HB4554 EnrolledLRB099 14964 MLM 39154 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5 as follows:
 
6    (305 ILCS 5/5-5)  (from Ch. 23, par. 5-5)
7    (Text of Section before amendment by P.A. 99-407)
8    Sec. 5-5. Medical services. The Illinois Department, by
9rule, shall determine the quantity and quality of and the rate
10of reimbursement for the medical assistance for which payment
11will be authorized, and the medical services to be provided,
12which may include all or part of the following: (1) inpatient
13hospital services; (2) outpatient hospital services; (3) other
14laboratory and X-ray services; (4) skilled nursing home
15services; (5) physicians' services whether furnished in the
16office, the patient's home, a hospital, a skilled nursing home,
17or elsewhere; (6) medical care, or any other type of remedial
18care furnished by licensed practitioners; (7) home health care
19services; (8) private duty nursing service; (9) clinic
20services; (10) dental services, including prevention and
21treatment of periodontal disease and dental caries disease for
22pregnant women, provided by an individual licensed to practice
23dentistry or dental surgery; for purposes of this item (10),

 

 

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

 

 

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1care, and any other type of remedial care recognized under the
2laws of this State, but not including abortions, or induced
3miscarriages or premature births, unless, in the opinion of a
4physician, such procedures are necessary for the preservation
5of the life of the woman seeking such treatment, or except an
6induced premature birth intended to produce a live viable child
7and such procedure is necessary for the health of the mother or
8her unborn child. The Illinois Department, by rule, shall
9prohibit any physician from providing medical assistance to
10anyone eligible therefor under this Code where such physician
11has been found guilty of performing an abortion procedure in a
12wilful and wanton manner upon a woman who was not pregnant at
13the time such abortion procedure was performed. The term "any
14other type of remedial care" shall include nursing care and
15nursing home service for persons who rely on treatment by
16spiritual means alone through prayer for healing.
17    Notwithstanding any other provision of this Section, a
18comprehensive tobacco use cessation program that includes
19purchasing prescription drugs or prescription medical devices
20approved by the Food and Drug Administration shall be covered
21under the medical assistance program under this Article for
22persons who are otherwise eligible for assistance under this
23Article.
24    Notwithstanding any other provision of this Code, the
25Illinois Department may not require, as a condition of payment
26for any laboratory test authorized under this Article, that a

 

 

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1physician's handwritten signature appear on the laboratory
2test order form. The Illinois Department may, however, impose
3other appropriate requirements regarding laboratory test order
4documentation.
5    Upon receipt of federal approval of an amendment to the
6Illinois Title XIX State Plan for this purpose, the Department
7shall authorize the Chicago Public Schools (CPS) to procure a
8vendor or vendors to manufacture eyeglasses for individuals
9enrolled in a school within the CPS system. CPS shall ensure
10that its vendor or vendors are enrolled as providers in the
11medical assistance program and in any capitated Medicaid
12managed care entity (MCE) serving individuals enrolled in a
13school within the CPS system. Under any contract procured under
14this provision, the vendor or vendors must serve only
15individuals enrolled in a school within the CPS system. Claims
16for services provided by CPS's vendor or vendors to recipients
17of benefits in the medical assistance program under this Code,
18the Children's Health Insurance Program, or the Covering ALL
19KIDS Health Insurance Program shall be submitted to the
20Department or the MCE in which the individual is enrolled for
21payment and shall be reimbursed at the Department's or the
22MCE's established rates or rate methodologies for eyeglasses.
23    On and after July 1, 2012, the Department of Healthcare and
24Family Services may provide the following services to persons
25eligible for assistance under this Article who are
26participating in education, training or employment programs

 

 

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1operated by the Department of Human Services as successor to
2the Department of Public Aid:
3        (1) dental services provided by or under the
4    supervision of a dentist; and
5        (2) eyeglasses prescribed by a physician skilled in the
6    diseases of the eye, or by an optometrist, whichever the
7    person may select.
8    Notwithstanding any other provision of this Code and
9subject to federal approval, the Department may adopt rules to
10allow a dentist who is volunteering his or her service at no
11cost to render dental services through an enrolled
12not-for-profit health clinic without the dentist personally
13enrolling as a participating provider in the medical assistance
14program. A not-for-profit health clinic shall include a public
15health clinic or Federally Qualified Health Center or other
16enrolled provider, as determined by the Department, through
17which dental services covered under this Section are performed.
18The Department shall establish a process for payment of claims
19for reimbursement for covered dental services rendered under
20this provision.
21    The Illinois Department, by rule, may distinguish and
22classify the medical services to be provided only in accordance
23with the classes of persons designated in Section 5-2.
24    The Department of Healthcare and Family Services must
25provide coverage and reimbursement for amino acid-based
26elemental formulas, regardless of delivery method, for the

 

 

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

 

 

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1    All screenings shall include a physical breast exam,
2instruction on self-examination and information regarding the
3frequency of self-examination and its value as a preventative
4tool. For purposes of this Section, "low-dose mammography"
5means the x-ray examination of the breast using equipment
6dedicated specifically for mammography, including the x-ray
7tube, filter, compression device, and image receptor, with an
8average radiation exposure delivery of less than one rad per
9breast for 2 views of an average size breast. The term also
10includes digital mammography.
11    On and after January 1, 2016, the Department shall ensure
12that all networks of care for adult clients of the Department
13include access to at least one breast imaging Center of Imaging
14Excellence as certified by the American College of Radiology.
15    On and after January 1, 2012, providers participating in a
16quality improvement program approved by the Department shall be
17reimbursed for screening and diagnostic mammography at the same
18rate as the Medicare program's rates, including the increased
19reimbursement for digital mammography.
20    The Department shall convene an expert panel including
21representatives of hospitals, free-standing mammography
22facilities, and doctors, including radiologists, to establish
23quality standards for mammography.
24    On and after January 1, 2017, providers participating in a
25breast cancer treatment quality improvement program approved
26by the Department shall be reimbursed for breast cancer

 

 

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

 

 

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1primary care providers with respect to their female patients
2over age 40 receiving an annual mammogram. This performance
3goal shall be used to provide additional reimbursement in the
4form of a quality performance bonus to primary care providers
5who meet that goal.
6    The Department shall devise a means of case-managing or
7patient navigation for beneficiaries diagnosed with breast
8cancer. This program shall initially operate as a pilot program
9in areas of the State with the highest incidence of mortality
10related to breast cancer. At least one pilot program site shall
11be in the metropolitan Chicago area and at least one site shall
12be outside the metropolitan Chicago area. On or after July 1,
132016, the pilot program shall be expanded to include one site
14in western Illinois, one site in southern Illinois, one site in
15central Illinois, and 4 sites within metropolitan Chicago. An
16evaluation of the pilot program shall be carried out measuring
17health outcomes and cost of care for those served by the pilot
18program compared to similarly situated patients who are not
19served by the pilot program.
20    The Department shall require all networks of care to
21develop a means either internally or by contract with experts
22in navigation and community outreach to navigate cancer
23patients to comprehensive care in a timely fashion. The
24Department shall require all networks of care to include access
25for patients diagnosed with cancer to at least one academic
26commission on cancer-accredited cancer program as an

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1timely fashion to other health care providers who are treating
2or serving persons eligible for Medical Assistance under this
3Article. All dispensers of medical services shall be required
4to maintain and retain business and professional records
5sufficient to fully and accurately document the nature, scope,
6details and receipt of the health care provided to persons
7eligible for medical assistance under this Code, in accordance
8with regulations promulgated by the Illinois Department. The
9rules and regulations shall require that proof of the receipt
10of prescription drugs, dentures, prosthetic devices and
11eyeglasses by eligible persons under this Section accompany
12each claim for reimbursement submitted by the dispenser of such
13medical services. No such claims for reimbursement shall be
14approved for payment by the Illinois Department without such
15proof of receipt, unless the Illinois Department shall have put
16into effect and shall be operating a system of post-payment
17audit and review which shall, on a sampling basis, be deemed
18adequate by the Illinois Department to assure that such drugs,
19dentures, prosthetic devices and eyeglasses for which payment
20is being made are actually being received by eligible
21recipients. Within 90 days after September 16, 1984 (the
22effective date of Public Act 83-1439) this amendatory Act of
231984, the Illinois Department shall establish a current list of
24acquisition costs for all prosthetic devices and any other
25items recognized as medical equipment and supplies
26reimbursable under this Article and shall update such list on a

 

 

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1quarterly basis, except that the acquisition costs of all
2prescription drugs shall be updated no less frequently than
3every 30 days as required by Section 5-5.12.
4    The rules and regulations of the Illinois Department shall
5require that a written statement including the required opinion
6of a physician shall accompany any claim for reimbursement for
7abortions, or induced miscarriages or premature births. This
8statement shall indicate what procedures were used in providing
9such medical services.
10    Notwithstanding any other law to the contrary, the Illinois
11Department shall, within 365 days after July 22, 2013 (the
12effective date of Public Act 98-104), establish procedures to
13permit skilled care facilities licensed under the Nursing Home
14Care Act to submit monthly billing claims for reimbursement
15purposes. Following development of these procedures, the
16Department shall, by July 1, 2016, test the viability of the
17new system and implement any necessary operational or
18structural changes to its information technology platforms in
19order to allow for the direct acceptance and payment of nursing
20home claims.
21    Notwithstanding any other law to the contrary, the Illinois
22Department shall, within 365 days after August 15, 2014 (the
23effective date of Public Act 98-963), establish procedures to
24permit ID/DD facilities licensed under the ID/DD Community Care
25Act and MC/DD facilities licensed under the MC/DD Act to submit
26monthly billing claims for reimbursement purposes. Following

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1payment under the medical assistance program, and the State
2shall have no liability for payment of those claims.
3    To the extent consistent with applicable information and
4privacy, security, and disclosure laws, State and federal
5agencies and departments shall provide the Illinois Department
6access to confidential and other information and data necessary
7to perform eligibility and payment verifications and other
8Illinois Department functions. This includes, but is not
9limited to: information pertaining to licensure;
10certification; earnings; immigration status; citizenship; wage
11reporting; unearned and earned income; pension income;
12employment; supplemental security income; social security
13numbers; National Provider Identifier (NPI) numbers; the
14National Practitioner Data Bank (NPDB); program and agency
15exclusions; taxpayer identification numbers; tax delinquency;
16corporate information; and death records.
17    The Illinois Department shall enter into agreements with
18State agencies and departments, and is authorized to enter into
19agreements with federal agencies and departments, under which
20such agencies and departments shall share data necessary for
21medical assistance program integrity functions and oversight.
22The Illinois Department shall develop, in cooperation with
23other State departments and agencies, and in compliance with
24applicable federal laws and regulations, appropriate and
25effective methods to share such data. At a minimum, and to the
26extent necessary to provide data sharing, the Illinois

 

 

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

 

 

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1lease, purchase or lease-purchase of durable medical equipment
2in a cost-effective manner, taking into consideration the
3recipient's medical prognosis, the extent of the recipient's
4needs, and the requirements and costs for maintaining such
5equipment. Subject to prior approval, such rules shall enable a
6recipient to temporarily acquire and use alternative or
7substitute devices or equipment pending repairs or
8replacements of any device or equipment previously authorized
9for such recipient by the Department.
10    The Department shall execute, relative to the nursing home
11prescreening project, written inter-agency agreements with the
12Department of Human Services and the Department on Aging, to
13effect the following: (i) intake procedures and common
14eligibility criteria for those persons who are receiving
15non-institutional services; and (ii) the establishment and
16development of non-institutional services in areas of the State
17where they are not currently available or are undeveloped; and
18(iii) notwithstanding any other provision of law, subject to
19federal approval, on and after July 1, 2012, an increase in the
20determination of need (DON) scores from 29 to 37 for applicants
21for institutional and home and community-based long term care;
22if and only if federal approval is not granted, the Department
23may, in conjunction with other affected agencies, implement
24utilization controls or changes in benefit packages to
25effectuate a similar savings amount for this population; and
26(iv) no later than July 1, 2013, minimum level of care

 

 

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1eligibility criteria for institutional and home and
2community-based long term care; and (v) no later than October
31, 2013, establish procedures to permit long term care
4providers access to eligibility scores for individuals with an
5admission date who are seeking or receiving services from the
6long term care provider. In order to select the minimum level
7of care eligibility criteria, the Governor shall establish a
8workgroup that includes affected agency representatives and
9stakeholders representing the institutional and home and
10community-based long term care interests. This Section shall
11not restrict the Department from implementing lower level of
12care eligibility criteria for community-based services in
13circumstances where federal approval has been granted.
14    The Illinois Department shall develop and operate, in
15cooperation with other State Departments and agencies and in
16compliance with applicable federal laws and regulations,
17appropriate and effective systems of health care evaluation and
18programs for monitoring of utilization of health care services
19and facilities, as it affects persons eligible for medical
20assistance under this Code.
21    The Illinois Department shall report annually to the
22General Assembly, no later than the second Friday in April of
231979 and each year thereafter, in regard to:
24        (a) actual statistics and trends in utilization of
25    medical services by public aid recipients;
26        (b) actual statistics and trends in the provision of

 

 

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1    the various medical services by medical vendors;
2        (c) current rate structures and proposed changes in
3    those rate structures for the various medical vendors; and
4        (d) efforts at utilization review and control by the
5    Illinois Department.
6    The period covered by each report shall be the 3 years
7ending on the June 30 prior to the report. The report shall
8include suggested legislation for consideration by the General
9Assembly. The filing of one copy of the report with the
10Speaker, one copy with the Minority Leader and one copy with
11the Clerk of the House of Representatives, one copy with the
12President, one copy with the Minority Leader and one copy with
13the Secretary of the Senate, one copy with the Legislative
14Research Unit, and such additional copies with the State
15Government Report Distribution Center for the General Assembly
16as is required under paragraph (t) of Section 7 of the State
17Library Act shall be deemed sufficient to comply with this
18Section.
19    Rulemaking authority to implement Public Act 95-1045, if
20any, is conditioned on the rules being adopted in accordance
21with all provisions of the Illinois Administrative Procedure
22Act and all rules and procedures of the Joint Committee on
23Administrative Rules; any purported rule not so adopted, for
24whatever reason, is unauthorized.
25    On and after July 1, 2012, the Department shall reduce any
26rate of reimbursement for services or other payments or alter

 

 

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

 

 

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

 

 

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1individuals who are not infected with HIV but who are at high
2risk of HIV infection.
3(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
498-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
58-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
6eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
799-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-433, eff.
88-21-15; 99-480, eff. 9-9-15; revised 10-13-15.)
 
9    (Text of Section after amendment by P.A. 99-407)
10    Sec. 5-5. Medical services. The Illinois Department, by
11rule, shall determine the quantity and quality of and the rate
12of reimbursement for the medical assistance for which payment
13will be authorized, and the medical services to be provided,
14which may include all or part of the following: (1) inpatient
15hospital services; (2) outpatient hospital services; (3) other
16laboratory and X-ray services; (4) skilled nursing home
17services; (5) physicians' services whether furnished in the
18office, the patient's home, a hospital, a skilled nursing home,
19or elsewhere; (6) medical care, or any other type of remedial
20care furnished by licensed practitioners; (7) home health care
21services; (8) private duty nursing service; (9) clinic
22services; (10) dental services, including prevention and
23treatment of periodontal disease and dental caries disease for
24pregnant women, provided by an individual licensed to practice
25dentistry or dental surgery; for purposes of this item (10),

 

 

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

 

 

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1care, and any other type of remedial care recognized under the
2laws of this State, but not including abortions, or induced
3miscarriages or premature births, unless, in the opinion of a
4physician, such procedures are necessary for the preservation
5of the life of the woman seeking such treatment, or except an
6induced premature birth intended to produce a live viable child
7and such procedure is necessary for the health of the mother or
8her unborn child. The Illinois Department, by rule, shall
9prohibit any physician from providing medical assistance to
10anyone eligible therefor under this Code where such physician
11has been found guilty of performing an abortion procedure in a
12wilful and wanton manner upon a woman who was not pregnant at
13the time such abortion procedure was performed. The term "any
14other type of remedial care" shall include nursing care and
15nursing home service for persons who rely on treatment by
16spiritual means alone through prayer for healing.
17    Notwithstanding any other provision of this Section, a
18comprehensive tobacco use cessation program that includes
19purchasing prescription drugs or prescription medical devices
20approved by the Food and Drug Administration shall be covered
21under the medical assistance program under this Article for
22persons who are otherwise eligible for assistance under this
23Article.
24    Notwithstanding any other provision of this Code, the
25Illinois Department may not require, as a condition of payment
26for any laboratory test authorized under this Article, that a

 

 

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1physician's handwritten signature appear on the laboratory
2test order form. The Illinois Department may, however, impose
3other appropriate requirements regarding laboratory test order
4documentation.
5    Upon receipt of federal approval of an amendment to the
6Illinois Title XIX State Plan for this purpose, the Department
7shall authorize the Chicago Public Schools (CPS) to procure a
8vendor or vendors to manufacture eyeglasses for individuals
9enrolled in a school within the CPS system. CPS shall ensure
10that its vendor or vendors are enrolled as providers in the
11medical assistance program and in any capitated Medicaid
12managed care entity (MCE) serving individuals enrolled in a
13school within the CPS system. Under any contract procured under
14this provision, the vendor or vendors must serve only
15individuals enrolled in a school within the CPS system. Claims
16for services provided by CPS's vendor or vendors to recipients
17of benefits in the medical assistance program under this Code,
18the Children's Health Insurance Program, or the Covering ALL
19KIDS Health Insurance Program shall be submitted to the
20Department or the MCE in which the individual is enrolled for
21payment and shall be reimbursed at the Department's or the
22MCE's established rates or rate methodologies for eyeglasses.
23    On and after July 1, 2012, the Department of Healthcare and
24Family Services may provide the following services to persons
25eligible for assistance under this Article who are
26participating in education, training or employment programs

 

 

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1operated by the Department of Human Services as successor to
2the Department of Public Aid:
3        (1) dental services provided by or under the
4    supervision of a dentist; and
5        (2) eyeglasses prescribed by a physician skilled in the
6    diseases of the eye, or by an optometrist, whichever the
7    person may select.
8    Notwithstanding any other provision of this Code and
9subject to federal approval, the Department may adopt rules to
10allow a dentist who is volunteering his or her service at no
11cost to render dental services through an enrolled
12not-for-profit health clinic without the dentist personally
13enrolling as a participating provider in the medical assistance
14program. A not-for-profit health clinic shall include a public
15health clinic or Federally Qualified Health Center or other
16enrolled provider, as determined by the Department, through
17which dental services covered under this Section are performed.
18The Department shall establish a process for payment of claims
19for reimbursement for covered dental services rendered under
20this provision.
21    The Illinois Department, by rule, may distinguish and
22classify the medical services to be provided only in accordance
23with the classes of persons designated in Section 5-2.
24    The Department of Healthcare and Family Services must
25provide coverage and reimbursement for amino acid-based
26elemental formulas, regardless of delivery method, for the

 

 

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

 

 

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1    All screenings shall include a physical breast exam,
2instruction on self-examination and information regarding the
3frequency of self-examination and its value as a preventative
4tool. For purposes of this Section, "low-dose mammography"
5means the x-ray examination of the breast using equipment
6dedicated specifically for mammography, including the x-ray
7tube, filter, compression device, and image receptor, with an
8average radiation exposure delivery of less than one rad per
9breast for 2 views of an average size breast. The term also
10includes digital mammography and includes breast
11tomosynthesis. As used in this Section, the term "breast
12tomosynthesis" means a radiologic procedure that involves the
13acquisition of projection images over the stationary breast to
14produce cross-sectional digital three-dimensional images of
15the breast.
16    On and after January 1, 2016, the Department shall ensure
17that all networks of care for adult clients of the Department
18include access to at least one breast imaging Center of Imaging
19Excellence as certified by the American College of Radiology.
20    On and after January 1, 2012, providers participating in a
21quality improvement program approved by the Department shall be
22reimbursed for screening and diagnostic mammography at the same
23rate as the Medicare program's rates, including the increased
24reimbursement for digital mammography.
25    The Department shall convene an expert panel including
26representatives of hospitals, free-standing mammography

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1effective date of Public Act 83-1439) this amendatory Act of
21984, the Illinois Department shall establish a current list of
3acquisition costs for all prosthetic devices and any other
4items recognized as medical equipment and supplies
5reimbursable under this Article and shall update such list on a
6quarterly basis, except that the acquisition costs of all
7prescription drugs shall be updated no less frequently than
8every 30 days as required by Section 5-5.12.
9    The rules and regulations of the Illinois Department shall
10require that a written statement including the required opinion
11of a physician shall accompany any claim for reimbursement for
12abortions, or induced miscarriages or premature births. This
13statement shall indicate what procedures were used in providing
14such medical services.
15    Notwithstanding any other law to the contrary, the Illinois
16Department shall, within 365 days after July 22, 2013 (the
17effective date of Public Act 98-104), establish procedures to
18permit skilled care facilities licensed under the Nursing Home
19Care Act to submit monthly billing claims for reimbursement
20purposes. Following development of these procedures, the
21Department shall, by July 1, 2016, test the viability of the
22new system and implement any necessary operational or
23structural changes to its information technology platforms in
24order to allow for the direct acceptance and payment of nursing
25home claims.
26    Notwithstanding any other law to the contrary, the Illinois

 

 

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1Department shall, within 365 days after August 15, 2014 (the
2effective date of Public Act 98-963), establish procedures to
3permit ID/DD facilities licensed under the ID/DD Community Care
4Act and MC/DD facilities licensed under the MC/DD Act to submit
5monthly billing claims for reimbursement purposes. Following
6development of these procedures, the Department shall have an
7additional 365 days to test the viability of the new system and
8to ensure that any necessary operational or structural changes
9to its information technology platforms are implemented.
10    The Illinois Department shall require all dispensers of
11medical services, other than an individual practitioner or
12group of practitioners, desiring to participate in the Medical
13Assistance program established under this Article to disclose
14all financial, beneficial, ownership, equity, surety or other
15interests in any and all firms, corporations, partnerships,
16associations, business enterprises, joint ventures, agencies,
17institutions or other legal entities providing any form of
18health care services in this State under this Article.
19    The Illinois Department may require that all dispensers of
20medical services desiring to participate in the medical
21assistance program established under this Article disclose,
22under such terms and conditions as the Illinois Department may
23by rule establish, all inquiries from clients and attorneys
24regarding medical bills paid by the Illinois Department, which
25inquiries could indicate potential existence of claims or liens
26for the Illinois Department.

 

 

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

 

 

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

 

 

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

 

 

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1completed, all resubmitted claims following prior rejection
2are subject to receipt no later than 180 days after the
3admission 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 necessary
12to perform eligibility and payment verifications and other
13Illinois 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 into
24agreements with federal agencies and departments, under which
25such agencies and departments shall share data necessary for
26medical assistance program integrity functions and oversight.

 

 

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

 

 

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1procedures, standards and criteria by rule for the acquisition,
2repair and replacement of orthotic and prosthetic devices and
3durable medical equipment. Such rules shall provide, but not be
4limited to, the following services: (1) immediate repair or
5replacement of such devices by recipients; and (2) rental,
6lease, purchase or lease-purchase of durable medical equipment
7in a cost-effective manner, taking into consideration the
8recipient's medical prognosis, the extent of the recipient's
9needs, and the requirements and costs for maintaining such
10equipment. Subject to prior approval, such rules shall enable a
11recipient to temporarily acquire and use alternative or
12substitute devices or equipment pending repairs or
13replacements of any device or equipment previously authorized
14for such recipient by the Department.
15    The Department shall execute, relative to the nursing home
16prescreening project, written inter-agency agreements with the
17Department of Human Services and the Department on Aging, to
18effect the following: (i) intake procedures and common
19eligibility criteria for those persons who are receiving
20non-institutional services; and (ii) the establishment and
21development of non-institutional services in areas of the State
22where they are not currently available or are undeveloped; and
23(iii) notwithstanding any other provision of law, subject to
24federal approval, on and after July 1, 2012, an increase in the
25determination of need (DON) scores from 29 to 37 for applicants
26for institutional and home and community-based long term care;

 

 

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1if and only if federal approval is not granted, the Department
2may, in conjunction with other affected agencies, implement
3utilization controls or changes in benefit packages to
4effectuate a similar savings amount for this population; and
5(iv) no later than July 1, 2013, minimum level of care
6eligibility criteria for institutional and home and
7community-based long term care; and (v) no later than October
81, 2013, establish procedures to permit long term care
9providers access to eligibility scores for individuals with an
10admission date who are seeking or receiving services from the
11long term care provider. In order to select the minimum level
12of care eligibility criteria, the Governor shall establish a
13workgroup that includes affected agency representatives and
14stakeholders representing the institutional and home and
15community-based long term care interests. This Section shall
16not restrict the Department from implementing lower level of
17care eligibility criteria for community-based services in
18circumstances where federal approval 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 and
23programs for monitoring of utilization of health care services
24and facilities, as it affects persons eligible for medical
25assistance under this Code.
26    The Illinois Department shall report annually to the

 

 

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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 filing of one copy of the report with the
15Speaker, one copy with the Minority Leader and one copy with
16the Clerk of the House of Representatives, one copy with the
17President, one copy with the Minority Leader and one copy with
18the Secretary of the Senate, one copy with the Legislative
19Research Unit, and such additional copies with the State
20Government Report Distribution Center for the General Assembly
21as is required under paragraph (t) of Section 7 of the State
22Library Act shall be deemed sufficient to comply with this
23Section.
24    Rulemaking authority to implement Public Act 95-1045, if
25any, is conditioned on the rules being adopted in accordance
26with all provisions of the Illinois Administrative Procedure

 

 

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

 

 

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

 

 

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1pre-exposure prophylaxis and related pre-exposure prophylaxis
2services, including, but not limited to, HIV and sexually
3transmitted infection screening, treatment for sexually
4transmitted infections, medical monitoring, assorted labs, and
5counseling to reduce the likelihood of HIV infection among
6individuals who are not infected with HIV but who are at high
7risk of HIV infection.
8(Source: P.A. 98-104, Article 9, Section 9-5, eff. 7-22-13;
998-104, Article 12, Section 12-20, eff. 7-22-13; 98-303, eff.
108-9-13; 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; 98-756,
11eff. 7-16-14; 98-963, eff. 8-15-14; 99-78, eff. 7-20-15;
1299-180, eff. 7-29-15; 99-236, eff. 8-3-15; 99-407 (see Section
1399 of P.A. 99-407 for its effective date); 99-433, eff.
148-21-15; 99-480, eff. 9-9-15; revised 10-13-15.)
 
15    Section 95. No acceleration or delay. Where this Act makes
16changes in a statute that is represented in this Act by text
17that is not yet or no longer in effect (for example, a Section
18represented by multiple versions), the use of that text does
19not accelerate or delay the taking effect of (i) the changes
20made by this Act or (ii) provisions derived from any other
21Public Act.
 
22    Section 99. Effective date. This Act takes effect January
231, 2017.