks of care to
2develop a means either internally or by contract with experts
3in navigation and community outreach to navigate cancer
4patients to comprehensive care in a timely fashion. The
5Department shall require all networks of care to include
6access for patients diagnosed with cancer to at least one
7academic commission on cancer-accredited cancer program as an
8in-network covered benefit.
9    The Department shall provide coverage and reimbursement
10for a human papillomavirus (HPV) vaccine that is approved for
11marketing by the federal Food and Drug Administration for all
12persons between the ages of 9 and 45. Subject to federal
13approval, the Department shall provide coverage and
14reimbursement for a human papillomavirus (HPV) vaccine for
15persons of the age of 46 and above who have been diagnosed with
16cervical dysplasia with a high risk of recurrence or
17progression. The Department shall disallow any
18preauthorization requirements for the administration of the
19human papillomavirus (HPV) vaccine.
20    On or after July 1, 2022, individuals who are otherwise
21eligible for medical assistance under this Article shall
22receive coverage for perinatal depression screenings for the
2312-month period beginning on the last day of their pregnancy.
24Medical assistance coverage under this paragraph shall be
25conditioned on the use of a screening instrument approved by
26the Department.

 

 

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

 

 

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

 

 

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1outpatient hospital care, home health services, treatment for
2alcoholism and substance abuse, and other services determined
3necessary by the Illinois Department by rule for delivery by
4Partnerships. Physician services must include prenatal and
5obstetrical care. The Illinois Department shall reimburse
6medical services delivered by Partnership providers to clients
7in target areas according to provisions of this Article and
8the Illinois Health Finance Reform Act, except that:
9        (1) Physicians participating in a Partnership and
10    providing certain services, which shall be determined by
11    the Illinois Department, to persons in areas covered by
12    the Partnership may receive an additional surcharge for
13    such services.
14        (2) The Department may elect to consider and negotiate
15    financial incentives to encourage the development of
16    Partnerships and the efficient delivery of medical care.
17        (3) Persons receiving medical services through
18    Partnerships may receive medical and case management
19    services above the level usually offered through the
20    medical assistance program.
21    Medical providers shall be required to meet certain
22qualifications to participate in Partnerships to ensure the
23delivery of high quality medical services. These
24qualifications shall be determined by rule of the Illinois
25Department and may be higher than qualifications for
26participation in the medical assistance program. Partnership

 

 

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1sponsors may prescribe reasonable additional qualifications
2for participation by medical providers, only with the prior
3written approval of the Illinois Department.
4    Nothing in this Section shall limit the free choice of
5practitioners, hospitals, and other providers of medical
6services by clients. In order to ensure patient freedom of
7choice, the Illinois Department shall immediately promulgate
8all rules and take all other necessary actions so that
9provided services may be accessed from therapeutically
10certified optometrists to the full extent of the Illinois
11Optometric Practice Act of 1987 without discriminating between
12service providers.
13    The Department shall apply for a waiver from the United
14States Health Care Financing Administration to allow for the
15implementation of Partnerships under this Section.
16    The Illinois Department shall require health care
17providers to maintain records that document the medical care
18and services provided to recipients of Medical Assistance
19under this Article. Such records must be retained for a period
20of not less than 6 years from the date of service or as
21provided by applicable State law, whichever period is longer,
22except that if an audit is initiated within the required
23retention period then the records must be retained until the
24audit is completed and every exception is resolved. The
25Illinois Department shall require health care providers to
26make available, when authorized by the patient, in writing,

 

 

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

 

 

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1and shall update such list on a quarterly basis, except that
2the acquisition costs of all prescription drugs shall be
3updated no less frequently than every 30 days as required by
4Section 5-5.12.
5    Notwithstanding any other law to the contrary, the
6Illinois Department shall, within 365 days after July 22, 2013
7(the effective date of Public Act 98-104), establish
8procedures to permit skilled care facilities licensed under
9the Nursing Home Care Act to submit monthly billing claims for
10reimbursement purposes. Following development of these
11procedures, the Department shall, by July 1, 2016, test the
12viability of the new system and implement any necessary
13operational or structural changes to its information
14technology platforms in order to allow for the direct
15acceptance and payment of nursing home claims.
16    Notwithstanding any other law to the contrary, the
17Illinois Department shall, within 365 days after August 15,
182014 (the effective date of Public Act 98-963), establish
19procedures to permit ID/DD facilities licensed under the ID/DD
20Community Care Act and MC/DD facilities licensed under the
21MC/DD Act to submit monthly billing claims for reimbursement
22purposes. Following development of these procedures, the
23Department shall have an additional 365 days to test the
24viability of the new system and to ensure that any necessary
25operational or structural changes to its information
26technology platforms are implemented.

 

 

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1    The Illinois Department shall require all dispensers of
2medical services, other than an individual practitioner or
3group of practitioners, desiring to participate in the Medical
4Assistance program established under this Article to disclose
5all financial, beneficial, ownership, equity, surety or other
6interests in any and all firms, corporations, partnerships,
7associations, business enterprises, joint ventures, agencies,
8institutions or other legal entities providing any form of
9health care services in this State under this Article.
10    The Illinois Department may require that all dispensers of
11medical services desiring to participate in the medical
12assistance program established under this Article disclose,
13under such terms and conditions as the Illinois Department may
14by rule establish, all inquiries from clients and attorneys
15regarding medical bills paid by the Illinois Department, which
16inquiries could indicate potential existence of claims or
17liens for the Illinois Department.
18    Enrollment of a vendor shall be subject to a provisional
19period and shall be conditional for one year. During the
20period of conditional enrollment, the Department may terminate
21the vendor's eligibility to participate in, or may disenroll
22the vendor from, the medical assistance program without cause.
23Unless otherwise specified, such termination of eligibility or
24disenrollment is not subject to the Department's hearing
25process. However, a disenrolled vendor may reapply without
26penalty.

 

 

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

 

 

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1payment claim or bill, either as an initial claim or as a
2resubmitted claim following prior rejection, must be received
3by the Illinois Department, or its fiscal intermediary, no
4later than 180 days after the latest date on the claim on which
5medical goods or services were provided, with the following
6exceptions:
7        (1) In the case of a provider whose enrollment is in
8    process by the Illinois Department, the 180-day period
9    shall not begin until the date on the written notice from
10    the Illinois Department that the provider enrollment is
11    complete.
12        (2) In the case of errors attributable to the Illinois
13    Department or any of its claims processing intermediaries
14    which result in an inability to receive, process, or
15    adjudicate a claim, the 180-day period shall not begin
16    until the provider has been notified of the error.
17        (3) In the case of a provider for whom the Illinois
18    Department initiates the monthly billing process.
19        (4) In the case of a provider operated by a unit of
20    local government with a population exceeding 3,000,000
21    when local government funds finance federal participation
22    for claims payments.
23    For claims for services rendered during a period for which
24a recipient received retroactive eligibility, claims must be
25filed within 180 days after the Department determines the
26applicant is eligible. For claims for which the Illinois

 

 

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

 

 

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

 

 

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1Professional Regulation.
2    Beginning in fiscal year 2013, the Illinois Department
3shall set forth a request for information to identify the
4benefits of a pre-payment, post-adjudication, and post-edit
5claims system with the goals of streamlining claims processing
6and provider reimbursement, reducing the number of pending or
7rejected claims, and helping to ensure a more transparent
8adjudication process through the utilization of: (i) provider
9data verification and provider screening technology; and (ii)
10clinical code editing; and (iii) pre-pay, pre-adjudicated, or
11post-adjudicated predictive modeling with an integrated case
12management system with link analysis. Such a request for
13information shall not be considered as a request for proposal
14or as an obligation on the part of the Illinois Department to
15take any action or acquire any products or services.
16    The Illinois Department shall establish policies,
17procedures, standards and criteria by rule for the
18acquisition, repair and replacement of orthotic and prosthetic
19devices and durable medical equipment. Such rules shall
20provide, but not be limited to, the following services: (1)
21immediate repair or replacement of such devices by recipients;
22and (2) rental, lease, purchase or lease-purchase of durable
23medical equipment in a cost-effective manner, taking into
24consideration the recipient's medical prognosis, the extent of
25the recipient's needs, and the requirements and costs for
26maintaining such equipment. Subject to prior approval, such

 

 

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

 

 

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1Pedorthics Practice Act and complex rehabilitation technology
2products and associated services) through the State's
3assistive technology program's reutilization program, using
4staff with the Assistive Technology Professional (ATP)
5Certification if the refurbished durable medical equipment:
6(i) is available; (ii) is less expensive, including shipping
7costs, than new durable medical equipment of the same type;
8(iii) is able to withstand at least 3 years of use; (iv) is
9cleaned, disinfected, sterilized, and safe in accordance with
10federal Food and Drug Administration regulations and guidance
11governing the reprocessing of medical devices in health care
12settings; and (v) equally meets the needs of the recipient or
13enrollee. The reutilization program shall confirm that the
14recipient or enrollee is not already in receipt of the same or
15similar equipment from another service provider, and that the
16refurbished durable medical equipment equally meets the needs
17of the recipient or enrollee. Nothing in this paragraph shall
18be construed to limit recipient or enrollee choice to obtain
19new durable medical equipment or place any additional prior
20authorization conditions on enrollees of managed care
21organizations.
22    The Department shall execute, relative to the nursing home
23prescreening project, written inter-agency agreements with the
24Department of Human Services and the Department on Aging, to
25effect the following: (i) intake procedures and common
26eligibility criteria for those persons who are receiving

 

 

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1non-institutional services; and (ii) the establishment and
2development of non-institutional services in areas of the
3State where they are not currently available or are
4undeveloped; and (iii) notwithstanding any other provision of
5law, subject to federal approval, on and after July 1, 2012, an
6increase in the determination of need (DON) scores from 29 to
737 for applicants for institutional and home and
8community-based long term care; if and only if federal
9approval is not granted, the Department may, in conjunction
10with other affected agencies, implement utilization controls
11or changes in benefit packages to effectuate a similar savings
12amount for this population; and (iv) no later than July 1,
132013, minimum level of care eligibility criteria for
14institutional and home and community-based long term care; and
15(v) no later than October 1, 2013, establish procedures to
16permit long term care providers access to eligibility scores
17for individuals with an admission date who are seeking or
18receiving services from the long term care provider. In order
19to select the minimum level of care eligibility criteria, the
20Governor shall establish a workgroup that includes affected
21agency representatives and stakeholders representing the
22institutional and home and community-based long term care
23interests. This Section shall not restrict the Department from
24implementing lower level of care eligibility criteria for
25community-based services in circumstances where federal
26approval has been granted.

 

 

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1    The Illinois Department shall develop and operate, in
2cooperation with other State Departments and agencies and in
3compliance with applicable federal laws and regulations,
4appropriate and effective systems of health care evaluation
5and programs for monitoring of utilization of health care
6services and facilities, as it affects persons eligible for
7medical assistance under this Code.
8    The Illinois Department shall report annually to the
9General Assembly, no later than the second Friday in April of
101979 and each year thereafter, in regard to:
11        (a) actual statistics and trends in utilization of
12    medical services by public aid recipients;
13        (b) actual statistics and trends in the provision of
14    the various medical services by medical vendors;
15        (c) current rate structures and proposed changes in
16    those rate structures for the various medical vendors; and
17        (d) efforts at utilization review and control by the
18    Illinois Department.
19    The period covered by each report shall be the 3 years
20ending on the June 30 prior to the report. The report shall
21include suggested legislation for consideration by the General
22Assembly. The requirement for reporting to the General
23Assembly shall be satisfied by filing copies of the report as
24required by Section 3.1 of the General Assembly Organization
25Act, and filing such additional copies with the State
26Government Report Distribution Center for the General Assembly

 

 

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1as is required under paragraph (t) of Section 7 of the State
2Library Act.
3    Rulemaking authority to implement Public Act 95-1045, if
4any, is conditioned on the rules being adopted in accordance
5with all provisions of the Illinois Administrative Procedure
6Act and all rules and procedures of the Joint Committee on
7Administrative Rules; any purported rule not so adopted, for
8whatever reason, is unauthorized.
9    On and after July 1, 2012, the Department shall reduce any
10rate of reimbursement for services or other payments or alter
11any methodologies authorized by this Code to reduce any rate
12of reimbursement for services or other payments in accordance
13with Section 5-5e.
14    Because kidney transplantation can be an appropriate,
15cost-effective alternative to renal dialysis when medically
16necessary and notwithstanding the provisions of Section 1-11
17of this Code, beginning October 1, 2014, the Department shall
18cover kidney transplantation for noncitizens with end-stage
19renal disease who are not eligible for comprehensive medical
20benefits, who meet the residency requirements of Section 5-3
21of this Code, and who would otherwise meet the financial
22requirements of the appropriate class of eligible persons
23under Section 5-2 of this Code. To qualify for coverage of
24kidney transplantation, such person must be receiving
25emergency renal dialysis services covered by the Department.
26Providers under this Section shall be prior approved and

 

 

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1certified by the Department to perform kidney transplantation
2and the services under this Section shall be limited to
3services associated with kidney transplantation.
4    Notwithstanding any other provision of this Code to the
5contrary, on or after July 1, 2015, all FDA approved forms of
6medication assisted treatment prescribed for the treatment of
7alcohol dependence or treatment of opioid dependence shall be
8covered under both fee-for-service fee for service and managed
9care medical assistance programs for persons who are otherwise
10eligible for medical assistance under this Article and shall
11not be subject to any (1) utilization control, other than
12those established under the American Society of Addiction
13Medicine patient placement criteria, (2) prior authorization
14mandate, or (3) lifetime restriction limit mandate.
15    On or after July 1, 2015, opioid antagonists prescribed
16for the treatment of an opioid overdose, including the
17medication product, administration devices, and any pharmacy
18fees or hospital fees related to the dispensing, distribution,
19and administration of the opioid antagonist, shall be covered
20under the medical assistance program for persons who are
21otherwise eligible for medical assistance under this Article.
22As used in this Section, "opioid antagonist" means a drug that
23binds to opioid receptors and blocks or inhibits the effect of
24opioids acting on those receptors, including, but not limited
25to, naloxone hydrochloride or any other similarly acting drug
26approved by the U.S. Food and Drug Administration. The

 

 

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1Department shall not impose a copayment on the coverage
2provided for naloxone hydrochloride under the medical
3assistance program.
4    Upon federal approval, the Department shall provide
5coverage and reimbursement for all drugs that are approved for
6marketing by the federal Food and Drug Administration and that
7are recommended by the federal Public Health Service or the
8United States Centers for Disease Control and Prevention for
9pre-exposure prophylaxis and related pre-exposure prophylaxis
10services, including, but not limited to, HIV and sexually
11transmitted infection screening, treatment for sexually
12transmitted infections, medical monitoring, assorted labs, and
13counseling to reduce the likelihood of HIV infection among
14individuals who are not infected with HIV but who are at high
15risk of HIV infection.
16    A federally qualified health center, as defined in Section
171905(l)(2)(B) of the federal Social Security Act, shall be
18reimbursed by the Department in accordance with the federally
19qualified health center's encounter rate for services provided
20to medical assistance recipients that are performed by a
21dental hygienist, as defined under the Illinois Dental
22Practice Act, working under the general supervision of a
23dentist and employed by a federally qualified health center.
24    Within 90 days after October 8, 2021 (the effective date
25of Public Act 102-665), the Department shall seek federal
26approval of a State Plan amendment to expand coverage for

 

 

HB4832- 34 -LRB103 37451 KTG 67573 b

1family planning services that includes presumptive eligibility
2to individuals whose income is at or below 208% of the federal
3poverty level. Coverage under this Section shall be effective
4beginning no later than December 1, 2022.
5    Subject to approval by the federal Centers for Medicare
6and Medicaid Services of a Title XIX State Plan amendment
7electing the Program of All-Inclusive Care for the Elderly
8(PACE) as a State Medicaid option, as provided for by Subtitle
9I (commencing with Section 4801) of Title IV of the Balanced
10Budget Act of 1997 (Public Law 105-33) and Part 460
11(commencing with Section 460.2) of Subchapter E of Title 42 of
12the Code of Federal Regulations, PACE program services shall
13become a covered benefit of the medical assistance program,
14subject to criteria established in accordance with all
15applicable laws.
16    Notwithstanding any other provision of this Code,
17community-based pediatric palliative care from a trained
18interdisciplinary team shall be covered under the medical
19assistance program as provided in Section 15 of the Pediatric
20Palliative Care Act.
21    Notwithstanding any other provision of this Code, within
2212 months after June 2, 2022 (the effective date of Public Act
23102-1037) and subject to federal approval, acupuncture
24services performed by an acupuncturist licensed under the
25Acupuncture Practice Act who is acting within the scope of his
26or her license shall be covered under the medical assistance

 

 

HB4832- 35 -LRB103 37451 KTG 67573 b

1program. The Department shall apply for any federal waiver or
2State Plan amendment, if required, to implement this
3paragraph. The Department may adopt any rules, including
4standards and criteria, necessary to implement this paragraph.
5    Notwithstanding any other provision of this Code, the
6medical assistance program shall, subject to appropriation and
7federal approval, reimburse hospitals for costs associated
8with a newborn screening test for the presence of
9metachromatic leukodystrophy, as required under the Newborn
10Metabolic Screening Act, at a rate not less than the fee
11charged by the Department of Public Health. The Department
12shall seek federal approval before the implementation of the
13newborn screening test fees by the Department of Public
14Health.
15    Notwithstanding any other provision of this Code,
16beginning on January 1, 2024, subject to federal approval,
17cognitive assessment and care planning services provided to a
18person who experiences signs or symptoms of cognitive
19impairment, as defined by the Diagnostic and Statistical
20Manual of Mental Disorders, Fifth Edition, shall be covered
21under the medical assistance program for persons who are
22otherwise eligible for medical assistance under this Article.
23    Notwithstanding any other provision of this Code,
24medically necessary reconstructive services that are intended
25to restore physical appearance shall be covered under the
26medical assistance program for persons who are otherwise

 

 

HB4832- 36 -LRB103 37451 KTG 67573 b

1eligible for medical assistance under this Article. As used in
2this paragraph, "reconstructive services" means treatments
3performed on structures of the body damaged by trauma to
4restore physical appearance.
5(Source: P.A. 102-43, Article 30, Section 30-5, eff. 7-6-21;
6102-43, Article 35, Section 35-5, eff. 7-6-21; 102-43, Article
755, Section 55-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123,
8eff. 1-1-22; 102-558, eff. 8-20-21; 102-598, eff. 1-1-22;
9102-655, eff. 1-1-22; 102-665, eff. 10-8-21; 102-813, eff.
105-13-22; 102-1018, eff. 1-1-23; 102-1037, eff. 6-2-22;
11102-1038, eff. 1-1-23; 103-102, Article 15, Section 15-5, eff.
121-1-24; 103-102, Article 95, Section 95-15, eff. 1-1-24;
13103-123, eff. 1-1-24; 103-154, eff. 6-30-23; 103-368, eff.
141-1-24; revised 12-15-23.)
 
15    Section 99. Effective date. This Act takes effect upon
16becoming law.