100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
HB4782

 

Introduced , by Rep. Kelly M. Burke

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.10
305 ILCS 5/5-5  from Ch. 23, par. 5-5

    Amends the Illinois Insurance Code and the Illinois Public Aid Code. In provisions concerning coverage for amino acid-based elemental formulas, provides coverage for the diagnosis and treatment of milk protein allergies and intolerances when the prescribing physician has issued a written order stating that the amino acid-based elemental formula is medically necessary.


LRB100 18998 SMS 34252 b

 

 

A BILL FOR

 

HB4782LRB100 18998 SMS 34252 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 356z.10 as follows:
 
6    (215 ILCS 5/356z.10)
7    Sec. 356z.10. Amino acid-based elemental formulas. A group
8or individual major medical accident and health insurance
9policy or managed care plan amended, delivered, issued, or
10renewed after the effective date of this amendatory Act of the
11100th General Assembly this amendatory Act of the 95th General
12Assembly must provide coverage and reimbursement for amino
13acid-based elemental formulas, regardless of delivery method,
14for the diagnosis and treatment of (i) eosinophilic disorders,
15and (ii) short bowel syndrome, and (iii) milk protein allergies
16and intolerances when the prescribing physician has issued a
17written order stating that the amino acid-based elemental
18formula is medically necessary.
19(Source: P.A. 95-520, eff. 8-28-07; 95-876, eff. 8-21-08.)
 
20    Section 10. The Illinois Public Aid Code is amended by
21changing Section 5-5 as follows:
 

 

 

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1    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
2    Sec. 5-5. Medical services. The Illinois Department, by
3rule, shall determine the quantity and quality of and the rate
4of reimbursement for the medical assistance for which payment
5will be authorized, and the medical services to be provided,
6which may include all or part of the following: (1) inpatient
7hospital services; (2) outpatient hospital services; (3) other
8laboratory and X-ray services; (4) skilled nursing home
9services; (5) physicians' services whether furnished in the
10office, the patient's home, a hospital, a skilled nursing home,
11or elsewhere; (6) medical care, or any other type of remedial
12care furnished by licensed practitioners; (7) home health care
13services; (8) private duty nursing service; (9) clinic
14services; (10) dental services, including prevention and
15treatment of periodontal disease and dental caries disease for
16pregnant women, provided by an individual licensed to practice
17dentistry or dental surgery; for purposes of this item (10),
18"dental services" means diagnostic, preventive, or corrective
19procedures provided by or under the supervision of a dentist in
20the practice of his or her profession; (11) physical therapy
21and related services; (12) prescribed drugs, dentures, and
22prosthetic devices; and eyeglasses prescribed by a physician
23skilled in the diseases of the eye, or by an optometrist,
24whichever the person may select; (13) other diagnostic,
25screening, preventive, and rehabilitative services, including
26to ensure that the individual's need for intervention or

 

 

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1treatment of mental disorders or substance use disorders or
2co-occurring mental health and substance use disorders is
3determined using a uniform screening, assessment, and
4evaluation process inclusive of criteria, for children and
5adults; for purposes of this item (13), a uniform screening,
6assessment, and evaluation process refers to a process that
7includes an appropriate evaluation and, as warranted, a
8referral; "uniform" does not mean the use of a singular
9instrument, tool, or process that all must utilize; (14)
10transportation and such other expenses as may be necessary;
11(15) medical treatment of sexual assault survivors, as defined
12in Section 1a of the Sexual Assault Survivors Emergency
13Treatment Act, for injuries sustained as a result of the sexual
14assault, including examinations and laboratory tests to
15discover evidence which may be used in criminal proceedings
16arising from the sexual assault; (16) the diagnosis and
17treatment of sickle cell anemia; and (17) any other medical
18care, and any other type of remedial care recognized under the
19laws of this State. The term "any other type of remedial care"
20shall include nursing care and nursing home service for persons
21who rely on treatment by spiritual means alone through prayer
22for healing.
23    Notwithstanding any other provision of this Section, a
24comprehensive tobacco use cessation program that includes
25purchasing prescription drugs or prescription medical devices
26approved by the Food and Drug Administration shall be covered

 

 

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1under the medical assistance program under this Article for
2persons who are otherwise eligible for assistance under this
3Article.
4    Notwithstanding any other provision of this Code,
5reproductive health care that is otherwise legal in Illinois
6shall be covered under the medical assistance program for
7persons who are otherwise eligible for medical assistance under
8this Article.
9    Notwithstanding any other provision of this Code, the
10Illinois Department may not require, as a condition of payment
11for any laboratory test authorized under this Article, that a
12physician's handwritten signature appear on the laboratory
13test order form. The Illinois Department may, however, impose
14other appropriate requirements regarding laboratory test order
15documentation.
16    Upon receipt of federal approval of an amendment to the
17Illinois Title XIX State Plan for this purpose, the Department
18shall authorize the Chicago Public Schools (CPS) to procure a
19vendor or vendors to manufacture eyeglasses for individuals
20enrolled in a school within the CPS system. CPS shall ensure
21that its vendor or vendors are enrolled as providers in the
22medical assistance program and in any capitated Medicaid
23managed care entity (MCE) serving individuals enrolled in a
24school within the CPS system. Under any contract procured under
25this provision, the vendor or vendors must serve only
26individuals enrolled in a school within the CPS system. Claims

 

 

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1for services provided by CPS's vendor or vendors to recipients
2of benefits in the medical assistance program under this Code,
3the Children's Health Insurance Program, or the Covering ALL
4KIDS Health Insurance Program shall be submitted to the
5Department or the MCE in which the individual is enrolled for
6payment and shall be reimbursed at the Department's or the
7MCE's established rates or rate methodologies for eyeglasses.
8    On and after July 1, 2012, the Department of Healthcare and
9Family Services may provide the following services to persons
10eligible for assistance under this Article who are
11participating in education, training or employment programs
12operated by the Department of Human Services as successor to
13the Department of Public Aid:
14        (1) dental services provided by or under the
15    supervision of a dentist; and
16        (2) eyeglasses prescribed by a physician skilled in the
17    diseases of the eye, or by an optometrist, whichever the
18    person may select.
19    Notwithstanding any other provision of this Code and
20subject to federal approval, the Department may adopt rules to
21allow a dentist who is volunteering his or her service at no
22cost to render dental services through an enrolled
23not-for-profit health clinic without the dentist personally
24enrolling as a participating provider in the medical assistance
25program. A not-for-profit health clinic shall include a public
26health clinic or Federally Qualified Health Center or other

 

 

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1enrolled provider, as determined by the Department, through
2which dental services covered under this Section are performed.
3The Department shall establish a process for payment of claims
4for reimbursement for covered dental services rendered under
5this provision.
6    The Illinois Department, by rule, may distinguish and
7classify the medical services to be provided only in accordance
8with the classes of persons designated in Section 5-2.
9    The Department of Healthcare and Family Services must
10provide coverage and reimbursement for amino acid-based
11elemental formulas, regardless of delivery method, for the
12diagnosis and treatment of (i) eosinophilic disorders, and (ii)
13short bowel syndrome, and (iii) milk protein allergies and
14intolerances when the prescribing physician has issued a
15written order stating that the amino acid-based elemental
16formula is medically necessary.
17    The Illinois Department shall authorize the provision of,
18and shall authorize payment for, screening by low-dose
19mammography for the presence of occult breast cancer for women
2035 years of age or older who are eligible for medical
21assistance under this Article, as follows:
22        (A) A baseline mammogram for women 35 to 39 years of
23    age.
24        (B) An annual mammogram for women 40 years of age or
25    older.
26        (C) A mammogram at the age and intervals considered

 

 

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1    medically necessary by the woman's health care provider for
2    women under 40 years of age and having a family history of
3    breast cancer, prior personal history of breast cancer,
4    positive genetic testing, or other risk factors.
5        (D) A comprehensive ultrasound screening and MRI of an
6    entire breast or breasts if a mammogram demonstrates
7    heterogeneous or dense breast tissue, when medically
8    necessary as determined by a physician licensed to practice
9    medicine in all of its branches.
10        (E) A screening MRI when medically necessary, as
11    determined by a physician licensed to practice medicine in
12    all of its branches.
13    All screenings shall include a physical breast exam,
14instruction on self-examination and information regarding the
15frequency of self-examination and its value as a preventative
16tool. For purposes of this Section, "low-dose mammography"
17means the x-ray examination of the breast using equipment
18dedicated specifically for mammography, including the x-ray
19tube, filter, compression device, and image receptor, with an
20average radiation exposure delivery of less than one rad per
21breast for 2 views of an average size breast. The term also
22includes digital mammography and includes breast
23tomosynthesis. As used in this Section, the term "breast
24tomosynthesis" means a radiologic procedure that involves the
25acquisition of projection images over the stationary breast to
26produce cross-sectional digital three-dimensional images of

 

 

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1the breast. If, at any time, the Secretary of the United States
2Department of Health and Human Services, or its successor
3agency, promulgates rules or regulations to be published in the
4Federal Register or publishes a comment in the Federal Register
5or issues an opinion, guidance, or other action that would
6require the State, pursuant to any provision of the Patient
7Protection and Affordable Care Act (Public Law 111-148),
8including, but not limited to, 42 U.S.C. 18031(d)(3)(B) or any
9successor provision, to defray the cost of any coverage for
10breast tomosynthesis outlined in this paragraph, then the
11requirement that an insurer cover breast tomosynthesis is
12inoperative other than any such coverage authorized under
13Section 1902 of the Social Security Act, 42 U.S.C. 1396a, and
14the State shall not assume any obligation for the cost of
15coverage for breast tomosynthesis set forth in this paragraph.
16    On and after January 1, 2016, the Department shall ensure
17that all networks of care for adult clients of the Department
18include access to at least one breast imaging Center of Imaging
19Excellence as certified by the American College of Radiology.
20    On and after January 1, 2012, providers participating in a
21quality improvement program approved by the Department shall be
22reimbursed for screening and diagnostic mammography at the same
23rate as the Medicare program's rates, including the increased
24reimbursement for digital mammography.
25    The Department shall convene an expert panel including
26representatives of hospitals, free-standing mammography

 

 

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

 

 

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1outreach and patient navigation to optimize these reminders and
2shall establish a methodology for evaluating their
3effectiveness and modifying the methodology based on the
4evaluation.
5    The Department shall establish a performance goal for
6primary care providers with respect to their female patients
7over age 40 receiving an annual mammogram. This performance
8goal shall be used to provide additional reimbursement in the
9form of a quality performance bonus to primary care providers
10who meet that goal.
11    The Department shall devise a means of case-managing or
12patient navigation for beneficiaries diagnosed with breast
13cancer. This program shall initially operate as a pilot program
14in areas of the State with the highest incidence of mortality
15related to breast cancer. At least one pilot program site shall
16be in the metropolitan Chicago area and at least one site shall
17be outside the metropolitan Chicago area. On or after July 1,
182016, the pilot program shall be expanded to include one site
19in western Illinois, one site in southern Illinois, one site in
20central Illinois, and 4 sites within metropolitan Chicago. An
21evaluation of the pilot program shall be carried out measuring
22health outcomes and cost of care for those served by the pilot
23program compared to similarly situated patients who are not
24served by the pilot program.
25    The Department shall require all networks of care to
26develop a means either internally or by contract with experts

 

 

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1in navigation and community outreach to navigate cancer
2patients to comprehensive care in a timely fashion. The
3Department shall require all networks of care to include access
4for patients diagnosed with cancer to at least one academic
5commission on cancer-accredited cancer program as an
6in-network covered benefit.
7    Any medical or health care provider shall immediately
8recommend, to any pregnant woman who is being provided prenatal
9services and is suspected of drug abuse or is addicted as
10defined in the Alcoholism and Other Drug Abuse and Dependency
11Act, referral to a local substance abuse treatment provider
12licensed by the Department of Human Services or to a licensed
13hospital which provides substance abuse treatment services.
14The Department of Healthcare and Family Services shall assure
15coverage for the cost of treatment of the drug abuse or
16addiction for pregnant recipients in accordance with the
17Illinois Medicaid Program in conjunction with the Department of
18Human Services.
19    All medical providers providing medical assistance to
20pregnant women under this Code shall receive information from
21the Department on the availability of services under the Drug
22Free Families with a Future or any comparable program providing
23case management services for addicted women, including
24information on appropriate referrals for other social services
25that may be needed by addicted women in addition to treatment
26for addiction.

 

 

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1    The Illinois Department, in cooperation with the
2Departments of Human Services (as successor to the Department
3of Alcoholism and Substance Abuse) and Public Health, through a
4public awareness campaign, may provide information concerning
5treatment for alcoholism and drug abuse and addiction, prenatal
6health care, and other pertinent programs directed at reducing
7the number of drug-affected infants born to recipients of
8medical assistance.
9    Neither the Department of Healthcare and Family Services
10nor the Department of Human Services shall sanction the
11recipient solely on the basis of her substance abuse.
12    The Illinois Department shall establish such regulations
13governing the dispensing of health services under this Article
14as it shall deem appropriate. The Department should seek the
15advice of formal professional advisory committees appointed by
16the Director of the Illinois Department for the purpose of
17providing regular advice on policy and administrative matters,
18information dissemination and educational activities for
19medical and health care providers, and consistency in
20procedures to the Illinois Department.
21    The Illinois Department may develop and contract with
22Partnerships of medical providers to arrange medical services
23for persons eligible under Section 5-2 of this Code.
24Implementation of this Section may be by demonstration projects
25in certain geographic areas. The Partnership shall be
26represented by a sponsor organization. The Department, by rule,

 

 

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1shall develop qualifications for sponsors of Partnerships.
2Nothing in this Section shall be construed to require that the
3sponsor organization be a medical organization.
4    The sponsor must negotiate formal written contracts with
5medical providers for physician services, inpatient and
6outpatient hospital care, home health services, treatment for
7alcoholism and substance abuse, and other services determined
8necessary by the Illinois Department by rule for delivery by
9Partnerships. Physician services must include prenatal and
10obstetrical care. The Illinois Department shall reimburse
11medical services delivered by Partnership providers to clients
12in target areas according to provisions of this Article and the
13Illinois Health Finance Reform Act, except that:
14        (1) Physicians participating in a Partnership and
15    providing certain services, which shall be determined by
16    the Illinois Department, to persons in areas covered by the
17    Partnership may receive an additional surcharge for such
18    services.
19        (2) The Department may elect to consider and negotiate
20    financial incentives to encourage the development of
21    Partnerships and the efficient delivery of medical care.
22        (3) Persons receiving medical services through
23    Partnerships may receive medical and case management
24    services above the level usually offered through the
25    medical assistance program.
26    Medical providers shall be required to meet certain

 

 

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

 

 

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1if an audit is initiated within the required retention period
2then the records must be retained until the audit is completed
3and every exception is resolved. The Illinois Department shall
4require health care providers to make available, when
5authorized by the patient, in writing, the medical records in a
6timely fashion to other health care providers who are treating
7or serving persons eligible for Medical Assistance under this
8Article. All dispensers of medical services shall be required
9to maintain and retain business and professional records
10sufficient to fully and accurately document the nature, scope,
11details and receipt of the health care provided to persons
12eligible for medical assistance under this Code, in accordance
13with regulations promulgated by the Illinois Department. The
14rules and regulations shall require that proof of the receipt
15of prescription drugs, dentures, prosthetic devices and
16eyeglasses by eligible persons under this Section accompany
17each claim for reimbursement submitted by the dispenser of such
18medical services. No such claims for reimbursement shall be
19approved for payment by the Illinois Department without such
20proof of receipt, unless the Illinois Department shall have put
21into effect and shall be operating a system of post-payment
22audit and review which shall, on a sampling basis, be deemed
23adequate by the Illinois Department to assure that such drugs,
24dentures, prosthetic devices and eyeglasses for which payment
25is being made are actually being received by eligible
26recipients. Within 90 days after September 16, 1984 (the

 

 

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1effective date of Public Act 83-1439), the Illinois Department
2shall establish a current list of acquisition costs for all
3prosthetic devices and any other items recognized as medical
4equipment and supplies reimbursable under this Article and
5shall update such list on a quarterly basis, except that the
6acquisition costs of all prescription drugs shall be updated no
7less frequently than every 30 days as required by Section
85-5.12.
9    Notwithstanding any other law to the contrary, the Illinois
10Department shall, within 365 days after July 22, 2013 (the
11effective date of Public Act 98-104), establish procedures to
12permit skilled care facilities licensed under the Nursing Home
13Care Act to submit monthly billing claims for reimbursement
14purposes. Following development of these procedures, the
15Department shall, by July 1, 2016, test the viability of the
16new system and implement any necessary operational or
17structural changes to its information technology platforms in
18order to allow for the direct acceptance and payment of nursing
19home claims.
20    Notwithstanding any other law to the contrary, the Illinois
21Department shall, within 365 days after August 15, 2014 (the
22effective date of Public Act 98-963), establish procedures to
23permit ID/DD facilities licensed under the ID/DD Community Care
24Act and MC/DD facilities licensed under the MC/DD Act to submit
25monthly billing claims for reimbursement purposes. Following
26development of these procedures, the Department shall have an

 

 

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1additional 365 days to test the viability of the new system and
2to ensure that any necessary operational or structural changes
3to its information technology platforms are implemented.
4    The Illinois Department shall require all dispensers of
5medical services, other than an individual practitioner or
6group of practitioners, desiring to participate in the Medical
7Assistance program established under this Article to disclose
8all financial, beneficial, ownership, equity, surety or other
9interests in any and all firms, corporations, partnerships,
10associations, business enterprises, joint ventures, agencies,
11institutions or other legal entities providing any form of
12health care services in this State under this Article.
13    The Illinois Department may require that all dispensers of
14medical services desiring to participate in the medical
15assistance program established under this Article disclose,
16under such terms and conditions as the Illinois Department may
17by rule establish, all inquiries from clients and attorneys
18regarding medical bills paid by the Illinois Department, which
19inquiries could indicate potential existence of claims or liens
20for the Illinois Department.
21    Enrollment of a vendor shall be subject to a provisional
22period and shall be conditional for one year. During the period
23of conditional enrollment, the Department may terminate the
24vendor's eligibility to participate in, or may disenroll the
25vendor from, the medical assistance program without cause.
26Unless otherwise specified, such termination of eligibility or

 

 

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1disenrollment is not subject to the Department's hearing
2process. However, a disenrolled vendor may reapply without
3penalty.
4    The Department has the discretion to limit the conditional
5enrollment period for vendors based upon category of risk of
6the vendor.
7    Prior to enrollment and during the conditional enrollment
8period in the medical assistance program, all vendors shall be
9subject to enhanced oversight, screening, and review based on
10the risk of fraud, waste, and abuse that is posed by the
11category of risk of the vendor. The Illinois Department shall
12establish the procedures for oversight, screening, and review,
13which may include, but need not be limited to: criminal and
14financial background checks; fingerprinting; license,
15certification, and authorization verifications; unscheduled or
16unannounced site visits; database checks; prepayment audit
17reviews; audits; payment caps; payment suspensions; and other
18screening as required by federal or State law.
19    The Department shall define or specify the following: (i)
20by provider notice, the "category of risk of the vendor" for
21each type of vendor, which shall take into account the level of
22screening applicable to a particular category of vendor under
23federal law and regulations; (ii) by rule or provider notice,
24the maximum length of the conditional enrollment period for
25each category of risk of the vendor; and (iii) by rule, the
26hearing rights, if any, afforded to a vendor in each category

 

 

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

 

 

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1a recipient received retroactive eligibility, claims must be
2filed within 180 days after the Department determines the
3applicant is eligible. For claims for which the Illinois
4Department is not the primary payer, claims must be submitted
5to the Illinois Department within 180 days after the final
6adjudication by the primary payer.
7    In the case of long term care facilities, within 45
8calendar days of receipt by the facility of required
9prescreening information, new admissions with associated
10admission documents shall be submitted through the Medical
11Electronic Data Interchange (MEDI) or the Recipient
12Eligibility Verification (REV) System or shall be submitted
13directly to the Department of Human Services using required
14admission forms. Effective September 1, 2014, admission
15documents, including all prescreening information, must be
16submitted through MEDI or REV. Confirmation numbers assigned to
17an accepted transaction shall be retained by a facility to
18verify timely submittal. Once an admission transaction has been
19completed, all resubmitted claims following prior rejection
20are subject to receipt no later than 180 days after the
21admission transaction has been completed.
22    Claims that are not submitted and received in compliance
23with the foregoing requirements shall not be eligible for
24payment under the medical assistance program, and the State
25shall have no liability for payment of those claims.
26    To the extent consistent with applicable information and

 

 

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

 

 

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

 

 

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1needs, and the requirements and costs for maintaining such
2equipment. Subject to prior approval, such rules shall enable a
3recipient to temporarily acquire and use alternative or
4substitute devices or equipment pending repairs or
5replacements of any device or equipment previously authorized
6for such recipient by the Department. Notwithstanding any
7provision of Section 5-5f to the contrary, the Department may,
8by rule, exempt certain replacement wheelchair parts from prior
9approval and, for wheelchairs, wheelchair parts, wheelchair
10accessories, and related seating and positioning items,
11determine the wholesale price by methods other than actual
12acquisition costs.
13    The Department shall require, by rule, all providers of
14durable medical equipment to be accredited by an accreditation
15organization approved by the federal Centers for Medicare and
16Medicaid Services and recognized by the Department in order to
17bill the Department for providing durable medical equipment to
18recipients. No later than 15 months after the effective date of
19the rule adopted pursuant to this paragraph, all providers must
20meet the accreditation requirement.
21    The Department shall execute, relative to the nursing home
22prescreening project, written inter-agency agreements with the
23Department of Human Services and the Department on Aging, to
24effect the following: (i) intake procedures and common
25eligibility criteria for those persons who are receiving
26non-institutional services; and (ii) the establishment and

 

 

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1development of non-institutional services in areas of the State
2where they are not currently available or are undeveloped; and
3(iii) notwithstanding any other provision of law, subject to
4federal approval, on and after July 1, 2012, an increase in the
5determination of need (DON) scores from 29 to 37 for applicants
6for institutional and home and community-based long term care;
7if and only if federal approval is not granted, the Department
8may, in conjunction with other affected agencies, implement
9utilization controls or changes in benefit packages to
10effectuate a similar savings amount for this population; and
11(iv) no later than July 1, 2013, minimum level of care
12eligibility criteria for institutional and home and
13community-based long term care; and (v) no later than October
141, 2013, establish procedures to permit long term care
15providers access to eligibility scores for individuals with an
16admission date who are seeking or receiving services from the
17long term care provider. In order to select the minimum level
18of care eligibility criteria, the Governor shall establish a
19workgroup that includes affected agency representatives and
20stakeholders representing the institutional and home and
21community-based long term care interests. This Section shall
22not restrict the Department from implementing lower level of
23care eligibility criteria for community-based services in
24circumstances where federal approval has been granted.
25    The Illinois Department shall develop and operate, in
26cooperation with other State Departments and agencies and in

 

 

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1compliance with applicable federal laws and regulations,
2appropriate and effective systems of health care evaluation and
3programs for monitoring of utilization of health care services
4and facilities, as it affects persons eligible for medical
5assistance under this Code.
6    The Illinois Department shall report annually to the
7General Assembly, no later than the second Friday in April of
81979 and each year thereafter, in regard to:
9        (a) actual statistics and trends in utilization of
10    medical services by public aid recipients;
11        (b) actual statistics and trends in the provision of
12    the various medical services by medical vendors;
13        (c) current rate structures and proposed changes in
14    those rate structures for the various medical vendors; and
15        (d) efforts at utilization review and control by the
16    Illinois Department.
17    The period covered by each report shall be the 3 years
18ending on the June 30 prior to the report. The report shall
19include suggested legislation for consideration by the General
20Assembly. The filing of one copy of the report with the
21Speaker, one copy with the Minority Leader and one copy with
22the Clerk of the House of Representatives, one copy with the
23President, one copy with the Minority Leader and one copy with
24the Secretary of the Senate, one copy with the Legislative
25Research Unit, and such additional copies with the State
26Government Report Distribution Center for the General Assembly

 

 

HB4782- 26 -LRB100 18998 SMS 34252 b

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

 

 

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

 

 

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1Administration.
2    Upon federal approval, the Department shall provide
3coverage and reimbursement for all drugs that are approved for
4marketing by the federal Food and Drug Administration and that
5are recommended by the federal Public Health Service or the
6United States Centers for Disease Control and Prevention for
7pre-exposure prophylaxis and related pre-exposure prophylaxis
8services, including, but not limited to, HIV and sexually
9transmitted infection screening, treatment for sexually
10transmitted infections, medical monitoring, assorted labs, and
11counseling to reduce the likelihood of HIV infection among
12individuals who are not infected with HIV but who are at high
13risk of HIV infection.
14(Source: P.A. 99-78, eff. 7-20-15; 99-180, eff. 7-29-15;
1599-236, eff. 8-3-15; 99-407 (see Section 20 of P.A. 99-588 for
16the effective date of P.A. 99-407); 99-433, eff. 8-21-15;
1799-480, eff. 9-9-15; 99-588, eff. 7-20-16; 99-642, eff.
187-28-16; 99-772, eff. 1-1-17; 99-895, eff. 1-1-17; 100-201,
19eff. 8-18-17; 100-395, eff. 1-1-18; 100-449, eff. 1-1-18;
20100-538, eff. 1-1-18; revised 10-26-17.)