SB3682 EnrolledLRB102 24087 CPF 33310 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 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.
16    "Department" means the Department of Public Health.
 
17    Section 15. Cervical cancer screening services; written
18report.
19    (a) A hospital, outpatient department, clinic, mobile
20unit, or other entity that provides a cervical cancer
21screening service shall prepare a written report of the

 

 

SB3682 Enrolled- 2 -LRB102 24087 CPF 33310 b

1results of any cervical cancer screening service provided to a
2patient. The written report shall be provided to the patient's
3referring health care professional. If a patient's referring
4health care professional is not available or if there is no
5such referring health care professional, only the summary of
6the written report under subsection (b) is required.
7    (b) A summary of the written report of the results of any
8cervical cancer screening service shall be sent directly to
9the patient in terms easily understood by a lay person. The
10summary of the written report may be provided electronically
11if the patient has consented to receive electronic
12communications. The summary of the written report shall advise
13the patient to consult with the patient's health care
14professional to discuss the results of the cervical cancer
15screening.
16    (c) The Department, in collaboration with experts in
17cervical cancer and cervical cancer screening, shall develop
18suggested cervical cancer screening reporting language, in
19terms easily understood by a lay person, to be sent to patients
20with the summary of the written report required under
21subsection (b).
22    (d) This Section does not create a duty of care or other
23legal obligation beyond the duty to provide a written report
24as set forth in this Section.
25    (e) This Section is operative beginning 6 months after the
26Department makes the suggested cervical cancer screening

 

 

SB3682 Enrolled- 3 -LRB102 24087 CPF 33310 b

1reporting language required under subsection (c) publicly
2available, including by posting the suggested cervical cancer
3screening reporting language on the Department's website.
 
4    Section 20. Human papillomavirus (HPV) vaccine services
5pilot program.
6    (a) The Department shall establish a pilot program to
7provide for the administration of human papillomavirus (HPV)
8vaccines to persons enrolled in the Department's Illinois
9Breast and Cervical Cancer Program who are:
10        (1) 26 years of age or younger, have not received the
11    full HPV vaccine series, and would like to receive the
12    vaccine series; or
13        (2) 26 years of age or older, have not completed the
14    HPV vaccine series, and whose clinicians recommend the HPV
15    vaccine series.
16    (b) The pilot program shall be implemented no later than
17July 1, 2024.
18    (c) Any lead agency of the Illinois Breast and Cervical
19Cancer Program may participate in the pilot program.
20    (d) This Section is repealed on June 30, 2027.
 
21    Section 50. The Illinois Public Aid Code is amended by
22changing Section 5-5 as follows:
 
23    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)

 

 

SB3682 Enrolled- 4 -LRB102 24087 CPF 33310 b

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

 

 

SB3682 Enrolled- 5 -LRB102 24087 CPF 33310 b

1disorders or co-occurring mental health and substance use
2disorders is determined using a uniform screening, assessment,
3and evaluation process inclusive of criteria, for children and
4adults; for purposes of this item (13), a uniform screening,
5assessment, and evaluation process refers to a process that
6includes an appropriate evaluation and, as warranted, a
7referral; "uniform" does not mean the use of a singular
8instrument, tool, or process that all must utilize; (14)
9transportation and such other expenses as may be necessary;
10(15) medical treatment of sexual assault survivors, as defined
11in Section 1a of the Sexual Assault Survivors Emergency
12Treatment Act, for injuries sustained as a result of the
13sexual assault, including examinations and laboratory tests to
14discover evidence which may be used in criminal proceedings
15arising from the sexual assault; (16) the diagnosis and
16treatment of sickle cell anemia; (16.5) services performed by
17a chiropractic physician licensed under the Medical Practice
18Act of 1987 and acting within the scope of his or her license,
19including, but not limited to, chiropractic manipulative
20treatment; and (17) any other medical care, and any other type
21of remedial care recognized under the laws of this State. The
22term "any other type of remedial care" shall include nursing
23care and nursing home service for persons who rely on
24treatment by spiritual means alone through prayer for healing.
25    Notwithstanding any other provision of this Section, a
26comprehensive tobacco use cessation program that includes

 

 

SB3682 Enrolled- 6 -LRB102 24087 CPF 33310 b

1purchasing prescription drugs or prescription medical devices
2approved by the Food and Drug Administration shall be covered
3under the medical assistance program under this Article for
4persons who are otherwise eligible for assistance under this
5Article.
6    Notwithstanding any other provision of this Code,
7reproductive health care that is otherwise legal in Illinois
8shall be covered under the medical assistance program for
9persons who are otherwise eligible for medical assistance
10under this Article.
11    Notwithstanding any other provision of this Section, all
12tobacco cessation medications approved by the United States
13Food and Drug Administration and all individual and group
14tobacco cessation counseling services and telephone-based
15counseling services and tobacco cessation medications provided
16through the Illinois Tobacco Quitline shall be covered under
17the medical assistance program for persons who are otherwise
18eligible for assistance under this Article. The Department
19shall comply with all federal requirements necessary to obtain
20federal financial participation, as specified in 42 CFR
21433.15(b)(7), for telephone-based counseling services provided
22through the Illinois Tobacco Quitline, including, but not
23limited to: (i) entering into a memorandum of understanding or
24interagency agreement with the Department of Public Health, as
25administrator of the Illinois Tobacco Quitline; and (ii)
26developing a cost allocation plan for Medicaid-allowable

 

 

SB3682 Enrolled- 7 -LRB102 24087 CPF 33310 b

1Illinois Tobacco Quitline services in accordance with 45 CFR
295.507. The Department shall submit the memorandum of
3understanding or interagency agreement, the cost allocation
4plan, and all other necessary documentation to the Centers for
5Medicare and Medicaid Services for review and approval.
6Coverage under this paragraph shall be contingent upon federal
7approval.
8    Notwithstanding any other provision of this Code, the
9Illinois Department may not require, as a condition of payment
10for any laboratory test authorized under this Article, that a
11physician's handwritten signature appear on the laboratory
12test order form. The Illinois Department may, however, impose
13other appropriate requirements regarding laboratory test order
14documentation.
15    Upon receipt of federal approval of an amendment to the
16Illinois Title XIX State Plan for this purpose, the Department
17shall authorize the Chicago Public Schools (CPS) to procure a
18vendor or vendors to manufacture eyeglasses for individuals
19enrolled in a school within the CPS system. CPS shall ensure
20that its vendor or vendors are enrolled as providers in the
21medical assistance program and in any capitated Medicaid
22managed care entity (MCE) serving individuals enrolled in a
23school within the CPS system. Under any contract procured
24under this provision, the vendor or vendors must serve only
25individuals enrolled in a school within the CPS system. Claims
26for services provided by CPS's vendor or vendors to recipients

 

 

SB3682 Enrolled- 8 -LRB102 24087 CPF 33310 b

1of benefits in the medical assistance program under this Code,
2the Children's Health Insurance Program, or the Covering ALL
3KIDS Health Insurance Program shall be submitted to the
4Department or the MCE in which the individual is enrolled for
5payment and shall be reimbursed at the Department's or the
6MCE's established rates or rate methodologies for eyeglasses.
7    On and after July 1, 2012, the Department of Healthcare
8and Family Services may provide the following services to
9persons eligible for assistance under this Article who are
10participating in education, training or employment programs
11operated by the Department of Human Services as successor to
12the Department of Public Aid:
13        (1) dental services provided by or under the
14    supervision of a dentist; and
15        (2) eyeglasses prescribed by a physician skilled in
16    the diseases of the eye, or by an optometrist, whichever
17    the person may select.
18    On and after July 1, 2018, the Department of Healthcare
19and Family Services shall provide dental services to any adult
20who is otherwise eligible for assistance under the medical
21assistance program. As used in this paragraph, "dental
22services" means diagnostic, preventative, restorative, or
23corrective procedures, including procedures and services for
24the prevention and treatment of periodontal disease and dental
25caries disease, provided by an individual who is licensed to
26practice dentistry or dental surgery or who is under the

 

 

SB3682 Enrolled- 9 -LRB102 24087 CPF 33310 b

1supervision of a dentist in the practice of his or her
2profession.
3    On and after July 1, 2018, targeted dental services, as
4set forth in Exhibit D of the Consent Decree entered by the
5United States District Court for the Northern District of
6Illinois, Eastern Division, in the matter of Memisovski v.
7Maram, Case No. 92 C 1982, that are provided to adults under
8the medical assistance program shall be established at no less
9than the rates set forth in the "New Rate" column in Exhibit D
10of the Consent Decree for targeted dental services that are
11provided to persons under the age of 18 under the medical
12assistance program.
13    Notwithstanding any other provision of this Code and
14subject to federal approval, the Department may adopt rules to
15allow a dentist who is volunteering his or her service at no
16cost to render dental services through an enrolled
17not-for-profit health clinic without the dentist personally
18enrolling as a participating provider in the medical
19assistance program. A not-for-profit health clinic shall
20include a public health clinic or Federally Qualified Health
21Center or other enrolled provider, as determined by the
22Department, through which dental services covered under this
23Section are performed. The Department shall establish a
24process for payment of claims for reimbursement for covered
25dental services rendered under this provision.
26    On and after January 1, 2022, the Department of Healthcare

 

 

SB3682 Enrolled- 10 -LRB102 24087 CPF 33310 b

1and Family Services shall administer and regulate a
2school-based dental program that allows for the out-of-office
3delivery of preventative dental services in a school setting
4to children under 19 years of age. The Department shall
5establish, by rule, guidelines for participation by providers
6and set requirements for follow-up referral care based on the
7requirements established in the Dental Office Reference Manual
8published by the Department that establishes the requirements
9for dentists participating in the All Kids Dental School
10Program. Every effort shall be made by the Department when
11developing the program requirements to consider the different
12geographic differences of both urban and rural areas of the
13State for initial treatment and necessary follow-up care. No
14provider shall be charged a fee by any unit of local government
15to participate in the school-based dental program administered
16by the Department. Nothing in this paragraph shall be
17construed to limit or preempt a home rule unit's or school
18district's authority to establish, change, or administer a
19school-based dental program in addition to, or independent of,
20the school-based dental program administered by the
21Department.
22    The Illinois Department, by rule, may distinguish and
23classify the medical services to be provided only in
24accordance with the classes of persons designated in Section
255-2.
26    The Department of Healthcare and Family Services must

 

 

SB3682 Enrolled- 11 -LRB102 24087 CPF 33310 b

1provide coverage and reimbursement for amino acid-based
2elemental formulas, regardless of delivery method, for the
3diagnosis and treatment of (i) eosinophilic disorders and (ii)
4short bowel syndrome when the prescribing physician has issued
5a written order stating that the amino acid-based elemental
6formula is medically necessary.
7    The Illinois Department shall authorize the provision of,
8and shall authorize payment for, screening by low-dose
9mammography for the presence of occult breast cancer for
10individuals 35 years of age or older who are eligible for
11medical assistance under this Article, as follows:
12        (A) A baseline mammogram for individuals 35 to 39
13    years of age.
14        (B) An annual mammogram for individuals 40 years of
15    age or older.
16        (C) A mammogram at the age and intervals considered
17    medically necessary by the individual's health care
18    provider for individuals under 40 years of age and having
19    a family history of breast cancer, prior personal history
20    of breast cancer, positive genetic testing, or other risk
21    factors.
22        (D) A comprehensive ultrasound screening and MRI of an
23    entire breast or breasts if a mammogram demonstrates
24    heterogeneous or dense breast tissue or when medically
25    necessary as determined by a physician licensed to
26    practice medicine in all of its branches.

 

 

SB3682 Enrolled- 12 -LRB102 24087 CPF 33310 b

1        (E) A screening MRI when medically necessary, as
2    determined by a physician licensed to practice medicine in
3    all of its branches.
4        (F) A diagnostic mammogram when medically necessary,
5    as determined by a physician licensed to practice medicine
6    in all its branches, advanced practice registered nurse,
7    or physician assistant.
8    The Department shall not impose a deductible, coinsurance,
9copayment, or any other cost-sharing requirement on the
10coverage provided under this paragraph; except that this
11sentence does not apply to coverage of diagnostic mammograms
12to the extent such coverage would disqualify a high-deductible
13health plan from eligibility for a health savings account
14pursuant to Section 223 of the Internal Revenue Code (26
15U.S.C. 223).
16    All screenings shall include a physical breast exam,
17instruction on self-examination and information regarding the
18frequency of self-examination and its value as a preventative
19tool.
20     For purposes of this Section:
21    "Diagnostic mammogram" means a mammogram obtained using
22diagnostic mammography.
23    "Diagnostic mammography" means a method of screening that
24is designed to evaluate an abnormality in a breast, including
25an abnormality seen or suspected on a screening mammogram or a
26subjective or objective abnormality otherwise detected in the

 

 

SB3682 Enrolled- 13 -LRB102 24087 CPF 33310 b

1breast.
2    "Low-dose mammography" means the x-ray examination of the
3breast using equipment dedicated specifically for mammography,
4including the x-ray tube, filter, compression device, and
5image receptor, with an average radiation exposure delivery of
6less than one rad per breast for 2 views of an average size
7breast. The term also includes digital mammography and
8includes breast tomosynthesis.
9    "Breast tomosynthesis" means a radiologic procedure that
10involves the acquisition of projection images over the
11stationary breast to produce cross-sectional digital
12three-dimensional images of the breast.
13    If, at any time, the Secretary of the United States
14Department of Health and Human Services, or its successor
15agency, promulgates rules or regulations to be published in
16the Federal Register or publishes a comment in the Federal
17Register or issues an opinion, guidance, or other action that
18would require the State, pursuant to any provision of the
19Patient Protection and Affordable Care Act (Public Law
20111-148), including, but not limited to, 42 U.S.C.
2118031(d)(3)(B) or any successor provision, to defray the cost
22of any coverage for breast tomosynthesis outlined in this
23paragraph, then the requirement that an insurer cover breast
24tomosynthesis is inoperative other than any such coverage
25authorized under Section 1902 of the Social Security Act, 42
26U.S.C. 1396a, and the State shall not assume any obligation

 

 

SB3682 Enrolled- 14 -LRB102 24087 CPF 33310 b

1for the cost of coverage for breast tomosynthesis set forth in
2this paragraph.
3    On and after January 1, 2016, the Department shall ensure
4that all networks of care for adult clients of the Department
5include access to at least one breast imaging Center of
6Imaging Excellence as certified by the American College of
7Radiology.
8    On and after January 1, 2012, providers participating in a
9quality improvement program approved by the Department shall
10be reimbursed for screening and diagnostic mammography at the
11same rate as the Medicare program's rates, including the
12increased reimbursement for digital mammography and, after the
13effective date of this amendatory Act of the 102nd General
14Assembly, breast tomosynthesis.
15    The Department shall convene an expert panel including
16representatives of hospitals, free-standing mammography
17facilities, and doctors, including radiologists, to establish
18quality standards for mammography.
19    On and after January 1, 2017, providers participating in a
20breast cancer treatment quality improvement program approved
21by the Department shall be reimbursed for breast cancer
22treatment at a rate that is no lower than 95% of the Medicare
23program's rates for the data elements included in the breast
24cancer treatment quality program.
25    The Department shall convene an expert panel, including
26representatives of hospitals, free-standing breast cancer

 

 

SB3682 Enrolled- 15 -LRB102 24087 CPF 33310 b

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

 

 

SB3682 Enrolled- 16 -LRB102 24087 CPF 33310 b

1    The Department shall devise a means of case-managing or
2patient navigation for beneficiaries diagnosed with breast
3cancer. This program shall initially operate as a pilot
4program in areas of the State with the highest incidence of
5mortality related to breast cancer. At least one pilot program
6site shall be in the metropolitan Chicago area and at least one
7site shall be outside the metropolitan Chicago area. On or
8after July 1, 2016, the pilot program shall be expanded to
9include one site in western Illinois, one site in southern
10Illinois, one site in central Illinois, and 4 sites within
11metropolitan Chicago. An evaluation of the pilot program shall
12be carried out measuring health outcomes and cost of care for
13those served by the pilot program compared to similarly
14situated patients who are not served by the pilot program.
15    The Department shall require all networks of care to
16develop a means either internally or by contract with experts
17in navigation and community outreach to navigate cancer
18patients to comprehensive care in a timely fashion. The
19Department shall require all networks of care to include
20access for patients diagnosed with cancer to at least one
21academic commission on cancer-accredited cancer program as an
22in-network covered benefit.
23    The Department shall provide coverage and reimbursement
24for a human papillomavirus (HPV) vaccine that is approved for
25marketing by the federal Food and Drug Administration for all
26persons between the ages of 9 and 45 and persons of the age of

 

 

SB3682 Enrolled- 17 -LRB102 24087 CPF 33310 b

146 and above who have been diagnosed with cervical dysplasia
2with a high risk of recurrence or progression. The Department
3shall disallow any preauthorization requirements for the
4administration of the human papillomavirus (HPV) vaccine.
5    On or after July 1, 2022, individuals who are otherwise
6eligible for medical assistance under this Article shall
7receive coverage for perinatal depression screenings for the
812-month period beginning on the last day of their pregnancy.
9Medical assistance coverage under this paragraph shall be
10conditioned on the use of a screening instrument approved by
11the Department.
12    Any medical or health care provider shall immediately
13recommend, to any pregnant individual who is being provided
14prenatal services and is suspected of having a substance use
15disorder as defined in the Substance Use Disorder Act,
16referral to a local substance use disorder treatment program
17licensed by the Department of Human Services or to a licensed
18hospital which provides substance abuse treatment services.
19The Department of Healthcare and Family Services shall assure
20coverage for the cost of treatment of the drug abuse or
21addiction for pregnant recipients in accordance with the
22Illinois Medicaid Program in conjunction with the Department
23of Human Services.
24    All medical providers providing medical assistance to
25pregnant individuals under this Code shall receive information
26from the Department on the availability of services under any

 

 

SB3682 Enrolled- 18 -LRB102 24087 CPF 33310 b

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

 

 

SB3682 Enrolled- 19 -LRB102 24087 CPF 33310 b

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

 

 

SB3682 Enrolled- 20 -LRB102 24087 CPF 33310 b

1    Partnerships and the efficient delivery of medical care.
2        (3) Persons receiving medical services through
3    Partnerships may receive medical and case management
4    services above the level usually offered through the
5    medical assistance program.
6    Medical providers shall be required to meet certain
7qualifications to participate in Partnerships to ensure the
8delivery of high quality medical services. These
9qualifications shall be determined by rule of the Illinois
10Department and may be higher than qualifications for
11participation in the medical assistance program. Partnership
12sponsors may prescribe reasonable additional qualifications
13for participation by medical providers, only with the prior
14written approval of the Illinois Department.
15    Nothing in this Section shall limit the free choice of
16practitioners, hospitals, and other providers of medical
17services by clients. In order to ensure patient freedom of
18choice, the Illinois Department shall immediately promulgate
19all rules and take all other necessary actions so that
20provided services may be accessed from therapeutically
21certified optometrists to the full extent of the Illinois
22Optometric Practice Act of 1987 without discriminating between
23service providers.
24    The Department shall apply for a waiver from the United
25States Health Care Financing Administration to allow for the
26implementation of Partnerships under this Section.

 

 

SB3682 Enrolled- 21 -LRB102 24087 CPF 33310 b

1    The Illinois Department shall require health care
2providers to maintain records that document the medical care
3and services provided to recipients of Medical Assistance
4under this Article. Such records must be retained for a period
5of not less than 6 years from the date of service or as
6provided by applicable State law, whichever period is longer,
7except that if an audit is initiated within the required
8retention period then the records must be retained until the
9audit is completed and every exception is resolved. The
10Illinois Department shall require health care providers to
11make available, when authorized by the patient, in writing,
12the medical records in a timely fashion to other health care
13providers who are treating or serving persons eligible for
14Medical Assistance under this Article. All dispensers of
15medical services shall be required to maintain and retain
16business and professional records sufficient to fully and
17accurately document the nature, scope, details and receipt of
18the health care provided to persons eligible for medical
19assistance under this Code, in accordance with regulations
20promulgated by the Illinois Department. The rules and
21regulations shall require that proof of the receipt of
22prescription drugs, dentures, prosthetic devices and
23eyeglasses by eligible persons under this Section accompany
24each claim for reimbursement submitted by the dispenser of
25such medical services. No such claims for reimbursement shall
26be approved for payment by the Illinois Department without

 

 

SB3682 Enrolled- 22 -LRB102 24087 CPF 33310 b

1such proof of receipt, unless the Illinois Department shall
2have put into effect and shall be operating a system of
3post-payment audit and review which shall, on a sampling
4basis, be deemed adequate by the Illinois Department to assure
5that such drugs, dentures, prosthetic devices and eyeglasses
6for which payment is being made are actually being received by
7eligible recipients. Within 90 days after September 16, 1984
8(the effective date of Public Act 83-1439), the Illinois
9Department shall establish a current list of acquisition costs
10for all prosthetic devices and any other items recognized as
11medical equipment and supplies reimbursable under this Article
12and shall update such list on a quarterly basis, except that
13the acquisition costs of all prescription drugs shall be
14updated no less frequently than every 30 days as required by
15Section 5-5.12.
16    Notwithstanding any other law to the contrary, the
17Illinois Department shall, within 365 days after July 22, 2013
18(the effective date of Public Act 98-104), establish
19procedures to permit skilled care facilities licensed under
20the Nursing Home Care Act to submit monthly billing claims for
21reimbursement purposes. Following development of these
22procedures, the Department shall, by July 1, 2016, test the
23viability of the new system and implement any necessary
24operational or structural changes to its information
25technology platforms in order to allow for the direct
26acceptance and payment of nursing home claims.

 

 

SB3682 Enrolled- 23 -LRB102 24087 CPF 33310 b

1    Notwithstanding any other law to the contrary, the
2Illinois Department shall, within 365 days after August 15,
32014 (the effective date of Public Act 98-963), establish
4procedures to permit ID/DD facilities licensed under the ID/DD
5Community Care Act and MC/DD facilities licensed under the
6MC/DD Act to submit monthly billing claims for reimbursement
7purposes. Following development of these procedures, the
8Department shall have an additional 365 days to test the
9viability of the new system and to ensure that any necessary
10operational or structural changes to its information
11technology platforms are implemented.
12    The Illinois Department shall require all dispensers of
13medical services, other than an individual practitioner or
14group of practitioners, desiring to participate in the Medical
15Assistance program established under this Article to disclose
16all financial, beneficial, ownership, equity, surety or other
17interests in any and all firms, corporations, partnerships,
18associations, business enterprises, joint ventures, agencies,
19institutions or other legal entities providing any form of
20health care services in this State under this Article.
21    The Illinois Department may require that all dispensers of
22medical services desiring to participate in the medical
23assistance program established under this Article disclose,
24under such terms and conditions as the Illinois Department may
25by rule establish, all inquiries from clients and attorneys
26regarding medical bills paid by the Illinois Department, which

 

 

SB3682 Enrolled- 24 -LRB102 24087 CPF 33310 b

1inquiries could indicate potential existence of claims or
2liens for the Illinois Department.
3    Enrollment of a vendor shall be subject to a provisional
4period and shall be conditional for one year. During the
5period of conditional enrollment, the Department may terminate
6the vendor's eligibility to participate in, or may disenroll
7the vendor from, the medical assistance program without cause.
8Unless otherwise specified, such termination of eligibility or
9disenrollment is not subject to the Department's hearing
10process. However, a disenrolled vendor may reapply without
11penalty.
12    The Department has the discretion to limit the conditional
13enrollment period for vendors based upon category of risk of
14the vendor.
15    Prior to enrollment and during the conditional enrollment
16period in the medical assistance program, all vendors shall be
17subject to enhanced oversight, screening, and review based on
18the risk of fraud, waste, and abuse that is posed by the
19category of risk of the vendor. The Illinois Department shall
20establish the procedures for oversight, screening, and review,
21which may include, but need not be limited to: criminal and
22financial background checks; fingerprinting; license,
23certification, and authorization verifications; unscheduled or
24unannounced site visits; database checks; prepayment audit
25reviews; audits; payment caps; payment suspensions; and other
26screening as required by federal or State law.

 

 

SB3682 Enrolled- 25 -LRB102 24087 CPF 33310 b

1    The Department shall define or specify the following: (i)
2by provider notice, the "category of risk of the vendor" for
3each type of vendor, which shall take into account the level of
4screening applicable to a particular category of vendor under
5federal law and regulations; (ii) by rule or provider notice,
6the maximum length of the conditional enrollment period for
7each category of risk of the vendor; and (iii) by rule, the
8hearing rights, if any, afforded to a vendor in each category
9of risk of the vendor that is terminated or disenrolled during
10the conditional enrollment period.
11    To be eligible for payment consideration, a vendor's
12payment claim or bill, either as an initial claim or as a
13resubmitted claim following prior rejection, must be received
14by the Illinois Department, or its fiscal intermediary, no
15later than 180 days after the latest date on the claim on which
16medical goods or services were provided, with the following
17exceptions:
18        (1) In the case of a provider whose enrollment is in
19    process by the Illinois Department, the 180-day period
20    shall not begin until the date on the written notice from
21    the Illinois Department that the provider enrollment is
22    complete.
23        (2) In the case of errors attributable to the Illinois
24    Department or any of its claims processing intermediaries
25    which result in an inability to receive, process, or
26    adjudicate a claim, the 180-day period shall not begin

 

 

SB3682 Enrolled- 26 -LRB102 24087 CPF 33310 b

1    until the provider has been notified of the error.
2        (3) In the case of a provider for whom the Illinois
3    Department initiates the monthly billing process.
4        (4) In the case of a provider operated by a unit of
5    local government with a population exceeding 3,000,000
6    when local government funds finance federal participation
7    for claims payments.
8    For claims for services rendered during a period for which
9a recipient received retroactive eligibility, claims must be
10filed within 180 days after the Department determines the
11applicant is eligible. For claims for which the Illinois
12Department is not the primary payer, claims must be submitted
13to the Illinois Department within 180 days after the final
14adjudication by the primary payer.
15    In the case of long term care facilities, within 120
16calendar days of receipt by the facility of required
17prescreening information, new admissions with associated
18admission documents shall be submitted through the Medical
19Electronic Data Interchange (MEDI) or the Recipient
20Eligibility Verification (REV) System or shall be submitted
21directly to the Department of Human Services using required
22admission forms. Effective September 1, 2014, admission
23documents, including all prescreening information, must be
24submitted through MEDI or REV. Confirmation numbers assigned
25to an accepted transaction shall be retained by a facility to
26verify timely submittal. Once an admission transaction has

 

 

SB3682 Enrolled- 27 -LRB102 24087 CPF 33310 b

1been completed, all resubmitted claims following prior
2rejection are subject to receipt no later than 180 days after
3the admission transaction has been completed.
4    Claims that are not submitted and received in compliance
5with the foregoing requirements shall not be eligible for
6payment under the medical assistance program, and the State
7shall have no liability for payment of those claims.
8    To the extent consistent with applicable information and
9privacy, security, and disclosure laws, State and federal
10agencies and departments shall provide the Illinois Department
11access to confidential and other information and data
12necessary to perform eligibility and payment verifications and
13other Illinois Department functions. This includes, but is not
14limited to: information pertaining to licensure;
15certification; earnings; immigration status; citizenship; wage
16reporting; unearned and earned income; pension income;
17employment; supplemental security income; social security
18numbers; National Provider Identifier (NPI) numbers; the
19National Practitioner Data Bank (NPDB); program and agency
20exclusions; taxpayer identification numbers; tax delinquency;
21corporate information; and death records.
22    The Illinois Department shall enter into agreements with
23State agencies and departments, and is authorized to enter
24into agreements with federal agencies and departments, under
25which such agencies and departments shall share data necessary
26for medical assistance program integrity functions and

 

 

SB3682 Enrolled- 28 -LRB102 24087 CPF 33310 b

1oversight. The Illinois Department shall develop, in
2cooperation with other State departments and agencies, and in
3compliance with applicable federal laws and regulations,
4appropriate and effective methods to share such data. At a
5minimum, and to the extent necessary to provide data sharing,
6the Illinois Department shall enter into agreements with State
7agencies and departments, and is authorized to enter into
8agreements with federal agencies and departments, including,
9but not limited to: the Secretary of State; the Department of
10Revenue; the Department of Public Health; the Department of
11Human Services; and the Department of Financial and
12Professional Regulation.
13    Beginning in fiscal year 2013, the Illinois Department
14shall set forth a request for information to identify the
15benefits of a pre-payment, post-adjudication, and post-edit
16claims system with the goals of streamlining claims processing
17and provider reimbursement, reducing the number of pending or
18rejected claims, and helping to ensure a more transparent
19adjudication process through the utilization of: (i) provider
20data verification and provider screening technology; and (ii)
21clinical code editing; and (iii) pre-pay, pre- or
22post-adjudicated predictive modeling with an integrated case
23management system with link analysis. Such a request for
24information shall not be considered as a request for proposal
25or as an obligation on the part of the Illinois Department to
26take any action or acquire any products or services.

 

 

SB3682 Enrolled- 29 -LRB102 24087 CPF 33310 b

1    The Illinois Department shall establish policies,
2procedures, standards and criteria by rule for the
3acquisition, repair and replacement of orthotic and prosthetic
4devices and durable medical equipment. Such rules shall
5provide, but not be limited to, the following services: (1)
6immediate repair or replacement of such devices by recipients;
7and (2) rental, lease, purchase or lease-purchase of durable
8medical equipment in a cost-effective manner, taking into
9consideration the recipient's medical prognosis, the extent of
10the recipient's needs, and the requirements and costs for
11maintaining such equipment. Subject to prior approval, such
12rules shall enable a recipient to temporarily acquire and use
13alternative or substitute devices or equipment pending repairs
14or replacements of any device or equipment previously
15authorized for such recipient by the Department.
16Notwithstanding any provision of Section 5-5f to the contrary,
17the Department may, by rule, exempt certain replacement
18wheelchair parts from prior approval and, for wheelchairs,
19wheelchair parts, wheelchair accessories, and related seating
20and positioning items, determine the wholesale price by
21methods other than actual acquisition costs.
22    The Department shall require, by rule, all providers of
23durable medical equipment to be accredited by an accreditation
24organization approved by the federal Centers for Medicare and
25Medicaid Services and recognized by the Department in order to
26bill the Department for providing durable medical equipment to

 

 

SB3682 Enrolled- 30 -LRB102 24087 CPF 33310 b

1recipients. No later than 15 months after the effective date
2of the rule adopted pursuant to this paragraph, all providers
3must meet the accreditation requirement.
4    In order to promote environmental responsibility, meet the
5needs of recipients and enrollees, and achieve significant
6cost savings, the Department, or a managed care organization
7under contract with the Department, may provide recipients or
8managed care enrollees who have a prescription or Certificate
9of Medical Necessity access to refurbished durable medical
10equipment under this Section (excluding prosthetic and
11orthotic devices as defined in the Orthotics, Prosthetics, and
12Pedorthics Practice Act and complex rehabilitation technology
13products and associated services) through the State's
14assistive technology program's reutilization program, using
15staff with the Assistive Technology Professional (ATP)
16Certification if the refurbished durable medical equipment:
17(i) is available; (ii) is less expensive, including shipping
18costs, than new durable medical equipment of the same type;
19(iii) is able to withstand at least 3 years of use; (iv) is
20cleaned, disinfected, sterilized, and safe in accordance with
21federal Food and Drug Administration regulations and guidance
22governing the reprocessing of medical devices in health care
23settings; and (v) equally meets the needs of the recipient or
24enrollee. The reutilization program shall confirm that the
25recipient or enrollee is not already in receipt of the same or
26similar equipment from another service provider, and that the

 

 

SB3682 Enrolled- 31 -LRB102 24087 CPF 33310 b

1refurbished durable medical equipment equally meets the needs
2of the recipient or enrollee. Nothing in this paragraph shall
3be construed to limit recipient or enrollee choice to obtain
4new durable medical equipment or place any additional prior
5authorization conditions on enrollees of managed care
6organizations.
7    The Department shall execute, relative to the nursing home
8prescreening project, written inter-agency agreements with the
9Department of Human Services and the Department on Aging, to
10effect the following: (i) intake procedures and common
11eligibility criteria for those persons who are receiving
12non-institutional services; and (ii) the establishment and
13development of non-institutional services in areas of the
14State where they are not currently available or are
15undeveloped; and (iii) notwithstanding any other provision of
16law, subject to federal approval, on and after July 1, 2012, an
17increase in the determination of need (DON) scores from 29 to
1837 for applicants for institutional and home and
19community-based long term care; if and only if federal
20approval is not granted, the Department may, in conjunction
21with other affected agencies, implement utilization controls
22or changes in benefit packages to effectuate a similar savings
23amount for this population; and (iv) no later than July 1,
242013, minimum level of care eligibility criteria for
25institutional and home and community-based long term care; and
26(v) no later than October 1, 2013, establish procedures to

 

 

SB3682 Enrolled- 32 -LRB102 24087 CPF 33310 b

1permit long term care providers access to eligibility scores
2for individuals with an admission date who are seeking or
3receiving services from the long term care provider. In order
4to select the minimum level of care eligibility criteria, the
5Governor shall establish a workgroup that includes affected
6agency representatives and stakeholders representing the
7institutional and home and community-based long term care
8interests. This Section shall not restrict the Department from
9implementing lower level of care eligibility criteria for
10community-based services in circumstances where federal
11approval has been granted.
12    The Illinois Department shall develop and operate, in
13cooperation with other State Departments and agencies and in
14compliance with applicable federal laws and regulations,
15appropriate and effective systems of health care evaluation
16and programs for monitoring of utilization of health care
17services and facilities, as it affects persons eligible for
18medical assistance under this Code.
19    The Illinois Department shall report annually to the
20General Assembly, no later than the second Friday in April of
211979 and each year thereafter, in regard to:
22        (a) actual statistics and trends in utilization of
23    medical services by public aid recipients;
24        (b) actual statistics and trends in the provision of
25    the various medical services by medical vendors;
26        (c) current rate structures and proposed changes in

 

 

SB3682 Enrolled- 33 -LRB102 24087 CPF 33310 b

1    those rate structures for the various medical vendors; and
2        (d) efforts at utilization review and control by the
3    Illinois Department.
4    The period covered by each report shall be the 3 years
5ending on the June 30 prior to the report. The report shall
6include suggested legislation for consideration by the General
7Assembly. The requirement for reporting to the General
8Assembly shall be satisfied by filing copies of the report as
9required by Section 3.1 of the General Assembly Organization
10Act, and filing such additional copies with the State
11Government Report Distribution Center for the General Assembly
12as is required under paragraph (t) of Section 7 of the State
13Library Act.
14    Rulemaking authority to implement Public Act 95-1045, if
15any, is conditioned on the rules being adopted in accordance
16with all provisions of the Illinois Administrative Procedure
17Act and all rules and procedures of the Joint Committee on
18Administrative Rules; any purported rule not so adopted, for
19whatever reason, is unauthorized.
20    On and after July 1, 2012, the Department shall reduce any
21rate of reimbursement for services or other payments or alter
22any methodologies authorized by this Code to reduce any rate
23of reimbursement for services or other payments in accordance
24with Section 5-5e.
25    Because kidney transplantation can be an appropriate,
26cost-effective alternative to renal dialysis when medically

 

 

SB3682 Enrolled- 34 -LRB102 24087 CPF 33310 b

1necessary and notwithstanding the provisions of Section 1-11
2of this Code, beginning October 1, 2014, the Department shall
3cover kidney transplantation for noncitizens with end-stage
4renal disease who are not eligible for comprehensive medical
5benefits, who meet the residency requirements of Section 5-3
6of this Code, and who would otherwise meet the financial
7requirements of the appropriate class of eligible persons
8under Section 5-2 of this Code. To qualify for coverage of
9kidney transplantation, such person must be receiving
10emergency renal dialysis services covered by the Department.
11Providers under this Section shall be prior approved and
12certified by the Department to perform kidney transplantation
13and the services under this Section shall be limited to
14services associated with kidney transplantation.
15    Notwithstanding any other provision of this Code to the
16contrary, on or after July 1, 2015, all FDA approved forms of
17medication assisted treatment prescribed for the treatment of
18alcohol dependence or treatment of opioid dependence shall be
19covered under both fee for service and managed care medical
20assistance programs for persons who are otherwise eligible for
21medical assistance under this Article and shall not be subject
22to any (1) utilization control, other than those established
23under the American Society of Addiction Medicine patient
24placement criteria, (2) prior authorization mandate, or (3)
25lifetime restriction limit mandate.
26    On or after July 1, 2015, opioid antagonists prescribed

 

 

SB3682 Enrolled- 35 -LRB102 24087 CPF 33310 b

1for the treatment of an opioid overdose, including the
2medication product, administration devices, and any pharmacy
3fees or hospital fees related to the dispensing, distribution,
4and administration of the opioid antagonist, shall be covered
5under the medical assistance program for persons who are
6otherwise eligible for medical assistance under this Article.
7As used in this Section, "opioid antagonist" means a drug that
8binds to opioid receptors and blocks or inhibits the effect of
9opioids acting on those receptors, including, but not limited
10to, naloxone hydrochloride or any other similarly acting drug
11approved by the U.S. Food and Drug Administration.
12    Upon federal approval, the Department shall provide
13coverage and reimbursement for all drugs that are approved for
14marketing by the federal Food and Drug Administration and that
15are recommended by the federal Public Health Service or the
16United States Centers for Disease Control and Prevention for
17pre-exposure prophylaxis and related pre-exposure prophylaxis
18services, including, but not limited to, HIV and sexually
19transmitted infection screening, treatment for sexually
20transmitted infections, medical monitoring, assorted labs, and
21counseling to reduce the likelihood of HIV infection among
22individuals who are not infected with HIV but who are at high
23risk of HIV infection.
24    A federally qualified health center, as defined in Section
251905(l)(2)(B) of the federal Social Security Act, shall be
26reimbursed by the Department in accordance with the federally

 

 

SB3682 Enrolled- 36 -LRB102 24087 CPF 33310 b

1qualified health center's encounter rate for services provided
2to medical assistance recipients that are performed by a
3dental hygienist, as defined under the Illinois Dental
4Practice Act, working under the general supervision of a
5dentist and employed by a federally qualified health center.
6    Within 90 days after October 8, 2021 (the effective date
7of Public Act 102-665) this amendatory Act of the 102nd
8General Assembly, the Department shall seek federal approval
9of a State Plan amendment to expand coverage for family
10planning services that includes presumptive eligibility to
11individuals whose income is at or below 208% of the federal
12poverty level. Coverage under this Section shall be effective
13beginning no later than December 1, 2022.
14    Subject to approval by the federal Centers for Medicare
15and Medicaid Services of a Title XIX State Plan amendment
16electing the Program of All-Inclusive Care for the Elderly
17(PACE) as a State Medicaid option, as provided for by Subtitle
18I (commencing with Section 4801) of Title IV of the Balanced
19Budget Act of 1997 (Public Law 105-33) and Part 460
20(commencing with Section 460.2) of Subchapter E of Title 42 of
21the Code of Federal Regulations, PACE program services shall
22become a covered benefit of the medical assistance program,
23subject to criteria established in accordance with all
24applicable laws.
25    Notwithstanding any other provision of this Code,
26community-based pediatric palliative care from a trained

 

 

SB3682 Enrolled- 37 -LRB102 24087 CPF 33310 b

1interdisciplinary team shall be covered under the medical
2assistance program as provided in Section 15 of the Pediatric
3Palliative Care Act.
4(Source: P.A. 101-209, eff. 8-5-19; 101-580, eff. 1-1-20;
5102-43, Article 30, Section 30-5, eff. 7-6-21; 102-43, Article
635, Section 35-5, eff. 7-6-21; 102-43, Article 55, Section
755-5, eff. 7-6-21; 102-95, eff. 1-1-22; 102-123, eff. 1-1-22;
8102-558, eff. 8-20-21; 102-598, eff. 1-1-22; 102-655, eff.
91-1-22; 102-665, eff. 10-8-21; revised 11-18-21.)