Rep. Robyn Gabel

Filed: 3/29/2022

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 3682

2    AMENDMENT NO. ______. Amend Senate Bill 3682 by replacing
3everything after the enacting clause with the following:
 
4    "Section 1. Short title. This Act may be cited as the
5Reducing Cervical Cancer and Saving Lives Act.
 
6    Section 5. Applicability. This Act applies to a hospital,
7outpatient department, clinic, mobile unit, or other entity
8that provides cervical cancer screening services in the State
9of Illinois.
 
10    Section 10. Definitions. As used in this Act:
11    "Cervical cancer screening service" means an examination
12and laboratory test for the screening and detection of
13cervical cancer, including conventional Pap smear screening,
14liquid-based cytology, or human papillomavirus (HPV) detection
15methods.

 

 

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1    "Department" means the Department of Public Health.
 
2    Section 15. Cervical cancer screening services; written
3report.
4    (a) A hospital, outpatient department, clinic, mobile
5unit, or other entity that provides a cervical cancer
6screening service shall prepare a written report of the
7results of any cervical cancer screening service provided to a
8patient. The written report shall be provided to the patient's
9referring health care professional. If a patient's referring
10health care professional is not available or if there is no
11such referring health care professional, only the summary of
12the written report under subsection (b) is required.
13    (b) A summary of the written report of the results of any
14cervical cancer screening service shall be sent directly to
15the patient in terms easily understood by a lay person. The
16summary of the written report may be provided electronically
17if the patient has consented to receive electronic
18communications. The summary of the written report shall advise
19the patient to consult with the patient's health care
20professional to discuss the results of the cervical cancer
21screening.
22    (c) The Department, in collaboration with experts in
23cervical cancer and cervical cancer screening, shall develop
24suggested cervical cancer screening reporting language, in
25terms easily understood by a lay person, to be sent to patients

 

 

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1with the summary of the written report required under
2subsection (b).
3    (d) This Section does not create a duty of care or other
4legal obligation beyond the duty to provide a written report
5as set forth in this Section.
6    (e) This Section is operative beginning 6 months after the
7Department makes the suggested cervical cancer screening
8reporting language required under subsection (c) publicly
9available, including by posting the suggested cervical cancer
10screening reporting language on the Department's website.
 
11    Section 20. Human papillomavirus (HPV) vaccine services
12pilot program.
13    (a) The Department shall establish a pilot program to
14provide for the administration of human papillomavirus (HPV)
15vaccines to persons enrolled in the Department's Illinois
16Breast and Cervical Cancer Program who are:
17        (1) 26 years of age or younger, have not received the
18    full HPV vaccine series, and would like to receive the
19    vaccine series; or
20        (2) 26 years of age or older, have not completed the
21    HPV vaccine series, and whose clinicians recommend the HPV
22    vaccine series.
23    (b) The pilot program shall be implemented no later than
24July 1, 2024.
25    (c) Any lead agency of the Illinois Breast and Cervical

 

 

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1Cancer Program may participate in the pilot program.
2    (d) This Section is repealed on June 30, 2027.
 
3    Section 50. The Illinois Public Aid Code is amended by
4changing Section 5-5 as follows:
 
5    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
6    Sec. 5-5. Medical services. The Illinois Department, by
7rule, shall determine the quantity and quality of and the rate
8of reimbursement for the medical assistance for which payment
9will be authorized, and the medical services to be provided,
10which may include all or part of the following: (1) inpatient
11hospital services; (2) outpatient hospital services; (3) other
12laboratory and X-ray services; (4) skilled nursing home
13services; (5) physicians' services whether furnished in the
14office, the patient's home, a hospital, a skilled nursing
15home, or elsewhere; (6) medical care, or any other type of
16remedial care furnished by licensed practitioners; (7) home
17health care services; (8) private duty nursing service; (9)
18clinic services; (10) dental services, including prevention
19and treatment of periodontal disease and dental caries disease
20for pregnant individuals, provided by an individual licensed
21to practice dentistry or dental surgery; for purposes of this
22item (10), "dental services" means diagnostic, preventive, or
23corrective procedures provided by or under the supervision of
24a dentist in the practice of his or her profession; (11)

 

 

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1physical therapy and related services; (12) prescribed drugs,
2dentures, and prosthetic devices; and eyeglasses prescribed by
3a physician skilled in the diseases of the eye, or by an
4optometrist, whichever the person may select; (13) other
5diagnostic, screening, preventive, and rehabilitative
6services, including to ensure that the individual's need for
7intervention or treatment of mental disorders or substance use
8disorders or co-occurring mental health and substance use
9disorders is determined using a uniform screening, assessment,
10and evaluation process inclusive of criteria, for children and
11adults; for purposes of this item (13), a uniform screening,
12assessment, and evaluation process refers to a process that
13includes an appropriate evaluation and, as warranted, a
14referral; "uniform" does not mean the use of a singular
15instrument, tool, or process that all must utilize; (14)
16transportation and such other expenses as may be necessary;
17(15) medical treatment of sexual assault survivors, as defined
18in Section 1a of the Sexual Assault Survivors Emergency
19Treatment Act, for injuries sustained as a result of the
20sexual assault, including examinations and laboratory tests to
21discover evidence which may be used in criminal proceedings
22arising from the sexual assault; (16) the diagnosis and
23treatment of sickle cell anemia; (16.5) services performed by
24a chiropractic physician licensed under the Medical Practice
25Act of 1987 and acting within the scope of his or her license,
26including, but not limited to, chiropractic manipulative

 

 

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1treatment; and (17) any other medical care, and any other type
2of remedial care recognized under the laws of this State. The
3term "any other type of remedial care" shall include nursing
4care and nursing home service for persons who rely on
5treatment by spiritual means alone through prayer for healing.
6    Notwithstanding any other provision of this Section, a
7comprehensive tobacco use cessation program that includes
8purchasing prescription drugs or prescription medical devices
9approved by the Food and Drug Administration shall be covered
10under the medical assistance program under this Article for
11persons who are otherwise eligible for assistance under this
12Article.
13    Notwithstanding any other provision of this Code,
14reproductive health care that is otherwise legal in Illinois
15shall be covered under the medical assistance program for
16persons who are otherwise eligible for medical assistance
17under this Article.
18    Notwithstanding any other provision of this Section, all
19tobacco cessation medications approved by the United States
20Food and Drug Administration and all individual and group
21tobacco cessation counseling services and telephone-based
22counseling services and tobacco cessation medications provided
23through the Illinois Tobacco Quitline shall be covered under
24the medical assistance program for persons who are otherwise
25eligible for assistance under this Article. The Department
26shall comply with all federal requirements necessary to obtain

 

 

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1federal financial participation, as specified in 42 CFR
2433.15(b)(7), for telephone-based counseling services provided
3through the Illinois Tobacco Quitline, including, but not
4limited to: (i) entering into a memorandum of understanding or
5interagency agreement with the Department of Public Health, as
6administrator of the Illinois Tobacco Quitline; and (ii)
7developing a cost allocation plan for Medicaid-allowable
8Illinois Tobacco Quitline services in accordance with 45 CFR
995.507. The Department shall submit the memorandum of
10understanding or interagency agreement, the cost allocation
11plan, and all other necessary documentation to the Centers for
12Medicare and Medicaid Services for review and approval.
13Coverage under this paragraph shall be contingent upon federal
14approval.
15    Notwithstanding any other provision of this Code, the
16Illinois Department may not require, as a condition of payment
17for any laboratory test authorized under this Article, that a
18physician's handwritten signature appear on the laboratory
19test order form. The Illinois Department may, however, impose
20other appropriate requirements regarding laboratory test order
21documentation.
22    Upon receipt of federal approval of an amendment to the
23Illinois Title XIX State Plan for this purpose, the Department
24shall authorize the Chicago Public Schools (CPS) to procure a
25vendor or vendors to manufacture eyeglasses for individuals
26enrolled in a school within the CPS system. CPS shall ensure

 

 

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1that its vendor or vendors are enrolled as providers in the
2medical assistance program and in any capitated Medicaid
3managed care entity (MCE) serving individuals enrolled in a
4school within the CPS system. Under any contract procured
5under this provision, the vendor or vendors must serve only
6individuals enrolled in a school within the CPS system. Claims
7for services provided by CPS's vendor or vendors to recipients
8of benefits in the medical assistance program under this Code,
9the Children's Health Insurance Program, or the Covering ALL
10KIDS Health Insurance Program shall be submitted to the
11Department or the MCE in which the individual is enrolled for
12payment and shall be reimbursed at the Department's or the
13MCE's established rates or rate methodologies for eyeglasses.
14    On and after July 1, 2012, the Department of Healthcare
15and Family Services may provide the following services to
16persons eligible for assistance under this Article who are
17participating in education, training or employment programs
18operated by the Department of Human Services as successor to
19the Department of Public Aid:
20        (1) dental services provided by or under the
21    supervision of a dentist; and
22        (2) eyeglasses prescribed by a physician skilled in
23    the diseases of the eye, or by an optometrist, whichever
24    the person may select.
25    On and after July 1, 2018, the Department of Healthcare
26and Family Services shall provide dental services to any adult

 

 

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1who is otherwise eligible for assistance under the medical
2assistance program. As used in this paragraph, "dental
3services" means diagnostic, preventative, restorative, or
4corrective procedures, including procedures and services for
5the prevention and treatment of periodontal disease and dental
6caries disease, provided by an individual who is licensed to
7practice dentistry or dental surgery or who is under the
8supervision of a dentist in the practice of his or her
9profession.
10    On and after July 1, 2018, targeted dental services, as
11set forth in Exhibit D of the Consent Decree entered by the
12United States District Court for the Northern District of
13Illinois, Eastern Division, in the matter of Memisovski v.
14Maram, Case No. 92 C 1982, that are provided to adults under
15the medical assistance program shall be established at no less
16than the rates set forth in the "New Rate" column in Exhibit D
17of the Consent Decree for targeted dental services that are
18provided to persons under the age of 18 under the medical
19assistance program.
20    Notwithstanding any other provision of this Code and
21subject to federal approval, the Department may adopt rules to
22allow a dentist who is volunteering his or her service at no
23cost to render dental services through an enrolled
24not-for-profit health clinic without the dentist personally
25enrolling as a participating provider in the medical
26assistance program. A not-for-profit health clinic shall

 

 

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1include a public health clinic or Federally Qualified Health
2Center or other enrolled provider, as determined by the
3Department, through which dental services covered under this
4Section are performed. The Department shall establish a
5process for payment of claims for reimbursement for covered
6dental services rendered under this provision.
7    On and after January 1, 2022, the Department of Healthcare
8and Family Services shall administer and regulate a
9school-based dental program that allows for the out-of-office
10delivery of preventative dental services in a school setting
11to children under 19 years of age. The Department shall
12establish, by rule, guidelines for participation by providers
13and set requirements for follow-up referral care based on the
14requirements established in the Dental Office Reference Manual
15published by the Department that establishes the requirements
16for dentists participating in the All Kids Dental School
17Program. Every effort shall be made by the Department when
18developing the program requirements to consider the different
19geographic differences of both urban and rural areas of the
20State for initial treatment and necessary follow-up care. No
21provider shall be charged a fee by any unit of local government
22to participate in the school-based dental program administered
23by the Department. Nothing in this paragraph shall be
24construed to limit or preempt a home rule unit's or school
25district's authority to establish, change, or administer a
26school-based dental program in addition to, or independent of,

 

 

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1the school-based dental program administered by the
2Department.
3    The Illinois Department, by rule, may distinguish and
4classify the medical services to be provided only in
5accordance with the classes of persons designated in Section
65-2.
7    The Department of Healthcare and Family Services must
8provide coverage and reimbursement for amino acid-based
9elemental formulas, regardless of delivery method, for the
10diagnosis and treatment of (i) eosinophilic disorders and (ii)
11short bowel syndrome when the prescribing physician has issued
12a written order stating that the amino acid-based elemental
13formula is medically necessary.
14    The Illinois Department shall authorize the provision of,
15and shall authorize payment for, screening by low-dose
16mammography for the presence of occult breast cancer for
17individuals 35 years of age or older who are eligible for
18medical assistance under this Article, as follows:
19        (A) A baseline mammogram for individuals 35 to 39
20    years of age.
21        (B) An annual mammogram for individuals 40 years of
22    age or older.
23        (C) A mammogram at the age and intervals considered
24    medically necessary by the individual's health care
25    provider for individuals under 40 years of age and having
26    a family history of breast cancer, prior personal history

 

 

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1    of breast cancer, positive genetic testing, or other risk
2    factors.
3        (D) A comprehensive ultrasound screening and MRI of an
4    entire breast or breasts if a mammogram demonstrates
5    heterogeneous or dense breast tissue or when medically
6    necessary as determined by a physician licensed to
7    practice medicine in all of its branches.
8        (E) A screening MRI when medically necessary, as
9    determined by a physician licensed to practice medicine in
10    all of its branches.
11        (F) A diagnostic mammogram when medically necessary,
12    as determined by a physician licensed to practice medicine
13    in all its branches, advanced practice registered nurse,
14    or physician assistant.
15    The Department shall not impose a deductible, coinsurance,
16copayment, or any other cost-sharing requirement on the
17coverage provided under this paragraph; except that this
18sentence does not apply to coverage of diagnostic mammograms
19to the extent such coverage would disqualify a high-deductible
20health plan from eligibility for a health savings account
21pursuant to Section 223 of the Internal Revenue Code (26
22U.S.C. 223).
23    All screenings shall include a physical breast exam,
24instruction on self-examination and information regarding the
25frequency of self-examination and its value as a preventative
26tool.

 

 

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1     For purposes of this Section:
2    "Diagnostic mammogram" means a mammogram obtained using
3diagnostic mammography.
4    "Diagnostic mammography" means a method of screening that
5is designed to evaluate an abnormality in a breast, including
6an abnormality seen or suspected on a screening mammogram or a
7subjective or objective abnormality otherwise detected in the
8breast.
9    "Low-dose mammography" means the x-ray examination of the
10breast using equipment dedicated specifically for mammography,
11including the x-ray tube, filter, compression device, and
12image receptor, with an average radiation exposure delivery of
13less than one rad per breast for 2 views of an average size
14breast. The term also includes digital mammography and
15includes breast tomosynthesis.
16    "Breast tomosynthesis" means a radiologic procedure that
17involves the acquisition of projection images over the
18stationary breast to produce cross-sectional digital
19three-dimensional images of the breast.
20    If, at any time, the Secretary of the United States
21Department of Health and Human Services, or its successor
22agency, promulgates rules or regulations to be published in
23the Federal Register or publishes a comment in the Federal
24Register or issues an opinion, guidance, or other action that
25would require the State, pursuant to any provision of the
26Patient Protection and Affordable Care Act (Public Law

 

 

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1111-148), including, but not limited to, 42 U.S.C.
218031(d)(3)(B) or any successor provision, to defray the cost
3of any coverage for breast tomosynthesis outlined in this
4paragraph, then the requirement that an insurer cover breast
5tomosynthesis is inoperative other than any such coverage
6authorized under Section 1902 of the Social Security Act, 42
7U.S.C. 1396a, and the State shall not assume any obligation
8for the cost of coverage for breast tomosynthesis set forth in
9this paragraph.
10    On and after January 1, 2016, the Department shall ensure
11that all networks of care for adult clients of the Department
12include access to at least one breast imaging Center of
13Imaging Excellence as certified by the American College of
14Radiology.
15    On and after January 1, 2012, providers participating in a
16quality improvement program approved by the Department shall
17be reimbursed for screening and diagnostic mammography at the
18same rate as the Medicare program's rates, including the
19increased reimbursement for digital mammography and, after the
20effective date of this amendatory Act of the 102nd General
21Assembly, breast tomosynthesis.
22    The Department shall convene an expert panel including
23representatives of hospitals, free-standing mammography
24facilities, and doctors, including radiologists, to establish
25quality standards for mammography.
26    On and after January 1, 2017, providers participating in a

 

 

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

 

 

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

 

 

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1access for patients diagnosed with cancer to at least one
2academic commission on cancer-accredited cancer program as an
3in-network covered benefit.
4    The Department shall provide coverage and reimbursement
5for a human papillomavirus (HPV) vaccine that is approved for
6marketing by the federal Food and Drug Administration for all
7persons between the ages of 9 and 45 and persons of the age of
846 and above who have been diagnosed with cervical dysplasia
9with a high risk of recurrence or progression. The Department
10shall disallow any preauthorization requirements for the
11administration of the human papillomavirus (HPV) vaccine.
12    On or after July 1, 2022, individuals who are otherwise
13eligible for medical assistance under this Article shall
14receive coverage for perinatal depression screenings for the
1512-month period beginning on the last day of their pregnancy.
16Medical assistance coverage under this paragraph shall be
17conditioned on the use of a screening instrument approved by
18the Department.
19    Any medical or health care provider shall immediately
20recommend, to any pregnant individual who is being provided
21prenatal services and is suspected of having a substance use
22disorder as defined in the Substance Use Disorder Act,
23referral to a local substance use disorder treatment program
24licensed by the Department of Human Services or to a licensed
25hospital which provides substance abuse treatment services.
26The Department of Healthcare and Family Services shall assure

 

 

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1coverage for the cost of treatment of the drug abuse or
2addiction for pregnant recipients in accordance with the
3Illinois Medicaid Program in conjunction with the Department
4of Human Services.
5    All medical providers providing medical assistance to
6pregnant individuals under this Code shall receive information
7from the Department on the availability of services under any
8program providing case management services for addicted
9individuals, including information on appropriate referrals
10for other social services that may be needed by addicted
11individuals in addition to treatment for addiction.
12    The Illinois Department, in cooperation with the
13Departments of Human Services (as successor to the Department
14of Alcoholism and Substance Abuse) and Public Health, through
15a public awareness campaign, may provide information
16concerning treatment for alcoholism and drug abuse and
17addiction, prenatal health care, and other pertinent programs
18directed at reducing the number of drug-affected infants born
19to recipients of medical assistance.
20    Neither the Department of Healthcare and Family Services
21nor the Department of Human Services shall sanction the
22recipient solely on the basis of the recipient's substance
23abuse.
24    The Illinois Department shall establish such regulations
25governing the dispensing of health services under this Article
26as it shall deem appropriate. The Department should seek the

 

 

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

 

 

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

 

 

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

 

 

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1promulgated by the Illinois Department. The rules and
2regulations shall require that proof of the receipt of
3prescription drugs, dentures, prosthetic devices and
4eyeglasses by eligible persons under this Section accompany
5each claim for reimbursement submitted by the dispenser of
6such medical services. No such claims for reimbursement shall
7be approved for payment by the Illinois Department without
8such proof of receipt, unless the Illinois Department shall
9have put into effect and shall be operating a system of
10post-payment audit and review which shall, on a sampling
11basis, be deemed adequate by the Illinois Department to assure
12that such drugs, dentures, prosthetic devices and eyeglasses
13for which payment is being made are actually being received by
14eligible recipients. Within 90 days after September 16, 1984
15(the effective date of Public Act 83-1439), the Illinois
16Department shall establish a current list of acquisition costs
17for all prosthetic devices and any other items recognized as
18medical equipment and supplies reimbursable under this Article
19and shall update such list on a quarterly basis, except that
20the acquisition costs of all prescription drugs shall be
21updated no less frequently than every 30 days as required by
22Section 5-5.12.
23    Notwithstanding any other law to the contrary, the
24Illinois Department shall, within 365 days after July 22, 2013
25(the effective date of Public Act 98-104), establish
26procedures to permit skilled care facilities licensed under

 

 

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1the Nursing Home Care Act to submit monthly billing claims for
2reimbursement purposes. Following development of these
3procedures, the Department shall, by July 1, 2016, test the
4viability of the new system and implement any necessary
5operational or structural changes to its information
6technology platforms in order to allow for the direct
7acceptance and payment of nursing home claims.
8    Notwithstanding any other law to the contrary, the
9Illinois Department shall, within 365 days after August 15,
102014 (the effective date of Public Act 98-963), establish
11procedures to permit ID/DD facilities licensed under the ID/DD
12Community Care Act and MC/DD facilities licensed under the
13MC/DD Act to submit monthly billing claims for reimbursement
14purposes. Following development of these procedures, the
15Department shall have an additional 365 days to test the
16viability of the new system and to ensure that any necessary
17operational or structural changes to its information
18technology platforms are implemented.
19    The Illinois Department shall require all dispensers of
20medical services, other than an individual practitioner or
21group of practitioners, desiring to participate in the Medical
22Assistance program established under this Article to disclose
23all financial, beneficial, ownership, equity, surety or other
24interests in any and all firms, corporations, partnerships,
25associations, business enterprises, joint ventures, agencies,
26institutions or other legal entities providing any form of

 

 

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

 

 

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

 

 

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1    shall not begin until the date on the written notice from
2    the Illinois Department that the provider enrollment is
3    complete.
4        (2) In the case of errors attributable to the Illinois
5    Department or any of its claims processing intermediaries
6    which result in an inability to receive, process, or
7    adjudicate a claim, the 180-day period shall not begin
8    until the provider has been notified of the error.
9        (3) In the case of a provider for whom the Illinois
10    Department initiates the monthly billing process.
11        (4) In the case of a provider operated by a unit of
12    local government with a population exceeding 3,000,000
13    when local government funds finance federal participation
14    for claims payments.
15    For claims for services rendered during a period for which
16a recipient received retroactive eligibility, claims must be
17filed within 180 days after the Department determines the
18applicant is eligible. For claims for which the Illinois
19Department is not the primary payer, claims must be submitted
20to the Illinois Department within 180 days after the final
21adjudication by the primary payer.
22    In the case of long term care facilities, within 120
23calendar days of receipt by the facility of required
24prescreening information, new admissions with associated
25admission documents shall be submitted through the Medical
26Electronic Data Interchange (MEDI) or the Recipient

 

 

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

 

 

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

 

 

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

 

 

10200SB3682ham002- 30 -LRB102 24087 CPF 38288 a

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

 

 

10200SB3682ham002- 31 -LRB102 24087 CPF 38288 a

1cleaned, disinfected, sterilized, and safe in accordance with
2federal Food and Drug Administration regulations and guidance
3governing the reprocessing of medical devices in health care
4settings; and (v) equally meets the needs of the recipient or
5enrollee. The reutilization program shall confirm that the
6recipient or enrollee is not already in receipt of the same or
7similar equipment from another service provider, and that the
8refurbished durable medical equipment equally meets the needs
9of the recipient or enrollee. Nothing in this paragraph shall
10be construed to limit recipient or enrollee choice to obtain
11new durable medical equipment or place any additional prior
12authorization conditions on enrollees of managed care
13organizations.
14    The Department shall execute, relative to the nursing home
15prescreening project, written inter-agency agreements with the
16Department of Human Services and the Department on Aging, to
17effect the following: (i) intake procedures and common
18eligibility criteria for those persons who are receiving
19non-institutional services; and (ii) the establishment and
20development of non-institutional services in areas of the
21State where they are not currently available or are
22undeveloped; and (iii) notwithstanding any other provision of
23law, subject to federal approval, on and after July 1, 2012, an
24increase in the determination of need (DON) scores from 29 to
2537 for applicants for institutional and home and
26community-based long term care; if and only if federal

 

 

10200SB3682ham002- 32 -LRB102 24087 CPF 38288 a

1approval is not granted, the Department may, in conjunction
2with other affected agencies, implement utilization controls
3or changes in benefit packages to effectuate a similar savings
4amount for this population; and (iv) no later than July 1,
52013, minimum level of care eligibility criteria for
6institutional and home and community-based long term care; and
7(v) no later than October 1, 2013, establish procedures to
8permit long term care providers access to eligibility scores
9for individuals with an admission date who are seeking or
10receiving services from the long term care provider. In order
11to select the minimum level of care eligibility criteria, the
12Governor shall establish a workgroup that includes affected
13agency representatives and stakeholders representing the
14institutional and home and community-based long term care
15interests. This Section shall not restrict the Department from
16implementing lower level of care eligibility criteria for
17community-based services in circumstances where federal
18approval has been granted.
19    The Illinois Department shall develop and operate, in
20cooperation with other State Departments and agencies and in
21compliance with applicable federal laws and regulations,
22appropriate and effective systems of health care evaluation
23and programs for monitoring of utilization of health care
24services and facilities, as it affects persons eligible for
25medical assistance under this Code.
26    The Illinois Department shall report annually to the

 

 

10200SB3682ham002- 33 -LRB102 24087 CPF 38288 a

1General Assembly, no later than the second Friday in April of
21979 and each year thereafter, in regard to:
3        (a) actual statistics and trends in utilization of
4    medical services by public aid recipients;
5        (b) actual statistics and trends in the provision of
6    the various medical services by medical vendors;
7        (c) current rate structures and proposed changes in
8    those rate structures for the various medical vendors; and
9        (d) efforts at utilization review and control by the
10    Illinois Department.
11    The period covered by each report shall be the 3 years
12ending on the June 30 prior to the report. The report shall
13include suggested legislation for consideration by the General
14Assembly. The requirement for reporting to the General
15Assembly shall be satisfied by filing copies of the report as
16required by Section 3.1 of the General Assembly Organization
17Act, and filing such additional copies with the State
18Government Report Distribution Center for the General Assembly
19as is required under paragraph (t) of Section 7 of the State
20Library Act.
21    Rulemaking authority to implement Public Act 95-1045, if
22any, is conditioned on the rules being adopted in accordance
23with all provisions of the Illinois Administrative Procedure
24Act and all rules and procedures of the Joint Committee on
25Administrative Rules; any purported rule not so adopted, for
26whatever reason, is unauthorized.

 

 

10200SB3682ham002- 34 -LRB102 24087 CPF 38288 a

1    On and after July 1, 2012, the Department shall reduce any
2rate of reimbursement for services or other payments or alter
3any methodologies authorized by this Code to reduce any rate
4of reimbursement for services or other payments in accordance
5with Section 5-5e.
6    Because kidney transplantation can be an appropriate,
7cost-effective alternative to renal dialysis when medically
8necessary and notwithstanding the provisions of Section 1-11
9of this Code, beginning October 1, 2014, the Department shall
10cover kidney transplantation for noncitizens with end-stage
11renal disease who are not eligible for comprehensive medical
12benefits, who meet the residency requirements of Section 5-3
13of this Code, and who would otherwise meet the financial
14requirements of the appropriate class of eligible persons
15under Section 5-2 of this Code. To qualify for coverage of
16kidney transplantation, such person must be receiving
17emergency renal dialysis services covered by the Department.
18Providers under this Section shall be prior approved and
19certified by the Department to perform kidney transplantation
20and the services under this Section shall be limited to
21services associated with kidney transplantation.
22    Notwithstanding any other provision of this Code to the
23contrary, on or after July 1, 2015, all FDA approved forms of
24medication assisted treatment prescribed for the treatment of
25alcohol dependence or treatment of opioid dependence shall be
26covered under both fee for service and managed care medical

 

 

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

 

 

10200SB3682ham002- 36 -LRB102 24087 CPF 38288 a

1transmitted infections, medical monitoring, assorted labs, and
2counseling to reduce the likelihood of HIV infection among
3individuals who are not infected with HIV but who are at high
4risk of HIV infection.
5    A federally qualified health center, as defined in Section
61905(l)(2)(B) of the federal Social Security Act, shall be
7reimbursed by the Department in accordance with the federally
8qualified health center's encounter rate for services provided
9to medical assistance recipients that are performed by a
10dental hygienist, as defined under the Illinois Dental
11Practice Act, working under the general supervision of a
12dentist and employed by a federally qualified health center.
13    Within 90 days after October 8, 2021 (the effective date
14of Public Act 102-665) this amendatory Act of the 102nd
15General Assembly, the Department shall seek federal approval
16of a State Plan amendment to expand coverage for family
17planning services that includes presumptive eligibility to
18individuals whose income is at or below 208% of the federal
19poverty level. Coverage under this Section shall be effective
20beginning no later than December 1, 2022.
21    Subject to approval by the federal Centers for Medicare
22and Medicaid Services of a Title XIX State Plan amendment
23electing the Program of All-Inclusive Care for the Elderly
24(PACE) as a State Medicaid option, as provided for by Subtitle
25I (commencing with Section 4801) of Title IV of the Balanced
26Budget Act of 1997 (Public Law 105-33) and Part 460

 

 

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1(commencing with Section 460.2) of Subchapter E of Title 42 of
2the Code of Federal Regulations, PACE program services shall
3become a covered benefit of the medical assistance program,
4subject to criteria established in accordance with all
5applicable laws.
6    Notwithstanding any other provision of this Code,
7community-based pediatric palliative care from a trained
8interdisciplinary team shall be covered under the medical
9assistance program as provided in Section 15 of the Pediatric
10Palliative Care Act.
11(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
12102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
1335, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
1455-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
15102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
161-1-22; 102-665, eff. 10-8-21; revised 11-18-21.)".